Annual Meeting Posters Abstract Book I - Hand
73RD ANNUAL MEETING OF THE ASSH SEPTEMBER 13 – 15, 2018 BOSTON, MA
822 W Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Fax: (847) 384-1435 Web: www.assh.org Email: [email protected]
All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. AM Poster 001: Dorsal Plating for Comminuted Intra-Articular Middle Phalangeal Base Fractures Category: Hand
Hand and Wrist;Diseases and Disorders;General Principles Level 4 Evidence
Travis Doering, MD Andrew Greenberg, MD David V. Tuckman, MD
Hypothesis Intra-articular middle phalangeal base fractures with volar instability are rare injuries with scant literature on optimal management. Our purpose is to describe our method of dorsal plating and report post-operative outcomes.
Methods A retrospective case review of 5 patients with intra-articular middle phalangeal base fractures with volar proximal interphalangeal joint instability, measuring subjective, clinical, and radiographic outcomes.
Results Patient age averaged 38.2 years (range 23-56), and 80% of whom were male. Sporting injuries were the most common mechanism (80%). Time to surgery averaged 7 days, and post-operative follow up duration averaged 19.6 months (median 8 months). All fractures were intra-articular at the PIP joint with volar instability. There were no complications and no patients required secondary surgery. Grip strength was maintained and range of motion was good, based on the American Society for Surgery of the Hand Total Active Motion score. Average Quick Disability of the Arm, Shoulder, and Hand was 0.5 (range 0-2.3), 100% of patients were satisfied, and average visual analogue pain score was 1.2. Patients returned to work at a median of 4 days. There was radiographic union at an average of 6.6 weeks (range 6-7) in all fractures.
Summary Points Dorsal plating using a 1.5mm modular hand plate is a viable option for rigid fixation of intra- articular middle phalangeal base fractures with volar instability. This fixation method allows for early range of motion without complications in this case series. All fractures united, patients had minimal functional deficits, and were able to maintain good range of motion.
Bibliography 1: Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am. 1998;23(3):368-80. 2: Rosenstadt BE, Glickel SZ, Lane LB, Kaplan SJ. Palmar fracture dislocation of the proximal interphalangeal joint. J Hand Surg Am. 1998;23(5):811-20. 3: Peimer CA, Sullivan DJ, Wild DR. Palmar dislocation of the proximal interphalangeal joint. J Hand Surg Am. 1984;9A(1):39-48. 4: Meyer ZI, Goldfarb CA, Calfee RP, Wall LB. The Central Slip Fracture: Results of Operative Treatment of Volar Fracture Subluxations/Dislocations of the Proximal Interphalangeal Joint. J Hand Surg Am. 2017;42(7):572.e1-572.e6. 5: Meyer ZI, Wall LB. The Central Slip Fracture: Results of Operative Treatment of Volar Fracture Subluxations/Dislocations of the Proximal Interphalangeal Joint. J Hand Surg Am. 2017;42(7):572.e1-572.e6. AM Poster 002: Comparison of Local-Only Anesthesia Versus Sedation in Patients Undergoing Staged Bilateral Carpal Tunnel Release Category: Hand
Hand and Wrist;Nerve Level 2 Evidence
Garrhett G. Via, BS Hisham M. Awan, MD Sonu Jain, MD Kanu Goyal, MD
Hypothesis It was hypothesized that after experiencing both types of anesthesia described, a greater proportion of patients would prefer wide-awake, local-only carpal tunnel release.
Methods Staged bilateral carpal tunnel release utilizing an open or endoscopic technique was scheduled to achieve completion in 30 patients, as driven by a priori power analysis. To date, 27 of the 30 desired patients (3 pending) have received both operations at an outpatient surgery center where the releases were performed by one of three board-certified hand surgeons. Patients chose initial hand laterality and were randomized regarding initial anesthesia method: local-only or sedation. Data collection via questionnaires began at consent and continued to 6 weeks post- operatively from the second procedure. Primary outcome measures included patient satisfaction with each procedure and patient anesthesia preference. Secondary outcomes included, but were not limited to, the Beck Anxiety Inventory, QuickDASH, surgical times and costs, pain assessment, and surgeon comfort.
Results At final follow-up 6-weeks post-operatively, 26 out of 27 patients reported high satisfaction with local-only anesthesia and 26 out of 27 with sedation. 16 patients preferred local-only anesthesia (95% CI = 41% – 78%), 8 preferred sedation (95% CI = 16% – 51%), and 3 had no preference. Although anesthesia fees were approximately $388 (95% CI = $320 – $456) lower with local-only anesthesia (p < 0.01), total surgery costs for carpal tunnel release were not significantly different with respect to the anesthesia cohorts (p = 0.52). Total time in the surgical facility was approximately 24 (95% CI = 14 – 34) minutes quicker with local-only anesthesia (p < 0.01) due to shorter time in the PACU. A scaled comparison of worst post-operative pain following the two procedures revealed no difference between local-only anesthesia and sedation (p = 0.71).
Summary Points • Patients reported equal satisfaction with both Methods of anesthesia • 59% of patients preferred local-only anesthesia
Bibliography 1: Davison, P. G., Lalonde, D. H., & Cobb, T. (January 01, 2013). The patient's perspective on carpal tunnel surgery related to the type of anesthesia: A prospective cohort study. Hand, 8, 1, 47-53. 2: Sambandam, S. N., Priyanka, P., Gul, A., & Ilango, B. (August 01, 2008). Critical analysis of outcome measures used in the assessment of carpal tunnel syndrome. International Orthopaedics, 32, 4, 497-504. 3: De Ayala, R. J., Vonderharr-Carlson, D. J., Kim D. (October 01, 2005). Assessing the reliability of the Beck Anxiety Inventory scores. Educational and Psychological Measurement, 65, 5, 742 – 756. AM Poster 003: Return to Sport After Hand Fractures in NCAA Athletes: When is Operative Fixation Necessary? Category: Hand
Hand and Wrist;Practice Management Level 4 Evidence
Christopher N. Carender, Joseph A. Buckwalter, V, Natalie A. Glass Robert W. Westermann,
Hypothesis Metacarpal and phalanx fractures are common amongst athletes. There is a paucity of data to guide NCAA team physicians on expected return to play after hand fractures treated operatively or non-operatively. The purpose of this study was to examine the epidemiology and return to play times after hand fractures in NCAA athletes. We hypothesized that surgical management of metacarpal and phalanx fractures may expedite return to play times.
Methods The NCAA Injury Surveillance Program database was queried for metacarpal and phalanx fractures during the 2009-2014 seasons in all available contact and non-contact sports. Injury rates per 100,000 athlete-exposures (AE) and return to play times for athletes treated with operative and non-operative management of hand fractures were calculated. Student’s t-test and Wilcoxon Rank sum tests were used for continuous variable and Chi-Squared tests and Fisher Exact Test were used for categorical variables to determine significance, set to p<0.05.
Results Sports with the highest rates of phalanx and metacarpal fractures included Men’s Football, Men’s Ice Hockey, Men’s Wrestling, and Women’s Field Hockey (Table 1). Multiple sports had participants with no hand fractures over the study period. Male student-athletes with metacarpal fractures treated operatively returned to play at a mean of 31.8±29.4 days versus 13.8±23.6 days for those treated non-operatively (Table 2). 92% of male student-athletes were able to return to sport in the same season without operative management versus 67% with operative management. Female student-athletes had a cohort too small for statistical analysis. Return to play times for male student-athletes with phalanx fractures were not significantly different between operative and non-operative groups (16.1±21.5 days versus 7.1±13.3 days) (Table 2). Rates of return to sport within the same season for male student-athletes following phalanx fractures were similar for operative and non-operative groups, with 97.9% returning with non-operative treatment, and 90.9% returning with operative treatment.
Summary Points • Hand fractures are relatively common among NCAA student-athletes participating in contact sports • Sports with the highest rates of phalanx and metacarpal fractures included Men’s Football, and Women’s Field Hockey • Operative fixation of equivocally unstable metacarpal or phalangeal fractures may subject athletes to excessive and unnecessary time-loss from participation • Additional studies are needed, as the effect of fracture type and stability on return to play time in this study is unknown • The return to play times illustrated within this study can be used to counsel athletes, athletic trainers, and coaches.
AM Poster 004: Eaton’s Plasty For the Treatment of the Traumatic Luxation of the Trapezium-Metacarpal Joint. Category: Hand
Hand and Wrist N/A - not a clinical study
Ana Maria Far-Riera, MD Carlos Perez-Uribarri, MD
Introduction Trapezium-metacarpal dislocations are infrequent lesions. Its treatment continues in controversy.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. 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.
Hypothesis Treatment proposal for acute instability of trapezium-metacarpal joint dislocation after failure of closed stabilization.
Methods We present a case of a 15-year-old male who presented a post-traumatic TMC dislocation self- reduced 4 weeks earlier. On the x-ray we can see a dorsoradial subluxation which prevents him from performing key pinch. A closed reduction was performed and remained immobilized for 6 weeks. After removal of kischner wires and immobilization the joint was unstable, so an open reduction and reconstruction by Eaton plasty with FCR was performed.
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.
Summary Points 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 promulgate 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.
Bibliography 1: B. Bosmans, MD, M. H. J. Verhofstad, PhD, T. Gosens, PhD. Traumatic Thumb Carpometacarpal Joint Dislocations. J Hand Surg 2008;33A:438–441. 2: Edmunds JO. Traumatic dislocations and instability of the trapeziometacarpal joint of the thumb. Hand Clin 2006;22: 365–392. 3: Colman M, Mass DP, Draganich LF. Effects of the deep anterior oblique and dorsoradial ligaments on trapeziometacarpal joint stability. J Hand Surg 2007;32A: 310 –317. 4: Simonian PT, Trumble TE. Traumatic dislocation of the thumb carpometacarpal joint: early ligamentous reconstruction versus closed reduction and pinning. J Hand Surg 1996;21A:802– 806. 5: Van Brenk B, Richards RR, Mackay MB, Boynton EL. A biomechanical assessment of ligaments preventing dorsoradial subluxation of the trapeziometacarpal joint. J Hand Surg 1998;23A:607– 611. AM Poster 006: Does Carpal Tunnel Release Increase the Risk of Trigger Finger? Category: Hand
Hand and Wrist;Nerve;Diseases and Disorders Level 4 Evidence
Dafang Zhang, MD Jamie Collins, BS Brandon E. Earp, MD Philip Blazar, MD
Hypothesis Carpal tunnel syndrome and trigger finger (TF) frequently present concomitantly and some studies suggest that carpal tunnel release (CTR) is a risk factor for the development of ipsilateral TF. The primary objective of this study is to elucidate the relationship between CTR and the development of TF. Our null hypotheses are that there are no differences (1) in the incidence of TF in the first postoperative year in the operative hand compared with the contralateral hand and (2) in the incidence of TF in the first postoperative year after CTR in the operative hand compared with the incidence of TF in the one year prior to CTR in the operative hand.
Methods In an IRB-approved retrospective study, we identified 1,386 primary CTR in 1,140 patients at a tertiary referral center from July 2008 to June 2013. To determine the association between CTR and TF in the first operative year in the operative hand compared with the contralateral hand, conditional logistic regression was used. Patients who had contralateral CTR within the first postoperative year of ipsilateral CTR were excluded from this analysis. To examine the association between CTR and TF in the year prior to surgery compared with the year following surgery, conditional logistic regression was used for the presence of TF and Poisson regression was used for the number of TF. Multivariable regression analysis was used to determine associated risk factors.
Results A new TF was seen in 81 out of 1,386 cases (5.8%) within one year after CTR. The Incidence of TF was 2.5 times higher in the operative hand compared with the contralateral hand (p=0.001). However, the incidence of TF was associated with 0.5 times lower odds during the year following CTR compared with the year prior to CTR (p<0.0001) in both conditional logistic regression and Poisson regression models. Increased BMI is statistically associated with the development of TF after CTR (p= 0.05), but the attributable risk is negligible (RR 1.01, 95% CI 1 to 1.03). Post-CTR TF most commonly occurs in the thumb (43.3%), followed by the long finger (21.1%), the ring finger (17.3%), the small finger (9.6%), and the index finger (8.7%).
Summary Points • CTR does not “cause” TF. • TF is more likely to develop in a hand which undergoes CTR than in the contralateral hand. • Post-CTR TF most commonly occurs in the thumb, followed by the long finger, ring finger, small finger, and index finger.
Bibliography 1: King BA, Stern PJ, Kiefhaber TR. The incidence of trigger finger or de Quervain's tendinitis after carpal tunnel release. J Hand Surg Eur Vol. 2013;38(1):82-3. 2: Hayashi M, Uchiyama S, Toriumi H, Nakagawa H, Kamimura M, Miyasaka T. Carpal tunnel syndrome and development of trigger digit. J Clin Neurosci. 2005;12(1):39-41. AM Poster 007: Utility of “Baseline” Electrodiagnostic Studies for Carpal Tunnel Release Category: Hand
Hand and Wrist;Nerve Level 4 Evidence
Dafang Zhang Brandon E. Earp, MD Philip Blazar, MD
Hypothesis The utility of routine pre-operative electrodiagnostic studies (EDS) for carpal tunnel syndrome is controversial. One argument in support of pre-operative EDS is the acquisition of an objective baseline for comparison in cases of post-operative persistence or recurrence of symptoms. The objectives of this study are (1) to determine the rate of acquisition of post-operative EDS in a large series of patients with pre-operative EDS who underwent carpal tunnel release and (2) to determine risk factors associated with post-operative EDS acquisition. Our primary null hypothesis is that the rate of acquisition of post-operative EDS to assess median nerve function is low.
Methods In an institutional review board approved retrospective study, we identified 1,003 patients who underwent carpal tunnel release (CTR) in 1,223 limbs at a tertiary care referral center from July 2008 to June 2013 with pre-operative EDS. Electronic medical records were reviewed for the response variable, post-operative EDS, and explanatory variables.
Results Post-operative EDS were acquired in 117 out of 1,223 limbs that underwent CTR (9.6%). Assessment of the median nerve in the carpal tunnel was part of the rationale for obtaining EDS in 82% of cases in which post-operative EDS were acquired (Table 1, Figure 1). Younger age, lower BMI, Hispanic race, and education level of eighth grade or less were associated with post- operative EDS acquisition.
Summary Points • The rate of acquisition of post-operative EDS after CTR is substantial. • The large majority of post-operative EDS are acquired, at least in part, to investigate median nerve function. • Acquisition of the “baseline” EDS is a reasonable strategy.
Bibliography 1: Fowler JR. Nerve Conduction Studies for Carpal Tunnel Syndrome: Gold Standard or Unnecessary Evil? Orthopedics. 2017;40(3):141-142. 2: Glowacki KA, Breen CJ, Sachar K, Weiss AP. Electrodiagnostic testing and carpal tunnel release outcome. J Hand Surg Am. 1996;21(1):117-21. 3: Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2008;90(12):2587-93. 4: Becker SJ, Makanji HS, Ring D. Changes in treatment plan for carpal tunnel syndrome based on electrodiagnostic test results. J Hand Surg Eur. 2014;39(2):187-93. 5: Sears ED, Lu YT, Wood SM, Nasser JS, Hayward RA, Chung KC, Kerr EA. Diagnostic Testing Requested Before Surgical Evaluation for Carpal Tunnel Syndrome. J Hand Surg Am. 2017;42(8):623-629.e1. AM Poster 008: Percutaneous Capsulotomy for Recurrent Digital Mucous Cysts Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Wei Hsiung Hui-Kuang Huang, MD Jung-Pan Wang, MD, PhD
Hypothesis Surgical treatment of the digital mucous cysts (DMCs) is challenging because of some concerns including wound problems, joint motion limitation, and recurrence. Treating the recurrent wrist ganglion with arthroscopic resection and capsulotomy was reported to have good surgical outcomes and low recurrence rates. Our hypothesis is that to mimic the capsulotomy through percutaneous capsulotomy treating the recurrent DMCs.
Methods This study enrolled 22 patients with recurrent digital mucous cysts. The procedure of percutaneous capsulotomy for DMCs was performed by using an 18-gauge needle intrafocally entering the cyst and directing toward the distal interphalangeal (DIP) joint to incise and cut the dorsal capsule of the DIP joint (Figure 1). At minimum 1- year follow-up, patients were evaluated by clinical, and patient-rated outcomes.
Results Five of 22 patients were male. Average age was 64.5 (range 54-75). After the percutaneous capsulotomy, there was only one patient encounter recurrence at 1 month follow up (1/22, 4.5%). After repeated percutaneous capsulotomy, no recurrence was noted after at minimum 1- year follow up. There’s no wound infection, new onset stiffness or extensor tendon injury. Nine of 12 cases with accompanied nail deformity can have improved nail appearance after regrowth and no new onset nail deformity was noted in all patients (Figure 2). The mean VAS score was 8.2 (range from 0-10).
Summary Points The percutaneous capsulotomy is an easy and minimally invasive method for treating recurrent digital mucous cysts. The connecting stalk of recurrent DMCs may be destroyed by percutaneous capsulotomy and good clinical outcomes could be achieved. The developed nail deformity could have improved nail appearance and the digital range of motion would not be impaired. Of note, for the cases with osteophyte, the related symptom of osteophyte may be persisted after percutaneous capsulotomy.
Bibliography 1: Rizzo M; Berger RA; Steinmann SP; Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: results with a minimum 2-year follow-up period. J Hand Surg Am. 2004; 29(1):59-62. 2: Kanaya K, Wada T, Iba K, Yamashita T. Total dorsal capsulectomy for the treatment of mucous cysts. J Hand Surg Am. 2014;39:1063-1067. 3: Johnson SM, Treon K, Thomas S, Cox QG. A reliable surgical treatment for digital mucous cysts. J Hand Surg Eur Vol. 2014;39:856-860. AM Poster 009: Return to Play in Elite Athletes After Thumb Ulnar Collateral Ligament Repair with Suture Tape Augmentation Category: Hand
Hand and Wrist;Diseases and Disorders;General Principles Level 4 Evidence
Daniel B. Gibbs, MD MD Anthony De Giacomo Steven S. Shin, MD MD
Hypothesis 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 Eleven thumb surgeries in 10 elite athletes were identified. One patient had bilateral surgery at different time points over the inclusion dates. The study group was comprised of 2 collegiate baseball players, 4 professional baseball players, 2 professional basketball players, 1 professional hockey player and 1 high level high school basketball player. Nine of the 11 UCL tears were treated in-season with an average return to play of 31.7 days (for return to play at any level) and 33.4 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 athletes returned to the same level of play.
Summary Points 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.
AM Poster 010: DupuytrEn Treatment EffeCtiveness Trial (DETECT): A Protocol for Prospective, Randomized, Controlled, Outcome Assessor- Blinded, Three Armed Parallel 1:1:1, Multicentre Trial Comparing the Effectiveness and Cost of Collagenase Clostridium Histolyticum Category: Hand
Hand and Wrist;Diseases and Disorders Level 2 Evidence
Mikko Petteri Räisänen Teemu Karjalainen, MD, PhD Harry Göransson, MD, PhD Aleksi Reito, MD, PhD Antti Malmivaara, MD, PhD Olli Ville Leppänen, MD, PhD
Hypothesis Our hypothesis is that there is no difference in effectiveness or cost between three treatment strategies in 5 years follow-up: 1) PNF (percutaneous needle fasciotomy) followed by surgical LF (limited fasciectomy) in patients who fail to respond; 2) CCH (collagenase clostridium histolyticum) followed by surgical LF in patients who fail to respond; and 3) LF as the primary (and secondary) treatment modality in patients suffering from mild to moderately severe Dupuytren’s contracture (DC).
Methods The trial design of DETECT is a multicentre, randomized, controlled, assessor blinded, three arms 1:1:1, superiority trial with three parallel groups. The participants will be recruited from six national tertiary and secondary referral centres in Finland (Figure 1). Primary outcome is a composite outcome comprising of 1) at least 50% contracture release from the date of recruitment and 2) participants in a patient-accepted symptom state (PASS). Secondary outcomes are: 1) angle of contracture 2) QuickDASH, 3) perceived hand function, 4) EQ-5D-3L, 5) rate of major adverse events, 6) patient’s trust of the treatment, 7) global rating, 8) rate of PASS, 9) rate of minimal clinically important improvement, 10) expenses, 11) progression of disease, 12) progression-free-survival, 13) favoured treatment modality, 14) patients achieving full contracture release and >50% improvement, and 15) patient satisfaction with the treatment effect. Predictive factors for achieving the PASS will also be analysed (Table 1). Sample size was calculated based on results in previous studies (ß=0.20, a=0.05). We will recruit 278 patients. All analyses will be performed on the intention-to-treat principle, defined as including all patients who will be randomized in the study. The statistical significance between groups will be evaluated by generalized linear models with appropriate distribution and link functions. Repeated measures will be analysed using generalized linear mixed-models. We will treat patient as one using the aforementioned composite outcome, regardless of the number of rays affected.
Ethics and Dissemination The protocol was approved by the Tampere University hospital institutional review board and Finnish Medicine Agency (FIMEA). The results of the trial will be disseminated as published articles in peer-reviewed journals.
Summary Points • This study aims to compare the effectiveness of treatment strategies rather than efficacy of single interventions. Such a study has not been ever published. • We will use a pragmatic approach and assess the outcomes from both the patient’s and health care provider’s perspective. • Long-term follow-up will give a better understanding of the cost-effectiveness of the treatment strategies.
AM Poster 011: Evaluation of the Pulley Function of the Hook of the Hamate for the Flexor Tendon Category: Hand
Hand and Wrist N/A – not a clinical study
Kenji Goto Yoichi Sugiyama Mayuko Kinoshita Nana Nagura Kazuo Kaneko, MD, PhD Kiyohito Naito
Hypothesis The aim of this study was to measure the curvature radii of the finger flexor tendons on CT acquired using tendon conditions to examine whether the hook of the hamate functions as a pulley of the flexor tendon.
Methods The subjects were 20 healthy volunteers (40 hands) (14 males and 6 females, mean age: 27.5 years old). Their hands were imaged in extension and flexion of the fingers on CT. The curvature radii of the little and middle finger flexor tendons at the hook of the hamate were calculated.
Results The curvature radii of the little and middle finger flexor tendons were 24.8 ± 7.3 and 327.1 ± 343.9 mm in finger extension, respectively, and 21.3 ± 5.3 and 265.1 ± 202.9 mm in finger flexion, respectively. The curvature radius of the little finger flexor tendon was significantly smaller than that of the middle finger flexor tendon in both finger extension and flexion (P<0.01).
Summary Points • Our study suggested that the hook of the hamate functions as a pulley for the little finger flexor tendon. AM Poster 012: In vivo Kinematics of the Thumb Carpometacarpal Joint During Flexion and Abduction Category: Hand
Hand and Wrist;Diseases and Disorders N/A – not a clinical study
Kaoru Tada, MD Daiki Yamamoto, MD Tadahiro Nakajima Mika Nakada Masashi Matsuta Hiroyuki Tsuchiya, MD
Hypothesis Our hypothesis is that new insight on thumb carpometacarpal joint kinematics may be obtained via CT imaging in multiple positions during extension-flexion and adduction-abduction motions of the thumb.
Methods The subjects were 10 healthy males aged 23-65 years (mean, 37.3 years). CT images were obtained in 4 equally divided positions during the motion from maximum extension to maximum flexion of the thumb using a supportive device. Similarly, images were obtained in 4 positions during maximum adduction to maximum abduction. A three-dimensional model was constructed from the obtained images, and the models of each position were superimposed with reference to the trapezium. A straight line connecting the extension line of the bone axis of the first metacarpal bone at each position with the shortest distance was defined as the rotation axis, and we hypothesized that the first metacarpal bone is translated while rotating around the rotation axis and the bone axis. The amount of angular change around the rotation and bone axes and the translational movement between each position were evaluated.
Results The amount of angular change around the rotation axis increased as the flexion angle increased during flexion and decreased as the abduction angle increased during abduction. In other words, the proportion of the motion that involved the carpometacarpal joints during movement of the entire thumb increased as the flexion angle increased and decreased as the abduction angle increased. The angular change around the bone axis involved internal rotation in both flexion and abduction, which increased as the flexion angle increased during flexion and was constant during abduction. In terms of translational movement, the first metacarpal bone shifted toward the palm side with respect to the trapezium during flexion, but then moved toward the dorsal side as maximum flexion was approached. During abduction, the first metacarpal bone moved toward the ulnar side with respect to the trapezium regardless of the abduction angle.
Summary Points • Regarding the kinematics of the thumb carpometacarpal joint, a movement called screw- home torque rotation has been known to occur in which the metacarpal bone internally rotates and flexes on the trapezium in the final phase of opposition. • In this study, as the flexion angle increased, the flexion of the first metacarpal bone and the angular change in the internal rotation also increased. Hence, the screw-home torque rotation appears to be more prominent in flexion than in abduction.
Bibliography 1: Edmunds JO. Current concepts of the anatomy of the thumb trapeziometacarpal joint. J Hand Surg Am 36: 170-82, 2011. AM Poster 013: Ulnar Nerve Transposition in the Hand Category: Hand
Hand and Wrist;Nerve N/A – not a clinical study
Remy V. Rabinovich, MD Steven Beldner, MD Daniel B. Polatsch, MD Derek M. Gonzalez, MD
Hypothesis Isolated transection of the deep motor branch of the ulnar nerve (DMBUN) is an injury with a predilection for a delayed or missed diagnosis. Primary repair of the affected nerve may be difficult due to retraction, scarring or segmental loss. The DMBUN takes a circuitous route around the hamate hook to reach the intrinsics of the hand. With the knowledge that the shortest distance between two points is a straight line, it was hypothesized that if the hamate hook was removed, then the nerve could be transposed to allow for a more direct course. This would aid in nerve repair by relieving unnecessary tension and potentially avoiding nerve grafting. An investigation was performed evaluating whether excision of the hamate hook with transposition of the DMBUN significantly shortened the course of the nerve to facilitate primary repair.
Methods Six upper extremity cadaveric specimens underwent open decompression of the ulnar tunnel. Length measurements of the DMBUN were obtained as it coursed through Guyon’s canal before and after hamate hook excision and nerve transposition. Statistical analysis using a paired sample t-test was performed to compare differences in the length of the nerve before and after hamate hook excision and nerve transposition.
Results The mean length of the DMBUN’s course after hamate hook excision and nerve transposition was noted to be significantly lower than when the hook of the hamate was left intact, signifying a shortened course of the nerve by 8.67 ± 1.58 mm (p < 0.0001).
Summary Points • Excision of the hamate hook followed by transposition of the DMBUN demonstrates a significantly decreased course of the nerve relative to when the hamate hook is left intact. • This technique with resultant shortening of the DMBUN’s course may serve as a useful option for primary repair of a transected DMBUN, especially in the setting of increased tension due to retraction and scarring of the affected nerve.
Bibliography 1: Fredericson M, Kim BJ, Date ES, McAdams TR. Injury to the deep motor branch of the ulnar nerve during hook of hamate excision. Orthopedics. 2006 May 1;29(5). 2: Kitay A, Wolfe SS. Isolated Laceration of the Deep Motor Branch of the Ulnar Nerve by a Retained Foreign Body. American Journal of Orthopedics. 2012 Aug;41(8):371. AM Poster 014: Unplanned Early Reoperation Following Thumb Basal Joint Arthroplasty Category: Hand
Hand and Wrist;Practice Management Level 4 Evidence
Jack Graham Michael Rivlin, MD Asif Ilyas, MD
Hypothesis Thumb trapeziometacarpal arthritis is a common degenerative condition of the hand that is often managed with thumb basal joint arthroplasty (BJA). This procedure generally results in a high level of patient satisfaction. However, the rate and cause of early unplanned reoperation following thumb BJA is not well understood. Therefore, to better understand the rate and cause of reoperation, a retrospective review was undertaken. This information can help both patient and surgeon in decision making and surgical planning.
Methods A retrospective review of all thumb BJA cases performed between 2014-2016 yielded 637 patients and 686 primary thumb BJAs with a minimum 1 year follow-up. Data collection included patient demographics, surgical technique and type of thumb BJA performed, time to reoperation, reason for reoperation, and type of reoperation. Fischer’s exact tests were performed to determine differences in reoperation and revision rates between surgical techniques.
Results A total of 10 out of 686 (1.5%) patients undergoing thumb BJAs had unplanned reoperation. The mean duration between the index procedure and reoperation was 5.2 months (range: 0.5 – 14.3). Four of ten unplanned reoperations were due to persistent pain requiring revision arthroplasties in four patients. Time to reoperation for revision arthroplasty was 9.6 months (range: 3.9 – 14.3). Three of ten reoperations were due to early infection. Two were for unplanned early removal of symptomatic Kirschner wires. One reoperation was a neurolysis performed to treat radial sensory neuritis.
Summary Points • In our series of nearly seven hundred consecutive cases, an unexpected reoperation rate of 1.5% was identified. • Only a 0.6% reoperation rate was found specifically for painful subsidence requiring a revision arthroplasty, with a mean time to revision of 9.6 months. • This information should be taken into consideration by patients and surgeons when planning and preparing for a thumb BJA.
AM Poster 015: Classification of Open Hand Fractures: Inter-Observer Reliability of a “New” and “Old” Classification System Category: Hand
Hand and Wrist;Diseases and Disorders;General Principles N/A - not a clinical study
William J. Warrender, MD Christopher J. Lucasti Asif Ilyas, MD
Hypothesis Open fractures of the hand are common injuries and warrant both accurate diagnosis and prompt treatment. Historically the Gustilo-Anderson (GA) classification system, while originally intended for open fractures of long bones, has also been utilized to classify open hand fractures. The hand, however, has unique fracture and soft tissue characteristics that are not accounted for in the GA classification system. The Tulipan & Ilyas (TI) classification system was introduced to address these shortcomings (FIGURE 1). This study compared the inter-observer reliability of both the GA and TI classification systems to test the null hypothesis that the TI system would have superior inter-observer reliability than the GA system for classifying and guiding treatment for open fractures of the hand.
Methods Sixteen hand surgery fellowship-trained attending orthopaedic surgeons agreed to participate as raters. All surgeons were unaware and blinded to the development and origin of the newly proposed TI classification system. Inter-observer reliability was computed using the multi-rater kappa described by Fleiss. The kappa values were interpreted according to the guidelines of Landis and Koch. The percent of agreement for each case defined as the proportion of observers agreeing with the most common selected category was also determined. RESULTS: The overall kappa value for inter-observer reliability was 0.339 (95% CI, 0.304-0.376) for the GA classification and 0.443 (95% CI, 0.423-0.463) for the TI classification, indicating fair and moderate agreement respectively. The average percent agreement for the most frequently selected category per case was 70% (range 50% to 100%) for the GA classification and 63% (range 31% to 100%) for the TI classification. According to the intra-class correlation coefficients, the inter-rater agreement for average measures for both classification systems was excellent, with ICC values, including the lower confidence intervals, all greater than 0.91. However for the ICCs for single measures, generalizing only to one rater, the inter-rater agreement for the GA classification (0.595, 95% CI, 0.387-0.836) was only good, but for the TI classification system was excellent (0.958, 0.912-0.987).
Summary Points • The new TI classification demonstrated greater inter-observer reliability than the GA classification system. • Consideration should be given to utilizing the TI classification for open fractures of the hand because of its superior inter-observer reliability and its hand-specific nature that takes into consideration the hand’s unique fracture and soft tissue characteristics.
Bibliography 1: Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty- five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453-458. 2: Tulipan JE, Ilyas AM. Open Fractures of the Hand: Review of Pathogenesis and Introduction of a New Classification System. Orthop Clin North Am. 2016;47(1):245-251. doi:10.1016/j.ocl.2015.08.021. AM Poster 016: Treatment for Proximal Interphalangeal Joint Fractures and Fracture-Dislocations: A Meta-Analysis of the Current Literature Category: Hand
Level 3 Evidence
John M. Yingling, DO Arianna Gianakos DO John Capo, MD Eoghan Hurley
Hypothesis Proximal interphalangeal (PIP) joint fractures and fracture-dislocations are common hand injuries and recognition of this injury pattern is essential in the management of these fractures. Although a variety of treatment options have been reported in the literature, the gold standard of treatment still remains controversial.
Methods MEDLINE, EMBASE and The Cochrane Library Database were screened for treatment strategies of proximal interphalangeal joint fracture and fracture-dislocation. Demographic data and outcome data were collected and recorded.
Results Forty-six studies evaluating 718 patients (505 male, 209 female) and 726 fingers were included in this review. Mean follow up was 26.7 months (range, 15-60). PIP and DIP ROM was greatest post-operatively in patients who underwent either CRPP or extension block pinning. Hemi- hamate resection arthroplasty resulted in the lowest PIP and DIP ROM. There were no differences in VAS and DASH scores. Dynamic external-fixation had the highest complication rate of 48%, followed by volar plate arthroplasty (32%) and hemi-hamate arthroplasty (22%). The most commonly reported complication included infection and osteoarthritis. Hemi-hamate arthroplasty had a significantly increased rate of revision of 9.3%.
Summary Points Overall, the outcomes of PIP fractures and fracture-dislocations are based on the severity of injury, and severity typically dictates the type of treatment. When the severity of the injury is mild-to-moderate, then hemi-hamate arthroplasty appears to have poorer outcomes and therefore should be reserved for more complex procedures. CRPP and extension block pinning had good clinical and functional outcomes with the lowest complication rates for mild-to- moderate injuries. AM Poster 017: Decision Aid for Trapeziometacarpal Arthritis: A Randomized Controlled Trial Category: Hand
Hand and Wrist;Practice Management Level 2 Evidence
Suzanne Caroline Wilkens, MD David Ring, MD, PhD Teun Teunis, BSc Sang-Gil Lee, MD Neal C. Chen, MD
Hypothesis Decision aids are developed to present patients with dispassionate information on current best evidence, including uncertainties. This study tested the hypothesis that review of a decision aid prior to the appointment has no effect on decisional conflict measured immediately after the visit, compared to usual care. Secondarily, we tested the effect of a decision aid on pain intensity, magnitude of limitations, symptoms of depression, treatment choice, satisfaction with the visit, consultation time, and patient-rated physician empathy after the visit. Additionally, differences in pain intensity, decision regret, satisfaction with treatment, change of treatment, and change of surgeon were assessed 6 weeks and 6 months after the initial visit.
Methods In this randomized controlled trial, we included 90 patients seeking care of a hand surgeon for TMC arthritis for the first time. Patients were randomly assigned to receive either usual care and an informational brochure or an interactive web-based decision aid. At enrollment, consultation time was recorded and patients completed the following measures: (1) Decisional Conflict Scale (DCS); (2) Quick Disabilities of Arm, Shoulder and Hand (QuickDASH); (3) pain intensity; (4) Physical Health Questionnaire (PHQ-2); (5) satisfaction with the visit; and (6) Consultation and Relational Empathy (CARE). At 6 weeks and 6 months, patients completed: (1) pain intensity measure; (2) Decision Regret Scale (DRS); and (3) satisfaction with treatment. We also recorded changes in treatment and surgeon.
Results Patients who reviewed the interactive decision aid prior to visiting their hand surgeon had less decisional conflict at the end of the visit. Other outcomes were not affected.
Summary Points • Patients who review the decision aid prior to their appointment are more comfortable with their decision. • A measurable reduction in decision conflict suggests that other factors such as variation by surgeon or changes in treatment might also be affected by an interactive web-based decision aid. • Given that most people stick with splints or other less invasive treatment options and most are satisfied with a single visit with one surgeon, it would take a much larger study to detect these differences.
Bibliography 1: Slover J, Shue J, Koenig K. Shared decision-making in orthopaedic surgery. Clin Orthop Relat Res. 2012;470(4):1046-1053. 2: Stacey D, Legare F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. The Cochrane database of systematic reviews. 2017;4:CD001431. 3: O'Connor AM. Validation of a decisional conflict scale. Med Decis Making. 1995;15(1):25-30. 4: de Achaval S, Fraenkel L, Volk RJ, Cox V, Suarez-Almazor ME. Impact of educational and patient decision aids on decisional conflict associated with total knee arthroplasty. Arthritis care & research. 2012;64(2):229-237. 5: Bozic KJ, Belkora J, Chan V, et al. Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial. J Bone Joint Surg Am. 2013;95(18):1633- 1639. AM Poster 018: New Classification for Osteoarthritis of the Carpometacarpal Joint of the Thumb Using Cluster Analysis Category: Hand
Hand and Wrist Level 4 Evidence
Kosuke Uehara Toshiki Miura Takashi Ohe Sakae Tanaka Yutaka Morizak
Hypothesis The most widely-used classification of osteoarthritis (OA) of the carpometacarpal joint (CMC joint) of the thumb is Eaton classification. However, sometimes there is discrepancy between the stage of Eaton classification and the intensity of pain. One reason for this might be that OA of the CMC joint of the thumb includes heterogeneous characteristics that are not represented by the Eaton classification. The aim of this study was to make a new classification of OA of the CMC joint of the thumb by using cluster analysis.
Methods Patients with OA of the CMC joint of the thumb who came to our outpatient hand clinic between June 2016 and October 2017 were included. There were 45 cases and 45 thumbs included. Average age was 67.9 years old. These items were measured: Eaton classification (1984), Maximum diameter of osteophyte, Presence or absence of sclerosis, Minimal joint space of CMC joint, Percentage of the dorsal subluxation, Hyperextension angle of the MP joint, Presence or absence of STT OA, Grinding test, and Visual analogue scale. We performed hierarchical cluster analysis
Results The dendrogram was divided into 5 clusters (Figure 1). The results was interpreted, and a new classification of OA of the CMC joint of the thumb was described (Figure 2). Type 1 represents Early stage OA with the largest Minimal joint space of CMC joint, and least osteophyte formation. Type 2 represents Late stage OA: with medium Minimal joint space of the CMC joint, with accompanying osteophyte, and most cases showed positive grinding test. Type 3 represents stiff joint with o osteophyte, but with less pain: All cases had accompanying osteophyte, lowest Visual analogue scale, and most cases showed negative grinding test. Type 4 represents Accompanied with OA of STT joint : All cases had STT joint OA, and no joint space of the CMC joint. Type 5 represented Apparent Z deformity: with No joint space of the CMC joint,
Summary Points The OA of CMC joint of the thumb can be newly statistically reclassified into five groups. Regarding hip or knee OA, it has been reported that osteophytes sometimes reduce the pain while decreasing the range of motion. Type 3 seems similar to such situations. Type 5 is accompanied with severe MP joint hyperextension, and such type might require more aggressive additional surgical procedure on the MP joint. Comparative study of surgical outcomes among each type should be performed in the future.
Bibliography 1: Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment. J Hand Surg Am, 1984 2: Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg, 1973 3: Kennedy CD, Manske MC, Huang JI. Classifications in Brief: The Eaton-Littler Classification of Thumb Carpometacarpal Joint Arthrosis. Clin Orthop Relat Res, 2016 4: van der Kraan PM, van den Berg WB. Osteophytes: relevance and biology. Osteoarthritis Cartilage, 2007 5: Poulter RJ, Davis TR. Management of hyperextension of the metacarpophalangeal joint in association with trapeziometacarpal joint osteoarthritis. J Hand Surg Eur, 2011 AM Poster 019: The Five Essentials for Restoring Normal First Web Space Function and Appearance After Burn Injury Category: Hand
Hand and Wrist Level 4 Evidence
Suzanne Caroline Wilkens, MD Taylor Pon Matthias Donelan Kyle Eberlin, MD
Hypothesis Burn injuries to the hand are common and often result in contracture of the first webspace. Little discussion exists in the literature indicating the optimal way to approach these defects. Accurate diagnosis of first webspace contractures requires a thorough understanding of the three-dimensional anatomy, complex function, and aesthetics of this critically important part of the hand. The aim of this study was to describe a cohort of pediatric patients who underwent post-burn contracture release of the first webspace and to present essential surgical components for successful restoration of first webspace function following burn injury.
Methods In this retrospective study, we identified 40 patients with 61 burned hands who underwent reconstruction of first webspace contracture; 28 boys (70%) and 12 girls (30%) with a median age of 3.5 years (IQR 1 – 3.8) at time of the burn injury. Fifty hands (82%) had an initial skin graft, 10 hands (16%) were treated conservatively, and for 1 hand (2%) it was unclear what was initially performed at another hospital. Medical records were reviewed to obtain patient and surgery related variables.
Results Thirty-four hands (56%) required a second revision, and some underwent >2 revisions. We propose five essential surgical components for successful restoration of first webspace function following burn injury: (1) Complete release of the first carpometacarpal joint, (2) Restoration of the full breadth of the palm and the convexity of the transverse metacarpal arch, (3) Adequate and aesthetic release of the leading edge of the first webspace with local tissue arrangement Z- plasty, if needed, (4) Restoration of palmar skin to the volar surface of the hand, (5) Proper selection of the best material to resurface the resultant soft tissue deficiencies.
Summary Points • Our data confirms there is a lack of organized and consistent approach for management of post-burn contracture injuries. Even in a highly specialized center, which suggests there is a need for principles. • The goals of first web space reconstruction in the burned hand are to allow for adequate function (thumb palmar abduction, opposition and pronation and ensure stability at the MCP joint) and appearance (breadth of the webspace). • All surgeons can treat this deformity, but it takes careful diagnostics to design the optimal reconstructive operation for these patients.
AM Poster 020: Fibre Reinforced Adhesive Patch: A New Treatment Option for Phalangeal Fractures Category: Hand
Hand and Wrist N/A - not a clinical study
Johanna von Kieseritzky,MD Marianne Arner, MD, PhD Viktor Granskog Michael Malkoch
Hypothesis Fibre Reinforced Adhesive Patch (FRAP) is a new chemical adhesive designed for bone repair based on the thiol-ene coupling (TEC) chemistry inspired by dental resin composites and self- etch primers. The patches are built from the bone surface by applying a novel primer solution followed by layers of the adhesives with imbedded hydroxyapatite and polyethylene terephthalate (PET) fibre meshes. By using tissue-friendly high-intensity light, the layers of the patch are fully cured(Figure 1). This yields a versatile and strong fixation of the fracture giving an opportunity for personalized constructions unique for every surgery. In this context we hypothesize that FRAP fixation can be useful for multifragmented complex phalangeal fractures.
Methods The FRAP adhesive was tested biomechanically in vitro regarding shear bond strength on processed wet bovine bone and compared to commercially available dental adhesives. The rigidity of the FRAP was compared to crossed 1,2 mm K-wires and AO Compact hand 1,5 plates in both transverse and oblique fractures of pig metatarsals using 1000 cyclic loads of 10-70 N using a three point bending set up. In vivo studies on a rat femur fracture model was performed regarding adhesion to bone, effect on bone healing and inflammation. A safety evaluation (ISO 10993-1:2009) on FRAP leachables was performed.
Results In vitro, the FRAP showed an extraordinary shear bond strength, 55% higher than commercially available acrylate dental adhesive, 9.0 MPa vs 5.8MPa. In comparison between available fixation techniques for phalangeal fractures in cyclic loading no difference in disturbance of the fixation could be seen between Compact Hand 1.5 and FRAP fixation, whereas fractures fixated by K- wires showed large movement and displacement. Histological results from in vivo studies on rat showed no inflammation, and no negative effect on bone healing. Pre- and post-in vivo adhesion test showed that FRAP maintained 60% bond strength after 5 weeks in vivo. The safety evaluation displayed no cytotoxicity nor genotoxicity and there were no signs of any skin irritation or inflammation.
Summary Points • The FRAP is a new versatile technique for osteosynthesis designed for phalangeal fractures and has a potentially wide field of applications within bone repair. • The FRAP is strong, adheres well to bone, does not cause inflammation and is benign to tissues. Bibliography 1: Granskog V, Andren OCJ, Cai YK, Gonzalez-Granillo M, Fellander-Tsai L, von Holst H, et al. Linear Dendritic Block Copolymers as Promising Biomaterials for the Manufacturing of Soft Tissue Adhesive Patches Using Visible Light Initiated Thiol-Ene Coupling Chemistry. Adv Funct Mater. 2015;25(42):6596-605. 2: Nordberg A, Antoni P, Montanez MI, Hult A, Von Holst H, Malkoch M. Highly Adhesive Phenolic Compounds as Interfacial Primers for Bone Fracture Fixations. Acs Appl Mater Inter. 2010;2(3):654-7. 3: Olofsson K, Granskog V, Cai Y, Malkoch M. Activated dopamine derivatives as primers for adhesive-patch fixation of bone fractures. RSC Advances. 2016;6(31):26398-405. 4: Tuusa SMR, Lassila LVJ, Matinlinna JP, Peltola MJ, Vallittu PK. Initial adhesion of glass-fiber- reinforced composite to the surface of porcine calvarial bone. J Biomed Mater Res B. 2005;75B(2):334-42. 5: Dahl OE, Garvik LJ, Lyberg T. Toxic Effects of Methylmethacrylate Monomer on Leukocytes and Endothelial-Cells in-Vitro. Acta Orthop Scand. 1994;65(2):147-53 AM Poster 021: A Novel Surgical Treatment for Chronic Tendon Mallet Injury Category: Hand
Hand and Wrist Level 4 Evidence
Taku Suzuki, MD, PhD Takuji Iwamoto, MD, PhD Noboru Matsumura, MD, PhD Satoshi Oki Kazuki Sato, MD, PhD
Hypothesis This study was designed to evaluate a novel surgical treatment for chronic tendon mallet injury, which involves an anatomical reconstruction of the terminal tendon and lateral band with palmaris longus (PL) tendon grafting.
Methods Between June 2014 and February 2016, five patients of mean age of 49 (32 to 63) years, who underwent this surgical procedure for chronic tendon mallet injury, were followed for a mean of 17 (12 to 30) years. Harvested PL tendon was folded in two or divided into two slips. The graft was attached to a remnant of the original terminal tendon around the distal interphalangeal (DIP) joint. Both half-slip tendons were passed under the transverse retinacular ligament and sutured side-to-side to the lateral band at the level of the proximal phalanx (Figure1a, b). The active ranges of motion (ROM) of the affected finger were evaluated pre- and postoperatively.
Results Extension lag and flexion of the DIP joint averaged 55°(50 to 60)° preoperatively. The mean preoperative extension lag improved to 3° (0 to 10)° postoperatively. Neither flexion of the DIP joint, ROM of the PIP joint, nor active ROM of the MP joint, changed in any of the patients postoperatively. Miller’s classification indicated an excellent result in two patients and a good result in three patients. Nail deformity was found in two patients, however, this deformity improved at final examination. One patient complained of slight cosmetic protrusion around the DIP joint.
Summary Points • Anatomical reconstruction of the terminal tendon and both lateral bands with PL tendon grafting leads to satisfactory postoperative results for chronic tendon mallet injury.
Bibliography 1: Suzuki T, Iwamoto T, Sato K. Surgical treatment for chronic mallet injury. J Hand Surg Am. 2018 [Epub ahead of print] 2: Suzuki T, Inaba N, Sato K. A novel surgical technique for chronic mallet finger injury: a case report. J Hand Surg Asian Pac Vol. 2017;24:114-117. AM Poster 022: A Solution to Limit Proximal Interphalangeal Joint Contracture with Homodigital Island Flap? Single or Double V-flap over a Direct-Flow Homodigital Island Flap: An Alternative Technique for Volar Fingertip Injuries of Long Fingers Category: Hand
Hand and Wrist;Diseases and Disorders N/A – not a clinical study
João Paulo Mussi, MD Germain Pomares Thomas Jager, MD
Hypothesis The use of the direct-flow homodigital island flap for coverage of fingertip injuries usually leads to a flexion contracture of the proximal interphalangeal joint to be able to reach the distal pulp, and donor area skin grafting in often necessary. Our study presents a different technique that could address these two shortcomings.
Methods We did an anatomic study in 8 upper limb specimens (32 long fingers) where we created a volar defect 54% of the pulp (50%-57%) and sequentially we performed 5 procedures measuring on each the advancement of the flap and the area of the flap island. The procedures were a direct- flow homodigital island flap with the dissection distal to the PIP joint (group 1), then a V-flap over that island (group 2), then a second V-flap over the distal flap (group 3), then the dissection of the neurovascular bundle until the proximal phalange (group 4) and finally suturing the V-flaps to mimic a traditional direct-flow homodigital flap (group 5) to compare the different options.
Results The group 1 had the lowest values in terms of advancement with 9,7mm (5-15mm) and a surface of 23,15mm2 (16,8-25,5mm2). When added one V-flap (group 2) the advancement was of 15,75mm (10-21mm) and the surface was 28,35mm (18-36mm2). The group 3 had the advancement of 18,62mm (13-23mm) and the surface of 30,81mm2 (20-37,8mm2). The group 4 presents the biggest advancement values with 20,56mm (12-27mm). Summary: The usage of either one or two V-flaps over an island flap dissected distal to the PIPJ can, respectively, produce an increased advancement of 4 and 7mm over the classic direct-flow homodigital flap but without crossing the PIPJ, thus decreasing the probability of flexion contracture. Furthermore, the application of one or two V-flaps can increase the covered area in 22% and 33% respectively thus decreasing the need of a donor site skin graft.
Bibliography 1: 2014 - Hand Surgery - S. Chung - Crescent Flap for fingertip reconstruction.pdf. 2: Bassiri B, Rampazzo A, Armijo BS, et al. Tranquilli-Leali or Atasoy flap?: an anatomical cadaveric study. Br J Plast Surg. 2010;63(4):681-685. doi:10.1016/j.bjps.2008.12.028. 3: 2017 - JHS E - E. Arpaci - Super Kutler Flap: An alteranative technique for reconstruction of fingertip defects.pdf. 4: Bakhach J, Guimberteau JC, Panconi B. Journal of Hand Surgery ( European Volume ). 2009. doi:10.1177/1753193408098904 5: Huang Y, Liu Y, Chen T. Use of Homodigital Reverse Island Flaps for Distal Digital. 2010;68(201). doi:10.1097/TA.0b013e3181a8b33d AM Poster 023: The Prevalence of Functional Absence of Flexor Digitorum Superficialis to the Little and Ring Fingers Category: Hand
Hand and Wrist;Congenital and Pediatric Problems;Diseases and Disorders Level 2 Evidence
Bruno M. Oliveira Carlos H. Fernandes, MD João B. G. Santos, MD Flávio Fallopa, MD Marcela Fernandes, MD, PhD Luis R. Nakachima
Hypothesis The prevalence of absence of a functional FDS to the ring and little fingers in a population studied is higher than other populational studies reported in previous medical literature.
Methods In order to evaluate the prevalence of little and ring superficial flexor function, 564 volunteers were examined, totalizing 1128 hands. The identification of superficial flexor function of each finger were performed by two tests. For the little finger, the identification was performed with all the fingers except for the little finger were held out in extension. The wrist was kept in full supination and neutral extension. The volunteer was asked to flex the little finger. If PIP joint flexion occurred with no DIP joint flexion, this was interpreted as showing presence of FDS function. If PIP joint flexion did not occur or PIP joint flexion occurred only in conjunction with DIP joint flexion, this was interpreted absence of FDS function. For the ring finger, the identification was performed with all the fingers except for the annular finger were held out in extension. The wrist was kept in full supination and neutral extension. The volunteer was asked to flex the annular finger. If PIP joint flexion occurred with no DIP joint flexion, this was interpreted absence of FDS function.
Results The prevalence of absent FDS function on ring fingers was 1.1% on right hands and 1.8% on left hands. On the little finger, the prevalence of absence of FDS function was 34.8% on left hands and 31.2% on right hands.
Summary Points • We did not find in the literature studies that evaluate the function of the superficial flexors of the ring fingers • Our results show a higher percentage of the prevalence of the absence of function of the superficial flexors of the ring and little fingers than in other populations studied in the literature • This fact may be due to the great miscegenation of races in the geographic region of the study
Bibliography 1: Godwin, Y., Wheble, G. A. C., & Feig, C. (2014). Assessment of the presence of independent flexor digitorum superficialis function in the small fingers of professional string players: Is this an example of natural selection? Journal of Hand Surgery: European Volume, 39(1), 93–100. https://doi.org/10.1177/1753193412474151 2: Townley, W. A., Swan, M. C., & Dunn, R. L. R. (2010). Congenital absence of flexor digitorum superficialis: Implications for assessment of little finger lacerations. Journal of Hand Surgery: European Volume, 35(5), 417–418. https://doi.org/10.1177/1753193409358523 3: Alzahrani, M. T., Almalki, M. A., Al-Thunayan, T. A., Almohawis, A. H., Al Turki, A. T., & Umedani, L. (2017). Clinical Assessment of the Congenital Absence of Palmaris Longus and Flexor Digitorum Superficialis Muscles in Young Saudi Population. Anatomy Research International, 2017, 1–6. https://doi.org/10.1155/2017/5342497 4: Thompson, N. W., Mockford, B. J., Rasheed, T., & Herbert, K. J. (2002). Functional absence of flexor digitorum superficialis to the little finger and absence of palmaris longus - Is there a link? Journal of Hand Surgery, 27 B(5), 433–434. https://doi.org/10.1054/jhsb.2002.0797 5: Guler, F., Kose, O., Turan, A., Baz, A. B., & Akalin, S. (2013). The prevalence of functional absence of flexor digitorum superficialis to the little finger: A study in a Turkish population. Journal of Plastic Surgery and Hand Surgery, 47(3), 224–227. https://doi.org/10.3109/2000656X.2012.742019 AM Poster 024: Percutaneous Release of Trigger Finger With and Without Corticosteroids: Systematic Review and Meta-analysis Category: Hand
Hand and Wrist;Practice Management Level 4 Evidence
Nicole L. Levine, BA Igor Immerman, MD Isabel E. Allen, PhD
Hypothesis Concurrent steroid administration with percutaneous release (PRS) of trigger finger leads to less pain post-operation, lower rates of trigger recurrence, and better functional outcomes post operation than percutaneous release alone (PR).
Methods A PRISMA-compliant search of PubMed, MEDLINE, EMBASE, and The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register) was conducted. The search terms were related to or described trigger finger disorder, percutaneous release of trigger finger, and steroid administration. Additionally, conference abstracts from AAOS, ASSH, AAHS, and FESSH from the last 5 years (2012 - 2017) were reviewed. Two independent reviewers (NL and II) assessed the eligibility of each report based on predefined inclusion criteria as published on PROSPERO. A meta-analysis using random effects models was performed to calculate pooled effect size estimates controlling for heterogeneity between studies. Sensitivity analyses including Egger's test for bias, individual study influence, and meta-regressions were performed to identify possible sources of heterogeneity between studies. All analyses were performed using Stata 15.1 (College Station, TX).
Results Of 404 abstracts reviewed, 58 studies and 3 conference abstracts were retrieved for full review based on inclusion criteria. Of these, 56 studies with a total of 4845 digits were included in the PR group and 9 studies with a total of 951 digits were included in the PRS group. The effect sizes and standardized mean differences (95% CI) are reported in Table I. Overall satisfaction (%), need for subsequent open release (%), trigger recurrence (%), and post-operative VAS scores were not significantly different between the groups. QuickDASH scores were higher in the PR group when compared to the PRS group (p=0.048), although only one PRS study was included (Table 1). Sensitivity analyses showed that none of the heterogeneity seen in our results is due to an identifiable study characteristic. Most of the studies reviewed had consistent results with small variability, so the statistical heterogeneity seen may not be clinically important.
Summary Points • Corticosteroid administration concurrently with percutaneous trigger release does not appear to significantly reduce post-operative pain, trigger recurrence, or need for subsequent open release when compared to percutaneous release alone • Corticosteroid administration in conjunction with percutaneous release may lead to statistically significant reductions in post-operative QuickDASH scores, although the result may not be clinically important. • Both PR and PRS are safe procedures that result in high post-operative satisfaction and low risk of nerve injury or other complication.
AM Poster 025: Epidemiology of Traumatic Digit Amputations: a 6-year Retrospective Review of 719 Amputations Category: Hand
Hand and Wrist Level 4 Evidence
Andrew P. Harris, MD Avi D. Goodman, MD Andrew D. Sobel, MD Neill Li, MD Jeremy Raducha, MD Julia Katarincic, MD
Hypothesis Digit amputations are one of the most common injuries managed by hand surgeons and can pose significant burdens to patients and society. The purpose of this study was to describe the epidemiology of digit amputations presenting to our institution.
Methods After IRB approval, our institution’s Emergency Department (ED) database and orthopedic billing department database were retrospectively examined for all patients presenting with traumatic finger and thumb amputations from January 2010 to December 2015. Inclusion criteria was defined as any patient presenting with presenting with partial or complete amputations through verdan zones I or II presenting for definitive care. All patient information was entered into REDCap, including demographic information, digits amputated, mechanism of injury (crush, laceration, avulsion, bite, blast, saw, snowblower, lawnmower), and verdan flexor tendon zone(s) of amputation.
Results 572 patients (497 males, 86.9%) (75 females, 13.1%), average age of 46.2 years (range 1.5 to 98 years old), sustained 719 traumatic digit amputations. Crush was the most common mechanism with 208 patients (36.4%) sustaining amputations by this mechanism. Saw and laceration mechanisms were the 2nd and 3rd most common affecting 127(25.7%) and 98(17.1%) patients respectively (Figure 1). The middle finger was the most frequently amputated digit (222, 30.8% of digits), followed by index (185, 25.7%) and ring (153, 21.3%) fingers (Figure 2). Verdan flexor tendon zone I amputations were more common than flexor tendon zone II amputations accounting for 609 (84.7%) and 110 (15.3%) of amputations, respectively.
Summary Points • The patient population sustaining traumatic digit amputations is predominantly male accounting for 86.9% of patients presenting with amputations • Crush was the most common mechanism of amputation followed by saw and laceration • The middle finger was the most frequently amputated digit accounting for 30.8% of all digit amputations • Distal amputations were more common with 84.7% of amputations occurring through zone 1
Bibliography 1: Conn JM, Annest JL, Ryan GW, Budnitz DS. Non-work-related finger amputations in the United States, 2001-2002. Ann Emerg Med. 2005;45(6):630-635. doi:10.1016/j.annemergmed.2004.10.012 2: Wightman JM, Gladish SL. Explosions and blast injuries. Ann Emerg Med. 2001;37(6):664-678. doi:10.1067/mem.2001.114906 3: Bachier M, Feliz A. Epidemiology of lawnmower-related injuries in children: A 10-year review. Am J Surg. 2016;211(4):727-732. doi:10.1016/j.amjsurg.2015.11.025 4: Vlot MA, Wilkens SC, Chen NC, Eberlin KR. Symptomatic Neuroma Following Initial Amputation for Traumatic Digital Amputation. J Hand Surg. 2018;43(1):86.e1-e86.e8. doi:10.1016/j.jhsa.2017.08.021. AM Poster 026: Infiltration of Collagenase Clostridium Histolyticum After Injection Category: Hand
Hand and Wrist Level 4 Evidence
Takako Kanatani, MD Issei Nagura, MD Yoshifumi Harada, MD
Hypothesis We hypothesized that injected Collagenase Clostridium Histolyticum (CCH) does not only concentrate inside the cord but also infiltrates the adjacent tissue.
Methods This study enrolled four male patients with Dupuytren contracture (three little fingers and one ring finger) with a mean age of 71 years (range; 60-78 years) on who we performed partial fasciotomies due to fixed flexion contracture (FFC) of the MP and PIP joints. Before the operation, we marked three hypothetical collagenase injection points at 2mm intervals on the skin above the cord around the level of the MP joint and measured the distance from the skin to the middle of the cord as “hypothetical injection depth” by ultrasonography with long axis images (SNiBLE; Konica Minolta, Tokyo, Japan). Then, we dispensed a total amount of 0.25 ml of povidone iodine into the three points after adjusting the needle length to the hypothetical injection depth by our method reported at ASSH Annual Meeting in 2017 (Fig. 1). In this we placed a precut, measured and sterilized silicone tube (BEAR Medic Corporation’s factory, Ibaraki, Japan) over the needle of a VA syringes (Nipro, Osaka, Japan). Intraoperatively, the extent of diffuse of povidone iodine was investigated visually. We obtained approval from the ethics committee of our institution and a written informed consent was obtained from each patient after oral explanation on the details of the study.
Results The injection depths were 3mm(Case 1), 3mm(Case 2), 2.5mm(Case 3) and 2.1mm (Case 4). In all cases the cord was symmetrically stained to the following extents; 8mm, 8mm, 4mm and 10mm consecutively, central to the injected sites. Also, the infiltration of povidone iodine into the subcutaneous structure underneath the injection sites was seen in all cases. Case 3 and 4 showed infiltration into the bilateral fat tissue and the neurovascular bundle to the cord. In addition, Case 4 showed an infiltration of povidone iodine underneath the cord.
Summary Points Although CCH and povidone iodine are different agents, this study demonstrated the diffusion and infiltration of a liquid body, after injection into the middle of the cord in vivo condition. The dissipation within the cord proximally and distally to the injected points may support the reports that CCH injection at the MP joint improved the FFC of the PIP joint1). Also, the infiltration into the adjacent tissue may explain the adverse complication events, such as pain, swelling, bruising, oedema, and skin laceration.
Biblioigraphy 1: 1) Hirata et al. Efficacy and safety of collagenase clostridium injection for Dupuytren’s contracture in non-Caucasian Japanese patients (CORD-J Study): the first clinical trial in a non- Caucasian population. J Hand Surg 42E: 30-38, 2017. AM Poster 027: Comparison of the Open Palm and Digit Technique with the Mixed Method of Partial Open Technique or Complete Wound Closure Technique According to the Degree of Dermal Contracture in Dupuytren’s Contracture Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Kenji Onuma, MD, PhD Koji Sukegawa, MD, PhD Yuya Otake, MD Yuji Yokozeki Masashi Takaso, MD, PhD
Hypothesis The open palm and digit technique (O technique, Figure 1a) for Dupuytren’s contracture involves transverse skin incisions on the palm and fingers and leaving the wounds open after limited fasciectomy [1]. The surprisingly good results with the O technique are due to the elimination of hematoma formation and finger edema, and the quality of the final scar is excellent [1]. However, these wounds are large and take time to heal. We hypothesized that leaving smaller wounds open according to the degree of dermal contracture would result in better wound healing.
Methods The mixed method consists of the partial open technique (PO technique, Figure 1b) and complete wound closure technique (C technique, Figure 1c) and involves limited fasciectomy after a zigzag incision. The technique was chosen according to the degree of skin tension or dermal contracture after wound closure. The C technique was chosen if the operated finger joints could be extended passively to 0 degrees after complete wound closure, while the PO technique was chosen if the operated finger could not be extended passively to 0 degrees after wound closure because of the high degree of skin tension, and a few sutures were removed. In our hospital, the O technique was performed for 15 hands of 14 patients from 2002 to 2007, while the mixed method was performed for 17 hands of 16 patients (PO technique for 9 hands, C technique for 8) from 2013 to 2016. We retrospectively compared the mixed method and the O technique with regard to the mean period for epithelialization after surgery, mean percentage improvement between the pre- and post-operative combined angle of the metacarpophalangeal joint and proximal interphalangeal joint (Table1) [2], and Tubiana’s postoperative evaluation [3].
Results The mixed method and the O technique significantly differed in the mean period of epithelialization (Table 2). In contrast, no significant differences were seen in mean improvement percentage of the pre- and post-operative combined extension loss of the metacarpophalangeal and proximal interphalangeal joints (Table 2), or in Tubiana’s postoperative evaluation between the mixed method and the O technique (Table 3).
Summary Points • The O technique and the mixed method, in which a partial open or complete wound closure technique is chosen according to the degree of dermal contracture, both showed good results. • Although the O technique showed good results, it is not required for all patients with Dupuytren’s contracture.
Bibliography 1: Beltran JE, Jimeno-Urban F, Yunta A. The open palm and digit technique in the Dupuytren's contracutre, Hand. 1976 2: Ishikawa J et al. Operative results of Dupuytren's contracture, J Jpn Soc Surg Hand, 1991. 3: Tubiana R. Prognosis and treatment of Dupuytren's contracture. J Bone Joint. 1955. AM Poster 028: Partial Excision of Volar Plate and Dorsal Capsulotomy in Patients with Post-Traumatic Ankylosis of Finger Joint in the Hand Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Jihyeung Kim, MD Hyun Sik Gong Kee Jeong Bae, MD Hyun Sik Seok, Yo Han Lee Goo Hyun Baek, MD
Hypothesis Post-traumatic ankylosis of the finger joint is one of the complications after traumatic hand injury. If there is no improvement through conservative treatments, surgical treatments can be considered. Although several surgical techniques such as dorsal capsulotomy and release of the accessory collateral ligament have been suggested, the result was not satisfactory. The purposes of this study are to suggest new surgical technique to restore finger joint motion and to present the surgical outcome of this technique.
Methods We retrospectively reviewed 14 patients, 7 males and 7 females, who were diagnosed as post- traumatic ankylosis of finger joint, underwent partial excision of volar plate and dorsal capsulotomy between January 2014 to June 2016 and followed up for more than one year. There were ten metacarpophalangeal (MCP) joints and four proximal interphalangeal (PIP) joints. The average interval between the initial injury and the surgery were 60 (range, 10 to 120) months.
Results Of the ten MCP joints, the average range of motion was improved from 31 degrees to 92 degrees one year after surgery. Of the four PIP joints, the average range of motion was improved from 20 degrees to 77 degrees one year after surgery. There were no acute complications such as instability, infection, and wound dehiscence. All the patients were satisfied with the surgical outcomes.
Summary Points • Because this technique does not release both collateral ligaments, the joint stability can be maintained. • We can also safely release volar plate and dorsal capsule through anterior and posterior dual approaches. • Partial excision of volar plate and dorsal capsulotomy can be one of the good options in patients with post-traumatic ankylosis of finger joint.
Bibliography 1: Curtis RM. Capsulectomy of the interphalangeal joints of the fingers. J Bone Joint Surg Am. 1954, 36-A: 1219-32. 2: Curtis RM. Management of the stiff proximal interphalangeal joint. Hand. 1969, 1: 32-7. 3: Gould JS, Nicholson BG. Capsulectomy of the metacarpophalangeal and proximal interphalangeal joints. J Hand Surg Am. 1979, 4: 482-6. 4: Houshian S, Gynning B, Schroder HA. Chronic flexion contracture of proximal interphalangeal joint treated with the compass hinge external fixator. A consecutive series of 27 cases. J Hand Surg Br. 2002, 27: 356-8. 5: Yang G, McGlinn EP, Chung KC. Management of the stiff finger: evidence and outcomes. Clin Plast Surg. 2014, 41: 501-12. AM Poster 029: The Change of Carpal Tunnel and Median Nerve in MRI Before and Two Years After Endoscopic Carpal Tunnel Release Category: Hand
Nerve Level 4 Evidence
Toshimitsu Momose, MD, PhD Yukio Nakatsuchi, MD Hiroyuki Oshiba, MD Hiroyuki KATO, MD
Hypothesis We investigated the structural changes of carpal tunnel and median nerve in MRI before and two years after ECTR (endoscopic carpal tunnel release). Our hypothesis was that the enlargement of carpal tunnel maintained two years after ECTR .
Methods 25 patients had undergone ECTR for idiopathic carpal tunnel syndrome. The patients included 6 males, 19 females. The mean age was 67 years old. ECTR was performed utilizing Chow’s two- portal technique. MRI of carpal tunnel and nerve conduction was performed before and two years after ECTR. Ten cases who had no symptom of carpal tunnel syndrome performed MRI for control. The cross-section area of carpal tunnel and median nerve at the hook of hamate was measured using T2* weighted gradient echo images. The cross-sectional area of the carpal tunnel and median nerve was outlined digitally. The ratio of expansion was calculated by dividing the postoperative cross-sectional area by the preoperative cross-sectional area. Preoperative data was compared with postoperative data using Wilcoxon signed-ranks test. Postoperative data was compared with asymptomatic data using Mann-Whitney’s test.
Results Motor distal latency was improved from 8.9ms to 4.2ms after ECTR. Detached flexor retinaculum was seen as a linear area of low signal intensity 2 years after ECTR. The ratio of expansion of carpal tunnel was 1.16 at hamate level. The ratio of expansion of median nerve was 1.2 at hamate level. The cross-sectional area of carpal tunnel and median nerve was significantly increased at hamate level two years after ECTR. The postoperative cross-sectional area of carpal tunnel and median nerve was significantly larger than that of asymptomatic cases.
Summary Points • The enlargement of carpal tunnel was maintained two years after ECTR. Flexor retinaculum was released during ECTR. However, a continuous linear area of flexor retinaculum was detected two years after ECTR.
AM Poster 030: Short Immobilization is Non-Inferior to Prolonged Immobilization after Surgery for Thumb Base Osteoarthritis: A Propensity Score Matching Study Category: Hand
Hand and Wrist;Diseases and Disorders;General Principles Level 2 Evidence Grant received from: The Geert Geertsen Foundation
Robbert Wouters, Msc
Hypothesis Different postoperative immobilization durations and rehabilitation protocols after thumb base (CMC-1) arthroplasty have been reported in literature, but no consensus regarding optimal postoperative immobilization has been reached yet. The aim of this study is to investigate if short immobilization is non-inferior to prolonged immobilization after CMC-1 arthroplasty.
Methods Participants that received short immobilization (3-5 days plaster cast followed by a thermoplastic thumb spica splint including wrist immobilization until 4 weeks, followed by a butterfly splint until 8 weeks) were compared with prolonged immobilization (10-14 days plaster cast followed by a thermoplastic thumb spica splint including wrist immobilization until 6 weeks, followed by a butterfly splint until 8 weeks). All the participants were surgically treated with the Weilby procedure and matched using propensity score matching (PSM) to control for confounders. Primary outcomes were pain measured with a Visual Analogue Scale (VAS) and hand function measured with Michigan Hand Questionnaire (MHQ) at three months. Secondary outcomes were complications, range of motion, grip and pinch strength, satisfaction with treatment and return to work.
Results Each group contained 131 patients. Both groups showed highly similar improvements in VAS pain during physical load and VAS pain during rest compared to preoperative measures, with no differences between groups (effect size 0.03, 95% C.I. -0.21 - 0.27). Similarly, the MHQ was not significantly different between both groups (effect size 0.01, 95% C.I. -0.23 - 0.25). More complications were observed in the prolonged immobilization group (20,6%), but this was not significantly different compared to the short immobilization group (17,6%;p=0.102). Between both groups, no differences were found in the secondary outcomes. In conclusion, we found that short immobilization after Weilby procedure was non-inferior to prolonged immobilization for outcomes on MHQ, pain and the secondary outcomes. Hence, we conclude that short immobilization is safe and can be recommended, since discomfort of immobilization may be prevented and patient may able to recover sooner, although this was not investigated in the present study
Summary Points • Short immobilization after Weilby procedure is non-inferior to prolonged immobilization • Short immobilization is safe and can be recommended, although this was not investigated in the present study • Future studies are needed to investigate the effects of early active and more progressive hand therapy (including early initiation of ROM and strengthening exercises) after CMC-1 arthroplasty
Bibliography 1: Wouters, R.M., et al., Postoperative rehabilitation following thumb base surgery: a systematic review of the literature. Arch Phys Med Rehabil. 2017 Oct 10. pii: S0003-9993(17)31261-3. doi: 10.1016/j.apmr.2017.09.114. [Epub ahead of print] 2: Horlock, N. and H.J. Belcher, Early versus late mobilisation after simple excision of the trapezium. J Bone Joint Surg Br, 2002. 84(8): p. 1111-5. AM Poster 031: Innervation of the Thumb Interphalangeal Joint: An Anatomical Study Category: Hand
Hand and Wrist;Nerve N/A - not a clinical study
Ezequiel Ernesto Zaidenberg, MD Efrain Farias Cisneros, MD, PhD Ezequiel Martinez Dante Palumbo DO Martin Jose Pastrana, MD Carlos Rodolfo Zaidenberg, MD
Hypothesis Joint denervation had shown promising results for the treatment of osteoarthritis involving metacarpophalangeal and interphalangeal joints of the ulnar digits. However, in view of the extensive study of hand anatomy, we found no detailed reports of the innervation of the thumb interphalangeal (IP) joint. The purpose of the study is to determine the detailed anatomy of the sensory branches to the thumb interphalangeal joint capsule.
Methods In the anatomical study, thirty fresh frozen cadaveric thumbs were dissected after injection of colored latex composite. The upper limbs analyzed corresponded to 10 males and 5 female specimens. The mean age was 76 years (range 70-83). All palmar (proper digital nerves) and dorsal (radial nerve) articular branches were dissected until their entrance to the IP joint capsule. Under magnification, the number of articular nerve (AN) branches that penetrate the IP joint on both sides of the fingers was quantified, trying to establish the patterns of presentation. We also measured the origin of the branches regarding of the IP articular line, the angle of emergence and the nerves diameter.
Results Four articular branches reaching the IP joint capsule were found in all specimens. Ulnar and radial proper digital nerve provide one palmar capsular nerve branch at the respective side. Of the two dorsal branches of the radial nerve at the dorsum of the thumb we observed that each nerve provided one branch to the IP dorsal capsule. On the palmar side the length from the apparent origin to the joint was 20 mm (range, 18-21) on both radial and ulnar sides. Connecting vessels between ulnar and radial proper digital arteries at the IP level were closely related with articular nerve branches from the proper digital nerves. On the dorsal side the radial AN had an apparent origin length of 20 mm (range, 17-21), and the ulnar AN apparent origin of 13 mm (range, 11-17). The palmar AN had a diameter relatively wider than the dorsal ones (0.4mm vs 0.5mm).
Summary Points • The IP joint of the thumb has a constant innervation pattern. Dorsally, provided by two branches of the radial nerve and palmarly, by two branches of the proper digital nerves • Intra-operative identification of anastomotic arterial vessels at IP level, may facilitate the finding of the palmar nerve articular branches.
Bibliography 1: Stilwell DJ. The innervation of deep structures of the hand. Am J Anat. 1957;101(1):75-99 2: Gray D, Gardner E. The innervation of the joints of the wrist and hand. Anat Rec. 1965;151(3):261-266. 3: Hirasawa Y, Sakakida K, Tokioka T, Ohta Y. An investigation of the digital nerves of the thumb. Clin Orthop Relat Res. 1985;198:191-196. 4: Braga-Silva J, Calcagnotto G. The innervation of the proximal interphalangeal joint and its application in neurectomy. J Hand Surg Br. 2001;26(6):541-543. AM Poster 032: The Snap Test: Correlating a Simple Clinical Test for Carpal Tunnel Syndrome with Electrodiagnostic Studies Category: Hand
Hand and Wrist;Nerve Level 4 Evidence
Brad Hyatt, MD Greg Ernst Mark R. Bagg, MD
Hypothesis A patient’s ability to snap their fingers is a simple and representative test of thumb function, as it requires a thumb that is stabilized against the snapping finger. We hypothesized that patients who are unable to snap their fingers have corresponding evidence of severe carpal tunnel syndrome on electrodiagnostic studies (EDS).
Methods This is a retrospective review of patients who underwent EDS and had a previously documented snap test. Correlations between EDS and the results of the snap test were evaluated using positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity, and likelihood ratios (+LR and -LR). Subgroup analyses were performed according to gender, age, patient-reported changes in snapping ability, and possible confounding factors (e.g. thumb arthritis).
Results A total of 140 patients (243 wrists) were analyzed, including 42 men (71 wrists) and 98 women (172 wrists). Overall, the snap test had a PPV of 27.5%, the NPV was 94%; the sensitivity and specificity of the snap test for severe CTS was 47.8% and 86.6%, respectively. When looking at females alone and excluding patients with confounding obstacles to snapping (e.g. thumb CMC arthritis), the PPV and NPV are 53.3% and 99.3%, respectively, and sensitivity and specificity was 88.9% and 95.0%, respectively. For female patients, the +LR was 17.9 and the -LR was 0.11. The similar analysis for men is not as sensitive or predictive. SUMMARY The snap test is a simple and representative test of thumb function, and is especially valuable in the evaluation of females suspected to have CTS.
Bibliography 1: Lane LB, Starecki M, Olson A, Kohn N. Carpal tunnel syndrome diagnosis and treatment: a survey of members of the American Society For Surgery of the Hand. J Hand Surg Am. 2014;39:2181-2187. 2: Kronlage SC, Menendez ME. The benefit of carpal tunnel release in patients with electrophysiologically moderate and severe disease. J Hand Surg Am. 2015 Mar;40:438-444. 3: Tomaino MM, Weiser RW. Carpal tunnel release for advanced disease in patients 70 years and older: does outcome from the patient's perspective justify surgery? J Hand Surg Br. 2001;26:481- 483. 4: Yip SL, Yen CH, Chan WL, Leung HB, Mak KH. Pick-up test: an indication for opponensplasty in patients with severe carpal tunnel syndrome. J Orthop Surg (Hong Kong). 2009;17:183-186. 5: Geere J, Chester R, Kale S, Jerosch-Herold C. Power grip, pinch grip, manual muscle testing or thenar atrophy - which should be assessed as a motor outcome after carpal tunnel decompression? A systematic review. BMC Musculoskelet Disord. 2007;8:114. AM Poster 033: Clinical Experience Using the Thenar Portal for Arthroscopic Partial Trapeziectomy Category: Hand
Hand and Wrist Level 4 Evidence
Julieta Puig Dubois, MD Agustin Donndorff, MD Gerardo L. Gallucci, MD Jorge G. Boretto, MD Pablo De Carli, MD
Hypothesis The thenar portal represents an alternative to the usual arthroscopic portals to achieve good visualization of the trapeziometacarpal joint and facilitate triangulation during partial arthroscopic trapeziectomy. The aim of this study is to evaluate the clinical-radiographic results and the complication rate of a consecutive series of patients treated with partial arthroscopic trapeziectomy without interposition using the thenar portal (TP).
Methods Between January 2010 and June 2016, twenty five partial arthroscopic trapezectomies through the TP were performed in 23 patients with Eaton-Glickel stage II or III first carpometacarpal joint osteoarthritis (except 1 case stage IV). Only cases with more than 1 year of follow-up were included for the retrospective evaluation. No patient was lost during follow-up. The average age at the time of surgery was 61 years (49-81). Dominant side was involved in 28%. Clinical- radiographic pre/postoperative data were collected from the clinical history. In addition, all patients underwent a clinical and radiological re-examination at an average of 52 (12-89) months.
Results There were no significant differences in the final range of motion and strength between the operated hand and the contralateral hand. The averages ROM compared to the contralateral were: radial thumb abduction: 52°/47°; volar abduction: 54.7°/51°; complete flexo-adduction in 83%/74%; and retropulsion (thumb extension) was present in 74%/65% of the cases. Comparative grip strength and key pinch, was 21kg and 8 kg both in the operated hand and in the contralateral side. Pulp pinch was 5.3kg/5kg. There were no cases of instability. The average pain at rest according to the VAS decreased from 7 preoperative to 0.4 at the final postoperative evaluation, and during activity improved from 9 to 1. The DASH score improved from an average of 59 preoperative to 11 postoperative. According to the VAS, mean final hand function was 9 points. Radiographically, proximal migration of the first metacarpal was average 2.9mm (0.7- 5.8mm). Two patients required revision surgery to open trapeziectomy with ligament reconstruction due to intense persistent pain, presenting a good final result. No other complications were documented in the immediate or distant postoperative period, nor related to the TP.
Summary Points Partial arthroscopic trapeziectomy through the thenar portal: • Improves visualization of the trapezio-metacarpal joint. • Facilitates arthroscopic triangulation for partial trapezectomy. • Represents a safe and effective alternative for the treatment of thumb osteoarthritis, with pain relief and improvement function in most patients, without a higher risk of complications.
Bibliography 1: Walsh EF, Akelman E, Fleming BC, PhD, DaSilva MF. Thumb Carpometacarpal Arthroscopy: A Topographic, Anatomic Study of the Thenar Portal. J Hand Surg. 2005;30A:373–9. 2: Yong-wei P, Leung-kim H. The Safety of the Thenar Portal: An Anatomical Study of the Thumb Carpometacarpal Arthroscopy. J Wrist Surg 2017;6:152–157. 3: Tsujii M, Iida R, Satonaka H, Sudo A. Usefulness and complications associated with thenar and standard portals during arthroscopic surgery of thumb carpometacarpal joint. Orthop Traumatol Surg Res. 2015;101(6):741–744. 4: Edwards SG, Ramsey PN. Prospective Outcomes of Stage III Thumb Carpometacarpal Arthritis Treated with Arthroscopic Hemitrapeziectomy and Thermal Capsular Modification Without Interposition. J Hand Surg. 2010;35A:566–571. 5: Adams JE. Does Arthroscopic Debridement With or Without Interposition Material Address Carpometacarpal Arthritis? Clin Orthop Relat Res. 2014;472:1166–1172. AM Poster 034: Extensor Pollicis Longus Tendon Reconstruction by Extensor Indicis Proprius Transfer or Free Tendon Graft Using a Novel 2 cm Retropulsion Tension Method Category: Hand
Hand and Wrist Level 4 Evidence
Fumiki Kamoi, MD Makoto Kondo, MD Masanori Hayashi, MD Hiroko Iwakawa Shigeharu Uchiyama, MD Hiroyuki Kato, MD
Hypothesis In extensor pollicis longus (EPL) tendon reconstruction, 2 factors are important to obtain optimum post-operative thumb motion: the reconstruction method of either extensor indicis proprius tendon transfer (EIP TT) or free tendon graft (FTG), the tension applied to the EPL tendon and the muscle selection for the power source. Based on these, we have hypothesized that: 1) results are similar between EIP TT and FTG, and 2) our novel 2 cm retropulsion tension method is reliable for consistently deciding optimal tension.
Methods Twenty-five consecutive patients with chronic rupture of the EPL tendon were treated by EIP TT or FTG between 2006 and 2014 by 3 different surgeons. EPL tendon rupture occurred after distal radius fracture in most cases. For all patients, tendon reconstruction was performed using a novel retropulsion tension method, in which we reconstructed the EPL tendon keeping the center of the thumbnail raised 2 cm above the operating table while the palm was pressed against the operation table with the elbow in extension, forearm in pronation, and wrist in a neutral position. FTG was carried out using the palmaris longus tendon within 3 months from episode to surgery in 7 patients. EIP TT was done in 13 patients after more than 3 months from episode to surgery. We examined 20 patients directly a minimum of 12 months after tendon reconstruction to assess Total Active Motion (TAM) of the thumb, elevation deficit of the thumb compared with the opposite thumb in active retropulsion position, flexion deficit of the thumb interphalangeal and metacarpophalangeal joints, and disabilities of the shoulder and hand (DASH) scores.
Results Mean TAM improved from preoperative 50% (range: 18-78%) to postoperative 90% (range: 60- 100%). Mean elevation deficit was 1.2 cm (range: 0-2.5 cm) and mean flexion deficit was 10 degrees (range: -12-45 degrees) at follow-up. Mean DASH score improved from 28.6 to 7.7. There were no significant differences in clinical outcome between EIP TT and FTG or among the results of individual surgeons.
Summary Points Various tension-deciding techniques have been proposed for EPL tendon reconstruction. By raising the thumb by 2 cm, we believe our new retropulsion tension technique is easy, reliable, and applicable for both EIP TT and FTG. Results after surgery using this method were satisfactory regardless of the surgeon or patient profile. With results comparable to EIP TT, FTG is recommended for patients within 3 months after tendon rupture to preserve independent index finger motion.
AM Poster 035: Concomitant Injuries Affect Prognosis in Patients with Central Slip Tear Category: Hand
Hand and Wrist Level 4 Evidence
Yuki Fujihara, MD Kentaro Watanabe, MD, PhD Hideyuki Ota, MD
Hypothesis Central slip tears often occur with concomitant hand injuries such as fractures, ruptured flexor tendons, or vascular injuries in the affected or adjacent fingers which can be a critical prognostic factor of postoperative result. 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, 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)).
Summary Points • 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. We can use these prognostic factors in surgical repair planning, particularly when considering central slip reconstruction versus primary arthrodesis.
Bibliography 1: O'Dwyer FG, Quinton DN. Early mobilisation of acute middle slip injuries. J Hand Surg Br 1990;15;404-6. 2: Verdan C. Syndrome of the quadriga. Surg Clin North Am 1960;40;425-6. 3: Wilhelm A. [The quadriga phenomenon of the extensor tendon system and the superficial transverse metacarpal ligament]. Handchir Mikrochir Plast Chir 1988;20;173-9. 4: McAuliffe JA. Early active short arc motion following central slip repair. J Hand Surg Am. 2011;36(1):143-146. AM Poster 036: Excision of Incomplete Hook of the Hamate Fractures in Competitive Athletes Category: Hand
Hand and Wrist Level 4 Evidence
Jarrad A. Barber Gary Lourie, MD Bryan J. Loeffler, MD R Glenn Gaston, MD
Hypothesis Early surgical excision of incomplete hook of the hamate fractures in competetive athletes optimizes return to sport at minimal risk for the patient.
Methods From January 2000 to November 2016 143 excisions of the hook of the hamate were performed by the senior authors (BL, RGG, GML) following fracture of the hook of the hamate. Of these 143 hamulus fractures, 17 were performed for a preoperative diagnosis of incomplete fracture. The inclusion criteria used to make the diagnosis were: 1) history of ulnar sided wrist pain 2) Positive hook of the hamate pull test on physical exam as described by Wright, Moser and Sahajpal6 3) Evidence on advanced imaging, CT or MRI, of an incomplete fracture of the hook of the hamate. Time to diagnosis and treatment of these injuries, return to sport, postoperative complications, preoperative treatment and effectiveness were recorded
Results Seventeen diagnoses of partially united hook of the hamate fractures were made since January 2000. All underwent excision of the hook of the hamate. The average time to diagnosis was 11.1 weeks. The average delay in surgical treatment was 6.2 weeks. All seventeen patients were able to return to sport at an average of 6.8 weeks. Patients initially seen by one of the senior hand surgeons had a 7.9 week earlier return to sport due to prompt recognition and excision. One patient had a slight ulnar nerve palsy which resolved by two weeks postoperatively. Eight patients received preoperative treatment. All eight of these patient failed preoperative treatment and underwent subsequent hamulus excision.
Summary Points • In competitive athletes, incomplete hook of the hamate fractures should be managed with early excision as they do well with early return to sport and are prone to fail nonoperative treatment. • Delay in diagnosis and treatment can result in increased time out of sport.
Bibliography 1: Bishop A MD, Beckenbaugh R MD. Fracture of the hamate hook. J Hand Surg.8;13A:135-9. 1987 2: Ashworth C MD, Boyes J MD, Jobe F MD, Stark H MD. Fracture of the hook of the hamate in athletes. Journ of Bone and Joint Surg 59-A 575-582, 1977 3: Smith P MD, Wright T MD, Wallace P MD, Dell P MD. Excision of the hook of the hamate: A retrospective survey and review of the literature. J Hand Surg 1988;13A:612-15. 4: Devers B MD, Douglas K MD, Naik R MD, et al. Outcomes of hamate fracture excision in high level amateur athletes. J Hand Surg 2013;38A:72-76. 5: Wright T MD, Moser M MD, Sahajpal D MD. Hook of hamate pull test. J Hand Surg 2010; 35A:1887-1889 AM Poster 037: Magnetic Resonance Imaging Evaluation of Cartilage Erosion and Ligament Integrity in Early Trapeziometacarpal Osteoarthritis Category: Hand
Hand and Wrist Level 3 Evidence
Hyun Sik Gong, MD Hyo-Seok Jang Seok Woo Hong Jihyeung Kim, MD Min Ho Lee Goo Hyun Baek, MD
Hypothesis There is still controversy about articular degeneration patterns and key mechanical structures in trapeziometacarpal joint (TMCJ) osteoarthritis. The purpose of this study was to evaluate the state of cartilage erosion and ligament integrity in patients with early TMCJ osteoarthritis using advanced magnetic resonance imaging (MRI) examinations.
Methods We analyzed 3-T MRI examinations of 20 patients with early TMCJ osteoarthritis (Eaton and Littler stage I or II) and 19 control patients without TMCJ pain or arthritis. All patients were examined in the static resting position of the thumb. We examined cartilage erosion in the trapezial surface of the metacarpal bone and in the metacarpal surface of the trapezium, which was divided into 4 quadrants: volar-ulnar (VU), volar-radial (VR), dorso-ulnar (DU), and dorso- radial (DR). We also examined 4 major ligaments of the TMCJ: the anterior oblique ligament (AOL), the intermetacarpal ligament (IML), the posterior oblique ligament (POL), and the dorsal radial ligament (DRL). The state of these ligaments were assessed as intact, ruptured, or non- assessable. We compared the incidences of cartilage erosion and ligament rupture between the osteoarthritic and control patients.
Results There was no case of cartilage erosion in the metacarpal bones. In the trapezial side, cartilage erosion was significantly more common in the VU quadrant in the osteoarthritic patients than in the control patients (12/20 vs. 2/19; P = 0.001). Rupture of the AOL was more common in the osteoarthritic patients (10/20 vs. 3/19; P = 0.02). However, there was no association between cartilage erosion and AOL rupture in the osteoarthritic or control groups. No difference existed in the incidence of cartilage erosion in the other quadrants of the trapezium or in the state of the other ligaments between the two groups.
Summary Points • Advanced MRI imaging of early TMCJ osteoarthritis commonly demonstrates cartilage erosion in the volar-ulnar quadrant of the trapezium and ligament rupture in the AOL. • No association of cartilage erosion and AOL rupture suggests that AOL rupture is not a mechanical factor leading to TMCJ osteoarthritis but a common finding secondary to arthritic changes.
Bibliography 1: Hirschmann A, Sutter R, Schweizer A, Pfirrmann CW. The carpometacarpal joint of the thumb: MR appearance in asymptomatic volunteers. Skeletal Radiol. 2013;42(8):1105-12. 2: Pelligrini VD, Jr. Osteoarthritis of the trapeziometacarpal joint: the pathophysiology of articular cartilage degeneration. II. Articular wear patterns in the osteoarthritic joint. J Hand Surg Am. 1991;16(6):975-82. 3: Edmunds JO. Current concepts of the anatomy of the thumb trapeziometacarpal joint. J Hand Surg Am. 2011;36(1):170-82. 4: Saltzherr MS, Coert JH, Selles RW, van Neck JW, Jaquet JB, van Osch GJ, et al. Accuracy of magnetic resonance imaging to detect cartilage loss in severe osteoarthritis of the first carpometacarpal joint: comparison with histological evaluation. Arthritis research & therapy. 2017;19(1):55. 5: Lee AT, Williams AA, Lee J, Cheng R, Lindsey DP, Ladd AL. Trapezium trabecular morphology in carpometacarpal arthritis. J Hand Surg Am. 2013;38(2):309-15. AM Poster 038: Arthroscopic Hemitrapeziectomy with Suspensionplasty Using a Half Slip of Extensor Carpi Radialis Longus Tendon for Treatment of Thumb Carpometacarpal Arthritis Category: Hand
Hand and Wrist Level 4 Evidence
Mitsuhiro Okada, MD, PhD Ema Onode, MD Takuya Yokoi, MD Hiroaki Nakamura, MD, PhD
Hypothesis Recently there are some articles describing arthroscopic treatment of the thumb carpometacarpal arthritis. A few articles reported arthroscopic hemitrapeziectomy with suspensionplasty resisting subsidence of the thumb ray, while others without interposition. The abductor pollicis longus tendon and suture button have been utilized for suspensionplasty with arthroscopic hemitrapeziectomy. However, the abductor pollicis longus tendon has many anatomic variations, and the long-term results of suture button is still unclear. The extensor carpi radialis longus tendon has few anatomic variations. We describe a novel technique of using a half slip of the extensor carpi radialis longus tendon for suspensionplasty of the thumb ray after arthroscopic hemitrapeziectomy together with mid-term results.
Methods Twelve patients with Eaton stage 3 thumb carpometacarpal arthritis had arthroscopic hemitrapeziectomy using ulnar (1-U) and thenar portals. A half slip of the extensor carpi radialis longus tendon was harvested and left intact at its insertion via 2 small incisions. A drill hole was made at the first metacarpal base, and the tendon was passed through the hole. Thereafter the tendon was fixed with an interference screw to sustain the space created by the hemitrapeziectomy. Each patient had objective and subjective assessments.
Results The mean follow-up was 48.4 months postoperatively. Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score improved from 37.9 to 5.9 (p<0.01). Visual analog scales decreased from 76.5mm to 1.3mm (p<0.01). Grip, key pinch, and tip pinch strength significantly improved from 16.1kg to 23.3kg, from 3.1kg to 4.9kg, from 2.4kg to 4.0kg. There were no complications and no cases of instability.
Summary Points • Arthroscopic hemitrapeziectomy with suspensionplasty using a half slip of the extensor carpi radialis longus tendon offers patients with Eaton stage 3 thumb carpometacarpal arthritis a minimally invasive alternative. • The extensor carpi radialis longus tendon has few anatomic variances, which can facilitate the operative procedure. • This procedure can improve objective and subjective results over 4 years after surgery.
Bibliography 1: Edwards SG, Ramsey PN. Prospective outcomes of stage III thumb carpometacarpal arthritis treated with arthroscopic hemitrapeziectomy and thermal capsular modification without interposition. J Hand Surg Am. 2010;35(4):566-71. 2: Desmoineaux P, Delaroche C, Beaufils P. Partial arthroscopic trapeziectomy with ligament reconstruction to treat primary thumb basal joint osteoarthritis. Orthop Traumatol Surg Res. 2012;98(7):834-9. 3: Cox CA, Zlotolow DA, Yao J. Suture button suspensionplasty after arthroscopic hemitrapeziectomy for treatment of thumb carpometacarpal arthritis. Arthroscopy. 2010;26(10):1395-403. 4: Walsh EF, Akelman E, Fleming BC, DaSilva MF. Thumb carpometacarpal arthroscopy: a topographic, anatomic study of the thenar portal. J Hand Surg Am. 2005;30(2):373-9. 5: Slutsky DJ. The role of arthroscopy in trapeziometacarpal arthritis. Clin Orthop Relat Res. 2014;472(4):1173-83. AM Poster 039: Clinical Outcomes of Limited Open Intramedullary Headless Screw Fixation of Metacarpal Fractures - 91 Consecutive Patients Category: Hand
Hand and Wrist Level 4 Evidence
Jason B. Clain David E. Ruchelsman, MD MD
Hypothesis To evaluate clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless compression screw (IMHS) fixation for metacarpal neck and shaft fractures.
Methods Retrospective review demonstrated 91 consecutive patients (79 men; 12 women), mean age 28 years (range, 15-69 y) treated with IMHS fixation for acute displaced metacarpal neck (N = 56) and shaft (N = 35) fractures at a single academic hand practice between 2010 and 2017. Mean follow-up was 10 months (range, 1 to 71 months), with 57 patient achieving =3 months of follow-up. Preoperative mean magnitude of metacarpal neck angulation was 48°° (range, 0° - 90°), and mean shaft angulation was 42° (range, 0° -70° ). Active motion was initiated within 5 days postoperatively. Clinical outcomes were assessed with digital goniometry, grip strength, and return to play. Time to radiographic union and radiographic arthrosis were assessed.
Results All 91 patients achieved full composite flexion (pad-to-distal palmar crease distance = 0mm), and all achieved full active MCP extension or hyperextension. Postoperative mean MCP joint flexion- extension arc was 88° (range, 55°-110°). Grip strength was available for 52 patients and measured 104.1% of the contralateral hand (range 58% - 230%). Radiographic union data was avaialable for 86 patients. 76% (65/86) achieved radiographic union by the end of week 6 (range 2 - 10) At latest follow-up, early arthrosis was noted in 1 patient (head split component). There were 3 cases of shaft re-fracture after recurrent blunt trauma, following prior evidence of full osseous union with the screw in place, necessitating revision with open reduction and plate- screw fixation.
Summary Points Limited open retrograde IMHS fixation is safe, reliable, and durable for metacarpal neck/subcapital, axially stable shaft fractures, and select delayed/malunions. IMHS allows for early postoperative motion without affecting union rates, and obviates immobilization. This technique offers distinct advantages over formal open reduction and percutaneous K-wire techniques.
Bibliography 1: Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. The Journal of hand surgery. 2001;26(5):908-915. 2: Carpenter S, Rohde RS. Treatment of Phalangeal Fractures. Hand Clin. 2013;29(4):519-534. 3: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, Roselius E. Green's operative hand surgery. 2005. 4: Omokawa S, Fujitani R, Dohi Y, Okawa T, Yajima H. Prospective outcomes of comminuted periarticular metacarpal and phalangeal fractures treated using a titanium plate system. The Journal of hand surgery. 2008;33(6):857-863. 5: Fusetti C, Meyer H, Borisch N, Stern R, Della Santa D, Papaloïzos M. Complications of plate fixation in metacarpal fractures. Journal of Trauma-Injury, Infection, and Critical Care. 2002;52(3):535-539. AM Poster 040: Expedited Return to Play Following Intramedullary Headless Screw Fixation of Metacarpal Fractures in Elite Athletes Category: Hand
Hand and Wrist Level 4 Evidence
Jason B. Clain David E. Ruchelsman, MD
Hypothesis To evaluate clinical, functional, and radiographic outcomes and time to return to play following limited open intramedullary headless screw (IMHS) fixation of metacarpal neck and shaft fractures in elite athletes.
Methods Retrospective review of a consecutive series of 16 elite (professional or division I) athletes (14 men; 2 women), mean age 21 years (range, 19-28 y) treated with IMHS fixation for acute displaced metacarpal neck/subcapital (N=12) and shaft (N=4) fractures at a single academic practice between 2010 and 2017. All patients initiated early range of motion. Outcomes included time to bony and clinical union, grip strength, return to full play. RESULTS Average preoperative metacarpal neck angulation was 52° (45°-65°) and shaft angulation was 35° (25°-50°). All 16 patients achieved full composite flexion, full active metacarpophalangeal joint extension/hyperextension. Grip strength measured 99% (72%-118%) of the contralateral hand. Mean time to radiographic union was 4 weeks (2-7). Mean return to full play was 5 weeks (2-12). There was no radiographic arthrosis at latest follow-up.
Summary Points Limited open retrograde IMHS fixation is safe and reliable for metacarpal neck/subcapital and axially stable shaft fractures. It allows for early postoperative motion without affecting union rates, and obviates immobilization. This facilitates early rehabilitation and expedited return to play in elite and professional athletes, and replaces the need for K-wire fixation or formal open reduction and internal fixation. ?
Bibliography 1: Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908-15. doi:10.1053/jhsu.2001.26322. 2: Ashkenaze DM, Ruby LK. Metacarpal fractures and dislocations. Orthop Clin North Am. 1992;23(1):19-33. [PubMed: 1729666]. ? 3: Diao E. Metacarpal fixation. Hand Clin. 1997;13(4):557-71. [PubMed: 9403293]. ? 4: Soong M, Chase S, George Kasparyan N. Metacarpal fractures in athletes Curr Rev Musculoskelet Med. 2017 Mar;10(1):23-27. doi: 10.1007/s12178-017-9380-0. Review 5: Toronto R, Donovan PJ, Macintyre J. An alternative method of treatment for metacarpal fractures in athletes. Clin J Sport Med. 1996 Jan;6(1):4-8 AM Poster 041: Excision of Hook of Hamate Fractures in Elite Baseball Players: Outcomes and Surgical Technique Category: Hand
Hand and Wrist Level 4 Evidence
Jason B. Clain David E. Ruchelsman, MD MD
Hypothesis Hook of hamate fractures are occurring with increasing frequency in elite baseball players. Early diagnosis followed by surgical intervention expedites return to play.
Methods Retrospective review of 32 consecutive elite baseball players who underwent acute (6 weeks) surgical excision of 32 hook of hamate fractures that were sustained while competing at professional (16) or varsity collegiate (16) baseball levels. Mean follow up was 10 months. The clinical history, timing of surgery, complications, and time to return to play are reported.
Results Patients underwent excision of their hook of hamate fracture at a mean of 8 weeks (range 0.5 - 52 weeks) from the onset of symptoms. All patients were able to return to full pre-injury level of baseball participation on average 7 weeks from the date of surgery (range 4-30 weeks). Two patients returned to the operating room; one for cicatrix creating secondary ulnar nerve compression with motor weakness and one for residual bone fragment causing recurrent ulnar sided pain.
Summary Points Acute/subacute surgical excision of hook of hamate fractures is a reliable option in elite baseball players to alleviate pain limiting play and predictably facilitates return to play. Meticulous adherence to proper surgical technique is mandatory to avoid complications and optimize clinical outcomes.
Bibliography 1: Morgan WJ, Slowman LS. Acute hand and wrist injuries in athletes: evaluation and management. J Am Acad Orthop Surg. 2001;9(6):389-400. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11730330. 2: Bishop AT, Beckenbaugh RD. Fracture of the hamate hook. J Hand Surg Am. 1988;13(1):135- 139. doi:10.1016/0363-5023(89)90032-4. 3: Marchessault J, Conti M, Baratz ME. Carpal Fractures in Athletes Excluding the Scaphoid. Hand Clin. 2009;25(3):371-388. 4: Rettig AC. Athletic injuries of the wrist and hand. Part I: traumatic injuries of the wrist. Am J Sports Med. 2003;31:1038-48. 5: Pajares-López M, Hernández-Cortés P, Robles-Molina MJ. Rupture of small finger flexor tendons secondary to asymptomatic nonunion of the hamate hook. Orthopedics 34, 142 (2011). doi:10.3928/01477447-20101221-35. AM Poster 042: Outcome of Tie-In Implant for Treatment After Failure of Primary Trapeziometacarpal Surgery Category: Hand
Hand and Wrist Level 4 Evidence
Bernard Lallemand, MD MD Damien Cheval Michel P. Merle, MD MD Thomas Jager, MD MD
Hypothesis The purpose of this study was to evaluate the mid-term and long-term outcome of Tie-in silicone implant used after failure of primary trapeziometacarpal surgery.
Methods We retrospectively reviewed 22 Tie-in silicone implants between January 2005 and December 2015. All Tie-in implants were used for revision after failure of trapeziometacarpal surgery. There were 17 women for 5 men with an average age of 57 years (40-72 years). We determined the time between implantation and the date of diagnosis of the failure (rupture, major wear, dislocation, or poor clinical tolerance) to achieve a survival curve according to the Kaplan and Meyer Method.
Results The median survival time was 2.15 years. Only three patients did not show any wear, but one of them was lost after one year of follow-up. We found 47% of implant rupture, 32% of implant instability (subluxation or dislocation), 16% of implant wear and 5% of residual pain (Fig. 1). Forty-two percent of the failures were associated with siliconitis.
Summary Points The survival time of the Tie-in silicone implant in trapeziometacarpal revision surgery is poor with nearly half of the implants failing at 2 years. The rate of siliconitis is also important which requires more complex surgical procedure due to bone loss. In these revisions, ligamentoplasty and capsular suture were often of poor quality. The primary stability of the implant is therefore insufficient, explaining these wear and dislocations. In addition, the design of the implant, to allow stabilization, increases its fragility and the risk of rupture.
Bibliography 1: Luria S, Waitayawinyu T, Nemechek N, Huber P, Tencer AF, Trumble TE. Biomechanic analysis of trapeziectomy, ligament reconstruction with tendon interposition, and tie-in trapezium implant arthroplasty for thumb carpometacarpal arthritis: a cadaver study. J Hand Surg. 2007;32(5):697-706. 2: Swanson A, deGoot Swanson G, Watermeier J. Trapezium implant arthroplasty. Long-term evaluation of 150 cases. J Hand Surg Am. 1981;6(2):125-41. 3: Avisar E, Elvey M, Tzang C, Sorene E. Trapeziectomy With a Tendon Tie-in Implant for Osteoarthritis of the Trapeziometacarpal Joint. J Hand Surg. 2015;40(7):1292-7. AM Poster 043: Possible Systemic Adverse Effects in Clostridium Histolyticum Collagenase (CCH) Treatment of Dupuytren Contracture Category: Hand
Diseases and Disorders Level 4 Evidence
Joachim Ganser, MD MD Moritz Scholtes
Hypothesis 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.
Summary Points • 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.
AM Poster 044: Evaluation of Pain Scales and Narcotic Usage: A Comparison of Liposomal Bupivacaine and Bupivacaine HCL in Trigger Finger Release and Carpal Tunnel Release Surgeries Category: Hand
Hand and Wrist Level 1 Evidence
Drake W. Daily Mark A. Dodson, MD
Hypothesis Due to the structure of liposomal bupivacaine it is thought to believe the liposomal bupivacaine in comparison to the bupivacaine alone will have lessened pain and opioid consumption for patients.
Methods This study contains randomized patients in a controlled study using a blinded protocol. The study consisted of 26 patients who received CTR and/or TFR procedures. Data was collected from the postoperative day of surgery (POD 0) to postoperative day 5 (POD 5). Patients were randomized to receive a mixture of liposomal bupivacaine and bupivacaine or receive bupivacaine alone. Patients who received the cocktail were injected with 6 ml of 0.5% HCL before the incision, and a combination of 2 ml of bupivacaine and 2 ml liposomal bupivacaine infiltrated at the end of the case. Patients who received bupivacaine alone were injected with 10 mls of bupivacaine 0.5% HCL. Patients are scored by numerical pain scale as well as non- prescription and opioid consumptions on daily basis (POD 0 - POD 5). The primary variable is the numerical pain scales, and the secondary variable is opioid consumptions.
Results Patients who received liposomal bupivacaine during TFR and/or CTR surgeries consumed on average 2.077 ( 2.95) opioid pills from post operative day 0 through day 5. Patients who received the bupivacaine in TFR and/or CTR surgeries consumed on average 4.846 ( 5.5407) prescription pills. The numerical differences in opioid consumption between liposomal bupivacaine and bupivacaine was statistically significant (p = 0.0412). Visual analog scale of patients with liposomal bupivacaine had on average 6.92 (. Patients that received bupivacaine alone averaged 17.23 ( VAS. This difference in liposomal bupivacaine and bupivacaine VAS was also significant (p = 0.0063). Non-prescription pills consumed by liposomal bupivacaine and bupivacaine patients statistically show no significant difference (p = 0.4940).
Summary Points • Liposomal Bupivacine improves post operative patient outcomes by decreasing pain scales in comparison to bupivacaine alone • Liposomal Bupivcaine has lessened opioid consumption in comparison to bupivacaine alone, making liposomal bupivacaine a successful drug in improving post operative patient outcome.
AM Poster 045: Incidence of Loss of Reduction After Open Reduction Internal Fixation of Metacarpal Shaft Fractures Category: Hand
Hand and Wrist Level 4 Evidence
Christina Marie Ward, MD Christina Marie Ward, MD Lauren O. Erickson, MS Olivia J. Wang, MD, MS
Hypothesis There is no difference in the incidence of post-operative loss of reduction after surgical fixation of metacarpal fractures with lag screw fixation when compared with plate fixation.
Methods Retrospective chart review of metacarpal shaft fractures that underwent lag screw fixation (LSF) or plate fixation (PF) from 2001-2017. Inclusion criteria were: patient age =18 and minimum of 3 weeks follow up with radiographs. Exclusion criteria were: Poly trauma patients, ipsilateral upper extremity fractures, intraarticular, head, neck, or base metacarpal fractures. We recorded patient age, sex, location of fracture, fracture pattern (transverse, short oblique, long oblique, other), presence of multiple metacarpal fractures and type of fixation (LSF or PF), and evidence of loss of fixation on final radiographs. Baseline demographics, fracture characteristics, and primary outcomes were compared between fixation types using chi-square and t-tests.
Results We identified 138 eligible metacarpal shaft fractures in 106 patients. The fractures (78 PF, 60 LSF) included 74 males (69.8%) and 32 females (30.2%) with an average age of 37 years (age range 18-92) at the time of surgery. The PF and LSF groups were similar by age, fracture location, and presence of multiple metacarpal fractures (Table 1). All patients with transverse fracture pattern were fixed with plate, while the majority of long oblique fractures were fixed with lag screws. The incidence of loss of reduction was 13.8% (Table 2). There was no difference between PF (15.4%) and LSF (11.7%) in the incidence of loss of fixation (P=0.05). Initial trends indicate that loss of reduction may be more common in index metacarpal fractures (33%, 4 of 12) and less common in the ring metacarpal (6%, 3 of 50) compared to other digits. The most common complication reported was loss of reduction (13.8%) followed by hardware removal (9.4%). Hardware removal appears to be slightly more common in patients treated with plates (12.8%) compared to lag screws (5.0%), however our study was not powered to test the statistical significance of this. Loss of fixation rates did not differ between fracture patterns. There was no difference in complication rates based on training background (orthopedic surgery, plastic surgery, hand fellowship)
Summary Points In this series, the incidence of loss of reduction after metacarpal shaft ORIF was higher than previously reported in recent literature. There was a trend towards the index metacarpal having a higher incidence of fixation failure, with loss of reduction occurring in 1/3 of index metacarpal fractures.
AM Poster 046: Washer and Post Augmentation of 90/90 Wiring for Proximal Interphalangeal Joint Arthrodesis: A Biomechanical Study. Category: Hand
Hand and Wrist N/A - not a clinical study
Ram Kiran Alluri, MD J. Ryan Hill, BA Paul Navo, BS Milan Stevanovic, MD, PhD Alidad Ghiassi, MD Amir Mostofi, MD
Hypothesis To describe a novel construct for proximal interphalangeal joint (PIPJ) arthrodesis using headless cannulated screws as an intramedullary washer to augment 90/90 intraosseous wiring; and to test the hypothesis that an intramedullary washer will improve the biomechanical properties of this construct when compared to 90/90 intraosseous wiring without headless screw augmentation.
Methods Biomechanical evaluation of augmented 90/90 intraosseous wiring with headless cannulated screws (group 1) or 90/90 intraosseous wiring, without augmentation (group 2) for PIPJ arthrodesis was performed in 3 matched-pair cadaveric specimens (12 digits per group) (Figure 1). A custom, 3-dimensionally (3D) printed jig with a built in cutting block allowed for reproducible flat bone cuts of the proximal phalangeal head at an angle of 30 degrees. A second perpendicular bone cut was made at the base of the middle phalanx. Each group was loaded to 10 N in the sagittal and coronal plane and the resultant stiffness from the load-displacement curve was calculated. Each group then underwent load to permanent deformation and load to catastrophic failure testing, both in extension.
Results The augmented 90/90 intraosseous wiring with cannulated screws construct demonstrated significantly greater stiffness by 132%, 64%, 79%, and 75% in flexion, extension, ulnar, and radial displacement, respectively (P<0.05) (Figure 2). During load to permanent deformation testing, a 46% greater force was required to create permanent deformation in group 1 compared to group 2 (P<0.05). There was no significant difference between the two groups during load to catastrophic failure testing (P=0.07).
Summary Points • Augmenting traditional 90/90 intraosseous wiring for PIPJ arthrodesis with two headless cannulated screws in the sagittal plane, that serve as intramedullary washers for the sagittal wire and posts for the coronal wire, significantly increases stiffness in all directions as well as load to permanent deformation compared with 90/90 intraosseous wiring without augmentation. • Augmentation of the traditional 90/90 intraosseous wire construct with headless cannulated screws can be considered in patients at risk for wire cutout or implant failure. • Clinical studies are needed to assess whether the use of this construct for PIPJ arthrodesis will improve osseous union, time to union, and decrease rates of fixation failure.
AM Poster 047: Union Rates and Complications after Thumb Metacarpophalangeal Fusion Category: Hand
Hand and Wrist Level 4 Evidence
Kevin Lutsky, MD David Edelman Cory Lebowitz Jonas L. Matzon, MD Pedro Beredjiklian, MD
Hypothesis Fusion of the thumb metacarpophalangeal joint(MPJ) can be performed using tension band wires(TBW) or plates and screws(PS). This study evaluated results and complications using these techniques.
Methods A retrospective review of patients who underwent thumb MPJ fusion at our institution from 2010-2016 was performed. Patients with >1 year follow-up were included. Demographic information, indication for fusion, time to fusion, and complications were collected. Final radiographs were examined and alignment measured. RESULTS: There were 56 thumbs in 53 patients(42 women and 11 men) including 12 TBW and 44 PS. The mean age was 60.9 years and follow-up was 32.4 months. Twenty-eight of 44 plates were non-locking, 16 were locking. Of the locking plates 7/26 used all locking screws and 9/26 had a combination of locked and non-locked screws. The mean flexion angle for TBW was 16.5° and PS was 12.8°. The mean coronal angle for TBW patients was 4.0° ulnar and PS was 2.5° ulnar.
Results The overall union rate was 95%. There were 12 complications, nine in the PS group. The TBW complications were painful hardware requiring removal. Eight complications in the PS group occurred in patients with locked plates. Five of the delayed or non-unions occurred in patients with locked plates and 4 of these were in plates with all screws locked.
Summary Points Complications using PS or TBW are not infrequent. Alignment with both techniques is similar, but use of locked plates specifically increases the rate of delayed or non-unions. We do not recommend routine use of locked plates for fusion of the thumb MPJ.
AM Poster 048: Do Ultrasound-Guided Basal Joint Injections Improve Accuracy and Speed Category: Hand
Hand and Wrist N/A - not a clinical study
Kristin Sandrowski, MD Jacob E. Tulipan, MD Peter P. Pham, MS Jonathan Shearin, MD Amir Reza Kachooei Michael Rivlin
Hypothesis Introduction: The use of ultrasound-guided injections at the basal joint has increased in an attempt to improve accuracy of intraarticular injections. This study aimed to evaluate the utility of ultrasound guidance for basal joint injection using a model that takes into account the limited patient tolerance for painful procedures. Our hypothesis was that ultrasound would not improve speed or accuracy for injecting the basal joint.
Methods Two senior residents, a hand fellows and attending were selected as participants. All subjects underwent an identical introduction to ultrasound, given by an experienced ultrasound technologist instructor. Evaluation of subjects was performed on 10 fresh frozen cadaver hands with attached forearms. Each subject attempted to insert a 22 gauge needle into the basal joint. The subjects were instructed to attempt to keep injection time under 5 seconds, and were informed when 5 seconds from skin puncture had elapsed. The process was then repeated for all subjects using a 7.5 MHz linear probe to localize the basal joint and guide needle placement. The time for needle placement and whether the needle was in the basal joint were recorded for all subjects. Confirmation of intraarticular placement of needle was by orthogonal fluoroscopic views evaluated by two blinded hand surgeons with a third surgeon as a tiebreaker.
Results Intraarticular injections were accurately placed in 42% of palpation based injections (17/40) and 25% (10/40) of ultrasound guided among all physicians. Our hypothesis was correct that ultrasound did not improve the accuracy of intraarticular injections (p=0.098). There was a difference in time for injection between the two groups, both with correctly and incorrectly placed injections. For properly sited injections, ultrasound guidance increased the duration of needle placement (14.41 versus 6.15 seconds). For improperly sited injections, ultrasound guidance increased the duration of needle placement (25.16 versus 5.85 seconds). There was no significant difference in accuracy or time between residents and attendings with or without ultrasound.
Summary Points • There was no significant difference between surgeons with different levels of training in accuracy with ultrasound-guided injections. • Ultrasound didn’t improve the accuracy of intraarticular injections despite a short tutorial. • For those without ultrasound experience, ultrasound-guided injections took significantly longer without improving accuracy.
Bibliography 1: Pollard, MA; Cermak,MB; Buck, WR; Williams, DP. Accuracy of injection into the basal joint of the thumb. Am J Orthop. 2007 Apr; 36(4): 204-6 2: Mandle, LA; Hotchkiss, RN; Adler, RS; Ariola, LA; Katz, JN. Can the carpometacarpal joint be injected accurately in the office setting? Implications for therapy. J Rheumatol. 2006 Jun; 33(6): 1137-9. 3: Umphrey,GL; Brault,JS; Hurdle,MF; Smiht,J. Ultrasound-guided intra-articular injection of the trapeziometacarpal joint: description of technique. Arch Phys Med Rehabil 2008 Jan; 89(1): 153- 6. 4: Wolf, JM; Delaronde, S. Current trends in nonoperative and opertive treatment of trapeziometacarpal osteoarthritis: a survey of US hand surgeons. J Hand Surg Am 2012 Jan; 37(1):77-82. 5: Naranjo, A; Jimenez-Nunez, FG; Medina-Luezas, J; Rodriguez-Garcia, A; Vazquez, M; Santos- Ramirez, C; Alvarez de Buergo, M; Lopez-Lasanta, M; Loza, E. Impact of the use of musculoskeletal ultrasound by rheumatologists in patients with shoulder and hand complaints compared with traditional clinical care. Clin Exp Rheumatol. 2012 Sep-Oct; 30(5): 768-71. AM Poster 049: Which Factors Affect the Rate of Surgery Performed in Patients with Carpal Tunnel Syndrome? Category: Hand
Hand and Wrist;Nerve;Diseases and Disorders Level 4 Evidence
Jihyeung Kim, MD Hyun Sik Gong Kee Jeong Bae, MD Hyun Sik Seok Yo Han Lee Goo Hyun Baek
Hypothesis Carpal tunnel release is recommended when patients with positive electrophysiologic test remain symptomatic in spite of conservative treatment. However, only some of them eventually undergo the surgery. The purposes of this study, therefore, were to evaluate the rate of carpal tunnel release performed among the patients with positive electrophysiologic test, and to identify which factors were associated with the rate of the surgery.
Methods Subjects of this study were 865 wrists of 495 patients (65 males and 430 females) who were diagnosed as carpal tunnel syndrome between January, 2013 and December, 2016. The diagnosis of carpal tunnel syndrome was confirmed by electrophysiologic test, and only the patients who were followed up for more than 1 year were enrolled in this study. The average age at the time of the electrophysiologic test performed was 61.4 years, and the severity of carpal tunnel syndrome was evaluated according to the Bland scale (Gr 1~6) based on the electrophysiologic test. Whether or not the patients received carpal tunnel release was evaluated at the last follow-up visit.
Results Among the 865 wrists, carpal tunnel release was performed on 528 wrists (61%). Rate of the surgery performed significantly increased in patients with more severe grades on electrophyisiologic test. More patients in female (63.3%) than in male (50.3%) and more patients with age under 60 (67.5%) than age over 60 (57.1%) received the surgery. However, there was no significant difference in the rate of carpal tunnel release according to the bilaterality or dominant hand.
Summary Points • The rate of carpal tunnel release among the patients diagnosed and confirmed as carpal tunnel syndrome was not higher than we expected. • We should also pay more attention to the patients who did not undergo carpal tunnel release and investigate the reasons why those patients did not undergo surgery.
Bibliography 1: Gong HS, Park JW, Shin YH, Kim K, Cho KJ, Baek GH. Use of a decision aid did not decrease decisional conflict in patients with carpal tunnel syndrome. BMC Musculoskelet Disord. 2017 Mar 21;18(1):118. 2: Hageman MG, Kinaci A, Ju K, Guitton TG, Mudgal CS, Ring D, et al. Carpal tunnel syndrome: assessment of surgeon and patient preferences and priorities for decision-making. J Hand Surg Am. 2014 Sep;39(9):1799-804 e1. 3: Nam KP, Gong HS, Bae KJ, Rhee SH, Lee HJ, Baek GH. The effect of patient involvement in surgical decision making for carpal tunnel release on patient-reported outcome. J Hand Surg Am. 2014 Mar;39(3):493-8. 4: Gong HS, Huh JK, Lee JH, Kim MB, Chung MS, Baek GH. Patients' preferred and retrospectively perceived levels of involvement during decision-making regarding carpal tunnel release. J Bone Joint Surg Am. 2011 Aug 17;93(16):1527-33. 5: Gong HS, Baek GH, Oh JH, Lee YH, Jeon SH, Chung MS. Factors affecting willingness to undergo carpal tunnel release. J Bone Joint Surg Am. 2009 Sep;91(9):2130-6. AM Poster 051: What's going on After Trapeziectomy? Arthroscopic Findings of the Post-Trapeziectomy Space Category: Hand
Hand and Wrist;Diseases and Disorders Level 5 Evidence
Sanshiro Kawahara Satoshi Usami Kohei Inami, MD
Hypothesis Hematoma and scar formation after trapeziectomy differ in their quality and quantity between total and partial trapeziectomy.
Methods We performed arthroscopic second-look for two patients who underwent trapeziectomy for the treatment of the thumb carpometacarpal joint osteoarthritis. The first case was a 75-year old male status post open full trapeziectomy and dual Mini TightRope suspensionplasty for Eaton stage IV arthritis. The indication for the second surgery was persistent pain presumably from arthritis at the scapho-trapezoid joint. Arthroscopic debridement was performed 11 months after the initial procedure. The second case was a 58-year male status post open hemi trapeziectomy and dual Mini TightRope suspensionplasty for Eaton stage III arthritis. The indication for the second surgery was pain and disability secondary to progressive hyperextension deformity of the metacarpophalangeal joint of the thumb. Abductor pollicis brevis volar half slip transfer to correct hyperextension was conducted 13 months after the initial procedure with concomitant arthroscopic second-look of the post-trapeziectomy space.
Results After full trapeziectomy, scar tissue within the trapeziectomy space existed very sparsely, making visualization of the distal scaphoid and the base of the first metacarpal bone clear. Probing of the scar tissue revealed fluffy and fragile quality of the scar tissue. At the final follow up, the pain at the scapho-trapezoid joint resolved, however, complete subsidence of the first metacarpal bone on the scaphoid was observed. In contrast, after partial trapeziectomy, dense and substantial scar tissue filled the post-trapeziectomy space, precluding visualization of the residual surface of the trapezium and the base of the first metacarpal bone. The second case has retained trapeziectomy space height 18 months after the initial procedure.
Summary Points • Our two cases demonstrated that the scar formation after trapeziectomy differed significantly between full and partial trapeziectomy in terms of its quality and quantity. • The difference in scar tissue formation may play some role in the ability to maintain post- trapeziectomy space height.
AM Poster 052: The Use of Pedicle Flaps for the Treatment of Amputation of the Fingertip Category: Hand
Hand and Wrist Level 4 Evidence
Hideyuki Mizushima, MD
Hypothesis 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. We evaluated the outcomes of using pedicle flaps for treating amputation of the fingertip.
Methods We reviewed 43 cases (men, 42; women, 1; average age, 45.7 years) of amputation of the fingertip and nail matrix from July 2008 to February 2016. The injury sites were as follows: thumb (2), index finger (8), middle finger (13), ring finger (10), and little finger (10). A pedicle flap, such as a bilateral V-Y advancement flap (modified Kutler method), cross-finger flap, volar advancement flap with a unilateral neuro-vascular bundle (V-Y method), and pedicled groin flap, was used in all cases. The modified Kutler method was used in case of transverse amputations, whereas a cross-finger flap was used for oblique amputations with large volar defects. For cases that fell between these two amputation types, the V-Y method was used to cover the defect. Large defects, which could not be covered by any of these three Methods, were treated with a pedicled groin flap. The average follow-up period was 63.9 weeks. Numbness, pain, and sensory defects were examined at the final follow-up. Sensory defects were evaluated by using a 10- point subjective estimation, in which 10 was the highest score.
Results Twenty-two patients were treated with the modified Kutler method, 13 with a cross-finger flap, 6 with the V-Y method, and 2 with a pedicled groin flap. All flaps survived. Among the patients who were treated with the modified Kutler method and V-Y method, numbness, hypersensitivity, or hypesthesia occurred in 15 and 4 cases, and pain due to an attack occurred in 4 and 1 case, respectively. All patients treated with a cross-finger flap and pedicled groin flap recovered well, with an average score of 8.6 and 5.0 points, respectively; hypersensitivity occurred in 3 cases and 1 case and pain due to an attack occurred in 5 and 0 cases, respectively.
Summary Points Good outcomes were anticipated after reconstruction of the defects with a pedicle flap. The incidence of numbness, or hypesthesia after using flaps with neuro-vascular bundles was higher than expected, and, surprisingly, sensory recovery was good after using flaps without neuro- vascular bundles. Considering that each flap has it merits and demerits, it is important to select the appropriate flap for treating amputation of the fingertip.
Bibliography 1: Kutler W. A new method for finger tip amputation.J Am Med Assoc. 1947 Jan 4;133(1):29. 2: Shepard GH. The use of lateral V-Y advancement flaps for fingertip reconstruction.J Hand Surg Am.1983 May;8(3):254-9 3: Curtis RM. Cross-finger pedicle flap in hand surgery. Ann Surg. 1957 May; 145(5):650-5 4: Atasoy E. The reverse cross finger flap. J Hand Surg Am. 2016 Jan;41(1):122-8. 5: García-López A, Laredo C, Rojas A. Oblique triangular neurovascular osteocutaneous flap for hook nail deformity correction. J Hand Surg Am. 2014 Jul;39(7):1415-8. AM Poster 053: Electrodiagnostic Severity and Carpal Tunnel Release Outcomes: A Prospective Analysis Category: Hand
Hand and Wrist;Nerve;Diseases and Disorders Level 2 Evidence
Michael Rivlin Amir Reza Kachooei Mark L. Wang, MD, PhD MD, PhD Asif Ilyas, MD MD
Hypothesis The value of electrodiagnostic testing (EMG) severity as a prognostic indicator of clinical results following carpal tunnel release (CTR) remains controversial, and our current understanding is largely limited to retrospective reviews. The aim of this study was to (1) prospectively evaluate the degree of symptomatic and functional postoperative improvement relative to preoperative EMG severity, and (2) test the hypothesis that symptom relief after CTR will differ based on EMG severity.
Methods Consecutive cases of EMG-confirmed CTR were prospectively enrolled. Data was collected preoperatively and at 2 weeks and 3 months postoperatively. Demographic, EMG severity (mild, moderate, or severe), surgical parameters, QuickDASH questionnaire, Symptom Severity Scale (SSS), Functional Status Scale (FSS), Pain Catastrophizing Scale (PCS), and Visual Analogue Scale (VAS) data were collected and analyzed.
Results A total of 295 patients were enrolled. By EMG severity, there were 20 patients with mild, 126 with moderate, and 110 patients with severe grades preoperatively. There was a significant improvement in QuickDASH, SSS, and FSS scores from the pre-operative to the 2-week and 3- month postoperative visits in all categories of EMG severity (P 0.05). Pain decreased dramatically at 2 week post-op (P < 0.05). Postoperative pain improvement occurred regardless of EMG severity. Lastly, there were no major complications or re-operations in any groups.
Summary Points • CTR demonstrated consistently significant improvement in functional outcomes regardless of EMG severity at 3 months. • The extent of postoperative improvement following CTR was not statistically different between groups with differing EMG severity. • This information can be of value to surgeons and patients as they plan surgery and discuss postoperative outcomes.
AM Poster 054: Conservative Treatment of Fractures Around the Metacarpophalangeal Joint with "Knuckle Splint” Category: Hand
Hand and Wrist;Practice Management Level 4 Evidence
Masashi Matsuta Kaoru Tada, MD Daiki Yamamoto, MD Tadahiro Nakajima Mika Nakada Hiroyuki Tsuchiya, MD
Hypothesis We developed the “Knuckle splint” made by subortholene which fixes the metacarpophalangeal (MP) joint at 90 degrees of flexion and allows free mobility of the wrist, proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. This functional splint is effective for treatment of fractures around the MP joint.
Methods In this retrospective case series study, we evaluated 50 patients with fractures around the MP joint who are treated either with a “Knuckle splint” for conservative treatment, or post- operatively, and we had been able to examine them for more than two months. The sample consisted of 38 men and 12 women between 15 and 90 years of age (average 44.42). Fractures included 32 fractures of the metacarpal diaphysis, 19 fractures of the distal metacarpal bone (neck fracture), and 12 fractures of the basal part of the proximal phalanx. We evaluated the duration of splinting, the stability of the fracture site, % total active motion(%TAM), and adverse events with the “Knuckle splint”
Results %TAM is 100 % in the index finger, 99.08 % in the middle finger, 98.57 % in the ring finger, and 96.54 % in the little finger. The duration of splinting ranged from 2 to 8 weeks (average 4.18 weeks). There were no patients in which transposition of the fracture progressed, and all cases achieved bony union. In three cases, skin disorders occurred on the dorsal aspect of the hand, but they healed with wound dressing.
Summary Points • Fractures around the MP joint are treated with the cast such as Burkhalter cast or Knuckle cast. On treatment of these fractures, fixation for bone union and mobilization to prevent joint contracture or tendon adhesion should be done concurrently, but in some cases the castings are complicated for the ideal position. • The “Knuckle splint” makes it very easy to achieve the ideal position of 90 degrees of flexion of the MP joint and early mobilization of the PIP and DIP joints. Every physician and patient can put on the splint regardless of their ability. The “Knuckle splint” is an effective splint for conservative treatment and post-operative splinting of fractures around the MP joint.
Bibliography 1: Franz T, von Wartburg U, Schibli-Beer S, Jung FJ, Jandali AR, Calcagni M, Hug U. Extra-articular fractures of the proximal phalanges of the fingers: a comparison of 2 Methods of functional, conservative treatment. J Hand Surd Am 2012; 37: 889-98 2: Burkhalter WE. Closed treatment of hand fractures. J Hand Surg Am 1989; 14: 390-3 AM Poster 055: Efficacy of Collagenase Injection for Y-Cord Lesion in Dupuytren’s Contracture Category: Hand
Hand and Wrist Level 4 Evidence
Kazuhiro Otani Ryosuke Kakinoki, MD, PhD Hiroki Tanaka Masao Akagi, MD, PhD Nakagawa Kohichi, MD, PhD
Hypothesis Collagenase Clostridium Histlyticum (CCH) is the first and only non-surgical treatment option for patients with Dupuytren contracture. Manufacturer approved the injection of 0.58mg of CCH into a single cord and injection can be repeated once a month, up to 3 injection cycles. Recently, some authors reported over dose injection and multi cord injection technique which were not approved. We hypothesized that injection of the commercial dose of CCH results in sufficient reduction in contractures of adjacent finger. Dupuytren contracture is a progressive fibroproliferative condition.
Methods We tried to inject manufacture approved dose of CCH into Y-cord lesion. 24 hours after injection, manipulation of the cord with finger extension was performed previously described under wrist block using 1% lidocaine. After the manipulation, an orthosis was fitted and applied at night for 3 months. At one month after manipulation, MCP and PIP joint contracture were measured using a goniometer and CCH treatment-related complications were recorded.
Results Eight patients were treated with Y cord method of CCH injection. Amount of reduction of joint contracture and clinical success rate 30 days after manipulation in contracted finger and adjacent finger are presented Table 1(contracted finger) and 2(adjacent finger). The mean total flexion contracture at the MCP and PIP joint of contracted finger decreased from 46 to 7, 33 to 18 ° ,respectively. That of adjacent finger decreased from 30 to 0, 14 to 10 ° ,respectively. Clinical success of contracted finger was noted in 83% of MCP and 0% of PIP joint. That of adjacent finger was noticed 100% of MCP and 75% of PIP joint. CCH treatment-related complications are presented 88% of patients. All of them had minor complications including swelling, ecchymosis and one patient had skin tear. None of major complication were recorded.
Summary Points • Y-cord technique using 0.58mg of CCH can provide efficacy at not only contracted finger, but also adjacent finger. • Injection of commercial dose of CCH may provide a cost saving to patients with mulita cord Dupuytren contracture.
Bibliography 1: Warwick D, et al. Collagenase Clostridium histriticum: emerging practice patterns and treatment advances. J. Plast. Surg. Hand Surg, 2016;50: 251-261 2: Verhyden JR. Early outcomes of a sequential series of 144 patients with Dupuytren's contracture treated by collagenase injection using an increased dose, multicord technique. J Hand Surg. 2015; 40: 133-140. AM Poster 056: Dynamic Ultrasound Analysis of the Median Nerve May Differentiate Clinically Significant Carpal Tunnel Syndrome Category: Hand
Hand and Wrist;Nerve;Diseases and Disorders Level 3 Evidence
Joseph A. Buckwalter, V, MD Dominik Mattioli Ericka A. Lawler, MD Jessica Goetz
Hypothesis Patients with clinically significant carpal tunnel syndrome (CTS) will have less transverse/axial plane movement of the median nerve within the carpal tunnel during functional hand movements.
Methods Ultrasound (US) movies were collected at the level of the wrist crease in two patient cohorts while individuals performed 10 specific functional hand movements at a self-selected pace. The first group consisted of 10 patients with electrophysiologically diagnosed and clinically significant CTS who underwent ultrasonographic data collection immediately prior to their carpal tunnel release. The second cohort consisted of 10 healthy individuals with no history of CTS. The total excursions of the median nerve during active movements were calculated in the radial/ulnar and dorsal/palmar directions. Total excursions were calculated using a custom analysis routine developed in Matlab (The Mathworks, Natick MA) to track the median nerve. The comparative analysis of the two cohorts utilized 2D image correlation to track the texture of the median nerve’s appearance through all sequential frames of the US movie, and included a convenient graphical user interface for visual interpretation of nerve movement.
Results Total median nerve excursion was not different between the groups in any of the 10 movements analyzed. In the radial/ulnar direction, median nerve excursion was not different between groups. However, median nerve excursion in the dorsal/palmar direction with several functional movements was significantly greater in the healthy participants than in the CTS patients. This significant difference in dorsal/palmar nerve movement was primarily a result of the median nerve’s considerable deformation in healthy patients.
Summary Points • Dynamic ultrasound can be used to quantify median nerve excursions in the transverse plane of the carpal tunnel during multiple common activities of the fingers and wrist. • CTS patients have similar magnitudes of radial/ulnarly directed nerve excursion as healthy individuals during finger movement. • CTS patients have significantly less median nerve excursion in the dorsal/palmar direction during finger movement • Median nerve material properties may govern tissue kinematics, which may relate to clinically significant CTS
AM Poster 057: Kinematic Study of the Range of Motion of the Metacarpal Bone of the Thumb After Trapeziometacarpal Arthrodesis Category: Hand
Hand and Wrist N/A – not a clinical study Grant received from: Japanese Society for Surgery of the Hand
Junya Hojo, MD Shohei Omokawa Akio Iida, MD Hiroshi Ono Yasuaki Nakanishi, MD Yasuhito Tanaka
Hypothesis Arthrodesis effectively eliminates pain in the trapeziometacarpal (TMC) joint, but it limits the postoperative range of motion (ROM), the degree of which remains unclear. We hypothesized that the thumb could move after trapeziometacarpal arthrodesis, and we used fresh-frozen cadavers to obtain three-dimensional (3D) measurements of the thumb ROM after TMC arthrodesis.
Methods We used 8 fresh-frozen arms. The upper arm was separated at the forearm, and the carpal bones other than the TMC joint were fixed to the laboratory table. We attached 3D electromagnetic tracking system sensors (trakSTARTM, Ascension, USA) to the base and head of the thumb’s metacarpal bone. A 50-gf load was applied at a point 20 cm from the TMC joint to generate passive circumduction of the thumb. We then measured the displacement and rotational angle of the metacarpal bone of the thumb. A normal thumb and a model of TMC joint arthrodesis at 20° radial abduction and 20° palmar abduction were used to measure the displacement and rotational angle of the metacarpal bone of the thumb.
Results The mean ROM of circumduction of the normal metacarpal bone of the thumb relative to the second metacarpal bone was as follows: 47° during radial abduction, 11° during radial adduction, 46° during palmar abduction, and 20° during palmar adduction. After arthrodesis, the mean ROM was 31°, -14°, 26°, and -13°, respectively, demonstrating significantly reduced ROM in all positions compared to the normal thumb (Fig. 1). The normal thumb rotated 42° medially from the radial abduction to radial adduction position, and rotated 34° medially from the palmar adduction to palmar abduction position. After arthrodesis, the medial rotation of the thumb was significantly reduced, rotating only 8° and 5°, but following the same rotation patterns as the normal thumb (Fig. 2).
Summary Points • TMC arthrodesis decreased the maximum ROM of circumduction of the metacarpal bone of the thumb to 29% from radial abduction to radial adduction, and to 20% from palmar abduction to palmar adduction of the normal thumb. • Circumduction was also decreased to 17% of the normal thumb. • Conservation of ROM after TMC arthrodesis was believed to be compensated by the scaphotrapezoid-trapezial joint.
Bibliography 1: Rizzo M, Moran SL, Shin AY. Long-Term Outcomes of Trapeziometacarpal Arthrodesis in the Management of Trapeziometacarpal Arthritis. J Hand Surg Am. 2009;34(1):20-26. 2: Kuczynski K. Carpometacarpal joint of the human thumb. J Anat. 1974;118(Pt 1):119-126. AM Poster 058: What Are the Important Factors for Success in Conservative Treatment of Volar Plate Avulsion Fractures of the Finger Proximal Interphalangeal Joint? Category: Hand
Hand and Wrist Level 4 Evidence
Sanglim Lee, MD, PhD Jiyun Ha Ji Yeong Kim, MD Jin Young Kim, MD, PhD Suk Ha Jeon, MD
Hypothesis The purpose of this study was to analyze the results of conservative treatment in volar plate avulsion fractures of the finger proximal interphalangeal joint.
Methods We reviewed retrogradely the medical records and radiologic exams of 86 patients with 91 volar plate avulsion fractures of the finger proximal interphalangeal joint. the mean age was 32 (range, 10-87) years, and the average follow-up time was 16 (range, 6-59) weeks. The patients were predominately male (53 patients). The fifth finger was the most commonly affected digit (36 fingers) and other fingers had similar prevalence. Among 84 acute (less than 3 weeks after injury) fractures, 77 fractures were treated conservatively with a finger splint and 7 underwent fragment excision after averaged 89 (range, 27-137) days of conservative treatment period due to pain during motion of the joint. Four out of 7 chronic fractures were treated conservatively and 3 underwent excision after averaged 118 (range, 47-164) days of conservative treatment. We compared factors between maintenance group for conservative treatment and operative group after conservative treatment.
Results Fractures treated with operation had the more initial fracture displacement (1.4 mm versus 0.7 mm, p= 0.0003) and rotation (81.8° versus 16.7°, p<0.0001), larger flexion contracture of the joint after conservative treatment (13.8° versus 7.2°, p= 0.09), and younger age (33 versus 19 years, p= 0.04). The size and shape of the avulsed fragment and further flexion of the joint after conservative treatment were not different between two groups.
Summary Points • Volar plate avulsion fractures of the proximal interphalangeal joint can be treated conservatively with good results. • Initial displacement and rotation of the avulsed fragment and the flexion contracture of the joint might be important factors to determine the successful conservative treatment.
Bibliography 1: Gaine WJ, Beardsmore J, Fahmy N. Early active mobilisation of volar plate avulsion fractures. Injury. 1998;29(8):589-91. 2: Takami H, Takahashi S, Ando M. Large volar plate avulsion fracture of the base of the middle phalanx with rotational displacement: a report of three cases. J Hand Surg Am. 1997;22(4):592-5. 3: Lee S, Jung EY, Kim JY. Operative treatment for volar plate avulsion fractures of the fingers. Arch Orthop Trauma Surg. 2013;133(10):1463-7. AM Poster 059: Mohs Surgery and Reconstruction for Digit Melanoma In Situ: Analysis of Techniques and Post-Operative Hand Function Category: Hand
Hand and Wrist;Diseases and Disorders;General Principles Level 4 Evidence
Jason D. Wink, MD Irfan Rhemtulla, MD Christopher Miller, MD Benjamin Chang Stephen J. Kovach Ines Lin
Hypothesis Digital melanoma of the hand is an insidious malignancy which has historically been treated with amputation, leading to significant morbidity. For melanoma in situ, the combination of Mohs excision with reconstruction has allowed for digit sparing treatment in some patients. The goal of our study is to analyze reconstructive techniques for patients undergoing digit-sparing treatment for melanoma and assess differences in functional outcomes in these patients when compared to those receiving immediate amputation.
Methods An IRB-approved retrospective review (2011-2017) of patients undergoing surgery for digit melanoma at the University of Pennsylvania was performed. Patients undergoing Mohs surgery plus reconstruction or immediate amputation were identified. Chart review identified melanoma location, defect size, tumor stage, reconstructive technique and cancer recurrence. Functional outcomes were assessed by administering the Neuro-QOL Upper Extremity Survey and compared against melanoma patients who were treated with immediate amputation. Statistical analysis was performed using Mann-Whitney Rank Sum tests.
Results 13 patients (Mean Age: 65.5) were identified who underwent Mohs excision and reconstruction, 12 with a diagnosis of melanoma in situ and 1 with a diagnosis of stage 1A melanoma. No recurrence was identified with average follow-up of 16.38 mos. Average defect size was 4.11 SD 1.57 cm2 and located on the distal phalanx in 11/13 cases. Reconstruction was performed 0-4 days after resection. Six lesions were located on the thumb and 5 lesions were located on the middle finger. Most common techniques included volar advancement flap (N=6) and Full Thickness Skin Graft (N=2). 12 patients (Mean Age 73.92 yrs) were identified who underwent first line amputation for melanoma treatment with a diagnosis of Clark Level 2 to 5 melanoma. Neuro-QOL upper extremity survey results displayed a trend toward a significant difference between patients who underwent digit-sparing treatment (n= 7) versus amputation (n= 5) (Mean T-Score: 42.54 SE 3.55 vs. 32.34 SE 4.85), p= 0.072). No cancer recurrence was identified in any patient in the amputation control group.
Summary Points • Our results indicate that melanoma in situ can be treated with digit-sparing therapy for adequate cancer treatment and that digit-sparing treatment appears to have a quality of life benefit when compared to an amputated digit. • Further investigation is required to evaluate the potential for Mohs in other skin cancers and more advanced stages of melanoma.
AM Poster 060: Thumb Carpometacarpal Pyrocarbon Arthroplasty Category: Hand
Hand and Wrist Level 4 Evidence
Christine Oh, MD Eric Wagner, MD Marco Rizzo, MD Bassem T. Elhassan, MD Steven L. Moran, MD
Hypothesis The purpose of this study was examine the outcomes of patients undergoing first carpometacarpal (CMC) joint arthroplasty using a pyrocarbon implant.
Methods An analysis of 138 consecutive first CMC pyrocarbon primary arthroplasties was retrospectively collected with a minimum one year follow up. Diagnoses included inflammatory arthritis (n=14), degenerative arthritis (n=107) and post-traumatic arthritis (n=17). The primary pyrocarbon implant utilized was the Pyrocarbon CMC implant (Integra LifeSciences, Plainsboro, NJ). Univariate logistic regression and Kaplan-Meier survival analyses were performed.
Results Mean age at time of surgery was 58 years. At an average follow-up of 32 months, 22 arthroplasties underwent revision surgery, with the majority performed for subluxation (n=10), dislocations (n=7) or pain and stiffness (n=5). There were 23 reoperations in addition to the 22 revision procedures performed, of which 17 implants were removed and suspension arthroplasty performed and 6 cases of partial trapeziectomy and Alloderm (LifeCell Branchburg, NJ) interposition for scaphotrapeziotrapezoidal (STT) arthritis. The most common complications observed were pain and implant subluxation. The 5 survival-free of reoperation rate for primary arthroplasty was 63%. The risk for reoperation was higher in patients with post-traumatic arthritis. In unrevised implants, patients had improvements in their preoperative to postoperative pain, opposition and apposition key pinch strengths and CMC range of motion.
Summary Points • In this analysis, approximately a third of first CMC pyrocarbon implants placed will require reoperation by 5 years. • Patients who do not require revision surgery experience pain relief and pinch and key grip strength. • Unrecognized STT arthritis may manifest after CMC arthroplasty and require reoperation.
Bibliography 1: Vitale MA, Taylor F, Ross M, Moran SL. Trapezium prosthetic arthroplasty (silicone, Artelon, metal, and pyrocarbon). Hand Clin 2013;29:37-55. 2: Martinez de Aragon JS, Moran SL, Rizzo M, Reggin KB, Beckenbaugh RD. Early outcomes of pyrolytic carbon hemiarthroplasty for the treatment of trapezial-metacarpal arthritis. J Hand Surg Am 2009;34:205-12. AM Poster 061: Hand Replantation: Successful Outcome in a Poly Trauma Patient with the Input of Multidisciplinary Team - A Case Report Category: Hand
Hand and Wrist Level 5 Evidence
Thilakshi Upamalika Subasinghe, MD Dammika Abyewickrama Dissanayake, MD Praveen Wijesinghe, MD Kavinda Rajapaksha, MD Weerasinghe Pathiranalage Kalyani, BSc
Hypothesis Amputation of a hand is a severe disability. Replantation is the re-attachment of a completely amputated hand. Complex reconstruction of limbs and digits has become a great success with the advancement in microsurgical techniques. Overall functional and aesthetic success depends on proper patient selection, technical skills and post-operative rehabilitation. We present a case report of a successful outcome of hand replantation in a poly-trauma patient.
Methods 37 year old female involved in domestic violence was presented with completely amputated right hand at radio-carpal joint level with multiple deep sword cut injuries involving her all four limbs. After complete resuscitation (following 3 units of blood transfusion) of the patient with proper clinical and radiological assessment, patient was consented for the re-plantation procedure with the input of multi-disciplinary team support. Careful dissection, bony fixation with K-wires, trimming and repair of tendons, nerves and vessels (2 arteries and 3 veins) were achieved successfully. Left hand compound fracture of ulnar and left leg non displaced compound fracture of tibia open reduction and internal fixation done by the orthopedic team after 72 hrs of re-implantation. She underwent supervised occupational therapy post-operative.
Results Post-operatively patient showed satisfactory functional and sensory recovery at 12 months. Wrist active range of motion was 50-60 ° with full range of active motion of thumb and digits with good power grip, tip-to-tip pincer grip, key pinch and tripod pinch. Her static 2-point discrimination was 6-10 mm in the ulnar and median nerve distribution. DASH score (Disabilities of the arm, shoulder and hand) was 14.2. She is able to perform activities of daily living now and highly satisfied with functional and aesthetic outcome of the hand.
Summary Points Functioning hand improves the quality of life of the patient. Despite increased higher risk of complications and failure, longer post-operative period, replantation is worthwhile procedure in a low-income country like Sri Lanka where patient cannot afford for the myoelectric prosthesis.
Bibliography 1: Marco Maricevich, Brian Carlsen, Samir Mardini, Steven Moran. Upper extremity and digital replantation. HAND (2011) 6:356–363 DOI 10.1007/s11552-011-9353-5 2: Richard D. Goldner, James R. Urbaniak, Replantation, Chapter 48, Green's Operative Hand Surgery, 6th edition: Scott W. Wolfe 2011 AM Poster 062: Arthrodesis For Chronic Carpometacarpal Instability in Elite Boxers Category: Hand
Hand and Wrist Level 4 Evidence
Feiran Wu, MA, MB BChir (Cantab), FRCS Iain Mclaughlin-Symon Ian Gatt Michael Loosemore Mike Hayton, MD
Hypothesis Isolated instability of the carpometacarpal joints [CMCJ] is rare in the general population, although it has been shown to be the second most common hand injury in elite boxers (1). In this cohort, chronic CMCJ instability is a serious, potentially career ending injury, and is associated with pain on punching impact (2). This study aims to present the treatment and outcomes of a cohort of elite boxers who presented with symptomatic chronic CMCJ instability.
Methods Twenty-three elite boxers, thirteen professional and ten amateur, who were unable to compete due to pain and weakness were treated with CMCJ arthrodesis. A total of 64 joints were fused in 26 hands, with an average of 2.8 joints treated per patient. The mean symptom duration was 14 months (range 2 to 60 months). All patients received non-operative intervention before proceeding to primary fusion, which was performed with K-wire stabilisation in 16 joints (five hands), headless screw fixation in 38 joints (17 hands) and speed staple fixation in 10 joints (four hands). Autologous corticocancellous bone graft was used in all cases (iliac crest in 60 joints, distal radius in four). All except two patients required fusion of the index and middle finger CMCJ. The mean age at surgery was 24 years (range 19-30).
Results All except three patients (5/64 joints) united at a mean duration of 10 weeks (range 6-30 weeks). Two patients (3 joints) required secondary iliac crest bone grafting and fixation (screw in one joint, K-wires in two joints). One patient (2 joints) required secondary iliac crest impaction bone grafting without fixation. These all united following revision surgery. One patient developed dysaesthesia in the distribution of the dorsal ulnar cutaneous nerve that resolved after exploration and neurolysis.
All except two boxers returned to competition at a mean duration of 33 weeks post-operatively (range 21-63 weeks). All professional boxers returned to competition at a mean of 36 weeks (range 26-63 weeks), and remain competing professionally at a mean of 36 months following surgery (range 7-66 months). Eight amateur boxers returned to fight competitively at a mean duration of 24 weeks (range 21-29 weeks).
Summary Points • Primary arthrodesis is a reliable and successful treatment for chronic CMCJ instability in elite boxers. • There is a low rate of complications and excellent return to competition in this cohort of athletes.
Bibliography 1: Loosemore M, Lightfoot J, Gatt I, Hayton M, Beardsley C. Hand and Wrist Injuries in Elite Boxing: A Longitudinal Prospective Study (2005-2012) of the Great Britain Olympic Boxing Squad. Hand (N Y). 2017 Mar;12(2):181–7. 2: Nazarian N, Page RS, Hoy GA, Hayton MJ, Loosemore M. Combined joint fusion for index and middle carpometacarpal instability in elite boxers. J Hand Surg Br. 2014 Mar;39(3):242–8. AM Poster 063: Risk Factors for Acute Carpal Tunnel Syndrome Complicating a Fracture of the Distal Radius Category: Hand
Hand and Wrist Level 4 Evidence
Jun M. Leow, MBChB Andrew D. Duckworth, PhD MSc, FRCSEd(Tr∨th) Nicholas D. Clement, PhD, FRCSEd(Tr∨th) Margaret M. McQueen, MD, FRCSEd
Hypothesis Acute carpal tunnel syndrome (ACTS) is a debilitating complication of distal radius fractures (DRF), which can result in poor sleep and quality of life. This study aims to document the demographics, range of presenting symptoms and risk factors of patients who develop ACTS.
Methods A consecutive series of 1189 patients with DRF treated in our unit over the period of a year were identified. Electronic records were retrospectively reviewed for patients who developed ACTS as a complication. Demographic and clinical variables were collected and compared against controls to determine their correlation with ACTS development. ACTS was defined as paraesthesia affecting any of the radial three and a half fingers within 12 weeks from the date of injury. Exclusion criteria include patients with a history of carpal tunnel syndrome or carpal tunnel decompression, symptoms arising after 12 weeks from time of injury and iatrogenic causes of carpal tunnel syndrome.
Results There were 51 (4%) patients with a fracture of the distal radius that was complicated by ACTS. The mean age was 56 years (range, 16-89 years; SD 18.9) and 36 (73.1%) were female. The median time of onset post injury was one week (range, 1-12), with 32 (62.7%) patients developing CTS within the first week of injury, and the remainder occurring within the first 3 months following injury. There was a significant association between AO-OTA grade type-C fractures and the occurrence of ACTS (p=0.001). Thyroid disease demonstrated a trend towards the development of ACTS (p=0.059).
Summary Points • AO-OTA group is a strong predictive factor for the development of ACTS following a fracture of the distal radius • Patients with type-C complete articular fractures have significantly higher rates of ACTS and should be monitored and considered for carpal tunnel decompression at an early stage
AM Poster 064: Median and Digital Nerve In Situ Tension in the Hand Category: Hand
Hand and Wrist;Nerve N/A - not a clinical study
Jacob T. Didesch, MD Patrick Schimoler, BEng Mark C. Miller, PhD Peter Tang, MD, MPH
Hypothesis Finger hyperextension and hand distraction will produce tension on the median and digital nerves, and will differ based on location.
Methods Three fresh frozen cadaveric hands were mounted to a custom platform with an attached clamp and load cell. 1 cm of the median nerve was exposed at the proximal carpal tunnel and placed into the clamp leaving all distal soft tissue intact. The tension produced by 30º of hyperextension of the index, middle, and ring finger MCP joints was recorded. The tension was then recorded with all three digits at 30º of hyperextension. The tension on the nerve imparted by distraction of the hand by 1 mm, 2 mm, and 5 mm was recorded with all digits in neutral position. Tension with distraction by 1 mm, 2mm, and 5 mm with MCP flexion to 90º of the index, and ring fingers were recorded, followed by MCP flexion to 90º of the three digits together. All tension data was recorded at 100 Hz for 2 seconds and averaged. The median nerve was then exposed and transected 1 cm distal and measurements repeated until reaching the common digital nerves. The protocol was repeated moving only the fingers supplied by the nerve. The radial proper digital nerves to the index, and ring fingers were tested in a similar manner. Once at the level of the proper digital nerve isolated PIP motion was tested instead of MCP motion.
Results Hyperextension of the MCP joint produces tension in the median and common digital nerves. More tension is produced with hyperextension of all of the digits supplied by a nerve compared to hyperextension of a single digit (Figure 1). Hyperextension of the PIP joint produces tension in the proper digital nerves. Increasing amounts of hand distraction results in increasing tension on the nerve (Figure 2). The largest tension produced was 0.67N in the median nerve at 5 mm of distraction. Increasing distraction combined with flexion also leads to increasing tension. However, maximum tensions were lower than distraction without joint flexion. The tension in the median nerve with 5 mm of distraction and flexing all three digits was < 0.1N.
Summary Points • There is in situ tension on the median and digital nerves with digital motion. • Hyperextension produces tension on the nerves in the hand • Tension on the median and digital nerves increases with increasing amounts of distraction. • Joint flexion reduces the amount of tension on the nerves.
AM Poster 065: Low Rate of Complications Following Intramedullary Headless Compression Screw Fixation for Metacarpal Fractures Category: Hand
Hand and Wrist Level 4 Evidence
William J. Warrender, MD Chaitanya S. Mudgal, MD Michael Livesey David E. Ruchelsman, MD Michael Rivlin, MD
Hypothesis Intramedullary fixation of metacarpal fractures is safe, with rare complications that can be easily managed.
Methods We performed a multicenter case series through retrospective review of all patients treated with intramedullary headless screw fixation of metacarpal fractures by three fellowship trained hand surgeons. Patient demographics, implant used, type of complication, pre- and post-operative radiographs, operative reports and sequelae were reviewed for each case. We defined complications as infection, loss of fixation, hardware failure, malrotation, nonunion, malunion, metal allergy and any repeat surgical intervention.
Results Four complications (2.5%) were identified through review of 160 total cases. One complication was a Nickel allergy that occurred two weeks after surgery. The screw was subsequently removed after fracture healing and there were no sequelae. One patient presented 10 months after surgery with a broken screw after repeat blunt trauma to the surgical area. This was treated with removal of the broken intramedullary screw and plate fixation of the resulting re- fractured metacarpal. Two patients had bent intramedullary screws. One of these patients had also sustained repeat blunt trauma to the surgical area at 6 months postoperatively. This was treated with removal of the bent hardware and plate fixation of the re-fractured metacarpal. The final patient presented at 18 months postoperatively for clearance into the military with a bent screw but was completely asymptomatic, the fracture was healed and the screw was left in place.
Summary Points • To our knowledge, this is the first case series to report on the complications and their management following intramedullary screw fixation of metacarpal fractures. • From this large series (n = 160), the rate of complication is low at 2.5%. Of these, 1 was asymptomatic and 2 were patient driven secondary to repeat blunt trauma to the surgical area. There were no cases of infection or extensor tendon disruption. • Intramedullary headless screws are a safe option for fixation of metacarpal neck and shaft fractures.
Bibliography 1: Doarn MC, Nydick JA, Williams BD, Garcia MJ. Retrograde Headless Intramedullary Screw Fixation for Displaced Fifth Metacarpal Neck and Shaft Fractures: Short Term Results. Hand. 2015;10(2):314-318. doi:10.1007/s11552-014-9620-3. 2: Ruchelsman DE, Puri S, Feinberg-Zadek N, Leibman MI, Belsky MR. Clinical Outcomes of Limited-Open Retrograde Intramedullary Headless Screw Fixation of Metacarpal Fractures. J Hand Surg Am. 2014;39(12):2390-2395. doi:10.1016/j.jhsa.2014.08.016. 3: Avery DM, Klinge S, Dyrna F, et al. Headless Compression Screw Versus Kirschner Wire Fixation for Metacarpal Neck Fractures: A Biomechanical Study. J Hand Surg Am. 2017;42(5). doi:10.1016/j.jhsa.2017.02.013. 4: Tobert DG, Klausmeyer M, Mudgal CS. Intramedullary Fixation of Metacarpal Fractures Using Headless Compression Screws. J Hand Microsurg. 2016;08(03):134-139. doi:10.1055/s-0036- 1593390. AM Poster 066: Heterodigital Adipofascial Turnover Flap: A Systematic Review and Case Presentation on the Application in a Septic Joint with Concurrent Skin Necrosis Category: Hand
Hand and Wrist Level 4 Evidence
Mehrad Mojtahed Jaberi, MD Yehuda Chocron Peter Davison, MD
Hypothesis The Heterodigital adipofascial turnover flap, also known as the reverse cross-finger flap can be used for soft tissue coverage of a variety of dorsal digital defects including nail bed injuries, extensor tendon injuries and open fractures. The specific indications, surgical techniques and common reported outcomes are limited to isolated case series and will be revisited in this systematic review with illustration of application in a septic joint with concurrent skin necrosis.
Methods This review was constructed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A comprehensive literature review of articles indexed to PubMed was performed using the keywords “turn-over”, “reversed”, “hinged”, “open book”, “cross finger”, “transdigital”, “heterodigital”, “adipofascial”, “dermal”, “de-epithelialized” and “flap”. The search was limited to English and French articles. Two independent reviewers screened the abstracts and the exclusion criteria consisted of non-digital flaps, homo-digital flaps, classical cross finger and non-adipofascial flaps. Selected manuscripts were analyzed in full text with regards to references and citations in order to expand the number of relevant articles. Upon reviewing full texts, individual cases within a study with vague surgical techniques, missing data and duplicated case reports were excluded. Independent data extraction was performed by two reviewers utilizing pre-determined study characteristics and outcomes. The prevalence of these characteristics was calculated to summarize indications, surgical techniques and common reported outcomes.
Results 23 out of 266 manuscripts met the inclusion criteria, yielding 163 patients treated with the heterodigital adipofascial turnover flap. Indications included, 144 patients with traumatic injuries, including 3 burn injuries. This flap was commonly used from the adjacent digit from extensor zone 2 or 4 (n=95). In 62 cases, the flap was de-epithelialized. 23 cases involved the nail bed, with 17 left to epithelialize and 6 cases covered with a toe nail bed graft. Post-operatively, digits were most commonly immobilized with a splint (n=88). The mean follow up time was 6 months. Complications included, cold intolerance (n=14), incomplete graft take (n=12), stiffness (n=8), infection (n=6), epidermal inclusion cyst (n=3), tendon adherence (n=1) and complete flap necrosis (n=1).
Summary Points • The Heterodigital adipofascial turnover flap is an excellent option for coverage of a variety of dorsal digital defects. • This method can be used for both traumatic and non-traumatic injuries. • Donor site morbidity is rare and functional outcomes are promising. • The complications reported are minimal with cold intolerance being the most common.
Bibliography 1: The reversed dermis flap. Pakiam AI.Br J Plast Surg. 1978 Apr;31(2):131-5. 2: The Reverse Cross Finger Flap. Atasoy E J Hand Surg Am. 2016 Jan;41(1):122-8. 3: Time of return back to work and complications following cross-finger flaps in industrial workers: Comparison between immediate post operative mobilization versus immobilization until flap division, Al-Qattan MM. Int J Surg Case Rep. 2017 Nov 28;42:70-74. 4: The "open book" flap: a heterodigital cross-finger skin flap and adipofascial flap for coverage of a circumferential soft tissue defect of a digit. Tadiparthi S, Akali A, Felberg L. J Hand Surg Eur Vol. 2009 Feb;34(1):128-30. AM Poster 067: Snow Blower Related Hand Injuries: Impact of Current Safety Regulations on Incidence Category: Hand
Hand and Wrist Level 2 Evidence
Jennifer Thomson Aaron Rubinstein Brianna L. Siracuse Mark Decotiis Irfan Ahmed, MBBS Michael M. Vosbikian, MD
Hypothesis Snow blowers represent a highly preventable mechanism of hand injury. Current safety features have had little impact on decreasing the incidence of snow blower related injuries.
Methods The United States Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS) was queried to look for injuries related to the use of snow throwers or blowers between 2001 and 2016. From all of the injuries related to snow blowers, we collected information on identifying characteristics, location of injury, and type of injury (i.e avulsion). Chi- squared tests were used for categorical variable comparisons and student t-tests were used for continuous variable comparisons. Data analysis was performed using SAS statistical software, version 9.3 (SAS Institute, Inc.; Cary, NC). The Consumer Product Safety Commission’s provided SAS algorithm was used to calculate all national injury estimates and variances. The extrapolated incidence from the NEISS was used instead of the reported incidence in all statistical analyses to prevent bias from a lack of power. Statistical significance was determined based on a p-value of < 0.05.
Results Within the study period, there were 3,550 reported injuries. The extrapolated national incidence was 92,799 (95% confidence interval [95% CI], 58,280-127,318) with an average annual incidence of 5,800 or 1.9 injuries per 100,000 US population per year. The most commonly injured body part was the finger (82.0% [45,593; 95% CI, 31,307-59,878]) followed by the hand (10.1% [5,597; 95% CI, 3,248-7,945]). Most common types of injuries were fractures (38.4% [21,328; 95% CI, 13,766-28,891]), lacerations (25.9% [14,402; 95% CI, 10,069-18,735]), and amputations (18.4% [10,210; 95% CI, 5,869-14,551]).
Summary Points • Snow blowers represent common, preventable injuries whose incidence continues to rise annually • Current safety features focusing on user education and preventing operation of the machine without active operator engagement have not correlated to a decrease incidence of injuries. • Prior studies have proven the implementation of safety features to decrease incidence of injuries regarding other power tools such as table saws. • Most commonly, snow blower related hand injuries occur because of individuals are unaware of the impeller device and attempt to free clogged snow from the exit chute without an appropriate tool • Despite the presence of a ‘dead man switch’, snow blower blades still contain residual potential rotational energy which may be released in the event an obstruction is cleared • Snow blowers should be designed to prevent operators from placing their hands into the exit chute
Bibliography 1: U.S. Consumer Product Safety Commission : National electronic injury surveillance system coding manual. 2: Vosbikian MM, Harper CM, Byers A, Gutman A, Novack V, Iorio ML. The Impact of Safety Regulations on the Incidence of Upper-Extremity Power Saw Injuries in the United States. J Hand Surg Am. 2017 Apr;42(4):296.e1-296.e10. doi: 10.1016/j.jhsa.2017.01.025. 3: Master D, Piorkowski J, Zani S, Babigian A. Snow blower injuries to the hand: epidemiology, patterns of injury, and strategies for prevention. Ann Plast Surg. 2008; 61:613–7. ? AM Poster 068: Nail Deformities of Digital Mucous Cysts Category: Hand
Diseases and Disorders Level 4 Evidence
Kohei Kanaya
Hypothesis This study aimed to classify the appearance of nail deformities of digital mucous cysts.
Methods Sixty digits in 59 patients with mucous cysts were treated with total dorsal capsulectomy. Thirty seven digits were followed for more than 6 months and had no recurrence for an average of 26 months (range; 6 to 60 months) after surgery. Twenty five digits with nail deformities by mucous cysts were improved for an average of 5 months (range; 2 to 8 months) after surgery. We demonstrated the frequency of nail deformities of mucous cysts and classified the appearance of nail deformities.
Results Thirty five of 60 digits (58%) had nail deformities. The distance from nail to cyst was 1.6 mm in patients with nail deformity and 7.9 mm in patients without nail deformity. All mucous cysts with nail deformities were appeared within 3mm from nail. Nail deformities were classified into 3 patterns that were flat, wave and atypical types. Twenty one digits (60%) were flat type, 9 digits (26%) were wave type and 5 digits (14%) were atypical type (Fig. A,B and C). The size of cyst and the distance from nail to cyst were 4.6 and 2.0 mm in flat type, 5.5 and 1.6 mm in wave type and 4.0 and 1.2 mm in atypical type, respectively, but there was no statistical correlation.
Summary Points • All mucous cysts with nail deformities were appeared within 3mm from nail. • This study demonstrated that nail deformities of digital mucous cysts were classified into 3 representative patterns.
Bibliography 1. Kanaya K, Wada T, Iba K, Yamashita T. Total dorsal capsulectomy for the treatment of mucous cysts. J Hand Surg Am 2014;39:1263-7. AM Poster 069: Comparison of LRTI and Suture-Button Suspensionplasty for Thumb CMC Arthritis Category: Hand
Hand and Wrist Level 4 Evidence
Brian Clair, MD Samantha Chase, MD Eric T. Tolo, MD Maximillian C. Soong, MD Alice Anne Hunter, MD N. George Kasparyan, MD, PhD
Hypothesis Suture-button suspensionplasty (SBS) is a recent technique for thumb CMC joint arthroplasty which theoretically obviates the need for ligament reconstruction and tendon interposition (LRTI) after trapeziectomy, while providing early stability and therefore faster recovery. Our hypothesis was that clinical outcomes of SBS would be superior to LRTI at short-term while achieving similar radiographic results.
Methods A single surgeon performed 20 consecutive LRTI cases followed by 20 consecutive SBS cases for thumb CMC arthritis. Average age and gender distribution were similar between groups (LRTI: 60 years, 90% female; SBS: 61 years, 80% female). Charts and radiographs were retrospectively reviewed. QuickDASH and pain VAS scores were recorded. Trapezial space height ratio (trapezial space height/proximal phalangeal length) was measured on hand PA radiographs by a single observer. Continuous data were analyzed using t-test. Categorical data were analyzed using Fisher’s exact test.
Results Preoperative QuickDASH and VAS scores were similar between groups. At an average of 6 months follow-up, these scores were significantly improved in both groups, and were superior with SBS. Trapezial space height ratio was similar in both groups preoperatively and at 1 month postoperatively. Complications were similar between groups. There were 5 complications for LRTI: superficial radial neurapraxia (2), hypersensitivity (2), and CRPS (1). There were 3 complications after SBS, all involving superficial radial neurapraxia.
Summary Points • SBS had greater improvement than LRTI with regard to QuickDASH and pain VAS scores at 6 months. • SBS may be appropriate for patients who require expedited return of function. • Longer-term follow-up is underway to determine whether these early advantages are maintained. • Trapezial space height ratio was similar between groups and comparable to the existing literature.
Bibliography 1: Hooke AW, Parry JA, Kakar S. Mini Tightrope Fixation Versus Ligament Reconstruction - Tendon Interposition for Maintenance of Post-trapeziectomy Space Height: A Biomechanical Study. JHS 2016;41(3):399-403. 2: Downing ND, Davis TR. Trapezial space height after trapeziectomy: mechanism of formation and benefits. JHS 2001;26(5):862-8. AM Poster 070: A Prospective, Multicentre Clinical Trial to Assess Safety and Efficacy of a Synthetic Cartilage Implant for Treatment of Eaton- Littler Stage II or III Osteoarthritis of the First Carpometacarpal Joint: The Cartiva GRIP Trial Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Lionel Chris Bainbridge, FRCS Philip Sauve, FRCS Sanjay Miranda, FRCS FRCS Paul A. Binhammer, MD MD Grey E. B. Giddins, FRCS FRCS David Lawrie
Hypothesis Although trapeziectomy with or without LRTI is the mainstay of surgical management of carpometacarpal osteoarthritis, better surgical techniques to reduce pain and increase pinch and grip strength are sought. We report the one-year outcomes of a prospective, multicentre, feasibility clinical trial of a synthetic cartilage implant for treatment of Eaton stage II/III osteoarthritis of the first carpometacarpal joint.
Methods Fifty patients =18 years of age with VAS pain =40 were enrolled. The 8mm implant was placed in a precision reamed central cavity in the base of the first metacarpal, stabilized by friction fit and rested 1-3mm proud. A plaster short arm cast was applied, and the thumb immobilised for 6 weeks. All patients received appropriate physiotherapy until stable. Radiographs were taken at 42 days. Radiographs, range of motion (ROM), pinch and grip strength, VAS pain, Michigan Hand Questionnaire (MHQ) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) were assessed at baseline and 3, 6 and 12 months postoperative. Adverse events and medications were recorded.
Results Forty-four patients (88%) were followed up at mean 12.02 ± 0.76 (range 10.56 – 13.88) months. One patient was lost to follow-up, and five are pending follow-up and/or data entry (their status will be included at the conference presentation). VAS pain, QuickDASH and MHQ scores improved at three, six and twelve months postoperative (Table 1). Clinically meaningful improvements in VAS pain, QuickDASH and MHQ scores were reported by 37/49 (76%), 47/49 (96%) and 35/48 (73%) patients at six months postoperative, respectively, and by 33/41 (81%), 39/41 (95%) and 27/40 (68%) patients at one year, respectively. Grip and pinch strength were 2 standard deviations below age- and gender-matched healthy norms at baseline, were further reduced at three months postoperative, but improved to within normal range at one year. Percent improvement in pinch strength was notably larger than published rates for LRTI or trapeziectomy (Figure 1). ROM was maintained postoperatively. Radiographs demonstrated maintenance of joint space and joint alignment over time. There were no serious device-related adverse events and no implant failures. Five of 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.
Summary Points • The implant is safe with low risk and an excellent outcome, demonstrating improved function and reduced pain at one year. • Our data show pinch strength results not achievable with trapeziectomy.
AM Poster 071: Carpal Tunnel Score (CTS-6) and Its Correlation with Electrodiagnostic Studies and the Boston Carpal Tunnel Questionnaire Category: Hand
Hand and Wrist;Nerve;Diseases and Disorders Level 4 Evidence
Bowen Qiu, MD Mark Schreck, MD Warren Hammert, MD
Hypothesis Our primary hypothesis is that higher preoperative carpal tunnel scores (CTS-6) correlate with increasing disease severity on electrodiagnostic studies (nerve conduction studies and electromyography) and a worse Boston carpal tunnel questionnaire (CTQ) score. A secondary hypothesis is that higher CTS-6 scores correlate with better symptom relief postoperatively based on CTQ scores.
Methods Patients treated for carpal tunnel syndrome between November 2014 and April 2017 were asked to participate in the study. Inclusion criteria are patients over the age of 18 who were evaluated for symptoms of carpal tunnel syndrome that underwent electrodiagnostic studies prior to carpal tunnel release. Grading of electrodiagnostic scores were determined from the raw results independent from the neurologist read, using criteria set by the American Association of Neuromuscular and Electrodiagnostic Medicine. Exclusion criteria are patients under the age of 18, patients with inadequate follow up.
Patients were grouped into mild, moderate, or severe based on electrodiagnostic studies. Mean CTS-6 scores were calculated for the three categories. CTS-6 scores were then categorized into three different categories of mild, and severe. Statistical analysis was performed using paired student t-test comparing mean scores as well as mean differences among the three groups based on electrodiagnostic studies, as well as based on CTS-6 scores. Mean Boston Carpal Tunnel Questionnaire scores for symptom severity and functional status were also calculated pre-operatively and at 2-week and 6-week follow up appointments and differences calculated.
Results Our results showed of 101 patients (161 hands) there were 91 hands with severe, 49 moderate, and 25 mild carpal tunnel syndrome, based on electrodiagnostic testing (Table 1). With increasing disease severity on electrodiagnostic testing, the mean CTS-6 increased from 9.9 to 10.81 to 11.10. The median score with increasing disease severity increased from 7.5 to 11.5 to 11.5. Increased CTS-6 scores correlated with increasing CTQ scores, but not increased fCTQ. Increasing CTS-6 scores were correlated with greater changes in pre- and post-operative two and six week CTQ, and six week fCTQ scores, while there was a negative correlation with two week fCTQ scores (Table 2), but these correlations were not found to be statistically significant.
Summary Points • Although we saw a positive trend correlating the CTS-6 with electrodiagnostic studies and the CTQ, we did not find a statistical significant correlation between the CTS-6 and electrodiagnostic testing nor the Boston carpal tunnel questionnaire.
Bibliography 1: Graham, B., Regehr, G., Naglie, Wright, JG. Development and validation of diagnostic criteria for carpal tunnel syndrome. J Hand Surg Am 2006 Jul-Aug;31(6):919-24. 2: Graham,B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am 2008/12; 12: 2587-2593 3: Jose C de Carvalho Leite,Christina Jerosch-Herold, Fujian Song, A Systematic Review of the Psychometric Properties of the Boston Carpal Tunnel Questionnaire. BMC Musculoskeletal Disorders Oct 2006. https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471- 2474-7-78 accessed 1/31/2018 4: Stevens,J. Clarke AAEM Mimimonograph #26: The Electrodiagnosis of Carpal Tunnel Syndrome, Muscle and Nerve December 1997 pg. 1477-1486 AM Poster 072: Biomechanical Study of Partial Extensor Tendon Lacerations over the Finger Metacarpalphalangeal Joints Category: Hand
Hand and Wrist N/A - not a clinical study
Justin H. Chan Ryan Harold Muturi Muriuki, PhD Robert M. Havey, MS David M. Kalainov, MD
Hypothesis We performed a biomechanical study to assess the percentage of extensor tendon lacerations over the finger metacarpophalangeal (MP) joints that may lead to MP joint extensor lags. From sparse clinical reports, we hypothesized that transverse cuts involving more than 50% of the combined widths of the tendon slips would lead to measurable MP joint extensor lags and tendon gapping.
Methods Eight fresh-frozen cadaveric hand specimens without recognized injury or motion-limiting finger arthritis were obtained. The finger flexor and extensor tendons were isolated proximal to the carpal bones for active loading of the extensor tendons and passive loading of the flexor tendons. The forearm bones and finger metacarpals were rigidly secured to a testing jig. The extensor tendon slips were exposed over the finger MP joints and sequential, full-thickness, transverse cuts were made through the tendon slips. The fingers were cycled, extensor tendon gaps were measured, and inclinometer measurements of MP joint rotation were obtained.
Results Incremental cuts of the extensor tendons caused sequential reductions in subjacent MP joint rotation (Fig. 1), in addition to interactive effects on other fingers (Fig. 2). Diminished rotations of the index and small finger MP joints were significant with lacerations extending across 75% or more of the combined widths of the extensor tendon slips, whereas diminished rotations of the long and ring finger MP joints were significant with lacerations involving 90% or more of the widths of the extensor tendons. A significant decrease in MP joint rotation in the index and small fingers was also observed when 1 of 2 extensor tendon slips in either finger was completely transected.
Summary Points • Laceration of finger extensor tendon slip(s) over the MP joints may cause a significant joint extensor lag when the damage involves 75% or more of combined tendon slip width in the index and small fingers, and 90% or more of combined tendon slip width in the long and ring fingers. • Not all extensor tendon injuries over the finger MP joints may necessitate repair.
Bibliography 1: Al-Qattan MM. Conservative management of partial extensor tendon lacerations greater than half the width of the tendon in manual workers. Ann Plast Surg 2015, 74: 408-409. 2: Manning DW, Spiguel AR, Mass DP. Biomechanical analysis of partial flexor tendon lacerations in zone II of human cadavers. J Hand Surg Am 2010, 35: 11-18. 3: Wehbe MA. Anatomy of the extensor mechanisms of the hand and wrist. Hand Clin 1995, 11: 361-366. 4: Qian J, Fang B, Yang WB, Luan X, Nan H. Accurate tilt sensing with linear model. IEEE Sensors Journal 2011, 11: 2301-2309. AM Poster 073: The CMC View: A Comparison of 3 Radiographic Views by Eaton-Glickel Classification and Correlation to Disease Severity Measured by Gross Anatomical Dissection Category: Hand
Hand and Wrist N/A - not a clinical study
Christina Salas, PhD Deana Mercer, MD Moheb S. Moneim, MD Norfleet Thompson, MD Cory Carlston, MD Christina Kurnick
Hypothesis We introduce the “CMC view” and compare this technique with commonly used x-rays of the hand (PA and Robert’s view) by staging using Eaton-Glickel (E-G) classification and correlate all staging to actual disease severity evaluated by gross dissection of the joint in cadaveric hands. We hypothesize that the CMC view allows for the best inter-rater reliability (IRR) between study participants and best predicts the actual disease severity of the joint.
Methods Twenty fresh-frozen human cadaveric hands were x-rayed using the CMC, PA, and Robert’s views by a trained radiology technician. The CMC view is performed as follows: • Hand in a lateral position, wrist in ulnar deviation • 45° sponge placed under hand allowing true PA view of CMC joint • Thumb placed on sponge crest, hand rests on slope The 60 x-rays were randomized and blinded by a co-author. Two attending hand surgeons and two hand fellows reviewed each image independently and staged each radiograph based on the E-G classification system. IRR was calculated for all readings and for each view independently. One attending and one fellow surgically excised the 20 trapeziums one month after their review, but were blinded to the specimen identification numbers. Trapezium, first metacarpal, and STT joint surfaces were inspected. Descriptions of joint surfaces were graded using a 1-4 value corresponding with that of the E-G system and these values were correlated to radiographic staging.
Results Average pairwise Cohen’s Kappa (K) of IRR using the E-G classification system across all views was 0.459. IRR for each view is as follows: 0.461 for PA, 0.411 for CMC, and 0.508 for Robert’s. When comparing the E-G classification to clinical disease severity using each view, we found the following average pairwise K values: 0.470 for PA, 0.447 for CMC, and 0.377 for Robert’s.
Summary Points • Although there were greater differences between reviewers’ staging for each x-ray using the CMC view, there were more instances in which the reviewers predicted the actual disease severity with the CMC view than with the other views. • The CMC view is comfortable for the patient, best predicts actual disease severity, and should be considered as an alternative to Robert’s and PA views.
AM Poster 074: A1 Pulley Stretching for Trigger Finger: A1 Pulley Luminal Region Under Digital Flexor Tendon Traction Category: Hand
Hand and Wrist;Diseases and Disorders;Practice Management N/A - not a clinical study Grant received from: Japanese Society for Surgery of the Hand, 2018
Atsuro Yamazaki Yusuke Matsuura, MD, PhD Takane Suzuki, MD Tomoyo Akasaka, MD Naoya Hirosawa Kazuki Kuniyoshi, MD, PhD
Hypothesis A1 pulley stretching, a clinically beneficial treatment for trigger fingers, requires resisted PIP and MIP joint flexion obtained by grasping a block to create an active flexion force and a counteracting flexion tendon force, resulting in an elevation in the cross-sectional areas (CSA) of the A1 pulley luminal region and conceivably improving trigger finger symptoms. In 2017, using fresh-frozen cadavers, we demonstrated the mechanism of A1 pulley stretching by illustrating that traction forces of the flexor digitorum profundus (FDP) increase the CSA of the A1 pulley luminal region. Furthermore, the presence of a relationship between traction forces and the grip power recorded by a grip dynamometer, which is widely used in clinical practice, would facilitate the confirmation of the ideal intensity of A1 pulley stretching. This study aimed to investigate the relationship between resultant traction forces of flexor tendons and the grip power by pulling flexor tendons of fresh-frozen cadavers and recording the generated grip power using the Jamar handgrip dynamometer (Lafayette Instrument Co, Lafayette, IN, USA).
Methods We used two upper extremities of a fresh-frozen cadaver in this study. We fixed the forearms and wrist in the neutral position to the jig. The Jamar handgrip dynamometer was set on the palm of the cadaver. Then, both the flexor digitorum superficialis (FDS) and FDP were pulled separately through the stiff string until they were broken, and at one time, we recorded the resultant traction forces of flexor tendons and the grip power.
Results We observed a close relationship between the generated grip power and traction forces of flexor tendons. The grip power increased gradually with the traction force of flexor tendons. In addition, the ratios of traction forces of flexor tendons to the grip power were 2.4–5.9.
Summary Points • The relationship between resultant traction forces of flexor tendons and the grip power recorded by the Jamar handgrip dynamometer in widespread clinical use had not yet been proven. • Using fresh-frozen cadavers, this study revealed the relationship between the generated grip power using the Jamar handgrip dynamometer and traction forces of flexor tendons. • As the CSA of the A1 pulley luminal region gradually increased in the flexor tendon traction, the grip power was closely associated with traction forces of flexor tendons. • Clinically, the CSA of the A1 pulley luminal region can be increased by performing A1 pulley stretching with more grip power.
Bibliography 1: Chiba Y, Abe Y, Tokunaga S. Stretching is effective conservative management for trigger fingers[in Japanese]. J Hand Surg Jpn. 2015, 31: 935-40. 2: Iwakura N, Tokunaga S, Chiba Y et al. Controlled clinical trial for evaluating the effects of the stretching on trigger finger[in Japanese]. J Hand Surg Jpn. 2017, 33: 791-3. AM Poster 075: Parameters of Soft Tissue Swelling in Pyogenic Flexor Tenosynovitis Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Anthony Yi Colin D. Kennedy, MD Benjamin Chia, MD Stephen A. Kennedy, MD
Hypothesis Fusiform swelling has been described as a differentiating physical sign of pyogenic flexor tenosynovitis (PFT). We hypothesized that, among patients with digit infections, radiographic soft tissue swelling differs between PFT and non-PFT infected digits.
Methods Patients with a finger infection and radiographic evaluation were identified retrospectively from an institutional coding database at a large academic medical center. They were subsequently divided into 2 groups: PFT (n=31) and non-PFT infections (n=31). PFT was defined as visible purulence in the tendon sheath or positive culture growth from the sheath at surgery. Non-PFT infections included all other finger infections such as abscesses and cellulitis. Fifteen radiographic measurements were made on all included digits (Figure 1). A series of ratios and differences were calculated for each infected finger to characterize the pattern of swelling. Bivariate analysis was performed to detect significant differences between the PFT and non-PFT groups. Logistic regression was performed to reduce confounding and model potential relationships.
Results Neither the presence of diffuse swelling nor the shape of finger swelling distinguished PFT from non-PFT infections. All finger infections resulted in diffuse swelling. PFT was distinguished, however, by the difference between the volar and dorsal soft tissue thickness on radiographs at the proximal phalanx (p<0.001). This alone was an independent predictor of pyogenic flexor tenosynovitis (p<0.001). Area under the receiver operating characteristic curve was 0.83. A difference between volar and dorsal soft tissue swelling of =10mm predicted PFT with =76% probability (95%CI=58.5% - 87.3%) and had a sensitivity and specificity of 74% and 84%, respectively. A difference of 0 mm predicted a non-PFT infection with =95% probability (95%CI=73.4%– 99.2%).
Summary Points • As recognized by Kanavel, fingers with PFT are uniformly swollen. • However, neither fusiform swelling nor uniform swelling distinguish PFT from other finger infections. • The term “fusiform swelling” indicates spindle shaped swelling with tapering ends and is a misnomer for the appearance of acute PFT. • Acute PFT swelling is distinguished by different volar and dorsal soft tissue thickness at the level of the proximal phalanx and this may be considered in future prospective studies that investigate diagnostic evaluation and transfer guidelines.
Bibliography 1: 1. Kennedy CD, Lauder AS, Pribaz JR, Kennedy SA. Differentiation Between Pyogenic Flexor Tenosynovitis and Other Finger Infections. HAND. 2017;12(6):585-590. doi:10.1177/1558944717692089. 2: 2. Kennedy CD, Huang JI, Hanel DP. In Brief: Kanavel's Signs and Pyogenic Flexor Tenosynovitis. Clin Orthop Relat Res. 2016;474(1):280-284. doi:10.1007/s11999-015-4367-x. AM Poster 076: Clinical Care Redesign to Improve Value for Trigger Finger Release: A Before-and-After Implementation Study Category: Hand
Practice Management Level 4 Evidence
Matthew B. Burn, MD Lauren M. Shapiro, MD Sara Lynn Eppler, MPH Raj Behal, MD, MPH Robin N. Kamal, MD
Hypothesis The primary goal of this study was to compare the institutional total direct cost for isolated trigger finger release (TFR) before and after redesigning our clinical care pathway for trigger finger release. We hypothesized that the total direct costs would decrease after implementing this pathway. Secondarily, we hypothesized that patient time spent at the surgery center would decrease without a change in quality (defined by visual analogue scale for pain, VAS pain).
Methods Total direct cost, time at the surgery center, and VAS pain scores were collected for one hand surgeon at an ambulatory surgery center over a 3-year period. During this time period, we implemented a redesigned care pathway that altered phases of care and anesthetic choice. Cost data was reported as percentage change in the median and compared pre- to post- implementation and was compared to two surgeons using the traditional pathway at the same health system as controls. Power analysis was based on prior work on a carpal tunnel pathway. Significance was defined by a p-value less than 0.05.
Results Ten TFR (90% MAC) and 44 TFR (89% local alone) were performed pre- and post- implementation. From pre- to post-implementation, the study surgeon’s total direct cost decreased by 18%. During the same period, the control surgeons performed 47 TFR and 70 TFR using MAC with only 2% decrease in total direct cost. Median time spent at the surgery center improved by 40 minutes post-implementation with significantly faster setup time in the operating room (OR), total time in the OR, and time spent in recovery prior to discharge. There was no difference in quality (VAS pain).
Summary Points Redesigning the clinical care pathway for trigger finger release led to: • a decrease in institutional total direct cost, • a decrease in patient time spent at the surgery center, and • no loss in quality of care received.
AM Poster 077: Quantitative Evaluation of Thenar Muscles in Carpal Tunnel Syndrome by Ultrasonography Category: Hand
Hand and Wrist;Nerve;Diseases and Disorders Level 3 Evidence
Issei Nagura, MD, PhD Takako Kanatani, MD Yoshifumi Harada, MD Masatoshi Sumi, MD Atsuyuki Inui, MD Yutaka Mifune, MD
Hypothesis Quantitative analysis of thenar muscles in carpal tunnel syndrome (CTS) by ultrasonography is practical for evaluating the clinical severity of CTS.
Methods Eighty five patients with CTS who had a carpal tunnel release procedure (24 males and 61 females) with a mean age of 67.4 years (range, 36-92 years) were included in this study. Ultrasonographic examination was performed to evaluate the abductor pollicis brevis (APB) and opponens pollicis (OPP) muscles. The transducer was applied onto the palmer surface of the hand perpendicularly to the longitudinal axis of the first metacarpal bone. Both muscles were analyzed by measuring their thickness; the “APB depth” (from the inserted prominence of the OPP muscle above the first metacarpal bone to the palmar surface) and the “OPP depth” (from the ulnar prominence of the first metacarpal bone to the palmar surface of the OPP) (Figure 1).Thenar atrophy was evaluated visually and classified by the visual grading scale1): none, mild, moderate and severe. Also, a nerve conduction test was performed and classified according to the electrophysiological severity scale2): Stage 1-5. The correlation of “APB depth” and “OPP depth” with the visual grading scale were analyzed by the Chi-squared test (p<0.05). The correlation of “APB depth” and “OPP depth” with the electrophysiological severity scale were analyzed by the Turkey-Kramer HSD test (p<0.05).
Results The visual classification of these hands resulted in; none: 8, mild: 11, moderate: 40 and severe: 26. As the severity of the visual grading scale increased, the averages of the “APB depth” and “OPP depth” decreased (Table1). The significant correlations of Males-APB (p=0.0008) and OPP (p=0.049), Females-APB (p<0.001) and OPP (p=0.0013) were found. However, in parallel comparing the severity of the electrophysiological grading, “APB depth” and “OPP depth” did not correlate.
Summary Points Our ultrasonographic evaluation of thenar atrophy in CTS could be a useful tool for evaluating the thenar atrophy level. This technique is more precise than visual evaluation because it is a quantitative assessment.
Bibliography 1: Nagaoka M, et al. Endoscopic release for carpal tunnel syndrome accompanied by thenar muscle atrophy. Arthroscopy. 848-50, 2004. 2: Kanatani T, et al. Electrophysiological assessment of carpal tunnel syndrome in elderly patients: one-year follow-up study. J Hand Surg Am. 2188-91, 2014. AM Poster 078: Rotational Arthrodesis in Osteoarthritis of First CMC Joint Category: Hand
Hand and Wrist Level 4 Evidence
Yoon-Min Lee, MD Joo-Dong Yeo, MD
Hypothesis Arthritis of carpometacarpal (CMC) joint is common arthritis in hands. Because the saddle shape of CMC joint, surgeons have difficulties in preparation of the joint to flat surface for arthrodesis, so nonunion or delayed union may occur. We report 6 cases of arthrodesis by making a block including the joint surface and rotating 180 degrees without denudation of joint cartilage. Methods: Rotational arthrodesis is a new technique, to make a bone block including joint surface of trapezium and base of 1st metacarpal bones, and rotate the bone block to 180° and insert it. By the procedure, joint space is located at base of metacarpal bone and metaphyseal bone of 1st metacarpal bone is located at CMC joint level.
Results Radiologic bone union was confirmed at 8 weeks postoperatively in average. Range of motion in MCP joint was 70° and IP joint was 80° in all patients after 10 weeks after surgery. We performed this procedure to 7 patients, and obtained good clinical and radiologic results in all patients. Summary: In order to overcome the possibility of nonunion that often occurs in arthrodesis of 1st CMC joint, the rotated bone block works like inlay bone grafting and increase the union rate in arthrodesis without bone graft and troublesome cartilage denuding. This procedure can obtain early and firm bone union which may lead to good clinical results as well.
AM Poster 079: A Retrospective and Propsective Look at Bilateral, Staged Carpal Tunnel Releases Category: Hand
Hand and Wrist;Nerve Level 4 Evidence Grant support received from: 2015 AFSH Residents and Fellows Fast Track Grant.
Katherine Celeste Faust, MD Patrick Andy Holt, MD Hanci Zhang, MD Eliana B. Saltzman, MD Alexandra V. Paul, BS Marc J. Richard, MD
Hypothesis Patients who present with bilateral carpal tunnel syndrome and undergo staged release like their first one more. Factors like hand dominance, profession, and quantitative nerve study findings influence outcomes. We hypothesize that the first side to receive surgery is most often the more symptomatic side, and that it has a greater change in Boston Carpal Tunnel Questionnaire scores (BCTQs) from preoperatively to postoperatively.
Methods In the first limb of our surgery, a retrospective review of 566 open carpal tunnel releases, including 85 staged bilateral patients, was performed. 46 patients met criteria for inclusion. Patients were contacted for a phone survey, and their nerve conduction studies were audited. History of steroid injection and referral source were also queried. In the second portion, we prospectively collected patients over two years presenting with bilateral carpal tunnel syndrome, and surveyed them preoperatively and postoperatively at intervals to assess the change in their BCTQs. 81 patients enrolled, and 19 of these patients had bilateral staged releases during the study.
Results In the retrospective portion, 67% of patients reported no difference in carpal tunnel outcomes between their first and second surgeries. Hand dominance and staged timing of surgery did not influence outcomes. There was a shorter time between emg and surgery when the study is ordered by a hand surgeon compared to other providers, but no difference in outcomes was noted. Preoperative corticosteroid injections did not correlate with disease severity, reported outcome, or order of surgical release. In the prospective portion, 47% of patients felt that a better outcome was obtained on one hand. BCTQs did not statistically differ between the hands that subjectively did better. There was a greater decrease in BCTQs from preoperatively to six weeks compared to six to 12 weeks in our data set. No data statistically correlated BCTQ to nerve study results.
Summary Points • The majority of patients who have remotely undergone bilateral, staged carpal tunnel releases do not recall one side doing better than the other. • There appears to be a greater decrease in dysfunction, as quantified by BCTQs, early in the recovery process (0-6 weeks) versus later (6-12 weeks). • At six or more months postoperatively, there is no statistical difference in patient- reported outcomes detected for carpal tunnel release relative to surgical timing, hand dominance, or nerve study severity.
Bibliography 1: Collier AM et al. A comparison of the functional difficulties in staged and simultaneous open carpal tunnel decompression. JHS(E) 2014; 39E(6): 627-31. 2: deBeer J et al. Staged bilateral total knee arthroplasty does history dictate the future. Arthroplasty 2013;28: 1148-51. 3: McCarthy JA et al. Bilateral endoscopic carpal tunnel release: simultaneous versus staged operative intervention . Arthroscopy, March 2002; 18 (3): 316-21. 4: Stern PJ et al. A cost analysis of staged and simultaneous bilateral carpal tunnel release. Hand 2012; 7: 327-32. 5: Thomson JG et al. Does the severity of bilateral carpal tunnel syndrome influence the timing of staged bilateral releases. PRS, July 2011; 67(1): 30-3.
This research was supported by a Residents & Fellows Fast Track Grant from the American Foundation for Surgery of the Hand. AM Poster 080: Wide-Awaken Approach Improves Outcome after Extensor Indicis Proprius to Extensor Pollicis Longus Tendon Transfer over Standard Non-Wide Awaken Approach Category: Hand
Hand and Wrist Level 4 Evidence
Ji Sup KIM, MD Won Taek Oh, MD Yoochul Jeong
Hypothesis The wide-awake approach enables surgeon to adjust tendon transfer tension with intraoperative active movement and enable immediate cortical adaptation of patient after tendon transfer. Thus, we have assumed that the Extensor Indicis Proprius(EIP)–to–Extensor Pollicis Longus (EPL) Tendon Transfer Using the Wide-Awake Approach will yield better results compared with conventional surgery under regional or general anesthesia. The aim of this study was to compare clinical outcomes and complications of the wide awaken and non-wide awaken approach to EIP to EPL Tendon Transfer for chronic EPL rupture.
Methods From May 2014 to December 2016, 30 patients with chronic EPL rupture underwent EIP to EPL tendon transfer. Group A with 12 patients were treated with wide awake approach by one senior surgeon, wheareas Group B with 18 patients were treated with general anesthesia by the other senior surgeon. The patient assignment was not randomized. The 2 groups were compared based on thumb motion, grip strength, pinch power, the specific EI-EPL evaluation method (SEEM) for scoring by lemmen et al., the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) score at 2, 4, 6, 12 months after surgery.
Results At 2 months and 4months, the Group A produced significantly better outcomes than Group B regarding Range of motion, SEEM score (85 ± 5.5 vs 71 ± 10.0, p=0.001 at 2 months, 92 ± 5.2 vs 83.3 ± 9.3, p=0.001 at 4 months) and DASH score (19.5 ± 8.4 vs 29 ± 11.0, 13.4 ± 7.2 vs 19.3 ± 9.3, p=0.001 at 4 months). clinical outcomes were similar at 6, and 12 months. The complication rates were 8% in group A and 22 % in group B; The complications included stiffness (n=1) in the group A and Re-rupture of tendon (n=1), Stiffness (n=3) in the group B
Summary Points • The clinical outcomes of both groups were favorably accepatable in a majority of the patients. • However, compared with conventional approach, wide awake approach group showed lower complication rates and better range of motion of thumb, functional and subjective outcomes especially at short-tearm follow-up.
AM Poster 081: Cylindrical Osteochondral Autograft for PIP Joint Contracture Treatment Category: Hand
Hand and Wrist Level 4 Evidence
Kozo Shimada, MD, PhD Ko Temporin, MD, PhD Keiichiro Oura, MD Hiroyuki Tanaka, MD, PhD
Hypothesis Cylindrical osteochondral autograft with external fixator for finger PIP Joint can survive and work well as a reconstructed finger PIP joint.
Methods Thirteen cases of post-traumatic or arthritic finger joint contracture including three bony ankylosis cases were treated with cylindrical osteochondral autograft. Surgical procedure: Through volar shotgun approach, the articular surface was explored. Damaged articular surface was debrided and made a cylindrical hole into the phalangeal bone (both sides of the joint in ten cases and only for base of mid-phalanx in three cases). Donor site of the graft was costal rib in 8 cases and 3rd CM joint in 5 cases. Harvested osteochondral graft is formed manually like an osteochondral wedge and introduced in the cylindrical hole of the donor site (Figure 1). Articular surface was shaved with a scalpel and the joint was reduced. External fixator was applied for 4 to 6 weeks after the operation allowing joint motion under the guidance of hand therapists. Therapy was continued three to five months postoperatively and clinical follow-up was done at postoperative 6 months.
Results All of the patients received postoperative follow-up at 6 months and ten cases were followed more than one year (6-96 months with mean of 24 months). Grafted bone was incorporated in the donor site and no absorption was observed at followed radiography. Average flexion/extension/arc of the PIP joint was 26/-16/10 preoperatively and improved to 61/-14/47 postoperatively. No one complained of finger pain both at rest and in motion. One case of posttraumatic severe bony ankylosis showed re-ankylosis but the other twelve cases gained functional range of motion (average gain of the PIP motion in those 12 cases was 50 degrees) at postoperative 6 months and the range of motion was kept in longer followed cases. In radiography, PIP joint was kept aligned and articular space was preserved after surgery.
Summary Points • PIP Joint arthroplasty is still challenging because of frequent implant failure and/or sinking in longer follow-up. • Osteochondral autograft is theoretically useful option as articular reconstruction, however longer survival is unreliable because of postoperative avascular necrosis. • Our cylindrical procedure promises stable fixation of the osteochondral graft surrounded by viable bony structure, which makes better graft incorporation. • This technique is useful for finger PIP joint contracture in posttraumatic and arthritic arthropathy.
Bibliography 1: Capo JT et al. Hemicondylar hamate replacement arthroplasty for proximal interphlangeal joint fracture dislocations: an assessment of graft suitability. J Hand Surg Am. 2008: 733-9. 2: Hasegawa T et al. Arthroplasty of the interphalangeal joint using costal cartilage graft. J Hand Surg Br 1992:583-5. 3: Shimada K et al. Cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans. J Bone Joint Surg Am 2012: 992-1002. AM Poster 082: Flexor Pollicis Brevis Muscle: An Anatomical Study and Clinical Implications Category: Hand
Hand and Wrist;Nerve;General Principles N/A - not a clinical study
Rodrigo Guerra Sabongi, MD Edie Benedito Caetano Yuri C. Nakamichi Renato A. Andrade Maico M. Sawada Luiz A. Vieira, MD
Hypothesis A variety of clinical aspects observed in isolated median or ulnar nerve lesions does not agree with the classic pattern of Flexor Pollicis Brevis muscle (FPB) innervation. The better knowledge of median and ulnar nerve innervation pattern helps to understand anatomic variations and paradoxic complains of sensory and motor loss. This paper reports an anatomical study of pattern, incidence, innervation and clinical implications of FPB.
Methods Sixty hands of 30 fresh adult cadavers were dissected from 1983 to 2015. Careful dissections were performed under high magnification (with a surgical microscope) to permit fine dissection. We investigated innervation of the two FPB muscle heads. Schematic drawings of the pieces were created and systematically photographed.
Results The superficial head of FPB was innervated by the median nerve in 70% while in 30% it received nervous fascicles from the median nerve and deep branch of the ulnar nerve (double innervation). Most commonly (41.6%), the median nerve fascicles to the FPB superficial head were detached from its thenar motor branch and approached this muscle by its palmar surface or by its medial border. The deep FPB head was absent in 15%. When present, 78.4% presented with a double innervation pattern. Double innervation of both FPB muscle heads was found in 16.6%. The most frequent FPB pattern of innervation that should be considered normal is the superficial head innervated by branches of the median nerve and the deep head receiving branches from both ulnar and median nerves.
Summary Points • The variety of clinical findings of median and ulnar nerves injuries is not in accordance with "classic" innervation patterns • The superficial head of the FPB usually receives branches from the median nerve • The deep head of the FPB generally receives double innervation (ulnar and median nerves)
Bibliography 1: Day MH, Napier JR. The two heads of flexor pollicis brevis. J Anat 1961; 95: 123-30. 2: Brooks HS. Variations in the nerve supply of the flexor brevis pollicis muscle. J Anat Physiol 1886/86; 20(Pt 4): 641-4. 3: Highet WH. Innervation and fuction of the thenar muscles. Lancet 1943; 1: 227-30. 4: Rowntree T. Anomalous innervation of the hand muscles. J Bone Joint Surg Br 1949; 31B(4): 505-10. 5: Harness D, Sekeles E, Chaco J. The double motor innervation of the opponenes pollicis muscles: An electromyographic study. J Anat 1974; 117(Pt 2): 329-31. AM Poster 083: Usefulness of Ectopic Transplantation in Multiple Finger Amputation Injury Category: Hand
Hand and Wrist;Practice Management Level 5 Evidence
Shuhei Yoshida, MD,PhD
Hypothesis In general, one by one replantation for each finger are attempted depending on the state of damage in case of multiple fingers amputation injuries. It is possible to reduce the burden on the operator by replacing multiple teams in an organization with many microsurgeons. However, it is impossible to reduce the operating time and the physical burden on the patients even by multiple microsurgeons team in one by one replantation. We attempted shortening the operation time by using Ectopic transplantation and examined its usefulness.
Methods The patient was a 44-year-old male who has a history of myocardial infarction. He suffered four fingers amputation injuries from the left index finger to little finger during a rubber cutting work. Although it was an emergency operation, multiple teams could be organized. In consideration of the patient's past history, in preparation for unexpected circumstances, we decided to perform simultaneous ectopic transplantation in parallel with usual one by one replantation for the purpose of shortening the operation time and reducing the physical burden on the patients. Ectopic transplantation was performed on the middle finger to the descending branch of lateral femoral circumflex artery. There was no problem in the general condition during the operation. That is why we re- replanted the middle finger to the original position after ectopic replantation during the initial replantation surgery so as to be advantageous for improving postoperative function.
Results It took around 15 hours until all replantation was done. It was estimated that the combined replantation with ectopic one could have reduced the operation time to 60%, if the re- replantation after ectopic replantation had not been performed. All the fingers completely survived. There is no problem in daily life for the patient, although there remains a slight stiffness on fingers.
Summary Points It was thought that the replantation surgery combined with ectopic replantation can reduce the operation time and the burdens on surgeons and patients at initial stage. It could be one of the options in multiple finger amputation injury.
AM Poster 084: Load On Hands While Using Forearm Crutches Category: Hand
Hand and Wrist;General Principles N/A - not a clinical study
Marion Mühldorfer-Fodor, MD Friederike Roesch Natascha Weihs Jörg van Schoonhoven, MD, PhD Renee Fuhrmann Karl Josef Prommersberger, PhD
Hypothesis The load on the hand while using forearm crutches varies for the left and right hand, for different kind of crutches, and while unloading one leg at different levels.
Methods For this experimental, biomechanical study, 26 healthy subjects used forearm crutches with anatomical and ergonomic handles, and arthritis crutches. All subjects performed tests with 1) unloading the left leg completely, 2) loading the left leg with 20kg load or 3) using crutches to assist full weight bearing on both legs. Pressure sensor soles were used to monitor the correct unloading of the left leg. During testing, pressure sensor pads captured the maximum load transmitted by the palm of both hands. Statistical tests were used to compare the left and right hand, ergonomic and arthritis crutches, and the different leg loading conditions. Further, the load on the radial and the ulnar half of the left palm were measured separately to compare ergonomic and anatomical handles.
Results Using ergonomic forearm crutches, the right and left hand bore on average 88 and 97 N (12/13% of the body weight) to assist full load on both legs, with arthritis crutches 10 and 12 N (1/2%). Loading the left leg with 20kg, there was on average 298 on the right and 356 N on the left hand (40/48%) with ergonomic crutches, 21 and 38 N (3/5%) with arthritis crutches. For completely unloading the left leg, there was on average 354 and 417 N (34/58%) with ergonomic crutches and 32 and 58 N (5/8%) with arthritis crutches. The difference between ergonomic and arthritis crutches was significant for all tests. For both kinds of crutches, the load was significantly lower on the right hand than on the left hand, performing partially and completely unloading the left leg. Using crutches to assist full load on both legs, there was no significant difference of both hands´ load. For all leg loading conditions, the load applied on the radial half of the palm was significantly higher than that on the ulnar half. Using anatomical handles, the load on the radial half was similar and the load on the ulnar half was slightly less in comparison to ergonomic handles.
Summary Points • Unloading one leg partially or completely results in significantly more load on the corresponding hand • The least load on the hand was measured when using arthritis crutches • There is more load on the radial than on the ulnar half of the palm
Bibliography 1: Sala DA, et al. (1998)."Crutch handle design: effect on palmar loads during ambulation." Arch Phys Med Rehabil 79(11):1473-6. 2: Cobb, T. K., et al. (1995). "Externally applied forces to the palm increase carpal tunnel pressure." J Hand Surg Am 20(2): 181-185. 3: Capitani, D. and S. Beer (2002). "Handlebar palsy--a compression syndrome of the deep terminal (motor) branch of the ulnar nerve in biking." J Neurol 249(10): 1441-1445 AM Poster 085: Comparative Study of Ultrasonography Guided Percutaneous A1 Pulley Release versus Blinded Percutaneous A1 Pulley Release Category: Hand
Hand and Wrist;Diseases and Disorders;Practice Management Level 4 Evidence
Hongje Kang Saintpee Kim HeeSeok Yang KyeongHoon Lim
Hypothesis The purpose of this study was to compare the results of blind vs ultrasonography-guided percutaneous A1 pulley release for treatment of trigger finger.
Methods This retrospective study included 42 patients (50 fingers) who underwent blind release, and 40 patients (46 fingers) who underwent ultrasonography-guided release. Visual analog scale (VAS) score, proximal interphalangeal joint contracture, complications, and patient satisfaction were compared between groups.
Results At the final follow-up, triggering had disappeared in all patients who underwent ultrasonography-guided release, whereas three patients who underwent blind release required revision surgery for postoperative trigging. No complications were observed. VAS score was significantly different between groups at two and four weeks postoperatively. All patients who underwent ultrasonography-guided release were satisfied, whereas three patients who underwent blind release were not satisfied.
Summary Points • Ultrasonography-guided percutaneous A1 pulley release for treatment of trigger finger is considered to reduce postoperative pain and complications, such as incomplete release, compared with a blind procedure.
Bibliography 1: Wang J, Zhao JG, Liang CC. Percutaneous release, open surgery, or corticosteroid injection, which is the best treatment method for trigger digits? Clin Orthop Relat Res. 2013;471:1879-86. 2: Quinnell RC. Conservative management of trigger finger. Practitioner. 1980;224:187-90. 3: Lin CJ, Huang HK, Wang ST, Huang YC, Liu CL, Wang JP. Open versus percutaneous release for trigger digits: Reversal between short-term and long-term outcomes. J Chin Med Assoc. 2016;79:340-4. 4: Lorthior J, Jr. Surgical treatment of trigger-finger by a subcutaneous method. J Bone Joint Surg Am. 1958;40-A:793-5. 5: Zhao JG, Kan SL, Zhao L, Wang ZL, Long L, Wang J et al. Percutaneous first annular pulley release for trigger digits: a systematic review and meta-analysis of current evidence. J Hand Surg Am. 2014;39:2192-202. AM Poster 086: Pathologic Fractures in Primary Bone Neoplasms of the Fingers Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Kamilcan Oflazoglu Jonathan Lans, MD Santiago Lozano-Calderon, MD Neal C. Chen, MD
Hypothesis There are no predictors for pathologic fractures in neoplasms affecting the bones of the fingers.
Methods We retrospectively identified 131 histologically confirmed neoplasms affecting the bone, 97 phalanges and 34 metacarpals, over a 13-year period. The mean age at presentation was 42 years and 57% of the patients were female. Most tumors (84%) were benign bone neoplasms and the remainder were primary bone sarcomas. Tumors were located most frequently in the long finger (27%), ring finger (23%) and small finger (23%). Predictors evaluated included demographics, clinical information, tumor size, Enneking and Lodwick-Madewell classifications. All explanatory variables with a p-value of 50%. Tumors of the metacarpal bones were less likely to fracture compared to the proximal phalanx, (OR=0.21, p=0.0070).
Summary Points • Primary benign or malignant bone tumors located in the small finger are at risk for pathologic fracture. • Tumors of the metacarpals have a lower risk for a pathologic fracture.
Bibliography 1: Sassoon AA, Fitz-Gibbon PD, Harmsen WS, Moran SL. Enchondromas of the hand: factors affecting recurrence, healing, motion, and malignant transformation. J Hand Surg Am. 2012;37(6):1229-1234. 2: Simon MJK, Pogoda P, Hövelborn F, Krause M, Zustin J, Amling M, et al. Incidence, histopathologic analysis and distribution of tumours of the hand. BMC Musculoskelet. Disord. 2014;15:182. doi:10.1186/1471-2474-15-182 AM Poster 087: Maximal Advancement of Homodigital Neurovascular Island Flaps Category: Hand
Hand and Wrist;General Principles N/A - not a clinical study
Chin Xi, MD Jin Xi Lim, MD Sandeep Sebastin, MD
Hypothesis Homodigital neurovascular island (NVI) flaps are used for reconstruction of pulp defects with varying degrees of advancement reported (maximum of 22mm in the literature). We find that such advancement is hard to achieve in practice. It is unclear how flap advancement was measured and if flexion of the digit was required (“relative advancement”). The aim of this study is to determine the maximal advancement of a homodigital neurovascular island flap measured with the digit fully extended (“absolute advancement”). Our hypothesis: 1) the “absolute advancement” measured in this study will be less than the maximal advancement reported in the literature; 2) maximal advancement can be predicted based on finger length.
Methods 27 cadaveric digits were used. The distances from the fingertip to specific anatomical landmarks were measured. A 1x1cm flap was designed on both radial and ulnar side of the pulp and was sequentially raised till the proximal interphalangeal joint (PIPJ) crease, palmo-digital crease, and bifurcation of the common digital artery. The ulnar digital artery of the index, middle and ring finger were then sacrificed and the flap dissected till the superficial palmar arch. The advancement of the flap at each dissection point was recorded after applying gentle traction.
Results Average advancement following dissection till the PIPJ crease, the palmo-digital crease, following division of adjacent digital artery and till the superficial arch were as follows: 8.0mm (SD 2.5), 12.4mm (SD 3.6), 15.7mm (SD 2.8) and 18.0mm (SD 3.4). When dissection was done till the palmodigital crease, it was found that advancement was 20% of the digit length.
Summary Points • A maximum of 18mm advancement was found when dissection was carried out till the superficial arch. • Flap advancement is about 20% of the digit length when dissection was done till the palmodigital crease.
Bibliography 1: Sano et al. Relationship Between Sensory Recovery and Advancement Distance of Oblique Triangular Flap for Fingertip Reconstruction. J Hand Surg 2008; 33A:1088 – 92 2: Adani et al. Homodigital Neurovascular Island Flaps with "Direct Flow" Vascularization. Ann Plast Surg 1997; 38:36-40 3: Foucher et al. Homodigital Neurovascular Island Flaps for Digital Pulp Loss. J Hand Surg 1989; 14B: 204-8 AM Poster 088: Additional Treatment after Collagenase Injections and Needle Fasciotomy for Dupuytren’s Disease: A Retrospective Cohort Study Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Denise M. J. Arnold, BSc Jonathan Lans, MD Ritsaart F. Westenberg, MD Neal C. Chen, MD
Hypothesis There are no factors associated with additional treatment in patients after collagenase injections or needle fasciotomy for Dupuytren’s disease.
Methods Using Current Procedure Terminology codes we retrospectively identified adult patients that underwent collagenase injection or needle fasciotomy for Dupuytren’s disease between February 1st 2010 and December 31st 2014 at a single institutional system. We included 244 patients that had 258 fingers treated with collagenase and 25 patients that underwent 30 needle fasciotomies. To avoid within-individual correlations, only the first procedure per patient was included. Patients had a median age of 68 (61-74) years and were followed for a median of 59 months (46-74). The ring (n=106) and the small finger (n=151) were mostly treated followed by the middle (n=26), thumb (n=4) and one patient had their index finger treated. Through a medical chart review we collected information regarding patient demographics and treatment characteristics. Additional treatment either for recurrence of contracture (increased joint contracture compared to after initial treatment) or persistence of contracture (persistent, but not increased contracture after initial treatment) was recorded. To evaluate factors associated with additional treatment we performed a bivariate analysis and multivariable logistic regression.
Results Additional treatment for recurrence after collagenase injection and needle fasciotomy was performed in 23% and 10% of the fingers respectively (p=0.41). Additionally, 11% of collagenase and 10% of needle fasciotomy patients had additional procedures because of persistent contracture. In multivariable logistic regression, younger age (p=0.036) and bilateral disease (p=0.003) were independently associated with additional treatment for recurrence after collagenase injection. Skin tears occurred after 36 (14%) collagenase manipulations and 6 (20%) needle fasciotomies. Fingers treated with needle fasciotomy underwent open fasciectomy more frequently compared to those that had an injection with collagenase (13% vs. 5.8%, p=0.015).
Summary Points • Additional treatment for recurrence after collagenase injection was performed in 23% of fingers and was associated with younger age and bilateral disease. Additional treatment for persistence after collagenase injection was performed in 11% of fingers. • Additional treatment for both recurrence and persistence after needle fasciotomy was performed in 10% of fingers. • Needle fasciotomy patients had higher rates of secondary open fasciectomies compared to collagenase injection.
AM Poster 089: Outcomes of Digital Pulley Reconstruction with Sterile, Acellular Allograft Pulleys: A Comparison with Tendon-Based Pulley Reconstruction Category: Hand
Hand and Wrist;Diseases and Disorders;General Principles Level 4 Evidence
Brent R. DeGeorge Jr., MD, PhD Roberto A. Martinez, MD Anthony Archual, MD Jane Gui A. B. Chhabra, MD David B. Drake, MD
Hypothesis We have previously demonstrated the safety and feasibility of sterile, acellular pulley allografts for reconstruction of pulley deficits with symptomatic bowstringing. However, comparisons to existing techniques for pulley reconstruction have not previously been reported. We hypothesized that the use of allograft pulleys for pulley reconstruction would result in reduced procedural time with equivalent clinical outcomes compared to tendon-based pulley reconstruction.
Methods After institutional approval, all cases of pulley reconstruction between November 2013 and November 2015 were reviewed using either sterile, acellular allograft A2 and A4 pulleys or a tendon-based reconstruction using a triple loop repair technique with autograft palmaris longus or flexor carpi radialis tendon. Patients with a history of multiple concomitant procedures were excluded. Patient demographics, co-morbidities, operative details (including tourniquet and total operative times, number of pulleys repaired), post-operative complications (including surgical site infection, re-operation, stiffness, or persistent pain), disability of the arm, shoulder, and hand (DASH) scores, and follow-up data were recorded. A p-value of < 0.05 was considered statistically significant.
Results Fifteen pulleys in 10 fingers of 10 patients were reconstructed. 5 tendon-based and 5 allograft- pulley based reconstructions were performed. Patients were followed for an average of 12.5 +/- 2.9 months. There were no differences between groups with regard to age, gender, body mass index, or co-morbidities. The most common indication for surgery was trauma followed by infectious etiologies. Four of 5 patients in the allograft pulley group had multiple pulleys reconstructed versus 1 in the tendon-based group. One patient in the tendon-based group required re-operation for persistent bowstringing, whereas no patients in the allograft pulley group required re-operation. Both total operative and tourniquet times were significantly reduced in the allograft pulley group compared to tendon-based reconstruction (46 +/- 5.5 vs. 89 +/- 12.9 minutes and vs. 34 +/- 6.8 vs. 63 +/- 5.3 minutes; p = 0.015 and 0.014, respectively). Post-operative DASH scores were lower in the allograft pulley group (56.8 vs 3.6, p=0.11). There was no significant difference in post-operative range of motion between groups.
Summary Points • Pulley reconstruction with allograft is an efficient, technically feasible, reconstructive technique that reconstructs “like with like” and eliminates donor site morbidity. • Overall operative and tourniquet times were significantly decreased using an allograft pulley-based technique for pulley reconstruction. • Multicenter, randomized clinical trials are indicated to demonstrate the potential functional benefits of allograft-based pulley reconstruction.
Bibliography 1: DeGeorge BR Jr, Rodeheaver GT, Drake DB. Operative technique for human composite flexor tendon allograft procurement and engraftment. Ann Plast Surg. 2014;72(6):S191-7. 2: DeGeorge BR Jr, Drake DB. The biophysical characteristics of human composite flexor tendon allograft for upper extremity reconstruction. Ann Plast Surg. 2014;72(6):S184-90. 3: Drake DB, Tilt AC, DeGeorge BR. Acellular flexor tendon allografts: a new horizon for tendon reconstruction. J Hand Surg Am. 2013 Dec;38(12):2491-5. AM Poster 090: Extended Dorsocommisural Flap for Finger Coverage: A Clinical Study Category: Hand
Hand and Wrist Level 4 Evidence
Hiroshi Yamamoto
Hypothesis The dorsocommissural flap (DCF) is originally harvested from the dorsal finger web. It has the pivot point just proximal to the proximal interphalangeal(PIP) joint. We show the flap may be extended using the dorsal metacarpal artery (DMA).
Methods We show three cases which needed the soft tissue reconstructions of the fingers. The extended DCF was harvested from the metacarpal space between the extensor digitorum tendons.including the fascia of the lumbricalis muscle. The metacarpal artery was identified through the fascia. The rate of the existence of DMAs is reported to be more than 86%. The pedicle was dissected to the neck of the proximal phalanx together with enough subcutaneous tissue. We tunneled subcutaneously at the proximal phalangeal region to lead the pedicle. An 26-year-old man suffered from flexion contracture of the right little finger after the flexor digitorum profundus (FDP) tendon re-rupture. When we removed the contracture to reconstruct the FDP tendon by the staged procedure, the volar skin defect occurred. We covered the wide defect with the extended DCF from the fourth metacarpal space. An 73-year old man lost the wide skin coverage of the right ring finger by the open fracture. We used the extended DCF from the fourth metacarpal space to fix and flap. An 48-year old man amputated the middle finger at the neck of the middle phalanx and degloved the middle phalangeal region. We used the extended DMF from the second metacarpal space in combination with the cross finger flap to preserve the length of the finger.
Results All flaps achieved primary healing. All patients returned to the pre-injury activity.
Summary Points • By harvesting the flaps from the metacarpal spaces, they can cover the wider skin defect and reach the tip of the fingers. • The DMAs frequently exist even at the fourth metacarpal space. • The extended DCF may be pretty reliable.
Bibliography 1: Msquelet AC, Vale ti P. Ann Chir Plast Esthet, 1994 2: Dauphin N, Casoli V. J Hand Surg, 2011 AM Poster 091: Treatment of Dupuytren’s Contracture with Needle Aponeurotomy is Safe in the Anticoagulated Patient Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Shelley S. Noland, MD Aaron Paul, MD Lacey Pflibsen Marco Rizzo, MD
Hypothesis It is safe to use needle aponeurotomy to treat Dupuytren’s contracture in the anticoagulated patient.
Methods A retrospective review of all patients undergoing a needle aponeurotomy for Dupuytren’s contracture by one surgeon between 2010 and 2017 was performed. Outcomes included demographics, type of anticoagulation, skin tear, sensory abnormality, tendon rupture, hematoma, and bleeding. Statistical analysis included chi-square and Fisher exact tests.
Results There were a total of 658 procedures performed in 287 patients. Treated locations included the first web space (n=18), thumb (n=20), index (n=26), middle (n=72), third web space (n=1), ring (n=222), and small fingers (n=299). 82% of patients were male (n=236), 18% female (n=51). Average age was 65. Average follow up was 303 days. Of the 658 procedures, 43% of the patients (n=280) were anticoagulated. The majority were taking aspirin (96%, n=270), followed by warfarin (6%, n=16), clopidogrel (0.4%, n=1), apixaban (0.7%, n=2), dabigatran (0.7%, and enoxaparin (0.7%, n=2). Several patients were taking multiple anticoagulants. There were 47 skin tears (7%), 16 in the anticoagulated group (6%), and 31 in the not-anticoagulated group (8%). 26% of the skin tears occurred in patients taking aspirin (n=12), 9% warfarin (n=4). 49 patients (7%) experienced temporary sensory disturbances, 18 patients in the anticoagulation group (6%), and 31 in the not-anticoagulated group (8%). No patients experienced tendon rupture, a hematoma requiring intervention, or uncontrollable bleeding.
Summary Points • Anticoagulation, particularly aspirin use, is commonly encountered by hand surgeons treating Dupuytren’s contracture. • When reviewing needle aponeurotomy, there is no significant difference in complications in the anticoagulated patient versus the not-anticoagulated patient. • It is safe to perform needle aponeurotomy for Dupuytren’s contracture in the anticoagulated patient, regardless of the type of anticoagulation.
Bibliography 1: Cheung K, Walley KC, Rozental TD. Management of complications of Dupuytren contracture. Hand Clin. 2015 May;31(2):345-54. PMID: 25934208 2: Morhart M. Pearls and pitfalls of needle aponeurotomy in Dupuytren's disease. Plast Reconstr Surg. 2015 Mar;135(3):817-25. PMID: 25719700 3: Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for Dupuytren contracture in over 1,000 fingers. J Hand Surg Am. 2012 Apr;37(4):651-6. PMID: 22464232 4: Diaz R, Curtin C. Needle aponeurotomy for the treatment of Dupuytren's disease. Hand Clin. 2014 Feb;30(1):33-8. PMID: 24286740 AM Poster 092: A New Suspensionplasty for Basal Joint Arthritis of the Thumb: An Easy Procedure without Bone Tunnel Category: Hand
Hand and Wrist Level 4 Evidence
Hironori Matsuzaki, MD
Hypothesis For basal joint arthritis of the thumb, a new simple arthroplasty consisting of trapeziectomy, tissue interposition, and ligament reconstruction using abductor pollicis longus tendon (APL) without bone tunnel, is easy and reliable to reduce pain and improve activity of daily living (ADL).
Methods We reviewed 13 hands (6 right, 7 left) of 12 patients (10 women) who underwent suspensionplasty using APL without bone tunnel, between April 2013 and July 2017. Average age at the surgery was 70 years (range, 53 to 87). Eaton grade was stage III in 11 hands and stage IV in 2. From dorsal skin incision, we removed trapezium and incised one slip of APL tendon at musculotendinous junction, leaving its attachment to the base of 1st metacarpal intact. The incised APL tendon was pulled distally and reattached to the dorsum of the first metacarpal with bone anchor, and was passed to the base of 2nd metacarpal under extensor pollicis brevis and longus, and radial artery. The transferred tendon was woven into the insertion of extensor carpi radialis longus tendon to reconstruct the dorsal ligament complex and the rest of the tendon was drawn back to the 1st metacarpal, augmenting the reconstructed ligament. Palmaris-longus tendon ball was inserted to the space created after removal of trapezium. The evaluated outcomes were pain, grip and pinch strength, limitation of ADL, complication, and trapezial space ratio (TSR) which was obtained by dividing trapezial space by the length of proximal phalanx.
Results At the final examination of 6 to 53 months (mean, 19) after surgery, pain was relieved in all hands (gone in 8, slightly in 5). Average values (% of normal) of grip strength, lateral pinch, and tripod pinch were 20 Kg (86%), 5.3 Kg (75%), and 6.1 Kg (79%) respectively. ADLs were improved in all patients; 2 patients complained weakness of pinch strength when using nail cutter or clothespin. TSR was decreased from 31% to 22%. Two patients complained irritation of radial sensory nerve.
Summary Points This procedure is a modification of an arthroplasty reported by Sammer [1] in terms of reattachment of the insertion of APL tendon to the dorsum of 1st metacarpal, which is useful to hold the base of metacarpal in appropriate position and to prevent the tendon from slipping down to the trapezial space. This procedure is technically easier because of easy access for trapezial excision and APL harvest from single dorsal incision and no need for drilling bone.
Bibliography 1: Sammer DM: Description and outcomes of a new technique for thumb basal joint arthroplasty. J Hand Surg 35A: 1198-1205, 2010 AM Poster 093: A Medial Thigh Adipofacial Flap For Hand Reconstruction Category: Hand
Hand and Wrist;General Principles N/A - not a clinical study
Todd Zuhlke, MD Ramesh C. Srinivasan, MD David W. Person, MD William C. Pederson, MD, FACS Lloyd P. Champagne, MD
Hypothesis The investing fascia of the medial thigh can be used as an adipofascial flap for free-tissue transfer in hand reconstruction. The perforator concept has expanded reconstructive options and provides better understanding of perfusion patterns. The gracilis muscle is a workhorse donor due to consistent neurovascular supply, limited donor morbidity, and ability to use as a functional muscle. Yousif etal., followed by Taylor eval., described the medial thigh anatomy. Specific hand reconstruction needs include thin and pliable flaps to restore form and function. No workhorse flap to date has been ideally suited. Drawbacks include tissue type, bulk, contour deformity, and donor site morbidity. Here, a medial thigh adipofascial flap is described as an alternative source for a thin, pliable, vascularized flap. The flap is supplied by the dominant pedicle to the gracilis muscle, a flap with low morbidity and familiar anatomy. The gracilis is a Mathes and Nahai type II flap. The dominant pedicle branches from the medial circumflex femoral (89.6%), passing between the adductor longus and brevis. Prior to entering the gracilis several divisions may be seen, with at least a transverse and one or two ascending branches, perfusing the medial thigh adipofascial tissues that invest the gracilis, adductor longus, and adductor magnus, creating a contiguous adipofascial (perforasome) flap (Figure 1).
Methods Flap dissection was performed on ten human cadaver thighs. Specimen data were recorded. Through a longitudinal incision, the gracilis dominant pedicle was identified. The borders of flap harvest were defined as lateral - the lateral aspect of the fascia overlying the adductor magnus; caudal - first distal gracilis minor pedicle; cephalad - first proximal gracilis minor pedicle. At the medial border, fascia overlying the gracilis was incised on the medial aspect. Dissection was continued posteriorly along the lateral surface of the gracilis muscle, ligating the dominant pedicle where it perforated the gracilis muscle. Dissection was continued posterior to where the fascia transitioned to the deep subcutaneous adipose tissue (deep to the superficial thigh fascia), then anterior along the medial border of the adductor magnus, lifting the entire flap, containing the pedicle, off the adductor magnus.
Summary Points • The medial thigh adipofascial tissue may be considered when a thin moderate size (19x9 cm) flap with low donor site morbidity is needed. • Specifically, it may be suitable in the hand where thin vascularized coverage is required to maintain tendon gliding and cover vital structures without creating excessive bulk.
Bibliography 1: Friedrich JB, Pederson WC, Bishop AT, Galaviz P, Chang J. New workhorse flaps in hand reconstruction. Hand (N Y). 2012; 7: 45-54. 2: Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009; 124: 1529-1544. 3: Taylor GI, Cichowitz A, Ang SG, Seneviratne S, Ashton M. Comparative anatomical study of the gracilis and coracobrachialis muscles: implications for facial reanimation. Plast Reconstr Surg. 2003; 112: 20-30. 4: Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg. 2011; 127: 1447-1459. 5: Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1992; 29: 482-490. AM Poster 094: The Feasibility and Usability of a Ranking Tool to Elicit Patient Preferences at Point of Care for Treatment of Trigger Finger Category: Hand
Hand and Wrist Level 4 Evidence
Lauren M. Shapiro, MD Sara Lynn Eppler, MPH Robin Kamal, MD
Hypothesis A point of care, preference elicitation tool will be feasible and usable in helping patients choose a treatment for trigger finger.
Methods Thirty patients with a diagnosis of trigger finger who had not undergone prior treatment were recruited from a hand and upper extremity clinic. We created a preference elicitation tool using attributes of care extracted from literature review. We presented these attributes to patients using the tool and had patients rank the relative importance (preference) of these attributes for their decision making. The System Usability Scale and time to complete the tool were used to evaluate usability and feasibility of the tool, respectively.
Results The tool was completed by thirty patients (43.3% female, 16.66% opting for therapy and splinting, 66.66% opting for injection, 16.66% opting for surgery, mean age 60.1 years old). The average SUS score was 88.7. The average time to complete was 3.05 minutes. Patients ranked success of treatment as the most important attribute and cost of treatment as the least important attribute. 96.7% of patients were very to extremely satisfied with the use of the tool. 93.3% of patients would recommend the use of this tool to other patients.
Summary Points • A patient-facing ranking tool for preference elicitation in treatment of trigger finger is feasible and usable at point of care • The process of preference elicitation may improve patient-centered care and facilitate shared decision making for trigger finger
Bibliography 1: Bozic KJ, Belkora J, Chan V, Youm J, Zhou T, Dupaix J, et al. Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial. J Bone Joint Surg Am. 2013;95:1633-1639. 2: Klifto K, Klifto C, Slover J. Current concepts of shared decision making in orthopedic surgery. Curr Rev Musculoskelet Med. 2017;10:253-257. 3: Pignone MP, Brenner AT, Hawley S, Sheridan SL, Lewis CL, Jonas DE, et al. Conjoint analysis versus rating and ranking for values elicitation and clarification in colorectal cancer screening. J Gen Intern Med. 2012;27:45-50. AM Poster 095: Acute Carpal Tunnel Syndrome in Inpatients with Operative Distal Radius Fracture Category: Hand
Hand and Wrist Level 2 Evidence
Kalpit N. Shah, MD Avi D. Goodman, MD Wesley M. Durand, Alan H. Daniel Arnold-Peter Weiss, MD
Hypothesis We aimed to determine the rate of carpal tunnel syndrome (CTS) and carpal tunnel release (CTR) in the setting of a DR fracture in inpatients. We also sought to establish risk factors that may be associated with prophylactic CTR and the development of CTS in the immediate postoperative period.
Methods Nationwide Inpatient Sample (NIS) database was queried from 2002 to 2014 to identify adult patients with DR fracture. Included patients were grouped by the presence or absence of a CTS diagnosis. Patients in both groups were further stratified by the procedure code for CTR and the timing of CTR in relation to the DR fracture fixation. Patients undergoing CTR on the same day as DR fracture fixation without a CTS diagnosis were considered prophylactically released. Those undergoing CTR on the same day as the DR fracture fixation with a CTS diagnosis were considered to have CTS concomitantly. Patients undergoing CTR on a day after DR fixation were considered complications. Multivariate analyses were performed to identify variables that are independently associated with category.
Results A total of 275,052 inpatients were included in our analysis. A minority of inpatients had CTS concomitant with their DR fracture (n=11,816; 4.3%). A small fraction of inpatients developed CTS after their DR fixation (n=530; 0.2%). Of those without CTS, a small portion underwent prophylactic CTR (n=4420; 1.6%). Male sex, age<50 years, polytrauma patients, non-profit hospitals and open reduction internal fixation of DR fracture were associated with increased odds of a prophylactic CTR
Summary Points • This study examined CTS in inpatients with DR fracture; 1.6% of patients underwent prophylactic CTR, 4.3% were diagnosed with CTS concomitant to their DR fracture, while 0.2% of patients developed CTS after surgical fixation of a DR fracture. • This study also establishes factors associated with the above categories. • This data may help the surgeon be vigilant and counsel patients appropriately regarding the risk of developing CTS in the setting of a DR fracture.
Bibliography 1: Rhee PC, Dennison DG, Kakar S. Avoiding and Treating Perioperative Complications of Distal Radius Fractures. Hand Clin. 2012;28(2):185–198. 2: Davis DI, Baratz M. Soft Tissue Complications of Distal Radius Fractures. Hand Clin. 2010;26(2):229–235. 3: Jhattu H, Klaassen S, Ying C, et al. Acute carpal tunnel syndrome in trauma. Eur. J. Plast. Surg. [Internet]. 2012 Sep 23 [cited 2017 Feb 9];35(9):639–646 4: Wilcke MKT, Hammarberg H, Adolphson PY. Epidemiology and changed surgical treatment Methods for fractures of the distal radius: a registry analysis of 42,583 patients in Stockholm County, Sweden, 2004–2010. Acta Orthop. 5: Koval KJ, Harrast JJ, Anglen JO, et al. Fractures of the Distal Part of the Radius. J. Bone Jt. Surgery-American Vol. [Internet]. 2008 Sep [cited 2017 Aug 20];90(9):1855–1861. AM Poster 096: The Aesthetics of Digit Amputation Category: Hand
General Principles Level 5 Evidence
John Collar, III, MD John Smetona James Clune, MD
Hypothesis Reconstruction of the traumatized hand can be difficult. Functionality is paramount when considering reconstructive goals. Often a cosmetically appealing hand is not the most useful. However, in some cases an aesthetic outcome may be achievable without sacrificing function. Unfotunately, the most visually appealing hand after amputation has not been defined, thus making the job of maximizing both functional and aesthetic outcomes challenging. The goal of this study is to define the optimal aesthetic levels of amputation in each digit.
Methods After review by the institutional review board, 303 participants were presented images of a normal hand that was digitally manipulated to simulate various single digit amputations. Participants ranked these images in order of most aesthetic (1) to least aesthetic (4). The images included amputations at the distal interphalangeal (DIP) joint, proximal interphalangeal (PIP) joint, metacarpophalangeal (MCP) joint, and ray amputation for each digit. Analysis of rank order data was represented in graphical octahedrons to demonstrate the frequency of rankings relative to one another. Additionally, each octahedron shows the frequency with which a given level of amputation was selected most aesthetic, as well as the frequency with which any two amputations were selected as most aesthetic and second most aesthetic. The data was also used to determine the pairwise frequency and marginal distribution for a given amputation.
Results Amputation at the distal interphalangeal joint was the most aesthetic site for amputation in all digits. Ray amputation was the second most aesthetic, and overhwhelmingly so in the middle and ring fingers.
Summary Points The study demonstrates that every effort should be made to limit amputations of mangled digits to the distal joint if a functional finger can be expected. However, in more severe injuries, when a more proximal amputation is unavoidable, cosmetic results can be achieved with a ray amputation rather than attempting to preserve the metacarpal phalangeal joint.
AM Poster 097: Trends in Emergency Room Management of Seymour Fractures and Fight Bite Injuries Category: Hand
Hand and Wrist;General Principles;Practice Management Level 5 Evidence
Jessell M. Owens, MD
Hypothesis We hypothesized that surgeons with assistants (resident, fellow or midlevel providers) in taking primary emergency department (ED) call are more likely to definitively manage open hand injuries (fight bite injuries and Seymour fractures) in the ED rather than the OR than surgeons without assistants.
Methods Following institutional review board approval, a survey comprising of 14 multiple choice questions was created to help determine current trends in the management of fight bite and Seymour fractures and distributed to members of the American Society for Surgery of the Hand (ASSH) email database. Once responses were obtained, they were analyzed and both group and subgroup analysis were completed using SAS statistical software, version 9.4.
Results Of 3,334 members surveyed, 479 responses were obtained for a response rate of 14.36%. 62.7% (n=300, p<0.0001) felt the emergency department was an appropriate location for irrigation and debridement with close follow up for “fight bite” injuries. 70.25% (p<0.0001) felt that ED management with close follow up was appropriate for well reduced Seymour fractures. 57% of respondents utilize non-attending (resident, fellow, midlevel) help to evaluate and treat patients in the ED. Subgroup analysis demonstrated that surgeons with resident or fellow level support were significantly more likely to treat acute fight bite and Seymour fractures in the ER (p = 0.02, p= 0.007, respectively) and to admit both subacute and acute fight bite injuries for IV antibiotics (p= 0.019, p=0.005, respectively).
Summary Points • The majority of hand surgeons responding to our survey feel that utilizing the ED for definitive management of fight bite injuries and Seymour fractures is appropriate. However, less than half of the respondents currently treat acute or subacute fight bite injuries in the ED • Academic surgeons (versus private practice surgeons) were more likely to admit acute and subacute fight bite injuries for IV antibiotics • Attending surgeons with resident and fellow support are more likely to definitively treat these open hand injuries in the ED compared to attending surgeons without resident and fellow support
Bibliography 1: Basadre JO, Parry SW. Indications for surgical debridement in 125 human bites to the hand. Arch Surg. 1991;126(1):65– 67. 2: Ganayem M, Edelson G. Base of distal phalynx fracture in children: a mallet finger mimic. J Pediatr Orthop. 2005;25(4):487-489. 3: Reyes BA, Ho CA. The high risk of infection with delayed treatment of open Seymour fractures: Salter-Harris I/II or juxta-epiphyseal fractures of the distal phalanx with associated nailbed laceration. J Pediatr Orthop. 2017; 37(4):247-253. 4: Seymour N. Juxta-epiphyseal fracture of the terminal phalynx of the finger. J Bone Joint Surg Br. 1966;48(2):347-349. AM Poster 098: Syringe External Fixator: An Inexpensive Treatment for Unstable Phalangeal Fractures Category: Hand
Hand and Wrist Level 4 Evidence Grant received from: Raymond M.Curtis Research Foundation, The Curtis National Hand Center
Omer Yousaf, MD Imran Yousaf DO Aviram M. Giladi, MD, MS Ryan D. Katz, MD
Hypothesis Hypothesis: We present a series of comminuted phalangeal fractures involving the interphalangeal joints of the hand treated with an alternative static external fixator consisting of a 1mL syringe and kirschner pins. This construct can be converted to a dynamic fixator during the post-operative period for early range-of-motion. We hypothesize that the syringe fixator can facilitate fracture union for unstable intraarticular phalangeal fractures, with a low incidence of postoperative complications, and adequate range of motion (ROM) outcomes.
Methods Four patients with unstable intraarticular phalangeal fractures affecting a single digit underwent external fixation of the affected digit. This was done utilizing an external fixator device consisting of a single 1mL syringe and kirschner pins – inexpensive items readily available in most operating rooms. The mean follow-up period was 6 months. All four patients had the most proximal pin removed within one month of placement to allow early ROM (Fig. 1). A retrospective chart review was conducted to record the final ROM of the proximal interphalangeal (PIP), distal interphalangeal (DIP), interphalangeal (IP) or metacarpophalangeal (MP) joints, as well as incidence of fracture union and postoperative complications.
Results Final ROM was collected from available measurements recorded at each patient’s most recent clinic visit. Postoperative radiographs in all four patients showed fracture union with congruity of the PIP joints. For patient 1, PIP ROM was 80 degrees; patient 2, PIP and DIP ROM were 90 degrees and 10 degrees, respectively; patient 3, IP and MP ROM were 30 degrees and 40 degrees, respectively; and patient 4 achieved full ROM of his affected finger. There were no postoperative complications.
Summary Points • Syringe external fixation allows for placement of an inexpensive static fixator that can easily be converted to a dynamic fixator in the post-operative period. • Syringe external fixation facilitates fracture union, has a low incidence of postoperative complications, and has good ROM outcomes for these challenging injuries. • Syringe external fixation is an effective, and likely cost-saving, method for treating unstable comminuted intraarticular phalangeal fractures.
Bibliography 1: Crowley TP, Jones AP, Rannan-Eliya SV. A novel external fixator used to treat open comminuted fractures ofthe middle and distalphalanges with concomitant FDP avulsion injury. Tech Hand Up Extrem Surg 2014;18(3):121-4. 2: Kapur B, Paniker J, Casaletto J. An alternative technique for external fixation of traumatic intra- articular fractures of proximal and middle phalanx. Tech Hand Up Extrem Surg 2015;19:163–167. 3: Namazi H, Mozaffarian K. A novel external fixator of the hand: a practice pearl. Tech Hand Up Extrem Surg 2013;17: 57-9. AM Poster 099: The Semilunar Pulley Orthosis (SPOrt) Decreases Flexor Tendon-Phalanx Distance in Climbers with Chronic A2 Pulley Ruptures Category: Hand
Hand and Wrist;Diseases and Disorders N/A – not a clinical study Grant received from: UW Orthopaedics Resident Research Grant
Kate D. Bellevue, MD Christopher H. Allan, MD Nelson Hager Galen Mills Todd Greenberg Winston Warme, MD
Hypothesis Modern rock climbing has become increasingly popular and with entry into the 2020 Olympics is now a recognized sport. A2 pulley ruptures are one of the most common injuries sustained by climbers and are associated with the “crimp grip” used to grasp small holds [1]. One study of competitive climbers found 26% of climbers had at least one pulley rupture [1]. Ruptures lead to increases in the flexor tendon-phalanx distance (TPD) and limit active joint flexion. Interventions to date, such as taping, have not been shown to be effective [2,3]. The purpose of this study is to assess the reduction in the flexor TPD with a novel Semilunar Pulley Orthosis (SPOrt), in climbers with A2 pulley ruptures, (Fig 1a).
Methods A prospective case series of climbers with chronic A2 pulley injuries was studied. Climbers with a history of a suspected pulley injury were screened with an ultrasound and those with TPD greater than 2 mm (Grade III or IV injuries) were included in the study [4,5]. TPD was measured with and without the SPOrt (modified with a cut out for ultrasound, Fig 1b) in both the stressed and relaxed positions (Fig 2).
Results 47 fingers were scanned in 41 climbers and 15 fingers in 15 climbers were diagnosed with a complete A2 pulley rupture. The middle finger was injured in 53% of climbers, the ring finger in 40% and the index in 7%. Average TPD in the stressed position was 3.02±0.67 mm without the SPOrt and 2.25±0.45 mm (p<0.0001) with the SPOrt applied. Average decrease in TPD was 0.78±0.45 mm for a 26% reduction in TPD in the stressed condition. Average TPD at rest, in the unstressed position was 2.47±0.67 mm without the SPOrt and 2.05±0.48 mm (p<0.005) with the SPOrt applied. Application of the SPOrt resulted in a 17% reduction in the TPD with the finger at rest.
Summary Points • A2 pulley ruptures are increasingly common in the climbing population, which is expanding. • Superior to tape alone, the SPOrt decreases the TPD in climbers with chronic A2 pulley injuries in a highly statistically significant manner, (p<0.0001). • The SPOrt is easily fabricated, customizable, facile to apply, readily adjustable, and as it is comfortable to wear while climbing, which should improve patient compliance and ultimately long-term efficacy.
Bibliography 1: Bollen SR. Soft tissue injury in extreme rock climbers. Br J Sports Med. 1988;22:145-7. 2: Schweitzer, A. Biomechanical Effectiveness of Taping the A2 Pulley in Rock Climbers. J Hand Surg. 2000;25B(1):102-7. 3: Warme, WJ, Brooks D. Effect of Circumferential Taping of Flexor Tendon Pulley Failure in Rock Climbers, Am. J. Sports Med. 2000; 28; 674-8. 4: Klauser A et al. Finger pulley injuries in extreme rock climbers: depiction with dynamic US. Radiology. 2002;222:755–761. 5: Schöffl V et al. Pulley Injuries in Rock Climbers. Wilderness Environ Med. 2003;14:94-100. AM Poster 100: Correlation of Ultrasound, Nerve Conduction Studies and Surgical Results in Carpal Tunnel Syndrome Category: Hand
Hand and Wrist;Nerve;General Principles Level 2 Evidence
Richard A. Bernstein, MD Jonathan N. Grauer, MD Ameya V. Save, BS Tamara John, MD
Hypothesis Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper extremity. Controversy remains regarding the appropriate manner to diagnoses CTS; whether clinical findings alone are sufficient or whether NCS are beneficial. Musculoskeletal ultrasound has seen tremendous growth and is a noninvasive option available to possibly diagnose CTS. To our knowledge, there are no published studies correlating ultrasound, NCS, patient outcome measures in a prospective cohort of patients with CTS
Methods After IRB approval, a prospective nonrandomized study was performed on a consecutive group of patients diagnosed with CTS by a fellowship trained hand surgeon. This study investigated the subgroup of patients who underwent surgical treatment. All patients underwent a complete history and physical examination, Semmes Weinstein monofilament testing, ultrasound examination by the senior author, Brigham CTS (BCTS) outcome scores, NCS (by trained neurologists). Patients were initially treated nonoperatively; this study comprises those who failed nonoperative treatment. Mean cross sectional area (CSA) alone has been used as the criteria for CTS, however we have noted different morphologies of the nerve; some flatter, some more robust. The study also investigated the length and width of the median nerve to correlate with NCS and surgical results
Results 200 consecutive operative cases of CTS were included in this study. Preop BCTS were 3.6/2.1. wimproved to 2.4/2.1, 2.3/2.0 and 2.2/1.6 at the first postop, 6week, and final followup visits. Ultrasound demonstrated a CSA of the median nerve of 14mm2 ( 6-28) with 7 patients falling beneath the 10 mm2 threshold. Six patients had "electrodiagnostic negative" CTS but all had CSA greater than 10, averaging 12.2 mm2. 35% of patients had no response (NR) on the sensory component of the NCS and 18% NR on their motor response. However the median nerve CSAranged from 8-20. The average AP length of the nerve was 2.49mm (2.3-3.8) and longitudinal 7.35mm (4.6-10.6)
Summary Points Ultrasound provides a convenient, pain free and useful adjunct in the evaluation of patients with CTS. Patients with normal NCS, demonstrated median nerve enlargement by US. Interestingly,there was no statistically significant relationship of CSA to NCS in patients with NR on their NCS. Previous studies have suggested that CSA increases with severity of CTS; however, this study may contradict that finding and queries whether "atrophy" occurs within the median nerve with long standing CTS, demonstrated by the decrease in CSA in patients with severe CTS by NCS.
AM Poster 101: Successful Treatment of Mucous Cysts by Aspiration and Injection Category: Hand
Hand and Wrist Level 2 Evidence
Richard A. Bernstein, MD
Hypothesis Mucous cysts of the DIP joint are common conditions. Previous literature have questioned the effectiveness of nonoperative treatment by aspiration/injection. Based on prior experience, we questioned whether surgery was necessary and whether satisfactory outcomes can be accomplished nonoperatively.
Methods After IRB approval, a level II prospective, non randomized study was performed on 151 digits in 142 consecutive patients presenting to a single fellowship trained hand surgeon with masses over the DIP joint. All patients underwent treatment with aspiration/injection of the mucous cyst. The cyst was entered from a midlateral approach with a 25 gauge needle and a mixture of 0.5 ml of Betamethasone 0.25ml Xylocaine and 0.25% Bupivacaine. The area was injected, aspirated and reinjected as needed until a concave "crater" appeared. If the fluid was too viscous, the needle was oriented midway through the cyst to evacuate the gelatinous material. Patients were reevaluated at 4 weeks, and if successful, followed up for this study, if unimproved the patient was offered repeat injection or surgical excision.
Results At mean follow up of 26 months, 94% of patients were satisfied with their treatment with resolution of the cyst, improvement of symptoms and improving nail deformity. 113 digits in 104 patients responded to one treatments, 18 digits responded to 2, two patients responded to three, and 1 patient requested (AMA) and healed with four treatments. 17 digits in 17 patients underwent surgery after a mean 1.3 injections with subsequent resolution, without complication. Three patients were retrospectively misdiagnosed; two had GCT and one a chondroma and were excluded from the study. Many patients with significant underlying osteoarthritis were noted to still have Heberdens nodes present, but no cyst and were satisfied with the outcome of treatment. When contacted a mean 26 months post treatment 94% were satisfied and would choose aspiration again.
Summary Points Prior studies, notably one from the Mayo clinic suggested that non operative treatment of mucous cysts had a low patient satisfaction rate and recurrence rate. We wonder whether their endpoint did not differentiate between mucous cysts and DIP osteophytes. Surgical treatment of mucous cysts can be complicated by recurrence, skin necrosis, infection and septic arthritis. We had no complications reported, with a high patient satisfaction and would recommend an attempts at nonoperative treatment of mucous cysts. To our knowledge this is the largest Level 2 study documenting the successful nonoperative treatment of digital mucous cysts.
Bibliography 1: Rizzo M1, Beckenbaugh RD., Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation.J Hand Surg Am. 2003 May;28(3):519-24. AM Poster 102: Anatomic Variations in the Extensor Digitorum Communis Tendon to the Fifth Digit is Associated with Differences in Adjacent Tendon Anatomy Category: Hand
Hand and Wrist;General Principles N/A - not a clinical study
Giacomo L. Cappelleti, MD Richard M. Hinds, MD Ruth Cadet, BA S. Steven Yang, MD, MPH
Hypothesis We surmised that the absence of the extensor digitorum communis tendon to the 5th digit (EDC- V) is associated with a larger extensor digiti minimi (EDM) to compensate and increased presence of juncturae tendinae from the 4th EDC to the extensor hood of the 5th digit (JT IV-V). We also suspected that increased JT IV-V presence may be associated with a larger EDC to the fourth digit (EDC-IV).
Methods The dorsal aspect of twenty-four upper extremity cadaver specimens were dissected to reveal the ulnar extensor tendon anatomy of the hand. Presence or absence of EDC-IV, EDC-V, JT IV-V, and EDM were noted. Tendon width was recorded using ImageJ analysis. In tendons with multiple slips, the sum of the slips provided total tendon width. Descriptive statistics were employed to display mean tendon width along with 95% confidence intervals (95%CI). Two- sample t-tests were used to compare tendon dimensions between anatomic variants. P < 0.05 was the level of significance for all tests.
Results EDC-IV and EDM tendons were identified in all specimens. The JT IV-V was identified in 21 specimens (87.5%) with an average size of 8.70mm (95%CI: 7.29–10.11mm). The EDC-V tendon was identified in 4 specimens (16.67%), two with a JT IV-V and two without. Average EDC-V tendon size was 3.69 mm (95%CI: 2.37–5.00mm).
In the presence of a JT IV-V, the average size of the EDM tendon was significantly larger compared to EDM tendons without a JT IV-V contribution [4.77mm (95%CI: 4.17–5.37mm) vs 3.88mm (95%CI: 3.45–4.31mm); P<0.05]. In regards to the EDC-IV tendon, the average size was also significantly larger with a JT IV-V contribution [8.77mm (95%CI: 7.80–9.74mm) vs 6.36mm (95%CI: 5.58–7.13mm) vs;0.05].
In the presence of an EDC-V, the EDM tendon was smaller on average compared to specimens without an EDC-V with a strong trend toward statistical significance [4.04mm (95%CI: 3.65– 4.41mm) vs 4.78mm (95%CI: 4.16–5.52mm); P=0.06]. There was no statistically significant difference in EDC-IV with or without the presence of EDC-V [7.84mm (95%CI: 5.26–10.41mm) vs 8.60mm (95%CI: 7.61–9.59mm), respectively; P=0.62].
Summary Points • EDC-IV and EDM tendons are significantly larger in the presence of a JT IV-V. • In the absence of EDC-V, EDM tendons are larger with a strong trend toward statistical significance. • With our small number of specimens we are unable to comment on the increased likelihood of JT IV-V in the absence of EDC-V
Bibliography 1: Hirai Y, Yoshida K, Yamanaka K, Inoue A, Yamaki K, Yoshizuka M. An Anatomic Study of the Extensor Tendons of the Human Hand. J Hand Surg 2001;26A:1009-1015 2: Tanaka T, Moran SL, Zhao C, Zobitz ME, An K, Amadio P. Anatomic Variation of the 5th Extensor Tendon Compartment and Extensor Digiti Minimi Tendon. Clinical Anatomy 20:677- 682, 2007 3: Yammine K. The prevalence of the extensor digiti minimi tendon of the hand and its variants in humans: a systematic review and meta-analysis. Anat Sci Int (2015) 90:40-46 AM Poster 103: Augmented External Fixation of Ulnar Carpometacarpal Joint Fracture / Dislocations Category: Hand
Hand and Wrist Level 4 Evidence
Reiji Nishimura, MD Lauren Wright, DO William H. Seitz, Jr., MD
Hypothesis Management of ulnar sided CMC fracture dislocations by means of ligamentotaxis provided through miniature spanning external fixation stabilization with precise but limited intra-articular fragment realignment and fixation with K wires can provide restoration of articular architecture and digital alignment while allowing early return to function followed by durable, positive patient reported outcomes and radiographic assessment.
Methods Clinical and chart review was performed on 10 patient's undergoing acute surgical repair of ulnar-sided CMC fracture dislocations with intra-articular comminution using minimally invasive percutaneous K wire fixation and spanning miniature external fixators. Minimal follow-up was 1 year (range 1-8 years, ave.3.4 years). 8 were male, 2 female. 3 were the results of falls on a closed fist, 7 resulted from punching a hard object. All radiographs to be most recent follow-up were reviewed and evaluated by 2 independent reviewer's. Patient's were asked to rate their level of pain, answer a series of patient perceived outcomes questions using the Quick DASH subjective outcome instrument for functional
Results There were no major complications. There were 2 transient pin tract infections which resolved with oral antibiotics. There are no nerve or tendon injuries and all implants were removed in the clinic without need for additional surgery. All hands healed primarily with maintenance of a congruent joint space without radiographic evidence of displacement or subsequent arthrosis. Patient's satisfaction was high and function was near normal with minimal if any pain (average 1.2 on VAS scale). All patient's felt they had returned to pre-injury hand function and status. All patients were enrolled in immediate active range of motion, functional hand use and pin site care on the day of surgery.
Summary Points Ulnar-sided CMC fracture dislocation tendons to be an injury sustained by Young males most frequently during an argument our moment of rage. Despite a potential for noncompliance in this group. The augmented external fixator has promoted early return to function, minimal disability with maintenance of early motion and functional activities of daily living. Because of the nature and visibility of the external fixation device, patients have been compliant in careful pin site care, returning for follow-up and especially fixator removal. As such we have found this surgical technique preferable to K wire fixation alone with casting. Our surgical technique with rehabilitation protocol will be presented.
Bibliography 1: Cain JE, Ahepler TR, Wilson MR. Hamatometacarpal fracture dislocation: classification and treatment. J Hand Surg. AM 1987; 12 (pt 1): 762-767 2: McDonald LS, Shupe PG, Hammel N, et al. The intermetacarpal angle screening test for ulnar- sided carpometacarpal fracture-dislocations. J Hand Surg Am. 2012; 37: 1839-1844 3: Yoshida R, Shah MA, Patterson RM, et al. Anatomy and pathomechanics of ring and small finger carpometacarpal joint injuries. J Hand Surg Am. 2003; 28: 1035-1043. 4: Zhang C, Wang H, Liang C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture dislocations. J hand Surg Am. 2015; 40: 2069-2175 5: Kato N, Fukumoto K. Suspension arthroplasty for old fracture-dislocations of the fifth carpometacarpal joint. Tech Hand Up Extrem Surg. 2016; 20: 83-87 AM Poster 104: Predictors of Range of Finger Motion after Proximal Interphalangeal Joint Replacement for Osteoarthritis Category: Hand
Hand and Wrist Level 2 Evidence
Tsutomu Kira, MD Shohei Omokawa, MD Takamasa Shimizu, MD Tadanobu Onishi, MD Kenji Kawamura, MD Yasuhito Tanaka, MD, PhD
Hypothesis Prosthetic arthroplasty is a motion and stability preserving reconstructive surgical option for painful osteoarthritis of the proximal interphalangeal joint. We hypothesized that surgical approach, selection of implant, and age may be a predictor of acquired range of joint motion after surface replacement arthroplasty.
Methods Twenty-one consecutive patients with primary osteoarthritis treated by prosthetic arthroplasties were enrolled in this study. There were 7 males and 14 females, with an average age of 61 years (45-75). We used a cementless implant in14 cases and a cement-retained implant in 7 cases. Fifteen implants were inserted through volar approach, and 6 were via dorsal. We compared acquired joint motion, during a period longer than 1-year follow-up, between volar and dorsal approach, cement and cementless implant, and young and older age > 60 years.
Results The average range of PIP joint motion improved from 37° to 56° (p < 0.05). The average increase of joint motion was larger in the elderly patients with volar approach and cementless implant, but there was no statistical difference between each group.
Summary Points • The use of surface replacement implant improved total arc of PIP joint motion in the patients with primary osteoarthritis. • There was a trend of increase in the range of motion after cementless implant by volarapproach in the elderly patients. AM Poster 105: Artery-Only Fingertip Replantation Distal to Lunula: A Retrospective Analysis of Clinical Results Category: Hand
Hand and Wrist Level 4 Evidence
Yasunori Kaneshiro, MD, PhD Koichi Yano, MD, PhD Hideki Sakanaka, MD, PhD Noriaki Hidaka, MD
Hypothesis Both arterial and venous repair are crucial for optimal results in digital replantation. However, anastomosis of veins becomes challenging in very distal fingertip amputation because of small vessel diameter or unavailability by damage. Our hypothesis is that artery-only fingertip replantation without vein can be enough for very distal fingertip replantation.
Methods We performed a retrospective review of 42 patients who had undergone fingertip replantation between 2015 and 2017 with a mean follow-up period of 12 months. All patients in this study had complete fingertip amputation distal to the lunula. By Ishilawa’s classification, 13 digits in subzone I, and 29 digits in subzone II. Only one central artery repair distal to arch was performed. All patients received the postoperative protocol including external bleeding with or without the use of medical leech, and anticoagulation therapy for a week until physiological outflow was restored. Successful replantation was confirmed with clinical observation.
Results The mechanism of injury was blunt in 23 digits, crush in 16 digits and guillotine in 3. The mean ischemia time was 6 hours. Thirty-three of the 42 fingertip replantations (78%) were successful (92% in zone I, 72% in zone II, respectively). The mean total active motion of injured digits was 85% of normal. Sensory evaluation at the final follow-up revealed an average moving two-point discrimination of 6.0 mm
Summary Points • This study shows that artery-only fingertip replantation achieved good success rate and satisfactory outcomes for very distal fingertip replantation including many blunt and crush injuries.
Bibliography 1: Erken HY, Takka S, Akmaz I. Artery-only fingertip replantations using a controlled nailbed bleeding protocol. J Hand Surg Am. 2013 Nov;38(11):2173-9. 2: Buntic RF, Brooks D. Standardized protocol for artery-only fingertip replantation. J Hand Surg Am. 2010 Sep;35(9):1491-6. 3: Matsuzaki H, Yoshizu T, Maki Y, Tsubokawa N. Functional and cosmetic results of fingertip replantation: anastomosing only the digital artery. Ann Plast Surg. 2004 Oct;53(4):353-9. AM Poster 106: Accuracy of Thumb Motion Measured Using a Low-Cost Hand-Tracking Sensor Category: Hand
Hand and Wrist N/A - not a clinical study Grant received from: Presbyterian Hospital Bach Fund 2017
Benjamin L. Gray, MD Rikesh A. Gandhi, MD Josh R. Baxter, PhD
Hypothesis We hypothesized that thumb motion could be accurately measured using a low-cost hand- tracking system. The aim of this preliminary study was to demonstrate that thumb extension and abduction could be measured simultaneously with a high-fidelity motion capture system and a low-cost hand-tracking system.
Methods A healthy-young male (age 34 y) participated in this preliminary research study. Thumb motion was simultaneously acquired using a 12-camera motion capture system (Raptor Series, Motion Analysis Corp) and a low-cost hand-tracking sensor (Leap Motion). The hand-tracking sensor was placed to ensure that the two coordinate systems were aligned. Thumb extension and abduction motions were performed to test the fidelity of the hand-tracking sensor. The subject sat in a chair with the arm fully extended and horizontal with the ground while the hand-tracking sensor was positioned approximately 0.3 m below the hand to image the volar aspect of the hand. Reflective markers were placed on the dorsal aspect of the hand and wrist to reduce the possible impact of these objects on the hand-tracking sensor’s algorithm.
Thumb kinematics were directly compared between the two measurement techniques: motion capture and the hand-tracking sensor. The direction of the thumb was quantified by both measurement systems by measuring the reflective markers placed along the thumb and evaluating the calculated thumb-tip direction, respectively. The hand-tracking sensor was accessed via a software development kit freely available from the vendor (Leap Motion, San Francisco, CA). Thumb extension and abduction was characterized as motion in the horizontal and sagittal planes, respectively.
Results Thumb extension and abduction were accurately measured with a low-cost thumb-tracking sensor when compared to motion capture data (Fig. 1). Both extension and abduction strongly correlated (R2 > 0.95) with motion capture data. Peak values of thumb extension and abduction were under-approximated by 4 and 8 degrees, respectively, when compared to motion capture values.
Summary Points • Thumb motion can accurately be quantified with a low-cost ($79) hand-tracking sensor that requires no calibration and can be run on a personal computer. • Motions of the hand and wrist are quantified using an intrinsic model that can be accessed using custom-written computer software. • Low-cost sensors may provide clinicians with a powerful tool to quantify patient progress throughout treatment. • On-going work is aimed at quantifying the reliability and robustness of this low-cost sensor.
AM Poster 107: Use of a Complex Decision Tree Machine Learning Model in the Prediction of Reoperation Following Traumatic Digit Amputation Category: Hand
Hand and Wrist Level 3 Evidence
Neill Li, MD Saisanjana Kalagara Alice Chu, MD Andrew P. Harris, MD Julia A. Katarincic, MD
Hypothesis Use of a complex decision tree machine learning model is more accurate in predicting reoperation following initial digit revision amputation compared to classic regression models.
Methods Upon IRB approval, the emergency and orthopedic billing department databases of a Level I trauma center were retrospectively examined for patients presenting with traumatic finger and thumb amputations between January 2010 to December 2015. Inclusion criteria were partial or complete amputations through verdan zones I or II. Variables extracted were demographic information, digits amputated, date of injury, work relation, and mechanism of injury. Independent-samples t-tests were performed to determine exposure variables of high classification ability and further evaluated with two standard regression models. The machine learning models were created in Python in which patient data was randomly separated into two sets: one for training the model and a subsequent model for testing. Accuracy for all tests were determined with 5-fold cross-validation to prevent overfitting.
Results A total of 576 traumatic finger and thumb amputation patients were identified on retrospective review. Independent samples t-tests revealed that 4 exposure variables (fingertip revision zone, tobacco use, work-related injury, and mechanism of injury) were significantly (p < 0.05) different between patients with revisions and patients without. Linear regression using these variables yielded an R-squared value of 0.36 and logistic regression yielded an AUC of 0.47, both of which indicate that the models performed no better than chance. Highest accuracy was given by a complex decision tree model with an accuracy of 0.84 and AUC of 0.6 for predicting subsequent fingertip revision amputations (Figure 1).
Summary Points • Improving on standard regression techniques, decision trees do not attempt to fit patient data to a predefined mathematical model. Instead patient data is classified at multiple levels (with each level representing a binary split created from one variable) in such a way that accuracy is maximized . • Four variables were significantly different in those undergoing reoperation for fingertip revision amputation: fingertip revision zone, and mechanism of injury. • Of the models used with these four variables, the complex decision tree model had the highest predictive power in determining whether patients needed subsequent operative interventions for fingertip amputations. • •Continue research into improving the accuracy of these models will potentially allow clinicians to enter data for each exposure variable and be given a likelihood for reoperation to better aid in management.
Bibliography 1: Hattori Y, Doi K, Ikeda K, Estrella EP. A retrospective study of functional outcomes after successful replantation versus amputation closure for single fingertip amputations. J Hand Surg. 2006;31(5):811-818. doi:10.1016/j.jhsa.2006.02.020. 2: Wang H. Secondary surgery after digit replantation: its incidence and sequence. Microsurgery. 2002;22(2):57-61 3: Wilkens SC, Claessen FMAP, Ogink PT, Moradi A, Ring D. Reoperation After Combined Injury of the Index Finger: Repair Versus Immediate Amputation. J Hand Surg. 2016;41(3):436-440.e4. doi:10.1016/j.jhsa.2015.12.013. AM Poster 108: Firework Injuries of the Hand: A Descriptive Analysis of Treatment Category: Hand
Hand and Wrist;Practice Management Level 4 Evidence
Ricardo Ortiz, BS Sezai Ozkan, MD Neal C. Chen, MD Kyle Eberlin, MD
Hypothesis Firework injuries to the hand can be devastating due to the explosive and ballistic nature of these injuries. The aim of this study was to describe patient, injury, and treatment related factors of patients with firework-related hand injuries presenting to two ACS Level I trauma centers in a state where fireworks are banned for consumer purchase.
Methods A retrospective chart review was performed and CPT codes were used to identify patients with firework-related injuries to the hand between 2005 and 2016. 20 cases of firework-related hand injuries were identified. These patients were evaluated for demographics, injury characteristics, number and types of surgical interventions, and utilization of other healthcare resources.
Results A total of 20 patients, all men except for one woman, with a mean age of 32 years (11.5 SD) presented to the emergency department with firework-related hand injuries. Despite laws banning the sale of fireworks within our state, most injuries occurred in state (15/20) compared to neighboring states in which purchase of fireworks is legal (5/20). Injuries ranged from digital nerve injuries to hand amputation. Most patients sustained at least one metacarpal or phalangeal fracture (18/20) and half (10/20) experienced traumatic amputation of at least one digit (Table 1). Each patient underwent a median of 3 (2-4 IQR) operations for their injury. Treatment consisted of debridement and K-wire fixation in 13/20, soft tissue coverage with a flap in 9/20, skin grafts in 9/20, and one patient underwent replantation. The median length of stay during initial hospitalizations was 7 (3-14 IQR) days (Table 2).
Summary Points • The morbidity inflicted by firework injuries to individual patients is substantial, even in states where fireworks are banned. • Patients with firework injuries undergo a median of 3 operations resulting from their injuries, and more than half can be expected to undergo flap or skin graft coverage of a soft tissue defect. • Firework injuries are associated with a prolonged length of stay (7 days) and further research into healthcare utilization is warranted for these preventable injuries.
AM Poster 109: Sonographic Evaluation and Muscle Strength Assessment of the Thenar Muscle in Carpal Tunnel Syndrome Category: Hand
Nerve Level 2 Evidence
Katsunori Ohno, MD, PhD
Hypothesis We hypothesized that sonographic thenar muscle evaluation and muscle strength assessment correlate in carpal tunnel syndrome (CTS).
Methods A total of 28 wrists subjected to endoscopic carpal tunnel release with diagnosis of idiopathic CTS constituted the disease group (group D). Among 14 healthy volunteers, 28 healthy wrists (group N) who matched group D with respect to average age, gender, and body mass index were examined and compared with those of group D. To acquire the image through ultrasonography (US), the reference line was marked between the radial sesamoid bone of the thumb and scaphoid tuberosity, that is, between the origin and insertion of the abductor pollicis brevis (APB) (Fig.1). The transducer was positioned on the perpendicular bisectors of the line to obtain an axial view of the APB. The thickness and cross-sectional area (CSA) of the APB were calculated using the measurement function of the ultrasound device. APB thickness was calculated on the perpendicular line of the most volar point of the first metacarpal bone. APB-CSA was also measured on the image (Fig. 2).
In group D, the US measurement and APB compound muscle action potential and distal motor latency (DML) were recorded before the surgery. In both groups, grip strength, tip, key, and pulp pinch strength were measured as indicators of muscle strength. For the comparison between the groups, the Mann-Whitney U test was performed, and Spearman’s rank correlation coefficient (?) was used to determine the correlation between US measurements and each muscle strength evaluation in group D.
Results The inter- and intra-observer reliability of the US measurement method was almost perfect in our previous research. There was a significant difference between the two groups in US measurement value and grip strength (p < 0.05). In group D, the correlation between the US measurement value and muscular strength was significantly correlated within the range of 0.56 to 0.78 (p < 0.05). A high correlation was found between p = 0.78 and p = 0.75 for the grip strength and tip pinch strength for APB thickness, respectively. No correlation was found between US measurements and DML.
Summary Points • The US measurement of APB thickness and grip and tip pinch strength showed high correlation in CTS. • There is a possibility that the US measurement of APB thickness may quantify muscle strength in CTS.
Bibliography 1: Simon NG, Ralph JW, Lomen-Hoerth C, Poncelet AN, Vucic S, Kiernan MC, Kliot M. Quantitative ultrasound of denervated hand muscles. Muscle Nerve 2015; 52:221-30. 2: Lee H, Jee S, Park SH, Ahn SC, Im J, Sohn MK. Quantitative Muscle Ultrasonography in Carpal Tunnel Syndrome. Ann Rehabil Med. 2016; 40:1048-1056. 3: Gupta S, Michelsen-Jost H. Anatomy and function of the thenar muscles. Hand Clin 2012; 28:1- 7. 4: Van Sint Jan, S., and Rooze, M. Anatomical variations of the intrinsic muscles of the thumb. Anat. Rec 1994. 238: 131. 5: Nagaoka M, Nagao S, Matsuzaki H. Endoscopic release for carpal tunnel syndrome accompanied by thenar muscle atrophy. Arthroscopy 2004; 20:848-50. AM Poster 110: Risk Factors for Skin Tears Following Collagenase Clostridium Histolyticum to Treat Dupuytrens Contractures Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
David H. Wei, MD, MS Matthew B. Cantlon, MD Mark A. Vitale, MD, MPH
Hypothesis Skin tears are an unpleasant complication that may occur after collagenase clostridium histolyticum (CCH) administration to treat Dupuytren’s contractures of the fingers. We hypothesize three factors may lead to increased incidence of this complication: (1) contractures measuring 90° or greater, (2) treatment of two cords simultaneously in the same finger, (3) treatment of patients on anticoagulation.
Methods Over a 6-year period (2012 – 2018), we prospectively followed patients with a measurable metacarpophalangeal (MP) or proximal interphalangeal (PIP) joint contracture and a palpable cord who were treated with injectable CCH. A digital goniometer was used to measure MP or PIP joint contractures at each visit. Patients were clinically assessed for the development of skin tears on the day of manipulation as well as 30 days after manipulation.
Results A total of 161 patients (177 cords) were included in our study, with an overall incidence of skin tears of 16.8% (27 patients, 33 cords). The average combined MP and PIP joint contracture was higher in those developing skin tears (mean=86.1°, SD=37.6°) compared to those that did not develop skin tears (mean=52.6°, SD=30.9°, p<0.05). Patients who had a combined MP and PIP joint contracture 90° or greater had a higher incidence of skin tears (22.2%) compared to those with contractures less than 90° (7.4%, p<0.05). We found no difference in the incidence of skin tears in patients who had two cords injected in the same finger compared to those with one cord injected. Patients on anticoagulation at the time of CCH injection had a higher incidence of developing a skin tear (28.6% incidence) compared to those who were not on anticoagulation (15.6% incidence, p<0.05). All skin tears healed with conservative management, but in most cases required change of the post-injection splinting protocol and activity modification for a period of time.
Summary Points Although a relatively minor complication, skin tears are not well tolerated by all patients and often change the post-injection course of splinting and activity. Our data suggests contractures greater than 90° will lead to a 22% chance of skin tear during manipulation. This information may be helpful in counseling patients before manipulation to reduce anxiety experienced by patients who develop skin tears. Additionally, the use of anticoagulation may contribute to the development of skin tears, a risk factor that would benefit from further investigation.
Bibliography 1: Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. 2009 Sep 3;361(10):968-79. 2: Gaston RG, Larsen SE, Pess GM, et al. The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study. J Hand Surg Am. 2015 Oct;40(10):1963-71 3: Sanjuan-Cerveró R, Carrera-Hueso FJ, Vazquez-Ferreiro P et al. Efficacy and adverse effects of collagenase use in the treatment of Dupuytren's disease: a meta-analysis. Bone Joint J. 2018 Jan;100-B(1):73-80. AM Poster 111: The Clinical Utility of Maceration Dressings in the Treatment of Hand Infections: An Evaluation of Treatment Outcomes Category: Hand
Hand and Wrist;Diseases and Disorders;Practice Management Level 2 Evidence
Vince Lands, MD MD Ajith Malige Kristofer Matullo, MD MD
Hypothesis Maceration dressings have been previously documented in wound management treatment in diabetic skin ulcerations, peri-operative wound complications, and gangrenous tissue. However, there are no documented studies evaluating the clinical utility of these dressings in the treatment of hand infections. This study looks to validate the authors’ hypothesis that using a maceration dressing will significantly improve hand infection treatment and clinical course. We believe this is due to the increased vasodilatory effect as well as to decrease eradication time of infection for hand infections.
Methods This prospective randomized control trial centered at a single suburban hospital looked to recruit all patients 18 years or older who presented with a primary hand infection after failing oral antibiotic treatment. Patients were randomized to either the control group (intravenous antibiotics, aqua K pad, and standard dressing) or the maceration dressing group (intravenous antibiotics, damp gauze, webril, and standard dressing). Baseline labs (complete blood count, erythrocyte sedimentation rate, and c-reactive protein) were obtained along with a full history and physical exam. All subjects were followed throughout their clinical course for response to their dressing, with patients either being transitioned to oral antibiotics after significant improvement or being taken to the operating room for formal incision and drainage with debridement if they became unstable or did not clinically improve after 72 hours. Patients were excluded if they had 3 or 4 Knavel signs or obvious abscess requiring drainage.
Results Overall, 25 patients consented to be included. 12 patients were randomized to the maceration dressing cohort, and 13 were randomized to the standard infection dressing. Maceration dressing patients had a significantly shorter duration of intravenous antibiotics needed to improve their clinical picture (median=24 hours) compared to those without the dressing (median=48 hours) (p=0.03). Maceration dressing patients approached significantly shorter hospital length of stay (median=2.5 days) compared to those patients without the dressing (median=3.0 days) (p=0.05). There was no significance (p=0.64) in preventing the need for formal Incision and Drainage in the operating room due to an unstable or non-improving clinical picture between the groups (16.7% versus 30.7%). Finally, there was no significance (p=0.22) between the maceration dressing (0%) and control group (23.1%) in infection recurrence rate.
Summary Points • Maceration dressings decreased the amount of intravenous antibiotic time and hospital length of stay in patients with hand infections • Maceration dressings did not significantly affect infection clearance rates, the need for formal incision and drainage, or infection recurrence
AM Poster 112: Zone 2 Flexor Tendon Repair Location and Risk of Catching on the A2 Pulley Category: Hand
Hand and Wrist;General Principles N/A – not a clinical study
Perry Ross Altman, MD Miles W. A. Fisher, BS Kanu Goyal, MD
Hypothesis A region of the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in Zone 2 exists which, when involved in a laceration repair, will reliably catch on the A2 pulley post-operatively. Knowledge of this region will guide surgeons regarding the need for partial release of the A2 pulley on sedated patients.
Methods Using fresh frozen cadavers (5 hands, 20 digits), differential excursion of the FDP and FDS tendons was measured in relation to A2. Skin and subcutaneous fat were resected to expose the digital pulley system. The C1, A3, and C2 pulleys were resected to exposed the flexor tendons. Holding the wrist in neutral, the digit was maximally flexed into the palm by pulling longitudinal traction on the flexor tendon proximal to the wrist. An 8-0 suture was then passed through the volar aspect of the flexor tendon immediately distal to A2. The digit was then fully extended, and tendon excursion was measured with a digital micrometer using the 8-0 suture as a marker. Tendon repairs distal to the final position of the suture tag were considered low risk for catching on A2, as the repair would not be expected to engage A2 in full flexion post-operatively. These measurements were repeated with 50% venting and 100% release of A4 to examine their impacts on tendon excursion. Measurements of the pulley system, tendon insertions, flexion creases, and finger length were obtained to obtain reference points. This protocol was repeated sequentially for the index, middle, ring, and small fingers.
Results -Suture placed into FDP distal to A2 universally traveled to within 2mm of A4, often ending 2- 4mm beneath A4. -FDS has roughly 8mm less excursion than FDP -Venting A4 50% and 100% increases the FDP and FDS excursion by at most 2mm. -FDP excursion can be reliably predicted as a percentage of the A2 (distal) to A4 (distal) distance (IF: 88%, MF: 79%, RF: 77%, SF: 77%).
Summary points • FDP repair proximal to A4 will slide under A2 with full digital flexion postoperatively. • FDS repairs within 1cm proximal to A4 should not catch on A2. • If A4 must be released to approach a laceration, that repair should not catch on A2. • A2 length averages 16mm across all digits, so a repair 8mm proximal to A4 should not require more than 50% A2 venting. • The Distance between the repair site and A4 approximately equals the length of A2 that requires release to avoid postoperative triggering.
Bibliography 1: Savage R. The mechanical effect of partial resection of the digital fibrous flexor sheath. J Hand Surg Br. 1990 Nov;15(4):435-42. 2: Kwai Ben I, Elliot D. "Venting" or partial lateral release of the A2 and A4 pulleys after repair of zone 2 flexor tendon injuries. J Hand Surg Br. 1998 Oct;23(5):649-54. 3: Tang JB. Release of the A4 pulley to facilitate zone II flexor tendon repair. J Hand Surg Am. 2014 Nov;39(11):2300-7. 4: Tanaka T, Amadio PC, Zhao C, Zobitz ME, An KN. The effect of partial A2 pulley excision on gliding resistance and pulley strength in vitro. J Hand Surg Am. 2004 Sep;29(5):877-83. 5: Franko OI, Lee NM, Finneran JJ, Shillito MC, Meunier MJ, Abrams RA, Lieber RL. Quantification of partial or complete A4 pulley release with FDP repair in cadaveric tendons. J Hand Surg Am. 2011 Mar;36(3):439-45. AM Poster 113: Volar Plate Position and Flexor Tendon Rupture: Lack of Validity of the Soong Classification Category: Hand
Hand and Wrist;Diseases and Disorders;General Principles Level 4 Evidence
Brent R. DeGeorge Jr., MD, PhD David M. Brogan, MD Hillary Ann Becker, MD Alexander Y. Shin, MD
Hypothesis The Soong classification relates the position of the volar plate to the watershed line of the distal radius and is reported to be predictive of flexor tendon rupture. The hypothesis of this study is that the Soong classification is not a reliable predictor of flexor tendinopathy and rupture following volar plate fixation of distal radius fractures, but rather a reflection of the overall appropriateness of the fracture reduction.
Methods Following institutional approval, a retrospective review of all patients who underwent volar plate fixation of distal radius fractures between 2000 and 2015 with a minimum of 6 months follow up was performed. Medical records and radiographs were reviewed for: demographics, fracture and operative characteristics, postoperative tendon-related complications, and postoperative radiographic characteristics. Inadequate fracture reduction was defined by ulnar variance > 3 mm, radial inclination +20°, or intra-articular step-off > 2mm. Statistical analysis was performed to determine the relationship between Soong Classification, tendon complications, and adequacy of reduction.
Results 648 patients with 659 distal radius fractures managed with volar plate fixation were identified and reviewed. Mean duration of follow-up was 9.0 ± 0.5 months. Mean age was 56.5 ± 0.7 years. The majority of fractures were AO class 23-C1 (32.3%) followed by 23-C2 (20.9%) and 23- A3 (13.9%). The incidence of isolated tendinopathy and tendon rupture was 13 (1.9%) and 4 (0.6%), respectively. Tendon ruptures included: 2 flexor pollicis longus and 2 extensor pollicis ruptures. Isolated tendinopathy included: extensor pollicis longus (5), extensor carpi radialis longus / brevis (3), flexor pollicis longus (2), flexor carpi radialis (2), and extensor digitorum communis (1). Mean radiographic parameters were radial inclination 21.9 ± 0.1 degrees, volar tilt 8.0 ± 0.2 degrees, ulnar variance -0.02 ± 0.07mm, and intra-articular step-off > 2 mm in 4.4 % of patients. Soong classification was 0 in 35.6%, 1 in 59.3% and 2 in 5.0%. Soong classification failed to independently predict tendon rupture, tendinopathy, or implant removal (p>0.05). Fractures classified as inadequately reduced were significantly associated with Soong grade 0 or Soong grade 2 (p=0.024 and p=0.003, respectively), whereas fractures meeting criteria for adequate reduction were significantly associated with Soong grade 1. (p=0.0001).
Summary Points • Tendinopathy and tendon ruptures are known complications following volar plate distal radius fracture fixation, however the overall incidence is low. • Soong classification was not associated with tendon rupture or tendinopathy; however, Soong classification did correlate with the quality of the reduction.
Bibliography 1: Rhee PC, Medoff RJ, Shin AY. Complex Distal Radius Fractures: An Anatomic Algorithm for Surgical Management. J Am Acad Orthop Surg. 2017 Feb;25(2):77-88. 2: Rhee PC, Shin AY. Management of Complex Distal Radius Fractures: Review of Treatment Principles and Select Surgical Techniques. J Hand Surg Asian Pac Vol. 2016 AM Poster 114: Management of Open Phalanx Fractures: A Case for Bedside Washout and Reduced Course of Prophylactic Antibiotics Category: Hand
Hand and Wrist;General Principles Level 4 Evidence
William K. Snapp, MD Jonathan Lee Bass, MD Geoffrey Hogan, BS Nicholas Nissen, BS Reena A. Bhatt, MD Scott Schmidt, MD
Hypothesis Although there is a plethora of data regarding the management of open long bone fractures with urgent operative washout and prophylactic antibiotics, there is little evidence available regarding the treatment of open fractures of the phalanges, including duration of antibiotic regimen or need for emergent operative washout. We predict that there is little indication for emergent operative intervention or prolonged antibiotics in open phalanx fractures
Methods We performed a retrospective chart review of 277 patients seen by the plastic surgery hand service in a single level A trauma center over the last 5 years. Inclusion criteria required that patients presented with an open phalanx fracture and received antibiotics beyond their evaluation in the emergency room. Charts were then evaluated for phalanx injured, mechanism, antibiotic duration and operative intervention, with the primary outcome being infection.
Results Of the 277 patients, the average duration of antibiotic treatment was 7.3 ? 2.2 days, ranging from 1 to 14 days. All 277 patients underwent bedside irrigation and debridement in the emergency room. 13/277 patients (4.6%) developed a subsequent infection, ranging in severity from superficial cellulitis to osteomyelitis. 12/13 (92.3%) patients who developed infections did so only after operative management of the initial injury. Univariate logistic regression demonstrates that the duration of antibiotics had no significant effect on the development of infection (p=0.21).
Summary Points • There is little evidence available regarding the treatment of open fractures of the phalanges. • Emergent operative washout is often expensive and time consuming. • Adverse effects related to prophylactic antibiotic use include enhanced resistance, hypersensitivity reactions and clostridium difficile infection. • This retrospective review demonstrates that the irrigation and debridement of open phalanx fractures can be performed safely at the bedside, and that a prolonged course of antibiotics is unnecessary after open phalanx fractures.
AM Poster 115: Posttraumatic Central Slip Reconstruction Using a Distally Based Flexor Digitorum Superficialis Tendon Slip Category: Hand
Hand and Wrist Level 4 Evidence
Jason Nydick, DO Neil Singh, DO Charles Clark, MD Jeffrey D. Stone, MD
Hypothesis Multiple reconstruction techniques have been described for correction of boutonniere deformity including direct repair, central slip reconstruction, lateral band reconstruction, transverse retinacular ligament reconstruction, staged reconstruction and extensor tenotomy. Each technique has been reported to have variable results with complications including capsular contracture, loss of PIP flexion, and residual deformity. Ahmad and Pickford described a new technique for a rheumatoid arthritis patient, which uses a distally based slip of FDS to reconstruct the central slip through a bone tunnel. This study is a case series utilizing this technique for traumatic central slip injuries.
Methods From 2010-2012, this technique was used on 5 patients by a single surgeon at our institution for boutonniere deformity. Clinical follow up greater than 3 months was available for 4 of these patients. Patients were placed in extension splint postoperatively and began hand therapy after their first postoperative visit. Data collected included PIP extensor lag, PIP active flexion, DIP hyperextension, and DIP active flexion at approximately 4 weeks and final follow up.
Results Average age of patients was 42 (range 30-69) years old. Two patients sustained laceration and two patients dislocations, which disrupted the central slip. Injuries were sustained 1 – 8 weeks prior to surgery. At 4 weeks postop, patients had average active motion of PIP joint of 4-47 degrees and active DIP motion of 0-25. At final follow up (avg 9.2 months, range 3.7-22), average active PIP motion was 30-80 degrees and DIP motion -5 to 42 degrees. There are no known secondary procedures.
Summary Points • All patients in the series had correction of their boutonniere deformity and function of the central slip in immediate postoperative period. • We believe this technique is a good option for posttraumatic reconstruction of the central slip, however the loss of motion reiterates the importance of an intensive hand therapy program after these reconstructions.
Bibliography 1: Ahmad F, Pickford M. Reconstruction of the extensor central slip using a distally based flexor digitorum superficialis slip. J Hand Surg. 2009;34:930–932. 2: Curtis RM, Reid RL, Provost JM. A staged technique for the repair of the traumatic boutonniere deformity. J Hand Surg 1983; 8:167–171. AM Poster 116: Extensor Tendon Proximal Phalanx Dorsal Shaft Attachment Contribution to Finger Extension Category: Hand
Hand and Wrist;General Principles N/A - not a clinical study
Deana Mercer, MD Robert Mercer, BS Christina Salas, MS Moheb S. Moneim, MD Elijah Kamermans Larry Benjey
Hypothesis We hypothesize that the extensor tendon attachment to the dorsum of the proximal phalanx suffices to fully extend the finger metacarpal phalangeal joint (MPJ)
Methods 15 fresh frozen cadaveric hands were utilized. We applied axial load in the line of pull to the extensor digitorum comunis of the index, middle, ring and small finger at the level just proximal to the MPJ. We had three groups: 1) native specimen, 2) extensor tendon release at the proximal interphalangeal (PIP) joint with release of lumbricals and lateral bands, 3) extensor tendon release at the PIP joint and dorsal proximal phalanx and lumbrical/lateral band release. We measured the force of extension at the MP joint in the three groups. Degree of change in extension was calculated using arctan function with change in height of the distal aspect of the proximal phalanx, and the length of the proximal phalanx. We utilized student T-test to analyze if there was a statistically significant decrease in the extension of the phalanges.
Results There was a slight decrease in the extension of all fingers when the extensor tendon were severed at the PIP joint with release of the lateral bands and lumbricals. (8deg+/-2deg) The extension was observed to occur through the dorsal attachment of the extensor tendon on the dorsal proximal phalanx. After release of this attachment, the finger no longer extended. The slight loss of extension was not statistically significant (p-value >.05) between group 1 and group 2. There was a significant difference between groups one and two when compared to group three. Extension was lost after release of the extensor attachments along the length of the proximal phalanx.
Summary Points • There was little change in force and degree of extension of the fingers with distal extensor tendon transection and release of lateral bands and lumbricals. The extension of the finger occurred through the extensor tendon attachment to the dorsum of the proximal phalanx, supporting our hypothesis. • We quantified the contribution of the extensor tendon proximal phalanx dorsal attachments to finger extension • This is clinically significant as the distal insertion of the extensor, which is released when exposing the proximal interphalangeal joint dorsally, may not need to be repaired to the base of the middle phalanx
Bibliography 1: Ueba et al. An anatomic and biomechanics study of the oblique reticular ligament and its role in finger extension. J Hand Surgery Am. 2011 Dec; 36(12):1959-64 2: MS Serge Van Sint Jan et al. The insertion of the extensor digitorum tendon on the proximal phalanx. J Hand Surgery Am. 1996 Jan;21(1):69-76 3: Afifi AM et al. The extensor tendon splitting approach to the proximal interphalangeal joint: do we need to reinsert the central slip. J hand Surgery Eur. 2010 Mar; 35(3):188-91 4: Mercer D et al. Extensor tendon repair with and without central slip reattachment to bone: a biomechanical study. J Han Sung Am. 2009 Jan;34(1):108-11 AM Poster 117: Comparing Pre-and-Post Surgical Hamate Hook Excision Batting Averages in Professional Baseball Players to Assess Impact on Performance Category: Hand
Hand and Wrist Level 4 Evidence
Andrew Z. Mo, MD Daniel Polatsch, MD Steven Beldner, MD
Hypothesis Hamate hook fractures are endemic in avid baseball players. They frequently occur due to impact of the butt of the bat on the nondominant hamate hook. Pain and discomfort limits the player’s ability to participate, requiring expeditious treatment to enable rapid return of function. Multiple studies have demonstrated that hamate hook excision results in reliable return of grip strength and range of motion but did not assess the effect on batting performance in elite athletes. The purpose of this study was to characterize the difference in batting average (BA) performance in professional baseball batters from the Major Leagues. Pre- and post-surgery batting averages were collected to determine if injury and its subsequent treatment had a deleterious effect on batting average performance over time.
Methods An online search was performed identifying Major League baseball players who sustained hamate hook fractures. Sources included news articles, websites, and injured player lists. BAs were collected from both pre- and post-injury seasons. Up to 4 seasons of BAs were collected, with the average BA utilized for analysis. Data was analyzed utilizing paired T-test. Exclusion criteria included non-batting injuries and acquisition of less than 1 season of BA data, pre- and post-surgical correction.
Results 21 competitive baseball players were initially identified. Of these, 19 met the following inclusion criteria. Players were members of Major League baseball teams who sustained hamate hook fractures from batting. They underwent surgical correction of injury and had available BA data from at least 1 season, pre- and post-injury and up to 4 years postinjury. All athletes were male, with a mean age of 26.3 years (range 23-33 years old). None of the injured players were switch hitters. Mean pre- and post-injury BAs were 0.267 and 0.264 respectively. Paired t-test revealed no statistical difference (p<0.77).
Summary Points • Professional baseball players who sustained a hamate hook fracture and underwent surgical correction returned to play with no significant differences in performance as assessed by BA. • These results did not appear to deteriorate over time with no reports of reinjury
AM Poster 118: Extensor Tendon Anatomy: Attachment of the Central Tendon to the Dorsum of the Proximal Phalanx Shaft Category: Hand
Hand and Wrist;General Principles N/A - not a clinical study
Deana Mercer, MD Robert Mercer, BS Moheb S. Moneim, MD Larry Benjey Elijah Kamermans Christina Salas, PhD
Hypothesis We hypothesize that the finger extensor mechanism has attachments along the dorsal surface of the entire length of the proximal phalanx and that this anatomy has not been clearly defined
Methods The attachment along the dorsal aspect of the proximal phalanx of the index, middle, index and small fingers were dissected in 20 fresh-frozen cadavers. The lateral bands as well as attachments along the lateral and medial surface were released in order to appreciate the attachments along the dorsal aspect of the proximal phalanx. Attachment of the ligaments were characterized as very robust, moderately robust and minimally robust at the distal, middle and proximal portions of the proximal phalanx. Three orthopaedic surgeons quantified the attachment and a consensus was reached.
Results We found that 93% of specimens had tendinous attachments along the length of the proximal phalanx with the most robust attachment found at the most proximal and distal aspects of the proximal phalanx adjacent to the articular cartilage. 87% of the specimens were found to have very robust attachments at the proximal portion of the proximal phalanx. The middle portion of the proximal phalanx was found to have moderate to minimally robust attachments. Greatest variability in attachment was found along the most distal portion of proximal phalanx adjacent to the proximal interphalangeal joint with 26% of specimens having a moderate to minimal robust attachment and 74% having robust attachments. The attachments along the proximal phalanx attached on the dorsal half of the proximal phalanx with no fibrous attachments extending past the lateral bands.
Summary Points • There is significant tendinous attachment along the proximal phalanx that may assist in finger extension • The attachments along the proximal phalanx may be adequate to extend the digit at the metacarpal phalangeal joint without central band contribution. Bibliography 1: Ueba et al. An anatomic and biomechanics study of the oblique reticular ligament and its role in finger extension. J Hand Surgery Am. 2011 Dec; 36(12):1959-64 2: MS Serge Van Sint Jan et al. The insertion of the extensor digitorum tendon on the proximal phalanx. J Hand Surgery Am. 1996 Jan;21(1):69-76 3: Afifi AM et al. The extensor tendon splitting approach to the proximal interphalangeal joint: do we need to reinsert the central slip. J hand Surgery Eur. 2010 Mar; 35(3):188-91 4: vMercer D et al. Extensor tendon repair with and without central slip reattachment to bone: a biomechanical study. J Han Sung Am. 2009 Jan;34(1):108-11 AM Poster 119: Incidence and Management of Septic Hand Joints in the Non-Urban Patient Population Category: Hand
Hand and Wrist;Diseases and Disorders;General Principles Level 4 Evidence
Douglas Helm, MD, FACS
Hypothesis An increasingly prevalent and serious infection caused by methicillin-resistant Staphylococcus aureus (ca-MRSA) has seen a recent rise in the urban populations with intravenous drug abuse (IVDA), an independent risk factor. (1) Little is known about the prevalence of this infection in non-urban populations as well in small joint infections. We hypothesize that for patients presenting with septic joints of the hand different patient characteristics and infection prevalence will be seen in non-urban populations.
Methods A 3 year retrospective chart review of all patients presenting to a non-urban hospital was performed to identify patient characteristics, presenting symptoms and causes of the septic hand joint. Differences between groups were assessed using Fishers exact test.
Results 22 septic small joints distal to the carpus were identified with an average patient age of 43 years. The most common mechanism for developing a septic joint were animal bites or sharp lacerations, 57% (p <0.05) compared to other injuries such as fight bites (13%) or infected mucous cysts (14%). The DIPJ (40%) was most frequently septic joint but no significant difference was noted among the small joints. The most common bacterial isolate was methicillin sensitive staph aureus (MSSA) 36% vs 9% for ca-MRSA (p<0.05). A history of diabetes or IVDA was not associated with ca-MRSA. All septic joints were treated with operative washout and treated with IV antibiotics with an average hospital stay of 4 days.
Summary Points • For this non-urban population, small joint hand infections are predominately caused by MSSA. • ca-MRSA was identified at a lower incidence with no identifiable risk factors • Applying principles learned from major urban centers do not necessarily apply to non-urban patient populations and hand surgeons should be aware of the local incidence of ca-MRSA while treating septic hand joints. Bibliography 1: (1) Houshian S, Seyedipour S, Wedderkopp N. Epidemiology of bacterial hand infections. Int J Infect Dis 2006;10:315–319 AM Poster 120: Long-Term Outcomes of Trapeziectomy with a Modified Abductor Pollicis Longus Suspension Arthroplasty Category: Hand
Hand and Wrist Level 4 Evidence Grant received from: Athrex, Inc.
Ariana Mora, BA Philip Blazar, MD Jacob Silver Jenna Rogers Brandon E. Earp, MD
Hypothesis There is limited literature characterizing surgical and clinical outcomes of basal thumb arthritis post-trapeziectomy and abductor pollicis longus suspension arthroplasty (APLSA). We hypothesized that patients who underwent APLSA would have favorable long-term outcomes.
Methods Patients were contacted post-APLSA at a median follow-up time of 4.8 years (interquartile range 3.0-6.0 years). Follow-up clinical evaluation included grip, key pinch, and tip pinch strength. The following patient reported outcomes surveys were obtained: Visual Analog Pain Score (VAS) and Disabilities of the Arm, Shoulder, and Hand (DASH). Information on the index surgery and concurrent ipsilateral surgery was obtained from the electronic medical record.
Results This study evaluated 66 hands in 60 patients (51 female, 9 male; 60.4 average age at surgery). At the time of index surgery, 7.5% of hands had prior ipsilateral surgery, 65.2% had concurrent ipsilateral surgery (65.1% DeQuervain’s release, 30.2% carpal tunnel release, 12.1% soft tissue procedures, 4.7% MP capsulodesis, 4.7% MP fusion), and 18.2% had hemitrapezoid resection. Median time between operation and most recent evaluation was 4.8 years (interquartile range [IQR] 3.0-6.0 years). Operative grip (43.3 lbs ± 24.1), key pinch (11.0 lbs ± 4.6), and tip pinch (7.4 lbs ± 3.7) strength was 87%, 80%, and 81%, respectively, of non-operative grip, and tip pinch strength. Median (IQR) outcome scores were VAS 0.0 (0.0-2.0) and DASH 9.1 (2.3-26.1).
Summary Points • Long-term results at 4.8 years are favorable for APLSA with patients demonstrating 80- 87% grip, and tip pinch compared to the contralateral side. • Patients experience little to no pain in the operated joint and experience minimal disability of their upper extremity at long term follow-up. • 65% of patients underwent concurrent ipsilateral hand surgeries,including Dequervain’s release, carpal tunnel release, MP procedures, and other soft tissue surgeries. • APLSA is a favorable procedure for alleviation of symptoms associated with basal thumb arthritis.
AM Poster 121: The Index Finger Metacarpal Tubercle: An Uncommon but Treatable Etiology of Pain Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
Paige L. Myers, MD Ronald D. Brown, Jr., MD Hannah M. Smith Joseph S. Khouri, MD Jeffrey A. Fink, MD
Hypothesis The region of the index finger metacarpophalangeal joint is a common source of hand pain with variable etiology. We have identified the tubercle at the dorsoradial neck of the index finger metacarpal tubercle as the distinct and specific site of pain in select subset of patients, for which we have found no previous description in the literature.
Methods A retrospective chart review was performed from January 2013 to June 2017 from a single hand surgeon private practice (JAF). Patients were included who presented with pain at the dorsoradial tubercle of the index finger metacarpal. All patients identified underwent a trial of nonoperative management which included steroid injections and buddy taping. Patients that did not respond to conservative measures underwent surgical excision of the tubercle. For further anatomic exploration, a single cadaveric human hand specimen was obtained. The skin, subcutaneous tissues and radial collateral ligament (RCL) of the index finger were carefully dissected to show the precise location of the deep and superficial portions of the RCL, in relation to the tubercle.
Results Ten patients were identified in the study period with pain and tenderness at the index finger metacarpal tubercle. The dominant hand was affected in 6/10 patients. Basal joint arthritis, tenosynovitis and carpal tunnel syndrome were the most common concomitant diagnoses. On exam, six patients exhibited pain with ulnarly directed RCL stress at 90 degrees flexion of the index finger, though none were unstable. On fluoroscopy, 7/8 patients exhibited a prominent bony tubercle (Figure 1). Two patients failed conservative measures and went on to surgical excision of the tubercle with complete resolution of pain. On the cadaver dissection, it was discovered that the superficial portion of the RCL partially splays out over the tubercle (figure 2). When this is transected, the metacarpophalangeal joint remains stable due to the strength of the deeper portion of the RCL.
Summary Points • A subset of patients with complaints of index finger pain present with localized and specific tenderness of palpation at the index finger metacarpal tubercle. Prominence of the tubercle can be detected on 45-60 degree pronated oblique plain film or fluoroscopic images. • The exact pathophysiology of the painful tubercle is unclear, possible due to bony ethesophytes or partial RCL tears. • Should pain persist or recur in spite of nonperative treatment, including steroid injection, excision of the index finger metacarpal tubercle is recommended as definitive management.
Bibliography 1: Dy CJ, Tucker SM, Kok PL, Hearns KA, Carlson MG. Anatomy of the radial collateral ligament of the index metacarpophalangeal joint. J Hand Surg Am. 2013 Jan;38(1):124-8. 2: Minami A, An KN, Cooney WP 3rd, Linscheid RL, Chao EY. Ligamentous structures of the metacarpophalangeal joint: a quantitative anatomic study. J Orthop Res. 1984;1(4):361-8. 3: Gaston RG, Lourie GM. Radial collateral ligament injury of the index metacarpophalangeal joint: an underreported but important injury. J Hand Surg Am. 2006 Oct;31(8):1355-61. 4: Dzwierzynski WW, Matloub HS, Yan JG, Deng S, Sanger JR, Yousif NJ. Anatomy of the intermetacarpal ligaments of the carpometacarpal joints of the fingers. J Hand Surg Am. 1997 Sep;22(5):931-4. 5: Hsieh YF, Draganich LF, Piotrowski GA, Mass DP. Effects of reconstructed radial collateral ligament on index finger mechanics. Clin Orthop Relat Res. 2000 Oct;(379):270-82. AM Poster 122: Surgical Fixation of Metacarpal Shaft Fractures Using Absorbable Implants: An Update of the Literature Category: Hand
Hand and Wrist Level 4 Evidence
Jessica Hazan
Hypothesis Despite the proven efficacy and advantages of absorbable implants, their use for metacarpal shaft fixation has been limited. This is likely due to the high reported complication rates in early studies with polyglycolic acid (PGA) implants, notably high rates of noninfectious inflammatory reaction (5-25%), occurring up to 30 weeks after fixation. The objective of this study was to assess the clinical outcomes of newer absorbable plates and screws composed of polylactic acid (PLA) in the treatment of metacarpal shaft fractures. We hypothesize that our findings will support the use of PLA implants for metacarpal fracture fixation.
Methods The authors performed a systematic search of the PubMed, Ovid MEDLINE and EMBASE databases dating from 1946 to 2017. Primary outcome measures were the development of non- infectious inflammatory reaction and implant failure.
Results A total of 42 metacarpal shaft fractures in 35 patients were included in this study. The average follow-up time was 20.4 months (n=24; range: 3.6-61 months). Only 1 case (2.4%) of non- infectious inflammatory reaction was reported with polylactic acid (PLA) plates and PLA/PGA compounds. Non-infectious inflammatory reaction was observed in 4 out of the 9 patients (44.4%) with a trimethylene carbonate/PLA compound. Symptoms appeared after an average time of 15.8 months (range 12-19 months) post-fixation. Painless prolonged inflammation that resolved spontaneously within 6 months was reported in 7.1% of cases (n=3). Implant failure with loss of fracture reduction was reported in 9.5% of cases (n=4).
Summary Points • Newer absorbable material (PLA or PLA/PGA) appear to have significantly lower rates of noninfectious inflammatory reaction than previously reported. • When compared to metallic fixation of the metacarpal shaft, absorbable fixation appears to have comparable complication rates and biomechanical properties.
Bibliography 1: Waris E, Ashammakhi N, Kaarela O, Raatikainen T, Vasenius J. Use of bioabsorbable osteofixation devices in the hand. Journal of hand surgery. 2004 Dec;29(6):590-8. 2: Böstman OM. Absorbable implants for the fixation of fractures. JBJS. 1991 Jan 1;73(1):148-53. 3: Waris E, Ninkovic M, Harpf C, Ashammakhi N. Self-reinforced bioabsorbable miniplates for skeletal fixation in complex hand injury: three case reports. Journal of Hand Surgery - American Volume. 2004;29(3):452-7. 4: Dumont C, Fuchs M, Burchhardt H, Appelt D, Bohr S, Sturmer KM. Clinical results of absorbable plates for displaced metacarpal fractures. Journal of Hand Surgery - American Volume. 2007;32(4):491-6. 5: Lionelli GT, Korentager RA. Biomechanical failure of metacarpal fracture resorbable plate fixation. Annals of Plastic Surgery. 2002;49(2):202-6. AM Poster 123: Risk Factors for Readmission and Failure of Digital Replantation: A Nationwide Analysis of 3896 Patients Category: Hand
Hand and Wrist;Diseases and Disorders;Practice Management Level 2 Evidence
Kareem Hassan, MD Edward Beck, MPH Patrick Reavey, MD
Hypothesis This study aims to analyze risk factors associated with readmission and failure of digital replantation in the United States using the Nationwide Readmission Database (NRD). The hypothesis is that readmission and failure following digital replantation is associated with medical comorbidities, demographics, and hospital characteristics.
Methods The 2010-2015 years of the NRD were queried to identify all admissions for patients who underwent a finger or thumb replantation. Each patient and admission was reviewed to determine medical comorbidities, replantation-related complications requiring readmission, and any additional surgeries or treatment rendered. Failure of replantation was defined as amputation occurring on a subsequent admission to the primary hospitalization. For 2014-2015, failure also included amputations occurring on days subsequent to the initial replantation. Patient comorbidities, hospital type/size, and hospital course were correlated to readmission and failure individually. Weighted statistical analysis was performed to elucidate the relative risk of readmission or failure for each variable.
Results From 2010-2015, a weighted 3896 patients in the United States underwent digital replantation. The average age of all patients was 37.8. Approximately 262 (6.7%) patients were readmitted to the same hospital following replantation, including outpatient surgical procedures. The average time to readmission for all patients was 30.6 days; patients with failed a failed replantation presented on average 17.2 days after discharge versus 37.8 days for those readmitted for other complications. Table 1 summarizes the rate and risk of readmission for each comorbidity. The most common complications leading to readmission were infection (31.6%), debridement (22.4%), gangrene (18.4%), pedicle revisions (6.8%), non-healing wound (2.5%), PE (2.5%) and upper extremity embolism (2.2%). Smokers were at greatest risk for readmission for debridement and pulmonary embolism, drug use was significantly correlated with infection, while hypertensive patients were most likely to have gangrene and pedicle revisions (p<0.05). Table 2 summarizes the rate and risk of failure for each comorbidity. Metropolitan teaching hospitals (85.2%), large hospitals (84.7%), non-profit (65.8%) performed the majority of all replantations. Failure rates were lower at nonprofit hospitals (35.8%, p=0.005) when compared with government (35.8%) and investor owned hospitals (25.5%). Metropolitan hospitals (OR 2.1) and nonprofit (OR 1.6) hospitals were most likely to treat patients for complications.
Summary Points • Several medical comorbidities are associated with readmission and failure of digital replantation. Identifying these can help guide preoperative decision making and counseling. • When compared to other national database studies, the ability to track patients across admissions allows for more accurate determination of patient outcomes.
AM Poster 124: Collateral Ligament Reconstruction of Chronic Proximal Interphalangeal Joint Instability Using a Half Slip of the Flexor Digitorum Superficialis Tendon: A Case Series Category: Hand
Hand and Wrist Level 4 Evidence
KangWook Kim, MD, PhD Jinho Kim, MD, PhD
Purpose To evaluate the clinical outcomes of collateral ligament reconstruction of chronic PIPJ instability using a slip of the flexor digitorum superficialis(FDS) tendon.
Hypothesis Chronic instability of proximal interphalangeal joint(PIPJ) is rare. In such cases, usually it requires surgical treatment, but there is no consensus on proper management.
Methods We retrospectively reviewed 5 patients who had collateral ligament reconstruction of chronic PIPJ instability using a distally based half slip of the FDS tendon. The mean age at the time of surgery was 45 years (range, 37-61 y). To evaluate the results, we compared preoperative and postoperative range of motion, instability. We obtained VAS pain and DASH scores at the final follow up. Average follow-up was 23 months (range, 18-36 month).
Results There is no significant change of the range of motion after surgery. The average angle of lateral instability improved after surgery from 23 degree to 1 degree. The mean VAS pain scores were 0.3 points and the DASH scores were 6.3 points
Summary Points Collateral ligament reconstruction using a half slip of the FDS tendon for chronic PIPJ instability obtains joint stability without change of range of motion.
Bibliography 1: J Hand Surg Am. 2016 Jan;41(1):129-32. doi: 10.1016/j.jhsa.2015.10.007. Epub 2015 Nov 21. 2: J Hand Surg Am. 1996 Jul;21(4):679-83. 3: J Hand Surg Br. 1992 Dec;17(6):625-8. 4: J Hand Surg Eur Vol. 2012 Nov;37(9):832-8. doi: 10.1177/1753193412436947. Epub 2012 Feb 6. 5: Acta Orthop Traumatol Turc. 2015;49(6):701-5. doi: 10.3944/AOTT.2015.14.0028. AM Poster 125: Baseline and Three-Year Evaluation of Early Carpometacarpal Osteoarthritis Kinetics Using Cylindrical and Gross Grasp Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence Grant received from: 1R13AR065906-01 National Institutes of Health
Monica Coughlan, MD Deborah Kenney Joseph J. Crisco, PhD Douglas Moore, PhD Arnold-Peter Weiss, MD Amy L. Ladd, MD
Hypothesis Gross grasp is a common clinical tool to evaluate grip strength in advanced carpometacarpal osteoarthritis (CMC OA), a prevalent and debilitating thumb disorder affecting over 50% of older adults (1), but recent studies have shown cylindrical grasp may be able to better detect changes in grip strength early in the disease process (2). This longitudinal study compares the responsiveness of gross and cylindrical grasp to evaluate the kinetics of the CMC in patients diagnosed at baseline with early CMC OA.
Methods Baseline measurements of gross grasp, as measured with a modified digital - Jamar dynamometer (Specialty Therapy Equipment, Inc., Towson, MD,), and cylindrical grasp, as measured with a force sensor at the thumb pad within a custom jig (3), were obtained at time of diagnosis in 78 subjects with early CMC OA (45-75 years old, mean = 56.5) and then at three years from time of diagnosis. Diagnosis of CMC OA was made based on symptoms with radiographic Modified Eaton 0 or 1. Percent change from baseline, effect size, standardized response mean (SRM), and T-test were used to compare the baseline and three-year data for each measurement, and the difference in force for the two measurements were compared over time using an independent samples T-test.
Results On average, cylindrical grasp decreased by 7.2% from the baseline to three-year measurements. Average gross grasp decreased by 5.8% from the baseline to three-year measurements. The effect size for cylindrical and gross grasp were 0.368 and 0.174 respectively. The SRM for cylindrical and gross grasp were 0.429 and 0.386 respectively. The T-test for both cylindrical and gross grasp demonstrated a statistically significant reduction in grasp from baseline (Cylinder=0.003 and Gross=0.001), but the independent samples T-test did not detect a difference between measures.
Summary Points • Small but significant decreases in both cylindrical grasp forces and gross grasp (Jamar) occur over time in early CMC OA . • Of the two measures, cylindrical grasp is the more sensitive measure to evaluate the health status of patients with early thumb OA over time. • Kinetic measurement of CMC loading, as measured by a gross and cylindrical grasp dynamometers, may not be sensitive enough to detect meaningful clinical changes in kinetics that may occur during early CMC OA. • Cylindrical and gross grasp should continue to be followed at time points in disease to understand how these correlate with pathology and treatment.
Bibliography 1: Van Heest AE, Kallemeier P. 2008 Mar. Thumb carpal metacarpal arthritis. Journal of the American Academy of Orthopaedic Surgeons. 16(3): 140-51. 2: Coughlan MJ, Bourdillion A, Crisco JJ, Keney D, Weiss AP, Ladd AL. 2017 Feb. Reduction in Cylindrical Grasp Strength is Associated with Early Thumb Carpometacarpal Osteoarthritis. CORR. 475(2):522-528. 3: Ladd Al, Messana JM, Berger AJ, Weiss AP. 2015 Mar. Correlation of clinical disease severity to radiographic thumb osteoarthritis index. Journal of Hand Surgery. 40(3):474-82. AM Poster 126: Clinical and Radiological Outcomes of a Trapezometacarpal Interposition Implant: Results of 39 Implants in 33 Patients Category: Hand
Hand and Wrist Level 4 Evidence
Mark Ross, MBBS, FRACS J. Alexa Potter Susan Peters, MAHTA Greg B. Couzens, MD
Hypothesis This study examined survivorship, clinical and patient-reported outcomes with the Pyrocardan® trapezometacarpal interposition implant. It was hypothesized that the postoperative outcome measures of the Pyrocardan implant would be comparable to those seen with LRTI surgeries and Bellemère’s original series (Bellemère et al, 2011).
Methods This study is a case series of patients at Brisbane Hand & Upper Limb Research Institute. Thirty- three patients (of which 21 were female and 12, male) from 2012 to 2017 received a total of 39 Pyrocardan® implants. Patients were tracked prospectively from pre-surgery, 6 weeks, 3 months, 6 months, 1 year, 2 years and beyond (long term) wherever possible. The post-operative pain and function outcome measures were analysed alongside a matched cohort of LRTI patients from our own institution. These results will be discussed in relation to Bellemère’s previously published results.
Results There have been no complications or revision surgeries for the series. All 39 joints were followed up post-operatively at an average of 17 months (min 6 weeks - max 5yrs). Average age at operation was 57.9 years. Thirty-four of the 39 joints were assessed greater than or equal to 6 months post index surgery. Outcome measure scores improved from pre-operative assessment to the most recent follow up (=6 months). PRWHE decreased from 64.4 to 26.1, QuickDASH from 48.4 to 28.50 and on VAS scales pain decreased from 59.4 to 23.2 and satisfaction increased from 16.2 to 80. Average grip strength at a minimum of two years was 28.8kg, as compared to LRTI (19.6kg) and Bellemere’s series (25kg). In an age matched cohort assessed at a minimum of 2 years, grip strength increased from 17kg pre-op to 28.9kg post-op in the Pyrocardan patients and from 17kg to 20kg in patients who underwent an LRTI procedure.
Summary Points • The Pyrocardan® implant is a free intra-articular spacer composed of pyrocarbon. It is a biconcave resurfacing implant that is both ligament and bone-stock sparing. A primary indication for use is early- to moderate-stage trapezometacarpal osteoarthritis. • Pyrocardan® provides a safe, effective treatment for pain relief and improved functional use of the hand for trapeziometacarpal arthritis. • Clinical outcomes appeared equivalent to LRTI and are comparable to Bellemere’s original series. Grip strength was better in the Pyrocardan series.
Bibliography 1: P. Bellemère, E. Gaisne, T. Loubersac, L. Ardouin, S. Collon, C. Maes. 2011. Pyrocardan implant: free pyrocarbon interposition for resurfacing trapeziometacarpal joint. Chirurgie de la main 30, S1, 28-35 AM Poster 127: Biomechanical Evaluation of Opponensplasty for Low Median Nerve Palsy Category: Hand
Hand and Wrist;Nerve N/A - not a clinical study
Maki Iwase Yusuke Matsuura, MD, PhD Kazuki Kuniyoshi, MD, PhD Takane Suzuki, MD Kengo Nagashima Seiji Ohtori, MD, PhD
Hypothesis We hypothesized that the Burkhalter Opponensplasty (BO) provided a good thumb pronation for median nerve palsy. The aim of the present study was to determine biomechanically the opposition angles of the three representative Methods Camitz Opponensplasty (CO), modified- Camitz Opponensplasty (m-CO), and BO.
Methods We reproduced thumb opposition in six fresh-frozen cadaveric arms. Firstly, after performing CO, we tied the proximal portion of the Palmaris Longus (PL) tendon, then cut the tendon to pull proximally. Secondly, we made the loop through under the Flexor Carpi Ulnaris (FCU) to represent the m-CO. The last step of the surgical procedure was making the path of the ulnar subcutaneous tunnel for representing BO instead of using the Extensor Indicis Proprius (EIP) for original Burkhalter Methods not to reattach the tendon insertion site. After all procedures, the cadaveric arms that were fixed with wrist at 0° and the forearms at neutral position were set in the frame. We attached sensors on the thumb nail, the radial styloid, and the dorsal aspect of the second metacarpal head. The donated PL tendon was mechanically pulled while tracking the sensor in the thumb opposition position. The first web and the thumb pronation angle of the three procedures were measured at loading forces of 10%, 20%, and 30% of the Estimated Muscular Force (EMF) and at 25 N.
Results For the 1st web angle, CO had significantly greater angle than that of m-CO at 10% EMF (CO 50.9° vs. m-CO 48.0°, P= 0.047), and m-CO had significantly greater angle than BO at 30% EMF(m-CO 56.0° vs. BO 52.7°, P= 0.014) and 25 N(m-CO 57.0° vs. BO 53.0°, P= 0.008). For the thumb pronation angle, BO had significantly greater angle than CO at 10% EMF (BO13.6° vs. CO 7.0°, P= 0.031), and m-CO and BO had significantly bigger angle than CO at 30% EMF(CO 19.4° vs. m-CO 25.1°,P=0.023; CO 19.4 vs. BO 27.7, P=0.002) and 25N (CO 20.4° vs. m-CO 26.1°, P=0.025; CO 20.4 vs. BO 29.4, P= 0.01).
Summary Points • BO produced the bigger pronation angle but the significantly smaller 1st web angle than the other procedures, while CO showed significantly smaller angle in pronation and m-CO had the bigger angle both in the 1st web and the pronation angle. • Present study proved that BO was the effective method for restoring thumb pronation.
Bibliography 1: Bunnell S. Reconstructive surgery of the hand. Surg Gyneco. 1924; 34:259-274. 2: Camitz H. Surgical treatment of paralysis of opponens muscle of thumb. Acta Orthop Scand. 1929;65:77-81. 3: Littler JW, Li CS. Primary restoration of thumb opposition with median nerve decompression. Plast Reconstr Surg. 1967;39(1):74-75. 4: Burkhalter WE. Early tendon transfer in upper extremity peripheral nerve injury. Clin Orthop Relat Res. 1974;(104):68-79. 5: Al-Quattan MM. Extensor indicis proprius opponensplasty for isolated traumatic low median nerve palsy: A case series. Can L Plast Surg. 2012 winter;20(4):255-7. AM Poster 128: Medium to Long Term Outcomes of Pyrocarbon Total PIP Joint Arthroplasty Category: Hand
Hand and Wrist Level 4 Evidence
J. Alexa Potter Mathias Haeffeli, MD Greg B. Couzens, MD David Gilpin, MBBS Mark Ross, MBBS, FRACS,
Hypothesis We hypothesized that despite the varied results published in literature, pyrocarbon for total proximal interphalangeal joint arthroplasty can produce reliable and effective outcomes.
Methods Data from a prospective patient cohort undergoing pyrocarbon total PIPJ arthroplasty was analysed. Imaging and clinical data was collected preoperatively and at 2, 5 and 10 years. Pain and satisfaction were assessed using a visual analogue scale. QuickDASH and PRWHE questionnaires were used to assess function, and joint motion, grip and pinch strength were recorded.
Results Ninety-four total PIPJ arthroplasties were performed in 70 patients from 2002 to 2017. Overall pain was improved and satisfaction was rated highly. Joint motion was preserved and standard outcomes questionnaires indicated satisfactory hand functioning. These results have been stable over the course of medium to long term follow up (average 5 years, range 1-14 years). VAS pain scores decreased from an average of 65 at pre-operative assessment to 4.4 at = 5 years, whilst satisfaction increased from 15.4 to 72.2 at the same intervals. QuickDASH and PRWHE scores improved from 36.7 and 62.4 respectively at pre-op assessment to 30.2 and 24.7 at = 5 year follow up. Similarly, assessments at = 10 years recorded an average QuickDASH score of 30.3 and PRWHE score of 25.4. In our series 14 patients required reoperation for any cause, 10 for joint release or tenolysis and 2 for joint revision (1 revision arthroplasty, 1 fusion). This compares favourably with published results.
Summary Points • Pyrocarbon total arthroplasty is now an established treatment option for arthritis of the PIPJ. • In our series only 1 out of 94 joints required fusion and 1 required revision arthroplasty at long term follow up. Secondary tenolysis / arthrolysis procedures yielded worthwhile functional improvements in 10 patients.Some specific surgical and rehabilitation techniques may be employed to achieve improved outcomes and reduce the likelihood of revision surgery. • Pyrocarbon for total PIPJ joint arthroplasty can produce reliable and effective outcomes.
AM Poster 129: Managing Advanced Dupuytren’s Disease with Collagenase: Is There a Suitable Cohort? Category: Hand
Hand and Wrist;Diseases and Disorders;Practice Management Level 4 Evidence
David J. Hunter-Smith, MBBS, MPH, FRACS, FACS Jessie Xin Xu Daniel Reilly, MD Vicky Tobin Bethany Reynolds, Warren M. Rozen, MBBS, BMedSC, MD, PhD, FRACS
Hypothesis 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.
Summary Points 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.
AM Poster 130: Dupuytren Disease Seven-Day Manipulation Following Collagenase: Safety, Efficacy and Outcomes Category: Hand
Hand and Wrist;Diseases and Disorders;Practice Management Level 4 Evidence
David J. Hunter-Smith, MBBS, MPH, FRACS, FACS Bethany Reynolds Warren M. Rozen, MBBS, BMedSC, MD, PhD, FRACS Michael Chae, MBBS, PhD
Hypothesis The manipulation of digits with Dupuytren's Disease 7 days after treatment with injectable collagenase clostridium histolyticum (CCH) is safe and effective.
Methods Patients presenting with Dupuytren’ Disease were offered treatment with collagenase injections. Baseline demographic and medical data, total passive extension deficit (TPED) and patient- reported outcome measures (PROMs) were recorded prior to treatment. Patients were injected D0 and manipulated D7 under local anaesthetic on an outpatient basis. Patients were reviewed and further measurements and PROMs collected at 6 weeks and 6 months post injection. Results were collected prospectively and analysed.
Results 139 patients (98 males, 74.2%) with a mean age of 65.7 years (range 38.6-87.7) have been treated to date. In 34% of cases the disease represented a recurrence. Anticoagulants were taken by 63% of patients. There was a significant improvement in TPED across injected rays (p<0.001). In addition, patients demonstrated highly significant improvement in function and quality of life on Southampton (P < 0.001), URAMS (P < 0.001) and Patient-Specific Functional Scale (P < 0.001) questionnaires. The adverse event profile was comparable to what has been reported in major clinical trials.
Summary Points Our data showed significant improvements in objective and subjective measures of hand function following manipulation 7 days after injection with collagenase. The data suggest that it is safe and efficacious to manipulate 7 days post injection with collagenase.
Bibliography 1: Hurst, L.C., et al., Injectable collagenase clostridium histolyticum for Dupuytren's contracture. New England Journal of Medicine, 2009. 361(10): p. 968-979 2: Beaudreuil, J., Unite Rhumatologique des Affections de la Main (URAM) scale: development and validation of a tool to assess Dupuytren's disease-specific disability. Arthritis care & research, 2011. 63(10): p. 1448-55. 3: Mohan, A., The southampton dupuytren's scoring scheme. Journal of Plastic Surgery and Hand Surgery, 2014. 48(1): p. 28-33. 4: Stratford, P., Assessing Disability and Change on Individual Patients: A Report of a Patient Specific Measure. Physiotherapy Canada, 1995. 47(4): p. 258-263. AM Poster 131: Mechanisms of Failure in Base of Thumb Implant Arthroplasty: A Systematic Review Category: Hand
Hand and Wrist;Diseases and Disorders Level 4 Evidence
David J. Hunter-Smith, MBBS, MPH, FRACS, FACS Aparna D. Ganhewa, MBChB MBChB Rui Wu, Bbiomed, MD George Miller, MD Vicky Tobin Michael Chae, MBBS, PhD MBBS, PhD Warren M. Rozen, MBBS, BMedSC, MD, PhD, FRACS
Hypothesis The objective of the current systematic review was to identify the complications leading to implant failure in basal thumb arthritis
Methods The systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines . The identified implants were grouped by design concept in to 5 groups: Total joint replacement, Hemiarthroplasty, Interposition with No, Partial and total trapezial resection. The number of reported complications were combined for each implant design group and overall by simple addition. Implant-years were calculated by multiplying number of arthroplasties in each study by the study mean length of follow up. The rate of each complication was calculated for each implant design group, and an overall rate as a proportion of the number of cases with each complication divided by the total number of Implant-years for each design group. A 10-year rate of complication was calculated.
Results A total 125 articles were included post full text review. 4 articles were level I, 2 level II, 21 level III, 98 level IV. A total of 5363 arthroplasties in 5313 patients were identified. 83% were done on females, and 57% on the dominant hand. The mean age of the patients ranged from 51 to 71 years, and the mean length of follow up of the studies ranged from 4 to 196 months (16 years). A total of 51 separate implant types for base of thumb arthritis were identified; 18 total joint replacements, 6 Hemiarthroplasty, 12 interposition with partial trapezial resection, 13 interposition with total trapezial replacement, and 2 interposition with no trapezial resection. 11 implant related complications were identified which lead to at least revision of one implant. The overall 10-year revision rate for all implants combined from most common to least common: Aseptic loosening (7.96%), Dislocation (6.40%), Persistent pain (3.86%), Subluxation (1.27%), Fracture of implant (1.35%), Peri-prosthetic fracture (0.76%), Foreign body reaction (1.59%), Infection (0.68%), Osteolysis (0.56%), Implant subsidence (0.44%), and Periprosthetic ossification (0.12%)
Summary Points • A range of complications can lead to implant failure in implant arthroplasty for base of thumb arthritis. • Designs found to be susceptible to aseptic loosening, dislocation, persisting pain and using materials inducing foreign body reaction need to be used with caution. • 3.The evidence supporting the use of implant arthroplasty can be strengthened by means of prospective studies with longer term follow up
Bibliography 1: Huang K, Hollevoet N, Giddins G. Thumb carpometacarpal joint total arthroplasty: A systematic review. J. 2015, 40: 338-50. 2: Vitale MA, Taylor F, Ross M, Moran SL. Trapezium prosthetic arthroplasty (silicone, artelon, metal, and pyrocarbon). Hand Clin. 2013, 29: 37-55. 3: Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW. Surgical management of primary thumb carpometacarpal osteoarthritis: A systematic review. J Hand Surg [Am]. 2011, 36: 157-69. 4: Wajon A, Vinycomb T, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2015: CD004631. 5: Bricout M, Rezzouk J. Complications and failures of the trapeziometacarpal maia prosthesis: A series of 156 cases. Hand Surg Rehabil. 2016, 35: 190-8. AM Poster 132: Morbidity of Interventions in the Treatment of Primary Dupuytren’s Disease Category: Hand
Hand and Wrist;Diseases and Disorders;Practice Management Level 4 Evidence
David J. Hunter-Smith, MBBS, MPH, FRACS, FACS
Hypothesis 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.
Summary Points The quantification of complication rates following treatment for primary Dupuytren disease may facilitate decision making and patient counselling. However, there is a paucity of data that specifically quantifies the risk profile of treatment options for primary Dupuytren's disease
AM Poster 133: Trapeziectomy Internal Brace Suspensionplasty Versus Ligament Reconstruction Tendon Interposition for Thumb Carpometacarpal Arthritis: A Biomechanical Study Category: Hand
Hand and Wrist N/A - not a clinical study
Steven J. Lee, MD David Porter Ryan Coyle Andrew Kim Ian Kremenic
Hypothesis Thumb carpometacarpal (CMC) arthritis is one the most common hand conditions requiring surgical treatment. Multiple
Methods of surgical management including trapeziectomy, CMC arthrodesis, and ligament reconstruction have been described but the literature on clinical results remain equivocal. Novel technique using suture anchors to form an internal brace between the 1st and 2nd metacarpal bases has been described but not previously tested. The purpose of this study is to test the biomechanical strength of trapeziectomy Internal Brace suspensionplasty (TIBS) compared with traditional ligament reconstruction tendon interposition (LRTI) for thumb carpometacarpal arthritis.
Methods Five matched-paired fresh human cadaveric hands underwent trapeziectomy and were divided into 2 treatmentgroups: Internal Brace suspensionplasty with tape augmentation or LRTI with ½ flexor carpi radialis. The TIBS wasperformed by securing the base of the first metacarpal to the second metacarpal using double stranded tape secured into each bone using a suture anchor. The forearm and hand were secured to a board, and the thumb was disarticulated atthe IP joint and secured using a custom jig. An axial load of20mm/sec was applied on an Instron to stress the reconstructions. Failure was defined as either catastrophic failure or contact between the base of the metacarpal with the scaphoid.
Results The average pretesting trapezial space height differed significantly between the TIBS (11.9±1.5 mm) and LRTI (10.5±1.5 mm) groups (p=0.043). The TIBS failed at 115±66 N while the LRTI failed at 38±22 N (p=0.043). This TIBS was thus 3.03 times stronger than the LRTI group. The TIBS was also significantly stiffer than the LRTI (10.3±5.9 vs 3.9±2.8 N/mm, p=0.043). Failure of TIBS was due to loss of trapezial space in each specimen rather than catastrophic failure. Failure of the LRTI appeared to be a combination of tendon stretch and loss of fixation.
Summary Points • In the cadaveric model, TIBS provides superior load bearing and maintenance of trapezial space height compared with • LRTI. The clinical importance of the TIBS reconstruction is that it obviates the need to sacrifice the flexor carpi radialis, an important wrist flexor, and need for another incision to harvest the graft. It also eliminates the need for supplemental • Kwire fixation which is often used in CMC arthritis surgery. The increased strength may also allow for smaller and shorterpostoperative immobilization and accelerated therapy as there is no delay in immobilization due to a healing tendon graft.
AM Poster 134: Biomechanical Properties of a Novel Mesh Suture in a Cadaveric Flexor Tendon Repair Model Category: Hand
Hand and Wrist N/A - not a clinical study
Lauren M. MIoton, MD Stephen J. Wallace, MD Robert M. Havey, MS Muturi G. Muriuki, PhD Jason H. Ko, MD
Hypothesis The purpose of this study is to compare the biomechanical properties of flexor tendon repairs using a novel mesh suture (Figure 1) to traditional suture repairs. The hypothesis is that mesh suture based repairs will be stronger than standard suture based repairs.
Methods Sixty human cadaveric flexor digitorum profundus tendons were harvested and assigned to one of three suture repair groups: 3-0 FiberWire (Arthrex, Inc, Naples, FL), 4-0 FiberWire, or 1mm diameter mesh suture; all tendons were repaired using a 4-strand core cruciate suture configuration. Each tendon repair underwent either linear loading or cyclic loading until failure. Outcome measures included yield strength, ultimate strength, the number of cycles and load required to achieve 1 mm and 2 mm gap formation and failure.
Results Mesh suture repairs had significantly higher yield and ultimate force values when compared to 3-0 and 4-0 FiberWire repairs under linear testing (Figure 2). The average force required to produce repair gaps was significantly higher in mesh suture repairs compared to conventional suture. Mesh suture repairs endured a significantly greater number of cycles and force applied before failure compared to 4-0 and 3-0 FiberWire.
Summary Points • This biomechanical study of flexor tendon repairs using a novel mesh suture reveals significant increases in repair site strength outcomes in the mesh suture repair cohort compared to conventional suture cohorts. • Such findings could allow for earlier mobilization, decreased adhesion formation, and lower rupture rates after flexor tendon repairs. AM Poster 135: Learning Curve and Risks in Carpal Tunnel Release by Ultrasounds or Endoscopy: A Comparative Pilot Study Between an Experienced Surgeon and a Junior Surgeon- 30 Cadaveric Cases Category: Hand
Hand and Wrist;Nerve N/A – not a clinical study
Richard Emmanuelle, MD Mares Olivier, MD Coulomb Remy, MD Pascal Kouyoumdjian, PhD
Hypothesis The learning curve and risks of sectionning the transverse carpal ligament (CTL) by ultrasounds have never been evaluated so far. We have choosen to evaluate these parameters by a comparative cadaveric study between a junior surgeon (JS) and an experimented one (ES) througt two section Methods : endoscopic versus ultrasound.
Methods We used 30 normal cadaveric wrists (5 fresh frozen, and 15 conserved). JS did performed 14 Ultrasouds Carpal Tunnel Release (UCTR) and 6 Endoscopic carpal tunnel release (ECTR) without external help, against 5 cases for each method for the senior surgeon. We then extensively dissected each wrist to evaluate the pourcentage of section on total CTL lenght. We also researched anatomical injuries (tendons, vessels, nerves) caused by the section, and checked distances to anatomical structures.
Results The CTL was fully realesed in half cases for the JS in each group. The mean pourcentage of section was 90% with 2 injuries using ECTR and 80% with 3 injuries using UCTR. The senior surgeon did not caused any damage, the mean section was 100% in ECTR and 88% in UCTR. There were significant differences between junior and senior surgeons in each method. The JS did acquire a section around 90% with 3 cases in ECTR than 10 cases in UCTR.
Summary Points • This study highligths that the learning curve of UCTR is harder compared to the reference method. • The cadaveric model training should be propose to train to UCTR with specific work shops.
Bibliography 1: Apard.T - Surgical ultrasound-guided carpal tunnel release 2: Chern.TC - A cadaveric and preliminary clinical study of ultrasonographically assisted percutaneous carpal tunnel release 3: Burnhan.R - Evaluation of the Effectiveness and Safety of Ultrasound-Guided Percutaneous Carpal Tunnel Release: A Cadaveric Study