IGHS Poster 01: History of the Australian Hand Surgery Society

Category: Other Keyword: Other Not a clinical study

♦ Michael Tonkin, MD ♦ Richard Honner, MD

Hypothesis: The Australian Hand Club was established in 1972, following discussion between members of the New South Wales Hand Surgery Association and the plastic surgeons of Melbourne under the direction of Sir Benjamin Rank, who became the first President.

The other elected Office Bearers were:  President Elect - Alan McJannet  Secretary - Frank Harvey  Treasurer - Richard Honner  Committee Members - Peter Millroy, Don Robinson, Bernard O’Brien

In 1990 the name was changed to the Australian Hand Surgery Society. This now has 159 active members, 18 overseas members, 28 honorary members and 9 provisional members.

The current Board consists of:  President - Randall Sach  President Elect - David Stabler  Ex-officio President - Stephen Coleman  Secretary - Philip Griffin  Treasurer - Douglass Wheen  Executive Committee - Anthony Beard, David McCombe, Jeffrey Ecker

An Annual Scientific Meeting with overseas Guest Professors is conducted each year, often associated with a separate two day program in hand surgery for Registrars on surgical training schemes in Australia and New Zealand. The AHSS also convenes hand surgery programmes for the Annual Scientific Meetings of the Australian Orthopaedic Association and the Royal Australasian College of Surgeons.

Combined meetings with other hand surgery societies have been held, including with New Zealand, Singapore and most recently with the ASSH in Kauai, USA, March 2012. The AHSS became a member of the International Federation of Societies for Surgery of the Hand (IFSSH) in 1977 and was a founding member of the Asia-Pacific Federation of Societies for Surgery of the Hand (APFSSH) in 1997. We were the host society for the IFSSH Congress in Sydney in March 2007. A number of Australian hand surgeons have been recognised as IFSSH Pioneers in Hand Surgery – Sir Benjamin Rank, Sir Sidney Sunderland, Bernard O’Brien, John Hueston and Bruce Conolly. Bernard O'Brien was the IFSSH President from 1979-83. Michael Tonkin takes up the position of IFSSH President in 2013. Wayne Morrison, Michael Tonkin and W. Bruce Conolly have been appointed to Presidency of the APFSSH. These, and many others, have contributed to Australia’s status in the international world of hand surgery.

♦ Nothing of financial value to disclose

IGHS Poster 02: A New Surgical Approach to Dupuytren’s Disease

Category: Other Keyword: Hand Level 4 Evidence

♦ Ian A. Edmunds, Dr

Hypothesis: Modern surgical approaches to Dupuytren’s disease usually involve straight incisions with Z-plasty closure, Bruner incisions (1), broad Y-V incisions (2,3) or a combination of the above. There are some problems and restrictions with these approaches. The disadvantage of a straight line incision is that one is committed to using skin grafts or Z-plasties because primary closure would result in a longitudinal scar contracture. With Bruner incisions, lengthening of the wound by use of advancement flaps is not possible and it is difficult to use skin grafts or the McCash open-wound technique (4) because the addition of transverse incisions makes the flap tips too narrow and susceptible to necrosis. With Bruner and broad Y-V flaps, the flaps are large and difficult to raise without buttonholing, access to retrovascular disease can be difficult, and the scar corner at the basal digital crease tends to hypertrophy because the lateral extent of this scar is limited by the web, which is volar to the mid-axial line.We present a new approach to Dupuytren’s surgery which overcomes some of the problems seen with traditional approaches.

Methods: This approach is simple but allows full exposure and accommodates all options for closure. It comprises transverse incisions at the skin creases of the digit joined by oblique incisions at 45º. The transverse incisions can be extended to the mid-axial line for improved exposure and skin release and to lateralize the apices of the scar. After excision of the disease and correction of the contracture the wound can be assessed and closed primarily, with advancement flaps or skin grafts, or left partially open.

Results: This study includes surgery on 105 rays in 75 patients with excellent results in 80 rays, good results in 20 rays, fair results in four rays and a poor result in one ray. There was only one significant complication.

Summary:  There are problems with traditional surgical approaches to Dupuytren's disease  This new approach overcomes those problems and is simple, universal, flexible and gives good exposure  It allows complete excision of the disease and complete correction of the contractures  It allows all alternatives in closure, and allows these to be assessed and implemnented after excision of the disease, rather than being committed to one technique from the outset.

References: 1. Bruner, JM. The zigzag volar-digital incision for flexor-tendon surgery. Plast. Reconstr. Surg. 1967, 40: 571. 2. King EW. Bass DM. Watson HK. Treatment of Dupuytren's contracture by extensive fasciectomy through multiple Y-V--plasty incisions: short-term evaluation of 170 consecutive operations. J Hand Surg Am. 1979, 4(3): 234-41. 3. Tubiana R, Leclercq C, Hurst LC et al. Dupuytren’s Disease, 1st Edn. London, Martin Dunitz, 2000: 2-3, 132, 139, 140. 4. McCash, CR. The open palm technique in Dupuytren’s contracture. Br. J. Plast. Surg. 1964, 17: 271.

♦ Nothing of financial value to disclose

IGHS Poster 03: Hand Surgery On Anticoagulated Patients – A Prospective Study of 121 Operations

Category: Other Keyword: Hand Level 4 Evidence

♦ Ian A. Edmunds, Dr

Hypothesis: Many patients requiring hand surgery are taking long term anticoagulant/antiplatelet medication. The management of these patients presents some challenges to the hand surgeon, especially since there has been increasing concern, expressed anecdotally, in the literature and in the courts, that stopping or altering a patient’s anticoagulation exposes the patient to an increased risk of a thrombotic event (1,2,3). There have been papers published reporting the safety of hand, skin, eye and dental surgery on patients taking anticoagulants, usually warfarin (4,5,6,7). Other studies have attempted to develop algorithms to aid the surgeon in making decisions regarding anticoagulation2. Despite this, there is a lack of large prospective studies addressing the management of patients on anticoagulation therapy who undergo hand surgery. The aim of this study is to prospectively study the results of hand surgery in patients taking warfarin, clopidogrel (Plavix/Iscover) alone and clopidogrel with aspirin.

Methods: The study design was to perform hand surgery without ceasing patients’ anticoagulation medication, whether that medication be warfarin, clopidogrel alone or clopidogrel with aspirin. All trauma and elective patients were to be included. The one proviso was that, for patient taking warfarin, the International Normalised Ratio (INR) was not greater than 3.0 for elective cases. Patients were to be reviewed post-operatively, at ten days and thence as needed. A log of complications was to be kept.

Results: In total, there were 107 patients who had 121 operations between December 2005 and August 2008. There were 57 operations on 51 patients taking warfarin with an average INR of 2.26 (range 1.4 – 3.2). There were 40 operations on 36 patients taking clopidogrel alone and 24 operations on 20 patients taking clopidogrel and aspirin.There was only one major complication, which occurred in a patient taking clopidogrel, which was a post-operative haematoma developed which required evacuation the following day.

Summary:  Long term anticoagulation is common.  Stopping anticoagulation therapy risks thrombotic complications.  It is safe to perform hand surgery on patients taking warfarin (INR < 3.0), or clopidogrel with or without aspirin.

References: 1. Blacker DJ, Wijdicks EFM, McClelland RL, Stroke risk in anticoagulated patients with atrial fibrillation undergoing endoscopy, Neurology 61:964–968, 2003. 2. Chassot PG, Delabays A, Spahn DR, Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction, British Journal of Anaesthesia 99:316–328, 2007. 3. Ferrari E, Benhamou M, Cerboni P, Marcel B, Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis, Journal of the American College of Cardiology 45: 456–459, 2005. 4. Morris A, Elder MJ, Warfarin therapy and cataract surgery, Clinical and Experimental Ophthalmology 28:419–422, 2000. 5. Wahl MJ, Dental surgery in anticoagulated patients, Archives of Internal Medicine 158:1610–1616, 1998. 6. Alcalay J, Cutaneous surgery in patients receiving warfarin therapy, Dermatological Surgery and Oncology 27:756–758, 2001. 7. Wallace DL, Latimer MD, Belcher HJ, Stopping warfarin therapy is unnecessary for hand surgery, Journal of Hand Surgery 29B:203–205, 2004.

♦ Nothing of financial value to disclose

IGHS Poster 04: Simplified Technique for Navigated Central Screw Placement in Fractured Scaphoids Utilizing Ultra Low Dose Computed Tomography

Category: Fractures and Dislocations Keyword: Wrist Level 4 Evidence

♦ Brad Gilpin, MBBS ♦ Greg Couzens, MD ♦ Ross Crawford, PhD

Hypothesis: The study hypothesis was that use of a navigation system with pre-operative ultra low dose CT imaging and a dorsal percutaneous operative technique would result in accurate and reproducible central screw placement in cadaver scaphoids.

Methods: Two cadaver wrists underwent navigation assisted scaphoid surgery (NASS) at the Queensland University of Technology Medical Engineering Research Facility. Cadaver wrists were secured to a custom built radio-lucent splint prior to undergoing pre-operative ultra low dose CT. A novel dorsal percutaneous operative technique was employed. Accuracy of screw placement as compared to the ideal screw trajectory was measured on post-operative CT. Parametric t-tests were used to determine whether there was a significant difference when comparing the actual screw positioning with the ideal trajectory path down the centre of the scaphoid bone. Significance was measured against an alpha value of 0.05.

Results: No statistical difference was demonstrated between the ideal and actual screw trajectories although post operative imaging demonstrated eccentric screw placement. Pre- operative ultra low dose CT provided an accurate image model for NASS. The custom built radio lucent wrist splint facilitated reproducible positioning of cadaver forearms. No penetration of the scaphoid articular surface occurred.

Summary:  Existing studies have been limited by their design and selection of operative approach.  Deviation of screw positioning from the ideal axis was attributed to unfamiliarity with the navigation software and inadequate pre-operative selection of the planned screw trajectory.  Alignment of the planned screw trajectory and actual drill hole demonstrated that navigation provides an accurate guide to screw insertion.  NASS preserved the integrity of the cortical surface of the scaphoid with no penetration of the articular surface.

♦ Nothing of financial value to disclose

IGHS Poster 05: Costo-Osteochondral Autograft for Proximal Scaphoid Deficiency – Long Term Review

Category: Other Keyword: Wrist Level 4 Evidence

♦ Michael Sandow, FRACS

Hypothesis: The scaphoid plays a crucial role in longitudinal stability of the carpus. Due to the precarious vascular supply, the proximal scaphoid pole is vulnerable to necrosis and collapse. Various management options have been proposed including vascularised grafts, soft tissue or prosthetic replacement and variable extents of carpal fusion. Costo-Osteochondral autograft (COCA) was first used in the jaw to address traumatic loss of the condyles. This paper reviews the long term outcome (greater than 10 years) of the COCA to address scaphoid deficiency.

Methods: Over the period from 1991 until 2011, 87 patients, in a single surgeon series, have undergone COCA to replace a deficient proximal scaphoid. Patients were contacted by mail or telephone. Subjective questions related to wrist function, satisfaction and the occurrence of further treatment.

Results: Of the 56 patients with a greater than 10 year follow-up, 40 have responded (71%). 73% reported nil, or mild pain, 91% were satisfied with the outcome and only 4 had undergone further treatment, 1 for radial styloidectomy, 1 underwent partial carpal fusion, and 2 have undergone total wrist fusion. Grip strength and range of motion were generally less than the normal wrist. 91.5% reported no problems with the chest donor site.

Summary: While frequently not able to match the function of a normal wrist, patients were generally very satisfied with the outcome, and this option may have advantages over alternate treatments. Other procedures such as partial or total wrist fusion remain an option if the COCA fails to deliver a satisfactory outcome. Despite this, only 3 patients in the longer term (greater than 10 years) and in fact only 5 patients overall have undergone partial or complete wrist fusion. This is even more notable as COCA was frequently performed following often multiple unsuccessful previous procedures, and in virtually all patients has remained the final intervention with a greater than 90% satisfaction level. Although the incomplete follow-up however must be considered when assessing these results, the COCA would appear to provide a durable solution to address proximal scaphoid deficiency.

♦ Nothing of financial value to disclose

IGHS Poster 06: Unifying Model of Carpal Mechanics Based on Computationally Derived Isometric Constraints and Rules Based Motion – The Stable Central Column Theory

Category: Other Keyword: Wrist Not a clinical study

♦ Michael Sandow, FRACS, MD ♦ Thomas Fisher, MBBS ♦ Carl Howard, PhD ♦ Sam Papas, MACS

Hypothesis: This study was part of a larger project that aims to develop a (kinetic) mathematical model of carpal motion based on computationally derived isometric constraints and carpal spatial relationships at physiological motion extremes. This incorporates the concept of rules based animation, which states that resultant motion of a joint is a net interplay of bone shape, isometric constraints, bone surface interaction, and applied load. This study aimed to identify the isometry and motion of the carpal bones using a 3D polygonal graphics analysis system.

Methods: Using a CT based three-dimensional surface rendering technique to create geometric primitives (true 3D models) of the wrist, the isometric constraints and positional relationships of the carpal bones in ten normal wrists were analysed in radial, neutral and ulnar deviation.

Results: Specific points on the volar surface of the lunate and the radius remained isometric through range, and similar pairs of points were found on the trapezium and scaphoid, and in the scapho-lunate, lunato-triquetral and radio-triquetral joints. There was a discrepancy (p<0.05) between those areas (typically volar or dorsal depending on the bones) that remained isometric and those that did not, and this corresponded to previously documented anatomical structures. The carpus appears to function as a stable central column (lunate-capitate-hamate-trapezoid- trapezium) with a supporting lateral column (scaphoid), which behaves as a “crossed five bar linkage”. The triquetrum functions as an ulnar translation restraint, as well as controlling lunate flexion. The “trapezoid” shaped trapezoid places the trapezium anterior to the transverse plane of the radius and ulna, and thus rotates the principal axis of the central column to correspond to that used in the “dart thrower’s motion”.

Summary: This study presents a forward kinematic analysis of the carpus which provides the basis of a unifying kinetic theory of wrist motion based on isometric constraints and rules based motion. This characterizes the wrist mechanics as a stable central carpal column, with a lateral column stabilizer, a medial column translation restraint, and physiological pronation of the mid- carpal axis.

♦ Nothing of financial value to disclose

IGHS Poster 07: Technical Difficulties of Zone 2 Flexor Tendon Repairs – Royal North Shore Hospital Simplifies It

Category: Tendon Keyword: Hand Level 1 Evidence

♦ Darryl Chew, MBBS, MRCS ♦ Umair Ansari, MBBS ♦ Ian Yuen, MBBS ♦ Marc Langbart, MBBS ♦ Richard Lawson, MBBS,FRACS ♦ Michael A Tonkin, MD

Hypothesis: A2 pulley preservation makes flexor tendon repairs technically difficult. Three methods are proposed to simplify such repairs: 1. Repair the volar epitendon only 2. Repair the dorsal and volar epitendon with different techniques 3. Divide the A2 pulley partially We investigate if these methods compromise tendon repair strength.

Methods: Three experiments were conducted: 1. Volar-only vs no epitendinous repair a. Three groups of 20 porcine tendons each were repaired with a 4-strand core (Adelaide) repair using 3-0 Tricron. The volar epitendon was repaired using 6-0 Prolene as follows: o Simple running (50SR) o Silfverskiold (50SK) o None b. Tendons were loaded to failure and force data were recorded. 2. Homogenous vs heterogeneous epitendinous repair a. Three groups of 20 porcine tendons each were repaired in a manner similar to Experiment 1, but the epitendon was repaired follows: o 100% simple running (100SR) o 50% simple running and 50% Silfverskiold (50SR/50SK) o 100% Silfverskiold (100SK) b. Tendons were loaded to failure. 3. A2 pulley division a. FDP tendons of 72 Cobb chicken feet were severed at the A2 pulley and repaired using a 4-0 Ticron 2-strand core (modified Kessler) repair and a 6-0 Prolene epitendinous suture. The A2 pulley was either left intact, divided by 50%, or completely divided (24 per group). Tendons were loaded to failure. Force data and A2 pulley integrity were analysed.

Results: 1. Volar-only vs no epitendinous repair a. 50SR and 50SK repairs added 100% and 70% extra strength at 1mm and 2mm gap formation respectively, and 20% extra strength at ultimate force when compared with no epitendinous repair (p < 0.05). There was no significant difference between 50SR and 50SK repairs. 2. Homogenous vs heterogeneous epitendinous repair a. There was no significant difference in force to 1mm and 2mm gap formation, or ultimate force between the groups. 3. A2 pulley division a. There was no significant difference in failure load between the groups. A2 pulleys remained intact in the undivided and partially divided groups.

Summary:  Volar-only epitendinous repairs increase the tensile strength of 4-strand core tendon repairs.  Heterogenous circumferential repairs are not stronger than homogenous simple running repairs. The decision to perform more complex volar repairs depends on the ability of the suture to improve the tendon gliding surface.  A2 pulley release does not increase tendon repair strength.  A2 pulley division by 50% does not predispose to pulley rupture.

♦ Nothing of financial value to disclose

IGHS Poster 08: Simultaneous Four Finger Metacarpophalangeal Joint Fusions - Indications and Results

Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Hand Level 4 Evidence

♦ James Ledgard, MBBS ♦ Michael A. Tonkin, MD

Hypothesis: Indications for the simultaneous fusion of all four finger metacarpophalangeal joints in one hand are few. Outcomes in suitable patients are good. The literature regarding this procedure is sparse with only two cases described for salvage of failed arthroplasties in rheumatoid arthritis (RA). 1. It is listed as a preferred treatment for cerebral palsy (CP) but with no clinical examples. 2. The purpose of our study is to analyse and assess the outcome and patient satisfaction in a series of patients, enabling us to provide indications for this rare procedure. A recent case stimulated the interest of the senior author and led to our study.

Methods: Nine patients were operated upon between 1995 and 2013. Three patients suffered from CP; two sustained brain injuries; two had RA; one distal arthrogryposis; and one sustained a traumatic four finger amputation. All arthrodeses were done through dorsal longitudinal incisions with osteotomies and fixation with two parallel 0.9mm K-wires and a 24 gauge figure of eight interosseous wire in a tension band technique. A retrospective chart review was performed to collect preoperative, intraoperative and postoperative data, including radiological assessments. Seven of nine patients were recalled for clinical and radiological review. One patient with RA had died; the patient with traumatic amputations was not contactable.

Results: Patients sought treatment for problems relating to hygiene, appearance and/or function, secondary to severe, uncorrectable MCP joint flexion deformities. Multiple fusions should be considered when motion preserving procedures are not suitable because of an inability to correct the deformity, the deformity is likely to recur or the joints will be left unstable. It is an appropriate procedure for RA patients with severe loss of bone stock and/or soft tissue support. It should not only be considered a salvage procedure used when motion preserving procedures fail, but in the right circumstances may be used as the primary reconstruction. Concurrent procedures are often required to rebalance extrinsic and intrinsic forces to allow correction and obtain optimal finger function. Fusion was achieved in all MCP joints and position ranged from 20 to 55 degrees, with greater flexion in the ulnar digits. Investigators and patients rated the outcomes as either good or excellent.

Summary:  Patients or their carers seek treatment for improvement in hygiene, appearance and/or function.  Concurrent procedures may be required to rebalance and correct their deformities.  Simultaneous fusion of all four MCP joints in one hand works well in carefully selected patients.

References: 1. Burgess S, Michiyuki K, Stern P. Revision Metacarpophalangeal Joint Surgery in Rheumatoid Patients Following Previous Silicone Arthroplasty. JHS. 2007;32A(10):1506-12. 2. Carlsen M. Cerebral Palsy. Green’s Operative Hand Surgery. 6th Ed. 2011.

♦ Nothing of financial value to disclose

IGHS Poster 09: Use of Local Anesthesia Prior to Finger Extension Following Injection of Collagenase Clostridium Histolyticum for Dupuytren’s Contracture

Category: Tendon Keyword: Hand Level 4 Evidence

♦ ▲Stephen Coleman, FRACS ♦ ▲David Gilpin, MBBS ♦ ▲Nigel Jones, BSc ♦ ▲James Tursi, MD ♦ ▲Brian Cohen, PhD ♦ ▲Gregory Kaufman, MD

Hypothesis: Collagenase clostridium histolyticum (CCH), a nonsurgical treatment option for adult patients with Dupuytren’s contracture with a palpable cord, hydrolyzes collagen which may achieve enzymatic disruption of the cord. CCH injection is followed by a finger extension procedure to facilitate disruption of the cord, performed the day after injection. Nerve block at the wrist with local anesthesia (LA) prior to finger extension, although not used in phase 3 clinical trials, may be used to minimize pain and allow greater force to be applied to disrupt the cord. We analyzed data from a recent clinical trial to evaluate whether use of LA prior to finger extension was associated with greater correction of contracture.

Methods: Data were analyzed from a multicenter, open-label, Phase 3b study. Patients (n=60) received two CCH injections into cords of two affected joints in the same hand during one visit (120 treated joints; 75 metacarpophalangeal [MP], 45 proximal interphalangeal [PIP]), followed by finger extension ~24 hours later. Outcomes at Day 30 post-injection, including fixed flexion contracture (FFC) and rates of clinical success (ie, FFC=5°), were analyzed for patients who did or did not receive LA prior to finger extension.

Results: Overall 27/60 patients (45%) received LA prior to finger extension. Use of LA among subgroups (by joints/fingers treated) is summarized in Table 1. Patients receiving LA tended to have more severe baseline contractures (total FFC 90.3° vs 84.2°) but had significantly greater percent changes from baseline (82.6% vs 69.8%; P=0.04) (Table 2). Percent changes from baseline FFC for PIP joints were 74.7% with LA and 59.7% without LA (P=0.07), and for MP joints were 87.8% and 83.8%, respectively (P=0.49) (Table 2). Clinical success rates for PIP joints were 44.4% (8/18) with LA and 25.9% (7/27) without LA (P=0.22), and for MP joints were 77.8% (28/36) and 74.4% (29/39), respectively (P=0.79). The use of anesthesia resulted in slightly higher rate of skin tears, all of which healed without complications and without any additional surgical procedures. Overall there were no meaningful differences in the adverse event profile between those who received anesthesia and those who did not.

Summary:  Patients receiving LA had significantly better responses despite having more severe contractures.  PIP joints tended to show a better response in terms of percent change from baseline and rate of clinical success with LA versus without LA, while MP joints showed similar responses.  No safety differences were observed.

▲ This presentation will discuss Xiaflex by Auxilium Pharmaceuticals, Inc. ♦ Nothing of financial value to disclose IGHS Poster 10: Prognostic Factors for Return to Work Outcomes Following Carpal Tunnel Release: A Systematic Review and Meta- Analysis

Category: Workplace/Rehabilitation Keyword: Hand Level 1 Evidence

♦ Susan Peters, BOccThy ♦ Mark Ross, MD ♦ Sonia Hines, PhD ♦ Michel Coppieters, PhD ♦ Venerina Johnston, PhD

Hypothesis: Workers undergoing carpal tunnel release (CTR) require time off work to recover from the surgery itself, and often to be rehabilitated back to work. The total time of being incapacitated following CTR is highly variable. Differences in these timeframes and outcomes are thought to be influenced by a number of factors. Identification of prognostic factors that can be influenced through appropriate management is especially pertinent to clinicians as it may improve patient outcomes. The objective of this systematic review was to synthesise the best available evidence on early prognostic factors for return to work (RTW) outcomes in patients with carpal tunnel syndrome who have undergone CTR. It is hypothesised that various factors influence return to work outcomes.

Methods: Comparative analytical observational studies were included in this review. Studies were assessed by two independent reviewers for methodological quality using a validated tool for systematic reviews of prognostic studies and relevant data were extracted. Narrative synthesis was performed on all included studies. For studies examining similar or the same prognostic factors, a meta-analysis was performed to estimate a weighted measure of effect across studies.

Results: 35 studies (40 publications) evaluating over 65 prognostic variables were included in the review. Statistical analyses identified prognostic variables which had an association with poor RTW outcomes, including legal counsel in the claim process, low self-efficacy, ergonomic exposure, blue-collar worker, poor nerve conduction study results, worse pre-operative functional status and two or more musculoskeletal pain sites. Variables associated with better RTW outcomes, included better self-efficacy and supportive employer organisational policies. Differences in study settings, populations, variables and outcome definitions caused considerable heterogeneity amongst studies.

Summary: Numerous factors have an association with RTW outcomes following CTR. Caution needs to be taken when interpreting results from studies with low methodological quality and that have been conducted in different study settings (societal and compensation settings).

♦ Nothing of financial value to disclose

IGHS Poster 11: Long Term Outcomes of Proximal Interphalangeal Joint Replacement: Preliminary Findings

Category: Arthroplasty Keyword: Hand Level 3 Evidence

♦ Lisa Dickson, MD

Hypothesis: The goal of this retrospective review was to evaluate the long-term results of PIPJ arthroplasty and to compare outcomes of the various implant and surgical approaches.

Methods: A retrospective chart review was performed and included all patients with PIPJ arthroplasty with a minimum of 12 months follow-up. Charts were reviewed to determine baseline demographics, surgical technique, implant type, and complications. Patients were assessed with questionnaire, physical examination and radiographic evaluation.

Results: Forty-five joints were replaced in 31 patients. Mean follow-up was 38.6 months. Twenty-seven suffered from osteoarthritis and 4 from rheumatoid arthritis. There were 19 silicone, 9 pyrocarbon and 17 SR(RMS) joints in the study group. A dorsal approach was utilized in 21 patients. A volar approach was used in 24 patients. Seventy-one percent of patients were satisfied with their arthroplasty and 87% had mild or no pain. The silicone and SR (RMS) implants resulted in a significantly greater mean arc when compared to pyrocarbon (64.2 & 69.7 vs 40.5 p=0.003 and p=0.016 respectively). No significant difference in mean arc was found between dorsal and volar approaches.

Summary:  Implant arthroplasty is a well-established treatment for PIPJ arthritis.  It is associated with high patient satisfaction and pain reduction.  The greatest functional range of motion is achieved with silicone and SR (RMS) implants.

♦ Nothing of financial value to disclose

IGHS Poster 12: Alignment of the Thumb Metacarpal and Trapezium at the Trapezio Metacarpal Joint

Category: Basic Science - Clinical Research Keyword: Hand Level 4 Evidence

♦ Stephen Tham, MBBS ♦ Philippa Rust, MD ♦ Eugene T. Ek, MD, PhD

Hypothesis: Subluxation of the trapezio metacarpal joint (TMJ) and subsequent joint incongruency is a cause for arthritis(1,2). In order to select patients with symptomatic early arthritis associated with joint subluxation who may be candidates for joint re alignment and ligament repair or reconstruction, we need to determine its normal alignment.

Methods: The TMJ of 50 patients undergoing CT scan of the wrist for conditions not involving the TMJ were analysed. As the thumb is positioned out of plane to the hand, the true saggital plane of the TMJ was used to determine dorsal subluxation and the true coronal plane to measure radial subluxation. Dorso radial subluxation of the TMJ was measured from a plane parallel to the coronal plane of the hand. The results did not follow a normal distribution (Kolmogorov- Smirnov test)and were analysed with Spearman rank correlation analysis and Wilcoxon test.

Results: The median radial subluxation of the TMJ was 1.4 mm, dorsal subluxation 1.5 mm and dorso radial subluxation 1.2 mm. There is a significant increase in radial (p=0.064, significant p 45 years. The mean percentage radial subluxation was 8.6% in patients 45 years.

Summary:  Calculations of the radial and dorsal subluxation of the TMJ need to take into account its out of plane position.  Radial and dorso radial subluxation of normal TMJ increases with age.

References: 1. Najima H et al. Anatomical and biomechanical studies of the pathogenesis of trapeziometarcarpal degenerative arthritis. J Hand Surg (Br). 1997:22:183-188. 2. Pelligrini VDJr. Pathomechanics of the thumb trapeziometarcarpal joint. Hand Clin,2001;17:175-184.

Alignment method Median Interquartile range Subluxation of subluxation (mm) (mm)

Planar analysis – radial subluxation 0.14 0 – 0.23 Coronal cut through thumb Planar analysis – dorsal subluxation 0.15 0.08 – 0.2 Sagittal cut through thumb Planar analysis- dorsalradial subluxation 0.12 0.04 – 0.23 Coronal plane through wrist

Correlation between TMJ alignment and age for each type of measurement

Alignment method Spearman correlation Significance (P coefficient of value) of subluxation subluxation

Coronal view – radial subluxation 0.306 0.031 (significant where p<0.05) Sagittal view – dorsal subluxation 0.187 0.194

Dorsalradial subluxation 0.468 0.001 (significant where p<0.005)

♦ Nothing of financial value to disclose

IGHS Poster 13: The Turkey Deep Flexor Tendon: A New Animal Model for Multi-Strand Ex-Vivo and In-Vivo Tendon Repair Experiments

Category: Tendon Keyword: Hand Not a clinical study

♦ Tim Sebastian Peltz, MD ♦ Peter Scougall, MBBS ♦ William R. Walsh, PhD

Hypothesis: Tendon healing and adhesion formation is too complex to replicate in in-vitro or ex- vivo experiments. Only an in vivo model can show healing propensities, adhesion formations and final functional outcome of different repair methods. Current in-vivo animal models for tendon repairs like the chicken, rabbit or rat model have tendons too small to perform modern multi-strand tendon repairs. The possibility to use dogs in research is very limited and ethically questionable. Sheep or pig trotters are used in ex-vivo experiments, but surgical access to the deep flexor apparatus is not practicable in an in-vivo setting. We present a new animal model that replicates comparable size, anatomy and function to human deep flexor tendons for ex-vivo and in-vivo experiments.

Methods: 1. Dissection of 10 turkey feet and analysis of flexor tendon apparatus, anatomical landmarks and measurement of anatomical structures. 2. Histological examination of turkey deep flexor tendons. 3. Ex-vivo biomechanical comparison of turkey deep flexor tendon to sheep deep flexor tendon. 4. N=15 each group, 4-strand cross locked cruciate repair (Adelaide repair) at zone 2 with 4/0 Ethibond, biomechanical testing, analysis of final failure force and 2mm gapping force. 5. In-vivo repair of twenty turkey feet (left middle toe deep flexor tendon) at zone 2 with 4- strand cross locked cruciate repairs (Adelaid repair) with 4/0 Ethibond and running circumferential repair with 6/0 Prolene. Analysis of function, tendon healing and biomechanical stability after one, three and six weeks.

Results: 1. Dissection of turkey deep flexor apparatus shows very similar features with human deep flexor apparatus. All anatomical landmarks are comparable. Tendon size is comparable to human deep flexor tendon. 2. Histological examination shows similar histological features in comparison to human deep flexor tendons. 3. Gapping force and ultimate failure load of repaired sheep deep flexor tendons and repaired turkey deep flexor tendons show no significant difference. 4. In vivo surgery on turkey deep flexor apparatus is practicable and surgical procedures are comparable to clinical scenarios in humans. Healing of tendons and adhesion formation is similar to humans. Animals tolerate casting and show uncomplicated recovery after surgery.

Summary: The anatomy of the turkey flexor tendon apparatus is similar to the chicken animal model and the human deep flexor apparatus. But in contrast to the chicken tendon model, tendon sizes are more comparable to the caliber of human deep flexor tendons. Therefore it is an ideal model to investigate modern multi-strand repair configurations.

References: 1. In reply to “Letter regarding influence of locking stitch size in a four-strand cross-locked cruciate flexor tendon repair”. Peltz TS, Walsh WR. J Hand Surg Am. 2012 Jan;37(1):188-9. 2. Influence of locking stitch size in a four-strand cross-locked cruciate flexor tendon repair. Peltz TS, Haddad R, Scougall PJ, Nicklin S, Gianoutsos MP, Walsh WR. J Hand Surg Am. 2011 Mar;36(3):450-5. Epub 2011 Feb 17. 3. The change in three-dimensional geometry of the Kessler flexor tendon repair under tension: a qualitative assessment using radiographs. Peltz TS, Haddad R, Walsh WR. J Hand Surg Eur Vol. 2010 Oct;35(8):676-7. 4. Biomechanical comparison of modified Kessler and running suture repair in 3 different animal tendons and in human flexor tendons. Hausmann JT, Vekszler G, Bijak M, Benesch T, Vécsei V, Gäbler C. J Hand Surg Am. 2009 Jan;34(1):93-101. 5. Biomechanics of the flexor tendons. Goodman HJ, Choueka J.Hand Clin. 2005 May;21(2):129-49.

♦ Nothing of financial value to disclose

IGHS Poster 14: Trigger Finger Release With Stepwise Preservation Of The A1 Pulley: A Functional Pulley-Preserving Technique

Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Hand Level 2 Evidence

♦ Vachara Niumsawatt, MBBS

Hypothesis: The first annular (A1) pulley is an important structure of the hand, providing a biomechanical support to the metacarpophalangeal joint (MCPJ) and maintaining joint stability and flexor tendon alignment. In trigger finger the common surgical management is the division of A1 pulley without a reconstruction. This can result in disruption of the flexor tendon and metacarpophalangeal joint biomechanics 1-4. We have developed a technique to increase the diameter of A1 pulley by way reconstitution. Thus, release the stenosis without sacrificing the A1 pulley integrity.

Methods: A prospective study was performed comprising 10 patients for trigger finger release with stepwise lengthening of the A1 pulley. The A1 pulley was delineated in its entire extent. The fibrous sheath was incised transversely in its proximo-distal midline. Two further incisions were made on either side of the A1 pulley; one over the entire border of the radial proximal half and one over the entire border of the ulnar distal half. The resultant released pulley formed two flaps which were approximated at their tips. The two flap edges were sutured together with simple interrupted 5/0 synthetic non-absorbable monofilament. This technique can thus safely achieve trigger release without sacrifice of the function of the A1 pulley.

Results: In all patients, there were no complications and good hand function as achieved with no recurrence of triggering at six weeks follow up. There were no intra or post-operative complication. Our operating times has a mean of 11 minutes with a ranged from 9 to 21 minuteThe patients had significant improvement in their function and symptoms with an improvement in their DASH score from 26.9±9.9 pre-operatively to 5.8±9.5 post operatively (p<0.001).

Summary:  While not common, disruption of this pulley can result in dislocation or ulnar drift of the digit, particularly pronounced in patients with rheumatoid arthritis. Despite this, the A1 pulley is commonly divided without reconstruction in trigger finger. There is a risk of bowstringing and ulnar drift 5.  Several annular pulley reconstructive techniques have been developed to preserve its function 6-8. However, development of recurrent triggering has been observed due to fibrosis, largely due to inadequate release of the pulley.  We have developed a technique of increasing the volume within the flexor sheath, while preserving the A1 pulley byway of stepwise lengthening. This has enabled an increase in diameter of the pulley to four times its original size.

References: 1. Sbernardori MC, Bandiera P. Histopathology of the A1 pulley in adult trigger finger. J Hand Surg Eur 2007;32;556-9. 2. Lin GT, Cooney WP, Amadio PC, An KN. Mechanical properties of human pulleys. J Hand Surg 1999;15;429-34. 3. De Jager LT, Jaffe R, Learmonth ID, Heywood AWB. The A1 pulley in rheumatoid flexor tenosynovectomy. To retain or divide?. J Hand Surg 1994;19;202-4. 4. Wise KS. The Anatomy of the metacarpo-phalangeal joints, with observations of the aetiology of ulnar drift. J Bone Joint Am, 1975;574;485-90. 5. Heithoff SJ, Millender LH, Helman J. Bowstringing as a complication of trigger finger release. The Journal of hand surgery. 1988;13(4):567-70. 6. Kapandji IA. Enlarging plasty of the metacarpal pulleys. Ann Chir Main 1998;32:281-2. 7. Mehrotra S. Trigger finger: functional pulley release by ‘N’ - plasty. J Plast Reconstr Aesthet Surg 2010;63;e114-5. 8. Pabari A. Correspondence and Communication; Trigger finger: Functional pulley release by ‘N’- plasty. J Plast Reconstr Aesthet Surg 2010;63:e803-4.

♦ Nothing of financial value to disclose

IGHS Poster 15: Supraretinacular Endoscopic Carpal Tunnel Release

Category: Nerve/Neuromuscular Keyword: Wrist Level 3 Evidence

♦ Jeff O. Ecker, MD

Hypothesis: Supraretinacular endoscopic carpal tunnel release was developed to avoid subretinacular endoscopic techniques which can be associated with transient neurological deficits. It was also developed to improve vision in the distal forearm and the carpal canal when performing the endoscopic carpal tunnel release.

Methods: Supraretinacular endoscopic carpal tunnel release is performed using a speculum with a dual light source. The speculum is inserted above the flexor retinaculum, no further than the distal extent of the flexor retinaculum (i.e. the hook of the hamate). Using an endoscope to see, the retinaculum is divided under direct vision with scissors. The procedure is performed using a 2.5 cm transverse incision in the proximal wrist flexion crease in the distal forearm. The median nerve is visualised in the distal forearm and the carpal canal.

Results: 130 supraretinacular endoscopic carpal tunnel operations were reviewed. The technique was found to be safe and has a low complication rate. There has been one case of retinacular fibrosis which resolved and 4 cases of suture infection.

Summary:  Supraretinacular endoscopic carpal tunnel release can be performed safely.  It improves visualisation compared to other endoscopic techniques.  It allows endoscopic carpal tunnel release to be performed in severe carpal tunnel syndrome with marked compression of the median nerve.  The anatomical variations of the recurrent motor branch of the median nerve can be seen during the procedure.  The technique and the endoscopic anatomy will be demonstrated.

♦ Nothing of financial value to disclose

IGHS Poster 16: Scaphotrapezoid Separation

Category: Basic Science - Anatomy Keyword: Wrist Level 3 Evidence

♦ Jeff O. Ecker, MD

Hypothesis: In rare cases the scaphoid loses partial or complete contact with the trapezoid on ulnar deviation.

Methods: An x-ray classification was devised grading scaphotrapezoid contact on ulnar deviation ranging from 1/4 to 4/4 where 4/4 was defined as complete loss of the contact of the scaphoid with the trapezoid. 127 sequential x-ray studies were reviewed. They were assessed for the degree of scaphotrapezoid contact on ulnar deviation. The initial plan was to review 100 cases and document the degree of loss of contact of the scaphoid with the trapezoid in ulnar deviation. 127 studies were reviewed because this was the first case that we identified with complete scaphotrapezoid dissociation on x-ray. The cases with complete scaphotrapezoid dissociation had a CT scan performed in ulnar deviation which demonstrated the complete scaphotrapezoid separation and loss of contact.

Results: Complete scaphotrapezoid separation where the scaphoid loses contact with the trapezoid on ulnar deviation is a rare and normal anatomical variation. Based on the results of this study, it is postulated that when a grade 4/4 or a grade 3/4 scaphotrapezoid separation exists, there is a risk of causing a DISI deformity when performing excision arthroplasty of the trapezium, which is possibly increased when an additional partial trapezoid excision arthroplasty is also performed.

♦ Nothing of financial value to disclose

IGHS Poster 17: The Existence of Cords Within Olecranon Bursa

Category: Other Keyword: Elbow Level 3 Evidence

♦ Jeff O. Ecker, MD

Hypothesis: Transverse cords exist in the olecranon bursa and have a different clinical presentation and outcome than olecranon bursa without transverse cords.

Methods: A retrospective study was performed on 33 cases that had had surgery to remove olecranon bursa over a five-year period.

Results:  24 cases had surgery to remove their olecranon bursae.  9 had transverse cords in the olecranon bursa.  Nearly all cases where cords were noted in the olecranon bursae had a coexistent olecranon enthesophyte.  100% of the cord group were males and 80% on the non cord group were females.  Patients with olecranon bursal cords were younger with a mean age of 40 years whereas those without olecranon cords were older with a mean age of 55 years.  Patients who had cords in their olecranon bursae did not have associated medical conditions.  Patients with cords were referred for treatment after a much shorter duration of symptoms.  All cases with cords in the olecranon bursa were involved in manual laboring jobs.  50% of patients who had surgery for a bursa, which did not have cords, had an episode of infection associated with their presentation. There was no infective episode identified in patients who presented with an olecranon bursa that had cords.

♦ Nothing of financial value to disclose

IGHS Poster 18: Bilateral Scaphotrapeziotrapezoid Coalition with Bipartite Scaphoid

Category: Congenital/Pediatric Keyword: Wrist Level 4 Evidence

♦ David A. Stewart, FRACS ♦ David McCombe, MD,FRACS

Hypothesis: Coalition or congenital fusion can affect any adjacent bones within the carpus, with lunotriquetral coalition being the most common form. Scaphotrapezial coalitions are very rare, with most cases associated with hereditary syndromes or other coalitions. The phenomenon of the bipartite scaphoid is controversial, with many cases thought to have arisen from previous trauma. Criteria for describing a true bipartite scaphoid are: the absence of a history of trauma; the presence of bilateral scaphoid bipartition; equal size and density of both ossicles; the abscence of degenerative change in the radial scaphoid carpal articulation; a clear space between the components with smooth edges at the joint surfaces.

Methods: A 15-year-old caucasian girl with no significant medical history presented with several months of bilateral radial sided wrist pain. She described no trauma, and examination demonstrated dorsoradial tenderness. X-rays and CT scans demonstrated a coalition of the scaphoid, trapezium and trapezoid bones bilaterally with a bipartite scaphoid component of the coalition. Bone scan showed high uptake in the fracture / scaphoid ossicle articulation bilaterally.

Results: With the presumptive diagnosis of peudarthrosis of the scaphoid component of a radial sided carpal coalition, she was splinted at the wrist and first carpometacarpal joints for two months. This did not bring about resolution of her symptoms but alleviated some of the pain while wearing the splints. She underwent osteosynthesis with debridement of the pseudarthrosis, iliac crest bone grafting and compression screw fixation. After an uneventful postoperative course and 8 weeks of immobilization, pain had resolved and plain x-ray demonstrated union at the site of the pseudarthrosis.

Summary:  We present a very rare case of bilateral scaphotrapeziotrapezoid coalition with bilateral bipartite or fractured scaphoid component. It is possible that a coalition of the radial carpus predisposed the proximal scaphoid component to fracture and this case represents a bilateral scaphoid fracture non-union.  The congenital fusion of the distal components of the coalition may have interfered with the union of two ossification centers of the developing scaphoid. Whether there are indeed two ossification centers is contested. The presentation with pain suggests a traumatic cause, although this and the high uptake of technetium-99 could also represent development of inflammation in the bipartite scaphoid articulation.  This case does not solve the riddle of the bipartite scaphoid but contributes to the debate as to the existence of the phenomenon and its aetiology.

References: 1. O'Rahilly R. A survey of carpal and tarsal anomalies. J Bone Joint Surg Am. 1953 Jul.;35-A(3):626–642. 2. Carlson DH. Coalition of the carpal bones. Skeletal Radiol. 1981;7(2):125–127. 3. Peters S, Colaris JW. Carpal Coalition: Symptomatic Incomplete Bony Coalition of the Capitate and Trapezoid—Case Report. The J Hand Surg (Am). 2011 Jun. 10;:1–3. 4. Ingram C, Hall R, Gonzalez M. Congenital fusion of the scaphoid, trapezium, trapezoid and capitate. J Hand Surg (Br). 1997 Apr.;22(2):167–168. 5. Wilson S, Moreel P, Roulot E. Symptomatic congenital fusion of the scaphoid and trapezium. J Hand Surg (Br). 2006 Oct.;31(5):581–581. 6. Louis DS, Calhoun TP, Garn SM, Carroll RE, Burdi AR. Congenital bipartite scaphoid-- fact or fiction? J Bone Joint Surg Am. 1976 Dec.;58(8):1108–1112. 7. Wollstein R Watson HK. Scaphotrapeziotrapezoid Arthrodesis for Arthritis. Hand Clin. 2005 Nov.;21(4):539–543.

♦ Nothing of financial value to disclose IGHS Poster 19: Pyrocarbon Hemiarthroplasty of the PIP joint: Case Study of a 10-year Follow-up and Review of the Literature

Category: Arthroplasty Keyword: Hand Level 4 Evidence

♦ ▲Christof Bollman, MBBS ♦ ▲Susan Peters, MAHTA ♦ ▲Mark Ross, FRACS

Hypothesis: Comminuted intraarticular fractures of the condyles on the proximal phalanx are difficult to manage and will often result in PIP stiffness. There are encouraging results in the literature[1] to manage non-reconstructible PIP fractures with a pyrocarbon hemiarthroplasty. We present a 10-year follow-up after management of a comminuted intraarticular fractures of the condyles on the proximal phalanx with a pyrocarbon hemiarthroplasty. We propose pyrocarbon hemi-arthroplasty as an alternative to other surgical interventions used to manage non- reconstructible fractures of the PIP joint.

Methods: A 27-year-old male patient sustained an axial trauma to his left little finger (Figure 1). The patient was seen three weeks after the injury. An open reduction and internal (or external) fixation in this situation is very difficult and would most probably result in PIP joint stiffness. The free vascularised joint transfer is theoretically another possibility, but has an increased incidence of donor morbidity. Also, functional outcome may not be satisfactory in this setting, with total range of motion between 33 [2] and 43 degrees [3] reported in the literature. Another alternative would be PIP joint fusion, however this often limits grip or grasp. A finger with a fused PIP joint also often gets in the way or might hinder the other fingers (quadriga effect). In terms of arthroplasty there are total PIP joint arthroplasty (Silicone or Pyrocarbon). We decided to use, after informed consent with the patient, an off-label use of a pyrocarbon PIP implant as a hemi-arthroplasty.

Results: At the review at 10-year follow up, the patient was very satisfied with the result. Quick- DASH result was 0. The patient had no pain (rated “0” on a 100-point VAS). He had grip strength of 44kg (versus 48kg on the contralateral dominant side). The joint mobility was (flexion/extension) 87/24 degrees (TAM 111 degrees) (Figure 2). He reported using the hand normally with no restriction. There were no complications reported by the patient or observed radiologically.

Summary: The first treatment option of an intra-articular distal proximal phalanx fracture is reduction and fixation. If a good fixation cannot be achieved and the joint cannot be mobilized early, PIP joint stiffness is very likely to occur. Research indicates that cartilage articulates well against a pyrocarbon hemi-arthroplasty, due to the similar elasticity module and joint-surface lubrication properties of pyrocarbon [4]. We propose that pyrocarbon hemi-arthroplasty is an appropriate and successful alternative to other surgical interventions in managing non- reconstructible fractures of the PIP joint.

References: 1. Henry, M. Prosthetic hemi-arthroplasty for post-traumatic articular cartilage loss in the proximal interphalangeal joint. Hand (N Y), 2011. 6(1): p. 93-7. 2. Hierner, R., A.K. Berger, and Z.L. Shen. [Vascularized joint transfer for finger joint reconstruction]. Handchir Mikrochir Plast Chir, 2007. 39(4): p. 249-56. 3. Dautel, G., et al. PIP reconstruction with vascularized PIP joint from the second toe: minimizing the morbidity with the "dorsal approach and short-pedicle technique". Tech Hand Up Extrem Surg, 2004. 8(3): p. 173-80. 4. Schwartz IM, Hills BA. Synovial surfactant: lamellar bodies in Type B synoviocytes and proteolipid in synioval fluid and the articular lining. Br. J. Rheumatol; 1998; 37:137-42.

▲ This presentation will discuss Pyrocarbon PIP joint Arthroplasty by Integra Ascension ♦ Nothing of financial value to disclose