Meeting Abstracts

e1 ABSTRACTS 2013 Annual Meeting Abstracts

This booklet contains the abstracts for the Scientific Session papers as submitted by the authors. Abstracts are in pre- sentation order by day and time. These abstracts are also available at www.ASSHAnnualMeeting.org.

Financial Disclosure and FDA Status

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e2 ABSTRACTS

PAPER 01 © Scott M. Tintle, MD L. Scott Levin, MD Best Papers Thursday, October 3, 2013 2:15e2:21 PM Hypothesis: We hypothesized that a rat model for composite tissue allo- Category: Evaluation/Diagnosis/Clinical Treatment transplantation (CTA) of the elbow joint could be developed. Keyword: Hand Methods: We developed an animal model for CTA of the elbow joint in rats. Microvascular elbow CTA was performed in 9 rats across a major histo- Comparison of Cortisone Injection and Percutaneous Trigger compatibility barrier. Three rats were treated with full-dose immunosu- Finger Release for Diabetic Trigger Fingers in 293 Patients pression consisting of cyclosporine until death. Three rats were provided Level 1 Evidence with 10 days of immunosuppression and then the cyslosporine was stopped. © Melissa Arief, MD Finally, 3 rats were used as a control and were given no immunosuppres- sion. Joint mobility and weight-bearing capability were assessed throughout © Mukund Patel, MD 90 days of life. Pedicle patency, bone blood flow, and histologic analysis Hypothesis: This study sought to compare the success rate of cortisone steroid were performed at the time of death. injection with that of percutaneous trigger finger release in diabetic patients. Results: In the cyclosporine group, forelimb activity was gradually recovered Methods: Data were collected over a 5-year period from 2008 to 2013. We over the postoperative 90 days. The operated extremity was used in daily studied 2 cohorts of patients with diabetes type 1 and 2 who were either activities such as ambulating and eating. There was little to no range of treated with local corticosteroid injection (N ¼ 191) or percutaneous trigger motion or use of the limb in the cyclosporine taper or the control groups. The release under local anesthesia in the office with a sterile 18-gauge needle vascular pedicles were patent at the time of death in the cyclosporine-treated (N ¼ 209). Patients were observed for at least 1 year. Patient demographics group, but not in the remaining groups. Micro-computed tomography scan included pain, trigger finger grade, and duration of symptoms. Patients were performed 3 months after the transplants revealed union at the bone junctions assessed at follow-up for pain, continued triggering, need for therapy after and the elbow joint appeared grossly normal upon death in the cyclosporine treatment, complications, and overall satisfaction. treatment group only. Incomplete healing was observed in the other 2 groups, Results: A total of 145 patients treated with corticosteroid injection were and the elbow joints were grossly destroyed. Histologic examination observed for 1 year and had an overall success rate based on patient revealed normal cartilage and bone cells in the cyclosporine-treated group, satisfaction of 75%. In this group, 4% required a second injection, 5% whereas the nontreated groups demonstrated lymphocytic infiltration and underwent a percutaneous trigger finger release, and 1 patient received an loss of normal histology. Flow cytometry of blood samples obtained on days open release. In the percutaneous release group, 147 patients were observed 14, 30, 60, and 90 showed no recipient cell chimerism in any of the groups. for 1 year. There was an overall success rate of 95%; 1 patient received a Summary: We have provided the first animal model for elbow CTA. In our corticosteroid injection. In both groups, there were no complications. cyclosporine-treated rats, animals regained near-normal function of fore- Summary: limbs after bone union and maintained grossly normal elbow cartilage. The results of this study demonstrate a greater rate of success of percu- Without cyslosporine treatment, the elbow transplants were rejected. taneous trigger finger release for diabetic trigger fingers compared with the standard corticosteroid injection. Royalties/Honoraria received from: Mavrek Medical This study demonstrated no complications for a large series of patients Receipt of Intellectual Property Rights/Patent Holder with: Sternal Talon demonstrating the safety of the percutaneous release in the office setting. REFERENCES PAPER 03 1. Pope DF, Wolfe SW. Safety and efficacy of percutaneous trigger finger release. J Hand Surg Am. 1995;20(2):280e283. Best Papers 2. Eastwood DM, Gupta KJ, Johnson DP. Percutaneous release of the trigger Thursday, October 3, 2013 2:35e2:41 PM finger: an office procedure. J Hand Surg Am. 1992;17(1):114e117. Category: Nerve/Neuromuscular 3. Bain GI, Wallwork NA. Percutaneous A1 pulley release: a clinical study. Hand Keyword: Forearm Surg. 1999;4(1):45e50. 4. Schramm JM, Nguyen M, Wongworawat MD. The safety of percutaneous A Collagen Conduit Versus Microsurgical Neurorrhaphy trigger finger release. Hand (N Y). 2008;3(1):44e46. 2-Year Follow-Up of a Prospective Blinded Clinical and 5. Calleja H, Tanchuling A, Alagar D, Tapia C, Macalalad A. Anatomic outcome of Electrophysiological Multicenter RCT percutaneous release among patients with trigger finger. J Hand Surg Am. Level 1 Evidence 2010;35(10):1671e1674. 6. Dahabra IA, Sawaqed IS. Percutaneous trigger finger release with 18-gauge Michel E. H. Boeckstyns, MD needle. Saudi Med J. 2007;28(7):1065e1067. © Christian Krarup, MD, FRCP fi 7. Stothard J, Kumar A. A safe percutaneous procedure for trigger nger release. J © Birgitta Rosen, OT, PhD R Coll Surg Edinb. 1994;39(2):116e117. © Joaquim Fores, MD 8. Patel MR, Moradia VJ. Percutaneous release of trigger digit with and without © cortisone injection. J Hand Surg Am. 1997;22(1):150e155. Allan Ibsen Sørensen, MD © Xavier Navarro, MD, PhD

PAPER 02 Hypothesis: The hypothesis to be tested in our study was that use of the collagen nerve guide conduit for repair of traumatic short gap nerve lesions Best Papers in humans is associated with reinnervation of the denervated organs and e Thursday, October 3, 2013 2:25 2:31 PM recovery of sensory and motor functions that are at least equivalent to those Category: Vascular/Microvascular after conventional repair (direct suture or nerve grafting). Keyword: Elbow Methods: In a prospective randomized trial, acute section of the ulnar or median Composite Tissue Transplantion of the Elbow Joint in Rats nerves was repaired with a collagen nerve conduit or with conventional Not a clinical study microsurgical techniques (direct suture or a short autologous nerve graft). Electrophysiological tests as well as hand function using a standardized clinical © Juyu Tang, MD evaluation instrument (the Rosen scoring system) were compared after 12 and © Hainan Zhu, MD 24 months using 1-way and 2-way analysis of variance (ANOVA) with repair © Xuson Luo, MD type (conduit or conventional) and nerve type (median or ulnar) as factors.

© Speaker has nothing of financial value to disclose e3 Results: Forty-three patients with 44 total nerve lacerations were enrolled. among older men. Most of the research focusing on fracture prediction and Operation time using the collagen conduit was significantly shorter than per- prevention to date has focused on postmenopausal women. The purpose of forming conventional repair. There were no surgical complications in terms of this study was to compare fracture characteristics, treatment, and subsequent infection, extrusion of the conduit, or other local adverse reaction. Thirty-two osteoporosis evaluation among men and women with these injuries. Our patients with 33 nerve lesions attended the 24-month follow-up. There were no hypothesis was that older men have similar patterns of injury and lower rates differences in the amplitudes, latencies, and conduction velocities when repair of evaluation for osteoporosis than women with DRF. with nerve conduit and suture was compared. When compared at 12 and 24 Methods: We retrospectively reviewed the records of 95 men and 344 women months, there was general further recovery of both motor conduction parameters over the age of 50 treated for DRF at a single institution over a 5-year (P < .01) and sensory conduction parameters (P < .05). At 1-way ANOVA, period. Data collected included age, mechanism of injury (high- vs low- there was no difference between sensory, discomfort, or total Rosen hand energy fall), fracture severity (according to the AO classification), associated function scores when guide and suture repairs were compared. The 2-way comorbidities, as well as type of treatment. We assessed whether patients ANOVA test showed significant differences in clinical motor recovery ac- received a dual-energy x-ray absorptiometry (DXA) scan and treatment with cording to nerve (median doing better than ulnar). In contrast, sensory recovery osteoporosis medication within 6 months of injury. Results were validated after ulnar nerve repair was better than after median nerve repair. The type with a telephone interview. Differences between men and women were of repair in itself had no influence on sensory or motor function after 24 months. assessed via chi-square, Fisher’s exact, and unpaired Student’s t-tests. Summary: Results: Men sustained DRF at a younger age than women (64 11 vs 68 The hypothesis was confirmed that use of the collagen nerve guide 12; P ¼ .004) but had similar associated comorbidities and mechanisms of conduit for repair of traumatic nerve lesions in humans is associated with injury (fall from a standing height). Men were less likely to have had a prior reinnervation of the denervated organs and recovery of sensory and motor fragility fracture (8 [4%] vs 66 [19.2%]; P ¼.008) and had less severe fracture functions that are equivalent to those after conventional repair, but they patterns than women (19 [20%] vs 18 [40%] type C; P < .500). Whereas 184 were not superior. (53%) women had a DXA after injury, only 17 (18%) men were evaluated for Use of the collagen conduits is safe in the distal forearm. bone mineral density (BMD) (P <.001). Among those evaluated with a DXA Obvious advantages above conventional repair are the shorter operation scan, 3 men (17.6%) and 75 women (25%) were given a diagnosis of oste- time and less donor side morbidity, in case nerve grafting is the only other oporosis. Fewer men than women were subsequently treated with medication alternative. for underlying abnormalities in BMD (17 [18%] vs 179 (52%); P < .000). Fracture Risk Assessment Tool calculations for the male population revealed REFERENCES a 7.8% 4.4% 10-year risk for major osteoporotic fracture for male patients. 1. Archibald SJ, Krarup C, Shefner J, Li ST, Madison RD. A collagen-based nerve Summary: guide conduit for peripheral nerve repair: an electrophysiological study of Distal radius fractures among men occur at a slightly younger average age nerve regeneration in rodents and nonhuman primates. J Comp Neurol. than among women. e 1991;306(4):685 696. Men and women with DRF have similar mechanisms of injury and 2. Krarup C, Archibald SJ, Madison RD. Factors that influence peripheral nerve medical comorbidities. regeneration: an electrophysiological study of the monkey median nerve. Ann Neurol. 2002;51(1):69e81. Fewer men than women are evaluated with a DXA scan after injury and 3. Madison RD, Archibald SJ, Lacin R, Krarup C. Factors contributing to preferential treated for abnormalities in BMD. motor reinnervation in the primate peripheral nervous system. J Neurosci. Evaluation and treatment rates for osteoporosis in men with fragility 1999;19(24):11007e11016. fractures are unacceptably low. 4. Rosen B, Dahlin LB, Lundborg G. Assessment of functional outcome after nerve Further studies are needed to better characterize this patient population repair in a longitudinal cohort. Scand J Plast Reconstr Surg Hand Surg. and to develop improved fracture prevention programs. 2000;34(1):71e78. 5. Bushnell BD, McWilliams AD, Whitener GB, Messer TM. Early clinical experience with collagen nerve tubes in digital nerve repair. J Hand Surg Am. 2008;33(7): REFERENCES 1081e1087. 6. Lundborg G, Rosen B, Dahlin L, Danielsen N, Holmberg J. Tubular versus conven- 1. Fitzpatrick SK, Casemyr NE, Zurakowski D, Day CS, Rozental TD. The effect tional repair of median and ulnar nerves in the human forearm: early results from of osteoporosis on outcomes of operatively treated distal radius fractures. e a prospective, randomized, clinical study. J Hand Surg Am. 1997;22(1):99e106. J Hand Surg Am. 2012;37(10):2027 2034. 7. Lundborg G, Rosen B, Dahlin L, Holmberg J, Rosen I. Tubular repair of the 2. Rozental TD, Branas CC, Bozentka DJ, Beredjiklian PK. Survival among elderly e median or ulnar nerve in the human forearm: a 5-year follow-up. J Hand Surg Br. patients after fractures of the distal radius. J Hand Surg Am. 2002;27(6):948 952. 2004;29(2):100e107. 3. Goldhahn S, Kralinger F, Rikli D, Marent M, Goldhahn J. Does osteoporosis increase complication risk in surgical fracture treatment? A protocol Contracted Research: Auxilum combining new endpoints for two prospective multicentre open cohort Royalties/Honoraria received from: Pfizer studies. BMC Musculoskelet Disord. 2010;11:256. Consulting Fees (eg, advisory boards) received from: Pfizer 4. Oyen J, Brudvik C, Gjesdal CG, Tell GS, Lie SA, Hove LM. Osteoporosis as a risk factor for distal radial fractures: a case-control study. J Bone Joint Surg Am. PAPER 04 2011;93(4):348e356. 5. Lill CA, Goldhahn J, Albrecht A, Eckstein F, Gatzka C, Schneider E. Impact Best Papers of bone density on distal radius fracture patterns and comparison between five different fracture classifications. J Orthop Trauma. 2003;17(4):271e278. Thursday, October 3, 2013 2:45e2:51 PM 6. Foote JE, Rozental T. Osteoporosis and upper extremity fragility fractures. J Category: Fractures and Dislocations Hand Surg Am. 2012;37(1):165e167. Keyword: Wrist 7. Kanis JA, Johnell O, Oden A, De Laet C, Mellstrom D. Epidemiology of oste- Distal Radius Fractures in Older Men: A Missed oporosis and fracture in men. Calcif Tissue Int. 2004;75(2):90e99. 8. Orwoll E. Assessing bone density in men. J Bone Miner Res. 2000;15(10): Opportunity? 1867e1870. Level 4 Evidence 9. Øyen J, Gjesdal CG, Brudvik C, et al. Low-energy distal radius fractures in — © Carl Harper, MD middle-aged and elderly men and women the burden of osteoporosis and fracture risk. Osteoporos Int. 2010;21(7):1257e1267. © Shannon K. FitzPatrick, BS 10. Bergström U, Björnstig U, Stenlund H, Jonsson H, Svensson O. Fracture Tamara D. Rozental, MD mechanisms and fracture pattern in men and women aged 50 years and © Lindsay Herder, BA older: a study of a 12-year population-based injury register, Umeå. Sweden. Osteoporos Int. 2008;19(9):1267e1273. Hypothesis: Distal radius fractures (DRF) are common and represent an important source of patient morbidity, yet little is known about this fracture Contracted Research: ASSH, OREF, RJOS e4 © Speaker has nothing of financial value to disclose PAPER 05 assistance is controversial. To our knowledge, no study exists combining fragment-specific fixation and arthroscopy. Clinical Paper Session 1: Distal Radius The procedure allowed for a detailed inspection of the joint for other e Friday, October 4, 2013 8:45 8:51 AM pathologies and showed that 42% of patients had additional pathology, Category: Evaluation/Diagnosis/Clinical Treatment although a large percentage did not have to be treated (97%). Keyword: Hand Incidentally, the main surgical approach when we used fragment-specific Fragment-Specific Fixation of Intra-articular Distal Radius: fixation was laterally from the radial styloid and not the traditional The Role of Arthroscopy to Confirm Anatomical Reduction Henry’s approach. Fixating the radial styloid from laterally stabilized the fracture in most Level 4 Evidence cases. © Mari Thiart, MBBS We also found that when a second fixation was needed, we used the © Ajmal Ikram, MD dorsal ulnar approach, which left the volar side completely intact. Hypothesis: The goal of this study was to discover whether intraoperative arthroscopy assists in the reduction of intra-articular distal radius fractures when using fragment-specific fixation. Methods: All patients who presented at our institution with intra-articular distal radius fractures were included. A computed tomograpghy scan was done preoperatively. Intraoperatively, the fragments were reduced and fragment-specific fixation was used. The reduction was confirmed with an image intensifier. After the reduction, a scope was inserted into the radiocarpal joint to evaluate the reduction. Other pathology was documented and treated accordingly. Seventy-one patients were included in the study. One patient needed the fracture to be reduced again and 1 had a pin repo- sitioned because it was intra-articular. Thirty patients (42%) had other intra- articular pathology; but only 2 (3%) needed further treatment. Six patients had complications: 1 had migrating hardware (K-wires backing out) and fracture collapse, and 5 had only fracture collapse. Thus, the complication rate was 8.5% for fracture collapse and 1.4% for migrating hardware. Results: A total of 85% of the patients had no gaps and 77% of the patients had no steps. Only 1 patient needed refixation of a fracture fragment (1.4%) and 1 had a K-wire reinserted because it was intra-articular (1.4% of pa- tients). An array of other pathology was seen intra-articularly, including 5 PAPER 06 osteochondral defects, 20 triangular fibrocartilage complex tears (only 1 Clinical Paper Session 1: Distal Radius needed to be repaired), 4 bruised scapholunate ligaments, 3 scapholunate Friday, October 4, 2013 8:55e 9:01 AM tears, 1 capsular tear, and 1 undisplaced scaphoid fracture (open reduction Category: Evaluation/Diagnosis/Clinical Treatment internal fixation was done). Summary: Keyword: Wrist The use of arthroscopy intraoperatively was shown not to assist in frac- Residual Radial Translation of Distal Radius Fractures— ture reduction. This is relevant because intraoperatively, arthroscopic Defining a New Radiographic Parameter and Occult Cause of DRUJ Instability Level 2 Evidence © Greg Couzens, MD © Livio Di Mascio, MD Mark Ross, FRACS

Hypothesis: Commonly used radiographic parameters that assess distal radius fracture reduction, do not take into account radial translation of the distal fragment, a cause of distal radioulnar joint instability.1 We hypothesized that having a normal radiographic parameter for residual radial translation will equip surgeons with a reliable and reproducible tool that can identify and evaluate the extent of this problem and direct appropriate surgical management. Methods: Anteroposterior radiographs with no evidence of an acute fracture, dislocation, or history of previous fracture or dislocation were identified. These radiographs were of skeletally mature individuals with no history of distal radioulnar instability. Radiographs were excluded if the distal 10 cm of the radius was not visible or if there was more than 5 radial or ulnar deviation of the wrist, assessed by deviation of the long axis of the middle metacarpal from that of the radius. Radial translation was measured by drawing a line along the ulnar aspect of the radius, into the proximal row of the carpus. This line intersects the lunate. The point of intersection was evaluated by drawing a second line along the transverse width of the lunate on the anteroposterior radiograph, which was parallel to the distal radial articular surface. The point of intersection was evaluated measuring from the radial side of the lunate. A single author repeated these measurements for all radiographs studied at 2 separate sittings to evaluate for intraobserved variability. In an attempt

© Speaker has nothing of financial value to disclose e5 to evaluate for interobserver variability, 2 fellowship-trained upper limb REFERENCE surgeons took measurements on 25 of the radiographs. The results were 1. Ross M, Heiss-Dunlop W. Volar angle stable plating for distal radius fractures. In: collated and statistical analysis was performed. David JS, Slutsky DJ, eds. Principles and Practice of Wrist Surgery. Philadelphia: Results: A total of 100 radiographs fulfilling the study entry criteria were WB Saunders; 2010:126e139. identified. There were 42 females and 58 males with a mean age of 43 years (range, 18e66 y). For all individuals studied, the point of intersection left a Contracted Research with: Integra Life Sciences, Lima Orthopaedics mean of 45.48% (range, 73% to 25%) of the lunate remaining on the radial Royalties/Honoraria received from: Ascension Orthopaedics,Surgicraft side. Good interrater (intraclass correlation coefficient, 0.967) and intrarater Consulting Fees (eg, advisory boards) received from: Ascension Ortho- (intraclass correlation coefficient, 0.780) reliability was observed. paedics, Lima, LMT surgical, Surgicraft Summary: Receipt of Intellectual Property Rights/Patent Holder with: Ascension With the advent and increasing popularity of volar locked plating systems Orthopaedics, Surgicraft for use in the treatment of distal radius fractures, there is potential for the Other Financial/Material Support received from: Depuy creation of a stable construct with a radial translation malreduction. We propose a new parameter to measure radial translation, so that distal PAPER 07 radioulnar joint instability can be minimized after distal radius fractures. This radiological parameter has been found to be reliable and reproducible. Clinical Paper Session 1: Distal Radius Friday, October 4, 2013 9:05e9:11 AM Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Wrist Demonstration of an Effective Postoperative Pain Management Protocol in Distal Radius Fractures Level 4 Evidence

▲David L. Nelson, MD © ▲Brandan La

Hypothesis: A multimodal pain program can help pain control in a common, moderately painful procedure (open reduction internal fixation distal radius fracture with volar plate). The effectiveness was assessed by a patient- centered outcome measure. The program could serve as an index of pain management effectiveness for other hand surgery practices. Methods: All patients undergoing open reduction internal fixation by a single surgeon for distal radius fracture within 7 days postinjury had a pain control program previously presented to this Society in 2002. The components included: (1) preoperative counseling regarding expected pain, (2) preoper- ative oral long-acting acetaminophen and long-acting nonsteroidal (celecoxib), (3) pre-incision lidocaine block, (4) intraoperative bupivicaine block, (5) noneas-needed oral long-acting acetamenophen and long-acting nonsteroid (celecoxib) for 48 hours postoperatively and thereafter as needed, (6) hydrocodone/acetaminophen 5:500 (Vicodin) Q4H for break-through pain, (7) postoperative telephone call, and (8) assessment of the efficacy of the pain management at the first follow-up visit. The outcome measure was the number of opioid doses (hydrocodone/acetaminophen 5:500) taken within 10 days of surgery. The patient alone determined whether the pain required opioid medication. The surgeon had no input into the evaluation of pain. Exclusion criteria were multiple trauma and concurrent use of opioids for other conditions. Data were verified by an independent ASSH member who: (1) examined the operative casebook (no cases were skipped), (2) reviewed patient charts (data were correct), (3) contacted patients (to verify data in charts), and (4) examined the study database (all data were entered correctly). Results: A total of 72 consecutive patients were eligible for the study; 59 patients met inclusion criteria and 13 were excluded. There were 10 males and 49 females, and 3 bilateral fractures. The average age was 62 years (range, 20e89 years). The average number of hydrocodone/acetaminophen doses taken within 10 days of surgery was 0.68 pills. A total of 72 of patients decided that the pain did not require opioids, and therefore took none. Eight percent took 1 pill, 6% took 2, 5% took 4, and 3% took 5. No patient asked for a refill. The review by an independent ASSH member verified the collected data. Summary: The pain management protocol resulted in low usage of narcotic analgesics. Volar plating of distal radius fractures is a common procedure and is performed in a uniform manner by most surgeons. This makes volar plating a suitable model for evaluation of pain management across different

FPO practices, without requiring significant additional time for postoperative = assessment, because only 1 question is required.

▲ fi web 4C This presentation will discuss Celebrex by P zer Royalties/Honoraria received from: Orthofix

e6 © Speaker has nothing of financial value to disclose Receipt of Intellectual Property Rights/Patent Holder with: Orthofix in pronation and supination. In specimens with a distinct oblique bundle, a Other Financial Relationships: Speaking for AO, International Hand and similar significant increase in DRUJ displacement after 2-mm coronal shift Wrist Biomechanics Symposium occurred in neutral forearm rotation (P ¼ .02) (Fig. 1B). Specimens without a distinct oblique bundle did not show differences in DRUJ displacement with coronal shift (Fig. 1C). PAPER 08 Summary: In the setting of an ulnar styloid fracture, coronal plane malalignment of Clinical Paper Session 1: Distal Radius the distal radial fragment causes increased DRUJ displacement. This was Friday, October 4, 2013 9:15e9:21 AM particularly pronounced in specimens with a distinct distal oblique bundle Category: Fractures and Dislocations of the IOM. Keyword: Wrist Based on our mechanical testing, failure to achieve anatomic alignment in The Impact of Coronal Alignment on Distal Radioulnar the coronal plane may predispose patients who have a distinct distal oblique bundle to DRUJ instability. Stability Following Distal Radius Fracture Not a clinical study

* Christopher J. Dy, MD, MSPH © Eugene Jang, MS © Kathleen Meyers, MS © Samuel A. Taylor, MD Scott W. Wolfe, MD

Hypothesis: It has been theorized that malalignment of the distal radial fragment in the coronal plane may compromise radioulnar stability afforded by the distal oblique bundle of the interosseous membrane (IOM).2 We hypothesized that anatomic reduction of coronal alignment of a distal radius fracture will decrease distal radioulnar joint (DRUJ) displacement, particularly in specimens with a distinct distal oblique FPO = bundle of the IOM. Methods: An extra-articular distal radius fracture model was created in 10

cadaveric specimens. The distal radius osteotomy was created at the level web 4C corresponding to the base of the sigmoid notch and the ulnar styloid was obliquely osteotomized at the fovea. Using a volar plate, the distal radius was secured to allow the distal fragment to be shifted radially in the coronal plane by 2-mm increments. A mechanical testing apparatus was used to apply 20 N of dorsal and volar tensile load to the distal fragment with the forearm in neutral rotation, 60 pronation, and 60 supination (Arimitsu). Dorsal-volar displacement of the radius relative to the fixed ulna was measured in a control state (distal radius anatomically reduced and the ulnar styloid fixed) and in 3 positions (anatomic reduction, 2-mm shift, and 4-mm shift) with the ulnar styloid displaced. After completion of testing, the specimens were dissected to quantify the distal oblique bundle of the IOM. Repeated-measures analysis of variance was used to compare DRUJ FPO displacement between the testing and control states, with separate analyses = conducted for specimens with and without a distinct (thickness > 0.5 mm) distal oblique bundle. Results: When analyzing all specimens and comparing with control, DRUJ web 4C displacement was significantly greater after a 2-mm coronal shift of the distal fragment (P ¼ .038) (Table 1, Fig. 1A) (neutral forearm rotation) but was not significantly different after a 4-mm shift. Similar results were seen

Table 1 P (Pairwise Comparison Neutral Average SD With Control) All specimens Control 11.69 4.51 Not available 0 mm 13.84 5.26 .033 2 mm 14.44 5.26 .038 FPO

4 mm 12.42 4.07 .580 = With bundle Control 12.19 3.93 Not available

0 mm 15.95 4.14 .038 web 4C 2 mm 17.33 4.37 .021 4 mm 14.19 2.26 .098 No bundle REFERENCES Control 11.20 5.45 Not available 1. Arimitsu S, Moritomo H, Kitamura T, et al. The stabilizing effect of the distal 0 mm 11.73 5.83 .004 interosseous membrane on the distal radioulnar joint in an ulnar shortening 2 mm 11.55 4.71 .004 procedure: a biomechanical study. J Bone Joint Surg Am. 2011;93(21): 4 mm 10.66 4.93 .012 2022e2030.

© Speaker has nothing of financial value to disclose e7 2. Moritomo H. The distal interosseous membrane: current concepts in wrist PAPER 10 anatomy and biomechanics. J Hand Surg Am. 2012;37(7):1501e1507. Clinical Paper Session 1: Distal Radius Contracted Research with: NIH/NIAMS T32 Research Fellowship (grant Friday, October 4, 2013 9:35e9:41 AM AR07281) Category: Fractures and Dislocations Royalties/Honoraria received from: TriMed, Inc, Elsevier, Inc, Extremity Keyword: Wrist Medical (S.W.W) Consulting Fees (eg, advisory boards) received from: Extremity Medical, Elderly Patient Activity Level Does Not Affect Wrist Function TriMed, Inc (S.W.W.) After Distal Radius Malunion Receipt of Intellectual Property Rights/Patent Holder with: KinematX Level 3 Evidence Total Wrist Arthroplasty, Extremity Medical, NJ (S.W.W.) © Jeffrey Stepan, BS * ASSH Resident/Fellow Fast Track Grant (C.J.D.) Gregory N. Nelson, MD, MHS PAPER 09 © Daniel A. Osei, MD © Ryan Patrick Calfee, MD Clinical Paper Session 1: Distal Radius Hypothesis: Prior investigations quantifying the impact of distal radius Friday, October 4, 2013 9:25e 9:31 AM malunion have categorized elderly patients by chronologic age without Category: Basic ScienceeClinical Research consideration of patient activity level. We hypothesized that high-activity Keyword: Hand elderly patients with malunited fractures would demonstrate worse func- Does Osteoporosis Increase the Risk of Mechanical Failure tional outcome than those with anatomically united fractures. After Locking Plate Fixation of Distal Radius Fractures? Methods: This cross-sectional investigation enrolled 102 patients greater than Level 3 Evidence 65 years of age at a minimum of 1 year after distal radius fracture. All patients returned for a study-related office visit, at which time we collected de- Jesse B. Jupiter, MD mographic and treatment data, completed standardized bilateral physical © Nicole Steinfelder examination measures (eg, motion, grip strength), and performed bilateral © Daniel Rikli, MD wrist radiographs (neutral posteroanterior and lateral). Validated patient-rated e Hypothesis: There is evidence that osteoporotic bone is a predictor for the questionnaires were collected to evaluate disability (Quick Disabilities of the e risk of treatment complications in elderly patients; this has yet to be sub- Arm, houlder, and Hand [DASH], Visual Analog Pain subscale [VAS-pain], fi stantially evaluated in clinical studies. Our prospective, multicenter, and function). Patient activity level was quanti ed with the validated Physical fi ¼ observational study set out to evaluate the influence of local bone mineral Activity Scale of the Elderly scale to de ne high- (n 40) and low-activity (n ¼ ’ density (BMD) on the rate of mechanical failure after locking plate fixation 62) groups. A fellowship-trained hand surgeon blinded to patients scores and examination data reviewed digitized radiographs. A difference of greater of distal radius fractures in the elderly. Methods: e than 4 mm ulnar variance, greater than 20 tilt on the lateral radiograph, A total of 249 patients (age range, 54 88 years) with a closed distal radius fracture were treated with a volar locking plate in 6 different greater than 15 radial inclination, and greater than 4 mm articular gap be- fi hospitals. Clinical and radiological examinations were scheduled at tween the fractured wrist and the uninjured contralateral wrist de ned mal- a < b ¼ 6 weeks, 12 weeks, and 1 year. All complications were reported and unions. We were adequately powered statistically ( 0.05, 0.80) for functional outcome of the upper limb and wrist was evaluated using the analysis to determine a minimally clinically relevant change on the Quick- Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated DASH and VAS ratings (primary outcomes). Results: Wrist Evaluation (PRWE) questionnaires, respectively. Dual-energy x-ray A total of 49 patients (48%) healed with a malunited distal radius. ¼ absorptiometry measurements from the contralateral distal radius were High-activity patients with malunited fractures (n 15) demonstrated taken at 6 weeks to assess local cancellous BMD status. For the compar- equivalent QuickDASH scores, VAS function, strength, and wrist ative analysis of BMD and patient outcomes, all patients were categorized range of motion compared with those with anatomically united fractures ¼ as either a mechanical failure or control, based on whether they experienced (n 25). High-activity malunions reported statistically but not adefined complication (eg, loss of reduction, delayed healing, secondary clinically relevant increases in VAS pain scores (Table 1). Using a linear screw loosening) or not during the 1-year period, respectively. regression analysis, neither Physical Activity Scale of the Elderly score Results: The study collective was composed of 230 women and 19 men with low BMD (mean, 0.624 g/cm2). Of 249 patients, 9 had a mechanical failure, with an estimated risk of 3.6%. The mean BMD for mechanical Table 1: Comparison of High-Activity Patients With Malunions Versus failure patients (0.561 g/cm2) was similar to that for the control group Unions (0.626 g/cm2). Functional outcome improved throughout the 1-year period, High Activity (PASE > 150) but DASH and PRWE scores did not return to pre-injury levels, which Union Malunion P Age* 70 (5.5) 68 (4.3) .190 indicated some remaining disability for the study population. At 1 year, † fi Sex, females 24 (96%) 9 (60%) .007 mechanical failure patients had signi cantly worse DASH and PRWE † scores compared with the control group (P < .001). Surgical management 12 (48%) 5 (33%) .510 Conclusions: The estimated risk for elderly patients with a volar locking Patient-rated outcome plateetreated distal radius fracture to experience a mechanical failure QuickDASH 4.5 4.5 .890 complication is low, and in line with already published data. No association VAS Pain score (0e10 cm) 0 0.5 .020 e could be shown between BMD and mechanical failure risk. This outcome is VAS Function score (0 10 cm) 0 0.6 .140 expected in older patients with lower BMD compared with the general Strength population, and supports the theory that factors other than BMD have a Non-injuredeinjured grip, lb forcez e0.78 (8.33) e4.5 (14.3) .370 greater role in the occurrence of mechanical failure complications associ- Non-injuredeinjured pinch, lb force* 0.13 (2.01) 0.71 (2.7) .360 ated with distal radius fractures in the elderly. Range of motion Non-injuredeinjured prono-supination e5.0 e8.0 .490 Contracted Research with: AO Foundation grant Non-injuredeinjured flexion-extension* e4.8 (17.0) e9.0 (14.2) .430 Ownership Interest (stocks, stock options, or other ownership interest Non-injuredeinjured radial-ulnar deviation 0 e7.0 .330 fi excluding diversi ed mutual funds) with: OHK company *Normal data for high and low active, mean (SD). Consulting Fees (eg, advisory boards) received from: OHK company †Chi-square tests. Receipt of Intellectual Property Rights/Patent Holder with: Trimed Co zNormal data for high active group only. e8 © Speaker has nothing of financial value to disclose (ß ¼ e0.003, 95% confidence interval: e0.006 to 0.000) nor malunion PAPER 11 (ß ¼ 0.31 95% confidence interval: e0.16 to 0.78) predicted Quick- — DASH scores after accounting for age, sex, and treatment. Examining Clinical Paper Session 2: Tendon Basic Science e only fractures displaced at presentation, there were no differences be- Friday, October 4, 2013 8:45 8:51 AM e tween surgically (n ¼ 46) and nonsurgically (n ¼ 21) managed patients Category: Basic Science Lab Research on any outcome measures except decreased grip strength in operatively Keyword: Hand managed patients (Table 2). Bone MarroweDerived Mesenchymal Stem Cell Summary: Augmentation of Rabbit Flexor Tendon Healing Distal radius malunion has minimal impact on elderly patients. Not a clinical study Even among the highly active elderly, there was no difference in motion, strength, or patient-rated disability between patients with malunions and © Alphonsus K. Chong, MD those with anatomically united fractures. © Min He, PhD Nonsurgical management of distal radius fractures may be appropriate for © Aaron Gan, MD elderly patients regardless of activity level. Hypothesis: Mesenchymal stem cell (MSC) treatment is a potential treatment option to augment tendon healing. Our hypothesis was that bone e fi fl Table 2: Comparisons of Displaced Distal Radius Fracture Undergoing marrow derived mesenchymal stem cells have bene cial effects on exor Surgery Versus Nonsurgical Treatment* tendon healing by attenuating adhesion formation and enhancing tendon regeneration. Displaced Distal Radius Fractures Methods: fl Surgery No Surgery A rabbit exor tendon injury and repair model was used. The fl (n ¼ 46) (n ¼ 21) P exor digitorum profundus equivalent tendon in the middle of zone II was Age 71 (5.5) 72 (5.4) .510 completely divided using a surgical blade. All injured tendons were Sex, females* 40 (87%) 18 (86%) .890 repaired with a prolene 5e0 suture under loupe magnification using a Malunion† 20 (44%) 10 (48%) .750 modified Kessler’s repair. Proximally, the tendon was divided at the com- Patient-rated outcomez mon tendon origin to unload the repair. The tendon sheath was left unclosed m fi QuickDASH 5.9 6.8 .950 and the skin wound was closed. In the control group, 100 L brin sealant VAS Pain score (0e10 cm) 0.2 0.2 .850 was administered immediately to the site of injury. In MSC groups, VAS Function score (0e10 cm) 1.1 0.4 .840 1 million autologous MSCs, 1 million allogeneic MSCs, or 4 million m fi Strength allogeneic MSCs were administered to the site of injury, using 100 L brn Non-injuredeinjured grip strength, e6.2 (13.4) 0.57 (11.5) .050 sealant as a cell carrier. The rabbits were killed at 3 or 8 weeks after surgery. lb force Biomechanical testing of repaired tendons was performed. The expression Non-injuredeinjured pinch strength, 0.12 (2.3) e0.08 (2.9) .760 of collagen I was studied by immunohistochemistry and the range of motion lb force of the digits was measured. Results: Range of motion Implantation of allogeneic or autologous MSCs did not induce fl Non-injuredeinjured prono-supination e11.8 (14.7) e6.4 (13.8) .160 evident immune response in exor tendons. Both autologous and allogeneic Non-injuredeinjured flexion-extension e12.6 (18.4) e9.2 (14.7) .460 MSCs increased collagen I expression 3 weeks after surgery. However, Non-injuredeinjured radial-ulnar e5.0 (10.5) e0.95 (7.8) .120 MSC implantation did not enhance the biomechanical properties of injured deviation flexor tendons. Mesenchymal stem cell implantation at high concentration m fi *Mean (SD). (4 million cells in 100 L brin sealant) increased range of motion 3 weeks †Chi-square tests. after surgery. zNon-normal data (median values used). Summary: Mesenchymal stem cell implantation attenuated adhesion formation at the early stage of flexor tendon healing in this animal model. Mesenchymal stem cell implantation also enhanced collagen I expres- REFERENCES sion, but it did not influence the biomechanical properties of flexor tendons. 1. Anzarut A, Johnson JA, Rowe BH, Lambert RGW, Blitz S, Majumdar SR. Radio- fi fi logic and patient-reported functional outcomes in an elderly cohort with Further studies are needed to con rm whether MSC therapy has bene - fl conservatively treated distal radius fractures. J Hand Surg Am. 2004;29(6): cial effects on exor tendon healing in humans. 1121e1127. 2. Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular frac- REFERENCES tures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br. 1. Chang J, Thunder R, Most D, Longaker MT, Lineaweaver WC. Studies 2005;87(6):837e840. in flexor tendon wound healing: neutralizing antibody to TGF-beta1 increases 3. Board T, Kocialkowski A, Andrew G. Does Kapandji wiring help in older pa- postoperative range of motion. Plast Reconstr Surg. 2000;105(1):148e155. tients? A retrospective comparative review of displaced intra-articular distal 2. Chong AK, Ang AD, Goh JC, et al. Bone marrow-derived mesenchymal stem radial fractures in patients over 55 years. Injury. 1999;30(10):663e669. cells influence early tendon-healing in a rabbit achilles tendon model. J Bone 4. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the Joint Surg Am. 2007;89(1):74e81. treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 3. Hammes LS, Korte JE, Tekmal RR, et al. Computer-assisted immunohisto- 2009;91(8):1868e1873. chemical analysis of cervical cancer biomarkers using low-cost and simple 5. Fujii K, Henmi T, Kanematsu Y, Mishiro T, Sakai T, Terai T. Fractures of the distal software. Appl Immunohistochem Mol Morphol. 2007;15(4):456e462. end of radius in elderly patients: a comparative study of anatomical and 4. James R, Kesturu G, Balian G, Chhabra AB. Tendon: biology, biomechanics, functional results. J Orthop Surg (Hong Kong). 2002;10(1):9e15. repair, growth factors, and evolving treatment options. J Hand Surg Am. 6. McQueen M, Caspers J. Colles fracture: does the anatomical result affect the 2008;33(1):102e112. final function? J Bone Joint Surg Br. 1988;70(4):649e651. 5. Luo Q, Song G, Song Y, Xu B, Qin J, Shi Y. Indirect co-culture with tenocytes 7. Roumen R, Hesp W, Bruggink E. Unstable Colles’ fractures in elderly patients: a promotes proliferation and mRNA expression of tendon/ligament related randomised trial of external fixation for redisplacement. J Bone Joint Surg Br. genes in rat bone marrow mesenchymal stem cells. Cytotechnology. 2009;61(1- 1991;73(2):301e311. 2):1e10. 6. Pacini S, Spinabella S, Trombi L, et al. Suspension of bone marrow-derived Other Financial/Material Support received from: Grant support received undifferentiated mesenchymal stromal cells for repair of superficial digital from Physician Services Incorporated Foundation (Nelson) flexor tendon in race horses. Tissue Eng. 2007;13(12):2949e2955.

© Speaker has nothing of financial value to disclose e9 PAPER 12

Clinical Paper Session 2: Tendon—Basic Science Friday, October 4, 2013 8:55e 9:01 AM Category: Tendon Keyword: Hand Platelet-Rich Plasma for Flexor Tendon Repair Not a clinical study © Katie K. Jegapragasan, BS © Erin M. Parsons, MS Jerry I. Huang, MD

Hypothesis: Autologous platelet-rich plasma (PRP) has shown promise in improving tendon healing, notably in rotator cuff and Achilles tendon re- pairs. We hypothesized that PRP would similarly benefit zone II flexor tendon repair in a rabbit model by increasing ultimate strength while minimizing scar tissue formation. Methods: Thirty New Zealand White rabbits were divided into treatment Consulting Fees with: Arthrex with PRP (Arthrex, Naples, FL) or control groups. The flexor digitorum profundus tendons of the fourth toes in the left forepaws were incised and repaired in zone II using a 4-strand technique with 6e0 prolene. In the treatment group, 0.5 mL of autologous PRP was applied intraoperatively. PAPER 13 Rabbits were killed at 2, 4, or 8 weeks postoperatively. Five tendons from Clinical Paper Session 2: Tendon—Basic Science contralateral paws were incised and repaired as day 0 controls. Tendon glide Friday, October 4, 2013 9:05e 9:11 AM was assessed with measurements of angular range of motion (ROM) Category: Basic ScienceeLab Research over the metacarpophalangeal and proximal interphalangeal joints as well Keyword: Hand as tendon excursion. Tendons were then dissected free from the sheath and surrounding peritendinous scar. The ultimate tensile strengths were Flexor Tendon Sheath Engineering Utilizing Decellularized determined using a custom materials testing system. An R2000 hexapod Porcine Pericardium robot (Mikrolar, Boston, MA) was used to apply tensile loads to the Not a clinical study tendon construct until failure at a constant velocity of 0.2 mm/s. The force © Kai Megerle, MD was recorded with an in-line LCFD-10 (Omegadyne, Sunbury, OH) load cell, with a reported accuracy of 0.067 N. A 1-way analysis of variance Colin Woon, MD was carried out on excursion, ROM, and ultimate strength. Categories Armin Kraus, MD © with P < .050 were further analyzed with Tukey’s honestly significant Shyam S. Raghavan, BS difference. James Chang, MD Results: fi The tensile strength increased signi cantly in the control and PRP Hypothesis: The flexor tendon sheath is an ideal target for tissue engineering ¼ ¼ fi groups between 4 and 8 weeks (P .002 and P .004). No signi cant because it is difficult to reconstruct by conventional surgical methods. We differences existed between time points or treatment groups for excursion hypothesized that decellularized porcine pericardium can be used as a ¼ ¼ (P .300), metacarpophalangeal ROM (P .970), proximal interphalan- scaffold for engineering a biologically active tendon sheath. ¼ ¼ geal ROM (P .880), or total ROM (P .770). There was a trend toward Methods: Cellular components were removed from fresh-frozen pericardium lower tensile strength at 2 weeks and higher ROM and excursion at 8 weeks and specimens were assessed for structural integrity and preservation fi in the PRP group, but these were not statistically signi cant. There was no of collagen and glycosaminoglycan content. Human sheath synoviocytes fi signi cant difference in ultimate tensile strength between the control and and adipoderived stem cells were seeded on the scaffold and the production ¼ ¼ ¼ PRP groups at 2 weeks (P .990), 4 weeks (P 1), or 8 weeks (P .980). of the main component of synovial fluid, hyaluronic acid (HA), was Summary: measured. Changes in cellular expression patterns of collagen and HA fi Platelet-rich plasma did not have a signi cant effect on the ultimate production were monitored. Cells were evaluated for 8 weeks after fl strength, excursion, or ROM in a rabbit exor tendon model, with no reseeding. difference at 2, 4, or 8 weeks. Results: Our protocol efficiently removed cellular material from the peri- In contrast to published studies on tendon repair, PRP did not seem to cardium while preserving the structural architecture as well as collagen fl enhance intrinsic tendon healing or minimize scar formation in exor and glycosaminoglycan content. The reseeded construct demonstrated tendon repair. continuous production of HA, the main component of synovial fluid. After

Table 1: Biomechanical Measurement Results Time Day 0 2 Weeks 4 Weeks 8 Weeks Control, Mean Control, Mean PRP, Mean Control, Mean PRP, Mean Control, PRP, Mean Group/measure (Range) (Range) (Range) (Range) (Range) Mean (Range) (Range) Excursion, mm 4.34 (1.72e8.94) 2.32 (0e4.73) 2.02 (0.90e4.77) 1.74 (0e5.32) 1.45 (0e3.17) 2.36 (0e3.75) 3.28 (3.14e3.50) Range of motion (MP), 32 (16e50) 28 (16e50) 34 (14e52) 30 (19e40) 27 (16e34) 30 (22e35) 30 (26e36) degrees Range of motion (PIP), 24 (0e55) 17 (10e28) 19 (13e32) 15 (8e25) 15 (0e28) 14 (0e23) 25 (18e33) degrees Range of motion 52.6 (23e71) 45 (30e67) 53 (28e75) 45 (34e65) 42 (24e57) 44 (33e57) 55 (47e59) (total) Ultimate 8.42 (5.76e11.45) 12.26 (5.82e19.44) 9.48 (6.65e12.51) 12.12 (5.37e17.83) 12.15 (4.66e22.88) 30.18 (16.65e44.21) 34.11 (27.32e38.18) strength, N e10 © Speaker has nothing of financial value to disclose being seeded on the membrane, adipoderived stem cells demonstrated Summary: downregulation of collagen I and III while upregulating hyaluronan syn- The differentiated state of human tenocytes is maintained in a low oxygen thase 2. environment, such as that which exists in the joint or the tendonebone Summary: interface (enthesis). Porcine pericardium can be decellularized and reseeded with different Human tenocytes dedifferentiate when grown in normoxic conditions. types of cells. Dedifferentiated tenocytes regain their phenotype when grown in hypoxic It may act as an inductive template for seeded cells and may lead to conditions. changes in phenotypes and induction of HA production. High Rac1 and low RhoA activity is necessary for tenocyte rediffer- Porcine pericardium is a potential scaffold for engineering a biologically entiation to occur. active human tendon sheath. Knowledge of the intracellular signaling pathways required for tenocyte differentiation lends insight to tissue engineering strategies for tenocyte Contracted Research: Multiple federal grants (J.C.) propagation, and thus tendon regeneration. Royalties/Honoraria received from: grant from VA Rehabilitation Research and Development Merit Review Grant (C.W.); Elsevier (J.C.) REFERENCES Consulting Fees (eg, advisory boards) received from: Tendon Bone 1. Zhao et al. SICOT. 2011;35:925e928. Innovations; Zone 2 Surgical (J.C.) 2. Schulze-Tanzil et al. Histochem Cell Biol. 2004;122:219e228. Intellectual Property Rights/Patent Holder: Patent for Decellularized 3. Rankin et al. Curr Osteoporos Rep. 2011;9:46e52. Tendon-Bone Constructs (J.C.) 4. Turcotte et al. J Cell Sci. 2003;116:2247e2260. Other Financial Relationships: Grant support received from VA RR&D Contracted Research with: Auxilium Merit Review Grant VA-FF4382R (A.K.) Royalties/Honoraria received from: Elsevier Consulting Fees (eg, advisory boards) received from: Medartis, Auxilium, Arthrex PAPER 14 Receipt of Intellectual Property Rights/Patent Holder with: Medartis, Clinical Paper Session 2: Tendon—Basic Science Biomet Friday, October 4, 2013 9:15e 9:21 AM Category: Basic ScienceeLab Research PAPER 15 Keyword: Hand Clinical Paper Session 2: Tendon—Basic Science Hypoxia Drives Tenocyte Differentiation Friday, October 4, 2013 9:25e9:31 AM Not a clinical study Category: Basic ScienceeLab Research © Rowena McBeath, MD, PhD Keyword: Hand © Andrzej Fertala, PhD Decellularized Human TendoneBone Grafts for Composite © Makarand Risbud, PhD Flexor Tendon Reconstruction © Irving Shapiro, PhD Not a clinical study Lee Osterman, MD © Paige M. Fox, MD, PhD Hypothesis: Oxygen content in connective tissues varies. At the ten- © Simon Farnebo, MD, PhD donebone interface, oxygen levels are low.1 Interestingly, human tenocytes © Derek P. Lindsey, MS lose their phenotype when cultured repeatedly in normal (normoxic) oxygen © Julia Chang tension in vitro.2 Given the low oxygen levels in the region of the tendon as Taliah Bosque, MD it joins the enthesis in vivo,3 we hypothesized that oxygen content may be James Chang, MD responsible for tendon cell differentiation in vitro. Furthermore, given that oxygen levels affect activity of the Rho family of small GTPases,4 we Hypothesis: Restoration of biomechanical strength after surgical reconstruc- hypothesized that oxygen tension drives tenocyte differentiation through tion of tendon insertion tears is challenging because these injuries typically differential activity of RhoA and Rac1 GTPase. heal as fibrous scars. In addition, tendon injuries or tendon loss along the Methods: Normal and dedifferentiated human tendon cells were grown entire flexor tendon sheath creates a challenge for hand surgeons. We in normoxic (atmospheric) and hypoxic (1%) oxygen concentrations. hypothesized that decellularized human flexor digitorum profundus (FDP) Cells were harvested at varying times and analyzed for markers of and distal phalanx tendonebone grafts could be used as a potential option tenocyte differentiation by immunofluorescence and reverse-transcriptione for flexor tendon reconstruction by replacing the entire injured zone. We polymerase chain reaction of collagen I, tenomodulin, and scleraxis. hypothesized that tendon, bone, and tendonebone interface strength would Cells were also harvested for RhoA and Rac1 activity to examine whether remain comparable to native constructs and would exceed the strength the Rho family of small GTPases affected the differentiation choice. necessary for postoperative rehabilitation. Pharmacologic inhibition of RhoA or Rac1 activity was performed via Methods: Paired human cadaver forearms were dissected to obtain the FDP administration of the ROCK inhibitor Y-27632 or Rac1 inhibitor tendon with an attached block of distal phalanx. Tendons were then pair- NSC23766 to tenocytes in normoxic conditions. matched from each arm and digit and divided into 2 groups: decellularized Results: Human tenocytes grown in normoxic conditions dedifferentiated in (group 1) and untreated (group 2). Grafts in group 1 were subjected to culture, whereas those grown in hypoxic conditions retained the tenocyte physiochemical decellularization according to a previously described phenotype, as seen by collagen I immunofluorescence as well as reverse- protocol. Pair-matched tendons, decellularized and untreated, were placed transcriptionepolymerase chain reaction of collagen I, tenomodulin, and back into the flexor tendon sheath. Distally, the distal phalanx bone block scleraxis. Interestingly, culture of dedifferentiated tenocytes in hypoxic was secured to the host distal phalanx using a tie-over button. Proximally, conditions reversed the dedifferentiated phenotype, causing increased the FDP was woven into the flexor digitorum superficialis tendon in the collagen I, tenomodulin, and scleraxis expression in human dedifferentiated distal forearm. Each construct was cycled and then pulled to failure on a tenocytes. Furthermore, examination of the signaling pathways responsible custom rig using a materials testing system. The strength (ultimate failure for tenocyte redifferentiation revealed high Rac1 activity but low RhoA load) of repair, stiffness, and location of failure were determined. Statistical activity to be key determinants of the tenocyte differentiated state. Simi- analysis was completed using paired Student’s t-test. larly, pharmacologic inhibition of Rac1 but not RhoA activity decreased Results: Decellularized tendonebone grafts in group 1 demonstrated no tenogenic differentiation. significant difference in ultimate failure load compared with untreated grafts

© Speaker has nothing of financial value to disclose e11 in group 2 (67.8 19.7 vs 78.1 27.1 N, respectively; P ¼ .3). Both 65 19 N, P ¼ .250, vs 76 N native), although with a decreased relative groups failed in various locations along the repair. The most common site strength: UTS (4 1.6 and 2.8 0.7 N/mm2, P ¼ .040 vs10 N/mm2 of failure in both groups was at the tie-over button. Both groups demon- native). At 12 weeks, both TBI grafts and pullout repairs had regained strated an average tendon excursion of 82 mm before failure. Micro- stiffness equal to native tissue (18.5 5.1 and 16.6 3.9 N/mm2, P ¼ .380 computed tomography imaging demonstrated an intact dorsal cortex and vs 18 N/mm2 native). joint surface of the distal phalanx after dissection, decellularization, and Histology showed a more organized extracellular matrix in the TBI graft repair. group at the early time points. Repopulation of the decellularized grafts Summary: increased over time. At 12 weeks, the insertion point was richly populated Decellularization of human flexor tendonedistal phalanx tendonebone with morphology similar to that in the native tissue. grafts does not compromise strength. Summary: Bony architecture is maintained despite chemical and mechanical Decellularized TBI grafts are stronger (UFL) compared with conventional decellularization. pullout repairs at 2 and 4 weeks. Decellularized flexor tendonebone grafts can exceed the strength and Decellularized TBI grafts and pullout repairs are as strong as and have excursion needed for hand therapy after reconstruction. stiffness equal to native tissue after 12 weeks. Tissue-engineered decellularized human tendonebone grafts show A more organized extracellular matrix and different collagen composition promise as an option for complex reconstruction in hand surgery. in the early time points may explain the differences in strength at early time points. Contracted Research: Bourse De La Fondation Pour La Recherche In the future, tissue-engineered TBI grafts may be used to repair complex e Medicale Master 2 (Bosque); Multiple Federal grants (J.C.) TBI tears in the flexor tendon, as well as other tendon and ligament Royalties/Honoraria received from: Elsevier (J.C.) injuries in the hand. Consulting Fees (eg, advisory boards) received from: Tendon Bone Innovations; Zone 2 Surgical (J.C.) Receipt of Intellectual Property Rights/Patent Holder with: Patent for Decellularized Tendon-Bone Constructs (J.C.) Other Financial Relationships: VA Medical Merit Review Award and VA Rehabilitation R&D Merit (T.B.)

PAPER 16

Clinical Paper Session 2: Tendon—Basic Science Friday, October 4, 2013 9:35e9:41 AM Category: Basic ScienceeLab Research Keyword: Hand Reconstruction of the TendoneBone Insertion Is Stronger With Decellularized TendoneBone Composite Grafts Compared to Conventional Pullout Repairs—An Experimental Study in Rats Not a clinical study © Simon Farnebo, MD, PhD Colin Y. L. Woon, MD © Maxwell Y. Kim, BS James Chang, MD

Hypothesis: Flexor tendon injuries involving the tendonebone insertion (TBI) are difficult to address. Standard techniques typically lead to diminished strength of the healed insertion site. We hypothesized that these injuries would benefit from being reconstructed with decellularized composite grafts. To test this hypothesis, decellularized composite grafts (TBI grafts) were compared with conventional pullout repairs in an in vivo animal model. Methods: Forty-eight Wistar composite TBI grafts (Achillesecalcaneus tendon insertion) were harvested. Grafts were physicochemically decellu- larized according to a previously described protocol. Tendonebone inser- tion graft and pullout reconstructions of Achilles tendon detachment from the calcaneus insertion were compared using a pair-matched design (Figs. 1, 2). The ultimate failure load (UFL), ultimate tensile stress (UTS), and stiffness were evaluated using a materials testing system at 2, 4, 8, and 12 weeks. Histological analysis of insertion morphology and cellular infiltration was evaluated after death. Statistical analysis of biomechanical data was performed using a paired Student’s t-test. Results: There was a significant increase in UFL (35 11 vs 24 7N; Contracted Research with: Multiple federal grants P ¼ .030) and UTS (1.5 0.3 vs 1.0 0.4 N/mm2; P ¼ .030) of Royalties/Honoraria received from: grant from VA Rehabilitation the TBI grafts compared with pullout repairs at 2 weeks. These Research and Development Merit Review Grant (C.Y.L.W.); Elsevier differences remained at 4 weeks; UFL (54 17 vs 43 19 N; P ¼ .046), (J.C.) UTS (2.9 1.0 vs 2.0 0.7 N/mm2; P ¼ .030). At 12 weeks, both TBI Consulting Fees (eg, advisory boards) received from: Tendon Bone grafts and pullout repairs were as strong as native tissue UFL (75 16 and Innovations; Zone 2 Surgical (J.C.)

e12 © Speaker has nothing of financial value to disclose Receipt of Intellectual Property Rights/Patent Holder with: Patent for those with a traumatic etiology, while having a lower incidence of Decellularized Tendon-Bone Constructs (J.C.) complications. The degree of improvement seen would provide near-full restoration of functional motion and minimal limitations in activities of daily living.4 PAPER 17

Clinical Paper Session 3: Shoulder/Elbow Friday, October 4, 2013 10:30e10:36 AM Category: Multiple Trauma Keyword: Elbow Outcomes of Anconeus Interposition for Proximal Radioulnar Synostosis Level 4 Evidence © Joseph J. Schreiber, MD © Aaron Daluiski, MD © Sophia Paul, BA Robert N. Hotchkiss, MD

Hypothesis: Proximal radioulnar synostosis after elbow injuries can pro- duce debilitating contractures.1e3 The arc of pronation-supination required for performing many activities of daily living is 100:50 of both pronation and supination.4 We hypothesized that excision of heterotopic bone and anconeus flap interposition could restore and maintain at least 100 of pronoation-supination in patients with proximal radioulnar REFERENCES synostosis. 1. Jupiter JB, Ring D. Operative treatment of post-traumatic proximal radioulnar Methods: A retrospective database review from 1997 to 2011 was performed synostosis. J Bone Joint Surg Am. 1998;80(2):248e257. to identify patients treated with proximal radioulnar synostoses. Patients 2. Bell SN, Benger D. Management of radioulnar synostosis with mobilization, were subdivided into 2 main categories based on etiology; after biceps anconeus interposition, and a forearm rotation assist splint. J Shoulder Elbow tendon repair or repair of complex proximal forearm trauma. All patients Surg. 1999;8(6):621e624. underwent excision of the synostosis through a posterior approach as 3. Henket M, van Duijn PJ, Doornberg JN, Ring D, Jupiter JB. A comparison of described by Pankovich,5 and interposition of an anconeus flap. Clinical proximal radioulnar synostosis excision after trauma and distal biceps reat- tachment. J Shoulder Elbow Surg. 2007;16(5):626e630. follow-up and motion assessment were performed by the operative surgeon. ’ 4. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional Student s t-test was used to compare mean motion preoperatively and elbow motion. J Bone Joint Surg Am. 1981;63(6):872e877. postoperatively. 5. Pankovich AM. Anconeus approach to the elbow joint and the proximal part of Results: A total of 25 patients (16 male and 9 female) were included, with a the radius and ulna. J Bone Joint Surg Am. 1977;59(1):124e126. mean age of 46 years and mean clinical follow-up of 33 months. Mean arc of motion improved from 19 to 127 , pronation increased from 11 to 64 , Contracted Research with: Auxilium Pharmaceuticals, Inc. and supination increased from 8 to 62 (P < .0001) (Fig. 1). Patients with biceps tendon rupture (n ¼ 8) had larger but not significantly greater im- provements than those with a traumatic etiology (n ¼ 17) (Fig. 2). Com- PAPER 18 plications included hematoma formation in 3 patients, 2 of whom required Clinical Paper Session 3: Shoulder/Elbow operative evacuation. Friday, October 4, 2013 10:40e10:46 AM Summary: Category: Nerve/Neuromuscular fl Anconeus interposition ap for management of proximal radioulnar Keyword: Shoulder synostosis produces significant and reliable clinical improvement in elbow arc of motion, pronation, and supination (P < .001). Distal Peripheral Neuropathy After Open and Arthroscopic Consistent with previous reports,3 patients with biceps tendon Shoulder Surgery: An Under-Recognized Complication rupture etiology had a trend toward greater motion improvements than Level 4 Evidence © Benjamin G. Thomasson, DO Luke Austin, MD © Brandon Eck, BS © Jonas L. Matzon, MD

Hypothesis: Shoulder surgery places patients at risk for distal peripheral neuropathy (DPN) owing to surgical positioning, upper extremity manip- ulation, dependent swelling, and sling immobilization. We hypothesized that DPN is a prevalent, yet often overlooked complication after anatomic total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and arthroscopic rotator cuff repair (RCR). Methods: A retrospective case series was performed over a 2-year period. Four fellowship-trained shoulder surgeons performed 57 TSA, 87 RSA, and 758 RCR. The primary outcome measure was the diagnosis of DPN, defined as carpal tunnel syndrome (CTS), cubital tunnel syndrome (CubTS), ulnar tunnel syndrome, and distal radial sensory neuropathy. The diagnosis of DPN was made based on subjective symptoms of numbness, tingling, and/or weakness in the appropriate nerve distribution, with confirmatory physical examination and/or nerve conduction velocity studies. Patient

© Speaker has nothing of financial value to disclose e13 demographics, workers’ compensation claims, onset of symptoms, duration were 8 cases of heterotopic ossification and 2 instances of early hardware of symptoms, resolution of symptoms, and treatment modalities were failure. recorded. Mean follow-up was 21 months for TSA, 15 months for RSA, and Summary: 12 months for RCR. Descriptive statistics were calculated. No significant clinical benefit with ORIF could be found compared with Results: Postoperatively, 10.5% of TSA, 9.2% of RSA, and 3.4% of RCR nonsurgical management of isolated partial articular radial head fractures patients were diagnosed with DPN. The incidence of DPN was significantly with displacement greater than 2 mm but less than 5 mm. higher for shoulder arthroplasty (TSA/RSA) compared with RCR, but there However, the groups were dissimilar in terms of age and fracture was no difference between the types of arthroplasty. Patient age, sex, and displacement. A well-designed randomized trial will provide more in- workers’ compensation claim did not correlate with DPN. The most com- formation as to the best treatment of these fractures. mon form of neuropathy was CubTS/CTS for TSA, CubTS for RSA, and CTS for RCR. After nonsurgical treatment, complete symptom resolution Royalties/Honoraria received from: Wright Medical Techonology, Tor- occurred in 50% of TSA patients at a mean of 197 days, 50% of RSA nier Inc, Tenet Medical Consulting Fees (eg, advisory boards) received from: Tornier Inc., Wright patients at a mean of 255 days, and 65% of RCR patients at a mean of 129 days. However, 17% of TSA patients with DPN, 13% of RSA patients with Medical Technology DPN, and 12% of RCR patients with DPN required surgical treatment of their neuropathy. Eighty percent of the patients undergoing surgical PAPER 20 decompression had complete resolution of symptoms. Summary: Clinical Paper Session 3: Shoulder/Elbow Patients undergoing TSA, RSA, or RCR are at risk for postoperative DPN Friday, October 4, 2013 11:00e11:06 AM and should be counseled about DPN as a potential complication of Category: Arthoscopy surgery. Keyword: Elbow Although most DPN resolves postoperatively, a subset of patients will require surgical decompression. Nerve Injuries Following Elbow Arthroscopy Consulting Fees (eg, advisory boards) received from: Tornier. Level 4 Evidence © Sameer Lodha, MD © Suhail K. Mithani, MD PAPER 19 © Ramesh C. Srinivasan, MD Marc J. Richard, MD Clinical Paper Session 3: Shoulder/Elbow e Fraser J. Leversedge, MD Friday, October 4, 2013 10:50 10:56 AM © David S. Ruch, MD Category: Fractures and Dislocations Keyword: Elbow Hypothesis: A relatively low incidence of nerve injuries after elbow arthros- A Comparison of Open Reduction Internal Fixation with copy has been reported in the literature. However, multiple case reports have detailed severe nerve injuries after elbow arthroscopy. Clinical experience Nonsurgical Treatment for Displaced Partial Articular with these types of injuries referred to our institution suggests a higher Fractures of the Radial Head incidence of severe nerve injury than previously reported. The purpose of this Level 3 Evidence study was to survey the ASSH membership to determine the nature and Graham J. King, MD, FRCS(C) distribution of nerve injuries treated after elbow arthroscopy. Methods: © Ruby Grewal, MSc, MD, FRSC(C) An online survey was sent to all members of the ASSH under an e © Albert Yoon, MBChB institutional review board approved protocol. Collected data included the number of nerve injuries observed (per nerve) over a 5-year period, the type Hypothesis: The purpose of this study was to test the hypothesis that there is of arthroscopic procedure being performed during the injury, the portal no difference in outcomes for displaced partial articular radial head fractures associated with the injury, the nature of treatment required for the injury, treated with open reduction and internal fixation (ORIF) versus nonsurgical and outcomes observed after any intervention. Responses were anonymous treatment, using validated outcome measures at a minimum of 2 years and results were securely compiled. postinjury. Results: A total of 349 responses were obtained and 190 nerve injuries were Methods: We retrospectively compared patients with isolated, displaced, reported. The most injured nerves reported were the ulnar, posterior inter- partial articular radial head fractures, who received either nonsurgical osseous, and radial nerves (40%, 20%, and 18%, respectively). The pro- treatment or ORIF at our institution. Patients were followed up at a minimum cedures most commonly associated with nerve injury were debridement of of 2 years (mean, 3 y 9 mo) with the Patient-Rated Elbow Evaluation used as osteoarthritis, synovectomy, and capsular release (29%, 19%, and 16%, the primary outcome measure. Evaluation also included the Mayo Elbow respectively). A significant proportion of patients with an injury required Performance Score, the QuickeDisabilities of the Arm, Shoulder, and Hand, operative intervention, including nerve graft, tendon transfer, or nerve repair the 12-item Short Form survey, and a clinical examination for all patients, (22%, 16%, and 12%, respectively). Of patients who sustained an injury, and a radiographic evaluation of the elbow in those who consented. Inclusion 67% had limited or no recovery. criteria were a partial articular radial head fracture that was displaced greater Summary: than 2 mm but less than 5 mm. Patients managed nonsurgically were Nerve injuries are likely under-reported in the literature. encouraged to begin range of motion exercises within 1 week of injury, This study indicates that the number of severe nerve injuries may be whereas those undergoing ORIF were treated with a minimum of 2 coun- much higher than previously thought. tersunk screws and early elbow mobilization. With the expanding practice of elbow arthroscopy, understanding the Results: The 2 groups were similar except for age and fracture displacement. nature and sequelae of significant complications is vital. Twenty-seven patients were treated nonsurgically and were reviewed at a mean of 3 years, and 30 patients were treated with ORIF and were reviewed REFERENCES at a mean of 4.5 years. There was no significant difference in the primary 1. Kelly EW, Morrey BF, O’Driscoll SW. Complications of elbow arthroscopy. J Bone outcome measure (Patient-Rated Elbow Evaluation) between groups, but a e fi Joint Surg Am. 2001;83(A):25 34. signi cant difference was found in the Mayo Elbow Performance Score 2. Ruch DS, Poehling GG. Anterior interosseous nerve injury following elbow ¼ favouring the nonsurgical group (93 vs 86; P .029). In the nonsurgical arthroscopy. Arthroscopy. 1997;13(6):756e758. group, 1 patient developed complex regional pain syndrome and 1 devel- 3. Gupta A, Sunil TM. Complete division of the posterior interossesous nerve after oped heterotopic ossification of the elbow. In the operative group, there elbow arthroscopy: a case report. J Shoulder Elbow Surg. 2004;13(5):566e567. e14 © Speaker has nothing of financial value to disclose 4. Dumonski ML, Arciero RA, Mazzocca ADl. Ulnar nerve palsy after elbow Each groups’ DASH scores improved significantly at both 7 and 28 days arthroscopy. Arthroscopy. 2006;22(5):577.e1e577.e3. compared with baseline. 5. Marti D, Spross C, Jost B. The first 100 elbow arthroscopies of one surgeon: When comparing performance in ADLs required for independence, pa- e analysis of complications. J Shoulder Elbow Surg. 2013;22(4):567 573. tients in both cohorts demonstrated levels of impairment that were not 6. Carofino BC, Bishop AT, Spinner RJ, Shin AY. Nerve injuries resulting from statistically different (Table 1, Fig. 1). arthroscopic treatment of lateral epicondylitis: report of 2 cases. J Hand Surg fi Am. 2012;37(6):1208e1210. Although the salary-related nancial cost to patients is similar in both groups, the ultimate cost of staged unilateral CTR would likely be sub- Contracted Research with: Orthohelix Surgical Designs; Axogen (F.J.L.) stantially higher because a second operation would be required. Royalties/Honoraria received from: Orthohelix Surgical Designs (F.J.L.) Ownership Interest (stocks, stock options, or other ownership interest Table 1: excluding diversified mutual funds) with: Orthohelix Surgical Designs Mean Change in QuickDASH Score at 7 and 28 Days (F.J.L.) Cohort Mean Difference SD P Consulting Fees (eg, advisory boards) received from: Stryker Orthopae- QuickDASH POV1-preoperative Unilateral e4.55 20.95 .923 e dics, OrthoHelix Surgical Designs, Bioventus, Axogen (F.J.L.); Acumed, Bilateral 5.13 23.43 QuickDASH POV2-preoperative Unilateral e17.07 18.39 .042 Synthes, Extremity Medical (M.J.R.). Bilateral e22.88 17.18 PAPER 21 Also see Figure 1.

Clinical Paper Session 4: Value in Hand Surgery Friday, October 4, 2013 10:30e10:36 AM Category: Nerve/Neuromuscular Keyword: Hand Simultaneous Bilateral Versus Unilateral Carpal Tunnel Release: A Prospective Comparison of Early Functional and Economic Impact in Patients With Bilateral Carpal Tunnel Syndrome Level 2 Evidence © Daniel A. Osei, MD Martin I. Boyer, MD, FRCS(C) FPO © Jeffrey Stepan, BS = Richard H. Gelberman, MD © Charles A. Goldfarb, MD © web 4C Ryan Patrick Calfee, MD Figure 1: Mean change in QuickDASH score at 7 and 28 days (also see Hypothesis: The degree of patients’ perceived impairment and loss of income Table 1). during the first month after surgery would be greater in patients undergoing bilateral simultaneous carpal tunnel release (CTR) compared with patients undergoing unilateral CTR. Methods: This prospective, dual cohort study enrolled 85 patients with elec- trophysiological studyeconfirmed bilateral carpal tunnel syndrome; all were candidates for bilateral CTR. Patients were offered a choice of either staged unilateral CTR (n ¼ 40) or bilateral simultaneous CTR (n ¼ 45) and completed validated patient self-rated questionnaires (QuickeDisabilities of the Arm, Shoulder, and Hand [QuickDASH] and Levine Katz Symptom Severity scores) preoperatively. After surgery, patients completed a daily log rating difficulty with activities of daily living (ADLs) for the first 7 post- operative days. The QuickDASH and Levine Katz questionnaires were administered again at 7 and 28 days after surgery. To determine income loss, patients completed a validated survey detailing the salary-equivalent costs of lost time at work at 28 days’ follow-up. This study was powered (a ¼ 0.05, b

¼ 0.9) to detect a clinically meaningful difference in QuickDASH and Levine FPO = Katz scores using appropriate parametric and nonparametric analysis. Results: There was no significant difference in DASH score between groups ’ at baseline and 7 and 28 days follow-up (Table 1, Fig. 1). In addition, web 4C QuickDASH scores were significantly improved from baseline in both Figure 2: Patient-reported activity of daily living log; activities required groups at 7 and at 28 days. Mean ADL scores were not significantly different for independence. during the first week after surgery. Patients who underwent bilateral CTR had fi no greater levels of dif culty with activities required for independent living REFERENCES (bathing, dressing, eating, or self-care) at all time points (Fig. 2). A total of 27% of patients in the unilateral group required assistance with personal 1. Atroshi I, Gummesson C, Johnsson R, et al. Prevalence of carpal tunnel syn- e hygiene, compared with 36% in the bilateral group (P ¼.7). At 1 month after drome in a general population. JAMA. 1999;281(2):153 158. 2. Bagatur AE, Zorer G. The carpal tunnel syndrome is a bilateral disorder. J Bone surgery, patients undergoing bilateral CTR demonstrated no greater number Joint Surg Br. 2001;83(5):655e658. of days out of work compared with unilateral CTR patients. 3. Padua L, Padua R, Nazzaro M, Tonali P. Incidence of bilateral symptoms in Summary: carpal tunnel syndrome. J Hand Surg Br. 1998;23(5):603e606. Patients treated with simultaneous bilateral CTR have no greater short- 4. Wang AA, Hutchinson DT, Vanderhooft JE. Bilateral simultaneous open carpal term impairment compared with patients who elect to undergo unilateral tunnel release: a prospective study of postoperative activities of daily living and CTR as part of a planned staged release. patient satisfaction. J Hand Surg Am. 2003;28(5):845e848.

© Speaker has nothing of financial value to disclose e15 5. Huracek J, Heising T, Wanner M, Troeger H. Recovery after carpal tunnel syn- In this situation is (electrodiagnostic testing) energy-dispersive x-ray drome operation: the influence of the opposite hand, if operated on in the (EDX) needed ALSO: same session. Arch Orthop Trauma Surg. 2001;121(7):368e370. Never/rarely: 46.6%; sometimes: 21.5%; usually/always: 31.9%. 6. Pagnanelli D, Barrer S. Bilateral carpal tunnel release at one operation: report of Association between responses to these questions, chi-square: P < .001. 228 patients. Neurosurgery. 1992;31(6):1030e1034. (Table 1) 7. Weber RA, Boyer KM. Consecutive versus simultaneous bilateral carpal tunnel release. Ann Plast Surg. 2005;54(1):15e19. Regarding how often CTR was performed in addition to classic his- 8. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the tory/exam: arm, shoulder and hand questionnaire (QuickDASH): validity and reliability Normal EDX: never/rarely: 62.3%; sometimes: 31.8%; usually/al- based on responses within the full-length DASH. BMC Musculoskel Disord. ways: 5.9%. 2006;7:44. Normal EDX, no improvement after injection: 9. Levine DW, Simmons BP, Koris MJ, Daltroy LH, et al. A self-administered never/rarely: 80.5%; sometimes: 14.9%; usually/always: 4.6%. questionnaire for the assessment of severity of symptoms and functional One cortisone injection completely helps, normal EDX: status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993;75(11): never/rarely: 41.1%; sometimes: 34.5%; usually/always: 24.5%. 1585e1592. Are you more likely to order EDX based on AAOS Guidelines Contracted Research: PI on NIH grant, Barnes-Jewish Hospital Founda- (Fig. 1): tion (R.H.G.) Never/rarely: 36.1%; sometimes/usually/always: 63.9%. Royalties/Honoraria received from: Medartis (Gelberman); Wolters If yes, is this because of potential medicolegal ramifications: Kluwer (R.H.G., C.A.G.) Yes: 57.3%; no: 42.7% (P < .001) Ownership Interest (stocks, stock options, or other ownership interest Regarding expectation of complete symptom resolution within 2 years excluding diversified mutual funds) with: OrthoHelix, LLC, MiMedX, after CTR: LLC (M.I.B.). If constant symptoms prior, and complete resolution after injection: Consulting Fees (e.g. advisory boards) received from: MiMedX LLC, Never/rarely/sometimes: 25.9%; usually/always: 74.1%. OrthoHelix LLC (M.I.B.) If constant symptoms, EDX “no response,” no improvement after Other Financial Relationships: Synthes (M.I.B.) injection: Never/rarely: 44.3%; sometimes: 40.8%; usually/always: 15.0%. PAPER 22 Are you able to predict whether complete resolution: Never/rarely: 12.2%; sometimes: 34.8%; usually/always: 53.0%. Clinical Paper Session 4: Value in Hand Surgery Summary: Friday, October 4, 2013 10:40e10:46 AM Most respondents were more likely to order EDX based on AAOS Category: Nerve/Neuromuscular Guidelines. Keyword: Hand A total of 57.3% were because of potential medicolegal ramifications. Carpal Tunnel Syndrome: Current Trends in Diagnosis, Despite guidelines recommending EDX before surgery, most reported: fi Treatment, and Prognosis Positive response to cortisone injection is suf cient indication for CTR Not a clinical study Use of EDX is not necessary in these cases © Mikael Starecki, MD Would perform CTR in face of normal EDX, if cortisone helped © Ashley Olson, MD completely. © Nina Kohn, PhD © Lewis B. Lane, MD Table 1: Treatment for Carpal Tunnel Syndrome Hypothesis: Evidence supporting select AAOS carpal tunnel syndrome Never/ Usually/ guidelines was not consistently from high-level studies, and some recom- Rarely Sometimes Always Total P mendations were controversial. The investigators postulated that a survey of 1. (Question 9) In addition 175 228 224 627 ASSH members would provide insight into: to supporting history 1. Practice patterns among surgeons treating carpal tunnel syndrome and examination, a 2. The extent to which concern about medicolegal ramifications resulting cortisone injection to from the guidelines influences practice behavior. temporarily resolve symptoms is sufficient Methods: A questionnaire of 28 questions, including detailed, commonly for indication for surgery? observed clinical scenarios (demographics: 6; workup/indications: 15; 2. (Question 11) In addition 292 135 200 627 prognosis: 7), was developed, pretested, and approved by institutional re- to the above, an view board and ASSH Web site chair. Anonymous electronic survey was electrodiagnostic study emailed to ASSH members. Comparisons between demographic factors and is ALSO needed for responses and between pairs of responses were made using chi-square test indication for surgery? or Fisher’s exact test, as appropriate. 3. People who responded 62 (21.2%) 87 (29.8%) 143 (49.0%) < .0001 Results: Of 3,001 members identified as eligible, 301 were self-screened, never/rarely to question 2,650 e-mailed surveys, and 5 declined; 714 responded within 8 weeks. 11 responded to question 9 with the following Primary specialty: orthopedics: 78.8%, plastics: 13.2%, and other: frequencies. 7.7%. 4. People who responded 25 (18.5%) 66 (48.9%) 44 (32.6%) < .0001 Years in practice: 67.9% were greater than 10 years. to question 11 responded Carpal tunnel releases (CTR) performed “last year”: 0 to 25: 11.8%; to question 9 with the 26 to 50: 17.6%; 51 to 100: 32.1%; and greater than100: 38.3%. following frequencies. Questions asked: 5. People who responded 88 (44.0%) 75 (37.5%) 37 (18.5%) < .0001 Is there sufficient justification to indicate CTR (in addition to classic usually/always to question history/exam): 11 responded to question When complete relief after cortisone injection: 9 with the following frequencies. Never/rarely: 27.9%; sometimes/usually/always: 72.1%.

e16 © Speaker has nothing of financial value to disclose Summary: Carpal tunnel surgery can have devastating consequences. Most patients improve after revision CTR, but a methodical approach to diag- nosis and adherence to safe surgical principles are critical to success. Symptom classification, number of prior CTR, baseline pain, pain medi- cations, and workers’ compensation status are important predictors of pain outcomes in this population. REFERENCE

1. Tung TH, Mackinnon SE. Secondary carpal tunnel surgery. Plast Reconstr Surg. 2001;107(7):1830e1843.

PAPER 24

Clinical Paper Session 4: Value in Hand Surgery Friday, October 4, 2013 11:00e11:06 AM Category: Congenital/Pediatric Keyword: Hand Fanconi Anaemia: Examining Guidelines for Testing All Patients With Radial Ray or Thumb Anomalies Level 3 Evidence © Anthony G. Barabas, FRCS (Plas) © REFERENCES Gillian D. Smith, FRCS (Plas)

1. American Academy of Orthopaedic Surgeons. Clinical guideline on diagnosis Hypothesis: Do all patients with thumb or radial ray anomalies, without a of carpal tunnel syndrome. http://www.aaos.org/Research/guidelines/CTS_ causative genetic disorder known, need referral to a geneticist (cost: £500/ guideline.pdf. $752 US) or directly for peripheral blood chromosome breakage testing 2. Keith MW, Masear V, Amadio P, et al. AAOS Clinical Practice Guideline summary. (PB-CBT) (cost: £282/$439 US) to screen for Fanconi Anaemia (FA), as J Am Acad Orthop Surg. 2009;17(6):397e405. suggested by the new United Kingdom guidelines released in 2008? 3. American Academy of Orthopaedic Surgeons. Treatment of carpal Methods: Over 3 years (January 1, 2009 to December 31, 2011), 169 patients tunnel syndrome: evidence report. http://www.aaos.org/research/guidelines/ from all departments at Great Ormond Street Hospital were tested for CTSTreatmentEvidenceReport2.pdf. FA by dieponybutane PB-CBT. Features that had precipitated testing in each PAPER 23 case were examined. Over the same period, 195 new patients were referred to the congenital hand service with a new diagnosis of a thumb or radial ray Clinical Paper Session 4: Value in Hand Surgery anomaly, only 9 of whom were referred directly for PB-CBT. e Friday, October 4, 2013 10:50 10:56 AM Results: Contrary to the guidelines, only 5% (n ¼ 9) of the 195 patients Category: Nerve/Neuromuscular seen in the congenital hand department were referred on for PB-CBT, 1 Keyword: Hand of whom (0.005%) was positive for FA. No other patient developed FA. Revision Carpal Tunnel Surgery: A 10-Year Review of Adherence to the new guidelines would produce £93,000/$140,000 in Intraoperative Findings and Outcomes costs for genetic outpatient referrals, or £52,452/$81,700 in direct PB-CBT referrals. Of the169 patients referred for PB-CBT, 43 (25%) had Level 4 Evidence upper limb anomalies. These included thumb hypoplasia (n ¼ 17), thumb © Kristen M. Davidge, MD, MSc duplications (n ¼ 14), and radial ray dysplasia (n ¼ 11). Other features © Lawrence Zieske, BA that precipitated testing were noneupper limb skeletal anomalies (n ¼ 16), © Gregory C. Ebersole, MSc craniofacial anomalies (n ¼ 49), short stature (n ¼ 20), abnormal © Ida Fox, MD skin pigmentation (n ¼ 39), visceral abnormalities (n ¼ 20), and blood © Susan E. Mackinnon, MD dyscrasias/anemia (n ¼ 40). Of the 169 patients, 13 (8%) were positive for FA. Three FA positive Hypothesis: This study sought to evaluate intraoperative findings and out- patients had upper limb anomalies: 1 with bilateral radial ray dysplasia and comes of revision carpal tunnel release (CTR), and to identify predictors of 2 with thumb duplications (1 bilateral and 1 unilateral). However, all 3 pain outcomes. patients had other serious visceral, skeletal, or hematological anomalies, all Methods: A retrospective cohort study was performed of all adult patients of which were features found to have a far greater association with FA than undergoing revision CTR (2001e2012). Patients were classified according upper limb anomalies (hand anomaly: 23%; microcephaly: 31%; short to whether they presented with persistent, recurrent, or new symptoms.1 stature: 31%; consanguity: 39%; renal/cardiac abnormalities: 46%; Study groups were compared on baseline characteristics, intraoperative abnormal skin pigmentation: 46%; and blood dyscrasia: 62%). findings, and outcomes (strength and pain). Within each group, changes in Conclusions: None of the 13 positive FA patients had an isolated upper limb postoperative pinch, grip strength, and pain from baseline were analyzed. anomaly in the absence of other FA features. The guidelines add consid- Predictors of postoperative average pain were examined using both multi- erable extra cost to patients with thumb or radial ray anomalies, and add variable linear regression analyses and univariable logistic regression to significant financial and clinical service implications. This study does not calculate odds ratios of worsened/no change in pain. support FA testing for isolated radial ray or thumb anomalies in the absence Results: Revision CTR was performed in 97 extremities (87 patients). of other concerning features. Symptoms were classified as persistent in 42 hands (43%), recurrent in 19 (20%), and new in 36 (37%). The recurrent group demonstrated more diabetes REFERENCES and a longer interval from primary CTR, and was less likely to present with 1. http://www.fanconi.org.uk/wp-content/uploads/2008/07/fanconi-anaemia-standards- ¼ pain (p1 prior CTR (P .015) had higher odds of worsened/no change in of-care-280209-online-v111.pdf. postoperative pain. Higher preoperative pain (P ¼ .008), use of pain medi- 2. http://www.fanconianaemia.nhs.uk. cation (P ¼ .002), and workers’ compensation (P ¼ .033) were significant 3. http://www.fanconi.org.uk/wp-content/uploads/2008/03/fanconi-anaemia-final- predictors of higher postoperative average pain in multivariable analyses. poster.pdf.

© Speaker has nothing of financial value to disclose e17 PAPER 25 ossification of the capitate in particular, with catch-up growth after release of the third web. We also noted the timing of the radiological appearance of Clinical Paper Session 5: Congenital/Pediatric symphalangism and fourth/fifth metacarpal synostosis and incidence of e Friday, October 4, 2013 1:00 1:06 PM abnormal radial angulation of the index finger and the little finger ulnarly. Category: Congenital/Pediatric Capito-hamate fusion and a diamond-shaped configuration were common Keyword: Other among our patients, and we believe that there may be a correlation with Results of Treatment of Delta Triphalangeal Thumbs by delayed release of the third web syndactyly. Excision of the Extra Ossicle Summary: Consistent findings of delayed ossification of the capitate and evidence of proximal migration of the third metacarpal, taken together with Level 4 Evidence © Angela A. Wang, MD © Douglas T. Hutchinson, MD

Hypothesis: We aimed to examine the results of treatment of delta tripha- langeal thumbs by excision of the delta ossicle alone. We hypothesized that these thumbs would have good range of motion (ROM) and no pain at the interphalangeal (IP) joint in the long term. Methods: We retrospectively reviewed charts to identify study patients who had Woods type I delta triphalangeal thumbs, and who underwent treatment by excision of the extra ossicle. These patients were then called in pro- spectively for examination, measurement of ROM, and radiographs. Results: We identified 21 thumbs in 14 patients. All patients but 1 who had bilateral thumb involvement were treated at the same surgery. The average age at surgery was 26 months (range, 5e69 mo). Seven patients had an additional congenital anomaly that minorly affected the surgical thumb. Only 2 patients had tip radial angulation preoperatively, averaging 52. The other 19 thumbs were deviated tip ulnarly with an average preoperative angulation of 40 (range, 20 to 85). All patients had an IP pin placed for an average of 4.5 weeks, and 16 thumbs had collateral ligament repair at the time of surgery. The average follow-up was 4.7 years (range, 1 mo t 17 y). Average ROM at final follow-up was less than 1 extension (range, 0 to 5)to52 flexion (range, 20 to 82). Average clinical angulation was less than 1 (range, 0 to 10) and average radiographic angulation was 6 (range, 0 to 25). There were no reports of pain and 1 patient had persistent IP instability. Summary: Delta triphalangeal thumbs treated by excision of the extra ossicle can be expected to yield good results with acceptable thumb IP ROM and no pain. Clinical appearance of the thumb with regard to angulation tends to be superior to radiographic findings.

PAPER 26

Clinical Paper Session 5: Congenital/Pediatric Friday, October 4, 2013 1:10e1:16 PM Category: Congenital/Pediatric Keyword: Hand In Apert Syndrome Is Timing of Surgical Release of Third Web Syndactyly Important? Level 3 Evidence © Sharon Leigh Kracoff, Jr. © Gillian D. Smith, MD, FRCS (Plas)

Hypothesis: Kim et al1 postulated that delayed release of the complex syn- dactyly of the third web in Apert syndrome patients causes compression on epiphyses, with early epiphyseal closure, leading to symphalangism and reduced capitate ossification. Those authors examined 7 patients. We wanted to see whether we could demonstrate this in a larger set of patients. Methods: We reviewed radiographs of 44 patients (77 hands) with Apert syndrome admitted to our department, between 1992 and 2012 for syndactyly release. Patients underwent surgical release in a staged fashion with the third web release left until last. Using the same methodology, we measured the size of the capitate ossification center relative to that of the hamate and determined the relative position of the middle finger metacarpal relative to the ring finger metacarpal. We compared each Apert syndrome hand with 3 different hands

with an age- and sex-matched control of healthy children whose radiographs FPO were taken after minor trauma. = Results: In all of our patients, the middle finger metacarpal radiologically migrated proximally, applying pressure on the carpals. There was a delay in web 4C e18 © Speaker has nothing of financial value to disclose the appearance of catch-up growth after surgical release, add support to the reconstruction. Clinical and radiographic records were reviewed to assess hypothesis that retention of complex syndactyly of the third web in these aesthetic and functional outcomes, the need for additional surgery, and patients creates pressure on the epiphyses that produces a risk of premature radiographic divergence angles. Statistical analysis was performed on all on closure. Accordingly, we speculate that we need to consider earlier release objective data collected comparing the 2 groups. Chi-square variable was of the third web. used for dichotomous variables, and Student’s t-test was used for continuous variables. P < .05 was used for statistical significance. REFERENCE Results: The average age at reconstruction was 15 months for the transverse 1. Kim JH, Rhee SH, Gong HS, Lee HJ, Kwon ST, Baek GH. Characteristic radio- bone group versus 20 months for the nontransverse group. There was no logical features of the central ray in Apert syndrome. J Hand Surg Eur Vol. difference in aesthetic or functional postoperative outcomes. Five hands (2 2013;38(3):257e264. transverse) continued to use the cleft for pinching. Eleven hands (5 trans- verse) had abnormalities of the index MP joint. Eleven hands (4 transverse) required additional surgery to address abnormal function or posture of the PAPER 27 index and ring fingers. Preoperative radiographic divergence angles were larger in the transverse bone group (37 and 45) versus the nontransverse Clinical Paper Session 5: Congenital/Pediatric Friday, October 4, 2013 1:20e1:26 PM group (31 and 32 ), whereas postoperative divergence angles were nearly fi Category: Congenital/Pediatric equivalent. There was no statistically signi cant difference in any objective Keyword: Hand outcome measure between groups. Summary: The Transverse Bone in Cleft Hand: A Case Cohort Analysis The presence of a transverse bone in a cleft hand was not associated with of Outcome After Surgical Reconstruction worse aesthetic or functional outcomes. Level 4 Evidence Early excision of the transverse bone may prevent worsening of the deformity. © Alexander W. Aleem, MD Preoperative narrowing of the thumb web space and postoperative © Lindley Wall, MD index finger MP abnormality are associated with worse functional outcomes. © Jennifer Steffen, BA © Mary Claire Manske, MD REFERENCES Charles A. Goldfarb, MD 1. Katarincic JC. Cleft hand. J Am Soc Surg Hand. 2003;3(2):108e116. Hypothesis: A transverse bone in cleft hand is associated with a worse aesthetic 2. Manske PR, Halikas MN. Surgical classification of central deficiency according to and functional outcome compared with hands without a transverse bone. the thumb web. J Hand Surg Am. 1995;20(4):687e697. Methods: This is a retrospective review of 23 hands in 18 patients after surgical 3. Goldfarb CA, Chia B, Manske PR. Central ray deficiency: subjective and objective e reconstruction of cleft hand. Eleven hands had a transverse bone component outcome of cleft reconstruction. J Hand Surg Am. 2008;33(9):1579 1588. (transverse phalanx or bifid metacarpal) and 12 hands did not. Patients and 4. Kallemeier PM, Mankse PR, Davis B, Goldfarb CA. An assesment of the rela- tionship between congenital transverse deficiency of the forearm and sym- their families were contacted to assess overall satisfaction after brachydactyly. J Hand Surg Am. 2007;32(9):1408e1412.

Table 1: Transverse Manske Patient Bone? Side Type Functional limitations Primary Pinch Cleft Use Postoperatively? Index Finger MP Joint 1 N R I None Thumb/index None Normal N L IIA None Thumb/index None Normal 2 Y* L III None Thumb/ring Uses cleft for grasp/scissors Limited extension at MP 3 Y* R IIA None Thumb/index Uses cleft for grasp/scissors Normal occasionally N L IIB None Thumb/index Uses cleft for grasp/scissors Normal occasionally 4 N R IIA None Thumb/index Ulnar deviation, limited extension at MP 5 N R IIA Basketball Thumb/index None Laxity at MP 6 N R IIA None Thumb/index None Normal 7 Y R IIB None Thumb/index None Limited flexion at MP 8 Y R IIA Difficulty with coins, snaps, Thumb/index None Normal tying shoes YLIDifficulty with coins, snaps, Thumb/index with ring for None Ulnar deviation at MP tying shoes stabilization 9 N R I None Thumb/index Use cleft for large objects Radial deviation at MP 10 N R III None Thumb/index None Radial deviation at MP Y* L IIB None Thumb/index None Normal 11 Y* R I None Thumb/index None Radial deviation at MP 12 Y R IIA None Thumb/index None Ulnar deviation, limited extension at MP 13 Y R I None Thumb/index None Normal 14 N L IIA None Thumb/index, thumb/ring finger None Normal for fine grasp 15 Y L III None Thumb/index None Radial deviation at MP 16 Y R III None Cleft Uses cleft for Laxity at MP 17 N R IIA None Thumb/index None Ulnar deviation, laxity at MP 18 N R IIB None Thumb/index None Radial deviation at MP Y L IIB None Thumb/index None Not addressed *Bifid metacarpal.

© Speaker has nothing of financial value to disclose e19 Nontransverse Bone Group Methods: We compared 13 upper extremities treated with notched centrali- zation alone against 13 upper extremities treated with ring fixator distrac- Metacarpal Divergence Phalangeal Divergence tion followed by centralization (distraction group). Patients were matched Angle, Degree Angle, Degree Final Final by Bayne and Klug type. We reviewed records for resting wrist position at fi Patient Side Preoperative Postoperative Preoperative Postoperative preoperative, postoperative, and nal follow-up appointments. Radiographs 1 R 18 15 18 16 were reviewed for handeforearm angle (HFA), handeforearm position, 1 L 20 10 23 10 volar subluxation, and ulnar length. Student’s t-test was used to compare 2 L 15 12 20 15 continuous variables, and chi-square test to compare categorical variables. 3 L 15 12 18 0 Results: In both groups, clinical resting wrist position improved significantly 4 R 55 30 42 25 from preoperative values to postoperative and final follow-up. The final 5 R 20 12 24 12 wrist position, however, was in significantly more radial deviation in the 6R558 508 distraction group (P ¼ .04). The resting wrist position in the centralization- 9 R 15 15 55 20 10 R 50 25 60 20 only group improved from 83 radial deviation preoperatively to 18 fi 14 L 37 24 42 24 postoperatively and worsened to 22 at nal follow-up. In the distraction 17 R 50 12 20 10 group, the resting position improved from 87 radial deviation preopera- 18 R 22 25 13 25 tively to 29 postoperatively and worsened to 43 at final follow-up. Average 31 17 P ¼ .013 32 15 P ¼ .004 Radiographically, there was a significant improvement in HFA in both *Bifid metacarpal. groups at final follow-up, even though both groups developed recurrence from postoperative to final follow-up. Handeforearm angle in the central- ization-only group improved from 53 preoperatively to 13 postoperatively Transverse Bone Group and worsened to 27 at final follow-up. In the distraction group, HFA Metacarpal Divergence Angle Phalangeal Divergence Angle improved from 53 preoperatively to 13 after distraction; HFA remained Final Final improved at 21 postoperatively but worsened to 36 at final follow-up. The Patient Side Preoperative Postoperative Preoperative Postoperative difference in HFA between groups at final follow-up was not significant. 3* R 37 15 34 15 There were no significant differences between groups in mean ulnar length 7* R 48 17 55 17 or ulnar length compared with age- and gender-matched controls. 8 R 25 10 65 15 Summary: 8 L 32 12 28 12 fi 10* L 45 20 45 15 Precentralization distraction with a ring xator facilitates a tensionless 11* R 40 0 35 0 centralization compared with centralization alone. 12 R 40 10 65 14 Both groups demonstrated a significant improvement in resting wrist 13 R 30 20 25 0 position at final follow-up; however, there was greater recurrence in the 15 L 45 23 40 25 distraction group. 16 R 30 15 75 25 The ulna length was similar between groups, without evidence of ulna 18 L 40 25 23 13 physeal injury in either group. Average 37 15 P < .001 45 14 P < .001 *Bifid metacarpal.

5. Flatt A. Cleft and Central Defects. St. Louis, MO: Mosby; 1977. 6. Wood VE. The treatment of crossbones of the hand. Handchir Mikrochir Plast Chir. 2004;36(2-3):161e165. 7. Rider MA, Grindel SL, Tonkin MA, Wood VE. An experience of the Snow-Littler procedure. J Hand Surg Br. 2000;25(4):376e381. 8. Naruse T, Takahara M, Takagi M, Oberg KC, Ogino T. Busulfan-induced central polydactyly, syndactyly and cleft hand or foot: a common mechanism of disrup- tion leads to divergent phenotypes. Dev Growth Differ. 2008;49(6):533e541. 9. Miura T, Suzuki M. Clinical difference between typical and atypical cleft hand. J Hand Surg Br. 1984;9(3):311e315. 10. Ogino T. Cleft hand. Hand Clin. 1990;6(4):661e671.

Royalties/Honoraria received from: Wolters Kluwer FPO PAPER 28 =

Clinical Paper Session 5: Congenital/Pediatric web 4C Friday, October 4, 2013 1:30e1:36 PM Category: Congenital/Pediatric REFERENCES Keyword: Wrist 1. Goldfarb CA, Murtha YM, Gordon JE, Manske PR. Soft-tissue distraction with a The Effect of Soft Tissue Distraction on the Outcomes of ring external fixator before centralization for radial longitudinal deficiency. J Centralization for Radial Longitudinal Deficiency Hand Surg Am. 2006;31(6):952e959. 2. Smith AA, Greene TL. Preliminary soft tissue distraction in congenital forearm Level 3 Evidence deficiency. J Hand Surg Am. 1995;20(3):420e424. © Mary Claire Manske, MD 3. Nanchahal J, Tonkin MA. Pre-operative distraction lengthening for radial lon- fi e © Jennifer Steffen, BA gitudinal de ciency. J Hand Surg Br. 1996;21(1):103 107. Charles A. Goldfarb, MD 4. Sabharwal S, Finuoli AL, Ghobadi F. Pre-centralization soft tissue distraction for Bayne type IV congenital radial deficiency in children. J Pediatr Orthop. Hypothesis: Children with radial longitudinal deficiency treated with 2005;25(3):377e381. centralization after soft tissue distraction with a ring external fixator have 5. Dana C, Aurégan JC, Salon A, Guéro S, Glorion C, Pannier S. Recurrence of radial better outcomes than children treated with centralization alone. bowing after soft tissue distraction and subsequent radialization for radial longitudinal deficiency. J Hand Surg Am. 2012;37(10):2082e2087. e20 © Speaker has nothing of financial value to disclose 6. Sestero A, Van Heest A, Aqel J. Ulnar growth patterns in radial longitudinal Table 1: Patient Demographic, Surgical, and Postoperative Data deficiency. J Hand Surg Am. 2006;31(6):960e967. 7. Kotwal PP, Varshney MK, Soral A. Comparison of surgical treatment and Time nonoperative management for radial longitudinal deficiency. J Hand Surg Eur Patient/ Age, Since Vol. 2012;37(2):161e169. Side y SCI, y Nerve Transfer(s) Done Complications 8. Danmore E, Kozin SH, Thoder JJ, Porter S. The recurrence of deformity after 1/Left 22 1 Brachialis to AIN None surgical centralization for radial clubhand. J Hand Surg Am. 2000;25(4):745e751. brachialis to FCR/FDS 1/Right 22 1 Brachialis to AIN Minor; hypesthesia Royalties/Honoraria received from: Wolters Kluwer brachialis to FDS thumb 2/Right 31 10 Brachialis to AIN None brachialis to FCR PAPER 29 3/Left 15 3 Exploration; no transfer Insufficient donors done available Clinical Paper Session 6: Nerve 4/Left 47 < 1(7 Brachialis to AIN Major systemic; urosepsis Friday, October 4, 2013 1:40e1:46 PM mo) FCR deltoid to triceps (1 wk postoperatively) 5/Right 22 1.5 Brachialis to AIN Minor; seroma Category: Nerve/Neuromuscular supinator to ECU (drained in office) Keyword: Hand 6/Right 28 12 Brachialis to AIN Major systemic; prolonged Use of Peripheral Nerve Transfers in Tetraplegia: Case Series brachialis to FCR stay owing to concern and Preliminary Results for urinary tract infection Minor; parasthesia thumb Level 4 Evidence 7/Right 34 12 Brachialis to AIN/FDS None © Kristen M. Davidge, MD AIN, anterior interosseous nerve; FCR, flexor carpi radialis; FDS, flexor digitorum © Christine B. Novak, PT, MS superficialis; ECU, extensor carpi ulnaris. © Lorna C. Kahn, PT Patient number, operative extremity, age at time of surgery, time since initial spinal fi © Susan E. Mackinnon, MD cord injury, surgical procedure with speci c nerve transfer(s) performed, and post- operative complications (minimum follow-up of 3 mo postsurgery) are listed. © Ida K. Fox, MD

Hypothesis: Adaptation and use of traditional tendon transfers to improve upper extremity function in cervical spinal cord injury (SCI) patients is limited. We hypothesized that the novel use of peripheral nerve transfers in this setting is feasible and has a low perioperative complication profile. Methods: A prospective clinical outcomes study design was used. After approval from our institutional ethics review board, all patients with cer- vical SCI referred for assessment of upper extremity dysfunction by the Physical Medicine and Rehabilitation Service were recruited for inclusion. Patients were observed for at least 3 months after initial evaluation. De- mographic and medical data (SCI level, comorbidities, previous procedures, and baseline function) were collected. Physical examination and electro- diagnostic testing were performed to establish suitability for possible nerve

transfer procedures. Patients meeting all criteria for a nerve transfer pro- FPO cedure were invited to participate in the study. Data regarding the results of = intraoperative nerve stimulation, procedure performed, and postoperative

complications were collected. web 4C Results: A total of 14 patients (13 male and 1 female) were referred by the Physical Medicine and Rehabilitation Service (12-mo study period) and 11 PAPER 30 were candidates for nerve transfer. To date, 7 patients have had surgical treatment (mean age, 28 9.9 y; mean time from SCI injury, 5.1 5.2 y) Clinical Paper Session 6: Nerve (Table 1). One patient underwent staged bilateral procedures, for a total of Friday, October 4, 2013 1:50e1:56 PM 8 extremities treated. Figure 1 shows a representative schematic of the Category: Nerve/Neuromuscular surgery. All patients had intact volitional biceps and brachialis (with or Keyword: Hand without brachioradialis) to power elbow flexion and no volitional hand function. The nerve to the brachialis muscle was used as the expendable The Supercharge End-to-Side Anterior Interosseous to Ulnar donor in all cases. Recipient nerves included the anterior interosseous Motor Nerve Transfer for Restoring Intrinsic Function: nerve, to restore volitional prehension, as well as nerve branches to the Clinical Experience flexor carpi radialis and flexor digitorum superficialis. Two patients un- Level 4 Evidence derwent additional nerve transfers: 1 had supinator to extensor carpi © Kristen M. Davidge, MD ulnaris; the second had deltoid to triceps. Table 1 presents the procedure(s) © Susan E. Mackinnon, MD performed and complications. No patients had loss of baseline upper ex- tremity function. Four patients had perioperative complications, all of Hypothesis: To review our initial clinical experience with the supercharge which resolved. end-to-side anterior interosseous to ulnar motor nerve (SETS) transfer, and Summary: to refine our indications for this technique. Nerve transfers provide a means to reestablish volitional control of hand Methods: A retrospective cohort study was performed of all patients under- function in people with cervical-level SCI. going the SETS procedure between August 2009 and December 2012. This surgery does not downgrade existing function, uses expendable Preoperative (diagnosis, comorbidities, clinical presentation, and electro- donor nerve, and has minimal perioperative down time for patients, which diagnostic findings) and intraoperative data were reviewed and related to might make it a more viable option than traditional tendon transfers for clinical successes and failures with regard to recovery of ulnar intrinsic func- tetraplegia. tion. General functional outcomes, including strength, pain, and Disabilites

© Speaker has nothing of financial value to disclose e21 of the Shoulder, Arm and Hand questionnaire, were also documented. Pre- preoperatively, to 55, with a relative score of 60% postoperatively (P <.01). and post-comparisons were performed using paired t-tests. The shoulder subjective value was 15% preoperatively to 45% post- Results: A total of 62 patients (71% male; mean age at surgery, 48.0 17.8 y) operatively (P <.01). The Disabilities of the Arm, Shoulder, and Hand score underwent the SETS procedure. Diagnoses were varied, but all patients improved from 64 to 42 points (P < .01). All patients reported successful presented with clinically significant ulnar intrinsic weakness and electro- retraining of the transferred muscles within the first year after surgery. No diagnostic evidence of acute or chronic denervation of the first dorsal patients reported any noticeable difference in function of the nonparalyzed interosseous muscle. The SETS transfer was performed at a mean distance shoulders. All patients were satisfied with the outcome of surgery and re- of 8.1 1.1 cm from the wrist crease. Of 42 patients, 32 (76%) with ported their shoulder as better or significantly better than preoperatively. adequate follow-up demonstrated recovery of ulnar intrinsic function at a Summary: This study demonstrates that contralateral lower trapezius transfer mean of 5.3 2.7 months postoperatively. In 7 patients undergoing is effective in improving ipsilateral shoulder external rotation. This transfer concomitant ulnar nerve decompression, intrinsic recovery was too rapid to adds an option for tendon transfer to restore shoulder external rotation when be attributable to the SETS procedure. Failures of the SETS procedure were no other ipsilateral muscle is available for transfer. most commonly seen in patients in whom the anterior interosseous nerve had also been injured. PAPER 32 Summary: The SETS transfer is a useful technique for augmenting intrinsic muscle function for second- and third-degree axonotmetic (in-continuity) Clinical Paper Session 7: Potpourri Wrist/Ligament e lesions of the ulnar nerve. The best probability of success is seen in patients Saturday, October 5, 2013 8:45 8:51 AM with acute ulnar nerve injuries with an intact, uninjured donor nerve. Category: Nerve/Neuromuscular Clinical determination of the proportion of intrinsic recovery attributable to Keyword: Hand the SETS transfer is challenging, and perhaps may be only confirmed by Retrospective Study Concerning Isolated Motor Ulnar Nerve electrodiagnostic evaluation in future studies. Compression at the Wrist: Diagnosis and Prognosis in 20 Cases REFERENCES Level 4 Evidence 1. Barbour J, Yee A, Kahn LC, Mackinnon SE. Supercharged end-to-side anterior © Pierre Croutzet, MD interosseous to ulnar motor nerve transfer for intrinsic musculature reinner- © Colin de Cheveigné, PhD vation. J Hand Surg Am. 2012;37(10):2150e2159. 2. Farber SJ, Glaus SW, Moore AM, Hunter DA, Mackinnon SE, Johnson PJ. Su- Hypothesis: There are many types of ulnar nerve compression; among them, percharge nerve transfer to enhance motor recovery: a laboratory study. J Hand motor-only compression at the wrist is one of the least well known. Surg Am. 2013;38(3):466e477. Considering difficulty and delay in recognizing the condition, we studied the diagnostic criteria (age, clinical signs, and electromyography benefits) and the efficiency of surgical treatment. PAPER 31 Methods: We reviewed all patients operated on for isolated motor ulnar compression at the wrist over 22 years (n ¼ 20). Clinical Paper Session 6: Nerve Patients included in this retrospective study were selected according to Friday, October 4, 2013 2:00e2:06 PM different criteria: Category: Tendon Motor ulnar nerve palsy of the first interosseous muscle always had to be Keyword: Shoulder present Contralateral Trapezius Transfer in Patients With Brachial Associated ulnar nerve palsies at the wrist and at the elbow were excluded Plexus Injuries to Restore Shoulder Function Ulnar nerve palsies with sensory symptoms were excluded Level 4 Evidence Secondary compressions were excluded (wounds, tumors, cycling, etc) © Eric Wagner, MD Analysis criteria were age, gender, time before surgery, importance of fi © Bassem T. Elhassan, MD the motor palsy (ulnar claw, and segmentar strength scale [one fth] of the first dorsal interosseous muscle and hypothenar muscles), associated factors Hypothesis: The purpose of this study was to evaluate the outcome for (diabetes, smoking, and carpal tunnel syndrome), and electromyographic contralateral trapezius transfer to restore shoulder external rotation in pa- signs. Clinical results were evaluated with different criteria: satisfaction, tients with brachial plexus injuries. pain, time and quality of strength recovery, and grasp strength. Methods: Nine patients were included in this study. All patients had a history of Results: There were 6 females and 14 males. The mean age was 52 years. persistent shoulder paralysis as a result of traumatic brachial plexus that failed Time before surgery was 8 months (range, 5e18 mo). Among the 20 pa- to recover spontaneously or after nerve reconstruction. Furthermore, these tients, none had bilateral symptoms, 2 had an associated carpal tunnel patients all had compromised ipsilateral lower trapezius muscle as a result of syndrome, and 14 had no motor deficit of the hypothenar muscles. Five either the original trauma or prior spinal accessory nerve transfer. Indications patients only had positive electromyographic signs that were found only for surgery included weakness in shoulder external rotation resulting in when the first interosseous muscle was tested, or on selective examination marked activity limitations, as well as some degree of shoulder pain from of the hypothenar muscles. Mean follow-up was 6 years. Seventeen patients instability. On physical examination, all patients had internal rotation con- were very satisfied, 16 patients recovered full strength in the first inter- tractures with no active external rotation, whereas most also demonstrated osseous muscle, 3 had only partial recovery, and 1 had no recovery. Mean significant loss of shoulder abduction and flexion. Each patient underwent time for recovery was 7 months (range, 3e15 mo). contralateral lower trapezius transfer prolonged with lumbar fascia to the Summary: ipsilateral infraspinatus tendon. The shoulder was then immobilized in In our study, most patients had only a partial hypothenar muscle deficit. external rotation with shoulder spica cast for 8 weeks; active assisted range of Electromyography was positive only when carried out thoroughly, motion was performed for 6 weeks, followed by progressive strengthening for including the first interosseous muscle. 8 weeks and unrestricted activities after 6 months. Diagnosis delay was always superior to 5 months; nevertheless, 16 of 20 Results: At an average follow-up of 23 months, all patients had significant patients had a full recovery. improvement of active shoulder external rotation from no motion preopera- However, the diagnostic delay was the only negative factor. Indeed, poor to tively (ie, no ability to move the hand away from the abdominal level) to 20 bad results were found in patients with a diagnostic delay exceeding 1 year. external rotation (ie, 110 from the abdomen) postoperatively (P < .01). In our study, clinical examination was more efficient than electromyog- Seven of 9 patients reported pain levels as moderate or severe preoperatively, raphy in diagnosing isolated motor ulnar nerve compressions at the wrist. whereas only 1 of 9 reported moderate or severe pain after surgery (P <.01). The recovery score was mainly excellent (16 of 20 patients) but a diag- The Constant Shoulder Score improved from 24, with a relative score of 31% nosis delay superior to 1 year was a negative prognostic factor. e22 © Speaker has nothing of financial value to disclose REFERENCES

1. Lebreton E. Éminence hypothénar. Chir Main. 29(4):213e223. 2. Shea JD, McClain EJ. Ulnar-nerve compression syndromes at and below the wrist. J Bone Joint Surg Am. 1969;51(6):1095e1103. 3. Narakas A. Les syndromes canalaires du membre supérieur. Cahiers d’En- seignement de la Sofcot. 1992;42:17e33. 4. Moutet F. Ulnar tunnel syndrome. Chir Main. 2004;23(Suppl 1):S134eS140. 5. Dumontier C, Apoil A, Meininger T, Monet J, Augereau B. Compression of the deep branche of the ulnar nerve as it exits the pisiforme-unciforme hiatus: report of an anomaly not yet described. Ann Chir Main Memb Super. 1991;10(4): 337e341.

PAPER 33

Clinical Paper Session 7: Potpourri Wrist/Ligament FPO Saturday, October 5, 2013 8:55e9:01 AM = Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Wrist web 4C Reverse Wedge Osteotomy of the Distal Radius in Madelung REFERENCES Deformity: About 12 Cases Level 4 Evidence 1. Dagrégorio G, Saint-Cast Y. Réorientation de la glène radiale dans la défor- mation de Madelung par ostéotomie cunéiforme avec retournement. Chir Main. © Florence Mallard, MD 2005;24(2):109e112. © Yann Saint Cast, MD 2. McCarroll JHR, James MA, Newmeyer III WL, Molitor F, Manske PR. Madelung’s © Guy Raimbeau, MD deformity: quantitative assessment of x-ray deformity. J Hand Surg Am. © Bruno D. Cesari, MD 2005;30(6):1211e1220. ’ © Fabrice Rabarin, MD 3. Watson HK, Pitts EC, Herber S. Madelung s deformity: a surgical technique. J Hand Surg Br. 1993;18(5):601e605. Hypothesis: Surgical procedures to improve aesthetics and function for Madelung deformity are numerous and difficult to assess because the dis- PAPER 34 ease is uncommon. The authors evaluated an original technique based on reverse wedge osteotomy of the distal radius in a retrospective study of 12 Clinical Paper Session 7: Potpourri Wrist/Ligament cases, and attempted to modelize the procedure. Saturday, October 5, 2013 9:05e9:11 AM Methods: Seven women with bilateral Madelung deformity were treated Category: Instability from 1992 to 2011. The 12 cases (5 bilateral and 2 unilateral) were Keyword: Hand reviewed with an average follow-up of 8 years (range, 7 mo to 18.9 y). Surgery was motivated by aesthetic and functional discomfort at the Outcomes After Repair of Subacute-to-Chronic Grade III average age of 27 years, before any complication. Reverse wedge osteot- Metacarpophalangeal Joint Collateral Ligament Injuries in omy was developed to reorient the radial joint surface while reducing the Lesser Digits Are Poor overall radius length as little as possible. Osteotomy was performed through Level 4 Evidence an antero-radial or radial approach with an average time of 106 minutes. © Justin Carmine Wong, MD The wedge was harvested from the excess cortical on the dorsal and Kevin F. Lutsky, MD radial aspect of the radius. The wedge was then removed, turned round, and Pedro K. Beredjiklian, MD put back into the osteotomy to ensure closing on cortical excess and lengthening on the opposite side. Fixation was achieved by an anterior Hypothesis: Injury to the metacarpophalangeal (MCP) joint collateral liga- plate. An associated osteotomy of the ulna was necessary to avoid an ulno- ment of the lesser digits is less common than corresponding injuries in the carpal conflict for 3 cases with severe deformity. Objective (morphology thumb. Outcomes after thumb MCP joint collateral ligament repair are of the wrist, range of motion, and grip strength) and subjective generally favorable. This study examines the outcome after primary repair (QuickeDisabilities of the Arm, Shoulder, and Hand and Patient-Rated of subacute-to-chronic grade III collateral ligament injuries of the MCP Wrist Evaluation) data were analyzed. Radiological settings were taken joints of the lesser digits. Our hypothesis was that the outcome after surgical from McCarroll et al.2 A vector model of the procedure was established to treatment of these injuries is suboptimal. estimate osteotomy angles from 2 indexes from McCarroll et al. The Methods: We retrospectively reviewed all patients who underwent primary nonparametric Wilcoxon test (a ¼ 0.05) was used for statistical analysis. repair of a lesser digit MCP collateral ligament over a 3-year period. Results: All cases achieved fusion at 3 months. Eight of 12 patients had the Postoperatively, we assessed disability outcomes using Disabilities of the plate removed. There was no complication except for hypoesthesia on the Arm, Shoulder, And Hand (DASH) scores and evaluated range of motion radial side of the thenar eminence in 2 cases. Aesthetics and range of motion and grip strength. These measures were compared with preoperative data to improved. Improvement was significant for flexion, pronation, and supina- assess results. tion, as well as the radiological parameters of McCarroll et al2: significant Results: A total of 25 digits in 23 patients underwent surgical treatment of correction of the palmar and ulnar deviation of the radial epiphysis, as well as complete MCP joint collateral ligament tear. All ligaments were of suffi- rising of the lunate and palmar displacement of the carpus. Average Quick- cient quality to permit primary repair using a suture anchor. The time from Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Eval- injury to surgery averaged 14.2 weeks (range, 6e52 wk). Average follow- uation scores were less than 30 out of 100 at review. All patients were satisfied up was 21 months (range, 12e34 mo). Average patient age was 47 years aesthetically and functionally. (range, 17e67 y). Eighty percent of injuries involved the dominant hand. Summary: The corrective power of reverse wedge osteotomy is well adapted The radial collateral ligament was involved in 18 of 25 fingers (72%), with to severe Madelung deformity. Clinical and radiological results are the little finger radial collateral liament being the most common injury. The convincing and meets patients’ expectations. Reverse wedge osteotomy has average preoperative DASH score was 45.9 (range, 17e77) in the 10 pa- a special place among the techniques proposed so far. Vector model allows tients (11 fingers) where this was available. Intraoperative findings revealed preoperative planning that should optimize realization. complete tears in all cases. Collateral ligament disruption occurred at the

© Speaker has nothing of financial value to disclose e23 insertion on the proximal phalanx in 80% of fingers (n ¼ 20), from the The group that combined both had 7 of 20 patients with a diagnosis change and origin of the metacarpal in 16% (n ¼ 4), and from both sites in 4% (n ¼ 1). 3 of 20 with a procedure change. There were no significant differences between Average postoperative DASH score was 22.5 (range, 0e65). Average grip the groups with regard to diagnosis change (P ¼ .570), whereas there was a strength as a percentage of the contralateral hand was 67.6% (range, 32.3% significant difference with regard to procedure change (P ¼.048). The surgeon to 100%). Average postoperative MCP joint arc of motion was 75 (range, was more likely to change the procedure performed for patients with a preop- 50 to 90). erative diagnosis of isolated SL pathology compared with patients with any Summary: Primary repair of complete MCP joint collateral ligament injuries other diagnosis preoperatively (P ¼ .014). of the lesser digits may be performed in the subacute-to-chronic setting. Summary: Although DASH scores were improved postoperatively, patients may In patients with suspected SL tears, performance of midcarpal arthros- continue to have decreased grip strength and residual disability. Given these copy often leads to a change in diagnosis, and also a change in procedure results, we recommend that surgeons remain vigilant for diagnosing this performed (nearly 50%). injury. Surgical repair of complete tears in the acute setting, much like in the In patients with TFC pathology preoperatively, there was an equivalent thumb, may be more appropriate to improve results. change in diagnosis with only a 17% change in procedure. The performance of midcarpal arthroscopy may not be clinically relevant in REFERENCES patients with TFC pathology, but appears necessary in treating SL pathology. 1. Delaere OP, Suttor PM, Degolla R, Leach R, Pieret PJ. Early surgical treatment for All wrist arthroscopic procedures performed for SL pathology should collateral ligament rupture of metacarpophalangeal joint of the fingers. J Hand include an evaluation of the midcarpal joint. Surg Am. 2003;28(2):309e315. 2. Gaston RG, Lourie GM. Radial collateral ligament injury of the index meta- carpophalangeal joint: an underreported but important injury. J Hand Surg Am. 2006;31(8):1355e1361. 3. Riederer S, Nagy L, Buchler U. Chronic post-traumatic radial instability of the metacarpophalangeal joint of the finger: long-term results of ligament recon- struction. J Hand Surg Br. 1998;23(4):503e506. 4. Kang L, Rosen A, Potter HG, Weiland AJ. Rupture of the radial collateral liga- ment of the index metacarpophalangeal joint: diagnosis and surgical treat- ment. J Hand Surg Am. 2007;32(6):789e794.

Consulting Fees (eg, advisory boards) received from: Synthes (K.F.L.). Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds) with: Tornier (P.K.B.). FPO

PAPER 35 =

Clinical Paper Session 7: Potpourri Wrist/Ligament

Saturday, October 5, 2013 9:15e9:21 AM web 4C Category: Arthoscopy Figure 1: Change in diagnosis and procedure for each preoperative Keyword: Wrist diagnosis group, by percentage. Does Midcarpal Arthroscopy Alter Diagnosis and Treatment Royalties/Honoraria received from: Stryker Orthopaedics of Scapholunate or Triangular Fibrocartilage Injuries? Ownership Interest (stocks, stock options, or other ownership interest Level 3 Evidence excluding diversified mutual funds) with: Small Bone Innovations (SBI) © Mark C. Shreve, MD Consulting Fees (eg, advisory boards) received from: Stryker Orthopae- © Ajay K. Balaram, MD dics, IMDS © Rachel Goldstein, MD © Anthony Sapienza, MD Nader Paksima, DO, MPH PAPER 36

Hypothesis: Traditionally wrist arthroscopy consists of evaluation of both Clinical Paper Session 8: Congenital/Pediatrics radiocarpal and midcarpal joints, but the use of midcarpal arthroscopy has Saturday, October 5, 2013 8:45e8:51 AM not been evaluated critically in the literature. Our hypothesis was that Category: Nerve/Neuromuscular arthroscopic evaluation of the midcarpal joint did not lead to a change in Keyword: Wrist either diagnosis or procedure for certain injury patterns. Methods: The study was a retrospective review from 2008 to 2013 of 66 Is Tendon Transfer Surgery in Upper Extremity Cerebral patients who underwent 67 wrist arthroscopic procedures by 3 orthopedic Palsy More Effective Than Botulinum Toxin Injections or hand surgeons at our institution. Patients were included only if both the Regular Ongoing Therapy? midcarpal and radiocarpal joints were evaluated arthroscopically. Patients Level 2 Evidence fi were strati ed into groups based on preoperative diagnosis of scapholunate © ▲Ann E. Van Heest, MD (SL) pathology, triangular fibrocartilage (TFC) pathology, or both © ▲Anita Bagley, PhD concomitantly, based on physical exam and magnetic resonance imaging. ▲Michelle A. James, MD Office notes and operative reports were used to determine whether mid- carpal arthroscopy: (1) resulted in changing the preoperative diagnosis and/ Hypothesis: For children with upper extremity cerebral palsy who meet or (2) resulted in changing the planed procedure performed. standard clinical indications for tendon transfer, those who receive surgical Results: There were 40 males and 26 females in the study, with average age of treatment would have greater improvement in function than either children 38.8 12.3 years, with no significant differences among groups (SL, TFC, or receiving botulinum toxin injections or those receiving regular ongoing both) with regard to age or sex (P ¼ .934 and .375, respectively). In the SL treatment, as measured by validated appropriate assessment tools. group, 11 of 23 patients had a change in diagnosis and 10 of 23 patients had a Methods: Using a prospective randomized control trial with patient prefer- change in procedure performed. In the TFC group, 12 of 24 patients had a ence arm, 38 children with hemiplegic cerebral palsy, who were 5 to 15 change in diagnosis and 4 of 24 patients had a change in procedure performed. years of age and were surgical candidates for flexor carpi ulnaris (FCU) to e24 © Speaker has nothing of financial value to disclose Table 1: Functional Scores at Baseline and 12 Months, Mean (SD) Box and Blocks AHA SHUEE SFA SHUEE DPA Baseline 12 mo Baseline 12 mo Baseline 12 mo Baseline 12 mo Surgery 14.6 (8.1) 15.6 (5.9) 55.2 (8.8) 56.4 (8.4) 50.4 (16.3) 54.9 (21.2) 67.7 (8.9) 88.9 (11.4)*† Botulinum toxin 11.0 (7.7) 10.0 (10.0) 48.1 (11.3) 49.7 (9.1) 44.1 (20.7) 48.4 (21.0) 61.3 (8.4) 63.7 (18.2) Therapy 12.5 (8.0) 13.8 (9.3) 54.8 (4.7) 57.3 (4.6)† 51.3 (17.6) 55.1 (14.0) 64.8 (13.5) 63.3 (14.6) *Difference between surgery and botulinum toxin, and between surgery and therapy, P < .01. †Difference between baseline and 12 months, P < .01. extensor carpi radialis brevis transfer, pronator teres (PT) release, and full elbow release (biceps z-lengthening, partial brachialis myotomy, extensor pollicus longus rerouting with adductor pollicus (AP) release, were and brachioradialis proximal release). Active range of motion, passive range prospectively randomized into 1 of 3 treatment groups: (1) surgery: treated of motion, and elbow flexion posture during ambulation were measured at with standard tendon transfer surgery; (2) botulinum toxin: treated with a each follow-up. Longitudinal results were compared using repeated-measures series of 3 botulinum toxin injections to FCU, PT, and AP over a 6-month analysis of variance or Friedman’s 2-way analysis of ranks, with pairwise period; and (3) therapy: treated with a home therapy program and contin- comparisons made after Bonferroni correction for statistical significance. uation of regular ongoing therapy interventions. Seven pediatric orthopedic Results: Follow-up averaged 113 months (range, 66e169 mo) and 124 months hospitals participated. Assessment tools included the Assisting Hand (range, 74e160 mo) for the partial lengthening and full elbow release cohorts, Assessment, the Shriners Hospital Upper Extremity Evaluation (SHUEE), respectively. After partial lengthening, active extension and flexion posture box and blocks, pinch and grip strength, Pediatric Outcomes Data Collec- angle during ambulation improved 12 (P < .001) and 63 (P < .001), tion Instrument, Canadian Occupational Performance Measure, and Chil- respectively, with 8 loss of active flexion (P ¼ .002). (Fig. 1). Active dren’s Assessment of Participation and Enjoyment. Assessment was done at extension improved 29 after full elbow release (P ¼ .042) in the 5 patients entry into the study and at 6 and 12 months. Because of high rates of refusal with long-term follow-up, but this did not meet the Bonferroni-adjusted of randomization, a patient preference option was added in 2010 to enable threshold for statistical significance (Fig. 2). Post-hoc power analysis revealed families to choose their child’s treatment group. this group to be underpowered to detect a statistically significant difference. Results: For the therapy group, significant improvement in hand function as Summary: Carefully selected soft tissue releases of the anterior elbow, measured by the Assisting Hand Assessment was noted between baseline guided by the amount of preoperative contracture, can provide significant and 12 months. For the surgery group, significant improvement in hand lasting improvements in active extension and flexion posture during function as measured by the SHUEE Dynamic Positional Analysis was ambulation in patients with cerebral palsy. Our long-term findings sub- noted between baseline and 12 months. The SHUEE Dynamic Positional stantiate previously reported short-term results. Analysis value at 12 months was significantly greater in the surgery group than in the botulinum toxin or therapy groups. Summary: For children with upper extremity cerebral palsy who are candidates for FCU to extensor carpi radialis brevis transfer, PT release, and extensor pollicus longus rerouting with AP release, surgical treatment provides greater improvements in upper extremity limb positioning than botulinum A toxin injections or regular ongoing therapy at 12 months’ follow-up.

▲ This presentation will discuss Botox by Allergan Contracted Research: Shriners Hospitals for Children; POSNA/OREF

PAPER 37

Clinical Paper Session 8: Congenital/Pediatrics Saturday, October 5, 2013 8:55e9:01 AM Category: Congenital/Pediatric Keyword: Elbow Long-Term Results Following Surgical Treatment of Elbow Deformity in Patients With Cerebral Palsy Figure 1: Partial lengthening (n ¼ 23). Level 4 Evidence

Christopher J. Dy, MD, MSPH © Morgan Swanstrom, MD © Christian A. Pean, MS © Krystle A. Hearns, MA © Lorene C. Janowski, OTR/L, MS Michelle G. Carlson, MD

Hypothesis: We believe that surgical treatment for elbow flexion deformity in cerebral palsy can be selected based on the degree of contracture. In this long-term study, we hypothesized that our approach to treatment would lead to enduring improvements in elbow extension and flexion angle during ambulation without compromising maximum flexion. Methods: A total of 86 patients (90 elbows) were treated for elbow spasticity resulting from cerebral palsy. Twenty-seven patients (28 elbows) were available for long-term follow-up. Twenty-three patients with fixed elbow contractures less than 45 were treated with partial elbow muscle lengthening (biceps partial lengthening and brachialis, and brachioradialis proximal Figure 2: Full elbow release (n ¼ 5 for active extension and active release). Four patients with fixed elbow contractures of 45 were treated with a flexion; n ¼ 3 for flexion posture during ambulation).

© Speaker has nothing of financial value to disclose e25 Contracted Research: NIH/NIAMS T32 Research Fellowship (AR07281) Hypothesis: In the current literature there are limited data on outcomes after RJOS/Zimmer Research Grant (M.J.C.) elbow contracture release in the pediatric and adolescent population; * ASSH Resident/Fellow Fast Track Grant (C.J.D.) existing studies report unpredictable results and potential loss of motion.1 The aims of this study were to evaluate the outcomes after open elbow PAPER 38 contracture release in patients less than 18 years of age and to identify factors associated with poorer outcomes. Clinical Paper Session 8: Congenital/Pediatrics Methods: A review was performed of 32 patients who had open elbow Saturday, October 5, 2013 9:05e9:11 AM contracture release at a mean age of 13.9 years (range, 5e18 y). At the time Category: Basic ScienceeClinical Research of surgery, 7 patients were 100. Twelve patients (38%) underwent a gentle Keyword: Other manipulation under anesthesia at a mean time of 2.7 weeks (range, 1e5 wk) Does the Trapezius Play a Role During Upper Extremity for early recurrence of stiffness. There were 3 complications (1 deep fi Motion in Patients With Obstetrical Brachial Plexus Birth infection, 1 hematoma, and 1 humerus fracture through the external xator pin site). No significant difference was seen among patients in the 3 Palsy? different age groups (P ¼ .542). However, patients who had dislocations of Level 4 Evidence the elbow with an associated fracture demonstrated less improvement in arc © Donato Perretta, MD of motion compared with patients with fractures without concomitant © Alice Chu, MD dislocation. As might be expected, extra-articular fractures improved the © Viswanath Aluru, MD most (P ¼ .005) (Table 2). © Preeti Raghavan, MD Summary points: © Alex Sher Elbow contracture release in the pediatric and adolescent population can provide significant improvements in range of motion similar to those Hypothesis: The purpose of this study was to determine whether the upper and achieved in adults. lower trapezius muscles have a role during gross shoulder and elbow move- Recurrence of stiffness in the early postoperative period is common; ments of patients with obstetrical brachial plexus birth palsy (OBPBP). however, it is responsive to early manipulation under anesthesia. Methods: Eight patients with OBPBP were evaluated with simultaneous There is no difference in results between younger children and older 3-dimensional motion analysis, 16-channel electromyography (EMG), and adolescents after contracture release. video monitoring. Age at initial presentation to our institution, history of Children who sustain complex fracture-dislocations of the elbow previous treatment, including prior surgery, botulinum toxin injections and/or demonstrated the least improvement in arc of motion after contracture casting, comorbidities and other known diagnoses, and social circumstances release, with extra-articular fractures of the distal humerus improving the were recorded. Mallet score and detailed neurological examination were most. obtained at the time of presentation. In several patients, radiographic studies and a diagnostic EMG with nerve conduction were performed as well. Results: The average age was 11.2 years (range, 7.6e18.1 y). Five were fe- male and 3 were male; 7 were affected on the left side. One patient had known Table 1: Improvement in Total Arc of Motion denervation of the trapezius muscle as an infant during nerve transfer surgery; Improvement Patients, n (%) 2 others potentially had the surgery but did not have available surgical re- > 100 4(13) cords. None of the patients were in active litigation. Modified Mallet score 71to 100 5(16) categorization was an average of 16.5 (range, 12e22). Neurological exam- 51to 70 8(25) ination classification was 6 (primarily C5-6-7 involvement); 2 (global). 20to 50 12 (38)   Data were recorded from both the affected and unaffected sides. Move- 0 to 20 3(9) Loss of motion None ments were analyzed from the shoulder (flexion-abduction/internal-external rotation) and elbow (flexion-extension/pronation-supination). With the ex- ception of elbow flexion and extension, the total arc of motion was markedly reduced on the affected side. Electromyelogram data from the unaffected Table 2: Mean Range of Motion After Contracture Release, According side showed significant levels of activity from the upper and lower trapezius to Etiology muscles during most shoulder and elbow motions. The same patterns existed on Improvement the affected side, but were diminished in patients who had trapezius inactivity. Patients, Total Arc of in Total Arc Summary: n Extension Flexion Motion of Motion This study reveals a significant level of EMG activity from the upper and Complex 10 11 136 125 35 lower trapezius muscles during gross motor movements of the affected as fracture- well as unaffected upper extremities in pediatric patients with OBPBP. dislocation Spinal accessory nerve transfer surgery, resulting in trapezius denerva- Intra-articular 518 132 114 43 tion, is one of the initial treatments for OBPBP. This may cause fracture Extra-articular 11 10 136 127 83 compensatory patterns of muscle activity. fracture Radial head/ 46 134 128 69 PAPER 39 neck fracture Nontraumatic 213 125 113 48 Clinical Paper Session 8: Congenital/Pediatrics contracture Saturday, October 5, 2013 9:15e9:21 AM Total/means 32 11 135 123 56 Category: Congenital/Pediatric Keyword: Elbow Outcomes Following Operative Treatment of Elbow Contractures in the Pediatric and Adolescent Population REFERENCE Level 4 Evidence 1. Stans AA, Maritz NG, O’Driscoll SW, Morrey BF. Operative treatment of elbow © Eugene T. Ek, MD, PhD, FRACS contracture in patients twenty-one years of age or younger. J Bone Joint Surg Am. 2002;84(3):382e387. © Sophia Paul, BA Robert N. Hotchkiss, MD Contracted Research with: Auxilium Pharmaceuticals, Inc. e26 © Speaker has nothing of financial value to disclose PAPER 40

Clinical Paper Session 9: Nerve/Microsurgery Saturday, October 5, 2013 8:45e8:51 AM Category: Nerve/Neuromuscular Keyword: Hand Allograft Nerve Reconstruction for Digital Nerve Loss Level 4 Evidence

John S. Taras, MD © Nirav Amin, MD © Nimit Patel, MD © Lucy A. McCabe, BS

Hypothesis: Reliable reconstruction of nerve gaps in the hand and digits remains a challenge to the hand surgeon. This prospective study investi- gated the outcomes of digital nerve reconstructions using processed nerve allograft for defects measuring 5 to 30 mm. Methods: A total of 17 patients with 21 digital nerve lacerations in the hand underwent digital nerve reconstruction with processed nerve allograft. Outcome data for 14 patients with 18 digital nerve lacerations were available for 3. Weber RA, Breidenbach WC, Brown RE, Jabaley ME, Mass DP. A randomized analysis. Postoperative testing was done at regular intervals through a minimum prospective study of polyglycolic acid conduits for digital nerve reconstruction of 12 months, with an average of 15 months. The average nerve gap measured in humans. Plast Reconstr Surg. 2000;106(5):1036e1045. 11 mm (range, 5e30 mm). Outcome measures included postoperative sensory 4. Hudson TW, Liu SY, Schmidt CE. Engineering an improved acellular nerve graft e examination, as assessed by Semmes-Weinstein monofilaments and static and via optimized chemical processing. Tissue Eng. 2004;10(9-10):1346 1358. 5. Karabekmez FE, Duymaz A, Moran SL. Early clinical outcomes with the use of moving 2-point discrimination. Pain was graded using a visual analog scale. In e decellularized nerve allograft for repair of sensory defects within the hand. addition, patients completed the Quick Disabilities of the Arm, Shoulder, and Hand. 2009;4(3):245e249. Hand (QuickDASH) survey preoperatively and postoperatively to qualify their 6. Whitlock EL, Tuffaha SH, Luciano JP, et al. Processed allografts and type I pain perception and functional impairment. collagen conduits for repair of peripheral nerve gaps. Muscle Nerve. 2009;39(6): Results: The Taras outcome measure was used to determine excellent, good, 787e799. and fair results. Using this criterion, 7 of 18 digits (39%) had an excellent result, 8 of 18 (44%) had good results, 3 of 18 (17%) had fair results, and Contracted Research with: AxoGen 0 of 18 (0%) had poor results. At final follow-up, average static 2-point Consulting Fees (eg, advisory boards) received from: Integra Life- discrimination results were 7.11 mm (range, 5e8 mm), and average moving Sciences, AxoGen 2-point discrimination results were 5.44 mm (range, 2e8 mm). Initial Receipt of Intellectual Property Rights/Patent Holder with: T-Pin Distal QuickDASH scores recorded at the patient’s first postoperative visit aver- Radius Fixation System/Union Surgical, LLC aged 44.8 (range, 2.3e79.5), and final QuickDASH scores averaged 26.1 Ownership Interest (stocks, stock options, or other ownership interest fi (range, 2.3e43.2). There were no signs of infection, extrusion, or graft excluding diversi ed mutual funds) with: Owner/Founder, Union Sur- reaction. gical, LLC. Summary: The data suggest that processed nerve allograft provides a safe Other Financial/Material Support received from: Union Surgical and effective option for the reconstruction of peripheral sensory nerve deficits in the hand measuring up to 30 mm. PAPER 41

REFERENCES Clinical Paper Session 9: Nerve/Microsurgery Saturday, October 5, 2013 8:55e9:01 AM 1. Taras JS, Jacoby SM, Lincoski CJ. Reconstruction of digital nerves with collagen Category: Nerve/Neuromuscular conduits. J Hand Surg Am. 2011;36(9):1441e1446. 2. Ducic I, Fu R, Iorio ML. Innovative treatment of peripheral nerve injuries: Keyword: Other combined reconstructive concepts. Ann Plast Surg. 2012;68(2):180e187. Can Processed Nerve Allografts Provide Functional Motor Recovery in the Upper Extremities? Level 3 Evidence

Bauback Safa, MD © Mickey Cho, MD © Wesley P. Thayer, MD, PhD © Jozef Zoldos, MD © John V. Ingari, MD © Gregory M. Buncke, MD

Hypothesis: Mixed and motor nerves of the upper extremity can be effec- tively repaired with processed nerve allografts. Methods: Sixteen sites with 32 surgeons contributed a total of 230 nerve injuries to an institutional review boardeapproved clinical registry of processed nerve allografts (Avance Nerve Graft; AxoGen, Inc). The registry database was queried for mixed and motor nerve repairs in the upper ex- tremity. Follow-up evaluations included MRCC scale for motor function, grip strength, range of motion, electromyography studies, qualitative questionnaires, and safety assessments. Meaningful recovery was defined as a score of M3 or higher on the MRCC scale. Demographics, outcomes and covariate analysis were performed to further characterize the subgroup.

© Speaker has nothing of financial value to disclose e27 Results: The subgroup analysis for mixed/motor nerve repairs in the upper superior to 55 in every case except 2 that had an IP arthrodesis, 1 of which extremities included 17 subjects having 18 nerve repairs with sufficient was referred with the arthrodesis done. Two-point discrimination was recovery time for quantitative outcomes analysis. This subset included 14 normal in dorsal oblique amputations and 7 to 11 mm in the rest. One case mixed nerves in the forearm and 4 motor nerves in the upper extremities. had a moderate nail deformity, whereas in the rest fairly normal growth The mean SD age was 39 21 years (range, 18e77 y). The mean time to (subjectively 9.5 on a visual analog scale) was appreciated. Patient satis- repair was 97 160 days (0e379 d). The most common mechanism faction was high from a functional and aesthetic standpoint 9.5 and 9.5 of injury was lacerations. The average gap length was 30 13 mm (over 10). All patients returned to work from 2 to 4.5 months after the (10e50 mm). Recovery was assessed for the intrinsic and extrinsics of the injury. One patient referred late and with an intra-articular fracture of the IP hand, biceps, deltoid, and trapezius, as well as extension and flexion of joint, which developed septic arthritis and was treated by IP arthrodesis. the forearm and wrist where applicable. Return of appropriate grip strength Delayed donor site healing was noted in 4 cases. and/or range of motion were observed in 16 of the 18 nerve repairs. Seven Summary: In contrast to classic teaching, which recommends stump closure repairs reported an M3, 5 reported an M4, and 4 reported an M5. There for cases of distal thumb amputations, we attained excellent results with were no reported adverse events related to the nerve allograft. partial toe transfer in manual workers. In our experience, the thumb can be Summary: restored nearly to original condition with acceptable donor site sequela. The Processed nerve allografts provided functional motor recovery when used best indication is for cases of dorsal oblique amputations, becauses thumb for mixed and motor nerve repairs in the upper extremity in gap lengths sensibility is preserved. Early transfer is strongly recommended. between 10 and 50 mm. Outcomes compare favorably with historical controls from available literature for nerve autograft. Continuation of this study will provide additional clinical evidence on the expanding role of processed nerve allografts in these repairs.

REFERENCES

1. Brooks D, Weber RV, Chao JD, et al. Processed nerve allografts for peripheral nerve reconstruction: a multicenter study of utilization and outcomes in sen- sory, mixed, and motor nerve reconstructions. Microsurgery. 2012;32(1):1e14. 2. Frykman G, Gramyk K. Results of nerve grafting. In: Gelberman R, ed. Operative Nerve Repair and Reconstruction. Philadelphia: JB Lippincott; 1991:553e567. FPO

3. Kim DH, Kam AC, Chandika P, Tiel RL, Kline DG. Surgical management and = outcomes in patients with median nerve lesions. J Neurosurg. 2001;95(4): 584e594. Erratum in: J Neurosurg. 2002;96(1):162.

4. Kim DH, Han K, Tiel RL, Murovic JA, Kline DG. Surgical outcomes of 654 ulnar web 4C nerve lesions. J Neurosurg. 2003;98(5):993e1004. 5. Vastamäki M, Kallio PK, Solonen KA. The results of secondary microsurgical PAPER 43 repair of ulnar nerve injury. JHandSurgBr. 1993;18(3):323e326. Clinical Paper Session 9: Nerve/Microsurgery Contracted Research with: AxoGen, Inc Saturday, October 5, 2013 9:15e9:21 AM Consulting Fees (eg, advisory boards) received from: AxoGen, Inc Category: Basic ScienceeLab Research Keyword: Other PAPER 42 Use of a Light-Activated Stent for Sutureless Vascular Anastamosis Clinical Paper Session 9: Nerve/Microsurgery Saturday, October 5, 2013 9:05e9:11 AM Not a clinical study Category: Vascular/Microvascular © Prabhu Senthil-Kumar, MD Keyword: Hand © Joanna Ng, MD Onycho-Osteocutaneous Defects of the Thumb © Amanda Meppelink, BS © Reconstructed by Partial Toe to Hand Doris Ling, MS © Mark A. Randolph, MAS Level 4 Evidence © Hatice Bodugoz-Senturk, PhD © Francisco Del Piñal, MD © Orhun K. Muratoglu, PhD © Eduardo Moraleda, MD © Robert Redmond, PhD © Guillermo H. De Piero, MD © Jonathan M. Winograd, MD © Carlos Galindo, MD Hypothesis: © Jaime S. Ruas, MD Vascular repair with suture remains the reference standard, but can lead to inflammation and thrombosis, especially in peripheral vessels. Hypothesis: To present our experience in very distal thumb amputations Use of clips and rings can minimize this risk, but they are difficult to use reconstructed by partial toe to hand, with special emphasis on manual on the microsurgical scale. Photochemical tissue bonding (PTB) is a workers. technique that covalently links protein without thermal damage to tissue, Methods: A total of 25 patients who had amputation of the thumb distal to and has been employed by our group in cornea, skin, tendon, and peripheral the interphalangeal (IP) joint, excluding pure soft tissue losses, were nerve.1e3 We hypothesized that use of PTB over a biocompatible intra- included in the study. Except for 3, all were manual workers. All were luminal stent would result in a watertight seal with minimal endothelial reconstructed in less than 2 weeks after the accident (most in less than 48 h), inflammation. except for 5 who were referred late. The bony defect varied from just the Methods: Thirty-five rats underwent unilateral femoral artery transection and tuft of the phalanx to most of the distal phalanx. In 3 cases, the IP joint had were randomized to repair with 10-0 nylon microsuture (SR), stent plus SR, an associated fracture that was treated concomitantly, and in all the IP was or stent plus PTB. For PTB, a 1-mm overlapping cuff was painted reconstructible. The toes were based on the proper digital artery (18 cases), with 0.1% Rose Bengal, and then illuminated with a 532-nm green light the intermetatarsal artery (6 cases), and the dorsalis pedis (in 1 early case). laser for 60 seconds on each side. One dose of heparin (100 U/kg) was Results: All transferred toes survived without complications. At a minimum administered before removal of the vessel clamps in all animals. Repair follow-up of 1 year (range, 14-1), active range of motion at the IP joint was time and vessel patency (immediately and at 1 h) were assessed. Histology e28 © Speaker has nothing of financial value to disclose was performed at 1 week to assess for endothelial damage and thrombus formation. Results: There was no difference in repair time (P ¼ .10). All 3 groups were patent immediately. At 1 hour, the SR and stent plus SR groups demon- strated 100% patency, with 93% patency in the stent plus PTB group. At 1 week, there was no hematoma or aneurysm formation in any of the groups. Summary: We demonstrated the development and use of an intraluminal stent in successful microvascular anastomosis. Photochemical tissue bonding creates an immediate watertight and sutureless vascular anasto- mosis with the intraluminal stent. Using a nondissolvable intraluminal stent causes thrombosis occasionally. We are currently developing a dissolvable stent to create a successful sutureless microvascular anastomosis using the PTB technique. FPO = web 4C Figure 4: Anastomosis time.

REFERENCES

1. O’Neill AC, Winogra JM, Zeballos JL, et al. Microvascular anastomosis using a photochemical tissue bonding technique. Lasers Surg Med. 2007;39(9):716e722. 2. Henry FP, Goyal NA, David WS, et al. Improving electrophysiologic and histo- logic outcomes by photochemically sealing amnion to the peripheral nerve repair site. Surgery. 2009;145(3):313e321. 3. Johnson TS, O’Neill AC, Motarjem PM, et al. Photochemical tissue bonding: a novel technique in peripheral nerve repair. J Surg Res. 2007;143(2):224e229. FPO = PAPER 44 web 4C Figure 1: Stent used for microvascular anastomosis. Clinical Paper Session 10: Tumors Saturday, October 5, 2013 9:25e9:31 AM Category: Congenital/Pediatric Keyword: Hand Long-Term Follow-Up and Natural History Study of Osteochondromas of the Hand in Patients With MHE Level 4 Evidence © Julie Colantoni, MD R. Glenn Gaston, MD

Hypothesis: We theorized that the prevalence of osteochondromas in the Figure 2: Confocal microscopy of the stent used in the study. hand would be increased around the ulnar digits and metacarpal joints (2+5). Long-term, natural history data will show greater change and in- crease in number, angulation, shortening during periods of increased skel- etal growth with a plateau of the number and deformity as patients reach skeletal maturity. Methods: Retrospective x-ray review of 83 hands (46 patients) with multiple hereditary osteochondromatosis assessed the location, type, number of le- sions as well as angulation and shortening of the involved bones of the hand. We then reviewed the same data along with long-term follow-up x-rays of 23 hands. These data was analyzed based on age of presentation for overall changes in location, number, and deformity of bones over time. Three age groups were defined based on age at initial presentation: group 1: ages 2 to 6 years; group 2: ages 7 to 10 years; and group 3: ages 11 years and older. Statistical analysis was carried out through Microsoft Excel programming. Results: A total of 83 hands (46 patients) were evaluated; average age was FPO = 11 years (range, 3e34 y). The average number of tumors was 13.1 per hand; the most affected finger was the little finger, at 3.3 tumors per finger, followed by the index (2.96 tumors/finger), middle (2.95 tumors/finger), web 4C Figure 3: Sutureless anastomosis of rat femoral artery with PTB with ring (2.7 tumors/finger), and thumb (1.63 tumors/finger). The most common stent in situ. type was small, sessile lesions affecting less than 50% of bone (98%). There

© Speaker has nothing of financial value to disclose e29 was an average of 5 bones per hand and 2 with regard to angulation and Average shortening, seen most commonly in the ring and little finger metacarpals. Average Age at Change in Change in There were 23 hands in 13 patients, with average age at final follow-up Age at Follow- Average Change Bones With Bones With of 14.1 years and average follow-up time of 4.6 years. Overall change in Presentation Up Years in Tumors Shortening Angulation tumors was +2.7 per hand (range, e8 to +16 per hand). Most gains were Group 1: 12.2 y 7.7 y +2.8 +1.2 +0.7 6 patients, tumors/ bones/ bones/ seen in the ring finger (1.7 tumors/hand) and individually in the ring and 10 hands hand hand hand fi little nger metacarpals (0.5 tumors/bone) (Fig. 1). 4.5 y Summary: Group 2: 13 y 3 y e0.2 +0.2 0 bones/ This was the largest study of osteochondromas of the hand (83 hands) and 2 patients, tumors/ bones/ hand largest long-term follow-up study (23 hands). 4 hands hand hand The ulnar side of the hand was more affected and showed the most 10 y angulation and shortening, centering on the metacarpophalangeal joints. Group 3: 16.8 y 1.9 y +0.1 e0.1 0 The thumb was the least affected. Some bones had no tumor present but 5 patients, had shortening or angulation. 9 hands 14.9 y Most were sessile, affecting less than 50% of bone. Large changes were seen in the number of tumors over a period of time; the most change was seen from age 4 years to follow-up at age 12 years. 5. Wood VE, Molitor C, Mudge MK. Hand involvement in multiple hereditary Trends were present but wide variations were seen between patients. exostosis. Hand Clin. 1990;6(4):685e692. As patients became older than age 12, less change was seen in all categories, Contracted Research with: ASSH which indicates a decrease in change as patients approach skeletal maturity. Royalties/Honoraria received from: Biomet Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds) with: MiMedX Consulting Fees (eg, advisory boards) received from: Biomet, MiMedx. Receipt of Intellectual Property Rights/Patent Holder with: MiMedx

PAPER 45

Clinical Paper Session 10: Tumors Saturday, October 5, 2013 9:35e9:41 AM Category: Tumor Keyword: Hand Predicting the Risk of Pathologic Fracture for Enchondromas of the Hand Using Reproducible Clinical Criteria Level 4 Evidence © Scott M. Riester, MD Sanjeev Kakar, MD, MBA © Andre van Wijnen, PhD © Doris Wenger, MD © Rishi Ramaesh, MD

Hypothesis: The risk of pathologic fracture for enchondromas of the hand can be determined using reproducible radiographic measurements and clinical observations. Methods: A total of 76 surgical cases of enchondromas involving the hand were retrospectively reviewed to determine whether radiographic and clinical criteria could be used to determine the likelihood of a patient having a pathologic fracture. The presence or absence of fracture for each case was determined based on preoperative radiographs and intraoperative findings. Cases without preoperative radiographs and syndromic cases of enchon- dromatosis were excluded. Criteria examined included gender, age, hand involved (left vs right), bone involved (distal phalanx, middle phalanx, proximal phalanx, or metacarpal), digit involved (little, ring, middle, index, or thumb), and longitudinal percentage of the occupied up by the lesion on anteroposterior (AP) radiographs. Preoperative radiographs and clinical Figure 1: criteria were evaluated independently by 2 physicians. Odds ratios were calculated for each clinical criterion; statistical significance was evaluated REFERENCES using chi-square test. Results: There was a statistically significant difference between the fracture 1. Black B, Dooley J, Pyper A, Reed M. Multiple hereditary exostoses. Clin Orthop and nonfracture group with regard to age (P ¼ .027), digit involved (P ¼ Relat Res. 1993;287:212e217. .007), bone involved (P ¼ .030), and percentage of bone invaded by the 2. Cates HE, Burgess RC. Incidence of brachydactyly and hand exostosis in he- ¼ fi reditary multiple exostosis. J Hand Surg Am. 1991;16(1):127e132. lesion on AP radiographs (P .016). The little nger was the most common 3. Stanton RP, Hansen MO. Function of the upper extremities in hereditary mul- one associated with fracture (19 of 20 cases). The distal phalanx and tiple exostoses. J Bone Joint Surg Am. 1996;78(4):568e573. proximal phalanx were the bones most likely to present with a fracture 4. Steiber JR, Dormans JP. Manifestations of hereditary multiple exostoses. JAm (distal phalanx: 10 of 11 cases; proximal phalanx: 18 of 23 cases). There Acad Orthop Surg. 2005;13(2):110e120. was a direct relationship between the percentage of longitudinal bone e30 © Speaker has nothing of financial value to disclose Table 1: Statistical Relationship Between Clinical Criteria and Presence of Pathologic Fracture No Fracture (N ¼ 17) Fracture (N ¼ 37) Total (N ¼ 54) Gender Male 3 (15.8%) 16 (84.2%) 19 (35.2%) OR ¼ 3.55 (0.96e17.34), P ¼ .058 Female 14 (40.0%) 21 (60.0%) 35 (64.8%) Reference Side P ¼ .939 L 9 (31.0%) 20 (69.0%) 29 (53.7%) OR ¼ 0.96(0.30e3.07), P ¼ .9393 R 8 (32.0%) 17 (68.0%) 25 (46.3%) Reference Finger P ¼ .007 Little 1 (5.0%) 19 (95.0%) 20 (37.0%) OR ¼ 12.67 (1.52e275.39), P ¼ .017 Ring 6 (42.9%) 8 (57.1%) 14 (25.9%) OR ¼ 0.89 (0.16e4.65), P ¼ .888 Middle 4 (40.0%) 6 (60.0%) 10 (18.5%) Reference Index 3 (50.0%) 3 (50.0%) 6 (11.1%) OR ¼ 0.67 (0.08e5.31), P ¼ .696 Thumb 3 (75.0%) 1 (25.0%) 4 (7.4%) OR ¼ 0.22 (1.19e221.39), P ¼ .228 Bone P ¼ .030 Distal phalanx 1 (9.1%) 10 (90.9%) 11 (20.4%) OR ¼ 10.00 (1.19e221.39), P ¼ .032 Middle phalanx 5 (50.0%) 5 (50.0%) 10 (18.5%) Reference Proximal phalanx 5 (21.7%) 18 (78.3%) 23 (42.6%) OR ¼ 3.60 (0.74e18.73), P ¼ .111 Metacarpal 6 (60.0%) 4 (40.0%) 10 (18.5%) OR ¼ 0.667 (0.11e3.93), P ¼ .602 Age P ¼ .027 N173754 Mean (SD) 45.6 (10.) 36.6 (15.0) 39.5 (14.3) Median 47 35 39.5 Range 23e67 13e75 13e75 Age 0e25 y 2 (20.0%) 8 (80.0%) 10 (18.5%) OR ¼ 6.43 (0.79e138.82), P ¼ .084 Age 25e50 y 11 (34.4%) 21 (65.6%) 32 (59.3%) OR ¼ 4.71 (0.74e92.67), P ¼ .108 Age 50e75 y 5 (41.7%) 7 (58.3%) 12 (22.2%) Reference Per 10-y unit increase OR ¼-0.62 per 10 y increase (0.38e0.95), P ¼ .027 Longitudinal ratio P ¼ .016 N173754 Mean 43.2 (18.4) 54.5 (15.2) 50.9 (17.0) Median 41.5 53.8 52.8 Range 22.2e87.9 30.0e93.6 22.2e93.6 0e0.33 6 (60.0%) 4 (40.0%) 10 (3.7%) Reference 0.33e0.67 9 (26.5%) 25 (73.5%) 34 (42.6%) OR ¼ 4.17 (0.97e19.80), P ¼ .054 0.67e1.00 2 (20.0%) 8 (80.0%) 10 (46.3%) OR ¼ 6.00 (0.90e56.31), P ¼ .063 Per 10% unit increase OR ¼ 1.59 per 10% unit increase (1.08e2.49), P ¼ .016 OR, odds ratio. involvement on AP radiographs and the presence of fracture. The median Consulting Fees (eg, advisory boards) received from: Arthrex, Inc (range) percentage of longitudinal bone involvement for the fracture and non- Other Financial/Material Support received from: Arthrex, Inc fracture outcomes was 53.8 (29.9e93.6) and 41.5 (22.2e87.9), respectively. Summary: Enchondromas are the most common primary bone tumor of the PAPER 46 hand, often found incidentally at presentation. Conservative treatment with observation and serial radiographs is frequently successful, but a Clinical Paper Session 10: Tumors e subset of patients exist who will go on to develop a pathologic fracture. Saturday, October 5, 2013 9:45 9:51 AM Objective criteria to predict the likelihood of fracture in these patients are Category: Tumor currently lacking, which makes it difficult for clinicians and patients to Keyword: Hand arrive at appropriate treatment decisions. This investigation provides Giant Cell Tumors of the Tendon Sheaths in the Hand: Review fi evidence that age, the affected nger, the affected bone, and the per- of 96 Patients With an Average Follow-Up of 12 Years centage of the bone occupied by the pathologic lesion on AP radiographs Level 4 Evidence can be used as objective criteria to predict fracture risk and guide clinical decision making. © Romain Lancigu, MD © Guy Raimbeau, MD REFERENCES © Bruno Cesari, MD © 1. Milgram JW. The orgins of osteochondromas and eEnchondromas: a histo- Fabrice Rabarin, MD pathologic study. Clin Orthop Relat Res 1983;(174):264e284. Hypothesis: Giant cell tumors of the hand are relatively common and have a 2. O’Connor MI, Bancroft LW. Benign and malignant cartilage tumors of the hand. Hand Clin. 2004;20(3):317e323. good prognosis, but the risk of recurrence is high. The goals of this study 3. Bickels J, Wittig JC, Kollender Y, et al. Enchondromas of the hand: treatment were to evaluate the long-term clinical results of a consecutive series of with curettage and cemented internal fixation. J Hand Surg Am. 2002;27(5): patients and to determine the risk factors for recurrence. 870e875. Methods: This was a retrospective study of 96 patients (57 women and 39 4. Yasuda M, Masada K, Takeuchi E. Treatment of enchondroma of the hand with men) operated on between February 1982 and October 2005 for giant cell injectable calcium phosphate bone cement. J Hand Surg Am. 2006;31(1):98e102. tumors of the tendon sheaths in the hand. The average age at the time of the 5. Tordai P, Hoglund M, Lugnegård H. Is the treatment of enchondroma in the procedure was 47.7 14.5 years (range, 13e75 y). All patients were hand by simple curettage a rewarding method? J Hand Surg Br. 1990;15(3): reviewed by an independent surgeon. 331e334. The tumor was located in the index finger in 29 cases, middle finger in 6. Arata M, Peterson H, Dahlin D. Pathological fractures through non-ossifying fi fi fibromas. J Bone Joint Surg Am. 1981;63(6):980e988. 23, thumb in 21, ring nger in 11, little nger in 11, hypothenar area in 2, 7. Sassoon A, Fitz-Gibbon P, Harmsen W, Moran S. Enchondromas of the hand: and thenar area in 1. In all cases, the lesion was isolated. The swelling was factors affecting recurrence, healing, motion, and malignant transformation. J palmar in 27 cases, dorsal in 20, and medial or lateral in 59. The most Hand Surg Am. 2012;37(6):1229e1234. common joint location was the distal interphalangeal joint (35% of cases).

© Speaker has nothing of financial value to disclose e31 The swollen area was sensitive in 12 cases. Time from the appearance of Methods: A total of 96 patients (61 females) presenting to hand surgeons for the tumor to physician consultation ranged between 1 month and 7 years. a symptomatic dorsal carpal ganglion were prospectively enrolled in this Before surgery, standard x-rays were taken in all patients; ultrasonography case-control investigation. Beighton scores were calculated to quantify was also performed in 8 patients and magnetic resonance imaging in 1 generalized ligamentous laxity in each patient (Table 1) and a scaphoid shift patient. The tumor had an average diameter of 15.8 2.6 mm (range, 5e30 test (scapholunate ligamentous laxity evaluation) was performed. A positive mm). Histological analysis revealed a multilobed lesion with multinucleated scaphoid shift test was defined as the presence of both pain and a palpable giant cells, with or without encapsulation. clunk during testing. Ninety-six individuals without ganglion cysts (past or Results: Average follow-up at the time of review was 12.1 3.8 years (range, present) were then enrolled to form an age and sex frequency-matched 5e29 y). There were 8 recurrences in 7 patients (8.3%). The average time to control cohort. The control group was similarly assessed for Beighton score recurrence was 2.75 2 years (range, 1e6.5 y). In every case of recurrence, and scaphoid shift test. Binary logistic regression was performed to assess there had been intra-articular tumor development and/or tendon destruction (P the association of ganglion cysts with generalized ligamentous laxity < .01). There was 1 functional complication: 1 distal interphalangeal joint (Beighton score 4) while accounting for effects of age and sex. fusion resulting from 1 of the recurrences. The average QuickeDisabilities of Results: Patients with symptomatic dorsal carpal ganglia demonstrated the Arm, Shoulder, and Hand score was 2.3 out of 100 (range, 0e31). significantly increased rates of generalized ligamentous hyperlaxity. Among Summary: Giant cell tumors of the synovial sheaths in the hand are benign those with ganglia, 27 of 96 patients (28.1%) exhibited generalized liga- lesions in which recurrence is the primary risk. The recurrence typically mentous hyperlaxity, compared with 12 of the 96 age- and gender-matched occurred within 36 months of the excision. Intra-articular tumor develop- individuals in the control group (12.5%) (P ¼ .007). Patients with symp- ment, marginal resection, and tendon involvement seem to contribute to tomatic dorsal carpal ganglia were also significantly more likely to recurrence. No correlation was found between the histological type of tu- demonstrate scapholunate laxity with a positive scaphoid shift test (25% mor (encapsulated or not) and recurrence. positive scaphoid shift test with ganglia vs 1% in controls; P < .001.) In logistic modeling, patients with a dorsal carpal ganglion had 2.9 times REFERENCES greater odds of generalized ligamentous hyperlaxity (95% confidence in- terval, 1.3e6.2) compared with patients without a dorsal carpal ganglion 1. Monaghan H, Salter DM, Al-Nafussi A. Giant cell tumor of tendon sheath after accounting for patient age and sex (Table 2). (localised nodular tenosynovitis): clinicopathological features of 71 cases. J Clin Summary: e Pathol. 2001;54(5):404 407. 2. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented villonodular synovitis, bursitis and Symptomatic dorsal carpal ganglia are associated with generalized liga- tenosynovitis. Arch Pathol. 1941;31:371. mentous hyperlaxity even when accounting for effects of patient age and sex. 3. Darwish FM, Haddad WH. Giant-cell tumor of tendon sheath: experience with Patients with symptomatic dorsal carpal ganglia are more likely to have 52 cases. Singapore Med J. 2008;49(11):879e882. localized scapholunate ligament hyperlaxity compared with controls. 4. Kotwal PP, Gupta V, Malhotra R. Giant-cell tumour of tendon sheath: is radio- therapy indicated to prevent recurrence after surgery? J Bone Joint Surg Br. Table 1: Examination and Scoring for Beighton Assessment of 2000;82(4):571e573. 5. Middleton WD, Patel V, Teefey SA, Boyer MI.Giant-cell tumors of thetendon sheath: Generalized Hyperlaxity analysis of sonographic findings. AJR Am J Roentgenol. 2004;183(2):337e339. Beighton Score 6. Williams J. Recurrence of giant cell tumors in the hand: a prospective study. J Passive thumb apposition L thumb touches forearm: 1 point Hand Surg Am. 2010;35(3):451e456. to ipsilateral volar forearm R thumb touches forearm: 1 point 7. Al-Qattan MM. Giant-cell tumours of tendon sheath: classification and recur- Passive hyperextension L MCP hyperextension > 90: 1 point rence rate. J Hand Surg Br. 2001;26(1):72e75. of fifth MCP joint R fifth MCP hyperextension > 90: 1 point 8. Rodrigues C, Desai S, Chinoy R. Giant cell tumor of the tendon sheath: a Elbow hyperextension L elbow hyperextension > 10: 1 point retrospective study of 28 cases. J Surg Oncol. 1998;68(2):100e103. R elbow hyperextension > 10: 1 point 9. Messoudi A, Fnini S, Labsaili N, Ghrib S, Rafai M, Largab A. Les tumeurs a cellules Knee hyperextension L knee hyperextension > 10: 1 point géantes des gaines synoviales de la main: a propos de 32 cas. Chir Main. R knee hyperextension > 10: 1 point 2007;26(3):165e169. Palms toward floor with Both palms touch floor: 1 point 10. Dartoy C, Fenol B, Leroy JP, Dubrana F, Le Nen D, Jehannin B. Tumeur à knees extended cellules géantes de la gaine du tendon du long fléchisseur du pouce chez une Total 9 possible points e enfant de 7 ans. Ann Chir Main Membre Super. 1994;13(3):198 201. MCP, metacarpophalangeal.

Table 2: PAPER 47 Variables in Final Logistic Model Variable Wald c2 b Odds Ratio 95% Confidence Interval Clinical Paper Session 10: Tumors Presence of ganglion 7.6 1.1 3.0 1.4e6.5 e Saturday, October 5, 2013 9:55e10:01 AM Female sex 4.2 0.88 2.4 1.0 5.6 Patient age, y 8.3 e0.046 0.96 0.93e0.99 Category: Tumor Constant e1.274 Keyword: Wrist

Hyperlaxity and Dorsal Carpal Ganglia: A Prospective Case- REFERENCES Control Study 1. Wolf JM, Cameron KL, Owens BD. Impact of joint laxity and hypermobility on Level 3 Evidence the musculoskeletal system. J Am Acad Orthop Surg. 2011;19(8):463e471. © Kathleen E. McKeon, MD 2. Wolf JM, Schreier S, Tomsick S, Williams A, Petersen B. Radiographic laxity of the © Daniel A. Osei, MD trapeziometacarpal joint is correlated with generalized joint hypermobility. J e Richard H. Gelberman, MD Hand Surg Am. 2011;36(7):1165 1169. 3. Juul-Kristensen B, Røgind H, Jensen DV, Remvig L. Inter-examiner reproduc- Charles A. Goldfarb, MD ibility of tests and criteria for generalized joint hypermobility and benign joint Martin I. Boyer, MD, FRCS(C) hypermobility syndrome. Rheumatology (Oxford). 2007;46(12):1835e1841. © Daniel A. London, BA 4. Watson HK, Ashmead DIV, Makhlouf MV. Examination of the scaphoid. J Hand © Ryan Patrick Calfee, MD Surg Am. 1988;13(5):657e660. Hypothesis: fi 5. Easterling KJ, Wolfe SW. Scaphoid shift in the uninjured wrist. J Hand Surg Am. Generalized ligamentous hyperlaxity, de ned by a Beighton score 1994;19(4):604e606. greater than or equal to 4, has been associated with musculoskeletal pathology. We hypothesized that the presence of generalized ligamentous hyperlaxity is Contracted Research with: PI on NIH grant, Barnes-Jewish Hospital associated with the presence of symptomatic dorsal carpal ganglia. Foundation (R.H.G.) e32 © Speaker has nothing of financial value to disclose Royalties/Honoraria received from: Medartis (R.H.G.), Wolters Kluwer (R.H.G., C.A.G.) Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds) with: OrthoHelix, LLC; MiMedX, LLC (M.I.B.) Consulting Fees: MiMedX, LLC, OrthoHelix, LLC (M.I.B.) Other Financial/Material Support received from: Synthes (M.I.B.) PAPER 48

Clinical Paper Session 11: Tendon Saturday, October 5, 2013 9:25e9:31 AM Category: Tendon Keyword: Hand The Impact of Suture Caliber and Core Suture Strands on Figure 2: Maximum load to failure for 3 repair techniques. Intrasynovial Flexor Tendon Repair Not a clinical study REFERENCES © Daniel A. Osei, MD 1. Taras JS, Raphael JS, Marczyk SC, Bauerle WB. Evaluation of suture caliber in flexor tendon repair. J Hand Surg Am. 2001;26(6):1100e1104. Richard H. Gelberman, MD © 2. Winters SC, Gelberman RH, Woo SL, Chan SS, Grewal R, Seiler III JG. The effects Jeffrey Stepan, BS of multiple-strand suture methods on the strength and excursion of repaired Martin I. Boyer, MD, FRCS(C) intrasynovial flexor tendons: a biomechanical study in dogs. J Hand Surg Am. © Ryan Potter, MS 1998;23:97e104. Ryan Patrick Calfee, MD 3. Nelson GN, Potter R, Ntouvali E, Silva MJ, Boyer MI, Gelberman RH, Thomopoulos S. Intrasynovial flexor tendon repair: a biomechanical study of variations in suture Hypothesis: There is little consensus regarding whether the number of core application in human cadavera. J Orthop Res. 2012;30(10):1652e1659. suture strands or the caliber of the core suture has a greater impact on time 4. Boyer MI, Meunier MJ, Lescheid J, Burns ME, Gelberman RH, Silva MJ. The in- 0 tensile properties. Our hypothesis was that a 3-0, 4-strand repair would fluence of cross-sectional area on the tensile properties of flexor tendons. J have similar tensile properties as a 4-0, 8-strand repair. Hand Surg Am. 2001;. 2001;26(5):828e832. Methods: This investigation was powered (a ¼ 0.05, b ¼ 0.80) to detect a 5. Kim HM, Nelson G, Thomopoulos S, Silva MJ, Das R, Gelberman RH. Technical fi fl relevant change in maximum load (30%) between repair groups. All mechan- and biological modi cations for enhanced exor tendon repair. J Hand Surg e ical testing was performed using a materials testing machine (Instron 5866). Am. 2010;35(6):1031 1037. 6. Brockardt CJ, Sullivan LG, Watkins BE, Wongworawat MD. Evaluation of simple This study was conducted in 2 stages. First, we tested the maximum fl fl and looped suture and new material for exor tendon repair. J Hand Surg Eur load to failure of 2 suture calibers most commonly used in exor tendon Vol. 2009;34(3):329e332. repair (3-0 and 4-0 Supramid). Next, we tested the time 0, ex vivo me- chanical properties of 40 cadaveric flexor digitorum profundus tendons after Royalties/Honoraria received from: Medartis, Wolters Kluwer (R.H.G.) zone II repair with 1 of 3 techniques: (1) 3-0, 4-strand core repair, (2) 4-0, 8- Other Financial/Material Support received from: Medartis, LLC (M.I.B.) strand repair, or (3) 4-0, 4-strand repair. Tendon repairs were made into a Ownership Interest (stocks, stock options, or other ownership interest clinically relevant model by adding a circumferential epitendinous suture excluding diversified mutual funds) with: OrthoHelix, LLC; MiMedX, (5-0 Prolene). Tensile properties were measured for the 3 repair methods. LLC (M.I.B.) All continuous paired data were analyzed using Student’s t-test. Other Financial Relationships from: Synthes Results: The maximum load to failure of 3-0 polyfilament caprolactam suture was 49% higher than that of 4-0 polyfilament caprolactam suture (Fig. 1). The cross-sectional area of 3-0 Supramid was 38% greater than that PAPER 49 of 4-0 Supramid. The 4-0, 8-strand repair produced greater maximum load Clinical Paper Session 11: Tendon to failure compared with the 2 4-strand techniques (82.2 vs 58.2 N Saturday, October 5, 2013 9:35e9:41 AM [3-0 suture] vs 49.8 N [4-0 suture]; P ¼ .0004) (Fig. 2). Load at 2-mm gap Category: Tendon (P ¼ .003), stiffness (P ¼ .025), rigidity (P ¼ .024), resilience (P ¼ .010), Keyword: Hand and toughness (P ¼ .014) were significantly higher in the 4-0, 8-strand repair compared wih the 3-0, 4-strand repair. The Knotless Tendon Repair With a Resorbable Summary: Unidirectional Barbed Suture Device: An In Vivo Failure force is directly proportional to suture cross-sectional area: Comparison in the Turkey Foot Increasing caliber from 4-0 to 3-0 increases failure force by 49%; Not a clinical study increasing the number of strands from 4 to 8 theoretically increases the failure force by 100%. © Tim S. Peltz, MD These suture testing trends were maintained when incorporated into a © Peter Scougall, FRCS repair construct; compared with a 4-0, 4-strand repair, a 3-0, 4-strand © Rema S. Oliver, PhD repair is 16% stronger and a 4-0, 8-strand repair is 67% stronger. © Mark P. Gianoutsos, MD A 4-0, 8-strand repair significantly outperformed a 3-0, 4-strand repair, © Nicky Bertollo, PhD which indicates that although suture caliber and sutureetendon interaction © William R. Walsh, PhD affect repair strength, the number of core repair strands is of greater impact. Hypothesis: With recent commercialization of barbed suture materials and reports of the use of these materials for tendon repairs, we felt the need to design a specific repair method to draw the best use from this material. In previous ex vivo studies, we could show superior biomechanical perfor- mances of our new knotless barbed suture tendon repair compared with conventional knotted tendon repairs. The aim of this present study was to investigate whether this superior repair stability applies to an in vivo sce- Figure 1: Material properties for Supramid suture, 3-0 and 4-0 caliber. nario in a healing tendon.

© Speaker has nothing of financial value to disclose e33 Methods: Forty male Meleagris gallopavo (turkeys) were used. The middle suitable small sizes. Resorbtion of the barbs on the suture surface of the toe of the right leg was operated on, while the left served as the contralateral currently available resorbable barbed sutures causes inferior repair stability control. Two groups were operated on: and increased repair failures compared with conventional repairs in an in 1. Repair of 20 turkey feet (right middle toe deep flexor tendon) at zone II vivo setting. with a 4-strand, knotted, cross-locked cruciate repair (Adelaid repair) REFERENCES with 4-0 Ethibond and running circumferential repair with 6-0 Prolene. 2. Repair of 20 turkey feet (right middle toe deep flexor tendon) at zone II 1. Peltz TS, Haddad R, Scougall PJ, Gianoutsos MP, Bertollo N, Walsh WR. Perfor- with 4-strand, knotless, barbed suture repair (3-dimensional repair) with mance of a knotless four-strand flexor tendon repair with a unidirectional a resorbable 4-0 V-Loc 180 suture device and running circumferential barbed suture device: a dynamic ex vivo comparison. J Hand Surg Eur Vol. 2013 repair with 6-0 Prolene. Feb 22. [Epub ahead of print]. 2. Haddad R, Peltz TS, Walsh WR. Biomechanical evaluation of flexor tendon repair Histological analysis was carried out at 1, 3, and 6 weeks and 10 repairs using barbed suture material: a comparative ex vivo study. JHandSurgAm. in each group were tested biomechanically after 6 weeks. 2011;36(9):1565e1566. Results: In vivo surgery on the turkey deep flexor apparatus is practicable and procedures are comparable to clinical scenarios in humans. Animals PAPER 50 tolerate casting and show similar functional recovery of operated digits to human postoperative recoveries. Clinical Paper Session 11: Tendon Histology shows similar healing phases compared with human tendon Saturday, October 5, 2013 9:45e9:51 AM repairs. Biomechanically, the barbed suture repairs could not reach the same Category: Tendon stability as the conventional knotted repairs. More tendon repair failures Keyword: Hand were noted in the barbed suture group compared with the conventional Early and Late Mobilization After a Flexor Tendon Injury in knotted repair group. Also, biomechanical testing after 6 weeks showed more stable repairs in the conventional repair group compared with the Children—A Long-Term Follow-Up barbed suture group. Level 4 Evidence Summary: This is the first in vivo investigation of a knotless barbed suture © Illugi Fanndal Birkisson, MD repair. Our aim was to prove whether a barbed suture repair could achieve Lars B. Dahlin, MD, PhD similar results in an in vivo setting as the conventional reference standard in © Hans-Eric Rosberg, MD, PhD 4-strand tendon repairs. This could not be proven. Unfortunately, no non- resorbable, permanent barbed suture is currently commercially available in Hypothesis: Our hypothesis was that late mobilization in children, because of lack of cooperation, would not, affect long-term results after a flexor tendon injury in fingers, in contrast to adults. We evaluated the functional outcome after repair of a flexor tendon injury and early or late mobilization in children. Methods: A retrospective follow-up study was conducted in 29 children, aged 1 to 16 years at the time of injury, with a flexor tendon injury. All patients were operated on at our department during 2003e2009 with repair of 1 or several flexor tendon injuries in fingers, excluding the thumb, using 2- or 4-strand core sutures, depending on the size of the tendon. During the rehabilitation, early (n ¼ 18; active mobilization; 12 boys and 6 girls; median, 13 y; range, 7e16 y) or late mobilization (n ¼ 11; cast immobi- lization for 3e4 wk; 4 boys and 7 girls; median, 4 y; range, 1e10 y) was used, depending on the cooperability of the patient. Functional and cosmetic subjective results were evaluated by a visual analog scale (VAS) (0e100; 100 indicated best results). Grip strength was recorded and range of motion (ROM) in metacarpophalangeal, proximal interphalangeal, and distal interphalangeal (DIP) joints was measured.

FPO Results: There were no ruptures of any flexor tendon repair. One patient was = operated on 3 weeks after an open fracture and tendon injury with DIP joint arthrodesis, and was excluded from the DIP joint range of motion evaluation.

web 4C The mean functional VAS scores in the early and late mobilization groups were 80 and 78, respectively. The corresponding values for the cosmetic VAS were 79 and 77, respectively. The mean ROM (ratio of the contralateral side) for the early mobilization group in metacarpophalangeal, proximal inter- phalangeal, and DIP joints was 95%, 86%, and 79%, respectively, compared with 103%, 86%, and 65% for the late mobilization group. Grip strength (ratio of the contralateral side) was 96% and 93% in the early and late mobilization groups (median; ranges, 53% to 116% and 78% to 112%, respectively). However, despite lower age in the late mobilization group, there were no statistical differences in the subjective or functional outcomes between the early and late mobilization groups after a flexor tendon injury in children. Summary: No differences were detected in the subjective or functional out- comes after a flexor tendon repair between early rehabilitation in older children compared with late mobilization in young children. The findings suggest that initiation of an early rehabilitation program after a flexor tendon repair is not necessary in young children. FPO

= Contracted Research with: Auxillium, Pfizer, Pergamum Consulting Fees (eg, advisory boards) received from: Auxillium, Pfizer, Pergamum web 4C

e34 © Speaker has nothing of financial value to disclose combined passive and active motion, and patients were offered weekly PAPER 51 therapy appointments. All patients were instructed to wear the splints for a Clinical Paper Session 11: Tendon period of 6 weeks. Range of motion of the injured digit was measured by a Saturday, October 5, 2013 9:55e10:01 AM clinical specialist hand therapist using a digital goniometer at 6 and 12  Category: Workplace/Rehabilitation weeks postoperatively. Keyword: Hand Results: In 2011, 62 patients (76 digits) (mean age, 34 y; range, 14e58 y) with acute, uncomplicated zone II flexor tendon injuries were rehabilitated Rehabilitation Following Zone II Flexor Tendon Repairs: using the forearm-based splint (group A). In 2012, 40 patients (45 digits) A Change to Splinting Practice Using the Manchester (mean age, 31 y; range, 15e71 y) with the same injuries were rehabilitated Short Splint using the Manchester short splint (group B). Level 3 Evidence At 6 weeks postoperatively, group B had significantly less mean flexion contractures at the proximal interphalangeal (PIP) joints (mean SD, © Chye Ng, MBChB(Hons), FRCS(T&O), DSEM, BDHS, EBHSD Æ 18 14) than group A (29 18)(t-test; P < .001). The mean arc of © Fiona Peck, MCSP Æ Æ PIP joint motion was also greater in group B than group A (53 23 vs © Alison Roe, MCSP Æ 41 24; P .008). Similarly, at the distal interphalangeal joints, group B © Christopher G. Duff, FRCS(Plas) Æ ¼ had significantly less mean flexion contractures than group A (6 9 vs © Æ Duncan A. McGrouther, MD, FRCS 10 10 ; P .034). ©   Vivien C. Lees, MD, FRCS AtÆ 12 weeks¼ postoperatively, group B continued to have significantly less mean flexion contractures than group A at the PIP joints (10 11 vs Null Hypothesis: There is no statistically significant difference in the out- Æ 19 16; P .002). During the study period, there were 3 ruptures (3.9%) comes (range of motion and rupture rate) after zone II flexor tendon repairs, Æ ¼ when comparing the traditional forearm-based splint and a newly designed in group A and 2 (4.4%) in group B (chi-square test with Yates’ correction; P .735). short splint. ¼ Methods: We performed a historical cohort study of patients with primary Summary: The Manchester short splint appears to be a safe, simple, and effective zone II flexor tendon lacerations, repaired using multi-strand suture tech-  niques. The results of rehabilitation using a traditional forearm-based splint splint for rehabilitation of patients with zone II flexor tendon repairs. Patients had significantly fewer flexion contractures at the PIP joints and (Fig. 1) were compared with the Manchester short splint (Fig. 2). The short  regained greater range of active motion of the digits at 12 weeks splint was fabricated to permit maximal wrist flexion and up to 45 wrist postoperatively. extension with a block to 30 metacarpophalangeal joint extension. Reha- The rupture rate remains within published acceptable levels (4%). bilitation began on the fourth or fifth postoperative day, using early  web 4C = FPO web 4C = FPO

© Speaker has nothing of financial value to disclose e35 PAPER 52 Summary: A multicenter clinical trial with the ambition of the WRIST team is the Clinical Paper Session 12: Wrist: Distal Radius and Scaphoid  cornerstone for the future of hand surgery research. Saturday, October 5, 2013 10:10e10:16 AM Despite the initial setbacks, lessons learned from this trial will be valuable   Category: Fractures and Dislocations to design additional large-scale studies in hand surgery. Keyword: Wrist New methods of site engagement, patient screening, and participant  A First-Year Update and Reflection of the 21 Center NIH- retention are being actively sought and put into action to increase WRIST potential for success. Funded Wrist and Radius Injury Surgical Trial (WRIST) Not a clinical study

© Kevin C. Chung, MD, MS REFERENCES © Melissa J. Shauver, MPH 1. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of out- © Sunitha Malay, MPH comes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005;30A(6):1185e1199. Hypothesis: The National Institutes of Healthefunded Wrist and Radius 2. American Academy of Orthopaedic Surgeons. The Treatment of Distal Injury Surgical Trial (WRIST) is a historic collaboration of 21 hand surgery Radius Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons; centers in the United States, Canada, and Singapore (Fig. 1). This multi- 2009. center clinical trial was initiated after the seminal systematic review by Margaliot et al1 and the Cochrane report that indicated marked deficiency in the quality of evidence in the distal radius fracture (DRF) literature, spe- cifically in the case of volar locking plate use in patients over the age of 55 PAPER 53 2 years. The WRIST team was created to answer questions about treatment Clinical Paper Session 12: Wrist: Distal Radius and Scaphoid of DRF in elderly patients with outcomes of function and patient-rated Saturday, October 5, 2013 10:20e10:26 AM  items including satisfaction and quality of life. Category: Fractures and Dislocations Methods: The Wrist and Radius Injury Surgical Trial is a 21-center National Keyword: Wrist Institute of Arthritis and Musculoskeletal and Skin Diseaseseand National Institute on Agingefunded, randomized, controlled trial evaluating DRFs in a Corrective Osteotomies in Malunions of the Distal Radius, patient group age 60 years and over. Participants are randomly allocated to 1 Using Preoperative 3-Dimensional Computer Planning and of the 3 surgical procedures: internal fixation with volar locking plate, external Patient-Specific Surgical Guides fixation, and percutaneous pinning. Those who opt out of surgery are Level 4 Evidence observed in an observation group. Outcomes include the Michigan Hand © Bianca Impelmans, MD Outcomes Questionnaire, the Short Form-36, grip and pinch strength, and Roger van Riet, MD, PhD wrist range of motion. The Wrist and Radius Injury Surgical Trial received  Frederik Verstreken, MD National Institutes of Health approval to begin screening in January 2012.  Results: The WRIST team experienced setbacks, including obtaining regu- Hypothesis: Preoperative 3-dimensional computer planning and patient- latory approval across all sites. Any changes to the protocol must be specific surgical guides allow precise reconstruction in malunions of the reviewed at every site. It took nearly a year for all sites to obtain approval distal radius. from their institutional review or ethics board. This severely limited the Methods: A total of 18 patients with a malunion of the distal radius had a time available for recruitment. Furthermore, WRIST has screened 252 pa- corrective osteotomy, using preoperative 3-dimensional computer plan- tients. Among these, 154 patients were excluded owing to noneligibility ning and patient-specific surgical guides. Fourteen patients had an isolated (61%). Of the 98 eligible patients, 40 were enrolled into the study, for an extra-articular malunion, 3 had a combined extra- and intra-articular enrollment rate of only 16%. When calculating sample size, we had malunion, and 1 had an isolated intra-articular malunion. Surgicase soft- anticipated a 50% refusal rate. We were not prepared for the large number ware (Materialise, Belgium) was used for 3-dimensional planning of the of ineligible patients. However, with the incorporation of additional sites corrective osteotomy, using the mirror image of the nonaffected side as a within and outside the United States, we expect to increase the number of template. Based on this planning, patient-specific surgical guides were patients screened, and thus to meet our recruitment goals. manufactured. Three independent observers measured radial tilt, radial inclination, ulnar variance, and articular congruency on the preoperative radiographs, on the computer planning, and on the postoperative radiographs. Results: The clinical and radiographic results of 17 patients were evaluated, with a mean follow-up of 15.2 months ( 4.6 mo). At the final follow-up, Æ there was significant improvement (P .80) for all criteria used to assess ¼ distal radius anatomy. The goal was to restore alignment of the radius to within 5 angular deformity (radial tilt and radial inclination) and 2 mm ulnar variance, compared with the opposite uninjured wrist. In 14 of 17 patients, all 3 measurements were within the planned limits. In 2 patients, correction of radial tilt was incomplete and 1 patient had incomplete correction of ulnar variance. When an intra-articular malunion was cor- rected (4 patients), residual articular incongruency on the postoperative radiographs was less than 2 mm in all patients. Summary: Preoperative 3-dimensional computer planning and the use of patient-  specific surgical guides allows precise correction of distal radius malunion. The radiographic outcome compares favorably with reported results of  1,2 more conventional techniques. Clinical results were excellent, with significant improvement of function web 4C = FPO  in all patients and a low complication rate.

e36 © Speaker has nothing of financial value to disclose CT scans of the CAS arms were obtained to compare the planned virtual screw location with that of the final actual screw position. Two-tailed unpaired Student’s t-tests were used to analyze the outcome variables. Results: Setup time for the traditional method was 0, wherease the computer- assisted group required on average 4.8 0.8 minutes (P < .001). The actual Æ time for placement of the guide wire in the ideal position was 4.6 1.5 minutes in the CAS group versus 11.8 4.4 minutes for the traditionalÆ Æ group (P .008). Total time from setup to final K-wire placement was 9.4 ¼ 1.3 minutes for the CAS group versus 11.8 4.3 minutes for the traditionalÆ group (P .280). Radiation exposure forÆ K-wire placement was ¼ 18.4 3.6 seconds for the CAS group versus 113.6 37.5 seconds for the Æ Æ traditional group (P .001). The CAS groups had 1.2 0.4 attempts for ¼ Æ ideal wire placement versus 1.8 0.4 attempts for the traditional group (P .070). Postoperative CT scansÆ of the CAS wrists were superimposed ¼ with their preoperative CT scans and demonstrated 1.5 0.56 mm devia- Æ tion from the planned ideal screw. No significant differences were found in the accuracy of either method. No cortical perforations were detected in either group. Summary: Computer-assisted surgical navigation of dorsal percutaneous scaphoid screw placement (Figs. 1, 2) took on average 5 minutes longer to set up but led to significantly reduced guide wire placement time, resulting in no significant differences in overall procedural time. Com- puter-assisted surgical navigation was as accurate as the traditional method and no cortical perforations were seen. Radiation exposure to the operating room staff was reduced approximately 6-fold with use of navigation.

REFERENCES 1. Von Campe A, Nagy L, Arbab D, Dumont CE. Corrective osteotomies in mal- unions of the distal radius. Clin Orthop Relat Res. 2006;(450):179e185. 2. Prommersberger KJ, Van Schoonhoven J, Lanz UB. Outcome after corrective osteotomy for malunited fractures of the distal end of the radius. J Hand Surg Br. 2002;27(1):55e60. Consulting Fees (eg, advisory boards) received from: Medartis, Pfizer  (F.V.); Acumed (R.V.)

PAPER 54 Clinical Paper Session 12: Wrist: Distal Radius and Scaphoid

Saturday, October 5, 2013 10:30e10:36 AM web 4C = FPO  Figure 1: The current trajectory of the smart drill guide is superimposed Category: Fractures and Dislocations on the preplanned virtual screw. Once the current trajectory correctly Keyword: Wrist matches the preplanned screw, the targeting guide on the bottom right Computer-Assisted Navigation for Dorsal Percutaneous corner will turn green. Scaphoid Screw Not a clinical study

© Check C. Kam, MD

 Jeffrey A. Greenberg, MD Hypothesis: To investigate a computer-assisted surgical (CAS) technique for antegrade insertion of percutaneous scaphoid screws and compare insertion time, accuracy, and radiation exposure with the traditional technique. We hypothesized that CAS navigation of dorsal percutaneous scaphoid screw placement would improve accuracy, reduce actual K-wire insertion time, and decrease radiation exposure to the operating room staff. Figure 2: Computer-assisted navigation (arm 0268): anteroposterior, Methods: Ten right fresh cadaveric limbs sectioned at the mid humerus were lateral, and hyperpronated oblique views. randomized to either CAS or traditional dorsal percutaneous scaphoid screw placement by a single surgeon. Custom thermoplastic thumb spica REFERENCE splints were applied to the CAS arms, followed by intraoperative computed 1. Walsh E, Crisco JJ, Wolfe SW. Computer-assisted navigation of volar percuta- tomography (CT) scan, which was used for navigation planning and neous scaphoid placement. J Hand Surg Am. 2009;34(9):1722e1728. 3-dimensional guidance. Time was recorded for the portion of setup that required surgeon input, ideal guide wire placement, and actual fluoroscopy Consulting Fees (eg, advisory boards) received from: Stryker Orthope-  time used. Number of K-wire attempts was also recorded. Postoperative dics, Acumed Orthopedics, Axogen Corporation

© Speaker has nothing of financial value to disclose e37 PAPER 55 Results: At follow-up, 6 wrists were asymptomatic and the remaining 5 had mild occasional pain. The mean range of extension significantly improved Clinical Paper Session 12: Wrist: Distal Radius and Scaphoid from 45 (range, 25 to 70) preoperatively to 71 (range, 50 to 90) Saturday, October 5, 2013 10:40e10:46 AM  postoperatively (P < .001). The mean percentage grip strength (affected Category: Evaluation/Diagnosis/Clinical Treatment side to contralateral side) significantly increased from 62% (range, 17% Keyword: Wrist to 154%) preoperatively to 90% (range, 64% to 100%) postoperatively Can Scaphoid Nonunions Be Predicted? (P < .05). Whereas the mean modified Mayo Wrist Score was 92 points Not a clinical study (range, 80e100), the mean Disabilities of the Arm, Shoulder, and Hand score was 5 points (range, 0e18). All patients achieved bony union at the © Joan Francis Arakkal, FRCS osteotomy site within 12 weeks postoperatively. At follow-up, no pro- © Abbey Perumpanani, DPhil Oxf gression of the Lichtman stages was found in any patients. There was no significant progressive lunate collapse in any patient. On the other hand, we Hypothesis: The main finding of this study is that optical density gradients found no MRI findings indicating revascularization of the lunate in 3 wrists. across scaphoid fracture can be used to predict the risk of nonunion in the Summary: Our study showed satisfactory clinical long-term results after early weeks after a fracture. Previous researchers in their quest for pre- 10 or more years in patients who underwent radial shortening. Although dictors of nonunion have looked at radiological hallmarks such as sclerosis, no revascularization of the lunate was found in 3 wrists, unloading of the rounding of the edges, or cyst formation. lunate after radial shortening for Kienböck disease gives long-lasting Methods: The study looked at optical density gradients within scaphoid symptom relief and prevents progressive lunate collapse. x-rays with a view to investigating their correlation with the pathophysi- ology of fracture healing. The study found temporally evolving, spatially REFERENCES varying optical density gradients in scaphoid bones with fractures. These 1. Hultén O. Über anatomische Variationen der Handgelenkknochen. Ein Beitrag fracture-induced gradients behave differently from early on, depending on zur Kenntnis der Genese zwei verschiedener Mondbeinveränderungen. Acta whether they are headed for union or nonunion. Radiol. 1928;9:155e168. Results: The main finding of the study is that optical density gradients across 2. Bonzar M, Firrell JC, Hainer M, Mah ET, McCabe SJ. Kienböck disease and scaphoid fractures can be used to predict the risk of nonunion in the early negative ulnar variance. J Bone Joint Surg Am. 1998;80(8):1154e1157. weeks after a fracture. 3. Makabe H, Iwasaki N, Kamishima T, Oizumi N, Tadano S, Minami A. Computed Summary: tomography osteoabsorptiometry alterations in stress distribution patterns Fracture-induced gradients are good predictors of nonunion. through the wrist after radial shortening osteotomy for Kienböck disease.  Fracture-induced gradients could provide a new and novel method to risk J Hand Surg Am. 2011;36(7):1158e1164. ’  stratify scaphoid fractures. 4. Almquist EE, Burns JF Jr. Radial shortening for the treatment of Kienböck s disease—a 5- to 10-year follow-up. J Hand Surg Am. 1982;7(4):348e352. Fracture-induced gradients could have wider orthopedic implications for  5. Salmon J, Stanley JK, Trail IA. Kienböck’s disease: conservative management the clinical and scientific approach to all fractures. versus radial shortening. J Bone Joint Surg Br. 2000;82(6):820e823. 6. Iwasaki N, Minami A, Oizumi N, Suenaga N, Kato H, Minami M. Radial osteotomy for late-stage Kienböck’s disease: wedge osteotomy versus radial PAPER 56 shortening. J Bone Joint Surg Br. 2002;84(5):673e677. 7. Iwasaki N, Minami A, Oizumi N, Yamane S, Suenaga N, Kato H. Predictors of Clinical Paper Session 13: Wrist clinical results of radial osteotomies for Kienböck’s disease. Clin Orthop Relat Saturday, October 5, 2013 10:05e10:11 AM Res. 2003;415:157e162.  Category: Arthritis 8. Iwasaki N, Minami A, Ishikawa J, Kato H, Minami M. Radial osteotomies for Keyword: Wrist teenage patients with Kienböck disease. Clin Orthop Relat Res. 2005;439: 116e122. Surgical Efficacy of Radial Shortening Osteotomy for 9. Matsuhashi T, Iwasaki N, Oizumi N, Kato H, Minami M, Minami A. Radial Kienböck Disease: A 10-Year-Minimum Follow-Up Study overgrowth after radial shortening osteotomies for skeletally immature Level 4 Evidence patients with Kienböck’s disease. J Hand Surg Am. 2009;34(7):1242e1247. 10. Nakamura R, Watanabe K, Tsunoda K, Miura T. Radial osteotomy for Kienböck’s © Yuichiro Matsui, MD, PhD disease evaluated by magnetic resonance imaging: 24 cases followed for © Tadanao Funakoshi, MD, PhD 1-3 years. Acta Orthop Scand. 1993;64(2):207e211. © Makoto Motomiya, MD, PhD © Michio Minami, MD, PhD PAPER 57 © Akio Minami, MD, PhD © Norimasa Iwasaki, MD, PhD Clinical Paper Session 13: Wrist Saturday, October 5, 2013 10:15e10:21 AM  Hypothesis: Although radial shortening osteotomy (radial shortening) is Category: Basic ScienceeClinical Research widely performed for patients with Kienböck disease, the long-term clinical Keyword: Wrist results of this procedure are still unclear. We hypothesized that radial shortening could provide favorable long-term postoperative results for more Scaphocapitate Arthrodesis in the Treatment of than 10 years in the treatment of Kienböck disease. Kienböck Disease Methods: Between 1991 and 2002, 11 wrists of 10 patients that had been Level 4 Evidence classified as Lichtman stages IIIA (2 wrists), IIIB (8 wrists), and IV © Peter C. Rhee, DO, MS (1 wrist) underwent radial shortening for the treatment of Kienböck disease. © Ines C. Lin, MD These included 8 male and 2 female patients whose mean age at the time of Steven L. Moran, MD surgery was 23.7 years (range, 11e44 y). The mean follow-up period was  © Allen Bishop, PhD 14.3 years (range, 10e21 y). All patients were clinically examined for range Alexander Y. Shin, MD of motion and grip strength. Postoperative clinical outcomes were measured  using the Japanese version of the Disabilities of the Arm, Shoulder, and Hypothesis: Scaphocapitate arthrodesis can result in improved functional Hand (DASH) questionnaire and the modified Mayo Wrist Score. Radio- outcomes in patients with Kienböck disease. logical and magnetic resonance imaging (MRI) studies were performed for Methods: Patients with Kienböck disease who had undergone scaphocapitate all patients preoperatively and at follow-up, except for preoperative MRI arthrodesis at our institution between 1991 and 2010 were identified with a from 1 patient. Statistical comparisons were performed using paired t-tests minimum of 1-year clinical follow-up. Hospital records were reviewed for (P < .05). operative details, preoperative and postoperative pain, range of motion, grip e38 © Speaker has nothing of financial value to disclose strength, functional status, and complications. Modified Mayo Wrist Score instability. The average follow-up was 54 months (range, 13e97 mo). The and Lichtman outcome sores were calculated. procedures performed before joint replacement were: distal radius open Results: A total of 27 patients (10 females and 17 males) with a mean age of reduction and internal fixation (20), ulna shortening (15), DRUJ ligament 41 years (range, 15e66 y) at the time of scaphocapitate arthrodesis and reconstruction (8), triangular fibrocartilage complex repair (4), Sauve- average follow-up period of 60 months (range, 12e195 mo) were included Kapandji procedure (4), Darrach procedure (3), DRUJ replacement (2), and in the study. Union was achieved in all patients. Significant loss of mean other wrist procedure (8). Sixteen patients underwent further procedures after wrist motion was noted from preoperatively to postoperatively in flexion implantation of the prosthesis: extensor carpi ulnaris release and implant (e14.2, P .0006), extension (e10.5, P .0001), and ulnar deviation coverage with dermal-fat graft (9), removal of ostheophytes from the distal ¼ ¼ (e9.1, P .010). However, significant improvement in grip strength was ulnar stump (3), replacement of the ultra-high-molecular-weight polyethylene noted (+6.6¼ kg, P .009). Outcome scores were calculated in 22 patients ball (2), adjustment of the radial plate (1), and loosening of the implant at ¼ and were good in 3, fair in 10, and poor in 9 patients based on the modified one-third distal of ulna (1). The average increase in grip strength and lifting Mayo Wrist Score. Satisfactory outcomes were achieved in 7 of 22 patients capacity was 27.90 kg (P < .001) and 7.45 kg (P .030), respectively. ¼ (32%) based on the Lichtman outcome score. Conversion to total wrist Supination improved 12.89 (P < .001) on average. Disabilities of the Arm, arthrodesis occurred in 2 patients. Complications included delayed union Shoulder, and Hand and Patient-Rated Wrist Evaluation scores decreased on (n 3) and complex regional pain syndrome (n 2). average 30.25 (P < .001) and 38.43 (P < .001) points, respectively. The ¼ ¼ Summary: average decrease in visual analog score score was 6 of 10 (P < .001). A total Scaphocapitate arthrodesis can result in improved grip strength for of 29 patients would recommend the procedure, whereas 3 would not.  patients with advanced stages of Kienböck disease who have failed Summary: revascularization attempts, or in the presence of an unsalvageable lunate. In this group of high-demand patients, the implant improved the func-  Coupling the distal and proximal carpal rows results in significant loss tional status of the extremity.  of mean wrist range of motion in flexion, extension, and ulnar deviation The most frequent complication was extensor carpi ulnaris tendonitis,  after scaphocapitate arthrodesis. which was addressed by incorporating into the main procedure the Nonetheless, functional outcomes in medium-term follow-up are interposition of an adipofascial flap to cover the prosthesis.  discouraging after scaphocapitate arthrodesis for advanced stages of The major complication rate (infection, implant loosening, and mechan- Kienböck disease.  ical failure) was extremely low (2%).

Contracted Research with: Integra Orthopedics (A.Y.S.) Ownership Interest (stocks, stock options, or other ownership interest   Royalties/Honoraria received from: Integra (S.L.M.); Trimed Orthopedics excluding diversified mutual funds) with: Aptis Co.  (A.Y.S.) Receipt of Intellectual Property Rights/Patent Holder with: Patent holder  Ownership Interest: Conventus, Axogen (S.L.M.) Other Financial Relationships: Part owner of APTIS Medical   Consulting Fees (eg, advisory boards) received from: Integra (S.L.M.);  Acumed Orthopedics, LMT Surgical, Biotech Orthopedics (A.Y.S.) Receipt of Intellectual Property Rights/Patent Holder with: Integra (S.L.M.)  PAPER 59 Clinical Paper Session 13: Wrist Saturday, October 5, 2013 10:35e10:41 AM PAPER 58  Category: Arthritis Clinical Paper Session 13: Wrist Keyword: Wrist Saturday, October 5, 2013 10:25e10:31 AM  Category: Arthroplasty Palmar-Shelf Arthroplasty, Long-Term Follow-Up Level 4 Evidence Keyword: Wrist © Hillel D. Skoff, MD Functional Outcome of the Distal Radioulnar Joint Replacement in Patients Under 40 Years of Age Hypothesis: Palmar-shelf arthroplasty (PSA) is an excellent surgical treat- Level 4 Evidence ment alternative for rheumatoid arthritis of the wrist. Methods: The PSA procedure consists of a resection of the distal radius © Antonio Rampazzo, MD preserving the volar cortex (palmar-shelf), distal ulna excision to achieve © Bahar Bassiri Gharb, MD, FEBOPRAS euvariance, scapholunate repair, and collagenebone wax interposition. An © Rebecca Jones, MS external fixator is applied in distraction for 6 weeks, with cast immobili- Luis R. Scheker, MD  zation until 3 months postoperatively. Hypothesis: The proposed method of distal radioulnar joint (DRUJ) There were 9 female and 4 male patients. Age at the time of surgery replacement can be effectively used to treat joint ostheoarthritis or insta- was 32 to 54 years (average, 43 y). Age at the time of follow-up was bility in young patients without an increase in complication rates. 46e65 years (average, 56 y). Patients were interviewed, examined, and Methods: A retrospective study was performed in patients under 40 years of x-rayed for the study. A questionnaire using a pain analog scale as well as age who underwent total DRUJ replacement. Patients’ charts were reviewed the QuickeDisabilities of the Arm, Shoulder, and Hand and MASS scoring and age at surgery, profession, hobbies, comorbidities, diagnosis, previous systems were completed to compare preoperative and postoperative sub- procedures, and complications were recorded. Preoperative and post- jective reports and wrist function. Standard error was calculated at a operative Disabilities of the Arm, Shoulder, and Hand and Patient-Rated confidence level of 95%. Preoperative to postoperative comparison used Wrist Evaluation scores, visual analog scores, grip strength, lifting capacity, the 2-sample t-test to derive the P value. wrist pronation, supination, flexion, extension, and radial and ulnar devia- Results: One patient required wrist fusion at 1 year postoperatively for wrist tion were registered. The differences between the pre- and postprocedure instability. Those data were excluded from the analysis of the series. Of the values were studied with a paired t-test. remaining 12 patients, none have requested or required a revision proce- Results: A total of 53 joints were replaced in 48 patients. Five patients had dure. All remaining patients experienced improvement with both pain and replacement of bilateral joints. The average age at the time of surgery was function. Patient satisfaction was very high. No wrist fused spontaneously. 31 years (range, 18e39 y). Twelve patients presented with comorbidities: Scoring results demonstrated a consistent decrease in the pain analog scale Ehlers-Danlos syndrome (2), Madelung deformity (5), connective tissue at rest ranging from 5 to 8 preoperatively to 0 to 2 postoperatively, and with disease (2), postburn scarring (1), stroke (1), and cervical radiculopathy (1). usage from 6 to 9 preoperatively to 1 to 3 postoperatively. The MASS score Forty-eight patients underwent surgery for ostheoarthritis, and 5 for decreased 40% to 100%, with an average of 75.5% 9.8% improvement. Æ

© Speaker has nothing of financial value to disclose e39 The QuickeDisabilities of the Arm, Shoulder, and Hand score decreased animals after nerve injury and only slightly increased up to 1.5-fold. His- from a score of 50 to 82 (average 63.4 5.7) to 0 to 36 (average 15.5 , tological analysis revealed differences in axon diameter and nerve fascicle 6.1) for a series composite of 76.0% 9.0%Æ improvement. This differenceÆ area relative to total cross-sectional area between age groups at different Æ was statistically significant (P < .001). Wrist range of motion averaged time points. The total number of axons was similar in both groups at each 35 6.5 extension and 32 3.6 flexion, for a motion arc of 67 time point (P > .05). Æ Æ Æ 8.2. Radiographic results demonstrated maintenance of radiocarpal pseu- Summary: darthrosis and sagittal plane alignment with ulnar translocation of the The significant reduction of MCP-1 expression in old animals revealed that  carpus, creating an equally weighted 2-bone forearm. aging affects the ability for sustained upregulation of the MCP-1 gene in Summary: In 1970, PSA was introduced by Chase as a resectional wrist response to injury, whereas the inflammatory response remained similar. arthroplasty. In 1999, this author reported results of 14 patients treated with Macrophage recruitment and activation may be decreased compared with  PSA and observed for 4.2 years. In the current series, the author reports the young animals, limiting the rate of myelin clearance during Wallerian long-term results of 12 patients treated with PSA, observed for 10 to degeneration. 20 years (average, 13.2 y). In the short, intermediate, and now long term, follow-up palmar shelf arthroplasty consistently yields satisfactory results. Contracted Research with: Wright Medical Palmar-shelf arthroplasty compares favorably with reported results of both  wrist arthrodesis and implant arthroplasty.

REFERENCES PAPER 61 1. Albright JA, Chase RA. Palmar-shelf arthroplasty of the wrist in rheumatoid Clinical Paper Session 14: Basic Science/Microsurgery arthritis: a report of nine cases. J Bone Joint Surg Am. 1970;52(5):896e906. Saturday, October 5, 2013 10:15e10:21 AM  2. Skoff H. Palmar-shelf arthroplasty: a follow-up note. J Bone Joint Surg Am. Category: Nerve/Neuromuscular 1988;70(9):1377e1382. Keyword: Hand 3. Skoff H. Palmar-shelf arthroplasty, the next generation: distraction/interposition for rheumatoid arthritis of the wrist. Plast Reconstr Surg. 1999;104(7): Comparison of Magnification in Primary Digital Nerve 2068e2072. Repair: Literature Review, Survey of Practice Trends, 4. Cavaliere CM, Chung KC. A systematic review of total wrist arthroplasty and Assessment of 90 Cadaveric Repairs compared with total wrist arthrodesis for rheumatoid arthritis. Plast Reconstr Not a clinical study Surg. 2008;122(3):813e825. © Derek T. Bernstein, MD © PAPER 60 Kristy L. Hamilton, BA © Christian Foy, MD Clinical Paper Session 14: Basic Science/Microsurgery © Nancy Petersen, PhD Saturday, October 5, 2013 10:05e10:11 AM David T. Netscher, MD   Category: Basic ScienceeLab Research Hypothesis: There is no consensus on the optimal magnification level for Keyword: Other digital nerve repair despite the importance of adequate visualization. We The Influence of Age on Chemotactic and Inflammatory hypothesized that microscopic magnification is associated with superior Marker Expression in Rats Following Peripheral Nerve Injury digital nerve repairs, and that despite this, hand surgeons do not uniformly Not a clinical study prefer 1 form of optical assistance over another. Methods: © F. Johannes Plate, MD 1. Published clinical outcomes of digital nerve repair accounting for © Jiaozhong Cai, MLT magnification level were reviewed. © Thomas L. Smith, PhD 2. Members of the American Society for Surgery of the Hand were sur-  Zhongyu Li, MD, PhD veyed regarding their surgical practices. Hypothesis: The rate of Wallerian degeneration after peripheral nerve injury 3. A total of 90 cadaveric digital nerve repairs required to achieve 80% power were performed by 9 hand surgeons using loupe ( 2.5 is limited by the clearance of myelin debris by macrophages. Increasing age  to 4.0) or microscopic ( 12.5) magnification. To ensure concor- lowers the rates of nerve recovery. This study hypothesized that inflam-   matory and monocyte chemotactic factor-1 (MCP-1) expression from dance, each repair was evaluated by 2 attending hand surgeons, Schwann cells in response to nerve injury decreases with age, resulting in who were blinded to the study protocol, using a visual grading decreased macrophage recruitment and activation. scale (Fig. 1). Univariate and multivariate analyses were used to Methods: In 15 young (mean weight, 146 g) and 15 old (mean weight, evaluate repairs. 471 g) Lewis rats, unilateral sciatic nerve crush injury was induced. Both Results: sciatic nerves from 5 animals in each group were harvested at 1, 3, and 1. Six relevant publications were identified, involving 130 repairs with 10 days after injury. Ribonucleic acid was extracted using TRI reagent loupes ( 4 to 6) and 255 by microscope. Univariate analysis revealed   (Ambion) and assessed for quantity and purity (NanoDrop Technologies) no statistically superior clinical outcomes using high-powered loupes and viability (electrophoresis). The RNA was transcribed to cDNA using ( 4 to 6) versus microscopic magnification, with no data on lower-   random hexamers and Superscript II (Invitrogen). Real-time polymerase magnification loupes more commonly used in practice. chain reaction was performed using Taqman (Applied Biosystems) for 2. Survey data indicated that 52% of hand surgeons use microscopes and tumor necrosis factor-a, interleukin-6, and MCP-1 as target genes and 48% used loupes for digital nerve repair. Of those preferring loupes, glyceraldehyde 3-phosphate dehydrogenase as endogenous control. Histo- 78.4% used 2.5 to 3.5 magnification. Furthermore, 75% of   logical analysis of axon diameter, the number of axon, and the mean nerve respondents worked in surgicenters, of which only 68.9% had access fascicle area was performed. to a designated operative microscope. Results: In old animals, MCP-1 expression increased 10.6-fold on day 1, but 3. Univariate and subsequent multivariate analysis of the cadaveric was significantly reduced at 3 (0.3-fold) and 10 days (1.3-fold) after injury repairs demonstrated excellent repairs in 60.0% of microscope re- (P .05). Tumor necrosis factor-a expression was increased 24.6-fold in pairs versus 28.9% of loupe repairs (odds ratio, 3.9; 95% confi- ¼ old animals and 20.0-fold in young animals on day 1 (P > .05) and dence interval, 1.5e10.2), with excellent concordance between the remained similar in old animals on day 3 (5.6-fold) and day 10 (12.2-fold) evaluating surgeons (Fig. 2). The surgeon, level of training, repair compared with young animals on day 3 (14.3-fold; P > .05) and day 10 time, and stitches per repair were not significantly related to an (15.1-fold; P > .05). Interleukin-6 expression was similar in old and young excellent repair. e40 © Speaker has nothing of financial value to disclose PAPER 62 Clinical Paper Session 14: Basic Science/Microsurgery Saturday, October 5, 2013 10:25e10:31 AM  Category: Basic ScienceeLab Research Keyword: Other Osteogenesis of Vascularized Tissue-Engineered Bone Scaffold Constructs Not a clinical study

© Kenichi Nakano, MD © Keiichi Murata, MD, PhD © Takamasa Shimizu, MD © Manabu Akahane, MD, PhD © Shohei Omokawa, MD, PhD © Yasuhito Tanaka, MD, PhD Hypothesis: This study aimed to investigate osteogenic potential of a vas- cularized tissue-engineered bone (VTEB), which was generated by implanting vascular bundle and osteogenic matrix cell-sheet (OMCS) into a b-tricalcium phosphate (ß-TCP) scaffold. We hypothesized that the OMCS would enhance angiogenesis as well as osteogenesis of the ß-TCP with vascular bundle, enabling generation of a VTEB scaffold with osteogenic potential. Figure 1: Visual grading scale for cadaveric digital nerve repair Methods: The OMCS was harvested by subculturing mesenchymal stem evaluation. cells (MSCs), obtained from a 7-week-old Fisher 344 rat, in standard medium containing dexamethasone and ascorbic acid phosphate for 2 weeks. A cylindrical-shaped ß-TCP (6 mm in diameter, 10 mm in length, 75% porosity) with a groove 2 mm wide was prepared. In an 11-week-old rat, the femoral artery and vein were elevated as a vascular bundle and were integrated into the groove of ß-TCP. We designated the following 3 groups (n 8 in each group). In group V, the vascular bundle was implanted to the ¼ ß-TCP, in group cV, the vascular bundle was implanted to the ß-TCP in which the MSC cell suspension was carried, and in group sV, the vascular bundle surrounded by the OMCS was implanted into the ß-TCP. Samples from each group were extirpated 4 weeks after the implantation to compare histological images and results of angiogenesis/osteogenesis by quantitative reverse-transcription polymerase chain reaction. Statistical significant was determined by 1-way analysis of variance post-hoc multiple comparisons using Tukey’s test, and values of P < .05 were considered statistically significant. Results: The histological images in the group sV showed vigorous vascu- larization and new bone formation radially from the vascular bundle (Fig. 1). The expression levels of mRNAs of alkaline phsophatase (ALP),

web 4C = FPO bone morphogenetic protein-2 (BMP2), osteocalcin (OC) and vascuar Figure 2: Visual grading scale outcomes of cadaveric digital nerve endothelial growth factoreA (VEGF-A) were significantly higher in group repair using microscopr versus loupe magnification. sV than in the other groups (P < .001). The expression levels of mRNAs of ALP and OC were higher in group cV than in group V (P < .01), and no significant difference was observed between those of BMP2 and VEGF-A Summary: in groups V and cV (Fig. 2). There is no consensus on the optimal magnification level for digital  neurorrhaphy in the literature despite the importance of adequate visu- alization for epineurial repair. More important, the loupe magnifications employed in these studies did not coincide with those currently used in practice, which limits their application. Our survey of members of the American Society for Surgery of the  Hand confirms the broad range of magnification levels used for digital nerve repairs. Furthermore, our survey highlights a significant number of hand surgeons without access to a designated operative microscope. Our cadaveric study indicates the clear superiority of microscopic  magnification in digital nerve repair. Our findings suggest that higher magnification levels might be associated with improved clinical outcomes. Figure 1: Histological observation at 4 weeks postoperatively (hema- toxylin-eosin stain). In group sV, new bone formation and vasculariza- tion were observed more than in group cV, whereas group V showed Consulting Fees (eg, advisory boards) received from: Deputy Editor, no neonatal bone, although a small amount of vascularization was  Journal of Hand Surgery observed in beTCP.

© Speaker has nothing of financial value to disclose e41 often do not relieve the patient’s symptoms. We hypothesized that a novel composite polymer “neoligament” would be able to be seeded with progenitor cells, and growth factors would be able to regenerate native ligamentous tissue. Methods: Polycaprolactone fumarate (PCLF), a novel polymer previously described in our laboratory, were synthesized into macroporous scaffolds (pore sizes, 500 e750 mm) to allow cellecell communication and nutrient flow. Porous scaffold molds were designed using SolidWorks CAD soft- ware and printed using a SolidScape 3-dimensional printer. Adipocyte- derived human mesenchymal stem cells were harvested and cultured in Dulbecco’s modified Eagle’s medium and 10% fetal bovine serum. The analysis compared this medium with a medium composed of Dulbecco’s modified Eagle’s medium with 5% platelet lysate (PL), a mixture of platelet release products. Seeding of scaffolds occurred in a dynamic bioreactor. Assays included cellular proliferation (MTS), viability (live/dead immu- nostaining), differentiation (aminoglycan, alkaline phosphatase, and total collagen), and immunostaining for collagen I, tenascin-C, and collagen III (ligament differentiation markers). Results: The PCLF scaffolds were created with pore sizes of 500 or 750 mm and porosities of 45% and 60%, respectively. After comparing multiple toxicity protocols to remove toxic byproducts, the preferred regimen led to pore shrinkage by 10%. After dynamic cell seeding of the progenitor cells on the PCLF, the cells remained viable for 2 weeks cultured on in vitro Figure 2: Expression levels of mRNAs in each group at 4 weeks post- culture plates (Fig. 1). The cell density throughout the pores and metabolic operatively (data are shown as mean SD; n 6). *P < .001, †P < .01. activity of the scaffolds increased as cell proliferation continued along Æ ¼ ALP, alkaline phosphatase; BMP2, bone morphogenetic proteine2; OC, the 3-dimensional PCLF scaffolds (P < .05). Adipocyte-derived human osteocalcin; VEGF-A, vascular endothelial growth factoreA; GAPDH, mesenchymal stem cell proliferation rates increased in PL compared with glyceraldehyde-3-phosphate dehydrogenase. fetal bovine serum (P < .05). The cells had a low baseline expression of alkaline phosphatase and aminoglycan, but increased expression of total collagen when induced by the ligament and tenogenic growth factor Summary: fibroblast growth factore2 (P < .05). This effect was significantly This study demonstrated the possibility of VTEB graft using the OMCS. augmented when cultured in the presence of PL (P < .01). Immunostaining  Addition of OMCS increased the expression levels of VEGF-A mRNA, at 2 and 4 weeks for the expression of ligament markers tenascin-C and  which indicates enhanced angiogenic potential in the vascular bundle collagen I significantly increased with fibroblast growth factor and PL, implanted ß-TCP. comparable to human fibroblasts grown on the PCLF scaffolds (Fig. 2). Increased ALP, BMP2, and OC mRNA expression was observed in the Summary: Our results demonstrate that adipocyte-derived human mesen-  vascular bundle implanted ß-TCP, with OMCS higher than that with chymal stem cells are able to attach, proliferate, and differentiate into suspended MSCs, which indicates that addition of OMCS maintained a ligamentous phenotypes along the porous PCLF scaffold. This novel high osteogenic potential at 4 weeks after vascular bundle implantation. scaffold has potential in stem cell engineering and ligament regeneration.

REFERENCES 1. Akahane M, Nakamura A, Ohgushi H, et al. Osteogenic matrix sheet-cell transplantation using osteoblastic cell sheet resulted in bone formation without scaffold at an ectopic site. J Tissue Eng Regen Med. 2008;2(4):196e201. 2. Nakamura A, Akahane M, Shigematsu H, et al. Cell sheet transplantation of cultured mesenchymal stem cells enhances bone formation in a rat nonunion model. Bone. 2010;46(2):418e424.

PAPER 63 web 4C = FPO Figure 1: Adipocyte-derived mesenchymal stem cells (aMSCs) seeded Clinical Paper Session 14: Basic Science/Microsurgery and cultured over 14 days on the PCLF scaffolds. Saturday, October 5, 2013 10:35e10:41 AM  Category: Basic ScienceeLab Research Keyword: Wrist Novel Porous Polycaprolactone Fumarate (PCLF) Scaffold for Adipocyte-Derived Mesenchymal Stem Cell Engineering and Platelet LysateeEnhanced Ligament Differentiation Not a clinical study

© Eric R. Wagner, MD

© Dalibel Bravo, BS web 4C = FPO © Steven Chase, BS Figure 2: Tenascin-C and collagen I immunostaining after aMSCs © Michael J. Yaszemski, MD, PhD were cultured for 4 weeks on the PCLF scaffolds under different © Mahrokh Dadsetan, PhD conditions. Red signal is tenascin-C or collagen I; blue is 4’,6-diamidino- 2-phenylindole)  Sanjeev Kakar, MD, MBA Hypothesis: Intra-articular ligament injuries are difficult to treat because of Consulting Fees (eg, advisory boards) received from: Arthrex, Inc  their poor regeneration potential; current attempts at surgical reconstruction Other Financial/Material Support received from: Arthrex, Inc  e42 © Speaker has nothing of financial value to disclose PAPER 64 DASH, and pain were compared between the preoperative and follow-up groups by paired t-test and linear regression to identify significant differences Clinical Paper Session 15: Finger Joint Arthritis and trends in long-term follow-up. Saturday, October 5, 2013 2:15e2:21 PM  Results: There was significant improvement between mean preoperative and Category: Arthroplasty follow-up ROM, DASH, and pain, with P values of .0006, .0007, and < .0001, Keyword: Hand respectively. Mean follow-up ROM, DASH, and pain scores were 69.5 3.0, 15.0 2.3, and 0.76 0.2, respectively. Linear regression showed signiÆficant Silicone Implant Arthroplasty for Nonrheumatic Æ Æ correlations between preoperative measurements and improvement at follow- Metacarpophalangeal Osteoarthritis up for ROM, DASH, and pain, with P values of .0003, .0310, and < .0001, Level 4 Evidence respectively. There was no significant difference for grip (P .593) or pinch ¼ © Mithun K. Neral, BS (P .296) strength when follow-up operative and nonoperative hand strengths ¼ © Douglas E. Pittner, MD were compared. Results of the questionnaire showed that 73% were “very

 Joseph E. Imbriglia, MD satisfied,” 87% would “definitely do it again,” and 70% experience “rare or no pain.” Follow-up x-rays showed 5 mean angulation and 2 mm mean subsi- Silicone arthroplasty of the metacarpophalangeal joint (MCP) is  Hypothesis: dence compared with immediate postoperative x-rays. Four arthroplasties a well-established treatment for rheumatoid arthritis.1,2 However, available required revision, for a revision rate of 11%. literature on treatment of nonrheumatic arthritis is limited to case reports Summary: and retrospective reviews of small patient populations. The purpose of this Results from this study show improved ROM and DASH score, excellent study was to evaluate the clinical effectiveness of MCP arthroplasty for  pain relief, and excellent patient satisfaction in patients undergoing MCP nonrheumatic arthritis in a larger group of patients with a longer follow-up arthroplasty for nonrheumatic arthritis. period. We hypothesized that MCP arthroplasty for nonrheumatic arthritis Patients with more severe ROM limitation, DASH score, and pain score would show significant improvement in hand function, pain relief, and  experienced a greater improvement of these measures at follow-up. overall patient satisfaction. Strength improvement was limited although it remained comparable to A search of all MCP arthoplasties performed by a single surgeon for  Methods: the nonoperative hand. nonrheumatic arthritis over a 12-year period found 136 arthroplasties. Of Angulation, subsidence, and complications in the study population were these, adequate prospective follow-up assessment could be completed for 30  1,3,4 consistent with those reported in current literature. patients with 38 MCP arthroplasties at 56 months average postoperative time. Objective measures included arc range of motion (ROM), grip and pinch strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and visual analog pain score. Follow-up x-rays were reviewed. Patients also REFERENCES completed a subjective patient satisfaction questionnaire. Mean ROM, 1. Rettig LA, Luca L, Murphy MS. Silicone implant arthroplasty in patients with idiopathic osteoarthritis of the metacarpophalangeal joint. J Hand Surg Am. 2005;30(4):667e672. 2. Namdari S, Weiss AP. Anatomically neutral silicone small joint arthroplasty for osteoarthritis. J Hand Surg Am. 2009;34(2):292e300. 3. Foliart DE. Swanson silicone finger joint implants: a review of the literature regarding long-term complications. J Hand Surg Am. 1995;20(3):445e449. 4. Abboud JA, Beredjiklian PK, Bozentka DJ. Metacarpophalangeal joint arthro- Figure 1: Correlating preoperative measurements to improvement at plasty in rheumatoid arthritis. J Am Acad Orthop Surg. 2003;11(3):184e191. follow-up of arc ROM (left), DASH score (middle), and visual analog pain Royalties/Honoraria received from: Auxilium (Xiaflex Presentations) score (right). All 3 measures showed significant correlations by linear  Consulting Fees (eg, advisory boards) received from: AuxiliumeXiaflex, regression, with P values of .0003, .0310, and < .0001 and R values of  Acumed 0.607, 0.524, and 0.971, respectively.

PAPER 65 Clinical Paper Session 15: Finger Joint Arthritis Saturday, October 5, 2013 2:25e2:31 PM  Category: Arthritis Keyword: Hand Thumb Carpometacarpal Fusion With Distal Scaphoid Excision: A Novel Procedure for Pantrapezial Arthritis in the High-Demand Hand: A Clinical and Biomechanical Study Level 4 Evidence

© Gary M. Lourie, MD © Scott Tanaka, MD © James Marino, MD

Hypothesis: Thumb carpometacarpal (CMC) fusion combined with distal scaphoid excision (DSE) improves range of motion (ROM) compared with fusion alone. This procedure may prove advantageous in the high-demand pantrapezial arthritic thumb. Methods: Thirteen fresh-frozen cadaveric specimens underwent fluoroscopic evaluation in the posteroanterior (PA) plane with the thumb in radial Figure 2: Results from the subjective survey showed mean values of abduction and adduction. In the lateral plane, thumb palmar abduction and 3.75 0.07, 3.87 0.06, 3.61 0.10, 3.47 0.10, and 3.03 0.13 for adduction were measured. A CMC fusion was then simulated by passing Æ Æ Æ Æ Æ overall satisfaction, willingness to do the procedure again, pain, func- 2 1.6-mm K-wires across the joint. The same 4 flouroscopic images were tion, and strength, respectively. taken after the fusion. The distal scaphoid was then excised and the

© Speaker has nothing of financial value to disclose e43 4 images were again obtained. The angle between the index finger meta- carpal and thumb metacarpal was recorded. Statistical analysis was performed using Wilcoxon signed-rank test. Eight patients, all deemed high demand with pantrapezial disease, underwent CMC fusion with DSE to prevent postoperative subsidence seen in conventional arthroplasty. Outcome measures included subjective assessment along with preoperative and postoperative ROM, pinch, and grip strength. Results: The mean arcs of motion in the PA plane prefusion, postfusion, and postfusion with DSE were 48.5, 25.1, and 34.6, respectively. An increase in arc of motion of 9.5 (P .0002) was obtained after DSE compared ¼ with thumb CMC fusion alone. In the lateral plane, the mean arcs of motion prefusion, postfusion, and postfusion with DSE were 53.4, 22.4 and 33.6, respectively. A statistically significant increase in arc of motion of 11.2 (P .0005) in the lateral plane was obtained after DSE compared with thumb CMC¼ fusion alone. This was a 20% (P .0002) and 21% (P .0005) increase in ¼ ¼ prefusion range of motion in the PA and lateral planes, respectively, from fusion alone compared with fusion and DSE. All 8 patients healed unevent- fully; showed no radiographic subsidence; achieved pain relief; and on objective evaluation demonstrated improved pinch and grip, and ROM, and were able to flatten the palm without difficulty. Summary: An increase in ROM in both the PA and lateral planes was observed after  DSE combined with fusion compared with CMC fusion alone, as shown in this cadaveric biomechanical study. Although thumb CMC fusion provides symptomatic relief, ROM is  significantly limited. Patients are often unable to place the palm flat on a table postfusion. Distal scaphoid excision improves ROM and addresses the scapho-  trapezotrapezoidal joint in patients with pantrapezial arthritis while maintaining the potential benefits of improved strength and decreased risk of subsidence in the younger, high-demand patient. web 4C = FPO Figure 1: Preoperative x-ray of the left hand of a patient with pan- trapezial arthritis. REFERENCES 1. Armstrong AL, Hunter JB, Davis TR. The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. J Hand Surg Br. 1994;19(3): 340e341. 2. Pellegrini VD Jr. Osteoarthritis at the base of the thumb. Orthop Clin North Am. 1992;23(1):83e102. 3. Barron OA, Glickel SZ, Eaton RG. Basal joint arthritis of the thumb. J Am Acad Orthop Surg. 2000;8(5):314e323. 4. Conolly WB, Rath S. Revision procedures for complications of surgery for osteoarthritis of the carpometacarpal joint of the thumb. J Hand Surg Br. 1993;18(4):533e539. 5. 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):20e26. 6. 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(1):157e169. 7. Malerich MM, Clifford J, Eaton B, Eaton R, Littler JW. Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis secondary to scaphoid nonunion. J Hand Surg Am. 1999;24(6):1196e1205. 8. Corbin C, Warwick D. Midcarpal instability after excision arthroplasty for scapho- trapezial-trapezoid (STT) arthritis. J Hand Surg Eur Vol. 2009;34(4):537e538. 9. Fulton DB, Stern PJ. Trapeziometacarpal arthrodesis in primary osteoarthritis: a minimum two-year follow-up study. J Hand Surg Am. 2001;26(1):109e114.

PAPER 66 Clinical Paper Session 15: Finger Joint Arthritis Saturday, October 5, 2013 2:35e2:41 PM  Category: Arthroplasty Keyword: Hand Suture Fixation Versus Reconstruction in CMC Arthroplasty: Double-Blind RCT Level 2 Evidence web 4C = FPO Figure 2: One-year postoperative x-ray after thumb carpometacarpal © ▲Michael S. Shuler, MD fusion and distal scaphoid excision. © ▲Mellisa Roskosky, MSPH

e44 © Speaker has nothing of financial value to disclose Hypothesis: Participants who receive the suture fixation technique will score significantly higher on functional outcome measures and will demonstrate greater strength and flexibility compared with patients who receive ligament reconstruction with tendon interposition. Methods: Study participants were randomly assigned to 1 of 2 groups of 30 patients (60 total participants). Subjects in both groups underwent a trapeziectomy. In the investigational group, the trapeziectomy was followed by a ligament reconstruction using a suture fixation system to restore thumb metacarpal alignment, without tendon interposition. In the control group, it was followed by the use of harvested flexor carpi radialis to reconstruct the palmar oblique ligament. Both groups went through identical immobilization procedures and therapy regimens. Overall functionality was measured using the Disabilities of the Arm, Shoulder, and Hand questionnaire score, assessed at baseline and at each follow-up visit. Participants were also asked to rate their pain from 0 to 10 at each follow-up visit. Measurements were taken at baseline and each follow-up visit from 6 weeks onward to assess strength (grip strength and key and tip pinch strength) and range of motion (radial and palmar abduction). Data collected at baseline and 2 weeks, 6 weeks, 3 months, and 6 months postoperatively were analyzed using t-tests and linear regression modeling. Results: There was no significant difference detected in Disabilities of the Arm, Shoulder, and Hand score or analog pain scale between the investi- gational and control groups at baseline or any follow-up visits. Strength and range of motion measurements at each follow-up visit were standardized by each patient’s baseline measurements. Similar to the functionality results, the groups did not differ significantly on any of these measures during the follow-up period. Operative time was significantly shorter in the investi- gational group, by 9.6 minutes. Summary: Despite finding no significant difference in functionality, strength, and  range of motion, we believe these results indicate that the 2 techniques are at least equivalent procedures. Using a suture fixation system to reconstruct the ligament eliminates the  need to harvest a tendon from the wrist, making it both a shorter and potentially less invasive alternative. To date, there have been no reports on the outcome of this stabilization  technique. These are the first reported data. ▲ This presentation will discuss Mini Tight-Rope by Arthrex

PAPER 67 Clinical Paper Session 15: Finger Joint Arthritis Saturday, October 5, 2013 2:45e2:51 PM  Category: Arthritis Keyword: Hand Sixteen-Year Experience of the ARPE Prosthesis for Symptomatic Trapezial-Metacarpal Osteoarthritis Level 4 Evidence

 Nicholas J. Goddard, FRCS Hypothesis: Sixteen years of experience are presented of trapezial-metacarpal joint replacement for Eaton stage 2 and 3 disease using an ARPE implant (Biomet). This is a ball and socket design with hydroxyapatite-coated metacarpal stems, a hydroxyapatite-coated high-density polyethylene/CoCr hemispherical socket, and a modular 4-mm head/neck component with variable offsets. Methods: This study reviews experience with 202 patients over a 16-year period, with a predominantly female population and mean age of 58.3 years. All patients were reviewed clinically (using the Disabilities of the Arm, Shoulder, and Hand questionnaire) and radiologically. Results: Of the 227 prostheses with a mean 7.8-year follow up (range, 1e16 y), 93% of implants were still in situ and functioning well. Complications can be divided into early and late. Four patients had early dislocations that were

© Speaker has nothing of financial value to disclose e45 either simply reduced or revised using a different head and neck compo- the study was cited (r 0.138; P .390), although this may be ¼ ¼ nent. The late dislocations were revised to simple excision arthroplasty. underpowered. There were 6 cases of loosening, 1 of trapezial fracture, and 5 of docu- Summary: mented wear. Overall, 7% were revised; a further 4% had radiological Despite an overall improvement in RCTs over the past decade, a large  evidence of loosening and were asymptomatic. number of studies were of poor quality based on MCMS and Jadad scale. Summary: Green stated in 2003 that “total joint arthroplasty appears Even with a high level of evidence, the study design and execution of not to offer any compelling functional advantage or durability of  RCTs should be critically assessed. trapezial excision and ligament reconstruction, and is clearly fraught Common methodological deficiencies include lack of power analysis,  with a high complication rate,” but our data suggest that this is in fact lack of withdrawal and dropout description, and failure to use validated a pessimistic view. Trapezial-metacarpal joint replacement using an outcomes assessments. These deficiencies may introduce bias and lead to ARPE implant provides excellent pain relief (which in a limited pa- statistically underpowered studies. tient cohort is preferable to ligament reconstruction with tendon interposition), good function, and in the event of failure, uncompli- REFERENCES cated potential for salvage. 1. Cowan J, Lozano-Calderon S, Ring D. Quality of prospective controlled ran- domized trials: analysis of trials of treatment for lateral epicondylitis as an Consulting Fees (eg, advisory boards) received from: Acumed example. J Bone Joint Surg Am. 2007;89(8):1693e1699.  2. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Scand J Med Sci Sports. 2000;10(1):2e11. PAPER 68 3. Bhandari M, Richards RR, Sprague S, Schemitsch EH. The quality of reporting of randomized trials in the Journal of Bone and Joint Surgery from 1988 through Clinical Paper Session 16: Evidence/Clinical Guidelines 2000. J Bone Joint Surg Am. 2002;84(3):388e396. Saturday, October 5, 2013 2:15e2:21 PM 4. Devereaux PJ, McKee MD, Yusuf S. Methodologic issues in randomized controlled  Category: Other trials of surgical intervention. Clin Orthop Relat Res. 2003;(413):25e32. Keyword: Other 5. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996; The Quality of Randomized Controlled Trials in Hand, Wrist, 17(1):1e12. and Elbow Surgery: A Critical Analysis of Current Literature 6. Balasubramanian SP, Wiener M, Alshameeri Z, Tiruvoipati R, Elbourne D, Not a clinical study Reed MW. Standards of reporting of randomized controlled trials in general surgery: can we do better? Ann Surg. 2006;244(5):663e667. © Jaehon M. Kim, MD 7. Sinha S, Sinha S, Ashby E, Jayaram R, Grocott MPW. Quality of reporting in © Ryan Michael Zimmerman, MD randomized trials published in high quality surgical journals. J Am Coll Surg. © Christopher M. Jones, MD 2009;209(5):565e571. © Norman H. Dubin, PhD Royalties/Honoraria received from: Integra LifeSciences, Inc © James P. Higgins, MD  Ownership Interest (stocks, stock options, or other ownership interest Kenneth R. Means, Jr, MD   excluding diversified mutual funds) with: Stryker and Zimmer stock Hypothesis: We hypothesized that randomized controlled trials (RCTs) in owner hand, wrist, and elbow surgery are of varying quality based on standardized metrics. Methods: We selected the 6 most frequently cited journals that regularly PAPER 69 publish hand, wrist, and elbow surgery manuscripts, based on 5-year average impact factors from the 2011 Journal Citation Reports. Using Clinical Paper Session 16: Evidence/Clinical Guidelines PubMed and journal-specific search query, we identified and screened Saturday, October 5, 2013 2:25e2:31 PM  2,114 articles. A total of 63 RCTs met the inclusion criteria for analysis. Category: Other Two authors were blinded to the study protocol and randomly assigned Keyword: Other to each paper. The reviewers used the Modified Coleman Methodology fi Score (MCMS) and Jadad scale (5-point validated quality measure) to Citation Accuracy for Scienti c Articles Published in Journal assess manuscript quality and the Consolidated Standards for Reporting of Hand Surgery (American) in 2011 of Trials statement to assess the completeness of reporting. We compared Not a clinical study study characteristics and methodology variables with the manuscript © Suhail K. Mithani, MD quality using Fisher’s exact test and 2-tailed Student’s t-tests in uni- © Daniel Blizzard, MD variate analysis. Pearson coefficient (R) determined the strength of  Marc J. Richard, MD correlation between the number of citations and the quality of the © David S. Ruch, MD studies. Fraser J. Leversedge, MD Results: There was a strong correlation between Jadad scale and MCMS  (R 0.73; P < .001) and between Consolidated Standards for Reporting Hypothesis: Previously, reference listings in the Journal of Hand Surgerye ¼ of Trials statement completeness and MCMS (R 0.74; P < .001). Based American (J Hand Surg Am) were reviewed for accuracy and improvement on MCMS, 9 studies were good, 25 were fair,¼ and 29 were poor. None was associated with a more stringent reporting process at the time of were graded excellent. Randomized controlled trial quality has signifi- manuscript submission.1 The accuracy of citations in supporting a statement cantly improved between 2001 and 2005 and 2006 and 2012 (P .006), of fact, however, has not been evaluated. The purpose of this study was ¼ and the top journal based on impact factor had a higher number of good to evaluate the accuracy of citation listing and the ability of the reference to quality RCTs (P .025). Important methodological deficiencies in poorly support a statement in scientific articles published in J Hand Surg Am ¼ scoring RCTs include lack of power analysis (P .002), lack of with- in 2011. ¼ drawal and dropout description (P .007), and failure to use validated Methods: All scientific articles for 3 months of J Hand Surg Am in 2011 ¼ outcomes assessments with an independent investigator (P < .001). In- were identified. Statements of fact were identified by the authors in dividual study quality was not associated with geography, funding, con- 40 articles and citation support for each statement was assessed by criteria flict of interest, or multicenter trials. Among studies published more than 3 described by Eichorn and Yankauer.2 Major errors were defined by the years ago (N 41), the quality of RCTs did not correlate with how often followein: (1) the cited reference did not substantiate the assertions of the ¼ e46 © Speaker has nothing of financial value to disclose author(s), (2) the cited reference contradicted the statement, or (3) the cited PAPER 70 reference was not related to the topic. Minor errors involved over- simplifications or generalizations of a cited reference. If a reference was Clinical Paper Session 16: Evidence/Clinical Guidelines Saturday, October 5, 2013 2:35e2:41 PM cited more than once, appropriateness of the citation was assessed for each  occurrence. Category: Evaluation/Diagnosis/Clinical Treatment Results: A total of 1,022 citations of fact or conclusion were assessed in Keyword: Hand 40 articles. All citation listings were accurate. Eighty-five total errors were Opinions Regarding Management of Hand and Wrist identified (8.3% of all citations). Of these, 26 major errors and 59 minor Injuries in Elite Athletes: A Survey of Consultant Hand errors were identified. Errors were identified in 21 of 40 articles reviewed. Of 26 major errors, 19 (73%) were identified in instances where multiple Surgeons Level 5 Evidence citations were assigned to a single statement of fact. Summary: The accuracy of citation listings in J Hand Surg Am has improved  Christopher J. Dy, MD, MSPH considerably since a previous review in 2003; nevertheless, the inaccurate © Ekaterina Khmelnitskaya, MD use of references to support a statement of fact in scientific articles remains © Krystle A. Hearns, MA a concern. Inaccurate use of references occurs more frequently when  Michelle Gerwin Carlson, MD multiple citations are used to support a single statement; and often, review articles are used to support scientific statements. Hypothesis: Decisions regarding appropriate treatment for hand and wrist injuries in elite athletes, the timing of treatment, and return to play are made while balancing desires to resume athletic activities and sound orthopedic principles. There is little recognition in the literature of the need for a REFERENCES different approach when treating these injuries in elite athletes, and timing 1. Jackson K, Porrino JA Jr, Tan V, Daluiski A. Reference accuracy in the Journal of to return to play. This study further explored the complexities of treating Hand Surgery. J Hand Surg Am. 2003;28(3):377e380. hand and wrist injuries in the elite athlete. 2. Eichorn P, Yankauer A. Do authors check their references? A survey of accuracy Methods: A total of 37 consultant hand surgeons for teams in the National of references in three public health journals. Am J Public Health. 1987;77(8): Football League, National Basketball Association, and Major League 1011e1012. Baseball completed an electronic survey about the management of common Contracted Research with: Orthohelix Surgical Designs (D.S.R., F.J.L.); hand injuries. This survey included questions about indications for surgery,  Axogen (F.J.L.) return to protected play, and return for unprotected play (Table 1). Cross-tab Royalties/Honoraria: OrthoHelix Surgical Designs (F.J.L.) calculations and chi-square analysis were performed. Responses were  Ownership Interest (stocks, stock options, or other ownership interest compared by sport treated by the surgeon (baseball vs no baseball, football  excluding diversified mutual funds) with: Orthohelix Surgical Designs (F.J.L.) vs no football, and basketball vs no basketball). Consulting Fees (eg, advisory boards) received from: Stryker Orthopae- Results: All but 2 surgeons recommend return to protected play within 3 to  dics, Bioventus, Axogen (F.J.L.); Acumed, Synthes, Extremity Medical 4 weeks after healing of a metacarpal fracture, but 73% recommend waiting 4 (M.J.R.) to 8 weeks for unprotected play (Table 1). Most surgeons allow patients with

Table 1: Return to Play Recommendations According to Hand or Wrist Injury Nondisplaced Metacarpal Shaft Fracture Return to Play Immediate When Healed, 4e8 wk Postoperation > 8 wk 3e4 wk Postoperation PP (n 37) 14 21 2 0 ¼ UP (n 37) 0 5 27 5 ¼ Scaphoid Fracture Return to Play Immediate When Healed, 6e12 wk Postoperation >1 2 wk 4e6 wk Postoperation PP (n 37) 12 19 6 0 ¼ UP (n 37) 0 9 18 10 ¼ Pisiform Fracture Treatment and Return to Play Immediate Immediate Excision 4 wk With Splint Excision After 4 wk Excision After 8 wk If Not Healed If Not Healed n 37 11 7 8 3 8 ¼ Hook of Hamate Fracture Return to Play Immediate When Skin In 6 wk In 3 mo Healed, 2 wk PP (n 36) 11 19 6 0 ¼ UP (n 37 1 15 20 1 ¼ Thumb UCL Tear Treatment No Surgery Immediate Repair Repair at End of Season Repair at End of Season Repair at End of Season (If 6 wk) (If 3 mo) ( 6 mo)    n 37 1 14 12 3 7 ¼ Return to Play Immediate 2 wk 6 wk 3 mo 6 mo PP (n 36) 5 20 10 1 0 ¼ UP (n 36) 0 0 12 23 1 ¼ Stable PIP Dislocation Return to Play Immediate 4 wk 4e8 wk > 3 mo PP (n 36) 34 2 0 0 ¼ UP (n 37) 9 11 14 3 ¼ PP, protected play; UP, unprotected play; PIP, proximal interphalangeal.

© Speaker has nothing of financial value to disclose e47 scaphoid fractures to return to protected play within 4 to 6 weeks of injury, compared with unaffected patients, but they would demonstrate a response whereas 76% wait at least 6 to 12 weeks and 24% wait more than 12 weeks to treatment comparable to unaffected patients. before allowing unprotected play. Most surgeons allow return to protected Methods: Sample size estimates indicated 50 depressed and/or pain cata- play within 2 weeks of hook of hamate fractures, but 54% of surgeons wait strophizing patients and 200 unaffected patients provided 94% power to until 6 weeks to allow unprotected play. Most surgeons recommend repair of detect a 10-point difference in Michigan Hand Questionnaire (MHQ) thumb ulnar clateral ligament (UCL) tears immediately or within 6 weeks of scores. A total of 256 patients presenting to an orthopedic hand clinic were injury, but 27% recommend waiting until the end of the season. Nearly 70% prospectively enrolled in this cohort investigation. Patients prescribed of surgeons recommend return to protected play within 2 weeks of thumb treatment for atraumatic conditions were eligible for inclusion. At enroll- UCL repair and 67% recommend waiting at least 3 months before unpro- ment, all patients completed the Center for Epidemiologic Stud- tected play. All but 2 surgeons permitted immediate return to protected play ieseDepression Scale (CES-D), the Pain Catastrophizing Scale (PCS), and after a stable proximal interphalangeal joint dislocation. the MHQ (0e100 scale, where 100 perfect function). One and 3 months ¼ Basketball surgeons were less likely to recommend early protected play than after treatment, patients recompleted the MHQ. Participants’ psychological non-basketball surgeons. Baseball surgeons were more likely to recommend comorbidity status was categorized as either affected (depressed: CES-D ¼ early unprotected play after scaphoid fixation. Football surgeons were more 16, or pain catastrophizing: PCS 30) or unaffected (CES-D < 16 and ¼ likely to recommend earlier protected play after thumb UCL injuries, whereas PCS < 30). Diagnoses and treatments between affected and unaffected basketball surgeons were less likely to recommend earlier protected play. patients were examined. The effects of time, patients’ status, and their Summary: There is wide variability in how consultant hand surgeons approach interaction on MHQ scores were evaluated by mixed modeling. the treatment of hand and wrist injuries in elite athletes. These findings Results: Of the 256 patients enrolled, 50 were affected and 206 were unaf- emphasize the need to individually tailor treatment decisions to the patient’s fected. Diagnoses and treatments were similar between groups (Table 1). At desires and demands, particularly in the high-performance athlete. the time of enrollment, unaffected patients’ mean MHQ score (64.9, 95% confidence interval [CI]: 62.5e67.3) was significantly higher than affected Contracted Research: NIH/NIAMS T32 Research Fellowship (grant patients’ mean MHQ score (48.1, 95% CI: 43.3e53.0). Affected and un-  AR07281) RJOS/Zimmer Research Grant (M.G.C.) affected patients demonstrated similar significant absolute improvement * ASSH Resident/Fellow Fast Track Grant (C.J.D.) over baseline at 3 months after treatment (affected: 12.4, 95% CI: 7.5e17.4; unaffected: 12.9, 95% CI: 10.4e15.3). Thus, affected patients still rated their hand function as worse compared with unaffected patients (unaffected: PAPER 71 77.7, 95% CI: 75.0e80.5; affected: 60.58, 95% CI: 54.96e66.18) at final follow up (Fig. 1). Clinical Paper Session 16: Evidence/Clinical Guidelines Summary: Saturday, October 5, 2013 2:45e2:51 PM Patients who are depressed and/or pain catastrophizers report worse self-   Category: Evaluation/Diagnosis/Clinical Treatment rated hand function at baseline and after treatment compared with unaf- Keyword: Hand fected patients. At 3 months after treatment, both depressed and/or pain catastrophizing  The Impact of Depression and Pain Catastrophization on patients and unaffected patients rate their hand function as significantly Patient-Rated Outcomes Before and After Treatment for improved compared with pretreatment. Atraumatic Hand Conditions Although depressed and/or pain catastrophizing patients report worse  Level 1 Evidence self-related hand function at both baseline and at follow-up, these patients show similar absolute improvement in self-rated hand function after © Daniel London, BA treatment compared with unaffected patients. © Jeffrey Stepan, BS

 Martin I. Boyer, MD, FRCS(C) © Ryan Patrick Calfee, MD Hypothesis: Evidence suggests that patient-rated hand function is affected by depression and pain catastrophization; however, the impact of these comorbidities on response to treatment is unknown. We hypothesized that patients affected by depression and/or pain catastrophization would have worse patient-rated hand function at baseline and 3 months after treatment

Table 1: Participant Diagnoses and Treatments According to Patient Status Participant Status Unaffected Affected Variable N%N% Diagnosis Arthritis 51 24.8 14 28.0 Cyst/mass 14 6.8 0 0 Figure 1: Mean MHQ scores over time based on patients’ status as Dupuytren disease 10 4.9 2 4.0 being either unaffected or affected. Both groups demonstrated signifi- Nerve compression 35 17.0 14 28.0 Tendonitis 74 35.9 9 18.0 cant improvement from baseline to 3 months after treatment. The fi Ulnar-sided wrist pain 5 2.4 2 4.0 affected group’s mean MHQ score was always signi cantly less than the Arthritis and tendonitis 5 2.4 2 4.0 unaffected group’s mean MHQ score. Error bars represent 95% confi- Nerve compression and tendonitis 8 3.9 4 8.0 dence intervals. Other 4 1.9 2 4.0 Treatment REFERENCES Aponeurotomy 9 4.4 2 4.0 1. Karels CH, Bierma-Zeinstra SMA, Burdorf A, Verhagen AP, Nauta AP, Koes BW. Brace/medication/therapy 52 25.2 19 38.0 Social and psychological factors influenced the course of arm, neck and Injection 97 47.1 16 32.0 shoulder complaints. J Clin Epidemiol. 2007;60(8):839e848. Surgery 47 22.8 13 26.0 2. Linton SJ, Nicholas MK, MacDonald S, et al. The role of depression and Other 1 0.5 0 0 catastrophizing in musculoskeletal pain. Eur J Pain. 2011;15(4):416e422. e48 © Speaker has nothing of financial value to disclose 3. Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling musculo- skeletal pain. J Bone Joint Surg Am. 2009;91(8):2014e2018. 4. Keefe FJ, Lefebvre JC, Egert JR, Affleck G, Sullivan MJ, Caldwell DS. The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing. Pain. 2000;87(3):325e334. 5. Leeuw M, Goossens M, Linton SJ, Crombez G, Boersma K, Vlaeyen JWS. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30(1):77e94. 6. De SD, Vranceanu A-M, Ring DC. Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability. J Bone Joint Surg Am. 2013;95(1): 76e81. 7. Ring D, Kadzielski J, Fabian L, Zurakowski D, Malhotra LR, Jupiter JB. Self- reported upper extremity health status correlates with depression. J Bone Joint Surg Am. 2006;88(9):1983e1988. 8. Edwards RR, Calahan C, Mensing G, Smith M, Haythornthwaite JA. Pain, cata- strophizing, and depression in the rheumatic diseases. Nat Rev Rheumatol. 2011;7(4):216e224. 9. Vranceanu AM, Ring D. Value of psychological evaluation of the hand surgical patient. J Hand Surg Am. 2008;33(6):985e987. 10. Vranceanu AM, Jupiter JB, Mudgal CS, Ring D. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35(6):956e960. Ownership Interest (stocks, stock options, or other ownership interest  excluding diversified mutual funds) with: OrthoHelix, LLC; MiMedX, LLC Consulting Fees (eg, advisory boards) received from: OrthoHelix, LLC;  MiMedX, LLC

PAPER 72 Clinical Paper Session 17: Wrist: Scaphoid/Scapholunate Saturday, October 5, 2013 3:40e3:46 PM  Category: Fractures and Dislocations Keyword: Wrist Functional Outcomes Following Treatment of Scaphoid Fractures in Children and Adolescents Summary: Children and adolescents who present with nonunions can be Level 4 Evidence successfully managed surgically with minimal midterm functional com- promise. Whereas patients treated for nonunions have significantly © J. Joseph Gholson, BS decreased wrist function compared with acute fractures, the level of func- Peter M. Waters, MD  tion for nonunion patients was in accordance with the general population © David Zurakowski, PhD (mean DASH of 10.1 14.68).1 No differences were seen in MMWS Donald S. Bae, MD Æ  between patients treated for acute fractures versus nonunions. Hypothesis: Pediatric scaphoid fractures predominantly involve the waist, and almost one third of patients present late with established REFERENCE nonunions, most which require surgical treatment. Little is known 1. Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American about the long-term functional outcomes of children treated for Academy of Orthopaedic Surgeons outcomes instruments: normative values scaphoid fractures. We hypothesized that with appropriate treatment, from the general population. J Bone Joint Surg Am. 2002;84(2):208e215. functional outcomes as measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) inventory and the Modified Mayo Wrist Contracted Research with: ASSH, POSNA (D.S.B.)  Score (MMWS) would not vary significantly between patients with Royalties/Honoraria received from: Textbooks LWW (P.M.W.); Lippin-  acute fractures and nonunions. cott Williams and Wilkins (D.S.B.) Methods: A previously established cohort of 312 patients was contacted to Ownership Interest (stocks, stock options, or other ownership interest  complete the DASH inventory, DASH work and sports modules, and MMWS. excluding diversified mutual funds) with: Optimer, Cubist, Osiris (D.S.B.) A total of 63 patients, age 8 to 18 years at the time of treatment, completed the surveys. Twenty-four patients presented with a chronic scaphoid nonunion and 39 presented with an acute fracture. Twenty of the 24 nonunions and 6 of PAPER 73 the 39 acute patients were treated surgically. The mean follow-up was 7.3 years (range, 2.6e17.7 y). Univariate analysis and multivariate linear Clinical Paper Session 17: Wrist: Scaphoid/Scapholunate Saturday, October 5, 2013 3:50e3:56 PM regression were used to identify predictors of MMWS and DASH scores.  Results: All patients went on to successful bony healing. The median Category: Instability DASH score for the overall cohort was 1, with a significantly higher DASH of Keyword: Wrist 4 for patients with nonunions compared with 0 for patients with acute frac- Radiological and Arthroscopic Assessment of Scaphoid tures (P < .001). Multivariate analysis determined that chronic nonunions Nonunion and Scapholunate Instability (P .020) and proximal pole fractures (P .030) are independent predictors Level 4 Evidence of a¼ higher DASH score, whereas surgery¼ (P .520), age (P .890), and ¼ ¼ gender (P .810) did not influence the DASH. The median work module © Masahiro Tatebe, MD ¼ score was 0 for both acute fractures and nonunions (P .110). The median © Takaaki Shinohara, MD ¼ sports and arts module score was 6 in nonunions and 0 in acute patients (P © Michiro Yamamoto, MD ¼ .010). The median MMWS for patients with both acute fractures and chronic © Shigeru Kurimoto, MD nonunions was 100 (P .110). © Hitoshi Hirata, MD ¼

© Speaker has nothing of financial value to disclose e49 Hypothesis: Some authors have reported acute scaphoid fracture with carpal trapezoid and dorsal scapholunate (SL) ligaments (SLL), and tightens the instability; these cases are not rare.1,2 However there are only a few reports dorsal radiocarpal ligament. However, recurrent diastasis is common, as about established scaphoid nonunion assessed by x-ray, computed tomog- with other reconstructions. A new reconstructive method, described by raphy, and arthroscopy. Our null hypotheses were as follows: (1) Scaphoid Ross et al,1 involves transossesous tunnels across the scaphoid, lunate, nonunion with scapholunate (SL) dissociation (SLD) is not rare, and triquetrum (scapholuno-triquetrum [SLT] tenodesis), for a biologic (2) scaphoid nonunion with SLD had severe dorsal intercalated segment tether along the central axis of the SL joint. The tendon is then instability deformity, (3) fracture patterns and/or lunate types are associated passed dorsally to tighten the dorsal radiocarpal and reconstruct the with SLD. dorsal SLL. We hypothesized that this novel method would provide Methods: We reviewed 70 (average, 28 y) scaphoid nonunions. Patients better anatomic reduction of the SL articulation and stronger demographic and injury characteristics were recorded. Fracture pattern and reconstruction in a cadaver model, as measured by SL angle and displacement of nonunion fragment (fragment gap > 1 mm) were confirmed diastasis on radiographs. by computed tomography.3,4 Carpal alignments (radiolunate, radioscaphoid, Methods: Ten fresh-frozen cadaveric wrists were radiographically examined and SL angle) were determined by plain radiograph. Scapholunate/luno- in neutral, ulnar deviation, and clenched fist positions. Scapholunate angle triquetral (SL/LT) instability and lunate morphology were confirmed by and diastasis were recorded in each position with the SLL intact, after arthroscopy.5,6 The patient was determined to have SL/LT instability when sectioning of the ligament and secondary restraints, and after reconstruction the arthroscopy showed Geissler grade 3 or 4. by either the MBT (5 arms) or the SLT technique (5 arms). Wrists were Results: Scapholunate instability was detected in 16 cases, and LT instability cycled through their maximum flexion and extension arc 100 times to in 12 cases; both SL and LT instability occurred in 7 cases. No significant simulate wrist motion, after ligament sectioning as well as after recon- association was found between instability and carpal alignment. Fracture struction. Statistical analysis was performed with JMP Pro 10.0.0 (SAS pattern showed 3 patterns: waist volar in 44, waist dorsal in 19, and Institute). Means were compared with Student’s t-test and matched-pair proximal pole in 7. Type 1 lunates were present in 34 patients and type 2 t-test where appropriate. lunates were in 36. Fracture patterns show no significant differences be- Results: After ligament sectioning and cycling, all wrists demonstrated tween SL/LT instabilities and lunate type. Type 1 lunate and displaced significantly increased SL diastasis on the clenched fist view, with average nonunion are associated with the radiolunate/SL angle (dorsal intercalated distance of 5.1 mm, compared with 2.2 mm in intact specimens (P .001). segment instability pattern). Patients’ demographic and injury characteris- After cycling, there was larger diastasis in the MBT reconstructions¼ tics also had no association with any parameters. compared with the SLT reconstructions, although this was not statistically Summary: significant (3.1 vs 2.5 mm; P .470). ¼ Combined scaphoid nonunion and SL/LT instability is not rare. After ligament sectioning and cycling, SL angle increased from an  The fracture pattern had no correlation with SL/LT instability. average of 50.1 to 64.9 in the clenched fist position (P < .0001). In the    Lunate type and displaced nonunion are associated with a DISI pattern. cycled MBT reconstructions, SL angle remained increased compared with  intact wrists (56.8 vs 47.4; P .030). In the cycled SLT reconstructions, ¼ REFERENCES SL angle was not significantly different from intact wrists (55.8 vs 52.8; P .150). 1. Jørgsholm P, Thomsen NO, Björkman A, Besjakov J, Abrahamsson SO. The ¼ incidence of intrinsic and extrinsic ligament injuries in scaphoid waist fractures. Summary: J Hand Surg Am. 2010;35(3):368e374. In this cadaveric model, both MBT and SLT techniques restored anatomic  2. Wong TC, Yip TH, Wu WC. Carpal ligament injuries with acute scaphoid frac- parameters after sectioning of the SLL. tures—a combined wrist injury. J Hand Surg Br. 2005;30(4):415e418. With cycling, normal diastasis was better maintained with the SLT re-  3. Compson JP. The anatomy of acute scaphoid fractures: a three-dimensional constructions compared with the MBT, although this was not statistically analysis of patterns. J Bone Joint Surg Br. 1998;80(2):218e224. significant. There was also greater variation in diastasis with MBT 4. Nakamura R, Imaeda T, Horii E, Miura T, Hayakawa N. Analysis of scaphoid reconstructions. fracture displacement by three-dimensional computed tomography. J Hand Restoration of the SL angle was better in wrists undergoing SLT recon- Surg Am. 1991;16(3):485e492.  5. Viegas SF, Wagner K, Patterson R, Peterson P. Medial (hamate) facet of the struction compared with MBT reconstruction. lunate. J Hand Surg Am. 1990;15(4):564e571. 6. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft- tissue lesions associated with an intra-articular fracture of the distal end of the REFERENCES e radius. J Bone Joint Surg Am. 1996;78(3):357 365. 1. Ross M, Loveridge L, Couzens G. Scapholunate ligament reconstruction. J Wrist Surg. In press. 2. Pollock P, Sieg R, Baechler M, Scher D, Zimmerman N, Dubin N. Radiographic fi PAPER 74 evaluation of the modi ed Brunelli technique vs the Blatt capsulodesis for scapholunate dissociation in a cadaver model. J Hand Surg Am. 2010;35(10): Clinical Paper Session 17: Wrist: Scaphoid/Scapholunate 1589e1598. Saturday, October 5, 2013 4:00e4:06 PM 3. Garcias-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treat-  ment of scapholunate dissociation: indications and surgical technique. J Hand Category: Basic Science - Lab Research Surg Am. 2006;31(1):125e134. Keyword: Wrist 4. Slater RR, Szabo RM, Bay BK, Laubach J. Dorsal intercarpal ligament capsu- Radiographic Evaluation of the Modified Brunelli Technique lodesis for scapholunate dissociation: biomechanical analysis in a cadaver model. J Hand Surg Am. 1999;24(2):232e239. Versus a Novel Scapholuno-triquetral Tenodesis Technique 5. Short WH, Werner FW, Sutton LG. Dynamic biomechanical evaluation of the for Scapholunate Dissociation in a Cadaver Model dorsal intercarpal ligament repair for scapholunate instability. J Hand Surg Am. Not a clinical study 2009;34(4):652e659. 6. Dunn MJ, Johnson C. Static scapholunate dissocation: a new reconstruction © Jennifer W. Hsu, MD technique using a volar and dorsal approach in a cadaver model. J Hand Surg © Katie K. Jegapragasan, MD Am. 2001;26(4):749e754. © Mithulan K. Jegapragasan, MD 7. Howlett J, Pfaeffle HJ, Waitayawinyu T, Trumble T. Distal tunnel placement fl  Jerry I. Huang, MD improves scaphoid exion with the Brunelli tenodesis procedure for scapho- lunate dissociation. J Hand Surg Am. 2008;33(10):1756e1764. Hypothesis: The modified Brunelli technique (MBT) is a popular triliga- ment tenodesis technique that reconstructs the volar scaphotrapezium- Consulting Fees (eg, advisory boards) received from: Arthrex 

e50 © Speaker has nothing of financial value to disclose PAPER 75 3. Weiss APC. Scapholunate ligament reconstruction using a bone retinaculum autograft. J Hand Surg Am. 1998;23(2):205e215. Clinical Paper Session 17: Wrist: Scaphoid/Scapholunate 4. Harvey E, Hanel D. What is the ideal replacement for the scapholunate ligament Saturday, October 5, 2013 4:10e4:16 PM in a chronic dissociation? Can J Plast Surg. 2000;8:143e146.  Category: Evaluation/Diagnosis/Clinical Treatment Contracted Research with: Integra Life Sciences Keyword: Wrist  Royalties/Honoraria received from: Ascension Orthopaedics,Surgicraft  Consulting Fees (eg, advisory boards) received from: Ascension Ortho- A New Technique for Scapholunate Ligament  Reconstruction Utilizing FCR and Interference Screw paedics, Lima, LMT Surgical, Surgicraft Receipt of Intellectual Property Rights/Patent Holder with: Ascension Fixation  Level 4 Evidence Orthopaedics, Surgicraft Other Financial/Material Support received from: Depuy   Mark Ross, FRACS © Greg Couzens, FRACS Hypothesis: Our technique for transosseous scapholunate (SL) ligament (SLL) reconstruction yields reliable and satisfactory results compared with PAPER 76 published surgical techniques. Clinical Paper Session 17: Wrist: Scaphoid/Scapholunate Methods: We present a consecutive prospective cohort of patients who had Saturday, October 5, 2013 4:20e4:26 PM an SLL reconstruction using a technique developed by the authors. This  1 Category: Fractures and Dislocations technique builds on the concepts of the Brunelli reconstruction and the Keyword: Wrist 3-ligament tenodesis reconstruction of Garcia-Elias et al.2 A strip of flexor carpi radialis is left attached distally and passed volar to the STT joint to Percutaneous Screw Fixation Without Bone Grafting control scaphoid flexion. The same graft is used to reconstruct the SLL. for Delayed Unions and Nonunions of Minimially However, security and tensioning of the graft and reduction of the SL in- Displaced Scaphoids terval are improved by passing the graft centrally through the scaphoid, Level 4 Evidence lunate, and triquetrum. The graft is secured by interference-screw fixation © into the triquetrum. Further passage of the graft dorsally from triquetrum to David Saper, MD © scaphoid augments the dorsal-intercarpal ligament. Akash Shah, BS © We report on the first 11 patients reviewed at an average of 14 months Andrew B. Stein, MD © postoperation (range, 12e24 mo). We excluded patients with concomitant Andrew Jawa, MD trauma to the same upper limb. Clinical and radiological outcomes were Hypothesis: Delayed unions and nonunions of the scaphoid are most often measured preoperatively and at defined intervals postoperation. treated with open reduction and internal fixation. We sought to evaluate a Results: Patients were between 23 and 54 years of age at surgery; 81.8% large consecutive series of nondisplaced or minimally displaced scaphoid were male. The operative hand was dominant in 91%. There was an average nonunions and delayed unions treated with a percutaneous compression of 11.5 months from the time of injury to surgery (range, 4e30 mo). A total screw without bone grafting. Our hypothesis was that drilling combined of 72% had static deformity of the SL articulation. with compression and rigid stabilization would allow for bony union in Results of the QuickeDisabilities of the Arm, Shoulder, and Hand nondisplaced and minimally displaced scaphoid fractures with delayed questionnaire improved from a preoperative mean average of 50 (SD, unions or nonunions. 15.22) to 21.2 (SD, 15.33). Patient-Rated Wrist Evaluation score improved Methods: A retrospective review was performed of consecutive patients with from a mean of 43.1 (SD, 7.25) to 18.92 (SD, 11.87). Grip strength (Jamar a delayed union or nonunion of the scaphoid treated with percutaneous dynamometer) improved from 37.4 kgf (SD, 17.35 kgf) to 44.4 kgf (SD, compression screw fixation by 2 fellowship-trained hand surgeons. Delayed 5.04 kgf). Pain during normal activity (100 mm, visual analog scale) union and nonunion were defined as minimal fracture healing seen at 3 and improved from 17.8 (SD, 6.54) to 13.56 (SD, 13.99). Flexion-extension 6 months, respectively. All fractures were nondisplaced or minimally dis- total arc of movement reduced from 130.18 (SD, 6.85) to 102.27 (SD, placed (< 2 mm) and patients with carpal malalignment or humpback 26.65). On x-ray, the SL interval improved from 4.18 mm (SD, 0.603 mm) deformity at the time of surgery were excluded. Clinical outcome measures to 1.627 mm (SD, 0.660 mm). The SL angle improved from 80.45 (SD, included evidence of radiographic union, revision surgery, and reported 5.68) to 56.82 (SD, 5.13). complications. We observed 1 complication in a patient who initially recovered well Results: A total of 23 patients (19 male and 4 female) were identified, with and returned to professional football. At 10 months postsurgery, he expe- fractures located at the distal third in 2 patients, at the waist in 18, and at the rienced a high-energy hyperextension injury and fractured the lunate (dorsal proximal third in the remaining 3. The average time from injury to surgery third). He was treated with a scaphocapitolunate arthrodesis. was 8.2 months (range, 3.1e27.6 mo); 3 fractures were classified as delayed Summary: unions, and the remaining were 20 nonunions. The average follow-up was This technique builds on the features of previous SLL reconstructions and  4.7 months. Of the 23 patients, 19 had complete follow-up with evidence of offers greater ease of reduction and improved graft security. radiographic union. Four patients had limited follow-up (< 6 wk) and were Graft placement close to the rotational axis of the SL articulation allows  not healed by the last radiograph. No complications or revision surgeries balanced reduction without favoring either dorsal or volar gap closure. were reported. This technique has demonstrated excellent results in treating patients with Summary: Nonunions and delayed unions for nondisplaced or minimally  1e4 static deformity, a challenging group with previous techniques. displaced scaphoid fractures without carpal malalignent can be successfully treated with percutaneous compression screw fixation without bone REFERENCES grafting. 1. Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg Am. 1995; REFERENCE 20(Pt 2):S82eS85. 2. Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment 1. Mahmoud M, Koptan W. Percutaneous screw fixation without bone grafting for of scapholunate dissociation: indications and surgical technique. J Hand Surg established scaphoid nonunion with substantial bone loss. J Bone Joint Surg Br. Am. 2006;31(1):125e134. 2011;93(7):932e936.

© Speaker has nothing of financial value to disclose e51 PAPER 77 Table 2: Specifies Regarding Tendon/Ligament Events Clinical Paper Session 18: Dupuytren Disease Tendon/ Saturday, October 5, 2013 3:40e3:46 PM Tendon Ligament  Category: Evaluation/Diagnosis/Clinical Treatment Finger and Joint Affected Rupture Injury Index finger, MCP 0 0 Keyword: Hand Index finger, PIP 0 0 fi Nonsurgical Treatment of Dupuytren Contracture: 3-Year Middle nger, MCP 0 0 Middle finger, PIP 0 0 Safety Results Using Collagenase Clostridium histolyticum Ring finger, MCP 4 1 ᶜ Level 4 Evidence Ring finger PIP 0 0 fi Clayton A. Peimer, MD Little nger, MCP 5 0  Little finger, PIP 8 0  Claudia A. McGoldrick, BA The joint and/or finger was unknown in remaining 9 reports.  Greg Kaufman, MD ᶜ A2 pulley injury. Hypothesis: Adverse events (AEs) observed after the approval of collagenase Clostridium histolyticum (CCH) (XIAFLEX and XIAPEX) are similar to those observed in the first year of postmarketing surveillance. The frequency of skin tear is consistent with what has been previously The current analysis is based on 3 years of postmarketing safety  Methods: reported in the literature, and most skin tears resolved without skin graft. data reported to Auxilium Pharmaceuticals, Inc. Reports analyzed were Tendon ruptures occurred rarely and appeared to occur predominantly in received from February 2, 2010 (United States approval date) through  the little finger. February 2, 2013. This analysis also includes reports of tendon rupture, Postmarketing surveillance provides valuable insight into the safety of ligament injury/rupture, and nerve injury.  CCH when used in clinical practice and outside the context of clinical The AEs reported during the first 3 years of global postmarketing Results: trial protocols. surveillance were similar in type and incidence to those reported in the first Voluntary reporting systems typically underreport expected AEs and do year of postmarketing surveillance. From February 2, 2010 through  not allow for determination of precise incidence rates. February 2, 2013, approximately 49,078 injections of CCH were admin- istered. An estimated 1,732 AEs were reported in 846 patients and were REFERENCES most commonly localized, nonserious reactions to CCH injections, including skin tears, contusion, peripheral edema, pain in extremity, and 1. Peimer CA, McGoldrick CA, Fiore GJ. Nonsurgical treatment of Dupuytren’s injection site reactions (Table 1). There were 19 reports of skin grafts contracture: 1-year US post-marketing safety data for collagenase clostridium histolyticum. Hand (N Y). 2012;7(2):143e146. among 228 patients who experienced skin tear postinjection; 11 of 19 were 2. Denkler K. Surgical complications associated with fasciectomy for Dupuytren’s considered to be associated with the finger manipulation procedure and disease: a 20-year review of the English literature. Eplasty. 2010;10:116e133. most commonly occurred in treatment of the little finger proximal inter- phalangeal joint. There were 26 reports of tendon rupture at a rate of 0.05% Contracted Research with: Auxilium Pharmaceuticals, Inc (C.A.P.)  (26 of 49,078) and 1 report each of A2 pulley injury, stretch neuropraxia Consulting Fees (eg, advisory boards) received from: Auxilium Phar-  (numbness without pain away from the injection site after full extension), maceuticals, Inc (C.A.P.). and ligament injury. Of the 17 tendon ruptures for which joint and finger Other Financial/Material Support received from: Employee of Auxilium  could be identified, most occurred in the little finger (5 meta- Pharmaceuticals, Inc (C.A.M., G.K.). Shareholder of Auxilium Pharma- carpophalangeal and 8 proximal interphalangeal) (Table 2). There were also ceuticals, Inc (G.K.) 2 reported cases of complex regional pain syndrome (reflex sympathetic dystrophy), 1 of which resolved within 3 months. PAPER 78 Clinical Paper Session 18: Dupuytren Disease Table 1: Most Commonly Reported Adverse Events Associated With Saturday, October 5, 2013 3:50e3:56 PM  CCH Injection During 3 Years of Postmarketing Surveillance at 2% Category: Other  Incidence Keyword: Hand Postmarketing Reporting Rate Reported AE AE, n (%)a per 1,000 Dosesb Delayed Manipulation Following Clostridial Collagenase Skin tearc 228 (13.2) 4.6 Histolyticum Injection for Dupuytren Contracture Contusiond 168 (9.7) 3.4 Level 1 Evidence Peripheral edema 164 (9.5) 3.4 F. Thomas D. Kaplan, MD Drug ineffective 106 (6.1) 2.2  ▲ Pain in extremity 80 (4.6) 1.6  ▲ Marie Badalamente, PhD Swelling, unspecified 67 (3.9) 1.4  ▲ Lawrence Hurst, MD Lymphadenopathy 53 (3.1) 1.1  ▲ Gregory A. Merrell, MD Hematomae 49 (2.8) 1.0 ©▲ Raymond Pahk, MD Injection site pain 47 (2.7) 1.0 Injection site hematoma 45 (2.6) 0.9 Hypothesis: After treatment of Dupuytren contracture with clostridial colla- genase histolyticum injection (CCH), manipulation for cord rupture can be aA total of 1,732 AEs were reported; % number of reported AEs/total AEs reported. ¼ bApproximately 49,078 doses in the 3-year postmarketing surveillance. performed in a delayed fashion, at 2 or 4 days after injection, without cIncludes laceration and skin lesions. compromising efficacy or safety. dIncludes the terms “contusion” (any body system) and “ecchymosis” (skin/ Methods: Patients with Dupuytren contracture involving the meta- subcutaneous). carpophalangeal joint caused by a palpable cord participated in a multi- eOther than injection site (vascular). center, prospective, randomized trial. Patients with a contracture of the metacarpophalangeal joint greater than 20 were randomized to undergo Summary: manipulation at 1 (group 1), 2 (group 2), or 4 (group 3) days after in- Three-year postmarketing surveillance shows a safety profile with jection. All patients received 1 dose of CCH (0.58 mg) and were observed  reporting rates consistent with the published 1-year postmarketing for 90 days. Primary end point was the percentage of patients obtaining a surveillance. greater than 50% reduction in contracture 30 days after injection. The e52 © Speaker has nothing of financial value to disclose secondary end point was the percentage of patients maintaining clinical Contracted Research with: Auxilium Pharmaceuticals (F.T.D.K., M.B.,  success (defined in the CORD 1 study as a reduction of contracture to L.H.) 50% reduction in contracture); results were 92% in group 1, 91% in group Consulting Fees (eg, advisory boards) received from: Acumed (F.T.D.K.);  2, and 85% in group 3, with the difference between groups not significant. IMDS (F.T.D.K.); Auxilium Pharmaceuticals (F.T.D.K., M.B., L.H.); At 90-day follow-up, the percentage of patients maintaining less than 5 Stryker (G.A.M.); Pfizer (L.H.) contracture was 91% in group 1, 82% in group 2, and 83% in group 3; the Royalties/Honoraria received from: Biospecifics Technologies Corp difference was not significant (Table 1). The Michigan Hand Outcomes  (M.B.); SUNY Stony Brook (L.H.); Trimed (G.A.M.) Questionnaire (MHQ) improved from an average of 72 to 93 in group 1, 78 to Receipt of Intellectual Property Rights/Patent Holder with: Ulnar Rod  94 in group 2, and 83 to 88 in group 3. There was no statistical difference in with Trimed (G.A.M.) MHQ score between groups at any time point, although there was a trend toward higher scores in patients with clinical success at day 90. Adverse events are shown in Table 2, and are comparable to rates seen in prior stud- PAPER 79 ies.1e3 There were no serious adverse events. Summary: Clinical Paper Session 18: Dupuytren Disease There was no significant difference in efficacy after CCH injection when Saturday, October 5, 2013 4:00e4:06 PM   manipulation was delayed until day 2 or 4 after injection. Category: Evaluation/Diagnosis/Clinical Treatment Delaying manipulation after CCH injection can be done safely, without Keyword: Hand  an increase in adverse events. Recurrence of Dupuytren Contracture After Nonsurgical Patients successfully treated with CCH for Dupuytren contracture showed  Treatment With Collagenase Clostridium Histolyticum: improvement in MHQ scores, demonstrating improved hand function Summary of 4-Year CORDLESS Data with reduction of contracture. Level 4 Evidence

Robert N. Hotchkiss, MD Table 1: Percentage of Clinical Improvement in Contracture After 30  Clayton A. Peimer, MD Days and Those Maintaining Clinical Success 90 Days After Injection,  Stephen Geoffrey Coleman, FRACS Stratified by Group   Ted Smith, PhD Group James P. Tursi, MD Characteristics Day 1 Day 2 Day 4 P  Greg J. Kaufman, MD Percent clinical  improvement in Hypothesis: Treating Dupuytren contracture with collagenase Clostridium contracture > 50% reduction 11/12 10/11 11/13 histolyticum (CCH) shows a sustained durability of response in most (N missing 1)* 30 d after injection (92%) (91%) (85%) .8271 ¼ subjects. Maintained clinical Reduction of 10/11 9/11 10/12 .8109 success contracture to (91%) (82%) (83%) Methods: The CORDLESS trial is an ongoing 5-year follow-up of patients (N missing 3)x 5maintained treated in clinical trials (CORD I/II and JOINT I/II). Beginning 2 years after ¼  to 90 d the first injection of CCH, each patient was reevaluated once each year, with 6 after injection months or more between visits. A clinical success or successfully treated joint *Patient L08 had missing data on day 30, but at day 90 had no residual contracture. was defined as achieving a correction to 0 to 5 after the initial treatment. xPatients JC012, L05, and H03 had missing data on day 90. Recurrence was defined as increase 20 or more, with a palpable cord from the last injection, or when a treated joint underwent medical/surgical intervention. In addition, the number of joints that demonstrated an increase 30 or more Table 2: Adverse Events  was also analyzed to represent a measure often cited as clinically relevant. Adverse Event Frequency Duration Results: Of 644 patients enrolled in the CORDLESS trial, 539 completed the Armpit pain 1 11 year 4 follow-up. In the original trials, of a total 1,081 treated joints, 623 Blood blister 3 12 4.36 Æ (57.6%) were treated successfully. At year 4 follow-up, nominal rate of Bruising 14 14.29 5.28 Æ Bruisingearmpit 1 9 recurrence in joints achieving clinical success was 42.1% and 27.9% for 20 Bruisingehand 1 9 or more and 30 or more worsening, respectively. The recurrence rate Itching 1 3 slowed from years 3 to 4 (7.1% increase) compared with years 2 to 3 Lymphadenopathy 1 8 (15.4% increase). Proximal interphalangeal joints showed a higher recur- Numbness 1 2 rence rate than metacarpophalangeal joints (Fig. 1). The recurrence rate for Edema 1 14 low-severity proximal interphalangeal joints (40) was 70.6%. To date, a Itching 1 1 total of 543 successfully treated joints (87.2%) have not had additional Itching in armpit 1 2 medical/surgical interventions. From years 3 to 4, the rate of CCH use for Pain 5 12 6.63 Æ the treatment of worsening contractures in joints with clinical success Pain in palm 1 49 Skin tear 1 8 surpassed the rate of secondary fasciectomy (Table 1). Adverse events were Swelling 18 13.28 5.23 reported by 311 of 644 patients (48.3%) but only 1 was related to treatment Æ (decrease in ring finger circumference resulting from Dupuytren contracture resolution), and there were no treatment-related serious adverse events. No REFERENCES long-term safety issues were identified. 1. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium Summary: histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361(10):968e979. The nominal recurrence rates at 4 years for 20 or more and 30 or more  2. Gilpin D, Coleman S, Hall S, et al. Injectable collagenase clostridium histo- contracture worsening were 42.1% and 27.9%, respectively, and the rate lyticum: a new nonsurgical treatment for Dupuytren’s disease. J Hand Surg Am. slowed from years 3 to 4 compared with years 2 to 3. 2010;35(12):2027e2038. Proximal interphalangeal joints with less severe contraction at baseline fi  3. Witthaut J, Jones G, Skrepnik N, et al. Ef cacy and safety of collagenase clos- had lower recurrence rates. tridium histolyticum injections for Dupuytren contracture: short-term results A total of 87.2% of successfully treated joints have not had further from 2 open-label studies. J Hand Surg Am. 2013;38(1):2e11.  medical/surgical treatment; retreatment with CCH was more common ▲ This presentation discusses clostridial collagenase histolyticum (Xiaflex) than fasciectomy in these patients. by Auxilium Pharmaceuticals No long-term safety/risk issues were identified. 

© Speaker has nothing of financial value to disclose e53 Hypothesis: An analysis was undertaken to determine the efficacy and safety of collagenase Clostridium histolyticum (CCH) in the treatment of Dupuytren contracture (DC) of the proximal interphalangeal (PIP) joint. Methods: This retrospective analysis examined DC of 644 PIP joints in 506 subjects enrolled in CORD I/II and JOINT I/II clinical trials,1e3 to determine the percentage of subjects who achieved clinical success (0 to 5 extension), clinical improvement ( 50% of baseline contracture), and improvement in  range of motion (ROM) at 30 days after the first injection and the last injection of CCH. Per protocol, a maximum of 3 injections/cord was allowed. Results: A total of 1,165 CCH injections were administered to cords affecting 644 PIP joints. Clinical success and clinical improvement were shown in 27.0% (174 of 644) and 49.0% (316 of 644) of PIP joints after 1 injection, and in 33.8% (218 of 644) and 58.0% (374 of 644) after the last injection, respectively; 60% of PIP joints received 1 injection, 24% received Figure 1: Nominal recurrence rates overall and by type of Dupuytren 2 injections, 15% received 3 injections, and 1% received 4 injections. Mean contracture joint. change in ROM increased from 51.0 at baseline to 71.2 after the first injection, and to 75.4 after the last injection. Clinical success and clinical improvement were highest in the index finger compared with the other Table 1: Intervention Types Chosen for Treatment of Worsening fingers (Table 1). Improvement in ROM was generally comparable among Contracture in Joints Originally Treated to Clinical Success (Reduction the fingers and slightly higher after the last injection. Clinical success in Dupuytren Contracture to 0to 5), by Year and clinical improvement were markedly better in the subgroup with low Intervention Year 2, n (%) Year 3, n (%) Year 4, n (%) ( 40 ) baseline severity than high baseline severity after the first and last   Total 15 (100) 32 (100) 38 (100) injection (Table 2). The most common adverse events included edema CCH 0 6 (18.8) 18 (47.4) (58.3%), contusion (38.0%), injection site hemorrhage (23.0%), pain in Fasciectomy 9 (60) 20 (62.5) 12 (31.6) extremity (22.4%), injection site pain (20.9%), and swelling (16.2%). Three Needle aponeurotomy 3 (20) 4 (12.5) 5 (13.2) flexor tendon ruptures of the little finger were reported. No further tendon Fasciotomy 0 1 (3.1) 1 (2.6) Dermofasciectomy 0 1 (3.1) 0 ruptures occurred after changing the injection method. Other 3 (20) 0 2 (5.3) Summary: Collagenase Clostridium histolyticum was effective for DC of PIP joints  of both low and high baseline severity and by finger. Outcomes after CCH injection were better in the low baseline severity REFERENCES  subgroup, which suggests that earlier intervention achieves better 1. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium outcomes. histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361(10):968e979. Clinical success and clinical improvement were most improved in the 2. Gilpin D, Coleman S, Hall S, Houston A, Karrasch J, Jones N. Injectable colla-  index finger and least improved in the little finger after the first and last genase clostridium histolyticum: a new nonsurgical treatment for Dupuytren’s injections in subjects with high baseline severity. disease. J Hand Surg Am. 2010;35(12):2027e2038. 3. Witthaut J, Jones G, Skrepnik N, Kushner H, Houston A, Lindau TR. Efficacy and safety of collagenase clostridium histolyticum injections for Dupuytren Table 1: Efficacy Results by Finger After First and Last Injections contracture: short-term results from 2 open-label studies. J Hand Surg Am. 2013;38(1):2e11. First Injection Little Ring Middle Index Clinical success, % of joints 24.3 27.5 29.6 46.5 Contracted Research with: Auxilium Pharmaceuticals, Inc (R.N.H., Clinical improvement, % of joints 44.7 53.8 51.9 67.4  C.A.P., S.G.C.) Range of motion, change in degrees 20.3 20.9 19.4 19.7 Consulting Fees (eg, advisory boards) received from: Auxilium Phar- Last injection  maceuticals, Inc (C.A.P.) Clinical success, % of joints 31.3 36.3 31.5 53.5 Ownership Interest (stocks, stock options, or other ownership interest Clinical improvement, % of joints 55.0 60.0 59.3 69.8  Range of motion, change in degrees 25.2 23.8 23.7 21.8 excluding diversified mutual funds) with: Auxilium Pharmaceuticals, Inc (S.G.C.) Other Financial/Material Support received from: Auxilium Pharmaceu-  fi ticals, Inc (S.G.C., T.S., J.P.T., G.J.K.) Table 2: Ef cacy Results by Baseline Severity of Contracture After First and Last Injections Little Ring Middle Index PAPER 80 First injection Low baseline severity ( 40contracture)  Clinical Paper Session 18: Dupuytren Disease Clinical success, % of joints 50.7 37.9 42.3 53.1 Saturday, October 5, 2013 4:10e4:16 PM Clinical improvement, % of joints 68.1 58.6 61.5 68.8  Category: Basic ScienceeClinical Research Range of motion, change in degrees 17.9 17.7 16.6 18.2 Keyword: Hand High baseline severity (> 40contracture) Clinical success, % of joints 9.6 15.1 17.9 27.3 Efficacy and Safety of Collagenase Clostridium histolyticum Clinical improvement, % of joints 31.7 48.0 42.9 63.6 in the Treatment of Proximal Interphalangeal Joints in Range of motion, change in degrees 21.6 24.7 21.9 24.1 Last injection Dupuytren Contracture: Combined Analysis of 4 Phase 3 Low baseline severity ( 40contracture)  Clinical Trials Clinical success, % of joints 55.8 46.0 46.2 56.3 Level 4 Evidence Clinical improvement, % of joints 73.2 63.2 65.4 71.9 Range of motion, change in degrees 19.8 17.8 17.6 19.3  Marie A. Badalamente, PhD High baseline severity (> 40contracture)  Lawrence C. Hurst, MD Clinical success, % of joints 17.7 24.7 17.9 45.5  Prosper Benhaim, MD Clinical improvement, % of joints 45.0 56.2 53.6 63.6 © Brian Cohen, PhD Range of motion, change in degrees 28.2 31.1 29.2 28.7 e54 © Speaker has nothing of financial value to disclose Adverse events in PIP joints were similar to those observed in meta-  carpophalangeal joints, and there was no evidence to support that the little finger PIP joints are more difficult to treat.

REFERENCES 1. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Eng J Med. 2009;361(10):968e979. 2. Gilpin D, Coleman S, Hall S, et al. Injectable collagenase clostridium histo- lyticum: a new nonsurgical treatment for Dupuytren’s disease. J Hand Surg Am. 2010;35(12):2027e2038. 3. Witthaut J, Jones G, Skrepnik N, et al. Efficacy and safety of collagenase clos- tridium histolyticum injections for Dupuytren’s contracture:short term results from 2 open label studies. J Hand Surg Am. 2013;38(1):2e11. Contracted Research with: Auxilium Pharmaceuticals (M.A.B., L.C.H.).  Royalties/Honoraria received from: Biospecifics Technologies Corp  (M.A.B.); SUNY Stony Brook (L.C.H.) web 4C = FPO Consulting Fees (e.g. advisory boards) received from: Auxilium Phar-  maceuticals (M.A.B., L.C.H., P.B.); Pfizer (L.C.H.)

PAPER 81 Clinical Paper Session 18: Dupuytren Disease Saturday, October 5, 2013 4:20e4:26 PM  Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Hand Open Fasciotomy: Still a Major Weapon in the Surgical Armamentarium Against Dupuytren Disease? Level 4 Evidence

© Camilla J. Stewart, MBChB © Issaq Ahmed © Dominique Davidson © Geoffrey Hooper, FRCS

Hypothesis: There is current interest in minimally invasive treatment of web 4C = FPO Dupuytren disease but little in effectiveness of treatment by open fasciotomy. We reviewed a series of 1,077 open fasciotomies performed by a single recurrent TED was greatest in rays that had undergone 3-level fasciotomy consultant to ascertain the reoperation rate and results of secondary surgery. (103 ) and least in those that had undergone a single-level fasciotomy (78 ). Methods: Theater coding data were used to identify a consecutive series of   Complete intraoperative release was obtained in most cases for all types of patients who underwent open fasciotomy as a primary procedure for revision procedure (140 of 144; 97%). Dupuytren disease over a 5-year study period. The initial fasciotomy was Summary: done using the same technique for all patients: under intravenous regional A low reoperation rate was identified, with good intraoperative correction anesthesia with small transverse incisions made over the cords at 1 to 3  achieved by initial open fasciotomy and secondary surgery. levels. These were allowed to heal by secondary intention for 2 to 3 weeks We believe that this refinement of the earlier method of percutaneous with free digital mobilization (Figs. 1, 2). Outcome measurements recorded  fasciotomy is a useful and safe technique in the surgical armamentarium for the initial open fasciotomy, included the completeness of intraoperative for the treatment of Dupuytren disease. correction, occurrence of perioperative or postoperative complications, time to reoperation, and degree of digital contracture at reoperation. The details of the revision operations were noted, together with the degree of intraoperative correction. Follow-up ranged between 5 and 10 years, and REFERENCES statistical analysis was performed using SPSS software. 1. Becker GW, Davis TRC. The outcome of surgical treatments for primary Results: A total of 1,077 consecutive patients were treated by open fas- Dupuytren’s disease—a systematic review. J Hand Surg Eur Vol. 2010;35(8): ciotomies for Dupuytren disease between January 2000 and January 2005. 623e626. Of these patients, 143 (13.5%) required operations for recurrent disease of 2. Davis TRC. Surgical treatment of primary Dupuytren’s contractures of the fin- the same hand. Data were obtainable for 97 cases, in which a total of 144 gers in the UK: surgeons’ preferences and research priorities. J Hand Surg Eur digits were reoperated. Complete intraoperative release was achieved in Vol. 2013;38(1):83e85. most digits (134 of 144; 93%), irrespective of the number of incisions 3. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fas- required, with 1 documented postoperative complication. The mean time to ciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129(2):469e477. reoperation was 46 months (SD, 22 mo; range, 8e98 mo). The mean pre- 4. Crean SM, Gerber RA, Le Graverand MP, Boyd DM, Cappelleri JC. The efficacy revision total extension deficit (TED) for the 144 reoperated rays was 81 and safety of fasciectomy and fasciotomy for Dupuytren’s contracture in (SD, 39; range, 30 to 180), which was similar to the mean TED before European patients: a structured review of published studies. J Hand Surg Eur the first procedure: 82 (SD, 38; range, 30 to 180). The severity of the Vol. 2011;36(5):396e407.

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