Motion Analysis of the Wrist and Finger Joints in Sport Climbing

Climbing is a fast-growing sport, with one of the most common injuries being a rupture of the finger flexor tendon pulley. The strain on pulleys increases as finger joints flex. However, to our knowledge, no study has conducted a kinematic analysis of climbers' fingers. Thus, this study aimed to examine finger kinematics during typical climbing tasks. Eleven elite climbers performed a sequence of four climbing moves, which were recorded by an optical motion capture system. Participants used crimp, half-crimp, and open-hand grips for three trials each, with the fourth condition involving campusing using any grip except crimp. Mean proximal interphalangeal joint (PIP) flexion during the holding phase was 87° (SD 12°), 70° (14°) and 39° (27°) for the crimp, half-crimp and open-hand grip, respectively. Hence, inter-individual PIP flexion ranges overlap between different gripping conditions. Two different movement patterns emerged in the open-hand grip, possibly influenced by the use of the little finger, leading to varying degrees of flexion in the middle and ring fingers. Avoiding little finger usage in the open-hand grip may reduce load during pulley rupture rehabilitation. The implications of PIP joint angle variability on individual pulley injury risk or prevention warrant further investigation. Motion capture proved effective for understanding finger kinematics during climbing and could guide future studies on pulley injury risk factors.

Basal osteotomy of the first metacarpal using patient-specific guides and instrumentation: biomechanical and 3D CT-based analysis

INTRODUCTION

The aim of this study was to investigate the radiological outcomes of proximal closing metacarpal extension osteotomies using patient-specific guides and instruments (PSI) in early-stage trapeziometacarpal osteoarthritis to gain further insight into the joint loading surface and the benefits of the procedure.

METHODS

In a prospective observational study, nine patients were included between 11/2020 and 12/2021, undergoing a total of ten proximal metacarpal extension osteotomies for basal thumb osteoarthritis. Computer-assisted surgical planning was performed using computed tomography (CT) and three-dimensional (3D) segmentation, allowing the fabrication of 3D-printed PSIs for surgical treatment. Inclusion criteria were a 1-year follow-up by CT to assess postoperative correction of the positional shift of the first metacarpal (MC1) and the location of peak loads compared with the preoperative situation.

RESULTS

Radiographic analysis of the peak loading zone revealed a mean displacement on the articular surface of the trapezius of 0.4 mm ± 1.4 mm to radial and 0.1 mm ± 1.2 mm to palmar, and on the articular surface of the MC1 of 0.4 mm ± 1.4 mm to radial and 0.1 mm ± 1.2 mm to dorsal.

CONCLUSION

There were trends indicating that a flatter pressure distribution and a dorsal shift of the peak loading zone may contribute to an improvement in subjective pain and patient satisfaction associated with this surgical procedure. The non-significant radiological results and the minor dorsal-radial shifts in our small study group limit a firm conclusion.

LEVEL OF EVIDENCE

III.

Stress Fractures of the Distal Phalanx in Skeletally Immature Sport Climbers

Stress fractures in the distal phalanx of skeletally immature patients are rare and previously unreported clinical occurrences. We report on 2 adolescent sport climbers with such fractures of the dorsal metaphysis of the distal phalanx at the point where parts of the extensor tendon insert. A conservative treatment approach alone was sufficient in healing this fracture type in both patients after 12 wk. Clinicians should be informed of the existence of this rare clinical phenomenon and counsel patients that a conservative treatment approach may result in complete healing without the need for an invasive procedure.

Stability of the distal radioulnar joint with and without activation of forearm muscles

The purpose of this study was to quantify the effect of the flexor carpi ulnaris and the extensor carpi ulnaris muscles on distal radioulnar joint stability. The anteroposterior ulnar head translation in relation to the radius was measured sonographically when the forearm was in a neutral resting position and when the hand was actively pressed on to a surface, with and without intentional flexor carpi ulnaris and extensor carpi ulnaris activation, while also being monitored by an electromyogram. Data on 40 healthy participants indicated a mean anteroposterior translation in the distal radioulnar joint of 4.1 mm (SD 1.08) without and 1.2 mm (SD 0.54) with muscle activation. Our results indicate that intentional ulnar forearm muscle activation results in 70% less anteroposterior ulnar head translation and greater distal radioulnar joint stability. Therefore, the flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint. This finding may be clinically significant since ulnar forearm muscles strengthening may increase distal radioulnar joint stability.

Fixed Subluxation of the Distal Radioulnar Joint following Malunion of the Ulnar Styloid Process

Purpose  Recent literature on significance and treatment of ulnar styloid fractures suggest that the ulnar styloid is not the central problem but the radioulnar ligaments and their impact on joint stability. However, specifically displaced ulnar styloid process fractures that secondarily heal in an ectopic position remain a rare situation for which diagnostics and treatment options remain a topic of discussion. Methods  This case series presents four patients with limited supination due to a fixed dorsal subluxation of the distal radioulnar joint (DRUJ). The reason here fore was a significant malunion of ulnar styloid fracture that was addressed by corrective ulnar styloid osteotomy. Three of these osteotomies used three-dimensional (3D) preoperative planning and patient specific guides. Results  All patients presented with a significant displacement of the malunited ulnar styloid fracture (average 32-degree rotation and 5-mm translation). In all four patients, the fixed subluxation of the ulnar head was resolved clinically and radiographically, and the forearm rotation restored after corrective osteotomy of the ulnar styloid and fixation in an anatomical position. Conclusion  This case series presents a very specific subset of patients with nonanatomically healed ulnar styloid fractures responsible for a chronic DRUJ dislocation and limited prosupination and its treatment. Level of evidence  This is a Level IV, therapeutic study.

Computer-assisted correction of incongruent distal radioulnar joints in patients with symptomatic ulnar-minus variance

Our study described a computer-assisted, three-dimensional (3-D), planned surgical technique of a radial shortening osteotomy. The osteotomy of the distal radius was planned with computer assistance on 3-D bone models based on computed tomography data. The objective was to maximize the contact zone of the sigmoid notch with the ulnar head. Between 2012 and 2020 we treated 14 wrists in 11 patients with symptomatic ulnar-minus variance with a mean follow-up of 44 months (range 8 to 98) and a mean age of 28 years (range 19 to 38). Postoperatively, patients showed a decrease in pain at rest and during effort (numeric rating scale from 4.4 to 0 and 7.5 to 4.5, respectively). The range of motion postoperatively was similar to the contralateral side. Grip strength increased from 24 kg to 30 kg. The Disability of the Arm, Shoulder, and Hand and the Patient-Rated Wrist Evaluation scores were 28 and 35 postoperatively, respectively. Our technique of 3-D computer-assisted distal radioulnar joint reconstruction led to a pain reduction and improvement of the hand function in patients with symptomatic ulnar-minus variance.Level of evidence: IV.

3D analysis of the distal ulna with regard to the design of a new ulnar head prosthesis

STUDY DESIGN

A retrospective, single center, data analysis.

OBJECTIVE

Persistent pain and instability are common complications after distal ulnar head arthroplasty. One main reason may be the insufficient representation of the anatomical structures with the prosthesis. Some anatomical structures are neglected such as the ulnar head offset and the ulnar torsion which consequently influences the wrist biomechanics.

METHODS

CT scans of the ulnae of forty healthy and asymptomatic patients were analyzed in a three-dimensional surface calculation program. In the best fit principle, cylinders were fitted into the medullary canal of the distal ulna and the ulnar head to determine their size. The distance between the central axes of the two cylinders was measured, which corresponds to the ulnar offset, and also their rotational orientation was measured, which corresponds to the ulnar torsion.

RESULTS

The mean medullary canal diameter was 5.8 mm (±0.8), and the ulnar head diameter was 15.8 mm (±1.5). The distance between the two cylinder axes was 3.89 mm (±0.78). The orientation of this offset was at an average of 8.63° (±15.28) of supination, reaching from 23° pronation to 32° supination.

CONCLUSION

With these findings, a novel ulnar head prosthesis should have different available stem and head sizes but also have an existing but variable offset between these two elements. A preoperative three-dimensional analysis is due to the high variation of offset orientation highly recommended. These findings might help to better represent the patients natural wrist anatomy in the case of an ulnar head arthroplasty.

LEVEL OF EVIDENCE

III.

Clinical, radiological and patient-rated outcome comparison between total and partial ulnar head implants

This study aimed to analyse the clinical and radiological outcomes after ulnar head replacement and to compare partial and total ulnar head implants. Twenty-two patients with 23 implants were available with a mean follow-up time of 7 years (range 1.3 to 17) after distal radioulnar joint arthroplasty. At the final follow-up, patients had a low level of pain at rest and during effort, a median Disabilities of the Arm, Shoulder, and Hand (DASH) score of 12 and Patient-Rated Wrist Evaluation score of 12 with partial ulnar head implants, and scores of 20 and 22 in total ulnar head implants, respectively. While the range of motion in patients with partial ulnar head implants was slightly reduced in comparison with the preoperative condition and to the patients with total ulnar head implants, there was a tendency to a higher grip strength and rotational torque. Both types of prosthesis showed sigmoid notch resorptions and resorptions around the neck. We conclude that the results after partial ulnar head replacement do not significantly differ from the total ulnar head implants in many aspects.Level of evidence: III.

Posttraumatic Carpal Instability Nondissociative

Background  Posttraumatic midcarpal instability nondissociative (CIND) is an exceptional rare condition, therefore the outcome after different treatment options remains unknown. Questions  The purpose of this study was to investigate the different treatment options for posttraumatic CIND. We also describe the different radiological and magnetic resonance imaging (MRI) findings in this patient cohort. Patients and Methods  We present outcomes of 10 patients who developed CIND following acute wrist trauma between 2007 and 2018, 3 with dorsal intercalated segment instability pattern (CIND-DISI) and 7 with volar intercalated segment instability (CIND-VISI) radiographically. Results  Three patients with CIND-VISI had satisfactory outcomes with conservative treatment. Two patients with irreducible CIND-DISI and one with CIND-VISI underwent proximal row carpectomy (PRC), two with reducible CIND-VISI had radiolunate fusion, and two with secondary osteoarthritis had total wrist fusion. All patients with CIND-DISI needed surgery, whereas only four of the seven patients with CIND-VISI needed surgery. On MRI, all three patients with CIND-DISI had rupture of the radiolunate ligament. Conclusions  The data collected in this study may provide the first step toward better understanding of the pathology for this exceptionally rare finding. In CIND-VISI, we have not seen any ligament injury in four patients. Therefore, conservative therapy is more likely to be the first step. In CIND-DISI, we recommend an operative procedure: if detected early, with ligament suture, otherwise by radiolunate fusion, PRC, or total wrist fusion. Level of Evidence  This is a Level IV study.

Arthroscopic three-corner or lunocapitate arthrodesis: technical tips and early outcomes

The purpose of the study is to present a technical approach for arthroscopic three-corner or lunocapitate arthrodesis with mini-open scaphoid excision and to report about the early clinical and functional results. The median surgery time was 112 min with shorter times achieved once mastering the technique. Radiological and clinical union was observed in 11 out of 12 patients in a median time of five months. For final assessments nine patients were included with a median follow-up of 15 months. Wrist extension and flexion after surgery decreased to 58 and 62% of preoperative measurements and represented 37 and 42% of the unaffected side. Grip strength also decreased to 80% of the preoperative value and 57% of the unaffected side. All patients reported significant pain relief and functional improvement. Arthroscopic three-corner or lunocapitate arthrodesis was a safe, reliable and minimally invasive technique for treating wrist osteoarthritis, while it was technically demanding and time-consuming during learning curve.

Long-term evolution of cartilage abnormalities and osteophytes in the fingers of elite sport climbers: A cross-sectional 10-year follow-up study

The sequelae of high mechanical stress to the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the fingers in elite sport climbers and its contribution to the development of osteoarthritis are still relatively unknown. The purpose of this study was to investigate the evolution of cartilage abnormalities of the PIP and DIP joints, as well as the progress of osteophytes, in the fingers of elite sport climbers with a minimum of 25 years of climbing history over the time period of the last 10 years. Moreover, their actual cartilage abnormalities and osteophyte occurrence were compared to non-climbing age-matched controls. Thirty-one elite male sport climbers and 15 male non-climbers underwent a sonographic examination of the PIP and DIP joint cartilage and osteophyte thickness in the frontal and sagittal plane of digits II-V of both hands. The same cohort had already been measured with an identical protocol 10 years earlier (follow-up rate of 100%). Compared to the baseline assessment 10 years earlier, the cartilage thickness of sport climbers has significantly decreased; however, it was still greater than in age-matched controls. Moreover, sport climbers showed significantly higher relative frequencies of osteophyte occurrence than non-climbers (all fingers and joints). Nevertheless, despite a substantial (and compared to baseline a further increased) occurrence of osteophytes in elite sport climbers, there was no association between the radiological signs of osteoarthritis and pain within the last six months prior the follow-up investigation.Highlights Long-term elite climbers show thicker cartilage and occurrence of Osteophytes in their fingers (especially Digit III) compared to controls already early in their career.Later occurrence of osteophytes increases (especially Digit II and IV) and cartilage decreases but is still thicker compared to controls. No association between those findings and pain was found.

Long-term results of Sauvé-Kapandji procedure

The Sauvé-Kapandji procedure is an established treatment option for distal radioulnar joint dysfunction. We retrospectively analysed 36 patients following Sauvé-Kapandji procedure between 1997 and 2013. Fifteen patients were available for a follow-up after a mean of 13 years (range 6 to 23). Six patients needed revision surgery because of ulnar stump instability. Radiographs and sonography were performed to quantify the instability of the proximal ulnar stump. These showed a radioulnar convergence of 8 mm without weight and 2 mm while lifting 1 kg. Sonographically, the proximal ulnar stump dislocated by 8 mm to the volar side while applying pressure to the palm, compared with 4 mm on the contralateral side. Sonographically measured ulnar stump instability showed a positive strong correlation with the Disabilities of the Arm, Shoulder and Hand questionnaire and Patient-Reported Wrist Evaluations and a negative strong correlation with grip strength and supination torque. Because of the high incidence of revision surgery due to instability of the proximal ulnar stump, we restrict the use of the Sauvé-Kapandji procedure only to very selected cases.Level of evidence: IV.

Feasibility of ultrasound-based measurement of dorsal scaphoid displacement: A 3D-model study

The present study aimed to develop a reliable dynamic measurement technique, which can be used directly in the outpatient setting, based on dorsal subluxation of the scaphoid on scaphoid shift test. This study was designed to evaluate feasibility and to quantify dorsal subluxation of the scaphoid in relation to the lunate. Based on a scaphoid shift test under ultrasonography, a standardized 3D test model was developed to measure subluxation. Sagittal subluxation ranged between 0 and 6 mm, as checked on the implemented scale. Four hand surgeons trained in ultrasonography (experience level II-V) performed blinded measurements (total of 52, n = 13 per investigator) with a standardized measurement protocol. Dorsal subluxation of the scaphoid was measured in relation to the lunate. Interobserver reliability on intraclass correlation coefficient (ICC) was excellent, at 0.97 (95% confidence interval, 0.930-0.992). Mean overall absolute measurement error was 0.27 mm ± 0.21. Dorsal subluxation of the scaphoid can thus be accurately measured on ultrasound with excellent interobserver reliability, quantifying and improving clinical assessment of scapholunate instability.

Finger reconstruction with dorsal metacarpal artery perforator flaps and dorsal finger perforator flaps based on the dorsal branches of the palmar digital arteries - 40 consecutive cases

Since the first description many variations of the dorsal metacarpal reverse island flap have been published but there is still uncertainty about which vascular component should be included for an optimal result. Therefore, it was the aim of this study to analyze vascular reliability and ischemic complications of dorsal metacarpal artery perforator (DMAP) flaps and dorsal finger perforator (DFP) flaps in our patient collective. We performed 40 of these flaps from the dorsum of hand and fingers for finger injuries. The choice of donor site was made according to the defect's location. Patients were analyzed with respect to flap necrosis, ischemic complications and achievement of overall reconstruction goals. In addition, we divided our patients in two groups, one group where we raised the flap from the dorsum of the proximal phalanx and a second one where the flaps were raised from the intermetacarpal space to identify complication rates based on the pedicles location. Of the 40 flaps, 36 survived completely. 4 partial necroses were observed in flaps transferred to more distal defects and in one flap that was used in a wrap-around technique for both dorsal and palmar proximal phalanx. These perforator flaps are a reliable method to cover finger defects and the dorsal metacarpal artery is not necessary for their survival, since the blood supply comes from perforating branches of the palmar vascular system. There is a clear trend for a higher complication rate in flaps raised from the dorsum of the fingers compared to the intermetacarpal space.

In-vivo three-dimensional motion analysis of the wrist during dart-throwing motion after midcarpal fusion and radioscapholunate fusion

We recorded the dart-throwing motion and basic motion tasks in patients following radioscapholunate fusion and midcarpal fusion with a three-dimensional motion capture system in vivo, using digital infrared cameras to track the movement of reflective skin markers on the hand and forearm. During the dart-throwing motion, 20 healthy volunteers showed a median range of motion of 107°. As expected, patients had significantly reduced wrist range of motion during basic motion tasks and dart-throwing motion compared with the healthy controls, except for ulnar flexion occurring in the dart-throwing motion in patients treated by midcarpal fusion and radial deviation after midcarpal fusion or radioscapholunate fusion. In addition, patients who had undergone radioscapholunate fusion had significantly reduced range of motion during dart-throwing motion compared with patients after midcarpal fusion.

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

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

Comparison of a New Inertial Sensor Based System with an Optoelectronic Motion Capture System for Motion Analysis of Healthy Human Wrist Joints

This study aims to compare a new inertial measurement unit based system with the highly accurate but complex laboratory gold standard, an optoelectronic motion capture system. Inertial measurement units are sensors based on accelerometers, gyroscopes, and/or magnetometers. Ten healthy subjects were recorded while performing flexion-extension and radial-ulnar deviation movements of their right wrist using inertial sensors and skin markers. Maximum range of motion during these trials and mean absolute difference between the systems were calculated. A difference of 10° ± 5° for flexion-extension and 2° ± 1° for radial-ulnar deviation was found between the two systems with absolute range of motion values of 126° and 50° in the respective axes. A Wilcoxon rank sum test resulted in a no statistical differences between the systems with p-values of 0.24 and 0.62. The observed results are even more precise than reports from previous studies, where differences between 14° and 27° for flexion-extension and differences between 6° and 17° for radial-ulnar deviation were found. Effortless and fast applicability, good precision, and low inter-observer variability make inertial measurement unit based systems applicable to clinical settings.

Minimal detectable difference of the finger and wrist range of motion: comparison of goniometry and 3D motion analysis

Background

The measurement of finger and wrist range of motion (ROM) is of great importance to clinicians when assessing functional outcomes of therapeutic interventions and surgical procedures. The purpose of the study was to assess the repeatability of ROM measurements of the hand joints with manual goniometer and 3D motion capture system and to calculate the minimal detectable difference for both methods.

Methods

Active finger and wrist joints ROM of 20 healthy volunteers were assessed using a manual goniometer and 3D motion capture system. Minimal detectable difference (MDD) and standard error of measurement (SEM) were calculated for both measurement systems and compared within the same task. Maximal ROM of all joints was registered twice on two different days to evaluate the test-retest repeatability. The intraclass correlation coefficients (ICC) was calculated and examined to determine if reliability ≥ 0.70 existed.

Results

MDD for the 3D motion capture was between 5 and 12° except for the metacarpophalangeal joint (MCP) 1, interphalangeal joint (IP), and MCP5. SEM values lay between 2 and 4° for all joints except for the MCP5, IP, and MCP1. For the goniometric measurements, MDD and SEM were between 12–30° and 4–11°, respectively. The reliability criterion (ICC > 0.7) was achieved for the ROM measurement with the 3D motion capture system for 94% of the joints and in only 65% of the joints with the manual goniometer.

Conclusions

Joint ROM assessed with 3D motion analysis showed higher test-retest agreement demonstrating overall better repeatability for this method. Because of the smaller measurement error, the 3D motion capture system has a smaller MDD. Only individual test-rest differences bigger than the MDD can be considered as real changes, and therefore, in an experimental situation, the use of a more precise measurement method can greatly reduce the number of subjects needed for a statistical significance. Goniometer measurements of some joints should be carefully interpreted, due to a low repeatability and reliability.

Trial registration

This study is approved by the Ethical Committee Zurich (Kek-ZH-Nr: 2015-0395).

Assessment of hand function during activities of daily living using motion tracking cameras: A systematic review

The human hand is the most frequently used body part in activities of daily living. With its complex anatomical structure and the small size compared to the body, assessing the functional capability is highly challenging. The aim of this review was to provide a systematic overview on currently available 3D motion analysis based on skin markers for the assessment of hand function during activities of daily living. It is focused on methodology rather than results. A systematic review according to the PRISMA guidelines was performed. The systematic search yielded 1349 discrete articles. Of 147 articles included on basis of title, 123 were excluded after abstract review, and 24 were included in the full-text analysis with 13 key articles. There is still limited knowledge about hand and finger kinematics during activities of daily living. A standardization of the task is required in order to overcome the nonrepetitive nature and high variability of upper limb motion and ensure repeatability of task performance. To yield a progress in the analysis of human hand movements, an assessment of human kinematics including fingers, wrist, and thumb and an identification of relevant parameters that characterize a healthy motion pattern during functional tasks are needed.

Hand and wrist joint procedures in patients with scleroderma: a systematic review

We aimed to examine if joint procedures in hands and wrists of patients with scleroderma could be performed without major morbidity and conducted a systematic review of the literature to assess this hypothesis. Studies were identified in four different databases; soft tissue procedures in scleroderma patients were excluded, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Seven studies out of an initial total of 203 articles were included. One-hundred and twelve scleroderma patients with a total of 402 joint procedures in the hand and wrist were identified. A low complication incidence, comparable with that of non-sclerodermic population, in terms of infection, wound healing problems, and nonunion was reported in all studies. The application of joint procedures in scleroderma hands and wrists seems to be associated with low morbidity.

Sonographic study of repair, gapping and tendon bowstringing after primary flexor digitorum profundus repair in zone 2

We report sonographic findings with clinical outcomes after zone 2 flexor digitorum profundus tendon repairs in ten fingers. The tendons underwent a six-strand M-Tang core repair, no circumferential suture, and partial or complete division of the pulleys. Over 12 months after surgery and using ultrasound, we found no gapping at the repair site during finger motion. When the pulleys were divided, there was sonographic evidence of tendon bowstringing, but the bowstringing was minimal. Clinically, we did not find any fingers that displayed tendon bowstringing or had functional loss. With ultrasound examination, the repaired tendons remained enlarged over 12 months. Two patients developed heterotopic ossifications at the repair site without tendon gliding, and these required tenolysis. We conclude that the tendon repair site does not gap when a strong core suture is used in the repair without adding peripheral sutures. There is no notable tendon bowstringing clinically, though the repaired tendons have sonographic evidence of minor bowstringing.

LEVEL OF EVIDENCE

III.

Flexor tendon repair in the hand with the M-Tang technique (without peripheral sutures), pulley division, and early active motion

We report outcomes in 29 patients with flexor tendon repairs in 32 digits (five thumbs and 27 fingers) with our modified protocols. We repaired the lacerated flexor digitorum profundus tendons with core suture repairs using the 6-strand M-Tang method and without circumferential sutures. We divided the pulleys as much as needed to allow excursion of the repaired tendons, including complete division of the A4 or A2 pulleys when necessary. In nine fingers, we repaired one slip of the flexor digitorum superficialis tendon and resected the other half. When the flexor digitorum profundus tendon would not glide under the A2 pulley, we excised the remaining slip of the flexor digitorum superficialis tendon. The wrist was splinted in mild extension post-surgery with early commencement of tenodesis exercises. No tendon repair ruptured. By the Strickland criteria, out of 27 fingers, 18 had excellent, six had good, two had fair, and one had poor results. We conclude that a strong core suture (such as the M-Tang repair) without peripheral sutures, and with division of pulleys as necessary is safe for early active motion and yields good outcomes.

LEVEL OF EVIDENCE

IV.

Midterm Results of Semiconstrained Distal Radioulnar Joint Arthroplasty and Analysis of Complications

Range of motion and stability are important outcome parameters to assess function of the distal radioulnar joint (DRUJ), in particular pronation, supination, and weight-lifting capacity. The DRUJ semiconstrained implant developed by Scheker et al is intended to reproduce all the functions of the triangular fibrocartilage complex and the DRUJ. The aim of the study was to investigate the subjective, clinical, and radiographic results in 10 patients after primary implantation of the semiconstrained DRUJ arthroplasty following DRUJ derangement and painful instability, with an average follow-up of 3 years with a special focus on the complications. Standardized preoperative and postoperative evaluation included assessment of pain by a visual analog scale, radiographic examination, range of motion measurements, lifting capacity, and grip strength. The patient-perceived function was investigated using clinical score charts. Compared with the preoperative status, range of motion showed little change, while grip strength, lifting capacity, pain score, and patient-perceived functions improved significantly. One patient developed an ulna stem loosening, while two patients had to be reoperated because of an irritation of the extensor tendons and the superficial radial nerve at the first dorsal compartment of the wrist. In this study, arthroplasty of the DRUJ using the semiconstrained DRUJ arthroplasty was found to result in satisfactory outcome. Level of evidence: Level IV.

Comparison of clinical outcome with radiological findings after trapeziectomy with ligament reconstruction and tendon interposition

The aim of our study was to investigate if pre- and postoperative radiographic thumb carpometacarpal position is correlated with clinical and subjective outcomes. Radiographs of 105 patients undergoing trapeziectomy with ligament reconstruction and tendon interposition were analysed before, as well as 1 year after, surgery for dorsal subluxation and proximal migration of the thumb metacarpal bone. Furthermore, key pinch strength was measured and patients completed the Michigan Hand Outcomes Questionnaire. Baseline dorsal subluxation and scaphometacarpal distances significantly decreased from 8.2 mm and 11.0 mm to 5.2 mm and 5.1 mm at 1 year, respectively. There was no correlation between the amount of subluxation or proximal migration and the Michigan Hand Outcomes Questionnaire score or key pinch strength. These results suggest that postoperative position of the metacarpal base of the thumb does not affect clinical or subjective outcomes after trapeziectomy with ligament reconstruction and tendon reposition of the thumb carpometacarpal joint.

LEVEL OF EVIDENCE

Level 3.

Determinants of patient satisfaction after surgery or corticosteroid injection for trapeziometacarpal osteoarthritis: results of a prospective cohort study

INTRODUCTION

The evaluation of patient satisfaction is becoming increasingly important in assessing treatment outcomes. The objective of this study was to analyze the determinants of treatment satisfaction in patients with trapeziometacarpal osteoarthritis (TMC OA) after surgery or corticosteroid injection.

MATERIALS AND METHODS

Prospective cohort study of patients with TMC OA who received surgery or corticosteroid injection was carried out. Socio-demographic and clinical data were recorded at baseline and 1 year after the intervention, and patients filled out the Michigan Hand Outcomes Questionnaire (MHQ). On a 5-point Likert scale, patients reported baseline expectations, expectation fulfillment at 1 year, as well as satisfaction with the treatment result. To identify determinants of satisfaction, we entered these variables into one ordered logistic regression model for surgical patients and another for patients with injection.

RESULTS

We included 146 patients, 88 of whom were treated surgically. With respect to satisfaction at 1 year, 87 % of the surgical patients were somewhat or very satisfied with the treatment result, whereas only 49 % of the patients with injection were satisfied. Expectations being fulfilled was the only determinant of treatment satisfaction in the surgical group. In the injection group, a more advanced Eaton stage of TMC OA and greater pain at 1 year were associated with reduced satisfaction.

CONCLUSIONS

Surgery for TMC OA leads to high patient satisfaction, whereas only half of the patients treated with corticosteroid injection were satisfied with the treatment result. An advanced stage of TMC OA and higher pain lead to reduced treatment satisfaction in the latter group, indicating that corticosteroid injection is only effective for patients in a lower stage of disease. As fulfillment of expectations was an important determinant of satisfaction in the surgical group, we emphasize the need to provide comprehensive information prior to surgery, so that the patient's expectations of treatment outcome are realistic.

Ten year follow-up of pyrocarbon implants for proximal interphalangeal joint replacement

Results of anatomical resurfacing of the proximal interphalangeal joint using pyrocarbon implants showed reasonable clinical results with a high radiographic migration rate. The aim was to investigate the subjective, clinical, and radiographic results 10 years following surgery, and to compare them with our 2-year follow-up data. We re-evaluated 12 patients with 15 proximal interphalangeal implants on average 9.7 years after surgery. Pain significantly improved from 7.6 on a visual analogue scale pre-operatively to 1.4 at 2 years, and to 0.7 at the final follow-up. The mean total range of motion in all replaced joints was 36° pre-operatively and 39° at the 2-year follow-up, but had decreased significantly to 29° at 10 years. We saw one implant migration in addition to the eight migrated implants we already found 2 years after surgery. The moderate clinical results, combined with the high migration rate, mean that we no longer use this kind of implant.

Can complications of titanium elastic nailing with end cap for clavicular fractures be reduced?

BACKGROUND

We found treatment of clavicular midshaft fractures using titanium elastic nails (TENs) in combination with postoperative free ROM was associated with a complication rate of 78%. The use of end caps reduced the rate to 60%, which we still considered unacceptably high. Thus, we explored an alternative approach.

QUESTIONS/PURPOSES

We investigated whether (1) the complication rate could be reduced by cautious lateral advancement of the TENs, intraoperative oblique radiographs to rule out lateral perforation, and limited ROM postoperatively; (2) fluoroscopy time could be reduced; and (3) shoulder function would be reasonable.

PATIENTS AND METHODS

From March 2006 to December 2009, we treated 44 patients with midshaft clavicular fractures with TENs and end caps. In the first group (n = 15), the TEN was advanced laterally using an oscillating drill. The patients were permitted free ROM. In the second group (n = 29), the TEN was advanced by hand, conversion to open reduction followed two failed closed attempts and lateral perforation was checked with an intraoperative oblique radiograph. Furthermore, anteversion and abduction of the shoulder were limited to 90° for the first 6 weeks. Minimum followup was 12 months (mean, 16.7 months; range, 12-28 months).

RESULTS

The total complication rate was reduced from nine of 15 in the first group to five of 29 in the second group. Medial perforations ceased with the use of the end cap. Fluoroscopy time was reduced from a mean of 10 to 4 minutes by converting to open reduction after two failed closed attempts. All but three patients exhibited full shoulder ROM at three months and these three had a slight deficit of 10° to 20° in anteversion and/or abduction. At last followup, the mean American Shoulder and Elbow Surgeons score was 92 (range, 88-100) and the Disability of the Arm, Shoulder, and Hand score 1.4 (range, 0-12.5).

CONCLUSIONS

Cautious insertion of the TENs, intraoperative oblique radiographs, and limiting the ROM for 6 weeks postoperatively reduced the complication rate. Using TENs with end caps for midshaft clavicular fractures is minimally invasive while associated with comparable complication rates and function to plate osteosynthesis.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Clinical and radiological results after operative treatment of mallet fracture using Kirschner wire technique]

BACKGROUND

In our clinic dorsal distal phalanx fractures involving more than 30% of the articulare line in the lateral view are treated operatively using the Kirschner wire technique. Recently conservative treatment of these fractures is more and more recommended. Therefore we investigated in a retrospective study our patients with special regards to complications.

PURPOSE

The aim of this study was to evaluate the complications, as well as the clinical and radiological results of patients after operative treatment of dorsal distal phalanx fractures using the Kirschner wire technique.

PATIENTS AND METHODS

43 patients with dorsal intraarticular fractures of the distal phalanx involving at least one third of the articular surface of the distal interphalangeal (DIP) joint were treated between 02/05 and 08/09 using Kirschner wire technique. At a mean follow-up of 28 (8-60, median 24,5) months, 32 patients were evaluated clinically and radiologically as well as with ultrasound.

RESULTS

5 patients developed superficial wound infections and were treated with antibiotics. 2 of these patients needed an early removal of the Kirschner wires. 2 patients showed nail deformity and 2 had an ulnar deviation of the DIP joint. The mean extension lag was 10° (0-30°, median 10°), the mean flexion lag was 19° (0-60°, median 15°). 11 patients had a flexion lag of more than 20°. 4 patients had an extension lag of more than 20°. All of these patients showed tendon tears or large lesions by ultrasound. Degenerative changes were noted in radiographs of 15 patients.

CONCLUSIONS

Because of unsatisfactory results in 63% (n=20), conservative treatment will be our treatment of choice in the future. Operative treatment will only be done in patients with subluxation of the distal phalanx.