Use of Low-profile Palmar Internal Fixation in Digital Replantation

There are multiple surgical techniques to stabilize the bone in digital replantation. Various criteria need to be considered when choosing appropriate bony fixation including operative time, ease of exposure, stability, limitation of the area of dissection, and reproducibility. We describe our technique using internal fixation with a low-profile plate on the palmar aspect of the proximal or middle phalanx during replantation of a digit. This technique allows coverage of the plate with no risk of compromising the dorsal venous anastomosis. In our experience, using this technique we have observed no complications including no secondary displacement of the fragments or extensor tendon rupture and no incidence of infection. In addition, this technique allows adequate bony fixation to enable an early active range of motion rehabilitation program

Correction of Residual Radial Translation of the Distal Fragment in Distal Radius Fracture Open Reduction

Distal radius fractures are common injuries of the upper extremity requiring treatment. In recent years, volar locking plate (VLP) fixation has become favored for operative treatment with the main goals being anatomic reduction and rigid fixation allowing for an early range of motion rehabilitation protocol. VLP fixation is excellent at correcting sagittal plane alignment with restoration of volar tilt. However, plate designs do not have any intrinsic features to their designs to assist with correction of coronal plane translation. One possible sequela of distal radius fractures is residual instability of the distal radioulnar joint. This instability can lead to pain and disability after treatment of distal radius fractures requiring further interventions. It has been demonstrated that coronal plane malreduction with residual radial translation of the distal fragment may contribute to ongoing distal radioulnar joint instability after distal radius fractures. We describe a technique for intraoperative correction of residual radial translation. It may be used when radial translation is recognized during internal fixation with a VLP or when correction of radial translation is required as part of a corrective osteotomy for radial malunion

Accuracy of magnetic resonance imaging of the wrist for clinically important lesions of the major interosseous ligaments and triangular fibrocartilage complex; correlation with radiocarpal arthroscopy

Objective: To demonstrate the utility of MRI in separating clinically relevant from minor or incidental lesions of the triangular fibrocartilage complex and the major interosseous ligaments in the wrist. Materials and methods: In this retrospective study, we identified 89 patients and correlated MRI finding with subsequent arthroscopy. Triangular fibrocartilage complex abnormalities have been subdivided into disc lesions—central and radial—or ulnar-sided tears according to MRI appearances and surgical findings as the clinical and surgical approach is very different. Interosseous ligament tears were subdivided into partial or complete, highlighting the principle of recognising surgically relevant lesions. Results: For simple central to radial tears and perforations of the triangular fibrocartilage complex, MRI was 98.3% accurate. MRI identified all peripheral triangular fibrocartilage complex tears seen at arthroscopy; however, the specificity of 66.7% may reflect partly the use of arthroscopy limited to the radiocarpal joint. MRI proved 95.4% accurate for surgically relevant scapholunate interosseous ligament tears and was highly accurate at separating limited from complete lunotriquetral interosseous ligament tears showing 100% accuracy for complete tears. Conclusions: The study shows excellent correlation between MRI and arthroscopic findings that determine surgical relevance with a very high sensitivity for triangular fibrocartilage complex lesions and accurate separation of minor versus surgically relevant ligamentous tears.</p

Measuring thumb range of motion in first carpometacarpal joint arthritis: the inter-rater reliability of the Kapandji index versus goniometry

Introduction: Goniometric measurement of thumb range of motion is often used as an outcome measure in assessing patients with first carpometacarpal osteoarthritis. Despite common use and demonstrated construct validity, the reliability of this technique has not been well established. The Kapandji Index is an alternate functional measure of thumb motion suitable for use with this client group. The purpose of this study was to examine the inter-rater reliability of the goniometric measures for thumb joint range of motion compared to the Kapandji Index in patients with first carpometacarpal joint osteoarthritis. Methods: Two independent assessors, who were blind to each other’s measurements, measured thumb range of motion in 33 patients (54 thumbs). All participants were undergoing treatment for carpometacarpal joint osteoarthritis. Active range of motion was measured with a goniometer for all the thumb joints using a standardised measurement protocol. The Kapandji Index score was recorded. Relative reliability was assessed by using the intraclass correlation coefficient. Absolute reliability was also calculated by determining the standard error of measurement (SEM ) and the minimal detectable difference (MDD ). Results: Inter-rater reliability for the goniometer was highly variable ranging from poor to excellent (intraclass correlation coefficient 0.128-0.860). The SEM ranged from 9° to 13°, and the resulting MDD varied from 21° to 31° for the different thumb joints. The Kapandji Index had excellent inter-rater reliability among the different raters (intraclass correlation coefficient 0.772-0.917). Conclusions: Measurement of goniometric active range of motion of the thumb may have limited utility as a measure of clinical effectiveness for patients with carpometacarpal joint osteoarthritis. However, the Kapandji Index is a reliable measure of functional range of motion

The effectiveness of the Push Brace™ orthosis and corticosteroid injection for managing first carpometacarpal joint osteoarthritis: A factorial randomised controlled trial protocol

Introduction: Various conservative treatments for first carpometacarpal joint osteoarthritis have been reported. We aim to investigate the short-term effectiveness of conservative management interventions used to improve pain and function for adults with first carpometacarpal joint arthritis in a randomised controlled trial. Methods: A pragmatic 2 × 2 factorial randomised controlled trial will be conducted. This randomised controlled trial will have one control group (hand therapy) and three intervention groups. Interventions will include Push Brace™ orthosis and hand therapy, ultrasound-guided intra-articular corticosteroid injection and hand therapy and a combination of all three interventions. A total of 276 participants will be recruited for the trial. The primary outcomes will be pain (reported using a Visual Analogue Scale) and function (using the Patient Rated Wrist/Hand Evaluation). Secondary outcomes will include osteoarthritis specific function, pinch strength, global change and quality of life. Adverse events and complications will be reported. Outcomes assessments will be completed prior to the intervention and at 3, 6, 12 and 24 months post-intervention. The trial will be conducted at a private hand surgery clinic in Queensland, Australia. Conclusions: Results from this trial will contribute to the evidence on conservative management of first carpometacarpal osteoarthritis

Pyrocardan Trapeziometacarpal Joint Arthroplasty-Medium-Term Outcomes

Objective Pyrocardan trapeziometacarpal interposition implant is a free intra-articular spacer composed of pyrocarbon. This biconcave resurfacing implant, both ligament and bone-stock sparing, is indicated for use in early-to-moderate stage trapeziometacarpal osteoarthritis. It was hypothesized that the postoperative outcome measures of the Pyrocardan implant would be comparable to those seen with ligament reconstruction and tendon interposition (LRTI) surgeries and those reported by the designer of the implant, Phillipe Bellemère, but that strength would be greater than for LRTI.Methods In this prospective case series, 40 Pyrocardan implants were performed in 37 patients. Average age was 58 years (range: 46–71). Patients were assessed preoperatively, 3 months, 6 months, 1 year, 2 years, and beyond (long term) wherever possible.Results There have been no major complications or revision surgeries for the series. Average follow-up was 29 months (range: 12 months–7 years). Twenty-eight joints were assessed at over 2 years post index surgery. Outcome measure scores improved from preoperative assessment to the most recent follow-up equal or greater than 2 years. Average grip strength at 2 years was 30 kg, as compared with 19.6 kg in an age-matched cohort who underwent trapeziectomy and 25 kg in Bellemère's original series of Pyrocardan implants.Conclusions Pyrocardan interposition arthroplasty appears to be a safe, effective treatment for trapeziometacarpal arthritis. Patient-reported clinical outcomes were at least equivalent to LRTI and are comparable to Bellemère's original series. Grip and pinch strength appear to be better than LRTI.Level of Evidence This is a Level III, prospective observational cohort study

Stainless steel versus titanium volar multi-axial locking plates for fixation of distal radius fractures: a randomised clinical trial

Background: Distal radius fractures are among the most common fractures seen in the hospital emergency department. Of these, over 40% are considered unstable and require some form of fixation. In recent years with the advent of low profile plating, open reduction and internal fixation (ORIF) using volar plates has become the surgical treatment of choice in many hospitals. However, it is currently unknown which plating system has the lowest complication rate and/or superior clinical and radiological outcomes following surgery. Few studies have compared different types of plates, which may have various features, different plate and screw designs or may be manufactured from different materials (for example, stainless steel or titanium). This study will specifically investigate and compare the clinical and radiological outcomes and complication rates of two commonly used volar plating systems for fixation of distal radius fractures: one made from stainless steel (Trimed (TM) Volar Plate, Trimed (TM), California, USA) and the other made from titanium (Medartis (R) Aptus Volar Plate, Medartis (R), Basel, Switzerland). The primary aim of this study is to determine if there is a difference on the Patient Reported Wrist Evaluation six months following ORIF using a volar plate for adult patients with a distal radius fracture