Radiological positioning of a proximal interphalangeal joint resurfacing implant: Reliability and functional outcomes correlation.

OBJECTIVES: The aims of this study were to define radiological measurements for quantifying the position of a surface replacing implant (CapFlex-PIP) in the proximal interphalangeal (PIP) joint, to test the reliability of these measurements, and to explore whether implant position influences patient-reported and clinical outcomes one year after surgery. MATERIAL AND METHODS: We developed 7 radiographic measurements to quantify the position of the proximal and distal implant components. Two independent surgeons analyzed the 1-year postoperative radiographs of 63 fingers documented in our registry. Inter-rater reliability of these measurements was calculated with the intraclass correlation coefficient (ICC). Correlations between the radiographic measurements and PIP range of motion (ROM), the brief Michigan Hand Outcomes Questionnaire (MHQ), and pain were determined using Spearman's correlation coefficient. Radiographic measurements of patients with the worst and best postoperative ROM were compared using the Mann-Whitney-U test. RESULTS: Inter-rater reliability was only good for 1 measurement (ICC = 0.89), but poor to moderate for the other measurements (ICC ranging from 0.34 to 0.69). These measurements neither correlated with ROM, brief MHQ nor pain based on correlation coefficients ranging from 0.00 to 0.31. There were no relevant differences in the radiographic measurements between patients with the worst and best ROM. CONCLUSION: The position of the CapFlex-PIP implant could not be reliably quantified on plain radiographs. The lack of correlations between implant position and postoperative outcomes can be attributed either to the unreliable measurements or the actual lack of influence of the implant position on pain and function.

Thumb Interphalangeal Joint Arthroplasty With a Surface Replacing Implant: Two-Year Results.

PURPOSE: The aim of this study was to evaluate the 2-year clinical and patient-reported outcomes of thumb interphalangeal (IP) joint arthroplasty. METHODS: In this prospective pilot study, we included patients who received a surface replacing implant at the thumb IP joint. Patients rated their pain at rest on a numeric rating scale (0-10) and completed the brief Michigan Hand Outcomes Questionnaire. The range of motion of the IP joint was also measured. If the patient acceptable symptom state was inadequate (i.e., pain at rest ≤ 1.5), the reasons for the remaining symptoms were descriptively presented. RESULTS: Of the 13 patients who underwent arthroplasty, 1 withdrew participation and 1 was considered for arthrodesis because of a dislocated implant. Therefore, the study included 11 patients with a median age of 67 years. The median pain at rest decreased from 6 preoperatively to 0 at 2 years, and the preoperative brief Michigan Hand Outcomes Questionnaire score increased from 38 to 58 at follow-up. The total range of motion of the IP joint was 45° at 2 years. Patient acceptable symptom state was not achieved in 4 patients including a heavy manual worker and a patient with severe systemic lupus erythematosus. CONCLUSIONS: Based on the inconsistency of the results, we conclude that thumb IP joint arthroplasty with a surface replacing implant is rarely indicated; it could be an alternative in patients who place great importance on precision tasks. For patients who either have high demands for a powerful pinch grip, the high physical demands of a manual job, or rheumatoid disease, IP joint arthrodesis should be preferred. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Determinants of long-term satisfaction after silicone MCP arthroplasty in patients with inflammatory diseases.

The aim was to identify determinants of satisfaction in patients with inflammatory diseases who underwent hand reconstruction using silicone metacarpophalangeal (MCP) arthroplasty. We hypothesized that patients taking biologic drugs would be more satisfied with the outcome. Patients who underwent silicone arthroplasty and had a minimum follow-up of 1 year were included. Patients rated their satisfaction with the treatment result and hand appearance on a 5-point Likert scale with a score of 5 indicating "very satisfied" and 1 indicating "very dissatisfied" and completed the brief Michigan Hand Outcomes questionnaire (MHQ). MCP range of motion (ROM), ulnar drift and grip strength were measured. Ordered logistic regression modelling and the Mann-Whitney U test were used. Forty-one patients with 118 operated fingers were available for follow-up at an average of 5.6 years after surgery. Patients were satisfied with the overall treatment result (score 4.4; SD 0.8), but only somewhat satisfied (score 3.3; SD 1.5) with their hand's appearance. Total MCP ROM was 61° (SD 21) with an ulnar deviation of 10° (SD 14). Appearance and ulnar deviation were significant determinants of satisfaction (R2=0.35). There was no difference in outcomes between patients using biologics and those who were not. Our hypothesis that patients taking biologics are more satisfied after surgery could not be proven. Hand appearance and ulnar drift are the most important determinants of satisfaction after reconstruction of MCP deformity.

Lateral stability in healthy proximal interphalangeal joints versus surface replacement and silicone arthroplasty: Results of a three-dimensional motion analysis study.

The objective of this study was to quantify the lateral stability of healthy proximal interphalangeal (PIP) joints using a three-dimensional motion capture system and compare it to affected joints after surface replacement or silicone arthroplasty. Three study groups comprised healthy participants, patients with PIP joint osteoarthritis treated with a surface replacing implant (CapFlex-PIP) and those with a silicone arthroplasty. All participants were matched on gender and finger, and the two patient groups were also matched on length of follow-up. An optical tracking system was used to measure lateral stability. Radial and ulnar stability of the PIP joint was measured as the maximal lateral deviation angle of the middle phalanx under loads of 40 g, 90 g and 170g at 0°, 20° and 45° PIP joint flexion. Measurement reliability was evaluated with a test-retest trial [intraclass correlation coefficient (ICC)]. A total of 30 joints were assessed with 5 index and 5 middle fingers per test group. Lateral deviation increased proportionally with applied weight. Silicone arthroplasty joints had a higher median lateral deviation angle of 5.1° (range 0.7-7.9) than healthy [3.0° (0.5-11.0)] and surface replacement joints [3.3° (0.3-7.4)] at 45° flexion and under 170g load. Test-retest reliability was high with an ICC of 0.93. Lateral PIP joint stability is highly variable in both healthy participants and patients after PIP joint arthroplasty. PIP joint surface replacement arthroplasty tends to achieve better anatomical stability compared to flexible silicone implants.

[Surface replacement of proximal interphalangeal joints using CapFlex-PIP]. / Oberflächenersatz am Fingermittelgelenk mittels CapFlex-PIP.

OBJECTIVE OF SURGERY: The cementless implantation of the surface replacement CapFlex-PIP enables pain relief, preservation of motion, improves lateral stability and corrects axis deviation in proximal interphalangeal (PIP) joints of patients with primary and secondary PIP osteoarthritis. INDICATIONS: Painful PIP joints as a result of degenerative or posttraumatic osteoarthritis with restriction of motion. Secondary inflammatory destruction of PIP joints in rheumatoid arthritis with low inflammatory activity and good bone conditions. CONTRAINDICATIONS: Destruction of PIP joints with severe bone loss, osseous defects and chronic joint luxation. Joint destruction induced by florid or subacute bacterial arthritis. Skin infections. SURGICAL TECHNIQUE: Dorsal or palmar incision over the affected PIP joint while sparing the peritendinous tissue. Exposure of the proximal phalangeal head and meticulous bone resection. Precontouring of the bone bed for proximal prosthesis. Insertion of the trial prosthesis. Exposure of the distal base and resection in the correct axis. Determination of distal prosthesis size and height of the polyethylene inlay. Insertion of the trial prosthesis without bone protrusion. After clinical and radiological control, implantation of the final prosthesis. FOLLOW-UP: Long finger splint, palmar flexor support splint for 2-3 weeks with active mobilization. Then active free mobilization with a twin bandage. After 6 weeks radiological check and free functional mobilization. RESULTS: The active range of motion of 50 patients increased from 43.4° before surgery to 55.9° after 1 year with concomitant pain relief (6.5 to 2.2). In one case revision surgery was required due to traumatic rupture of the radial collateral ligament and four secondary tenolyses were performed.

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

UNLABELLED: 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.

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.

Intramedullary splinting or conservative treatment for displaced fractures of the little finger metacarpal neck? A prospective study.

Forty patients with a 30° to 70° palmar displacement of a little finger metacarpal neck fracture were treated either with closed reduction and intramedullary splinting, or conservatively without reduction. Functional mobilization was started after 1 week in both groups. A radiological and clinical assessment of flexion and extension of the small finger metacarpophalangeal joint was done at 2 and 6 weeks, and at 3, 6 and 12 months. In addition patient satisfaction and grip strength were recorded at 12 months. No statistically significant differences in range of motion and grip strength were found between the two groups. Patient satisfaction and the appearance were superior in the surgically treated group. We conclude that intramedullary splinting for displaced fractures of the little finger metacarpal neck offers an aesthetic, but not a functional advantage.

Palmar multidirectional fixed-angle plate fixation in distal radius fractures: do intraarticular fractures have a worse outcome than extraarticular fractures?

INTRODUCTION: The results and complications using a palmar plate system with the possibility of multidirectional fixed-angle screw fixation (Aptus® Radius 2.5 mm by Medartis®) for the treatment of unstable distal radius fractures were evaluated in a single cohort study including 62 patients. PATIENTS: Patients with extra- and intraarticular fractures were evaluated separately. The mean follow-up was 14.7 months. Active wrist motion averaged 60.1° extension, 52.0° flexion, 86.3° pronation, and 84.6° supination. Grip strength averaged 89% of the contralateral wrist. RESULTS: There was no loss of the initial reduction with bony union in all cases. The mean DASH-score was 12.6 points. Postoperative complications included two extensor pollicis longus tendon ruptures, two median nerve compression syndromes, one complex regional pain syndrome, and one postoperative haematoma. In our series the results of the intraarticular fracture group were similar to the extraarticular fracture group. The complication rate, however, was substantially higher in the intraarticular fracture group. CONCLUSION: We conclude that palmar plating with multidirectional fixed-angle screw insertion is an effective and useful treatment option, especially for complex intraarticular distal radius fractures.

A randomised clinical study comparing palmar and dorsal fixed-angle plates for the internal fixation of AO C-type fractures of the distal radius in the elderly.

Current surgical treatments for distal radial fractures include dorsal and palmar plate fixation. We report results of a randomised study comparing these methods for AO C1-3 fractures. The emphasis was placed on the early postoperative functional recovery within the first 6 months as this interval is of decisive importance for elderly patients. Thirty patients with unilateral AO C1-3 fractures were enroled, 15 were treated with a palmar plate and 15 received a dorsal Pi-plate. Results were assessed 6 weeks, 3 months and 6 months postoperatively focusing on functional recovery. The palmar plate group demonstrated significantly better results in range of motion, grip strength and pain.

Problematic bone fixation with pyrocarbon implants in proximal interphalangeal joint replacement: short-term results.

Seventeen pyrocarbon PIP prostheses were implanted into 14 patients, followed prospectively and reviewed clinically. The patients were assessed after a mean follow-up of 20.5 months subjectively by a VAS pain scale and radiographically. Significant pain relief was noted in all patients from a mean of 7.6 pre-operatively to 1.3 at final follow-up. Migration of one, or both, components was observed radiographically in eight joints and radiolucent lines were evident in three more cases. The clinical results of the implants which had migrated were less favourable for range of motion and grip strength than the stable joints of this series, although, statistically, the results were not significant. The number of possibly unstable prostheses in this series raises the question as to whether pyrocarbon is suitable for uncemented pressfit fixation in combination with early functional rehabilitation.

[Early results of NeuFlex silastic implant in MCP arthroplasty]. / Frühresultate des arthroplastischen Grundgelenkersatzes mit der NeuFlex-Silikonprothese.

For the reconstruction of destroyed metacarpophalangeal (MP) joints in rheumatoid arthritis, the Swanson silicon spacer is still the golden standard. However, long-term follow-up reveals an increasing number of complications, particularly mechanical failure. In order to deal with these problems a number of new, biomechanically different silicone implants have been designed. Among these, the NeuFlex prosthesis has a preflexed hinge of 30 degrees in relation to the shaft axis, a more palmar lying center of rotation and a rectangular hinge with a collarlike platform against the bony surfaces. In a prospective study, the early results of the first thirteen patients operated with the NeuFlex arthroplasty are reported. All patients suffered from rheumatoid arthritis with destruction of the MP joints. The mean follow-up was 12.3 months. A total of 37 joints were replaced. All patients were female with an average age of 56 years. Postoperative reduction of pain, measured on a visual analog scale with the maximum of 10 (VAS), decreased from 6.6 to 0.7 (p < 0.001). Jamar grip strength improved from 4.2 kg preoperatively to 9.9 kg postoperatively (p < 0.005). Range of motion improved from 37 degrees to 57 degrees (p < 0.0001) as a result of a reduction in active extension deficit which reduced from 35 degrees to 15 degrees postoperatively. Ulnar drift was reduced from 20.2 degrees to 3.4 degrees at follow-up (p < 0.005). Radiological evaluation showed no implant failure, no subsidence, and no signs of inflammatory reaction. Overall the NeuFlex silicone implants show encouraging early results which must be confirmed in the long term.

[Patient education before orthopedic elective interventions. "The Lagenthal model of 3-step patient education"]. / Patienten-Aufklärung vor orthopädischen Wahleingriffen. "Das Langenthaler Modell der 3-Stufen-Aufklärung".

There is still quite a controverseY when and how an informed consent should be obtained from a patient in the surgical field. As has been stated of the federal court the patient need to be given that information which is understandable to him and which will not cause him undue anxiety. This information has to be sufficient for the decision whether to proceeD or decline a surgical procedure. The federal courts are therefore asking for the optimal patient consent not necessarily the total and complete revelation during the patient information. For this reason the act of obtaining an informed consent was thought to be turned into a scientific question in identifying the base from optimal quality of giving informed consent respecting at the same time the principal of evidence based medicine. The support presents a sample of an oral and written consent-form given in three stages as it is currently being used in the orthopaedic service of the Langenthal hospital. 100 patients were given this type of a consent and were later on asked for their opinion of acceptance. Most of the patients felt to be sufficiently informed on their procedure after having undergone a three times repeated interview as well as having been given a consent form including hand-drawings concerning their particular procedure. The advantages as well as the disadvantage of this type of consent form are being discussed.

No indications for percutaneous lumbar discectomy?

A questionnaire was used to assess the outcome of automated percutaneous lumbar discectomy (APLD), to correlate patients' data and to identify criteria for pain relief and patient satisfaction. Two hundred and thirty eight patients were operated on by APLD between 1988 and 1990. The questionnaire returned by 182 patients (76.4%) was suitable for evaluation. The mean follow-up was 2.5 years. Overall, 60% reported pain relief and 52% were satisfied with APLD. Conventional operations were carried out subsequently on 45 patients (25%). Bivariate and multivariate analyses were done for preoperative (age, gender, neurological deficit, Lasegue's sign, sports activity), perioperative (weight of disc material removed, level of APLD) and post-operative (conventional nucleotomy, change in condition, pain relief, satisfaction, sports activity, return to work, compensation claims) parameters. The only significant parameters for improvement in condition and pain relief was age, where patients younger than 41 do better. Risk factors for reoperation were a positive Lasegue's sign and over 41 years of age. Patient satisfaction was significantly higher for patients without sensory deficit preoperatively.