Dome versus single-cut osteotomies for correction of long bone deformities-technical considerations.

Corrective osteotomy allows to improve joint loading, pain and function. In complex deformities, the biggest challenge is to define the optimal surgical solution, while considering anatomical, technical and biomechanical factors. While the single-cut osteotomy (SCOT) and focal dome osteotomy (FDO) are well-established treatment options, their mathematical relationship remain largely unclear. The aim of the study was (1) to describe the close mathematical relationship between the SCOT and FDO and (2) to analyze and introduce a novel technique-the stepped FDO-as a modification of the classic FDO. The mathematical background and relationship of SCOT and FDO are described for the example of a femoral deformity correction and visualized using a 3D surface model taking into account the benefits for the clinical application. The novel modifications of the stepped FDO are introduced and its technical and clinical feasibility demonstrated. Both, SCOT and FDO, rely on the same deformity axis that defines the rotation axis k for a 3D deformity correction. To achieve the desired correction using a SCOT, the resulting cutting plane is perpendicular to k, while using a FDO will result in a cylindrical cut with a central axis parallel to k. The SCOT and FDO demonstrate a strong mathematical relation, as both methods rely on the same deformity axis, however, resulting in different cutting planes. These characteristics enable a complementary use when defining the optimal type of osteotomy. This understanding enables a more versatile planning approach when considering factors as the surgical approach, biomechanical characteristics of fixation or soft tissue conditions. The newly introduced stepped FDO facilitates an exact reduction of the bone fragments and potentially expands the clinical applicability of the FDO.

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.

Proximal phalanx flexor tendon tenodesis after severe frostbite in a rock climber.

A 32 year-old climber sustained a grade IV frostbite injury to the right hand which required amputation at the neck of the proximal phalanges of all the long fingers. To increase range of motion and strength in the remaining metacarpophalangeal joints, tenodesis of the flexor digitalis superficialis and profundus tendons onto the proximal phalanges was performed. Several revisions for removal of bony spurs, dorsal skin advancement flaps and web space deepening were necessary. After 2 years, the patient achieved 10-0-100° metacarpophalangeal joint range of motion in extension-flexion and could do full body-weight pull-ups on 1 cm deep holds, lift 50 kg on a 2 cm deep hold (normal contralateral side, 40 kg), climb up to F7a routes and use a mechanical 4-finger functional prosthesis.

Reasons for scaphoid non-union: Analysis of behavior of health care providers and patients.

To assess factors related to health-system and patient behavior in scaphoid fracture non-union, a retrospective analysis of 134 patients treated by scaphoid reconstruction was performed. Mean age at the accident was 26 years (range, 9-75 years), and the mean age at surgery was 28 years (range, 13-75 years). Mean time to first consultation was 233 days (range, 0-12,136 days), and time to surgery 740 days (range, 19-12,362 days). The physician was mainly a general practitioner (52.2%), or an orthopedist/traumatologist (17.9%), general surgeon (12.7%), or hand surgeon (17.2%). The initial diagnostic procedure was X-ray in 76.9% of cases, computed tomography (CT) in 20.9%, magnetic resonance imaging (MRI) in 13.4%, and none in 11.2%. A fracture was diagnosed in 32.8% of cases, and non-union in 14.9%. Patients mainly presented late: 63% within 3 weeks, and a minority on the day of the accident (39%). In 11% of cases, healthcare providers performed either no or inadequate imaging (77%) and missed correct diagnosis in 52% of cases. 128 patients had a second consultation, and 77 a third, with the same or different physicians, before surgery, leading to increased healthcare costs due to delayed diagnosis and treatment. Delayed presentation and lack of suspicion by attending physicians were the main reasons. Speeding up diagnosis and improving physician training are vital and could significantly reduce health care costs. CT or MRI should be performed if scaphoid fracture is suspected.

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.

[Sport Injuries to Wrist and Fingers].

INTRODUCTION: About one fifth of all sports accidents involve the hand. Many injuries can be diagnosed and treated easily. However, some of them such as fractures of the scaphoid or the hamate of the hamulus are difficult to detect with conventional radiographs and are often missed without a CT scan. Ligament injuries such as the skier's thumb must be recognized and treated properly, often surgically. There are also sport-specific injuries, such as the closed rupture of a flexor tendon pulley in climbers, which otherwise occur rarely and are little known. These topics, pitfalls and tricks will be discussed.

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.

Is increased trapezial slope a cause of early trapeziometacarpal osteoarthritis?

OBJECTIVES: Thumb carpometacarpal joint osteoarthritis is one of the most common forms of osteoarthritis in the hand. The underlying causes are multifactorial. We investigated whether increased trapezial slope could be a causal factor. MATERIAL AND METHODS: We measured trapezial slope and 1st metacarpal slope in 37 patients with early thumb carpometacarpal joint osteoarthritis and compared results with 41 patients without osteoarthritis, using computer-supported 3D-analysis based on CT scans. RESULTS: There was a significant intergroup difference in trapezial slope (111° in patients with osteoarthritis, and 107° in patients without) and in 1st metacarpal slope (17° versus 14°). CONCLUSION: Steeper trapezial slope seemed to be a risk factor for thumb carpometacarpal joint osteoarthritis. Therefore, correction of trapezial slope by trapezium osteotomy could be a valuable surgical approach in early thumb carpometacarpal joint osteoarthritis.

Does distal interphalangeal joint arthrodesis affect proximal interphalangeal joint arthroplasty outcomes in the same finger?

The purpose of this study was to analyse the 1-year outcomes after combining a surface replacing proximal interphalangeal joint arthroplasty and a distal interphalangeal screw arthrodesis and to compare the combined surgery with proximal interphalangeal joint arthroplasty alone. To obtain two groups with similar baseline data from our prospective registry, propensity score matching was used to match 23 fingers with the combined operations with 115 fingers with proximal interphalangeal joint arthroplasty alone. One year after surgery, the mean ranges of motion were 60° (95% CI: 53° to 67°) in the combined group and 63° (95% CI: 60° to 66°) in the control group and did not differ significantly. Grip strength, the brief Michigan Hand Questionnaire and pain also did not differ between the groups 1 year after surgery. All the proximal interphalangeal implants in patients treated with a distal interphalangeal screw arthrodesis remained in situ. Combining proximal interphalangeal joint arthroplasty with distal interphalangeal arthrodesis leads to 1-year outcomes that are similar to those achieved by proximal interphalangeal joint replacement alone.Level of evidence: III.

Palmar Shift of the Proximal Interphalangeal Joint in Different Grip Positions as a Potential Risk Factor for Periphyseal Injuries in Adolescent Climbers.

INTRODUCTION: The aim of this study was to evaluate different grip positions as a contributing factor for primary periphyseal stress injuries of the finger phalanges in climbing. METHODS: Ultrasound imaging of the proximal interphalangeal joint was performed on 37 asymptomatic adolescent climbers. Longitudinal images were obtained of middle and ring fingers of both hands in different grip positions (open, half-open, and crimp), unloaded and loaded. The translation between the dorsal head of the proximal phalanx and the shaft of the middle phalanx was measured in an unloaded and loaded situation for all grip positions. The resulting difference was determined as the palmar shift. RESULTS: The mean age of the study population was 13 y. Results showed a palmar shift of 0.57 mm in a loaded crimp grip position compared to 0.13 mm in an open position and 0.20 mm in a half-open grip position. With a P value of <0.001, this shift was significantly higher in a crimp grip position compared to open or half-open grip positions. CONCLUSIONS: This leads to an increase in joint incongruity and much higher peak forces on the dorsal aspect of the epiphyseal-physeal-metaphyseal complex, which is particularly vulnerable during the adolescent growth spurt. Thus, climbing and training behavior should be adapted accordingly during this phase by avoiding the crimp grip position until epiphyseal fusion.

Quantification of Malalignment and Corrective Osteotomies in Patients With Malunion After Elastic Stable Intramedullary Nailing of Pediatric Forearm Fractures.

Purpose: This study looked at postoperative malunion with restricted function after elastic stable intramedullary nailing (ESIN) in pediatric patients in their childhood or adolescence. The primary objective was to compare the magnitude of the osseous malposition to the healthy opposite side. Second, these individuals were treated with patient-specific surgical instrumentation, and functional outcomes were documented. Methods: Patients under the age of 18 at the time of a corrective osteotomy due to a forearm malunion after initial ESIN treatment were included in this study. The healthy contralateral side was used as a reference for preoperative analysis and planning of the osteotomy. Osteotomies were performed using patient-specific guides and the direction and extent of the malunion were compared to the change in range of motion (ROM) after the operation. Results: Fifteen patients met the inclusion criteria at three years after initial ESIN placement, with the most pronounced malposition in the rotational axis. The postoperative function significantly improved by 12° (pre-op: 60° ± 17; post-op: 72° ± 10) of pronation and 33° (pre-op: 43° ± 26; post-op: 76° ± 13) of supination. There was no correlation between the amount and direction of malformation and the change in ROM. Conclusions: The most noticeable malunion after forearm fractures treated with the ESIN technique is in the rotational direction. Patient-specific corrective osteotomy of pediatric forearm malunion following forearm fracture fixation with ESIN achieves significant improvement in forearm range of motion. Clinical relevance: The findings are clinically relevant since forearm fractures are the most common pediatric fracture, affecting a large number of patients who can benefit from the findings of this study. It has the potential to raise awareness of the significance of the accurate rotational component of intraoperative bone alignment in the ESIN 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.

[Malunion of the distal radius: 3D planning and performance of intra- and extra-articular corrective osteotomy]. / Malunion der distalen Radiusfraktur: 3-D-Planung und Durchführung von intra- und extraartikulären Korrekturosteotomien.

OBJECTIVE: Restoration of the original anatomy with reduction of both current symptoms and risk of posttraumatic osteoarthritis. INDICATIONS: Symptomatic intra- or extra-articular malunion due to limitation of movement and/or painful function, intra-articular step of > 1 mm, instability of the distal radioulnar joint. CONTRAINDICATIONS: Minimal deformity. Pre-existing osteoarthritis Knirk and Jupiter II or higher. Simpler surgical alternative, e.g., ulna shortening osteotomy. Smoking or advanced age are not contraindications. SURGICAL TECHNIQUE: Preoperative assessment and performance of a bilateral computed tomography (CT). Three-dimensional (3D) malposition analysis and calculation of the correction. Planning of the corrective osteotomy on the 3D model and creation of patient-specific drilling and sawing guides. Performing the 3D-guided osteotomy. POSTOPERATIVE MANAGEMENT: Early functional unloaded mobilization with the splint for 8 weeks until consolidation control with CT. RESULTS: Significant reduction of the step to < 1 mm (p ≤ 0.05) can be achieved with intra-articular corrections. In extra-articular corrective osteotomies, a mean residual rotational malalignment error of 2.0° (±â€¯2.2°) and a translational malalignment error of 0.6 mm (±â€¯0.2 mm) is achieved. Single-cut osteotomies in the shaft region can be performed to within a few degrees for rotation (e.g., pronation/supination 4.9°) and for translation (e.g., proximal/distal, 0.8 mm). After surgery, a mean residual 3D angle of 5.8° (SD 3.6°) was measured. Furthermore, surgical time for 3D-assisted surgery is significantly reduced compared to the conventional technique (140 ± 37 vs 108 ± 26 min; p < 0.05). Thus, the progression of osteoarthritis can be reduced in the medium term and improved mobility and grip strength are achieved. The clinical outcome parameters based on patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) scores are roughly comparable.

Study protocol: short against long antibiotic therapy for infected orthopedic sites - the randomized-controlled SALATIO trials.

BACKGROUND: Few studies address the appropriate duration of post-surgical antibiotic therapy for orthopedic infections; with or without infected residual implants. We perform two similar randomized-clinical trials (RCT) to reduce the antibiotic use and associated adverse events. METHODS: Two unblinded RCTs in adult patients (non-inferiority with a margin of 10%, a power of 80%) with the primary outcomes "remission" and "microbiologically-identical recurrences" after a combined surgical and antibiotic therapy. The main secondary outcome is antibiotic-related adverse events. The RCTs allocate the participants between 3 vs. 6 weeks of post-surgical systemic antibiotic therapy for implant-free infections and between 6 vs. 12 weeks for residual implant-related infections. We need a total of 280 episodes (randomization schemes 1:1) with a minimal follow-up of 12 months. We perform two interim analyses starting approximately after 1 and 2 years. The study approximatively lasts 3 years. DISCUSSION: Both parallel RCTs will enable to prescribe less antibiotics for future orthopedic infections in adult patients. TRIAL REGISTRATION: ClinicalTrial.gov NCT05499481. Registered on 12 August 2022. PROTOCOL VERSION: 2 (19 May 2022).

Surgical fixation techniques in four-corner fusion of the wrist: a systematic review of 1103 cases.

BACKGROUND: Four-corner fusion (4CF) is a known treatment option for degenerative wrist conditions. Different techniques may be used and there is no general consensus on best implant. As such, it was the purpose of the current systematic review to compare fusion rates and outcomes depending on the fixation technique. METHODS: The systematic review was registered in the international prospective register of systematic reviews (PROSPERO): CRD42020164301. It followed the PRISMA guidelines. Original articles were screened using the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and Web of Science Core Collection. Studies reporting on outcome for 4CF surgery were included. Studies with a minimum Level IV of evidence were considered eligible. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: A total of 29 studies met the inclusion criteria, for a total of 1103 wrists. The mean age was 41.8 years (range 19-83). Mean follow-up overall was 43.5 months (range 24-146 months). Reported fusion weighted rates were >90% and did not differ significantly between techniques. Reoperations due to different reasons occurred in 135 (12%) of all 1103. There was significant data heterogeneity regarding fusion rates (I2 = 70%). Inconsistency and heterogeneity in data reporting did not allow meta-analysis with direct data pooling and comparison of subgroups. CONCLUSIONS: Satisfactory fusion rates (over 90%) can be achieved independent of the fixation technique used in 4-corner arthrodesis. Due to the high data heterogeneity and reporting inconsistency across studies, no statements regarding PROMs, ROM or grip strength can be made. LEVEL OF EVIDENCE: Systematic Review of Level IV Studies.

Malunion deformity of the forearm: Three-dimensional length variation of interosseous membrane and bone collision.

It remains unclear to what extent the interosseous membrane (IOM) is affected through the whole range of motion (ROM) in posttraumatic deformities of the forearm. The purpose of this study is to describe the ligament- and bone-related factors involved in rotational deficit of the forearm. Through three-dimensional (3D) kinematic simulations on one cadaveric forearm, angular deformities of 5° in four directions (flexion, extension, valgus, varus) were produced at two locations of the radius and the ulna (proximal and distal third). The occurrence of bone collision in pronation and the linear length variation of six parts of the IOM through the whole ROM were compared between the 32 types of forearm deformities. Similar patterns could be observed among four groups: 12 types of deformity presented increased bone collision in pronation, 8 presented an improvement of bone collision with an increase of the mean linear lengthening of the IOM in neutral rotation, 6 had an increased linear lengthening of the IOM in supination with nearly unchanged bone collision in pronation and 6 types presented nearly unchanged bone collision in pronation with a shortening of the mean linear length of IOM in supination or neutral rotation. This kinematic analysis provides a better understanding of the ligament- and bone-related factors expected to cause rotational deficit in forearm deformity and may help to refine the surgical indications of patient-specific corrective osteotomy.

A Life Dedicated to Climbing and Its Sequelae in the Fingers-A Review of the Literature.

Fingers of sport climbers are exposed to high mechanical loads. This work focuses on the fingers of a 52-year-old active elite climber who was the first in mankind to master 8B (V13), 8B+ (V14) and 8C (V15) graded boulders, bringing lifelong high-intensity loads to his hands. It is therefore hypothesized that he belongs to a small group of people with the highest accumulative loads to their fingers in the climbing scene. Fingers were analyzed by means of ultrasonography, X-rays and physical examination. Soft tissue and bone adaptations, as well as the onset of osteoarthritis and finger stiffness, were found, especially in digit III, the longest and therefore most loaded digit. Finally, this article aims to provide an overview of the current literature in this field. In conclusion, elite sport climbing results in soft tissue and bone adaptations in the fingers, and the literature provides evidence that these adaptations increase over one's career. However, at later stages, radiographic and clinical signs of osteoarthritis, especially in the middle finger, seem to occur, although they may not be symptomatic.

3D planning and patient specific instrumentation for intraarticular corrective osteotomy of trapeziometacarpal-, metacarpal and finger joints.

BACKGROUND: Intra-articular malunions of the finger can lead to deformity and loss of function and can be treated with intra-articular corrective osteotomies. The aim of this study was to evaluate radiographic joint congruency, feasibility and functional outcome of three-dimensional (3D) printed patient-specific instrumentation (PSI) for corrective osteotomies at the trapeziometacarpal and finger joints. METHODS: Computer-tomography (CT) scans were acquired preoperatively for standard 3D planning, which was followed by calculation of cutting planes and the design of individualized bone surface contact drilling, sawing and reposition guides. Follow-up CT scans and clinical examinations (range of motion, grip strength) were performed. Postoperative complications were documented and patient-reported outcome measurements were assessed (Single Assessment Numeric Evaluation (SANE) score, brief Michigan Hand Questionnaire (MHQ)). RESULTS: Ten patients (mean age 28.4 ± 12.8,range 13.8-51.3) years) were included with a mean follow-up of 21 ± 18 (3-59) months including seven osteotomies at the trapeziometacarpal or metacarpophalangeal joints and three at the proximal interphalangeal joint (PIP). All radiographic follow-up examinations showed the planned correction with good joint congruency and regular osseous consolidation. At the latest follow-up, the range of motion (ROM) increased and the average grip strength recovered to the level of the contralateral side. No postoperative complication was detected. The mean SANE score improved from 44 ± 23 (0-70) to 82 ± 12 (60-90) after a mean of 72 ± 20 (44-114) months. The mean postoperative brief MHQ was 92 ± 8 (71-98). CONCLUSION: The use of 3D PSI in treating intra-articular malunions at the trapeziometacarpal and finger joints restored articular congruency accurately. ROM and grip strength improved postoperatively comparable to the healthy contralateral side and patient-reported outcome measures improved after medium-term follow-up.

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.