Risk profiles in two different alpine rock climbing styles.

INTRODUCTION: The aim of this study is to evaluate the injury risk profile of the two different styles of rock climbing, alpine climbing with minor route protection (AC) and alpine sport climbing on well-protected routes (SC), in order to develop preventive strategies for risk management.  PATIENTS AND METHODS : 18 SC and 12 AC rock climbing accidents were evaluated retrospectively with a focus on climbers` demographics (age, experience, training intensity, performance level), accident demographics (unforeseen events preceding the injury, ascending or descending, fall height), injury patterns (injury severity, pathologies, pathomechanism) and environmental conditions (rock characteristics, route frequency, route grade, weather).  RESULTS : Injuries were mainly sustained by male lead climbers during ascent (80%). The lower extremity was injured in 46%, the upper extremity in 40%, the pelvis in 6% and the head, chest and spine in 3%. Climbers were significantly older (43 vs. 31 years; p=0.03) and more experienced (21.5 vs. 5.7 climbing years) in AC. Falling height was significantly greater in AC (14.8 vs. 4.7m). Unforeseen events preceding the injury differed significantly between both groups. Slipping off and letting go preceded the fall in 78% in SC, while rock dislodging occurred only in AC. There was a tendency that climbers in SC climbed near or above their performance level, while climbers in AC climbed below their level. SC climbers tended to show more ankle fractures while AC climbers tended to present more cases with multiple injuries. DISCUSSION: AC and SC climbers differ in their risk profiles. Poorer route protection in AC resulted in more severe injuries. Yet in SC routes, good protection alone was not enough to avoid severe injuries. For prevention, climbers should be aware of the specific risks in AC and SC routes and should adjust their behaviour accordingly. Athletic skills were overestimated in SC, while alpine demands were underestimated in AC. A higher focus on visual and haptic grip control may help to prevent loss of hold. A careful lining of the rope into solid rock can reduce rockfalls for the seconder. Continuous attention is mandatory in rope handling and belaying. Applying more mobile pros is recommended in AC because they may shorten fall heights.

Arthroscopic debridement of the dorsal capsule in intraarticular distal radius fractures: does it provide superior outcomes?

INTRODUCTION: Distal radius fractures (DRFs) are very common. One of the most significant complications after intraarticular DRF is arthrofibrosis with loss of wrist motion and pain. Wrist arthroscopy has become increasingly popular in the treatment of DRF with the advantage of good visualization of the joint surface and soft tissue injuries. In intraarticular DRFs injuries of the dorsal capsule are a characteristic finding which potentially cause loss of wrist motion. In this study, we investigated if arthroscopic debridement of dorsal capsule injuries at time of surgical fixation provides superior outcomes compared to the same treatment without debridement. MATERIALS AND METHODS: Between 2013 and 2017, we included 42 patients who underwent arthroscopy-assisted palmar plating for intraarticular DRFs in a prospective randomized controlled study. In group A (intervention group), the dorsal capsule tears were debrided during primary surgery, while in group B these were left in place. Active range of motion (AROM), grip strength, subjective outcomes and radiographic results were assessed 3, 6 and 12 months after primary surgery. A subgroup analysis was performed for patient age, fracture severity and duration of immobilization. RESULTS: Arthroscopic debridement of the dorsal capsule improved AROM in patients over 60 years of age, more severe fractures (AO 23 C2/C3) and prolonged postoperative immobilization for more than two weeks, while it was not relevant for younger patients with simple fractures and short immobilization. CONCLUSIONS: Debridement of the injured dorsal capsule in arthroscopic-assisted surgical treatment of intraarticular DRFs can improve surgical performance and optimize patient outcomes in a specific subgroup of patients.

Long-term outcome after hand and forearm transplantation - a retrospective study.

Between 2000 and 2014, five patients received bilateral hand (n = 3), bilateral forearm (n = 1), and unilateral hand (n = 1) transplants at the Innsbruck Medical University Hospital. We provide a comprehensive report of the long-term results at 20 years. During the 6-20 years follow-up, 43 rejection episodes were recorded in total. Of these, 27.9% were antibody-related with serum donor-specific alloantibodies (DSA) and skin-infiltrating B-cells. The cell phenotype in rejecting skin biopsies changed and C4d-staining increased with time post-transplantation. In the long-term, a change in hand appearance was observed. The functional outcome was highly depending on the level of amputation. The number and severity of rejections did not correlate with hand function, but negatively impacted on the patients´ well-being and quality of life. Patient satisfaction significantly correlated with upper limb function. One hand allograft eventually developed severe allograft vasculopathy and was amputated at 7 years. The patient later died due to progressive gastric cancer. The other four patients are currently rejection-free with moderate levels of immunosuppression. Hand transplantation remains a therapeutic option for carefully selected patients. A stable immunologic situation with optimized and individually adopted immunosuppression favors good compliance and patient satisfaction and may prevent development of DSA.

Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects.

Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.

Arthroscopic assisted treatment of distal radius fractures and concomitant injuries.

Wrist arthroscopy is mainly used to assist fracture reduction and fixation and to diagnose and treat concomitant injuries mainly to the scapholunate (SL), lunotriquetral (LT) ligament and the triangular fibrocartilage complex (TFCC). Arthroscopy is beneficial in improving anatomical reduction of fracture steps and gaps in intra-articular distal radius fractures (DRFs). Yet, the literature that the functional outcome correlates with the use of arthroscopy, is limited. Non-surgical treatment and immobilization is recommended for Geissler grade I-III Sl-ligament injuries, while open reduction, ligament suture and/or K-wire pinning is mandatory for complete ligament tears according to Geissler grade IV. This manuscript describes the current literature and gives insight into the authors' opinions and practice.

Clinical and radiological results of the vascularized medial femoral condyle graft for scaphoid non-union.

INTRODUCTION: This study evaluated the use of a free vascularized bone graft with and without cartilage from the medial femoral condyle (MFC) in patients with recalcitrant scaphoid non-union, with a special focus on union rates and the osteochondral graft for proximal pole destruction. MATERIALS AND METHODS: Thirty-eight avascular scaphoid non-unions in 37 patients who were treated with a free osteoperiosteal or osteochondral MFC graft were retrospectively evaluated (mean follow-up 16 months). Bone union, the scapholunate and the radiolunate angles were evaluated on X-ray images. The range of motion, grip strength, VAS, DASH and PRWE scores were evaluated clinically. RESULTS: The overall union rate was 95%. Bone union was achieved in 27 out of 29 (93%) scaphoids treated with a free osteoperiosteal MFC grafts and in 9 out of 9 (100%) scaphoids treated with a free osteochondral MFC graft. The range of motion remained almost unchanged, while grip strength increased significantly (34 kg vs. 44 kg) and the VAS (22-5), DASH (59-19) and PRWE (62-30) score decreased significantly. The scapholunate (71°-65°) and radiolunate (28°-18°) angle decreased. No major donor site morbidity was observed. Postoperative complications were observed in eight cases (21%). CONCLUSIONS: The vascularized medial femoral bone graft leads to a good functional outcome in the treatment of scaphoid non-unions. The graft provides adequate blood supply and structural stability to the scaphoid. A proximal pole destruction can be replaced using an osteochondral graft with promising short-term results preventing carpal osteoarthritis and collapse.

Positioning of a Volar Locking Plate with a Central Flexor Pollicis Longus Tendon Notch in Distal Radius Fractures.

Background Volar locking plates with a central notch were designed to reduce the risk of flexor pollicis longus (FPL) tendon irritation after volar plating for distal radius fractures. Objective The purpose of this study was to evaluate the course of the FPL tendon after FPL-plate osteosynthesis to identify a plate position that avoids an impingement with the FPL tendon. Patients and Methods Nineteen patients treated with volar plating using an FPL plate for a distal radius fracture were evaluated. Transverse ultrasound images were used to assess whether the profile of the FPL tendon lied within the plate notch. The position of the FPL tendon on transverse ultrasound images was transferred onto postoperative dorsovolar X-ray images to define an FPL tendon corridor for a plate position not interfering with the FPL tendon. Results The FPL tendon was aligned inside the plate notch completely in three cases, partially in 11 cases, and missed the notch in five cases. An FPL corridor was defined at the level of the watershed line with all FPL tendons being completely (74%) or partially (26%) aligned inside that corridor. There was a moderate correlation between the plate notch being positioned inside this corridor and the FPL tendon being positioned inside the plate notch ( r = 0.49; p = 0.033). Conclusion It seems advantageous to place the plate notch within a corridor parallel to the radial shaft between the ulnar edge of the scaphoid tubercle and the scapholunate interval for the FPL tendon protection. Level of Evidence This is Level IV study.

Hook Plate for Volar Rim Fractures of the Distal Radius: Review of the First 23 Cases and Focus on Dorsal Radiocarpal Dislocation.

Background Fragment-specific fixation of the distal radius is born to fix each articular fragment with limited surgical approach and low-profile devices. Over time, many devices with different designs and characteristics have been developed. However, many of them have showed the inability to securely fix marginal, small, and comminuted fragments as bony ligament avulsions and bony compression injuries. Purpose The purpose of this study was to evaluate the clinical and radiological outcome of a new device born to treat marginal articular fractures of the distal radius. Patients and Methods A retrospective review was conducted on 23 patients with a mean follow-up of 21 months including postoperative clinical evaluation, grip strength, computed tomography scan, and X-ray control. Results All fragments healed and maintained reduced until the final follow-up. The carpus was aligned with the distal radius in all patients presenting with a radiocarpal dislocation. Conclusion The volar rim fragment is an attachment site for the short radiolunate and the volar distal radioulnar ligament. Its unstable fixation can lead to articular incongruity, volar or dorsal subluxation of the carpus, and distal radioulnar instability. The involvement of this fragment on distal radius fractures is relatively common and many studies of the literature have been focused on its treatment. The Hook Plate stabilizes distal fragments at their bone-ligament interface. In addition to bony reduction, the device permits to stabilize the capsule and ligaments, as volar bony ligament avulsions, in a picture of dorsal radiocarpal dislocation. Level of Evidence This is a Level IV, case series.

Compliance assessment and flip-angle measurement of the median nerve: sonographic tools for carpal tunnel syndrome assessment?

OBJECTIVES: To assess the diagnostic performance of median nerve (MN) flip-angle measurements, deformation during wrist flexion [transit deformation coefficient (TDC)], during compression [compression deformation coefficient (CDC)] and fascicular freedom to potentially identify fibrotic MN changes in patients with carpal tunnel syndrome (CTS). METHODS: This prospective study was performed with institutional review board approval; all participants provided oral and written informed consent. Wrists in 21 healthy participants and 29 patients with CTS were examined by ultrasound. MN movement during wrist flexion, MN deformation during transition over the flexor tendons (TDC) and during controlled compression (CDC) as well as fascicular freedom were assessed. Diagnostic properties of these parameters were calculated and compared to clinical findings and cross-section area measurements (ΔCSA). RESULTS: Low flip angles were associated with high ΔCSA at a receiver-operator characteristics area under the curve (AUC) of 0.62 (0.51-0.74). TDC [AUC, 0.83 (0.73-0.92), 76.3% (59.8-88.6%) sensitivity, 88.5% (76.6-95.7%) specificity], restricted fascicular movement [AUC, 0.86 (0.78-0.94), 89.5% (75.2-97.1%) sensitivity, 80.8% (67.5-90.4%) specificity] and compression-based CDC [AUC, 0.97 (0.94-1.00), 82.1% (66.5-92.5%) sensitivity, 94.2% (84.1-98.8%) specificity] demonstrated substantial diagnostic power (95% confidence intervals in parentheses). CONCLUSIONS: Fascicular mobility, TDC and CDC show substantial diagnostic power and may offer insights into the underlying pathophysiology of CTS. KEY POINTS: • Dynamic ultrasonography during wrist flexion and compression enables median nerve deformability assessment. • Overall, reduced median nerve deformability is highly indicative of CTS. • Median nerve compressibility shows higher diagnostic power than conventional cross-section area measurements.

[Therapy of Dupuytren's contracture with collagenase - Evidence-based Consensus Statement of Austrian Surgical Societies]. / Therapie der Dupuytren'schen Kontraktur mit Kollagenase.

Dupuytren's contracture (DC) or Dupuytren's disease (DD) is a progressive fibro-proliferative disease of palmoplantar connective tissue, resulting in characteristic nodal and/or cord formation from collagen disposition. When the disease progresses, the thickening and shortening of the cords eventually leads the affected fingers to being pulled into flexion, which may be associated with marked disability, especially with bilateral disease. DD is relatively common in Europe, with the highest prevalence in Nordic countries. In Austria approx. 200 000 people are affected. The incidence increases with increasing age, with men being more often and earlier affected than women. The aetiology of DC is not completely clear, but it seems to be multifactorial; twin and familial studies confirm a genetic predisposition. The natural course of the disease can vary between relatively benign and massive progression and recurrence. In most cases, there is a fluctuating course. The DC is not curable; treatment methods range from minimally invasive to open surgical procedures. Collagenase Clostridium histolyticum (CCH) is a nonsurgical, enzymatic injection treatment for adult patients (≥ 18 years) with a palpable cord and has been approved in Europe since 2011. Clinical studies and practical experience of individual centres confirm the efficacy and safety of CCH treatment of DC. The present consensus statement was prepared under the auspices of the Austrian Society of Hand Surgery with the participation of the Austrian Society for Trauma Surgery, the Society of Orthopaedics and Orthopaedic Surgery as well as the Society for Plastic, Aesthetic and Reconstructive Surgery. On the basis of current literature and the experts' experience, it describes the various surgical procedures, with particular reference to collagenase treatment and provides guidance for their use. The statement is intended not only to illustrate the state of the art of current treatment, but also to support the achievement of uniform high quality standards in the treatment of DC in surgical centres and specialised medical practices throughout Austria.

Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery.

INTRODUCTION: For the treatment of scaphoid non-unions (SNU), different surgical techniques, including vascularized and non-vascularized bone grafts, are applied. Besides stability, vascularity, and the biological situation at the non-union site are important for healing and the appropriate choice of treatment. We assessed the healing potential of SNUs by histological parameters and compared it to CT parameters of bone structure and fracture location. Based on the results, we developed a CT classification and a treatment algorithm to impact graft selection in SNU surgery. PATIENTS AND METHODS: Preoperative 2D-CT reformations of 29 patients were analyzed for trabecular structure, sclerosis, and fragmentation of the proximal fragment. The fracture location was assessed on 3D-CT reconstructions and grouped in three zones depending on the potential blood supply. Samples were taken during surgery for histological evaluation. Histological parameters of bone healing were defined and a bone healing capacity score (BHC), reflecting histological bone viability, was calculated. CT findings were compared to BHC, age of SNU, and time to union. RESULTS: Cases with trabecular structure and without fragmentation showed a statistically significant higher BHC. Time to union was significantly faster if trabecular structure was present and sclerosis was absent. In intraarticular proximal pole non-unions, where no blood supply is assumed, the BHC was statistically significantly lower and time to union was longer compared to SNUs of the other locations. A statistically significant correlation between BHC and time to union was found in the proximal and distal fragment with higher BHC associated with faster healing. CONCLUSIONS: CT parameters of bone structure and fracture location can reflect histological healing capacity of SNUs. This can guide bone graft selection in SNU surgery.

Time-dependent changes in bone healing capacity of scaphoid fractures and non-unions.

The scaphoid is the most frequently fractured carpal bone and prone to non-union due to mechanical and biological factors. Whereas the importance of stability is well documented, the evaluation of biological activity is mostly limited to the assessment of vascularity. The purpose of this study was to select histological and immunocytochemical parameters that could be used to assess healing potential after scaphoid fractures and to correlate these findings with time intervals after fracture for the three parts of the scaphoid (distal, gap and proximal). Samples were taken during operative intervention in 33 patients with delayed or non-union of the scaphoid. Haematoxylin and Eosin (HE), Azan, Toluidine, von Kossa and Tartrate-resistant acid phosphatase (TRAP) staining were used to characterise the samples histologically. We determined distribution of collagen 1 and 2 by immunocytochemistry, and scanning electron microscopy (SEM) was used to investigate the ultrastructure. To analyse the samples, parameters for biological healing status were defined and grouped according to healing capacity in parameters with high, partial and little biological activity. These findings allowed scoring of biological healing capacity, and the ensuing results were correlated with different time intervals after fracture. The results showed reduced healing capacity over time, but not all parts of the scaphoid were affected in the same way. For the distal fragment, regression analysis showed a statistically significant correlation between summarised healing activity scores and time from initial fracture (r = -0.427, P = 0.026) and decreasing healing activity for the gap region (r = -0.339, P = 0.090). In contrast, the analyses of the proximal parts for all patients did not show a correlation (r = 0.008, P = 0.969) or a decrease in healing capacity, with reduced healing capacity already at early stages. The histological and immunocytochemical characterisation of scaphoid non-unions (SNUs) and the scoring of healing parameters make it possible to analyse the healing capacity of SNUs at certain time points. This information is important as it can assist the surgeon in the selection of the most appropriate SNU treatment.

Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects.

Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.

Ulna Rotation Osteotomy in Complete Dislocation of the Distal Radioulnar Joint.

Background Complete dislocation of the distal radioulnar joint (DRUJ) is a rare injury. Dislocation can present as uni- or multidirectional, acute or chronic, reducible or irreducible. It can occur due to isolated loss of ligamentous restraints or more frequent in Galeazzi - or Essex-Lopresti-type fractures. Case Description A 28-year-old man sustained a distal radius fracture and presented after conservative treatment with blocked supination. Examination revealed a malunion of the distal radius in combination with an irreducible dorsal dislocation of the DRUJ. Corrective osteotomy of the distal radius was performed, the DRUJ was reduced, and the ulnar avulsed triangular fibrocartilage complex (TFCC) refixed with transosseous sutures. Redislocation occurred 8 weeks later. Revision surgery showed a palmar dislocated TFC fixed in a palmar scar formation along the distal interosseous membrane (DIOM). The scar was released and a rotation osteotomy of the distal ulna was performed. At follow-up, the patient was pain-free, had good range of motion, and returned to work and sport activities. Literature Review For reconstruction of chronic complete dislocations of the DRUJ, ligament plasty procedures are described. In case of additional cartilage damage, salvage procedures are recommended. Clinical Relevance We report a procedure in which the rotation of the distal ulna is corrected to restore DRUJ congruity in chronic dislocations. The rotation osteotomy described is useful in gross ligamentous instability following loss of constraint by the TFCC and the DIOM.

Functional and Psychosocial Outcomes of Hand Transplantation Compared with Prosthetic Fitting in Below-Elbow Amputees: A Multicenter Cohort Study.

BACKGROUND: Hand-transplantation and improvements in the field of prostheses opened new frontiers in restoring hand function in below-elbow amputees. Both concepts aim at restoring reliable hand function, however, the indications, advantages and limitations for each treatment must be carefully considered depending on level and extent of amputation. Here we report our findings of a multi-center cohort study comparing hand function and quality-of-life of people with transplanted versus prosthetic hands. METHODS: Hand function in amputees with either transplant or prostheses was tested with Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP) and the Disabilities of the Arm, Shoulder and Hand measure (DASH). Quality-of-life was compared with the Short-Form 36 (SF-36). RESULTS: Transplanted patients (n = 5) achieved a mean ARAT score of 40.86 ± 8.07 and an average SHAP score of 75.00 ± 11.06. Prosthetic patients (n = 7) achieved a mean ARAT score of 39.00 ± 3.61 and an average SHAP score of 75.43 ± 10.81. There was no significant difference between transplanted and prosthetic hands in ARAT, SHAP or DASH. While quality-of-life metrics were equivocal for four scales of the SF-36, transplanted patients reported significantly higher scores in "role-physical" (p = 0.006), "vitality" (p = 0.008), "role-emotional" (p = 0.035) and "mental-health" (p = 0.003). CONCLUSIONS: The indications for hand transplantation or prosthetic fitting in below-elbow amputees require careful consideration. As functional outcomes were not significantly different between groups, patient's best interests and the route of least harm should guide treatment. Due to the immunosuppressive side-effects, the indication for allotransplantation must still be restrictive, the best being bilateral amputees.

Sesamoid bone transfer for metacarpophalangeal hyperextension instability of the thumb: A CT-osteoabsorptiometry study.

BACKGROUND AND AIM: Hyperextension instability of the metacarpophalangeal (MCP) joint of the thumb may result in pain, malfunction, and accelerated osteoarthritis in the carpometacarpal (CMC) joint. One method of treatment is sesamoid arthrodesis. The aim of this study is to investigate if a sesamoid transfer as a treatment of hyperextension instability of the thumb MCP joint leads to an altered distribution of the subchondral mineralisation and a negative clinical outcome. METHODS: Sesamoid transfer was performed on 12 patients with hyperextension instability of the MCP joint of the thumb. The range of motion (ROM) and radiologic outcome were assessed. Pinch and power grip strength were measured and compared to the nonoperated side. To determine the areas of maximum subchondral mineralisation in the joint, computed tomography (CT)-osteoabsorptiometry was performed to determine the long-term stress distribution within the joint. RESULTS: The distributions of the stress zones in the operated and nonoperated thumbs were not statistically different a median of 5 years following the sesamoid transfer procedure. There was no difference in the functional and radiological results between the operated and nonoperated thumbs. CONCLUSION: If it is assumed that the nonoperated thumb represents the normal condition for each individual, then it may be deduced that the operation achieves good clinical results, and the distribution of the subchondral mineralisation does not change.

Sonographic cross-sectional area measurement in carpal tunnel syndrome patients: can delta and ratio calculations predict severity compared to nerve conduction studies?

OBJECTIVE: To evaluate the accuracy of two different sonographic median nerve measurement calculations in predicting carpal tunnel syndrome (CTS) severity in a study population with clinically and electrophysiologically confirmed CTS. METHODS: 643 wrists of 427 patients (325 females and 102 males, age range: 17-90 years, mean ± SD: 57.9 ± 14.7) were included with CTS diagnosis based on clinical and nerve conduction studies (NCS). Cross-sectional area (CSA) measurement of the median nerve was performed at the carpal tunnel level (CSAc) and at the pronator quadratus muscle level (CSAp). Two parameters were calculated: delta (∆-CSA), which is the difference between proximal and distal measurements, and ratio (R-CSA), calculated by dividing distal over proximal measurements. RESULTS: Patients were classified into mild, moderate and severe CTS based upon NCS. The mean ∆-CSA (4.2 ± 2.6, 6.95 ± 2.2 and 10.7 ± 4.9 mm(2)) and mean R-CSA (1.5 ± 0.4, 1.95 ± 0.4 and 2.4 ± 0.7) values were significantly different between all groups (p < 0.001). Optimal cut-off values for ∆-CSA and R-CSA were 6 mm(2) and 1.7, respectively, to distinguish mild from moderate disease, and 9 mm(2) and 2.2, respectively, to distinguish moderate from severe disease. CONCLUSION: Threshold values for the calculated sonographic parameters ∆-CSA and R-CSA are useful in predicting CTS severity compared to NCS. KEY POINTS: • Two proposed parameters were calculated (∆-CSA, R-CSA) and compared to NCS. • A defined sonoanatomical proximal landmark was used for the calculation. • Both parameters showed ability to detect CTS severity comparable to NCS. • Cut-off values could be determined for both parameters.

The effect of delayed treatment on clinical and radiological effects of anterior wedge grafting for non-union of scaphoid fractures.

INTRODUCTION: The aim of the treatment of displaced scaphoid non-unions is the restoration of normal scaphoid anatomy. Restoration of normal scaphoid anatomy at an earlier stage might have functional benefits as maladaptive carpal ligament contractures and the development of preliminary osteoarthritis could be avoided. The purpose of this retrospective study was to determine if late reconstruction (delayed reconstruction group) was as effective as early reconstruction (early reconstruction group) of scaphoid non-union in restoring clinical and radiological outcome. PATIENTS AND METHODS: The early reconstruction group included patients who underwent surgery between 6 and 12 months after the original fracture. This group consisted of 14 male and 2 female patients. The delayed reconstruction group included patients who underwent surgery 12 or more months after the original fracture. This group consisted of 9 male and 1 female patients. Average time from injury to surgery in the early reconstruction group was 10 months (range 6-12 months) and mean postoperative follow-up period averaged 58 months (range 19-72 months). Average time from injury to surgery in the delayed reconstruction group was 69 months (range 12-88 months) and mean postoperative follow-up period averaged 62 months (range 24-80 months). All patients showed a humpback deformity as well as a DISI deformity with the radiolunate angle being greater than 15°. The outcome was assessed on the basis of measurement of active wrist range of motion and grip power. Wrist pain was evaluated using a visual analogue scale. Functional subjective outcome was evaluated with the DASH and PRWE scores. Results were compared to preoperative measurements as well as to the uninjured contralateral side. Pre- and post-operative radiographs were assessed for scapholunate angle (SLA) as a measure of palmar rotation and radiolunate angle (RLA). The presence of DISI was defined by a difference of >60° for the SLA or of >10° for the RLA between the affected and unaffected wrist. RESULTS: In the early reconstruction group bone union and correction of DISI deformity could be achieved for all patients (n = 16). In the delayed reconstruction group bone union could only be achieved without correction of the DISI deformity in six patients (60 %). In four patients (40 %) of the delayed reconstruction group non-union persisted. For the early reconstruction group at final follow-up mean flexion-extension arc, mean ulnar-radial-deviation arc and mean grip strength were 82, 91.5 and 82 % of uninjured side, respectively. Mean pain level decreased from 6 points before surgery to 1 point at final follow-up. The preoperative DASH changed from 48 to 17 and the preoperative PRWE changed from 30 to 14. The SLA changed from 51° to 48° and the RLA from 18° to 9°. Six patients from delayed reconstruction group showed bone union, but no correction of DISI deformity at final follow-up. Functional and radiological results showed only slight improvement. The remaining four patients from delayed reconstruction group with a persistent non-union continued to experience pain, reduced grip strength and limited range of wrist movement and DISI deformity persisted. CONCLUSION: In conclusion, wedge-shaped bone grafting of scaphoid non-union leads to increased functional scores as well as to improved carpal angles as long as bony union can be achieved. Remaining non-union and the inability to correct DISI deformity are severely correlated with an increased time frame between fracture and surgical treatment. Furthermore, the vascularization of the proximal fragment and patients' smoking habits has to be taken into consideration preoperatively.

Intraosseous rotation of the scaphoid: assessment by using a 3D CT model--an anatomic study.

OBJECTIVES: The purpose of this study was to assess intraosseous rotation as the third dimension of scaphoid anatomy on a 3D CT model using common volume rendering software to impact anatomical reconstruction of scaphoid fractures. METHODS: CT images of 13 cadaver wrist pairs were acquired. Reference axes for the alignment of distal and proximal scaphoid poles were defined three-dimensionally. Two methods for rotation measurement-the reference axis method (RAM) and the scapho-trapezio-trapezoidal joint method (STTM)-were developed and compared by three independent observers. RESULTS: Rotation measured by the RAM averaged 66.9° ± 7 for the right and 67.2° ± 5.8 for the left wrists. Using the STTM there was a mean rotation of 68.6° ± 6.6 for the right and 68.6° ± 6.8 for the left wrists. The overall results showed a significant variability of the measured values between different specimens (P < 0.05). There was no significant difference between left and right wrists of the same specimen, neither for the RAM (P = 0.268) nor for the STTM (P = 0.774). Repeatability coefficients between the observers were low, indicating good repeatability. CONCLUSIONS: The presented methods are practical tools to quantify intraosseous rotation between distal and proximal scaphoid poles using common volume rendering software. For clinical application the opposite side provides the best reference values to assess malrotation in scaphoid fracture cases. KEY POINTS: Scaphoid intraosseous rotation can be measured using common volume rendering software. The opposite uninjured side provides good reference values for rotation measurement. Assessment of malrotation may impact anatomical reconstruction of scaphoid fractures.

Intracarpal tunnel contents: evaluation of the effects of corticosteroid injection with sonoelastography.

PURPOSE: To define the stiffness of the intracarpal tunnel contents and to evaluate the effect of corticosteroid injection on the intracarpal tunnel contents by using sonoelastography. MATERIALS AND METHODS: This study was conducted with the approval of the institutional review boards, and all participants provided written, informed consent. Both hands were studied in 20 healthy volunteers, including eight men (mean age, 59.6 years; range, 50-76 years) and 12 women (mean age, 61.0 years; range, 39-79 years) and 22 hands were studied in 20 patients with carpal tunnel syndrome (CTS) (five men [mean age, 49.0 years] and 15 women [mean age, 61.1 years]; range, 39-89 years) between April 2012 and August 2012. The stiffness of the intracarpal tunnel contents was estimated as the standardized acoustic coupler (AC)-to-intracarpal tunnel contents surrounding the nerve (AC/C) strain ratio, analyzed with the Mann-Whitney U test. The patients were treated with corticosteroid injections, and the strain ratio was reexamined 6 weeks later, analyzed with the Wilcoxon t test. RESULTS: The mean AC/C strain ratio in the CTS patients was 12.6 ± 4.7 (standard deviation), which was higher (stiffer) than that in the healthy volunteers with a mean strain ratio of 8.2 ± 3.5 (P = .0013). Six weeks after the injection, the mean AC/C strain ratio had decreased to 8.5 ± 4.1 (P = .00069, compared with the preinjection value) in the CTS patients. CONCLUSION: The stiffness of the intracarpal tunnel contents in untreated CTS patients is higher than that of healthy volunteers but decreases 6 weeks after corticosteroid injection.