Surface replacing arthroplasty of a post-traumatic stiff and deviated proximal interphalangeal joint in an adolescent.

This case report describes the 4-year outcomes of proximal interphalangeal joint arthroplasty in a 14-year-old girl with a stiff joint after trauma. At follow-up, active range of motion was 35°, she was pain-free and satisfied with the outcome. Implant arthroplasty seems to be a valuable option for young patients with persistent post-traumatic stiff and deviated PIP joints to-at least temporarily-increase quality of life.

Diagnostic and treatment recommendations for recurrent or persistent symptoms after trapeziectomy: a Delphi study.

The aim of this Delphi study was to provide a diagnostic and treatment algorithm for patients with persistent or recurrent symptoms after trapeziometacarpal joint resection arthroplasty. Three Delphi rounds were conducted in which surveys were sent to 182 experienced hand surgeons worldwide. Responses were received from 140 participants. A consensus threshold was set at 67% agreement. Diagnostic tools and treatment approaches for six common revision scenarios achieved consensus. Radiographs are appropriate as primary (97%) and CT scans as secondary (76%) diagnostic tools. For scaphometacarpal impingement, 67% of respondents agreed that revision interposition is appropriate, with 93% recommending autologous tendon for the interposition. Additional suspension was considered appropriate by 68% of the participants. The diagnostic and treatment algorithm can help the surgeon to identify the reason for persistent symptoms after trapeziometacarpal joint resection arthroplasty and to choose an appropriate treatment strategy.Level of evidence: V.

Management of the capsule in trapeziometacarpal joint implant arthroplasty: resection versus repair.

We compared the effects of capsule resection versus capsule suturing in patients treated with a dual-mobility trapeziometacarpal joint prosthesis. We included 131 patients with capsular resection and 57 patients with repair. The mean scores for pain and the brief Michigan Hand Outcomes Questionnaire were similar between the groups preoperatively and at 6 weeks and 1 year postoperatively. Mean key pinch strength was also similar in both groups before surgery and at 1 year, but higher in the capsular resection than in the suture group at 6 weeks. The incidence of complications reported throughout the 1-year postoperative period was not significantly different between the groups. One implant in the capsular resection group was revised for reasons most likely unrelated to capsule management. We conclude that the capsule can be safely resected during trapeziometacarpal joint implant arthroplasty.Level of evidence: III.

Revisions after trapeziometacarpal joint resection arthroplasty: A systematic literature review.

BACKGROUND: The aim of this systematic literature review was to describe current indications and interventions for revisions after trapeziometacarpal joint (TMJ) resection arthroplasty. METHODS: The literature search was conducted by an experienced librarian in the Medline, EMBASE, Cochrane Library, Web of Science and Scopus databases. We included all articles that investigated any TMJ arthroplasty procedure in which the trapezium was completely resected and if any subsequent revision procedure including joint-related and soft-tissue surgeries was mentioned. Two independent reviewers selected the articles and were involved in data extraction. RESULTS: Sixty-two articles reporting on 5,284 operated thumbs and 434 revision surgeries were included. We extracted 24 indications for revision and 31 revision techniques. Most revisions were performed because of subsidence/impingement of the first metacarpal bone (n=194 thumbs) followed by unspecified pain (n=53), metacarpophalangeal joint problems (n=28) and scaphotrapezoidal osteoarthritis (n=17). Eleven treatment strategies were found for subsidence/impingement of the first metacarpal, the most frequent being revision of the existing interposition using autologous tendon (n=46) and soft tissue interposition with distraction pinning (n=28). CONCLUSIONS: There are a wide variety of indications and even more surgical techniques described in the literature to treat persisting or recurrent pain after TMJ resection arthroplasty. Currently, there is no uniform treatment guideline available how to diagnose and treat such cases. Therefore, the results of this literature review will form the basis for a Delphi study aiming to develop recommendations for the diagnosis and treatment of persistent / recurrent pain after TMJ resection arthroplasty. LEVEL OF EVIDENCE: IV.

Are patients satisfied with online video consultations for assessing their hand disorder?

OBJECTIVES: The aim was to evaluate patient satisfaction with online video consultations in assessing hand disorder. MATERIAL AND METHODS: This prospective study included patients who attended a video consultation, either as an initial meeting to assess the need for further evaluation or treatment or as an early postoperative follow-up consultation. After the consultation, they completed a satisfaction questionnaire. Regression models were used to reveal determinants of patient satisfaction. RESULTS: We included 100 patients, with a mean age of 55 years (range 17-81 years). 95% were satisfied or very satisfied. The main reasons for choosing this form of consultation were shorter travel and wait times. Age, gender and educational level did not determine satisfaction. Significant factors for dissatisfaction were insufficient video and sound quality. CONCLUSION: Online video consultation in hand surgery is a valuable alternative to in-clinic appointments for all age groups. However, it is crucial to ensure adequate video and audio quality.

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.

Short-term recovery after implant versus resection arthroplasty in trapeziometacarpal joint osteoarthritis.

We compared the short-term recovery of patients treated with trapeziometacarpal joint (TMJ) implant arthroplasty versus resection-suspension-interposition (RSI) arthroplasty. Implant patients (n = 147) had a better 3-month postoperative brief Michigan Hand Outcomes Questionnaire (MHQ) score (mean 82) compared to RSI patients (n = 127), who had a mean score of 69. Key pinch strength at 3 months was also higher in the implant group compared to the RSI group (6.8 kg vs. 3.1 kg). At 1 year, both groups had similar brief MHQ scores, but key pinch remained higher in the implant group (7.0 kg vs. 3.9 kg [RSI]). After implant arthroplasty, employed patients returned to work after a mean of 44 days, which was significantly faster than the 84 days for RSI patients. Patients after TMJ implant arthroplasty recover significantly faster in the first 3 postoperative months compared to RSI patients. However, 1-year postoperative outcomes are similar for both cohorts, with key pinch strength remaining higher for patients with TMJ implant arthroplasty.Level of evidence: II.

Low complication rate and high implant survival at 2 years after Touch® trapeziometacarpal joint arthroplasty.

We analysed complications, revision surgeries, and patient-reported and clinical outcomes 2 years after trapeziometacarpal joint implant arthroplasty using the Touch® prosthesis. Of 130 operated patients with trapeziometacarpal joint osteoarthritis, four had to be revised owing to implant dislocation, loosening or impingement, leading to an estimated 2-year survival rate of 96% (95% confidence interval: 90 to 99). Of 101 patients available for the 2-year follow-up, complications occurred in 17, with the most frequent being de Quervain stenosing vaginosis (n = 6) and trigger thumb (n = 5). Pain at rest decreased significantly from a median value of 5 (interquartile range [IQR]: 4 to 7) before surgery to 0 (IQR: 0 to 1) at 2 years. Key pinch strength increased significantly from 4.5 kg (IQR: 3.0 to 6.5) to 7.0 kg (IQR: 6.0 to 8.0). We recommend surgery with the Touch® prosthesis as the standard procedure for patients with isolated trapeziometacarpal joint osteoarthritis because of the high survival rate and promising outcomes at 2 years.Level of evidence: IV.

Preoperative Thresholds of Pain and Function to Achieve a Minimal Important Change and Patient Acceptable Symptom State After Proximal Interphalangeal Joint Arthroplasty.

PURPOSE: There is ongoing discussion about the level of symptoms patients with proximal interphalangeal (PIP) joint osteoarthritis should have to undergo surgery. The aims of our study were to determine the minimal important change (MIC) and patient acceptable symptom state (PASS) for PIP joint range of motion (ROM), and define clinically relevant thresholds of preoperative pain and function at which patients have the greatest chance to achieve a MIC and PASS in these outcomes 1 year after PIP arthroplasty. METHODS: We analyzed registry data that included patients with PIP joint osteoarthritis who underwent an arthroplasty for this condition and had a 1-year follow-up. Patients indicated pain on a numeric rating scale (0-10) and completed the brief Michigan Hand Outcomes Questionnaire (MHQ). Active total PIP ROM was measured. The preoperative thresholds, predictive of achieving the MIC and PASS for each outcome measure of pain, function, and ROM, were determined using receiver operating characteristics curves. RESULTS: We included 196 patients who experienced a relevant improvement in ROM (= MIC) when there was an increase by ≥8° compared with the ROM preoperatively. Patients were satisfied with their postoperative ROM (= PASS) if they achieved PIP mobility of at least 66°. Pain at rest and during activities was predictive for achieving a MIC but not a PASS. Due to an insufficient area under the curve for the brief MHQ and ROM, their baseline values cannot predict the postoperative achievement of MIC or PASS. We suggest that patients with preoperative pain at rest ≥4.5 or pain during activities ≥5.5 have the greatest chance of achieving a subjectively relevant change 1 year after surgery. CONCLUSIONS: The determined thresholds may support surgeons in the preoperative process of deciding for or against a surgical intervention and explain the probability of achieving sufficient postoperative symptom relief for the patient. LEVEL OF EVIDENCE: Prognostic I.

Three-Dimensionally Planned and Printed Patient-Tailored Plates for Corrective Osteotomies of the Distal Radius and Forearm.

PURPOSE: We evaluated the 1-year postoperative clinical and patient-reported outcomes in patients who had a 3-dimensional planned corrective osteotomy of their distal radius, radial shaft, or ulnar shaft using a printed, anatomical, patient-tailored plate to determine the feasibility and effectiveness of this methodology. METHODS: Simulations in computer-assisted preoperative planning of corrective osteotomies resulted in 3-dimensionally printed surgical guides, surgical models, and anatomically customized plates for application at the distal radius and forearm. Patients with malunions of the distal radius or forearm who underwent fixation with the custom-made plates were documented in our registry. Grip strength and range of motion assessments were made before surgery (baseline), as well as at 6 weeks and 3 and 12 months. Additionally, patients rated their wrist-related pain and disability using the Patient-Rated Wrist Evaluation. RESULTS: Fifteen patients underwent corrective surgery, and the 1-year follow-up data of 14 patients with a median age of 56 years (interquartile range, 24-64 years) were available for analysis. The median baseline Patient-Rated Wrist Evaluation score improved from 47 to 7 after 1 year. The flexion-extension arc of motion of the wrist increased from 90° at baseline to 130° at 1 year and the pronation-supination arc of motion of the wrist increased from 135° to 160° in the same time period. Differences in radiological measurements for palmar and radial inclinations, as well as for ulnar variance between the affected and contralateral wrists, were reduced with the osteotomy. In 1 case, the plate was removed 11 months after the osteotomy. No severe adverse events were reported. CONCLUSIONS: Three-dimensionally planned and printed patient-tailored plates offer a reliable method for correcting even complex malunions of the distal radius and forearm. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Intraoperative Load Tolerance of the Thumb Carpometacarpal Joint After Resection-Suspension-Interposition Arthroplasty.

Purpose: The objective was to measure the intraoperative load tolerance of the thumb carpometacarpal (CMC) joint after trapeziectomy, tendon suspension, and interposition. Methods: In this single-center prospective study, preoperative pinch grip, thumb mobility, and hypermobility of the thumb CMC joint were determined by 2 hand surgeons. Patients completed the brief Michigan Hand Outcomes Questionnaire. During surgery and upon removal of the trapezium, the surgeon subjectively rated the degree of thumb CMC load tolerance as "stable," "medium stable," or "unstable." A measurement system with an integrated force sensor was used to measure intraoperative thumb CMC load tolerance. The thumb ray was displaced manually by 10 mm toward the scaphoid, and the counteracting force was measured over the entire displacement. The objective load tolerance was determined as the maximal measured force after trapezium resection, tendon suspension, and interposition. Analysis of variance was used to test for the differences in load tolerance between the surgical steps. Spearman's coefficient was used to find correlations between load tolerance and clinical or patient-reported variables. Results: Twenty-nine patients with a mean age of 70 years (SD, 8.1 years) were available for analysis. The measured intraoperative load tolerance after trapeziectomy was 15.5 N (SD, 5.4 N) and significantly increased to 18.7 N (SD, 5.5 N) after suspension. Load tolerance only slightly increased after tendon interposition, increasing the force to 20.3 N (SD, 6.7 N). Neither the surgeon's subjective stability rating nor the clinical or patient-reported variables correlated with the measured load tolerance after trapeziectomy. Conclusions: Our results show that tendon suspension leads to the highest increase in thumb CMC load tolerance during resection-suspension-interposition arthroplasty. Clinical relevance: Tendon suspension appears to be the most important step in stabilizing the metacarpal base after trapeziectomy, whereas tendon interposition does not seem to have a relevant additional effect regarding load tolerance, at least immediately after surgery.

Cost-Utility Analysis of Thumb Carpometacarpal Resection Arthroplasty: A Health Economic Study Using Real-World Data.

PURPOSE: Knowledge about the costs and benefits of hand surgical interventions is important for surgeons, payers, and policy makers. Little is known about the cost-effectiveness of surgery for thumb carpometacarpal osteoarthritis. The objective of this study was to examine patients' quality of life and economic costs, with focus on the cost-utility ratio 1 year after surgery for thumb carpometacarpal osteoarthritis compared with that for continued nonsurgical management. METHODS: Patients with thumb carpometacarpal osteoarthritis indicated for resection arthroplasty were included in a prospective study. The quality of life (using European Quality of Life-5 Dimensions-5 Level), direct medical costs, and productivity losses were assessed up to 1 year after surgery. Baseline data at recruitment and costs sustained over 1 year before surgery served as a proxy for nonsurgical management. The total costs to gain 1 extra quality-adjusted life year and the incremental cost-effectiveness ratio were calculated from a health care system and a societal perspective. RESULTS: The mean European Quality of Life-5 Dimensions-5 Level value for 151 included patients improved significantly from 0.69 to 0.88 (after surgery). The productivity loss during the preoperative period was 47% for 49 working patients, which decreased to 26% 1 year after surgery. The total costs increased from US $20,451 in the preoperative year to US $24,374 in the postoperative year. This resulted in an incremental cost-effectiveness ratio of US $25,370 per quality-adjusted life year for surgery compared with that for simulated nonsurgical management. CONCLUSIONS: The calculated incremental cost-effectiveness ratio was clearly below the suggested Swiss threshold of US $92,000, indicating that thumb carpometacarpal surgery is a cost-effective intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analyses II.

Outcomes and recommendations for revision of thumb carpometacarpal resection arthroplasty.

This study investigated revision surgery for the thumb after failed trapeziectomy with ligament reconstruction and tendon interposition and defined a revision concept. Twenty-four patients with 25 affected thumbs were examined at a mean of 5.5 years after their last revision operation. Pain during daily activities was 2.7 on a 0-10 numeric rating scale, pain at rest was 1.6 and the brief Michigan Hand Outcomes Questionnaire score was 63. Although 68% of patients indicated that their thumb was better than before primary surgery, the outcome after revision surgery was less favourable than that reported for primary trapeziectomy with ligament reconstruction and tendon interposition. We defined a revision algorithm to use as a guide for patients with residual symptoms after resection arthroplasty. The main reason for revision, symptomatic impingement of the thumb metacarpal, should be treated with resection of the metacarpal base and scaphotrapezoidal joint. An existing interposition should be revised, or a new interposition should be used, preferably with an autologous tendon or alternately with an allograft.Level of evidence: IV.

Functional genomics atlas of synovial fibroblasts defining rheumatoid arthritis heritability.

BACKGROUND: Genome-wide association studies have reported more than 100 risk loci for rheumatoid arthritis (RA). These loci are shown to be enriched in immune cell-specific enhancers, but the analysis so far has excluded stromal cells, such as synovial fibroblasts (FLS), despite their crucial involvement in the pathogenesis of RA. Here we integrate DNA architecture, 3D chromatin interactions, DNA accessibility, and gene expression in FLS, B cells, and T cells with genetic fine mapping of RA loci. RESULTS: We identify putative causal variants, enhancers, genes, and cell types for 30-60% of RA loci and demonstrate that FLS account for up to 24% of RA heritability. TNF stimulation of FLS alters the organization of topologically associating domains, chromatin state, and the expression of putative causal genes such as TNFAIP3 and IFNAR1. Several putative causal genes constitute RA-relevant functional networks in FLS with roles in cellular proliferation and activation. Finally, we demonstrate that risk variants can have joint-specific effects on target gene expression in RA FLS, which may contribute to the development of the characteristic pattern of joint involvement in RA. CONCLUSION: Overall, our research provides the first direct evidence for a causal role of FLS in the genetic susceptibility for RA accounting for up to a quarter of RA heritability.