A Stepwise Intraoperative Protocol to Minimize Complications after Volar Plating.

Background Although outcome of volar plating is generally good, care should be taken to avoid specific iatrogenic and preventable complications, with an incidence reporting averaging 15%. Flexor tendon rupture due to a prominent plate, extensor tendon rupture due to a dorsal protruding screw tips, cartilage lesions due to intra-articular screw placement, loss of reduction due to insufficient stability, and persisting ulnar pain with distal radioulnar joint instability due to unstable triangular fibrocartilaginous complex lesions or unstable ulnar styloid base fractures all have been described. Purpose We believe that a majority of these complications can be prevented by meticulous assessment of several intraoperative parameters during volar plating. Therefore, we introduce the WRIST protocol, a stepwise easy-to-remember manual that combines multiple fluoroscopic measurements to guide intraoperative decision making. Conclusion Large prospective studies of the "WRIST" protocol are needed for validation. But we believe that it may help surgeons to optimize surgical technique, functional and radiographic outcome, and prevent complications when treating distal radial fractures.

Standardised Tendon Fenestration with ITEC-Technique for Lateral Epicondylosis with Injection of Betamethasone versus Autologous Blood.

Background: Infiltration is one of the treatment options for lateral epicondylosis, a degenerative process in the tendon of the musculus extensor carpi radialis brevis. The aim of this study was to evaluate the clinical outcome of a standardised fenestration technique, the Instant Tennis Elbow Cure (ITEC) technique, with injection of betamethasone versus autologous blood. Methods: A prospective comparative study was performed. Twenty-eight patients received an infiltration with 1 mL betamethasone, in combination with 1 mL 2% lidocaine. Twenty-eight patients received an infiltration with 2 mL autologous blood. Both infiltrations were administered using the ITEC-technique. The patients were evaluated at baseline, 6 weeks, 3 months and 6 months using Visual Analogue Scale (VAS), Patient-Rated Tennis Elbow Evaluation (PRTEE) and Nirschl staging. Results: At the 6-week follow-up, the corticosteroid group showed significantly better results for VAS. At the 3-month follow-up, no significant differences were observed for all three scores. At the 6-monthfollow-up, the autologous blood group showed significantly better results for all three scores. Conclusions: Standardised fenestration using the ITEC-technique with corticosteroid infiltration is more effective in reducing pain at the 6-week follow-up. At the 6-month follow-up, the use of autologous blood is more effective in pain reduction and functional recovery. Level of Evidence: Level II.

Radiological imaging of the trapeziometacarpal joint: a historical and clinical perspective.

The opposable thumb provides both stability and mobility and is needed to accomplish different prehensile tasks. The trapezium is a complex bone, with a distal articular surface that is convex in the sagittal plane of the thumb and concave in the coronal plane of the thumb. The numerous additional articulations with the carpus and the oblique orientation to the main plane of the hand makes it difficult to evaluate the trapeziometacarpal joint using standard hand or wrist radiographic views. This review gives an overview of the different radiological views that have been described for the thumb with an emphasis on their historical origin and positioning during radiography. We also describe different measurements and classifications that can be obtained using different thumb radiographs.

Standardized Tendon Fenestration with Injection of Autologous Blood for Treatment of Lateral Epicondylitis.

Lateral epicondylitis (LE) of the elbow is often treated with conservative methods. Several techniques including injections with different substances are widely performed. No standardization exists. This prospective study describes the results of the short-term follow-up of 56 patients with mean age 48 years (range: 30-68 years) treated with the Instant Tennis Elbow Cure Medical device, which fenestrates the injured tendon in a standardized way through a holder of 12 small needles. Depth and position of the needles are determined beforehand by ultrasonography. Unprepared autologous blood was injected through the holder in the tendon. Visual analog pain scale (VAS) decreased significantly in rest by 61% and during activity by 47% after 6 weeks. VAS decreased significantly in rest by 79% and during activity by 66% after 3 months. VAS did not remain significantly different after 6 months. Satisfaction rates were 71% after 6 weeks and 82% after 6 months. This suggests that the therapeutical effect sustains and in some cases increases over time. Patient Related Tennis Elbow Evaluation score ameliorated after 3 months by 71%. Comparative studies are needed to confirm this effect versus other techniques as physiotherapy, shockwave therapy, and injections with other substances.

Minimally Invasive Pronator Quadratus Sparing Approach versus Extended Flexor Carpi Radialis Approach with Pronator Quadratus Repair for Volar Plating in Distal Radial Fractures.

Background Several volar plating techniques exist to treat distal radial fractures. Question We investigated minimally invasive plate osteosynthesis (MIPO) with pronator quadratus (PQ) sparing versus conventional flexor carpi radialis approach for volar plating with PQ repair after distal radial fractures during the first postoperative year. Patients and Methods Prospective data of two consecutive cohorts were compared: 62 patients in MIPO group with an average age of 61.2 years and 66 patients in PQ repair group with an average age of 61.4 years completed the entire follow-up period. Results Range of motion was not significantly different, except flexion-extension that was significantly higher in the MIPO group. Quick Disabilities of the Arm, Shoulder and Hand was significantly lower in the MIPO group. Pain visual analogue scale was only significantly lower at 6 weeks. Grip strength measurements and patient satisfaction were not significantly different. Conclusions MIPO volar plating with PQ sparing is a surgical technique that can be chosen according to surgeon's preference and expertise, resulting in a better flexion-extension mobility and function score according to our study. Level of evidence This is a Level 3 study.

Addition-Subtraction Osteotomy With Ligamentoplasty for Symptomatic Trapezial Dysplasia With Metacarpal Instability: A 10-Year Follow-Up.

PURPOSE: Symptomatic trapezial dysplasia with metacarpal instability in a nonarthritic joint can lead to a disabling condition characterized by decreased pain, mobility, and strength. Bony correction may be required in dysplastic joints, because soft tissue correction might be insufficient to stabilize the trapeziometacarpal (TMC) joint. We combined 2 techniques described previously, an abduction-extension osteotomy of the first metacarpal and an opening wedge osteotomy of the trapezium, including a ligament reconstruction (hemi-flexor carpi radialis). The aim of this study was to investigate the long-term results of this technique. METHODS: In this single-center, retrospective cohort study, we included patients treated surgically for primary instability of the TMC joint with trapezial dysplasia between 2003 and 2007. We measured pain (visual analog scale), mobility (opposition and retropulsion), patient-reported disability (Quick-Disabilities of the Arm, Shoulder, and Hand), and radiographic evaluation (Devers' angle) 10 years after surgery. Results were compared with preoperative data. RESULTS: We reviewed 17 thumbs retrospectively (mean follow-up, 12 years). One patient was converted to a TMC prosthesis. Key pinch improved significantly from 5.2 kg (±2.4 kg) at baseline to 6.3 kg (±2.1 kg) at 10-year follow-up. Quick-Disabilities of the Arm, Shoulder, and Hand score and Devers' angle were significantly better after 10 years compared with preoperative data. There was a mean visual analog scale score of 0.5 (±1.4) at rest and 2.3 (±2.6) during activities. Ten years after surgery, 5 patients had a stable Eaton score of 1. Four patients had progression to stage 2, and 5 to stage 3. CONCLUSIONS: Addition-subtraction osteotomy with ligamentoplasty has a positive long-term effect on symptomatic trapezial dysplasia with TMC joint instability. Although this operation did not protect the TMC joint from further wear, pain was acceptable for most patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical and ultrasonographical follow-up after standard removal of distal radius volar plates positioned distal to the watershed line.

Marginal fracture types of the distal radius may require volar plate positioning distal to the watershed line. Subsequently, plate prominence with direct friction with the flexor tendons occurs which is associated with flexor tendon pathology. Standard plate removal can be proposed. This cohort study examined clinical outcome, patient satisfaction and ultrasonographical assessment of the relation of the flexor pollicis longus (FPL) and the volar rim after standard plate removal. Twenty patients with volar plate prominence after osteosynthesis for distal radius fractures were included. Plate removal was performed at least 4 months after initial surgery. The mean age was 60 years (range 39-84). The average delay from hardware removal to assessment was 2.9 years (range 1.0-5.0 years). Mean flexion, extension and radial deviation were significantly decreased (p < 0.05) compared to the contralateral side, while ulnar deviation, pro- and supination and grip strength were not. Mean QuickDASH score was 21.5. 85% of patients described their result as good to excellent. 80% would undergo the intervention again. During ultrasonography, distance from FPL to volar rim remained significantly decreased compared to the uninjured side in neutral and flexed position (p < 0.05) despite plate removal. The largest distance between the FPL and the volar cortical bone, which is mainly occupied by the pronator quadratus, did not differ. In this study, the range of motion and FPL distance to the distal radius normalized only partially compared to the uninjured wrist after standard plate removal.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Ivory arthroplasty for trapeziometacarpal osteoarthritis: 10-year follow-up.

This prospective study investigates long-term functional outcome after total trapeziometacarpal joint replacement with the Ivory arthroplasty for trapeziometacarpal joint osteoarthritis. Clinical outcome, overall function, pain, and radiologic outcome after a minimum of 10 years were evaluated for 26 Ivory arthroplasty in 24 patients. Two patients had bilateral arthroplasties. The female to male ratio was 22:2, and the mean age was 71 years (range 57-83). The mean follow-up period was 130 months (range 120-142). Overall functioning as defined by the QuickDASH score and visual analogue pain score improved by 50% and 81%, respectively, when compared with the preoperative status. However, these outcomes deteriorated beyond 5 years after surgery. Long-term results suggest the Ivory arthroplasty to be a reliable treatment for trapeziometacarpal osteoarthritis since it improves overall function and reduces pain up to 10 years postoperatively. However, revision within 10 years after surgery was needed in four of 26 cases. Level of evidence: II.

Short-Term Results after Total Trapeziectomy with a Poly-L/D-Lactide Spacer.

Background Proximal migration of the first metacarpal can be seen after total trapeziectomy and various techniques have been described to prevent this subsidence. Purpose We hypothesized the insertion of a poly-L/D-lactide spacer to prevent proximal migration of the first metacarpal without the need of an additional ligament reconstruction, allowing early mobilization and less demanding rehabilitation. Patients and Methods Ten thumbs were treated with a total trapeziectomy and insertion of a poly-L/D-lactide scaffold. Clinical and radiological evaluation was performed after 6 months and 1 year. Patient satisfaction, pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, mobility of the thumb, and strength were assessed. Results Pain according to the visual analog scale decreased ( p = 0.01) and QuickDASH score decreased ( p = 0.02) significantly after 1 year. Radiological evaluation after 12 months showed a collapse of the scaphometacarpal distance of 45% ( p = 0.01). Osteolysis of the distal scaphoid pole and/or proximal metacarpal was seen in 6 out of 10 cases. Because of the osteolysis, the use of the poly-L/D-lactide scaffold was discontinued in our practice. Conclusion In this limited series, total trapeziectomy with the use of the poly-L/D-lactide scaffold provides significant pain reduction and improvement of overall function. Radiographic evaluation shows significant collapse of the scaphometacarpal distance after 1 year and frequent signs of osteolysis. We do not encourage the use of the poly-L/D-lactide scaffold with total trapeziectomy before long-term clinical and radiological follow-ups of the osteolysis are available.

Midterm Follow-up of Treating Volar Marginal Rim Fractures with Variable Angle Lcp Volar Rim Distal Radius Plates.

BACKGROUND: Specific treatment of the volar marginal rim fragment of distal radius fractures avoids occurance of volar radiocarpal dislocation. Although several fixation systems are available to capture this fragment, adequately maintaining internal fixation is difficult. We present our experience of the first 10 cases using the 2.4 mm variable angle LCP volar rim distal radius plate (Depuy Synthes®, West Chester, US), a low-profile volar rim-contouring plate designed for distal plate positioning and stable buttressing of the volar marginal fragment. METHODS: Follow-up patient satisfaction, range of motion, grips strength, functional scoring with the QuickDASH and residual pain with a numeric rating scale were assessed. Radiological evaluation consisted in evaluating fracture consolidation, ulnar variance, volar angulation and maintenance of the volar rim fixation. RESULTS: The female to male ratio was 5:5 and the mean age was 52.2 (range, 17-80) years. The mean follow-up period was 11 (range, 5-19) months postoperatively. Patient satisfaction was high. The mean total flexion/extension range was 144° (range, 100-180°) compared to the contralateral uninjured side 160° (range, 95-180°). The mean total pronation/supination range was 153° (range, 140-180°) compared to the contralateral uninjured side 170° (range, 155-180°). Mean grip strength was 14 kg (range, 9-22), compared to the contralateral uninjured side 20 kg (range, 12-25 kg). Mean pre-injury level activity QuickDASH was 23 (range, 0-34.1), while post-recovery QuickDASH was 25 (range 0-43.2). Residual pain was 1.5 on the visual numerical pain rating scale. Radiological evaluation revealed in all cases fracture consolidation, satisfactory reconstruction of ulnar variance, volar angulation and volar rim. We encountered no flexor tendon complications, although plate removal was systematically performed after fracture consolidation. CONCLUSIONS: The 2.4 mm variable angle LCP volar rim distal radius plates is a valid treatment option for treating the volar marginal fragment in distal radius fractures.

De Quervain Tenosynovitis Following Trapeziometacarpal Ball-and-Socket Joint Replacement.

Background One of the surgical treatment options for trapeziometacarpal (TMC) joint arthritis is a prosthetic ball-and-socket replacement. One of the complications in the postoperative setting is de Quervain tendinopathy. Purposes Although this complication has been reported following a resection athroplasty, we questioned whether lengthening of the thumb following the Ivory (Memometal, Stryker Corporate, Kalamazoo, MI, USA) ball-and-socket arthroplasty could be a causal factor. Methods In a prospective study regarding the overall outcome of the Ivory prosthesis, we analyzed 96 cases (83 patients; 69 female, 12 male, 8 bilateral) of primary implanted Ivory prosthesis and the incidence of de Quervain disease during the first year following surgery. We found a particularly high incidence (17%) of de Quervain tendinopathy the first year following this ball-and-socket arthroplasty. We measured the lengthening of the thumb radiographically in the group presenting de Quervain and the asymptomatic group and compared this measure between the two groups. Results We did not find any measurable or statistically significant difference between the groups regarding lengthening. Discussion These findings suggest that lengthening of the thumb following ball-and-socket arthroplasty is not a causal factor in the development of de Quervain tendinopathy within one year after surgery.

Addition-subtraction osteotomy without ligamentoplasty for symptomatic trapezial dysplasia with metacarpal instability.

Trapeziometacarpal joint pain is often associated with a dynamic adduction deformity of the thumb metacarpal, combined with radial subluxation at the base of the thumb metacarpal, due to trapeziometacarpal dysplasia. Addition-subtraction osteotomy is a surgical option to correct the bony deformity when conservative treatment fails. Eight patients who underwent surgery with this technique were prospectively evaluated. All patients were female and mean age was 42 (range 27-59) years. Mean follow-up period was 23 (range 10-42) months postoperatively. Seven patients (87.5%) were very satisfied. Joint mobility and strength of the operated thumb was restored to a degree comparable to the contralateral thumb. Overall function according to the Quick-DASH score improved by 75.5% and pain according to the Visual Analogue Scale decreased by 65%. Radiological evaluation showed a decrease of the trapezial slope. Mean angle between the articular surface of the trapezium and the long axis of the second metacarpal measured 1420 preoperatively 1290 and postoperatively. In the present study results of addition-subtraction osteotomy without ligamentoplasty were promising, especially for function and pain. The technique may be a valuable treatment option for trapeziometacarpal dysplasia with metacarpal instability.

Primary shortening of the forearm and Sauvé-Kapandji for severely comminuted fractures of the distal forearm in elderly patients: a case report.

We report a case of an elderly female who sustained a severely comminuted distal radial and ulnar fracture, treated by shortening of the forearm, combined with a primary Sauvé-Kapandji procedure and volar plating of the distal radius.

Treatment of fractures of the proximal phalanx of long fingers with an isometric traction splint.

Treatment of fractures of the proximal phalanx of the long fingers remains difficult and challenging ; several options have been used. We report our experience with an isometric traction splint, modified from the Southampton design. A cohort of 32 patients with displaced fractures of a proximal phalanx was treated and assessed retrospectively after a short term (9 weeks after splint application). Traction splint was applied to realign the fracture and to control rotation. This construct was used for approximatively 5 weeks (mean: 36 days; range: 21-44 days), considering the usual progression of fracture healing in closed phalangeal fractures and patient tolerance to the splint. Three weeks after splint removal, almost full range of motion was regained in the metacarpophalangeal and interphalangeal joints in all patients, except in 3 cases. Two of these three patients had a displaced fracture of the proximal phalanx as a result of a compression trauma. The combination of the trauma type with static traction splint led to a tenodesis effect with a severe active flexion deficit in the metacarpophalangeal and interphalangeal joints. Our results suggest that isometric traction splint is a valid treatment option for displaced fractures of the proximal phalanx, however compression type fractures should be excluded.

Reconstruction of the medial patellofemoral ligament for patellar instability using an autologous gracilis tendon graft.

Patellofemoral dislocations are common. In cases with recurrence or residual instability, surgical intervention is usually considered. Numerous treatment protocols have been used in the past to treat patellofemoral instability secondary to patella dislocation. Reconstruction of the medial patellofemoral ligament is one of the possible options, since it was acknowledged to have a major medial stabilising role on the patella. We present a technique for reconstruction of the medial patellofemoral ligament using an autologous gracilis tendon graft.