Session 12: Hand

Fredag den 25. oktober
11:00 – 12:00
lokale: Stockholm/Copenhagen
Chairmen: Maiken Stilling / Anders Lorentzen

116. Satisfaction with Upper Extremity Surgery in Individuals with Tetraplegia
Hanne Gregersen, Mille Lybæk, Inger Lauge Johannesen, Pernille Leicht, Ulla Vig Nissen, Fin Biering-Sørensen
Clinic for spinal cord injuries, Copenhagen University Hospital, Glostrup Hospital; West Danish Center for spinal cord injuries, Viborg Hospital; Clinic for Orthopaedic Surgery, handsurgery section, Copenhagen University Hospital, Rigshospitalet

Background: All tetraplegia patients are offered an evaluation and reconstructive surgery of the upper extremity if it is possible.
Purpose / Aim of Study: Evaluate the satisfaction with upper extremity reconstructive surgery in spinal cord injured individuals with tetraplegia.
Materials and Methods: Retrospective study with questionnaire follow-up. 49 tetraplegic individuals had 119 surgical procedures performed to the upper extremities. Seven had died and 42 were invited to participate in the survey. 40 (95%; median age 48 years at time of survey) answered a questionnaire with a 5- level Likert scale ranging from strongly agree to strongly disagree regarding satisfaction within 8 areas: 1) General satisfaction; 2) Life impact; 3) Activity of daily living (ADL); 4) Independence; 5) Appearance; 6) Reliability; 7) Information; and 8) Postoperative therapy.
Findings / Results: The median time from first surgery till survey was 13 years (range 2-36). 65% were C5-C6 spinal cord lesions; 64% had American Spinal Injury Association Impairment Scale grade A. The positive responses (sum of strongly agree and agree): 76% for general satisfaction, 84% for Life impact, 73% for ADL, 53% for independence, 66% for reliability, 78% for information prior to surgery, and 65% for postoperative-therapy. However, only 28% reported that they were satisfied with the appearance of their hand. There was a trend towards an ability to perform more activities and in particular more independence was obtained when pinch/specific hand surgery was performed compared to triceps activation. Specifically easier in drinking and eating was mentioned by 17, in particular by those with C6-C8 lesions.
Conclusions: The overall satisfaction with upper extremity surgery is high. It has a positive impact on life in general, the ability to perform ADL as well as an increase in the level of independence.

117. Xiapex® (collagenase clostridium histolyticum) – treatment of patients with Dupuytren’s contracture – 1 year follow-up
Søren Larsen , Karina Liv Hansen, Tune Ipsen, Jens Lauritsen
Department of Orthopaedic Surgery, Odense University Hospital

Background: Dupuytren’s contracture (DC) is a disorder that affect the palmar fascia were a pretendinous cord with time causes the finger to flex resulting in impaired hand function. .
Purpose / Aim of Study: The aim of this study was to evaluate the efficacy of Xiapex® in the treatment of DC at least 12 month after injection. The study was initiated following a Minimal Health Technology Assessment
Materials and Methods: The study was a prospective study on consecutive series of patients with DC and flexion deformities of the metacarpophalangeal and/or proximal interphalangeal joint of >200 . Primary end point was reduction in contracture and improving hand function. All patients gave informed consent.
Findings / Results: 194 patients were enrolled, 163 men and 31 women, mean age 67 years [22-85]. 91% of the treated fingers are the 4. and 5. finger. At manipulation cord disruption succeed in 87% of the patients at the first attempt. Despite 31 % had skindisruption no infections were seen. Mean DASH pre-injection was 17 [0- 52] and 12 months follow-up 9 [0-61]. In 1 case there had been a need for further treatment of the Xiapex® treated finger at 12 month (=unacceptable recurrence) At 12 monts patient satisfaction was high.
Conclusions: Our results are promising and we find Xiapex® a good treatment option for DC-patients with a palpable cord. The treatment is effective and with acceptable recurrence at 12 months.

118. High revision rates with the metal on metal Motec trapeziometacarpal total arthroplasty
Janni Kjærgaard Thillemann, Theis Muncholm Thillemann, Bo Munk, Karsten Krøner
Department of Hand Surgery, Aarhus University Hospital; Ortopædkirurgisk Afdeling , Regional Hospital, Horsens

Background: Results after trapeziometacarpal (TMC) total joint arthroplasty are divergent and recently there has been many concerns regarding the metal on metal (MoM) articulations.
Purpose / Aim of Study: The aim of this study was to evaluate the short term results after Motec Basal Thumb Joint Prosthesis with MoM articulation and compare the results with patients who were revised.
Materials and Methods: We retrospectively evaluated a consecutive series of 42 Motec MoM Prosthesis (40 patients, 33 women) performed between 2009 and 2012. Revision rates were calculated and patients were divided in patients with the prosthesis in situ and in patients who had been revised with implant removal and trapeziectomy. The two groups were compared concerning Disability of the Arm Shoulder and Hand (DASH) score, pain on a numerical ranking scale (NRS), serum chrome and cobalt concentrations.
Findings / Results: After 4 years 17 (40%) of the 42 prostheses were revised. Revisions were performed due to aseptic loosening of the cup (9), pain (4), dislocation (3) and deep infection (1). Mean follow-up was 2.2 years (range 1.2-3.8) and 2.1 years (range 1.3-3.8) for the prosthesis and the revision group, respectively. The DASH score was comparable between groups (p= 0.77). Pain at rest and in activity was comparable between groups. The frequency of patients with serum chrome and cobalt levels above 10 nmol/L was comparable between the two groups (p=0.28). DASH scores were significantly higher in patients with elevated serum chrome and cobalt.
Conclusions: The revision rate after TMC prosthesis in this study is disappointing. However, DASH scores after revision with implant removal and trapeziectomy are acceptable. In this study elevated chrome and cobalt levels was associated with at higher dash score but not associated with revision.

119. Compensation claims from the use of an arterial tourniquet during limb surgery in Denmark in the years 1998 -2010
Lasse E. Rasmussen, Søren Larsen, Kim L Mikkelsen
Orthopaedic Surgery, Unit for Handsurgery, Odense University Hospital; Danish Patient Insurance Association ,

Background: The use of an arterial tourniquet may be associated with reversible and irreversible damage during limb surgery. Such damage may result in a financial compensation in Denmark. Currently limited scientific evidence is available regarding the outcome from the use of the arterial tourniquet in limb surgery. Yet in Denmark, damage from the arterial tourniquet is among the compensation claim cases with the highest level of recognition.
Purpose / Aim of Study: Thus, the cases in the Danish Patient Insurance Association for compensation claims from the damage due to the use of an arterial tourniquet in were investigated.
Materials and Methods: Data were extracted from cases in the Danish Patient Insurance Association for compensation claims in the years 1998 – 2010, where patients with an acknowledged tourniquet injury were registered. Injury resulting in 5% damage- level or more triggered a compensation payment, otherwise not.
Findings / Results: In the time-period a total of 69 patients had there case recognized, resulting in a total payment of 10.89 million. Danish kroner. The cases were distributed among 35 men, and 34 women (age 0-77 years). Causes of injury (listed in order of frequency): (1) Long tourniquet time n = 20 (2) Defective equipment n = 15 (3) Direct tissue crush n = 9 (4) “Unknown” n = 9 (5) "Unusual" complications n = 6 (6) Bleeding n = 5 (7) Tourniquet in vascular disease n = 4 (8) Skin damage n = 4
Conclusions: Surprisingly, the proportion of injuries that could not be predicted totals a maximum of 35%. The remaining could potentially be avoided. Thus it is encouraged that the surgeon ensures that the equipment is properly maintained, that the shortest possible duration of ischemia is ensured, and that the lowest possible tourniquet pressure is applied.

120. Tendon Gene Therapy by Electroporation holds Potential to Modify Flexor Tendon Healing
Sys Hasslund, Hanne Gissel, Carl Christian Danielsen, Mette Koefoed, Lars Aagaard, Kjeld Søballe
Orthopedics, Aarhus University Hospital; Biomedicin, Aarhus Universitet

Background: Flexor tendon injury and repair are complicated by formation of fibrotic adhesion. Despite decades of research in this field our understanding of the biological mechanisms of tendon healing and adhesion formation remains incomplete. Previously we have developed a model of murine flexor tendon repair. Using this model we have already demonstrated that Gdf5 gene delivery via viral vectors loaded on freeze- dried allografts significantly reduced tendon adhesions.
Purpose / Aim of Study: In this study we wanted to develop a non- viral method for tendon gene therapy, and via gene delivery of Vegf or Gh to modify the tendon healing response.
Materials and Methods: The study was performed on our murine model. We used electroporation for non-viral gene delivery. To evaluate gene delivery, a marker gene (Luc) and an in vivo imagine system was used. In order to test the effect of the active genes functional tests of tendon adhesions and tensile strength were performed.
Findings / Results: We used electroporation for non-viral gene delivery of a marker gene. In a kinetics study we compared this novel method of tendon gene therapy with the previously used viral method. Remarkably we found that the marker gene was expressed as early as two hours after gene delivery by electroporation. The onset of gene expression in the viral vector group did not start until day 3. The last part of this study, delivery of the functional genes Gh or Vegf and assessment of the effect on the biomechanical properties is still ongoing.
Conclusions: Electroporation can be used as a non-viral method of gene delivery. The preliminary results from the biomechanical testing of the mice electroporated with Vegf or Gh vs. control have been encouraging. Tendon healing has previously been modified by local gene delivery by others and us.

121. Amputation of a spastic, paralysed arm after a stroke, prosthetic supply and functional outcome.
Pernille Leicht, Ellen Thomsen Rasmussen, Lisbeth Villemoes Sørensen, Stig Jensen
Ortopædkirurgisk klinik, Håndkirurgisk sektion, Rigshospitalet; Klinik for ergo og fysioterapi, Rigshospitalet; , Sahva

Background: Amputation of a spastic, paralysed arm after a stroke and prosthetic supply afterwards is unusual and to our knowledge not described previously.
Purpose / Aim of Study: Amputation of a spastic paralysed arm and prosthetic substitution may open opportunities for better quality of life and better physical function in patients after right hemisphere stroke.
Materials and Methods: Eight years after a severe right hemisphere stroke a man age 63 was referred to orthopaedic surgery clinic for evaluation of possible amputation of his paralysed and spastic left arm. He wanted to replace his left useless arm with a prosthetic arm to be able to accomplish ’two hand activities’. To make sure he would be able to use a prosthetic arm his ability was assessed by neurologist, neuropsychologist and a temporary artificial arm was produced by prosthetist and tested under supervision of occupational therapist. Subsequent his left arm was amputated 10 cm proximal to the elbow, prosthetic arm produced and he was trained in using it.
Findings / Results: The amputation had a positive impact on patient’s body balance, ADL activities, mood, and sleep. A year after amputation he used his prosthetic arm daily in ’two hand activities’,
Conclusions: Prosthetic substitution of a spastic paralysed arm after a stroke can improve patients function and well- being.

122. Treatment of proximal interphalangeal joint fractures by the pins and rubbers traction system - a follow up
Jessica Agneta Nilsson, Hans-Eric Rosberg
General practitioner, Gøtzsche & Johnsen, Hørsholm, Copenhagen Denmark; Hand Surgery, Skåne University Hospital, Malmö

Background: A fracture of the proximal interphalangeal (PIP) joint at the base of the middle phalanx is rare, but is a challenge to treat. Posttraumatic osteoarthritis is a known complication causing impaired hand function and disability.
Purpose / Aim of Study: The aim of the present retrospective study was to evaluate characteristics and outcome of complex PIP joint fractures treated by the pins and rubbers traction system (PRTS).
Materials and Methods: Medical records of 42 patients, with fractures treated with a PRTS in 1999 - 2010, were reviewed, and followed up by questionnaires (QuickDASH, CISS, self- composed questionnaire). The fractures were divided into three types of fractures: volar lip, dorsal lip and pilon fractures.
Findings / Results: The volar lip fracture was most frequent (26/42; dorsal lip 3/42; pilon 13/42). Most fractures were sport related (19/42; 45%) and males predominated (M:F ratio 1.8). All fractures united. Infection occurred in 17/41 (41%) cases. Radiological signs of posttraumatic osteoarthritis were found in 25/41 (61%) patients. In 18/42 patients, where an objective evaluation was performed, 66% of contralateral total active range of motion (TAM), 93% grip strength and 100% pinch strength were achieved. The volar lip fracture had the best outcome according to the self-reported QuickDASH and CISS score and regained 77% of contralateral TAM.
Conclusions: Fractures of the PIP joint in the middle phalanx can be treated with the PRTS, but reduced mobility, grip strength, infection and osteoarthritis are seen. The device is well tolerated by the patients, easy to apply and with ready accessible materials for the surgeon.

123. Small Joint Arthroscopy in Hands - technique and clinical uses in RA patients
Charlotte Schultz, Martin Andersen, Vendel Jensen Ninna, Niels H. Søe, Henning Bliddahl
Department of Hand Surgery, Gentofte Hospital; Biopharmaceuticals Research Unit, Novo Nordisk, Måløv; The Parker Institute, Frederiksberg Hospital

Background: Smaller equipment has made arthroscopy of small joints (MCP and PIP joints) possible. Only few articles have been published on this subject. Different techniques and portals have been described. In two articles the technique was developed and used on cadavers. The clinical uses for needle arthroscopy have not been fully determined and it remains to be shown that the objective findings correlate with the histopathological changes in the joints.
Purpose / Aim of Study: To describe and to evaluate the technique and portals used in small joint arthroscopy and to assess the possibility of objectively determining the degree of synovitis and obtaining biopsies of a sufficient size and quality from small joints with a needle arthroscope.
Materials and Methods: 6 MCP joints, 3 PIP joints and 2 IP joints from 10 RA patients were biopsied and synvectomised by needle arthroscopy. All needle arthroscopies were performed by the same hand surgeon. The overall histopathological synovitis score (Krenn) was compared to the synovitis score as seen with the needle arthroscope. The sample size was measured as well and tested for ability of detecting lining for histopathological purposes in the biopsy.
Findings / Results: All samples were of a sufficient size (average 3.07 mm2) however the success rate of including the lining was only 0.58. Synovitis as seen by the surgeon was predictive of synovitis determined by a histopathological synovitis score.
Conclusions: Our results indicate that it is possible to determine synovitis in small joints with a needle arthroscope and to get biopsies of a good size with a fair chance of including the lining in the samples taken.