Session 3: Hand / Wrist
Ondag den 21. oktober
09:00 – 10:30
Lokale: Helsinki/Oslo
Chairmen: Bo Munk / Maiken Stilling
Allan Ibsen Sørensen, Peter Axelsson, Christer Sollerman
Clinic of Hand Surgery, University Hospital Sahlgrenska
Background: A slowly increasing number total wrist prosthesis failes due to loosening.
Purpose / Aim of Study: The aim of this study is was to review our short-term results of revision of wrist-arthroplasty.
Materials and Methods: Maestro and Remotion total wrist prostheses are used for revision of former failed wrist prostheses. 11 cases were bone grafted and some combined with cementing. In 6 cases almost the whole carpus where gone and a new technique for reconstruction of carpus with a structural bone block was used. Patients evaluated pre- and postoperatively with ROM, grip strength, VAS of pain and satisfaction. Functional and general outcomes were evaluated using the Quick-DASH and PRWE questionnaires. Radiographs were obtained pre- operatively and at follow-up. The procedure performed in 5 men and 10 women. Their median age was 62 years (32-76). Median follow-up was 16 month (3-68). Revision arthroplasty performed with 8 Maestro implants and 7 Remotion implants.
Findings / Results: Wrist extension and flexion was preoperatively 30/24 degrees and at follow-up 45/22. Radial/ulnar deviation was 0/30 degrees preoperatively versus 8/30 postoperatively. Grip strength (KgF) was preoperatively 7 (range 2-20) and at follow-up 16 (4- 22). VAS pain was preoperatively at rest/activity 28/43 and at follow-up 9/28. Quick DASH and PRWE scores were preoperatively 66 respectively 67 and at follow-up 43 and 34. VAS satisfaction was high at latest follow-up 75 mm (4-100). No infections or dislocations were encountered, but radio-graphically loosening of 2 Remotion prosthesis occurred and they were consequently revised to total wrist arthrodesis.
Conclusions: The short-term outcome of this small heterogeneous case series indicates that revision arthroplasty is a viable option in case of aseptic implant loosening even if the risk for subsequent loosening is substantial.
Clinic of Hand Surgery, University Hospital Sahlgrenska
Background: A slowly increasing number total wrist prosthesis failes due to loosening.
Purpose / Aim of Study: The aim of this study is was to review our short-term results of revision of wrist-arthroplasty.
Materials and Methods: Maestro and Remotion total wrist prostheses are used for revision of former failed wrist prostheses. 11 cases were bone grafted and some combined with cementing. In 6 cases almost the whole carpus where gone and a new technique for reconstruction of carpus with a structural bone block was used. Patients evaluated pre- and postoperatively with ROM, grip strength, VAS of pain and satisfaction. Functional and general outcomes were evaluated using the Quick-DASH and PRWE questionnaires. Radiographs were obtained pre- operatively and at follow-up. The procedure performed in 5 men and 10 women. Their median age was 62 years (32-76). Median follow-up was 16 month (3-68). Revision arthroplasty performed with 8 Maestro implants and 7 Remotion implants.
Findings / Results: Wrist extension and flexion was preoperatively 30/24 degrees and at follow-up 45/22. Radial/ulnar deviation was 0/30 degrees preoperatively versus 8/30 postoperatively. Grip strength (KgF) was preoperatively 7 (range 2-20) and at follow-up 16 (4- 22). VAS pain was preoperatively at rest/activity 28/43 and at follow-up 9/28. Quick DASH and PRWE scores were preoperatively 66 respectively 67 and at follow-up 43 and 34. VAS satisfaction was high at latest follow-up 75 mm (4-100). No infections or dislocations were encountered, but radio-graphically loosening of 2 Remotion prosthesis occurred and they were consequently revised to total wrist arthrodesis.
Conclusions: The short-term outcome of this small heterogeneous case series indicates that revision arthroplasty is a viable option in case of aseptic implant loosening even if the risk for subsequent loosening is substantial.
Allan Ibsen Sørensen, Peter Axelsson
Clinic of Hand Surgery, University Hospital Sahlgrenska
Background: Earlier designs of the Elektra cup had revision rates up to 40 percent. A new Electra cup design was developed for the first carpo-metacarpal joint.
Purpose / Aim of Study: The aim of this study was to evaluate the preliminary results after joint replacement with the Elektra prosthesis, a non-cemented, HAP-coated 3- component titanium-implant. The cup is the third generation Elektra cup with a metal to metal CR-CO articulation.
Materials and Methods: 28 patients were operated and followed prospectively. Diagnosis was idiopathic osteoarthritis in all cases. 23 were women and five men. The operated hand was dominant in 10 cases and non- dominant in 18 cases. Median age 60 years (48-78). Medium values are used.
Findings / Results: The follow-up is 26 month (3-60). Pain on VAS in rest/activity decreased from 44/78 mm preoperatively to 2/2 mm at last follow-up. Abduction/volar adduction were 36/35 degrees preoperatively and 40/40 degrees at last follow- up. Grip-strength increased from 19 KgF preoperatively to 24 KgF at last follow-up. Pinch- strength increased from 3,5 KgF preoperatively to 5,5 KgF at last follow-up. Quick-DASH was preoperatively 49 and at last follow-up 18. VAS satisfaction at last follow-up was 97 mm (3-100). Revision of the total prosthesis to interposition arthroplasty occurred in one case. Revision of the cups to cemented polyethylene cups done in four cases. One neck of the prosthesis changed to a longer neck due to instability. Total rate of revision was 18% and revision due to loosening 14%. No infections occurred.
Conclusions: Electra prosthesis with third generation cup had at last follow-up still improved ROM, pain score, strength, Quick-DASH and a high degree of patient’s satisfaction of the prosthesis. Complication rate were unacceptable high concerning loosening of the cup.
Clinic of Hand Surgery, University Hospital Sahlgrenska
Background: Earlier designs of the Elektra cup had revision rates up to 40 percent. A new Electra cup design was developed for the first carpo-metacarpal joint.
Purpose / Aim of Study: The aim of this study was to evaluate the preliminary results after joint replacement with the Elektra prosthesis, a non-cemented, HAP-coated 3- component titanium-implant. The cup is the third generation Elektra cup with a metal to metal CR-CO articulation.
Materials and Methods: 28 patients were operated and followed prospectively. Diagnosis was idiopathic osteoarthritis in all cases. 23 were women and five men. The operated hand was dominant in 10 cases and non- dominant in 18 cases. Median age 60 years (48-78). Medium values are used.
Findings / Results: The follow-up is 26 month (3-60). Pain on VAS in rest/activity decreased from 44/78 mm preoperatively to 2/2 mm at last follow-up. Abduction/volar adduction were 36/35 degrees preoperatively and 40/40 degrees at last follow- up. Grip-strength increased from 19 KgF preoperatively to 24 KgF at last follow-up. Pinch- strength increased from 3,5 KgF preoperatively to 5,5 KgF at last follow-up. Quick-DASH was preoperatively 49 and at last follow-up 18. VAS satisfaction at last follow-up was 97 mm (3-100). Revision of the total prosthesis to interposition arthroplasty occurred in one case. Revision of the cups to cemented polyethylene cups done in four cases. One neck of the prosthesis changed to a longer neck due to instability. Total rate of revision was 18% and revision due to loosening 14%. No infections occurred.
Conclusions: Electra prosthesis with third generation cup had at last follow-up still improved ROM, pain score, strength, Quick-DASH and a high degree of patient’s satisfaction of the prosthesis. Complication rate were unacceptable high concerning loosening of the cup.
Daniel Wæver, Mette Normann Lund, Rikke Thorninger, Jan Duedal Rölfing
Department of Orthopaedics, Aarhus University Hospital
Background: The current trend in treatment of displaced distal radius fractures favours volar plating. However, recent studies question both the clinical advantage and the cost effectiveness of this treatment modality. An alarming number of complications ranging from 5 to 30% have been reported in the literature.
Purpose / Aim of Study: To estimate the complication rate of volar plating of distal radius fractures in correlation to surgeon experience, type of plate (VariAx® and Acu-Loc®) and AO- fracture type.
Materials and Methods: We reviewed all cases operated with a volar locking plate at Aarhus University Hospital between February 2009 and June 2013. Surgeon experience was categorized as orthopaedic consultant, 2nd-5th-year resident, or 1st-year resident. Correlation coefficients between complications, surgeon’s experience, type of volar plate and type of fracture (AO classification) were estimated.
Findings / Results: 595 patients (mean age 60, 78% females) presenting with distal radius fractures were operated with a volar plate by 21 consultants, 27 2nd-5th-year residents and 16 1st-year residents. Within the mean observation time of 3.2 years (min=1.0; max 5.4) 69 reoperations were performed including 44 plate removals. We observed 30 nerve complications, 2 flexor tendon ruptures, 13 extensor tendon ruptures, 3 cases of complex regional pain syndrome, 5 disturbances of the distal radius ulna joint or scapholunar dissociations and 2 deep infections. No correlation was found between complication rates and type of plate or surgeon experience. Correlation analysis between complications and the type of fracture (AO) are pending.
Conclusions: We observed a reoperation rate of 12%. Neither surgeon experience, nor type of volar plate were related to the complication rate.
Department of Orthopaedics, Aarhus University Hospital
Background: The current trend in treatment of displaced distal radius fractures favours volar plating. However, recent studies question both the clinical advantage and the cost effectiveness of this treatment modality. An alarming number of complications ranging from 5 to 30% have been reported in the literature.
Purpose / Aim of Study: To estimate the complication rate of volar plating of distal radius fractures in correlation to surgeon experience, type of plate (VariAx® and Acu-Loc®) and AO- fracture type.
Materials and Methods: We reviewed all cases operated with a volar locking plate at Aarhus University Hospital between February 2009 and June 2013. Surgeon experience was categorized as orthopaedic consultant, 2nd-5th-year resident, or 1st-year resident. Correlation coefficients between complications, surgeon’s experience, type of volar plate and type of fracture (AO classification) were estimated.
Findings / Results: 595 patients (mean age 60, 78% females) presenting with distal radius fractures were operated with a volar plate by 21 consultants, 27 2nd-5th-year residents and 16 1st-year residents. Within the mean observation time of 3.2 years (min=1.0; max 5.4) 69 reoperations were performed including 44 plate removals. We observed 30 nerve complications, 2 flexor tendon ruptures, 13 extensor tendon ruptures, 3 cases of complex regional pain syndrome, 5 disturbances of the distal radius ulna joint or scapholunar dissociations and 2 deep infections. No correlation was found between complication rates and type of plate or surgeon experience. Correlation analysis between complications and the type of fracture (AO) are pending.
Conclusions: We observed a reoperation rate of 12%. Neither surgeon experience, nor type of volar plate were related to the complication rate.
Johannes Heindl, Per Hølmer, Per Rasmussen, Anders Klahn
Ortopedic department, Nordsjællands Hospital
Background: Displacement is an important factor associated with failure of a scaphoid fracture to heal. Treatment decisions and the need for further imaging are often made according to the findings on plain radiographs.
Purpose / Aim of Study: The purpose of the study was to investigate how CT scans of nondisplaced scaphoid fractures affect the treatment decisions.
Materials and Methods: We retrospectively searched the medical records for patients registered for suspected scaphoid fractures from 01/2009 – 05/2014 at the Orthopedic department at Nordsjaellands Hospital, Hillerød. 70 patients with a scaphoid fracture and a complete set of radiographs and CT-scan available could be included. All images were evaluated by 2 senior hand surgeons for displacement, stability, fracture localization and treatment was recommended. CT scans served as reference standard in our study.
Findings / Results: Of the 140 cases reviewed (2x70) 111 fractures were found to be nondisplaced at the radiographs. 10% of these were found to be displaced on CT resulting in an agreement on nondisplacement of 90%. Agreement on stability and treatment recommendation was 78% and agreement on localization 80%. Sensitivity and specificity for stability and treatment were 29% and 89% with a positive and negative predictive value of 28% and 93%. We found a change in treatment recommendation after the evaluation of CT scans in 24 out of 111 cases (21,6%). In 10 cases review of CT scans changed the recommended treatment from conservative to operative and in 14 cases the recommendation changed from operative to conservative.
Conclusions: Our study shows that in scaphoid fractures found to be nondisplaced on radiographs, CT scans lead to a significant change of treatment recommendation. According to our findings we will continue to make CT scans of all scaphoid fractures diagnosed on plain radiographs.
Ortopedic department, Nordsjællands Hospital
Background: Displacement is an important factor associated with failure of a scaphoid fracture to heal. Treatment decisions and the need for further imaging are often made according to the findings on plain radiographs.
Purpose / Aim of Study: The purpose of the study was to investigate how CT scans of nondisplaced scaphoid fractures affect the treatment decisions.
Materials and Methods: We retrospectively searched the medical records for patients registered for suspected scaphoid fractures from 01/2009 – 05/2014 at the Orthopedic department at Nordsjaellands Hospital, Hillerød. 70 patients with a scaphoid fracture and a complete set of radiographs and CT-scan available could be included. All images were evaluated by 2 senior hand surgeons for displacement, stability, fracture localization and treatment was recommended. CT scans served as reference standard in our study.
Findings / Results: Of the 140 cases reviewed (2x70) 111 fractures were found to be nondisplaced at the radiographs. 10% of these were found to be displaced on CT resulting in an agreement on nondisplacement of 90%. Agreement on stability and treatment recommendation was 78% and agreement on localization 80%. Sensitivity and specificity for stability and treatment were 29% and 89% with a positive and negative predictive value of 28% and 93%. We found a change in treatment recommendation after the evaluation of CT scans in 24 out of 111 cases (21,6%). In 10 cases review of CT scans changed the recommended treatment from conservative to operative and in 14 cases the recommendation changed from operative to conservative.
Conclusions: Our study shows that in scaphoid fractures found to be nondisplaced on radiographs, CT scans lead to a significant change of treatment recommendation. According to our findings we will continue to make CT scans of all scaphoid fractures diagnosed on plain radiographs.
Karina Liv Hansen, Jens Christian Werlinrud, Søren Larsen, Jens Lauritzen
Ortopædkirurgisk afd., Odense Universitets Hospital
Background: Dupuytren’s contracture (DC) is a fibropoliferative disorder effecting the palmar fascia causing flexion contractures and impairing hand function. Since July 2011 Collagenase has been a treatment option for patients with Dupuytrens contracture. The efficacy of Collagenase and its place in treatment of DC is still debated.
Purpose / Aim of Study: The aim of this study is to evaluate the efficacy of Xiapex® in the treatment of DC effecting the PIPjoints of the little finger at least 12 month after injection. Primary endpoint is reduction in contracture.
Materials and Methods: The study is an ongoing prospective study on a consecutive series of patients with primary and recurrent DC and flexion deformities of the proximal interphalangeal joint of >20 degrees of the little finger.
Findings / Results: 85 treatments have been enrolled, 65 men and 20 women, mean age 67 years [22-83]. 44 treatments of primary DC and 41 treatments of recurrent DC. 41% had skinrupture, no infections were seen. Mean pre-injection-contracture 65 degrees. Mean qDASH pre-injection was 12 [0-52]. Excellent results defined as 0-10 degree extension lack was achieved in 47% of the treatments. Mean follow up 16 months [12- 22] Improvement in contracture 40 degrees. Mean qDASH at 12 month follow-up was 10 [0-57]. In 7 cases (8%) there had been a need for further treatment of the Xiapex® treated finger joint at 12 months (=unacceptable recurrence) At 12 months 56 % of the patients were satisfied or very satisfied. Adverse events were mild in all cases. Recurrence defined as > 20 degree los of extension was seen in 47% of the cases.
Conclusions: The treatment does improve hand function but excellent results can be difficult to achive. Choosing Xiapex for treatment for contractures of the 5th PIPjoint may not be the best solution for the patient.
Ortopædkirurgisk afd., Odense Universitets Hospital
Background: Dupuytren’s contracture (DC) is a fibropoliferative disorder effecting the palmar fascia causing flexion contractures and impairing hand function. Since July 2011 Collagenase has been a treatment option for patients with Dupuytrens contracture. The efficacy of Collagenase and its place in treatment of DC is still debated.
Purpose / Aim of Study: The aim of this study is to evaluate the efficacy of Xiapex® in the treatment of DC effecting the PIPjoints of the little finger at least 12 month after injection. Primary endpoint is reduction in contracture.
Materials and Methods: The study is an ongoing prospective study on a consecutive series of patients with primary and recurrent DC and flexion deformities of the proximal interphalangeal joint of >20 degrees of the little finger.
Findings / Results: 85 treatments have been enrolled, 65 men and 20 women, mean age 67 years [22-83]. 44 treatments of primary DC and 41 treatments of recurrent DC. 41% had skinrupture, no infections were seen. Mean pre-injection-contracture 65 degrees. Mean qDASH pre-injection was 12 [0-52]. Excellent results defined as 0-10 degree extension lack was achieved in 47% of the treatments. Mean follow up 16 months [12- 22] Improvement in contracture 40 degrees. Mean qDASH at 12 month follow-up was 10 [0-57]. In 7 cases (8%) there had been a need for further treatment of the Xiapex® treated finger joint at 12 months (=unacceptable recurrence) At 12 months 56 % of the patients were satisfied or very satisfied. Adverse events were mild in all cases. Recurrence defined as > 20 degree los of extension was seen in 47% of the cases.
Conclusions: The treatment does improve hand function but excellent results can be difficult to achive. Choosing Xiapex for treatment for contractures of the 5th PIPjoint may not be the best solution for the patient.
Lone Kirkeby, Poul Frost, Susanne Wulff Svendsen, Torben Bæk Hansen
University clinic for hand-, hip- and knee surgery, Regional Hospital Holstebro, Aarhus University; Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital; Danish Ramazzini Centre, Department of occupational medicine, Regional Hospital Jutland - University Research Clinic, Herning
Background: There are no studies concerning disability and return to work after trapeziometacarpal total joint arthroplasty in younger and active patients.
Purpose / Aim of Study: To determine the prognosis after trapeziometacarpal total joint arthroplasty with respect to disability and return to work. We examined the hypothesis that occupational mechanical exposures are negative prognostic factors.
Materials and Methods: We conducted a register-based follow-up study in 133 patients aged 39-65 years, who in the period 2003-2013 had a total of 164 trapeziometacarpal total joint arthroplasty operations. Prospectively collected clinical data concerning DASH, VAS, and grip strength before the operation and 3 and 12 months postoperatively was combined with information about occupation and labour market attachment from the Danish National Register on Public Transfer Payments. Job title was linked with a job exposure matrix to obtain estimates of occupational mechanical hand-arm exposures. Uni- and multivariable Cox regression models were used.
Findings / Results: A high preoperative DASH score was a positive predictor of a high DASH score after 12 months. 73 patients were listed as active on the labour market at the time of surgery. Half of these patients returned to work within 3 months after surgery, and only 2 patients did not return to work. Preoperative sick leave and forceful work were predictors of prolonged sick leave before return to work.
Conclusions: The prognosis with respect to disability and return to work after trapeziometacarpal total joint arthroplasty is generally excellent. However, high occupational mechanical exposures and preoperative sick leave may lead to prolonged sick leave.
University clinic for hand-, hip- and knee surgery, Regional Hospital Holstebro, Aarhus University; Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital; Danish Ramazzini Centre, Department of occupational medicine, Regional Hospital Jutland - University Research Clinic, Herning
Background: There are no studies concerning disability and return to work after trapeziometacarpal total joint arthroplasty in younger and active patients.
Purpose / Aim of Study: To determine the prognosis after trapeziometacarpal total joint arthroplasty with respect to disability and return to work. We examined the hypothesis that occupational mechanical exposures are negative prognostic factors.
Materials and Methods: We conducted a register-based follow-up study in 133 patients aged 39-65 years, who in the period 2003-2013 had a total of 164 trapeziometacarpal total joint arthroplasty operations. Prospectively collected clinical data concerning DASH, VAS, and grip strength before the operation and 3 and 12 months postoperatively was combined with information about occupation and labour market attachment from the Danish National Register on Public Transfer Payments. Job title was linked with a job exposure matrix to obtain estimates of occupational mechanical hand-arm exposures. Uni- and multivariable Cox regression models were used.
Findings / Results: A high preoperative DASH score was a positive predictor of a high DASH score after 12 months. 73 patients were listed as active on the labour market at the time of surgery. Half of these patients returned to work within 3 months after surgery, and only 2 patients did not return to work. Preoperative sick leave and forceful work were predictors of prolonged sick leave before return to work.
Conclusions: The prognosis with respect to disability and return to work after trapeziometacarpal total joint arthroplasty is generally excellent. However, high occupational mechanical exposures and preoperative sick leave may lead to prolonged sick leave.
Lone Kirkeby, Poul Frost, Torben Bæk Hansen, Susanne Wulff Svendsen
University clinic for hand-, hip- and knee surgery, Regional Hospital Holstebro, Aarhus University; Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital; Danish Ramazzini Centre, Department of occupational medicine, Regional Hospital Jutland - University Research Clinic, Herning
Background: There are no studies concerning disability and return to work after wrist injury in relation to forceful work, including the prognosis for patients with wrist injury without MRI features of any acute carpal pathology.
Purpose / Aim of Study: To determine the prognosis after early MRI on suspicion of scaphoid fracture with respect to disability and return to work. The hypotheses of MRI pathology and high occupational mechanical exposures as negative prognostic factors were examined.
Materials and Methods: A follow-up study based on register and questionnaire information on 469 patients, aged 18-89 years, who in the period 2006- 2010 had early MRI on clinical suspicion of scaphoid fracture. Questionnaires included DASH, PRWE, job title, and lifestyle factors. Information on time until return to work was obtained from the Danish National Register on Public Transfer Payments. Job title was linked with a job exposure matrix to obtain estimates of occupational mechanical hand- arm exposures. Uni- and multivariable Cox regression models were used.
Findings / Results: 249 patients (53%) responded to the questionnaire after a mean of 4.8 years after the trauma. Mean age was 43.5 years (SD 19.7), there were 43% males. 46% of respondents had pathological findings on MRI. Predictors of DASH-score >20 and PRWE-score >20 were higher age, female sex, tobacco smoking, and increasing body mass index. Predictors of prolonged time until return to work were MRI pathology, forceful work, and habitual sickness absence.
Conclusions: MRI pathology and high occupational mechanical exposures were negative prognostic factors regarding return to work after wrist trauma, while tobacco smoking and high BMI were negative prognostic factors regarding disability.
University clinic for hand-, hip- and knee surgery, Regional Hospital Holstebro, Aarhus University; Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital; Danish Ramazzini Centre, Department of occupational medicine, Regional Hospital Jutland - University Research Clinic, Herning
Background: There are no studies concerning disability and return to work after wrist injury in relation to forceful work, including the prognosis for patients with wrist injury without MRI features of any acute carpal pathology.
Purpose / Aim of Study: To determine the prognosis after early MRI on suspicion of scaphoid fracture with respect to disability and return to work. The hypotheses of MRI pathology and high occupational mechanical exposures as negative prognostic factors were examined.
Materials and Methods: A follow-up study based on register and questionnaire information on 469 patients, aged 18-89 years, who in the period 2006- 2010 had early MRI on clinical suspicion of scaphoid fracture. Questionnaires included DASH, PRWE, job title, and lifestyle factors. Information on time until return to work was obtained from the Danish National Register on Public Transfer Payments. Job title was linked with a job exposure matrix to obtain estimates of occupational mechanical hand- arm exposures. Uni- and multivariable Cox regression models were used.
Findings / Results: 249 patients (53%) responded to the questionnaire after a mean of 4.8 years after the trauma. Mean age was 43.5 years (SD 19.7), there were 43% males. 46% of respondents had pathological findings on MRI. Predictors of DASH-score >20 and PRWE-score >20 were higher age, female sex, tobacco smoking, and increasing body mass index. Predictors of prolonged time until return to work were MRI pathology, forceful work, and habitual sickness absence.
Conclusions: MRI pathology and high occupational mechanical exposures were negative prognostic factors regarding return to work after wrist trauma, while tobacco smoking and high BMI were negative prognostic factors regarding disability.
Lone Kirkeby, Poul Frost, Susanne Wulff Svendsen, Torben Bæk Hansen
University clinic for hand-, hip- and knee surgery, Regional Hospital Holstebro, Aarhus University; Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital; Danish Ramazzini Centre, Department of occupational medicine, Regional Hospital Jutland - University Research Clinic, Herning
Background: There are no studies concerning the influence of occupational mechanical exposures on the risk of implant failure and revision in trapeziometacarpal (TMC) total joint arthroplasty in younger and active patients.
Purpose / Aim of Study: To determine the prognosis with respect to risk of revision after TMC total joint arthroplasty, evaluating the hypothesis that occupational mechanical exposures are negative prognostic factors for implant survival.
Materials and Methods: A register based follow-up study in 133 patients aged 39-65 years (mean age 56 years), who in the period 2003-2013 had a total of 164 TMC total joint arthroplasty operations. Prospectively collected clinical data concerning DASH, VAS, and grip strength before the operation and after 3 and 12 months plus data concerning revision were combined with self-reported job title and information about labour market attachment from the Danish National Register on Public Transfer Payments. Job title was linked with a job exposure matrix to obtain estimates of occupational mechanical hand-arm exposures. Uni- and multivariable Cox regression models were used.
Findings / Results: 45 of the 164 implants had been revised due to failure with high revision rates linked to the early part of the inclusion period. Implant type with a cup with collar predicted a high DASH score after 12 months and implant revision during the observation period. Implant fixation (cementless vs cemented) was not a predictor. Forceful work increased the risk of implant revision, however not significant (p=0.17) in a multivariate analysis.
Conclusions: The prognosis for implant survival after TMC total joint arthroplasty in younger and active patients is relatively poor and highly influenced by implant design. High occupational mechanical exposures may be important and studies with a larger number of patients are needed.
University clinic for hand-, hip- and knee surgery, Regional Hospital Holstebro, Aarhus University; Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital; Danish Ramazzini Centre, Department of occupational medicine, Regional Hospital Jutland - University Research Clinic, Herning
Background: There are no studies concerning the influence of occupational mechanical exposures on the risk of implant failure and revision in trapeziometacarpal (TMC) total joint arthroplasty in younger and active patients.
Purpose / Aim of Study: To determine the prognosis with respect to risk of revision after TMC total joint arthroplasty, evaluating the hypothesis that occupational mechanical exposures are negative prognostic factors for implant survival.
Materials and Methods: A register based follow-up study in 133 patients aged 39-65 years (mean age 56 years), who in the period 2003-2013 had a total of 164 TMC total joint arthroplasty operations. Prospectively collected clinical data concerning DASH, VAS, and grip strength before the operation and after 3 and 12 months plus data concerning revision were combined with self-reported job title and information about labour market attachment from the Danish National Register on Public Transfer Payments. Job title was linked with a job exposure matrix to obtain estimates of occupational mechanical hand-arm exposures. Uni- and multivariable Cox regression models were used.
Findings / Results: 45 of the 164 implants had been revised due to failure with high revision rates linked to the early part of the inclusion period. Implant type with a cup with collar predicted a high DASH score after 12 months and implant revision during the observation period. Implant fixation (cementless vs cemented) was not a predictor. Forceful work increased the risk of implant revision, however not significant (p=0.17) in a multivariate analysis.
Conclusions: The prognosis for implant survival after TMC total joint arthroplasty in younger and active patients is relatively poor and highly influenced by implant design. High occupational mechanical exposures may be important and studies with a larger number of patients are needed.
Maiken Stilling, Torben Bæk-Hansen
Department of Orthopedics, Universityclinic for Hand, Hip and Knee Surgery, Hospital Unit West
Background: Cup failure is a recognized problem in total trapeziometacarpal (TM) joint prosthesis and may be related to poor fixation, which can be measured by radiostereometry (RSA).
Purpose / Aim of Study: To compare implant migration of cemented polyethylene TM cups with cementless screw TM cups.
Materials and Methods: In a prospective, parallel-group, randomized patient-blinded clinical trial, we included 32 hands in 28 patients (5 males) at a mean age of 58 years (40-77) with Eaton stage 2 and 3 osteoarthritis of the TM joint. Patients were randomised to surgery with A) a cemented DLC all-polyethylene cup (PC) (n=16) or B) a cementless hydroxyapatite-coated chrome-cobalt Elektra screw cup (SC) (n=16) that was inserted without threading of the bone. Stereoradiographs for evaluation of cup migration (primary effect size), and alongside DASH and pain scores were obtained at 5 years follow-up. 4 patients entered the study with both hands, and secondarily had the last operated hand excluded from final analysis.
Findings / Results: The 5 year total translation (TT) was similar (p=0.09) with 0.90mm (SD 1.04) for the PC (n=7) and 0.26mm (SD 0.20) for the SC (n=9). Subsidence was also similar (p=0.22). 4 cups ( 2 PC and 2 SC) were revised and the 2 SC implants both had TT>1mm. 2 other PC cups migrated above 1mm TT to 5 years follow-up. Additionally 1 SC cup was radiographically loose between 1 year and 5 years, but had not been revised, and could not be measured with RSA because of loose markers. Grip strength, pain, and DASH scores were similar between the two groups at all measure points.
Conclusions: Midterm implant fixation and clinical outcome was similar with both cup designs. Although RSA has natural limitations in anatomical small regions, the method is feasible for measurement of TM joint translational stability.
Department of Orthopedics, Universityclinic for Hand, Hip and Knee Surgery, Hospital Unit West
Background: Cup failure is a recognized problem in total trapeziometacarpal (TM) joint prosthesis and may be related to poor fixation, which can be measured by radiostereometry (RSA).
Purpose / Aim of Study: To compare implant migration of cemented polyethylene TM cups with cementless screw TM cups.
Materials and Methods: In a prospective, parallel-group, randomized patient-blinded clinical trial, we included 32 hands in 28 patients (5 males) at a mean age of 58 years (40-77) with Eaton stage 2 and 3 osteoarthritis of the TM joint. Patients were randomised to surgery with A) a cemented DLC all-polyethylene cup (PC) (n=16) or B) a cementless hydroxyapatite-coated chrome-cobalt Elektra screw cup (SC) (n=16) that was inserted without threading of the bone. Stereoradiographs for evaluation of cup migration (primary effect size), and alongside DASH and pain scores were obtained at 5 years follow-up. 4 patients entered the study with both hands, and secondarily had the last operated hand excluded from final analysis.
Findings / Results: The 5 year total translation (TT) was similar (p=0.09) with 0.90mm (SD 1.04) for the PC (n=7) and 0.26mm (SD 0.20) for the SC (n=9). Subsidence was also similar (p=0.22). 4 cups ( 2 PC and 2 SC) were revised and the 2 SC implants both had TT>1mm. 2 other PC cups migrated above 1mm TT to 5 years follow-up. Additionally 1 SC cup was radiographically loose between 1 year and 5 years, but had not been revised, and could not be measured with RSA because of loose markers. Grip strength, pain, and DASH scores were similar between the two groups at all measure points.
Conclusions: Midterm implant fixation and clinical outcome was similar with both cup designs. Although RSA has natural limitations in anatomical small regions, the method is feasible for measurement of TM joint translational stability.
Rehne Lessmann Hansen, Morten Søndergaard, Jeppe Lange
Orthopaedic surgery, Silkeborg regional hospital
Background: Trigger finger (TF) is a common disorder, which affects more than two in a hundred persons during a lifetime. Open surgery (OP) is the gold standard and cures near 100%, steroid- injections (SI) are reported to cure between 60-90%. Comparative trials on this disorder are limited.
Purpose / Aim of Study: To investigate the long term follow-up of patients treated for TF with ultrasound-guided SI compared to OP.
Materials and Methods: 51 males and 102 females, mean age 60 (range 19-87) was randomised to open surgery (n=76) or ultrasound- guided SI (n=77). Follow-up was conducted at 12 weeks and one year. The affected finger was graded using a trigger finger score (TFS); I)normal movement, IIa)normal movement with pain at the A1-pulley, IIb)history of uneven movement, III)uneven movement, IV)locked, actively correctable and V)locked, passive correctable, static. If the finger was graded above IIa at follow-up, it was considered a failure. Pain was assessed with a numeric rating scale (NRS) from 1 to 10, 10 being the worst imaginable pain.
Findings / Results: No difference was found in baseline data between the groups (p>0.1). At 3 months 98.5% (OP) and 85.5% (SI) patients were successfully treated for TF (chi2 p=0.003). At one year the number of successfully treated patients were reduced to 97.5% (OP) and 48.5% (SI) (chi2 p<0.001). The mean TFS and NRS was reduced in both groups at three months and one year follow-up (p<0.001). Willingness-to- repeat after one year were positive in 84% (OP) and 67% (SI) patients (chi2 p=0.016). When evaluating the failures of SI (n=39), the mean time until recurrence was 7 months (range 0-12).
Conclusions: Open surgery is superior to steroid injection. Our findings indicated that the curative effect of a single SI is overestimated in the literature and the effect declines rapidly between 3 and 12 months after injection.
Orthopaedic surgery, Silkeborg regional hospital
Background: Trigger finger (TF) is a common disorder, which affects more than two in a hundred persons during a lifetime. Open surgery (OP) is the gold standard and cures near 100%, steroid- injections (SI) are reported to cure between 60-90%. Comparative trials on this disorder are limited.
Purpose / Aim of Study: To investigate the long term follow-up of patients treated for TF with ultrasound-guided SI compared to OP.
Materials and Methods: 51 males and 102 females, mean age 60 (range 19-87) was randomised to open surgery (n=76) or ultrasound- guided SI (n=77). Follow-up was conducted at 12 weeks and one year. The affected finger was graded using a trigger finger score (TFS); I)normal movement, IIa)normal movement with pain at the A1-pulley, IIb)history of uneven movement, III)uneven movement, IV)locked, actively correctable and V)locked, passive correctable, static. If the finger was graded above IIa at follow-up, it was considered a failure. Pain was assessed with a numeric rating scale (NRS) from 1 to 10, 10 being the worst imaginable pain.
Findings / Results: No difference was found in baseline data between the groups (p>0.1). At 3 months 98.5% (OP) and 85.5% (SI) patients were successfully treated for TF (chi2 p=0.003). At one year the number of successfully treated patients were reduced to 97.5% (OP) and 48.5% (SI) (chi2 p<0.001). The mean TFS and NRS was reduced in both groups at three months and one year follow-up (p<0.001). Willingness-to- repeat after one year were positive in 84% (OP) and 67% (SI) patients (chi2 p=0.016). When evaluating the failures of SI (n=39), the mean time until recurrence was 7 months (range 0-12).
Conclusions: Open surgery is superior to steroid injection. Our findings indicated that the curative effect of a single SI is overestimated in the literature and the effect declines rapidly between 3 and 12 months after injection.
Sepp De Raedt, Peter Bo Jørgensen, Paolo M. Cattaneo, Maiken Stilling
Orthopaedic Research Unit, Aarhus University Hospital - NRT X-Ray; Department of Dentistry, Aarhus University
Background: With the introduction of dynamic radiostereometric analysis (RSA) it is possible to study the kinematics of the wrist and diagnose injuries. Using patient specific bone models, it is possible to use Model- based RSA. To reduce the radiation dose, cone-beam CT (CBCT) can be used instead of multi-detector CT (MDCT). The reduction in dose is associated with a decrease in image quality. However, it is unclear if the difference results in a difference in model fitting and subsequent accuracy of model- based RSA.
Purpose / Aim of Study: To investigate the use of bone models of the wrist created from CBCT and MDCT in a cadaver study.
Materials and Methods: A single arm was scanned with CBCT (NewTom 5G, Verona, Italy) and with MDCT (Brilliance 64, Best, The Netherlands). The wrist bones were automatically segmented and bone models were created. Tantalum beads were inserted in the radius and ulna and dynamic RSA images were acquired during radioulnar deviation. Paired migration analysis with respect to bone markers were performed with MBRSA (MBRSA, Medis specials bv, Leiden, NL). We report mean difference and standard deviation.
Findings / Results: CBCT images were noisier than MDCT. Dose length product was 10 times lower for CBCT. The radius and the ulna were analyzed in five frames. No differences were found between the radius and ulna. Combined mean model fitting error was 0.10±0.01 for both CBCT and MDCT based models (P-value: 1.0, 95% CI: -0.01:0.01). No differences for translations and rotations were found between CBCT and MDCT compared to marker-based RSA.
Conclusions: We found no difference between model fitting error or migration analysis for CBCT and MDCT based bone models. With further investigation, we believe that CBCT based bone models may be a good alternative for MDCT due to a ten fold reduction in dose without a difference in accuracy.
Orthopaedic Research Unit, Aarhus University Hospital - NRT X-Ray; Department of Dentistry, Aarhus University
Background: With the introduction of dynamic radiostereometric analysis (RSA) it is possible to study the kinematics of the wrist and diagnose injuries. Using patient specific bone models, it is possible to use Model- based RSA. To reduce the radiation dose, cone-beam CT (CBCT) can be used instead of multi-detector CT (MDCT). The reduction in dose is associated with a decrease in image quality. However, it is unclear if the difference results in a difference in model fitting and subsequent accuracy of model- based RSA.
Purpose / Aim of Study: To investigate the use of bone models of the wrist created from CBCT and MDCT in a cadaver study.
Materials and Methods: A single arm was scanned with CBCT (NewTom 5G, Verona, Italy) and with MDCT (Brilliance 64, Best, The Netherlands). The wrist bones were automatically segmented and bone models were created. Tantalum beads were inserted in the radius and ulna and dynamic RSA images were acquired during radioulnar deviation. Paired migration analysis with respect to bone markers were performed with MBRSA (MBRSA, Medis specials bv, Leiden, NL). We report mean difference and standard deviation.
Findings / Results: CBCT images were noisier than MDCT. Dose length product was 10 times lower for CBCT. The radius and the ulna were analyzed in five frames. No differences were found between the radius and ulna. Combined mean model fitting error was 0.10±0.01 for both CBCT and MDCT based models (P-value: 1.0, 95% CI: -0.01:0.01). No differences for translations and rotations were found between CBCT and MDCT compared to marker-based RSA.
Conclusions: We found no difference between model fitting error or migration analysis for CBCT and MDCT based bone models. With further investigation, we believe that CBCT based bone models may be a good alternative for MDCT due to a ten fold reduction in dose without a difference in accuracy.
Søren Larsen, Karina Liv Hansen, Jens Christian Werlinrud, Tune Ipsen, Jens Lauritsen
Department of Orthopaedic Surgery, Unit for Handsurgery, 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 Dupuytren’s contracture at least 3 years after injection.
Materials and Methods: The study is a prospective study on consecutive series of patients with DC and flexion deformities of the metacarpophalangeal and/or proximal interphalangeal joint of >20 degree . Primary end point was reduction in contracture. Secondary end points was improving hand function and recurrence rate. All patients gave informed consent.
Findings / Results: 422 treatments of patients with primary DC were enrolled of which 40 treatments had reached 3 years follow-up. 36 men and 4 women, mean age 67 years [22-85]. 95 % of the treated fingers are the 4. and 5. finger. Mean pre-injection-contracture MP/PIP-joint 50 degree/62 degree [20-90]. Mean pre-injection qDASH was 15 [0-52] 40 treatments, MP/PIP-joint 29/11, were seen for follow-up after a mean of 38 months [36-41] At follow-up: Improvement in contracture MP/PIP-joint 33 degree/11 degree corresponding to a corrections- degree of 66% /18% Mean qDASH was 7 [0-34]. 82 % of the patient were satisfied or very satisfied. In 2 cases (5%) there had been a need for further treatment (=unacceptable recur-rence)
Conclusions: Our results are still promising at 3 years and we find Xiapex® a good treatment option for DC-patients with a palpable cord. The treatment is effective although declining for PIPjoints and with acceptable recurrence.
Department of Orthopaedic Surgery, Unit for Handsurgery, 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 Dupuytren’s contracture at least 3 years after injection.
Materials and Methods: The study is a prospective study on consecutive series of patients with DC and flexion deformities of the metacarpophalangeal and/or proximal interphalangeal joint of >20 degree . Primary end point was reduction in contracture. Secondary end points was improving hand function and recurrence rate. All patients gave informed consent.
Findings / Results: 422 treatments of patients with primary DC were enrolled of which 40 treatments had reached 3 years follow-up. 36 men and 4 women, mean age 67 years [22-85]. 95 % of the treated fingers are the 4. and 5. finger. Mean pre-injection-contracture MP/PIP-joint 50 degree/62 degree [20-90]. Mean pre-injection qDASH was 15 [0-52] 40 treatments, MP/PIP-joint 29/11, were seen for follow-up after a mean of 38 months [36-41] At follow-up: Improvement in contracture MP/PIP-joint 33 degree/11 degree corresponding to a corrections- degree of 66% /18% Mean qDASH was 7 [0-34]. 82 % of the patient were satisfied or very satisfied. In 2 cases (5%) there had been a need for further treatment (=unacceptable recur-rence)
Conclusions: Our results are still promising at 3 years and we find Xiapex® a good treatment option for DC-patients with a palpable cord. The treatment is effective although declining for PIPjoints and with acceptable recurrence.