Session 3: Hand/wrist

Ondag den 22. oktober
09:00 – 10:30
Lokale: Helsinki/Oslo
Chairmen: Jesper O. Schønnemann / Pernille Leicht

25. Increased migration and more revisions of MOTEC compared with ELECTRA cups. A 2-year RSA study of trapeziometacarpal prostheses
Maiken Stilling, Torben Bæk-Hansen
Department of Orthopaedics, Regional Hospital Holstebro, Hospital Unit West

Background: Cup failure is a recognized problem in total trapeziometacarpal (TM) joint prosthesis. Several cup designs are available but clinical documentation is sparse. Cementless cups are inserted pressfit and depend on a primary mechanical and secondary osseous stability, which may be evaluated with radiostereometric analysis (RSA).
Purpose / Aim of Study: To compare cup stability with two cementless screw cups and the possible relation to cup revision.
Materials and Methods: 2 consecutive prospective patient cohorts, Eaton type 2-4, were operated with TM joint prostheses using two differently designed trapezium screw cups: the MOTEC cup with a collar (n=22), and the ELECTRA bimetal cup without a collar (n=22). Mean age was 60 (45-74) years. There were 31 female and 13 males. Model-based RSA was used to measure cup migration with respect to the trapezium, which was marked with 1mm tantalum beads during surgery. Stereoradiographs and DASH score was measured at baseline, 3 and 6 months, and 1 and 2 years postoperative.
Findings / Results: At 2 years total translation of mean 2.32 (sd 2.4) mm with MOTEC cups (n=7) was higher (p=0.01) than mean 0.87 (sd 1.61) mm with ELECTRA cups (n=16). At 3 months total translation was higher in cups that were revised later on (p=0.03). There was a tendency for more subsidence with MOTEC cups (1.03 vs 0.22 mm; p=0.053). There was no significant cup migration between 1 and 2 years (p=0.62). However, at 2 years the revision rate in the MOTEC group was 41% (9/22), versus 0% (0/22) in the Elektra group (p= 0.02). There were no significant differences in clinical results between the two groups.
Conclusions: The MOTEC trapeziometacarpal cup with a collar has higher implant migration and more revisions compared with the ELECTRA collarless bimetal cup at 2 years followup. Early migration was higher in cups that were later revised.

26. High early revision rate in a new cemented polyethylene cup in trapeziometacarpal total joint arthroplasty
Jens Knak, Torben Bæk Hansen
Department of Orthopaedics and The Orthopaedic Research Unit, Hospital Unit West, Holstebro

Background: Trapeziometacarpal total joint arthroplasty may be used in treatment of trapeziometacarpal osteoarthritis preserving the length of the thumb and providing rapid rehabilitation and good grip strength. Unfortunately high revision rates have been reported, and new implant designs strive to reduce the revision rates.
Purpose / Aim of Study: To evaluate the mid term results using a new cemented cup design with the Motec polyethylene trapezium cup in ball and socket trapeziometacarpal total joint arthroplasty.
Materials and Methods: We did a prospective study in 58 patients, 11 males and 39 females, mean age 61 years (range 41-77) operated with a Motec polyethylene trapezium cup in the period december 2010 to November 2012. All patients were followed with DASH score, VAS and measurement of grip strength as well as radiological follow- up at 3, 12 and 24 months.
Findings / Results: After a mean follow-up of 33 months (range 19-43) 8 patients had been revised due to early aseptic loosening or osteonecrosis, (14%), 2 patients due to recidivant luxation, 1 patient due to traumatic cup loosening and 1 patient due to deep infection. 5 of the 8 patients with aseptic loosening/osteonecrosis were revised during the first 12 months. The clinical results in the remaining 47 patients were equivalent to other published series.
Conclusions: The early revision rate due to aseptic loosening or osteonecrosis has been surprisingly high indicating a technical failure during cementing. We suspect heat induced bone necrosis to be a possible cause, and further studies are needed looking at the cementation technique in trapeziometacarpal total joint arthroplasty.

27. Test-retest reliability of Antonovsky’s 13-item Sense of Coherence scale in patients with hand-related injures
Alice Ørts Hansen, Hanne Kaae Kristensen, Ragnhild Cederlund, Hans Tromborg
Department of Orthopedic , Odense University Hospital; Department of Rehabilitation, Odense University Hospital; Health Sciences, Lund University

Background: Patients with identical hand injuries, who gets the same treatment and rehabilitation, recover differently from their injuries. It might be due to personal factors. Antonovsky developed a questionnaire measuring Sense of Coherence (SOC13) reflecting person’s ability coping in a stressful situation. Studies have shown that patients with strong Sense of Coherence (SOC) get better functional outcome and satisfaction in daily activities after hand- and orthopaedic injuries compared to patients with weak SOC. Psychometric properties of SOC 13 have not been tested on patients with hand injuries. This is necessary before using SOC13 to predict outcome and plan rehabilitation.
Purpose / Aim of Study: To report on distribution, stability and test-retest reliability of SOC13 in patients with hand-related injuries and explore associations between SOC13 and age, education level, gender and type of injury.
Materials and Methods: The design was a survey with test- retest using self-administered questionnaire. SOC13 and demographic data was collected before occupational therapy in an Outpatient Clinic from 170 patients with hand-related injuries aged 18 and older. SOC13 was completed after 14 days and 3 months.
Findings / Results: 170 patients completed SOC13 at baseline (median score 71, range 30- 91). Intra-class correlation coefficient (ICC) between baseline and 14 days was 0.87 (n=151), 3 months 0.82 (n=113). Weak correlations was found between SOC, age (r=0.17, p<0.03), education(r= 0.02, p<0.02). No correlation was found between SOC and gender or type of injury.
Conclusions: SOC13 showed stability and reliability for patients with hand injuries before and 3 months after hand therapy. Age and education had a weak relationship with SOC without clinical relevance. SOC13 has potential to be a powerful tool measuring personal factors before hand therapy.

28. Skin tear correlates to the degree of contracture when treated for Dupuytrens contracture with Xiapex
Christian Fagernæs, Susanne Mallet
Orthopaedics, Køge Hospital

Background: Xiapex is used in the treatment of Dupuytren’s disease (DD). Xiapex is injected into the cord which the next day is manipulated to attempt rupture. No trial has explored the number of skin tear as an adverse effect (AE).
Purpose / Aim of Study: The aim was to explore the joint level and the degree of contracture to the risk of the AE of skin tear.
Materials and Methods: 105 cases (90 patients) with DD with DIP and/or PIP contracture from august 1st 2012 till april 1st 2014 were enrolled prospectively. Excisting skin defects were cause for exclusion. DIP and PIP contractures were treated with 0.25 mL and 0.20 mL of Xiapex .The degree of contracture was measured with a goniometer and skin tears were classified as yes/no.
Findings / Results: 77 (73%) had the contracted cord at the level of the MCP joint and 28 (27%) at the level of the PIP joint. 59 (56%) got skin tear. The RR of skin tear is 1,5 for MCP level of >60 degrees compared to MCP level at 20-59 degrees (p=0,17). The RR of skin tear is 2,2 for PIP level of >60 degrees compared to PIP level at 20-59 degrees (p=0,04). The relative risk for skin tear is 1,1 (CI = (0.72; 1.58), p=0,74) for MCP level compared to PIP level. By logistic regression it is shown that the degree is the most important factor concerning skin tear with a higher risk in the >60 degree-group compared to the 20-59 degree-group with an odds ratio of 5.4 ((95%CI (1.4; 20.6), p=0.01).
Conclusions: There is a higher risk of skin tear when the contracture is >60 degree and located at the level of the PIP joint. Overall the factor most important for higher risk of skin tear is the degree of the contracture more that the level. Focus on patients with contracture of more than 60 degrees is needed. A type of skin-softener could be helpful but should be explored.

29. Long-term effect of surgery for thumb in palm in adolescent cerebral palsy patients.
Hans Tromborg, Alice Ørts
Hand Surgery, Dept of Ortopaedic Surgery, Odense University Hospital; Department of Rehabilitation (Hand), Odense University Hospital

Background: Cerebral palsy of the hand can be a seriously debilitating illness, especially hand activities demanding the use of two hands can be affected. The ability to open the hand to grip objects and bringing the fist finger into contact with the second finger (pinch key grip) are cornerstones of hand function.
Purpose / Aim of Study: To evaluate the long-term effect of thumb surgery for thumb in palm spasticity in adolescent patients with cerebral palsy.
Materials and Methods: Twenty six patients with cerebral palsy was surgically reconstructed with flexor carpi ulnaris (FCU) transferal to the extensor carpi radialis brevis (ECRB) and surgery to correct the thumb in palm deformity. Age 15(6) years (AVG (SD)). Hand opening was measured as the ability to grasp a wooden cylinder with contact to the web space between the first and the second finger. Two hand activities (THAc) were measured by awarding points for the use of two hands in pre-defined and standardized two hand activities (modified Sollerman hand test). Maximum possible points was 15. After surgery, the patients were treated with immobilization in a cast for eight weeks. All patients initially received highly specialized rehabilitation and afterwards guided therapy.
Findings / Results: Patients increased hand opening from 4.6 (1.5) cm (AVG (SD)) preoperatively to 5.5 (1.3) cm (p<0.05) after half a year and increased points of THAc from 9.2 (4.1) points preoperatively to 11.8 (4.0) points (p<0.001) after half a year. Hand opening and THAc increased a little from 6 months to 18 months and therefore remained statistically significantly improved.
Conclusions: In carefully selected adolescent children with cerebral palsy hand opening and two hand function can be improved by surgery and subsequent hand therapy.

30. Short term results of the Maestro Total Wrist Arthroplasty for primary and revision arthroplasty
Allan Ibsen Søensen, Peter Axelsson
Clinic of Hand Surgery, University Hospital Sahlgrenska

Background: Wrist arthroplasties have been used for dekades with better results for the newer designs.
Purpose / Aim of Study: The aim of this study is was to review our short-term results of the Maestro prosthesis used for primary and revision wrist- arthroplasty.
Materials and Methods: The Maestro implant is a modular total wrist joint prosthesis. The indications for it´s use in this study were rheumatoid arthritis (RA), degenerative (OA) and posttraumatic arthritis (POA) and revision of former Wrist arthroplasty. The procedure was performed in 14 patients, 3 men and 11 women. Median age was 64 years (41-75). 10 RA, 3 OA and 1 POA patients were operated. Median follow-up was 13 month (range 12-25). Primary arthroplasty was performed in 11 patients and revision arthroplasty in 3 (2 KMI - and 1 Remotion prosthesis were removed). Cement was used in 4 cases. Additional Darrach procedures were performed in 4 cases.
Findings / Results: Wrist extension and flexion was preoperatively 35/30 degrees and at follow-up 40/25. Radial/ulnar deviation was 10/30 degrees versus 10/25 postoperatively. Grip strength, in KgF, was preoperatively 8 (range 2-36) and at follow-up 18 (7-30). VAS pain (0-100 mm) was preoperatively at rest/activity; 30/65 mm and at follow-up; 2/4 mm. Minor radiographic osteolysis around one screw was seen in 2 of 14 cases at the last follow-up, but no signs of loosening were detected. Quick DASH and PRWE were preoperatively; 50 and 68 and at follow-up; 28 and 12. VAS satisfaction at latest follow-up was 98 mm (34-100).2 minor hematomas and 1 moderate hematoma were observed. No infections, dislocations or other early complications were encountered and no reoperations performed.
Conclusions: In this small selected case series the Maestro Total Wrist Arthroplasty had a low complication rate and showed promising short-term results.

31. Trapezium resection vs. cemented cup revision in cup failures of the trapeziometacarpal total joint prostheses of the thumb
Jens Knak, Torben Bæk Hansen
Department of Orthopaedics and The Orthopaedic Research Unit, Hospital Unit West, Holstebro

Background: Total joint prostheses may be used as treatment of trapeziometacarpal osteoarthritis of the thumb, but unfortunately a relatively high rate of loosing of the trapezium component has been observed. Revision may be performed as a cup revision or as a conversion into a trapeziectomy, but so far no studies have been made to compare these two treatment options.
Purpose / Aim of Study: The primary aim of this study was to compare the outcome in patients with failure of the trapezium cup revised into a cemented cup or into a trapeziectomy.
Materials and Methods: We did a follow up-study in 44 patients (with 49 operations) revised in the period 2004 until 2014. 13 patients were excluded because of a less than 12 months follow-up or declined to participate, and it left us with 36 hands/operations in 31 patients, respectively 23 trapezium resections and 13 cup to cemented cup revisions. Clinical measures were VAS-score, DASH, strength and movement of the thumb, and in all implants an AP and lateral radiograph.
Findings / Results: We did not find any difference regarding VAS-, DASH-score, grip strength and movement of the thumb comparing. In the series of cup revision we found a re-revision rate of 4 out of 18 operations (22%). These 4 patients were revised into trapeziectomy.
Conclusions: Cup revision into trapeziectomy gives a good functional result, and cup revision into a cemented new cup should be used in selected patients only due to a high risk of re-revision.

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

Background: Dupuytren’s contracture (DC) is a disorder that affect the palmar fascia where 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® treatment of recurrence- DC at least 12 month after Xiapex® injection.
Materials and Methods: The study was a prospective study on consecutive series of patients with recurrent DC and flexion deformities of the metacarpophalangeal and/or proximal interphalangeal joint of >200 and a palpable cord. Our end points was reduction in contracture, improving hand function and patient satisfaction
Findings / Results: 144 treatments were enrolled, 124 men and 20 women, mean age 66 years [36-85]. 91% of the treated fingers are the 4. and 5. finger. Treatment distribution MP/PIP joints were 45/55%. 49% had a skin-rupture after manipulation and 89% of these patients had a need for additional visit in our out-patient-clinic. Mean follow-up was 15 month [12-23]. At follow-up a mean reduction in contracture of 60/30% for MP/PIP-joint. Mean DASH pre-injection was 15 [0-61] and at 3 months follow-up 8 [0-39]. In 6 cases (7%) there had been a need for further treatment of Xiapex® treated finger at 12 month (=unacceptable recurrence). At 12 months follow-up 44% of the patients were satisfied or very satisfied.
Conclusions: Our results are acceptable and we find Xiapex® a possible treatment option for recurrence-DC-patients with a palpable cord. The treatment is not as effective, has a higher recurrence-rate and lower patient satisfaction compared to Xiapex® treatment of primary DC.

33. Long - term results of total joint arthroplasties with Elektra prothesis in trapeziometacarpal osteoarhritis
Barbara Kulinski
Hand Unit, Southern Jutland Hospital

Background: The Elektra prothesis is a cementless prothesis used in trapeziometacarpal osteoarthritis.Early follow-up studies showed fast recovery and good functional results.Later studies with longer follow-up indicated severe problems with implant survival.
Purpose / Aim of Study: To report our long-term results with the Elektra TMC prothesis
Materials and Methods: Between 2005 -2009 14 TMC joints in 13 patients (3 men,10 women) with a mean age of 52(range 40-73) years were operated using the Elektra prothesis.All patients were diagnosed with symptomatic and radiological TMC oeteoarthritis, Eaton- Littler stage 2 and 3.One hand surgeon performed all operations.Clinical and radiological follow-up were performed at 3 weeks,12 weeks,52 weeks postoperatively.In 2014 two hand surgeons examined all implants still in place with radiographs, grip/pinch strength and patient perceived outcome. Blood samples were analysed for serum cobalt and chrome.
Findings / Results: 4 implants(28%) had been revised because of dislocation of the neck 34 months(range 3-70)postoperatively.The necks were changed to longer ones,however in two patients the protheses later had to be removed. One patient had the prothesis removed after trauma. In two patients revision with trapezectomy was performed due to loose cup after 7 and 36 months.After mean follow-up of 93 months (range 60-108) 8 patients with 9 retaining implants (62%) were available for follow-up.Radiographs showed no loosening, mean quickDASH was12 (range 0-32 ),mean pinch strength was 6.5 (range 4-9)kg,mean grip strength was 30.6(range 20-42)kg.Mobility was excellent in all patients.2 patients had elevated serum cobalt and chrome values.
Conclusions: We found a high revision rate but excellent functional result in the surviving protheses. Due to high revison rate the Elektra prothesis should be used in selected patients.

34. Equally good methods for determination of bone quality of the trapezium
Kamille Breddam Mosegaard, Nadja Bouteldja, Maiken Stilling, Torben Bæk Hansen
Department of Orthopaedics , Regional Hospital Holstebro, Hospital Unit West, Denmark; Department of Radiology, Regional Hospital Holstebro, Hospital Unit West, Denmark; Department of Orthopaedics, Regional Hospital Holstebro, Hospital Unit West, Denmark

Background: High loosening rates of the trapezium component in total joint arthroplasty of the trapeziometacarpal joint may be caused by multiple independent factors, and one possible cause is poor bone mineral quality of the trapezium. However technical difficulties in measuring the bone mineral density (BMD) has been described due to the irregular and sclerotic bone contours.
Purpose / Aim of Study: We wanted to compare the measurements of bone quality of the trapezium using DXA scan BMD with bone quality measurements using computed tomography (CT) and Houndsfield units (HU).
Materials and Methods: We included 71 hands in 60 patients, 13 males and 47 females, mean age 59 years (43-77) diagnosed with Eaton– Glickel stage II–IV osteoarthritis. In all patients we measured the BMD of the trapezium with two different methods: DXA including the circumferential/cortical part of the bone or in the center of the trapezium alone. We also measured the BMD of the distal radius. All BMD measurements were compared to measurements of the bone quality using the HU.
Findings / Results: In the trapezium the CT measured HU in the trapezium correlated with DXA measured BMD (r=0.49, p=0.000) of the trapezium (perimeter method) and with DXA measured BMD (r=0.55, p=0.000) in the trapezium (inner-circle method). DXA measured BMD of the trapezium (perimeter method) correlated (r=0.94, p=0.000) with DXA measured BMD of the trapezium (inner-circle method). In the radius the average CT measured HU in distal radius correlated with DXA measured BMD (r=0.67, p=0.000).
Conclusions: The correlation between the two DXA measurement methods was excellent, and the easier inner-circle method may be preferred. We found a good correlation between measurements made by CT with HU and DXA BMD in both the distal radius and in the trapezium using the inner circle method, and both methods may be used.

35. Complication rates following volar plating of distal radius fractures in relation to fracture pattern and surgeon experience.
Andreas Qvist Christensen, Nina Madsen, Erik Valen, Casper Bindzus Foldager
Orthopedics, Randers Regional Hospital ; Radiology, Randers Regional Hospital

Background: Fractures of the distal radius are among the most common injuries in orthopedics, accounting for up to 15% of all extremity fractures. Internal fixation using volar plating has become increasingly popular. Reported complication rates following volar plating vary widely (9-60%), but are unknown in the Danish population.
Purpose / Aim of Study: To examine complication rates following volar plating of distal radius fractures in relation to fracture pattern and surgeon experience in patients operated at Randers Regional Hospital in 2011-2012.
Materials and Methods: Patients with distal radius fractures surgically treated with volar plating in 2011 and 2012 at Randers Regional Hospital were enrolled in the study. Radiological classification was performed using the AO and Frykman. Clinical journals were reviewed for complications. Surgeons were categorized as resident, orthopedic surgeon or hand surgeon. Correlation between complications and surgeon experience or fracture classification was investigated using Spearman’s correlation.
Findings / Results: Seventy three patients were identified. Mean age 64yrs (18-91) with 81% females. Most common type was AO-27 A2.2 (25%) and Frykman type was II (47%). Seventeen different surgeons performed the procedures (9 residents, 7 consultants, and 1 hand surgeon). The complication rate was 31.5%. Revision surgery rate was 16.4% (12 pts). The most common complications were wrist pain and implant-related discomfort (61%). There was no correlation between complication rate and surgeon experience (P=0.49); fracture classification (OA P=0.72; Frykman P=0.18).
Conclusions: We found a high complication rate of 31.5% following volar plating, which was not related to fracture classification or surgeon experience in the present cohort.

36. Short term result of a stable modified Brunelli 360 degree technique for reconstruction of scapho-lunate ligament .
Allan Ibsen Sørensen, Jonny Andersson
Clinic of Hand Surgery, University Hospital Sahlgrenska

Background: Several techniques for reconstruction of the scapho-lunate ligament have been used during the years, but none of the techniques have full stability of the ligament.
Purpose / Aim of Study: The aim of the study is to present short term result of a stable modified Brunelli 360 degree technique for reconstruction of scapho- lunate ligament .
Materials and Methods: In the modified Brunelli technique a part of FCR tendon or Plantaris tendon were tunneled through scaphoideum as Brunelli described. Then the tendon graft is tunneled through lunate bone in AP direction and then passed along the volar capsule to tuberculum of the scaphoid bone and fixed with either suture at tuberculum or biocomposit screw in scaphoideum. Furthermore the graft is fixed in lunate bone with a biocomposit screw. Fourteen patients were operated and 2 patients twice, 13 men and 1 woman. Median age 39,8 years (19-52). Median values are used.
Findings / Results: Median follow-up 15,6 month (2,8-36,5). Preoperative SL distance 5,7mm and at follow-up 2,7 mm. Dorsal/volar flexion preoperatively 94 (35-185) of normal wrist and at follow-up 77% (40-109), radial/ulnar flexion 92% (35-193) versus 76% (35-133). Grip strength in KgF preop 40 (11-60) and at follow-up 42 (11-74). VAS pain (mm) preop at rest/activity 19/67 and at FU 0/43. Watsons test preop. positive in 10 of 11 cases and post. op positive in 2 of 15. DISI in 8 of 13 cases preoperatively compared with one positive of 13 post. op.. Quick DASH and PRWE preop. 41 and 55 and at follow-up 23 and 27. There were one superficial pin tract infection and one deep infection in the two patients who were re- operated due to instability.
Conclusions: In this small series modified Brunelli 360 degree technique for reconstruction of scapho-lunate ligament seemed to have promising short term results with a stable fixation.