Session 3: Hand / Wrist
Ondag den 21. oktober
09:00 – 10:30
Lokale: Helsinki/Oslo
Chairmen: Bo Munk / Maiken Stilling
25. Short term results of Total Wrist revision arthroplasties
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.
26. THE ELEKTRA PROSTHESIS FOR TOTAL REPLACEMENT OF THE FIRST CMC-JOINT
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.
27. Complication rates of volar plating of distal radius fractures – a retrospective analysis of 595 consecutive cases
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.
28. CT-scanning of nondisplaced scaphoid fractures diagnosed on primary plain radiographs: Consequences for decision of treatment. A cross sectional study.
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.
29. Does Xiapex have a roll in the treatment of flexion deformities of the proximal interphalangeal joint of the little finger caused by Dupuytrens disease – Experiences after 1 year follow up of 85 treatments.
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.
30. Disability and return to work after trapeziometacarpal total joint arthroplasty: influence of occupational mechanical exposures
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.
31. Disability and return to work after early MRI on suspicion of scaphoid fracture: influence of MRI pathology and occupational mechanical exposures
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.
32. Do high occupational mechanical exposures influence the risk of failure of trapeziometacarpal total joint arthroplasty?
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.
33. Fixation of cemented and cementless cups in total joint trapeziometacarpal prostheses. A randomized clinical RSA study with 5 years follow-up
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.
34. Surgery versus ultrasound-guided steroid injection for trigger finger: A randomised controlled trial with one year follow-up
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.
35. Accuracy of cone-beam versus multi-detector computed tomography bone models in analysis of wrist kinematics using dynamic radiostereometric analysis
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.
36. Xiapex® (collagenase clostridium histolyticum) – treatment of patients with primary Dupuytren’s contracture – 3 years follow-up
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.