Hand Carpometacarpal Joint Instability in Elite Boxers: Injury Characteristics, Surgical Technique, and Outcomes.

PURPOSE: We describe a single-surgeon's experience of managing hand carpometacarpal joint (CMCJ) instability in elite boxers, focusing on injury characteristics, surgical technique, and outcomes. METHODS: This retrospective cohort included consecutive elite boxers undergoing surgery for hand CMCJ instability from 2009 to 2021. CMC joint instability is usually clear on clinical examination using a 'seesaw' test. All cases had a plain radiograph and in equivocal cases for instability advanced imaging such as MRI or ultrasound scan. CMCJs were accessed via longitudinal incisions between index/middle rays, and additionally ring/little. Often marked deficiency in the CMCJ ligamentous capsule was seen. The articular surfaces were decorticated to cancellous bone and autogenous bone graft impacted. The CMCJs were fixed in extension using various methods, latterly memory staples. Outcomes included radiographic fusion, return to boxing, and complications. RESULTS: Forty hands had surgery in 38 boxers. In total, 101 CMCJs were fused, with an average of 2.5 joints per patient. Patients were mainly young (mean age 24.1 years), male (37/38) with the trailing hand more commonly affected (trailing hand 87.5%, leading hand 12.5%). The most frequently fused CMCJ was the index (97.5%, n = 39), then middle (95%, n = 38), ring (45%, n = 18), and little (15%, n = 6). There were 82% (31/38) of patients who returned to the same level of boxing at a median of 8 months from surgery (range 3-27 months). Three patients had revision surgery for non-union, a median of 10.3 months after initial surgery (range 9.4-133.1 months): 2 for index/middle and one for the little CMCJ. All 3 revisions fused and the patients returned to boxing at the same level, although the little CMCJ required a second bone graft and fixation. CONCLUSIONS: Patients can achieve full recovery after treatment of CMCJ instability, and most can return to boxing at the same level with little risk of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Extensor hood injuries in elite boxers: injury characteristics, surgical technique and outcomes.

We describe our experience of managing extensor hood injuries in boxers (57 fingers). The diagnosis was mostly clinical, with imaging only if the diagnosis was equivocal. The middle (61%) and index (26%) digits were most frequently injured. On exploration, 26% had no hood tear, however all required tenolysis from the adherent capsule. Of 42 hood tears, 15 were central splits between adjacent extensor tendons in the index or little fingers,15 tears were on the ulna side of the extensor tendon and 12 tears were on the radial side. A pseudobursa was encountered in 35%, capsular tears in 28% and chondral injury in one patient. Longitudinal curved metacarpophalangeal joint incisions were used, with hood repair performed in flexion using a locked running suture. Mean postoperative metacarpophalangeal joint flexion was 90°. Ninety-eight per cent returned to the same level of boxing at a mean of 8 months (range 1-24) from surgery. One finger was revised for re-rupture 6 months later. A reproducible technique for treating these injuries is described, with patients able to return to boxing with little risk of complications.Level of evidence: IV.

Wide-Awake Wrist and Small Joints Arthroscopy of the Hand.

The minimally invasive nature of wrist and small joint arthroscopy renders it particularly suitable for the application of the wide-awake local anesthesia no tourniquet (WALANT) technique. The application of WALANT wrist and small joint arthroscopy has given surgeons the ability to visualize both static and dynamic movements of a joint, to show the pathology and discuss with the patient, and to visualize a patient's repaired structures. This reinforces confidence in surgeons and encourages patients to comply with postoperative rehabilitation.

When can a professional athlete return to play following scapholunate ligament delayed reconstruction?

BACKGROUND: The aim of this study was to determine the outcomes in relation to return-to-play in professional athletes who had undergone a delayed scapholunate ligament reconstruction. METHODS: We searched our prospectively managed database and identified 15 professional athletes who had undergone the modified Brunelli procedure for scapholunate instability. They were contacted to complete a telephone interview. We established the duration between the operation and return-to-play, the level of competition before and after the procedure and if applicable, reasons for reduction in the level of competition. RESULTS: Between 2008 and 2011, 15 professional male athletes underwent the modified Brunelli procedure. One was lost to follow-up and 14 athletes (11 rugby, 2 boxing and 1 golf) were contactable. The mean age of the patients was 30 years (range 18-42). The mean follow-up period was 25 months (range 3-43). Eleven of the 14 (79%) athletes returned to play within 4 months of surgery. By the final review, 9 of the 14 (64%) athletes had returned to play at their preinjury level of competition. CONCLUSIONS: A majority (approximately 80%) of professional athletes return to competitive playing within 4 months of undergoing a scapholunate ligament reconstruction. Approximately two-thirds return to play at their preinjury level of competition.

Isolated and spontaneous correction of proximal interphalangeal joint contractures in Dupuytren's disease: an exploratory analysis of the efficacy and safety of collagenase Clostridium histolyticum.

BACKGROUND AND OBJECTIVE: Dupuytren's contractures affecting proximal interphalangeal (PIP) joints are challenging to treat. We explored the effects of collagenase Clostridium histolyticum (CCH) on PIP joint contractures after injection of an affected metacarpophalangeal (MP) joint in the same finger and after injection of an isolated PIP joint contracture. METHODS: Two patient subsets were evaluated: those with MP/PIP joints contractures in the same finger, but only the MP joint contractures were treated (Group A); and those with isolated PIP joint contractures that were treated (Group B). Endpoints included correction and improvement in contracture. Fixed-flexion contracture (FFC) and range of motion (ROM) were also assessed; adverse events (AEs) were monitored. RESULTS: In Group A, 28 and 43 % of PIP contractures spontaneously corrected after the first and last injection of CCH, respectively, for MP contractures; 40 and 63 %, respectively, improved. In Group B, 31 and 39 % of PIP joint contractures corrected after the first and last injection of CCH, respectively, 56 and 66 %, respectively, improved. In Groups A and B, FFC improvements were largest after the last injection; ROM improvements were largest after the last injection in Group A and third injection in Group B. For 46 and 44 % of patients in Groups A and B, respectively, the first injection was the last injection. In Group B, the median (minimum, maximum) injections/joint was 1.0 (1.0, 4.0). Nearly all patients (98 %) experienced ≥1 AE; most were injection-site reactions. CONCLUSIONS: The efficacy of CCH for improving PIP joint contracture was similar whether treated in isolation or after treatment of an MP joint contracture.

Chronic exertional compartment syndrome of the forearm in elite rowers: a technique for mini-open fasciotomy and a report of six cases.

Chronic exertional compartment syndrome (CECS) of the forearm may occur in sports requiring prolonged grip strength. CECS is a function of increasing pressure following muscle expansion within an inelastic tissue envelope resulting in compromise of perfusion and tissue function. Typical symptoms are pain, distal paraesthesia and loss of function. The condition is self-limiting and resolves completely between periods of activity. With no effective medical treatment, the gold standard remains four compartment open fasciotomy (Söderberg, J Bone Joint Surg Br 78(5):780-2, 1996; Wasilewski and Asdourian, Am J Sports Med 19(6):665-7, 1991). Minimally invasive techniques have been described (Croutzet et al., Tech Hand Up Extrem Surg 13(3):137-40, 2009) but have a risk of neuro-vascular injury, especially to the ulnar nerve while releasing the deep flexor compartment. We present a safe technique used with six elite rowers for mini-open fasciotomy to minimise scarring and time away from training while reducing the risk of neurovascular injury.

Salvage of failed distal radioulnar joint reconstruction.

In the patient in whom primary distal radioulnar joint surgery has failed, consideration must be given to the anatomy and biomechanics of the native joint; how this has been disrupted by injury, disease, and previous trauma; and what is required to reconstruct the joint. The forearm relies on a congruent condylar cam of the distal ulna, with intact soft tissue restraints for normal biomechanics. Surgical reconstruction using tendon graft, autologous bone graft, allograft interposition, and prosthetic reconstruction are discussed in this article. If these procedures fail, then salvage procedures including wide excision of the ulna or one-bone forearm can be performed.

Injury to the ulnar collateral ligament of the thumb.

Injury to the ulnar collateral ligament of the thumb is very common and can be disabling when missed or left untreated. We present a review of literature and our preferred way of management.

Involvement of adenosine 5'-triphosphate in ultrasound-induced fracture repair.

Ultrasound (US) accelerates fracture healing; however, the mechanism of this effect remains unclear. Adenosine 5'-triphosphate (ATP) stimulates bone remodeling and is released constitutively from intact osteoblasts; this is a process that is enhanced after mechanical stimulation. We hypothesized that ATP release from osteoblasts is increased after US stimulation and that this leads to accelerated fracture healing. US was applied to SaOS-2 human osteoblasts and the concentration of ATP in the cell culture medium was determined. Cell proliferation and gene expression were subsequently investigated. Increased concentrations of ATP were detected in the culture medium of US-treated cells and both ATP and US stimulation caused increased receptor activator of nuclear factor-kappa B ligand (RANKL), decreased osteoprotegerin expression and increased cell proliferation by SaOS-2 cells. These findings indicate that US causes ATP release by osteoblasts in vitro and that this may contribute to accelerated fracture healing by enhancing osteoblast proliferation and increasing RANKL expression and decreasing osteoprotegerin expression by osteoblasts to promote osteoclastogenesis.