Locking plate versus retrograde intramedullary headless compression screw for unstable extra-articular metacarpal base fractures of the thumb.

The purpose was to compare clinical and radiological outcomes between two fixation techniques used to treat extra-articular fractures involving the base of the thumb metacarpal: retrograde intramedullary cannulated headless screw (RICHS) and locking plate (LP). Fifty-one patients who underwent RICHS (n = 22) or LP fixation (n = 29) from January 2010 through 2020 were included in this retrospective case-control study with mean follow-up 39 months. No inter-group differences were observed comparing mean time to radiological union, grip strength, range of motion, pain severity or QuickDASH scores. Mean surgery time was shorter with RICHS (18.9 min) than with LP fixation (44.4 min). Mean time to return to work or routine activities was less in RICHS than LP (22 vs. 32 days), as was the percentage of patients requiring hardware removal (0% vs. 44.8%). We conclude that RICHS fixation requires less operating time and yields faster post-operative return to full function and fewer secondary procedures.

Vascularized Ulnar Periosteal Pedicled Flap for Upper Extremity Reconstruction in Adults: A Prospective Case Series of 11 Patients.

PURPOSE: We hypothesized that a vascularized ulnar periosteal pedicled flap (VUPPF) is a versatile graft applicable in adult patients that yields good outcomes and is a reliable alternative to other vascularized bone grafts to reduce both the technical demands and donor site morbidity of other options. METHODS: We reviewed 11 adult patients who underwent surgical treatment of forearm atrophic nonunion with a VUPPF. Patients' demographics, outcomes (measured by pain on the visual analog scale; Quick Disabilities of the Arm, Shoulder, and Hand score; range of motion; and grip strength), and associated complications were reported. RESULTS: Of the 11 patients, 5 had previous surgery in an attempt to treat the nonunion with an autologous cancellous bone graft from the iliac crest or olecranon. The average time from nonunion until the VUPPF was 9 months (SD, ±3 months; range, 6-14 months). The mean visual analog scale score improved considerably after surgery (8.7 vs 0.6), and considerable improvement was also noted in the Quick Disabilities of the Arm, Shoulder, and Hand score (50 vs 6). A notable improvement was seen in grip strength after surgery. Pronation/supination also improved considerably between the preoperative assessment and the final postoperative follow-up. CONCLUSIONS: A vascularized ulnar periosteal pedicled flap seems to be a useful and versatile option for a variety of bone union failures of the upper extremity in adults, either at initial presentation or as a salvage technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Accidents and injuries in elite MotoGP motorcycle riders.

OBJECTIVE: Evaluating incidence, characteristics and risk factors of accidents and injuries in each elite motorcycle racing class (MotoGP, Moto2 and Moto3), 2013-2017. DESIGN: Descriptive epidemiological study. SETTING: MotoGP Medical Team, Dorna Sports SL. PARTICIPANTS: Competing riders in elite motorcycling racing classes, 2013-2017. INTERVENTIONS: Benchmarking incidence, characteristics and risk factors of accidents and injuries in each elite motorcycle racing class, 2013-2017. MAIN OUTCOME MEASURES: Association between accident type (by class and year) and fracture, withdrawal from race, need for surgery, injuries (fractures or contusions/wounds) and time riders kept inactive. Circuit and curve, weather conditions, presence and type of fracture, clinical outcome, and time until return to competition. Event outcomes were defined as rider fit/rider unfit after each accident. Racing class, track curves and circuits with the most and fewest accidents, circuit characteristics, speed and deceleration, G-forces, and time race differences between classes. RESULTS: 9092 accidents (mean 1818,4 per year). Most during race and under wet-weather conditions. Class and circuit with most accidents 2013-2017 were Moto3 (3374; 37.11%) and MWC - Marco Simoncelli -with 430.119/9092 accidents resulted in a fracture (1.31%), 83, surgical fractures (70%). Most frequent surgical fractures were upper extremity (clavicular; 29/119; 21%). On average, riders returned to competition after two circuits (1-5 weeks). CONCLUSIONS: Accidents are not uncommon among elite motorcycle riders; incidences of fractures and surgical fractures are low. Factors such as weather conditions and circuit's characteristics influence the risk of accidents. Further research is necessary to clarify the magnitude of the role each of these factors play.

Analysis of 3 Different Operative Techniques for Extra-articular Fractures of the Phalanges and Metacarpals.

Background: Several techniques have been described for treating metacarpal and phalangeal fractures. We sought to compare the 3 techniques most frequently used for extra-articular metacarpal and phalangeal fractures: plate screw (PS), Kirschner wire (KW), and retrograde intramedullary screw (RIS) fixation. We aimed to determine whether using an RIS provides better clinical outcomes than using either a PS or a KW fixation. Methods: We conducted a retrospective review of patients who underwent surgical treatment of metacarpal and phalangeal fractures from January 2011 to December 2017 in our department. Only patients with an acutely displaced short oblique or transverse extra-articular metacarpal or phalangeal fracture were included. Patients were classified into 3 groups depending on the treatment they received: PS, KW, or RIS fixation. The duration of each procedure was recorded. Clinical assessments included measuring total active motion (TAM), grip strength, and an evaluation of plain radiographs through to ultimate healing. A Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was collected on all patients. Data were analyzed by analysis of variance or Kruskal-Wallis rank test, as indicated. Results: A total of 253 fractures (202 metacarpal and 51 phalangeal) in 230 patients were included in analysis. In all, 135 fractures (53.3%) underwent PS fixation; 53 (20.9%), KW fixation; and 65 (25.6%), RIS fixation. In the KW fixation group, Bouquet pinning was performed for metacarpal fractures and cross pinning for phalangeal fractures. When more than 1 fracture coexisted in the same patient, they were considered separate instances. No differences among the 3 groups were observed when evaluating mean time to radiological union, grip strength, TAM, or QuickDASH score. Mean surgery time was significantly shorter with KW (20 minutes) and RIS (25 minutes), than with PS (32 minutes). Mean return to work or routine activities time was significantly less in the RIS (7.8 weeks) group than in the PS and KW groups (8.3 and 9.2 weeks, respectively). Conclusions: Surgical treatment is recommended in patients with unstable metacarpal and phalangeal fractures. The use of RIS was associated with shorter mean surgery duration and return to work times than PS and KW, respectively.

Are Vascularized Periosteal Flaps Useful for the Treatment of Difficult Scaphoid Nonunion in Adults? A Prospective Cohort Study of 32 Patients.

PURPOSE: To evaluate clinical and radiological outcomes after surgical treatment of difficult scaphoid nonunion in adults with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). MATERIALS AND METHODS: Thirty-two patients at least 18 years old, with scaphoid nonunion and characteristics associated with a poor prognosis, who underwent a VTMPF procedure, were included in this retrospective cohort study with a mean follow-up of 17 months. Factors associated with a poor prognosis were a delay in presentation of over 5 years, the presence of avascular necrosis, and previous nonunion surgery. All patients had at least 1 poor prognostic factor and 25% had 2 or more. RESULTS: In 30 men and 2 women, the mean age was 36 years (range, 19-56 years). There were 11 type D3 nonunions (Herbert classification) and 15 type D4. Five patients had delayed presentation of over 5 years. Fourteen patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The patients experienced no postoperative complications. Overall union rate was 97% (31 of 32 patients), with 72% cross-sectional trabecular percentage bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS). Overall 41% and 42% gains in strength and wrist motion, relative to the contralateral normal side, were observed. At final follow-up, there were no differences between the treated and the untreated (healthy) hands, in terms of wrist range of motion, grip, or pinch strength. CONCLUSIONS: In this study, the use of VTMPF for difficult scaphoid nonunion in adults was associated with good general outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Retrograde intramedullary headless compression screws for treatment of extra-articular thumb metacarpal base fractures.

The purpose of the study was to evaluate clinical and radiological outcomes of extra-articular fractures involving the base of the thumb metacarpal treated with fixation using a retrograde intramedullary cannulated headless screw. A review of prospectively collected data was conducted on a consecutive series of 13 patients, treated with headless screw fixation for acute displaced fractures. All workers resumed full duties, while non-workers returned to unlimited leisure activities within a mean of 42 days. At 3 months follow-up, all range of motion measurements in the treated and untreated thumb were similar. Mean visual analogue pain score was 0.8 at rest and 1.4 during exercise and mean Quick Disabilities of the Arm, Shoulder, and Hand score was 5. All patients achieved radiographic union by 8 weeks. We conclude that the intramedullary headless screw fixation is safe and reliable for base of thumb metacarpal fractures, allowing for early postoperative motion and good functional recovery. Level of evidence: IV.

Partial trapeziectomy and pyrocarbon interpositional arthroplasty for trapeziometacarpal osteoarthritis: minimum 8-year follow-up.

We undertook a retrospective study to evaluate minimal 8-year outcomes of 46 trapeziometacarpal joints (46 patients) treated with pyrocarbon implant arthroplasty after partial trapeziectomy for trapeziometacarpal joint osteoarthritis in two different hand surgery units. The mean follow-up interval was 9.5 years (average 113 months with a range 97-144 months). The study showed that pyrocarbon interpositional arthroplasty provided pain relief and high patient satisfaction. All patients experienced a reduction in the DASH score, with an average change of 30 points. The visual analogue scale score, the Kapandji score, and key pinch also showed remarkable improvement. The PyroDisk implant exhibited good longevity, with good implant survival. A review of the literature revealed that the functional outcomes after implant surgery are not superior to more common techniques, such as trapeziectomy with or without ligamentoplasty. Therefore, this is a reliable surgery but may not have added benefits over simpler surgical treatments. This implant could have a role, perhaps in a select group of young patients, as a time-procuring procedure. Level of evidence: IV.

Vascularized Thumb Metacarpal Periosteal Flap for Scaphoid Nonunion in Adolescents: A Prospective Cohort Study of 12 Patients.

PURPOSE: To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). METHODS: Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting, were included for this prospective cohort study, at a mean follow-up of 10.2 months. Patients were operated on by 3 different hand surgeons at 3 hand surgery institutions. All patients received a VTMPF, but with different scaphoid internal fixation modalities, in 10 cases using 1 or 2 retrograde 2-mm headless compression screws and in 2 cases without internal fixation. RESULTS: In 11 boys and 1 girl, the mean age was 15.6 years. There were 1 type D1 nonunions (Herbert classification), 6 type D2, 2 type D3, and 2 type D4. Six patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The mean anterior bone defect was 3.5 mm in length. The patients experienced no postoperative complications. Successful consolidation was achieved in all cases, with 79% cross-sectional trabecular bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS) results. Overall, 34% and 40% gains in strength and wrist motion, relative to the contralateral normal side, were observed. CONCLUSIONS: In this study, the use of VTMPF for scaphoid nonunion in children and adolescents is associated with generally good outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Dorsolateral Biplane Closing Radial Osteotomy and Lunate Fixation for Stage IIIC Kienböck Disease: A New Surgical Approach.

The treatment of advanced-stage Kienböck disease (KD) remains highly controversial. Particularly important is stage IIIC KD, which includes patients with a lunate coronal fracture. The purpose of this paper was to describe a new approach to KD in patients with Lichtman stage IIIC KD, and our results using it. The procedure combines a dorsolateral biplane closing radial osteotomy and lunate fixation. A total of 11 patients from January 2002 through December 2016 with documented KD who underwent this technique were included. The patients were assessed before surgery, then postoperatively at 1 and 10 days, 3 and 6 weeks, 3 and 6 months, and annually. Wrist range of motion, grip and pinch strength, the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, a Modified Mayo Wrist Score (MMWS), 10-point visual analog scale, radiologic measurements, and data related to consolidation were collected. All statistical analyses were performed using the statistical software package SPSS. Some degree of pain relief, improvements in the QuickDASH score, MMWS score, grip strength, and the degrees of flexion and extension were observed, the results being statistically significant (P<0.05). After surgery, the values for radial and sagittal tilt were statistically different than those measured before surgery. Carpal collapse was not evident either before or after surgery. In conclusion, combining a dorsolateral radial osteotomy and a lunate compression screw may expand the options for patients with Lichtman stage IIIC KD. Our experience indicates that it is a viable option in challenging clinical scenarios.

Volar Plate Fixation to Treat Scaphoid Nonunion: A Case Series With Minimum 3 Years of Follow-Up.

PURPOSE: Several options exist for treating scaphoid nonunion. For selected cases, some authors recommend using a volar buttress plate. The aim of the study was to report the clinical and radiological outcomes achieved at a minimum of 3 years' follow-up of treating scaphoid nonunion with a scaphoid volar plate. METHODS: We retrospectively reviewed 15 patients with symptomatic scaphoid nonunion treated with scaphoid plate osteosynthesis and a bone graft from the volar aspect of the distal radius between January 2011 and November 2013. The patients' average age was 32 years (range, 21-62 years). No patient had undergone previous scaphoid surgery. Clinical assessments included wrist range of motion (ROM), grip strength, and a 10-point visual analog scale rating of pain. Further subjective assessment was performed using validated measurement tools. All patients underwent plain radiography with 6 different views and computed tomography before and after surgery. The scapholunate angle was measured to evaluate carpal alignment. RESULTS: The mean follow-up period was 42 months (range, 36-51 months). Bone union was obtained in 13 of 15 patients (87%) at an average of 5 months (range, 3-8 months) after surgery. Significant improvements in the scapholunate angle and visual analog scale pain score were observed. However, both wrist ROM and grip strength remained significantly decreased relative to the opposite side (62% and 55% of normal, respectively). Four patients experienced hardware complications: plate breakage (1 scaphoid) and screw back-out (3 scaphoids). Impingement between the radial styloid and the scaphoid plate was identified in 6 patients. Five patients required additional surgery to remove the plate. CONCLUSIONS: Our study indicates unsatisfactory results treating scaphoid nonunion with a volar scaphoid plate. Although the rate of union was comparable with that of other series, we noted more complications. We are concerned about both the high proportion of hardware complications and required secondary surgical procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

TRest as a New Diagnostic Variable for Chronic Exertional Compartment Syndrome of the Forearm: A Prospective Cohort Analysis of 124 Athletes.

OBJECTIVES: To measure the accuracy of currently used intracompartmental pressure (ICP) diagnostic variables for forearm chronic exertional compartment syndrome (CECS) and a new ICP diagnostic variable, TRest, the recovery time between the maximum ICP and return to resting pressure. DESIGN: Retrospective cohort. Level evidence IV. SETTING: University-affiliated tertiary hospital. PARTICIPANTS: Patients with suspected forearm CECS, 1990 to 2014. INTERVENTIONS: All patients underwent physical examination and exertional stress test, preceded and followed by measuring ICP in all suspicious CECS. Surgery was proposed when indicated. Minimum follow-up was 18 months. Final diagnosis was established at the final follow-up. MAIN OUTCOME MEASURES: Intracompartmental pressure measurements: PRest (baseline/pre-exercise pressure), P1 min (pressure 1 minute after exercise), P5 min (pressure 5 minutes after exercise), and TRest. Patients rated their pain and completed Quick-DASH in all follow-ups. Patients ultimately were classified into 4 groups (true positives, true negatives, false positives, and false negatives) for each ICP measurement relative to the final diagnosis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: A total of 124 male athletes were diagnosed with CECS, 27 bilateral. Accuracy with standard ICP diagnostic variables was lower (sensitivity 73.5%, specificity 84.2%, positive predictive value 97%, and negative predictive value 31.4%) than with TRest (SN 100%, SP 94.7%, PPV 99.3%, and NPV 100%); 23% of patients would have been missed following the standard ICP diagnostic criteria. CONCLUSIONS: Diagnostic thresholds for current standard ICP measurements should be lowered. TRest, a new measure, might be more accurate.

Surgical Decompression of Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Racers: Comparative Long-term Results of Wide-Open Versus Mini-Open Fasciotomy.

OBJECTIVE: To compare the long-term results of 2 surgical techniques for forearm chronic exertional compartment syndrome (CECS) in professional motorcycling racers and to study a new diagnostic variable for CECS, TRest. DESIGN: Retrospective case series. LEVEL OF EVIDENCE: 4. SETTING: University Hospital. PARTICIPANTS: Thirty-four patients identified from a surgical database who had been operated on for upper-limb CECS. INTERVENTIONS: The purpose of the study was to report and compare the long-term results of 2 surgical techniques using fasciotomies [wide-open fasciotomy (WOF) versus mini-open fasciotomy (MOF)] for forearm CECS in professional motorcycling racers. PATIENT CHARACTERISTICS: Pain [visual analog scale (100-point scale)] and functional scores (Quick-DASH) at 3 months after surgery and at regular intervals during clinical visits. Surgical complications: Level of satisfaction with the outcome. Time to return to full activity after surgery. RESULTS: Thirty-four racers, 22 with bilateral involvement (n = 56), were diagnosed with CECS and were treated either with WOF (n = 24) or MOF (n = 32) depending on the surgeon's indication. Mini-open fasciotomy was usually selected in cases who need a faster recovery because of competition schedule. Visual analog scale and Quick-DASH improved 63 and 73 points, respectively (P < 0.001) with no significant difference between both surgical methods (P = 0.512). Both WOF and MOF were equally effective. Ninety-four percent of the patients were satisfied after 45.35 ± 12 months of follow-up, with no significant difference between surgical groups (P = 0.642). The time to return to full activity was 2.7 ± 1 week, also with no significant difference (P = 0.544). The time between when the stress testing was halted for pain and the return to baseline pressure (TRest) was superior to 15 minutes (defined as the mean minus 2 SDs) in 100% patients. CONCLUSIONS: Surgical open or mini-invasive fasciotomy is equally successful in motorcycling racers with forearm CECS. Although the sensitivity of TRest is quite high in our series, further studies are still needed to validate its diagnostic value. CLINICAL RELEVANCE: Surgical open or mini-invasive fasciotomy is equally successful in motorcycling racers with forearm CECS.

Pyrocarbon interposition (PyroDisk) implant for trapeziometacarpal osteoarthritis: minimum 5-year follow-up.

PURPOSE: To report outcomes after a minimum of 5 years following pyrocarbon interposition (PyroDisk) trapeziometacarpal joint implant for osteoarthritis at a single center. METHODS: We retrospectively reviewed the midterm clinical and radiological outcomes of 19 patients who had a pyrocarbon interposition implant (PyroDisk; Integra Life Sciences, Plainsboro, NJ) arthroplasty. The rate and causes of repeat surgeries, revisions, and complications were examined. RESULTS: The mean follow-up period was 68 months. Patient satisfaction was high. The mobility of the operated thumb was restored to a range of motion comparable with that of the contralateral thumb. Grip strength improved by 26%. Overall function, according to the Quick Disabilities of the Arm, Shoulder, and Hand score, showed an average improvement of 71 to 20. Pain decreased by 78% according to the numerical rating scale. Radiological evaluation using a modification of the system described by Herren revealed progression of the periprosthetic lucency (grade I-II) of the implant after 5 years in 5 of 19 (26%) patients. Progression of lucency did not predict implant loosening or failure at 5 years. Two patients had symptomatic instability that required revision. No dislocations occurred. The 5-year survival of the prosthesis was 90%. CONCLUSIONS: The PyroDisk implant for treating advanced trapeziometacarpal arthritis did not demonstrate superiority over published outcome data of trapeziectomy with or without ligament reconstruction and tendon interposition. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Osteoid osteoma of the distal humerus mimicking sequela of pediatric supracondylar fracture: arthroscopic resection-case report and a literature review.

Osteoid osteoma (OO) is a small and painful benign osteoblastic tumour located preferentially in the shaft of long bones near the metaphyseal junctions, with a predilection for the lower limbs. Juxta- and intra-articular OOs are rare and even though hip, elbow, and talus are the most commonly reported locations, they may be found in any joint accounting for approximately 13% of all osteoid osteomas. There is usually a significant time delay between symptom initiation and diagnosis when the lesion is present in an uncommon location due to the diagnostic challenge it presents due to the lack of classical clinical signs and/or radiographic features found in the extra-articular lesions. A case of a distal humerus OO of a 15-year-old girl is presented to point out that a confounding factor, such as a previous paediatric supracondylar fracture, may further delay the already difficult diagnosis of a juxta- or intra-articular osteoid osteoma and also to emphasize the possibility of arthroscopic treatment of such lesions.