Intramedullary headless compression screw fixation of the middle phalanx: tips, tricks, and pitfalls.

This report emphasizes careful consideration of surgical technique for intramedullary screw fixation in middle phalanx fractures. Highlighting pitfalls, particularly with K-wire placement, it suggests the antegrade trans-articular approach as superior, urging further research for improved patient outcomes.

Thumb Arthroplasty as Reliable Long-term Solution for Trapeziometacarpal Osteoarthritis: A Minimum of 15 Years of Follow-up.

BACKGROUND: In patients with symptomatic trapeziometacarpal (TMC) joint arthritis resistant to conservative treatment, surgical treatment can be advised. One of the many surgical treatment options is TMC arthroplasty. The Arpe prosthesis is one example of these TMC arthroplasties. METHODS: This retrospective study evaluated patients who underwent TMC arthroplasty with the Arpe prosthesis after a minimum of 15 years of follow-up. Clinical, radiologic, and qualitative outcomes were assessed for 43 Arpe arthroplasties in 41 patients, of whom 2 had bilateral arthroplasties. The female to male ratio was 39:4. The mean follow-up time was 197 months (range = 180-225). RESULTS: The cumulative survival rate after a mean of 16.5 years was 84%. Seven failures (16%) were registered, of which 5 during the first 3 years after primary surgery. All patients were successfully converted to a trapeziectomy. Quick Disabilities of the Arm, Shoulder and Hand score improved with 44.9 points and visual analogue pain score with 97% and 91% at rest and during exercise, respectively. CONCLUSIONS: This series demonstrates that thumb arthroplasty is a reliable long-term solution for thumb base arthritis, with significant pain reduction and functional improvement, even after 15 years of follow-up.

Retrospective evaluation of an intervention bundle on OPAT implementation in a large non-university hospital.

OBJECTIVES: Optimization of outpatient parenteral antimicrobial therapy (OPAT) requires interdisciplinarity and an operational algorithm. This report retrospectively assesses the impact of a multimodal quality-enhancement intervention bundle on the implementation rate, efficacy, and safety of a home OPAT program in a Belgian large community-based hospital. METHODS: OPAT recipients between 1 March 2019 and 30 June 2022 were included. The OPAT trajectories were divided into pre-intervention (from 1 March 2019 to 31 October 2020) and post-intervention (from 1 November 2020 to 30 June 2022) groups. The quality-enhancement intervention bundle consisted of the involvement of an infectious disease specialist, revision and implementation of a state-of-the-art prosthetic joint infection diagnosis and treatment protocol, weekly multidisciplinary discussion of all prosthetic joint infections, revision of the OPAT algorithm, and the introduction of teicoplanin as an OPAT-convenient antimicrobial. RESULTS: Eighty-five patients were included in a total of 96 OPAT trajectories (n = 33 pre-intervention; n = 63 post-intervention). After the intervention, the number of OPAT trajectories nearly doubled. The number of patients with a recurrent infection within 6 months after OPAT completion decreased 15%. The overall 6-month mortality and readmission rates during OPAT treatment decreased 8% and 10%, respectively. Mortality during OPAT treatment did not change. These differences between pre- and post-intervention did not achieve statistical significance, despite the higher risk for complications in the post-intervention group because of increased infection complexity and required treatment duration. CONCLUSION: Within a Belgian, single, large community-based hospital, a multimodal intervention bundle resulted in increases in OPAT implementation, infection complexity, and required treatment durations without statistically significant differences in outcomes.

Digital mucous cysts of the finger without osteoarthritis: optimizing outcome of long needle trajectory aspiration and injection.

Digital mucous cysts are common, benign and highly recurrent tumors of the distal interphalangeal joints of the fingers and often associated with osteoarthritis. Multiple treatment modalities have been described, but still no consensus is stated. In the absence of degenerative changes, we promote a novel non-surgical approach. The aim of this study was to examine all patients with digital mucous cysts without underlying osteoarthritis, undergoing this injection technique and to assess outcome and complications of this procedure. This was a single center study (2018-2019) of 17 patients who received a long needle trajectory aspiration and injection for treatment of digital mucous cysts. Exclusion criteria were prior surgical treatment, post-traumatic cyst formation and the presence of radiographic distal interphalangeal joint osteophytosis. A total of 15 patients were found eligible for inclusion. The patient reports were retrospectively analyzed with a follow-up of 6 months. The primary study outcome was resolution of the cyst; secondary outcomes were complications of the procedure. Twelve (80%) resolved completely and three (20%) had limited local recurrence at 6 months. No complications were reported. None of the patients with limited recurrence desired further treatment. We believe that this technique offers a non-invasive, low-cost treatment option for digital mucous cysts, particularly in the subset of patients with ample evidence of degenerative articular changes in the distal interphalangeal joint. The described technique can be performed in an office-based setting and avoids typical surgical as well as aspiration-associated complications.

Shortening arthrodesis combined with limited fasciectomy in severe recurrent Dupuytren's disease of the fifth finger.

OBJECTIVE: Management of recurrent Dupuytren's disease of the little finger is challenging. Various treatment modalities have been proposed: external fixation, local skin flap, dermofasciectomy, or even amputation. An alternative surgical technique was introduced by Honecker et al. in 2016 and refined by Raimbeau et al. in 2019, consisting in resection of the middle phalanx and shortening arthrodesis. We modified the technique by combining arthrodesis with a limited fasciectomy of the abductor and/or pretendinous cord in the fifth ray to improve cosmetic and functional outcomes. METHODS: Patients with severe recurrent Dupuytren's disease of the little finger (Tubiana stage III/IV) were treated with proximodistal interphalangeal arthrodesis, combined with limited fasciectomy. Range of motion was assessed preoperatively and postoperatively. QuickDASH and a VAS were assessed to determine overall function and pain respectively. Radiographic evaluation was made at 6 and 12 weeks postoperatively. RESULTS: Thirteen patients were eligible for inclusion. Mean age was 69 years (range 49-87). Radiographic consolidation was obtained at a mean 58 days (range 27-97). Full extension of the metacarpophalangeal joint was achieved in 11 patients and full adduction in 12. Mean active flexion was 94° (range 90-100). QuickDASH scores decreased from 18 to 12 after surgery. Pain scores were low and unchanged. CONCLUSION: By combining proximodistal interphalangeal arthrodesis with limited fasciectomy through a volar approach, finger extension improved, and fixed abduction was also treated. The combined volar and dorsal approach did not induce vascular impairment or other complications.

Symptomatic bifid insertion of the Flexor Carpi Radialis Brevis.

A 35 year-old right-handed female presented with persistent wrist pain lasting two years. Imaging disclosed an accessory tendon-shaped structure, identified as a Flexor Carpi Radialis Brevis, strangling the Flexor Carpi Radialis tendon at the wrist during effort. Surgical exploration found the insertion of the Flexor Carpi Radialis Brevis to be bifid. Resection of the stenosing branch and the fibrotic tendon sheath restored strength in the right wrist and painless symmetrical motion compared to the left wrist ten weeks postoperatively.

Arthroplasty of the Proximal Interphalangeal Joint With the TACTYS Prosthesis: Clinical and Radiographic Results With a Mean Follow-up of 5 Years.

BACKGROUND: Degenerative arthritis of the proximal interphalangeal (PIP) joint of the long fingers is a common disorder affecting mainly a female middle-aged population. Conservative treatment is often effective, but in some cases, pain can persist which can lead to invalidating function. Besides denervation and arthrodesis, arthroplasty is a valuable alternative treatment. The goal of this retrospective study was to determine the clinical and radiological outcomes of the TACTYS prosthesis with a mean follow-up of more than 5 years. METHODS: Between October 2005 and August 2019 10 joints in 9 patients, one patient had two prostheses in two separate fingers (4 males and 6 women) were treated for painful degenerative arthritis of the long fingers with a TACTYS prosthesis (Stryker Inc, Kalamazoo, Michigan). Power grip and pinch force were tested preoperatively and postoperatively, and the functional outcome survey is performed using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), recall QuickDASH, and Patient-Rated Wrist Evaluation standardized questionnaires scored of 100 and the Visual Analog Scale (VAS) from 0 to 10. RESULTS: Mean follow-up was 65.70 months (range: 23-106). Mean age was 71.5 years (range: 64-83). QuickDASH score evolved from 68.43 to 41.92, range of motion from 37.5° to 45.1°, VAS from 6.65 to 1/10. Power grip and precision pinch evolved from 16.44 to 20.80 kg and 1.97 to 2.85 kg, respectively. CONCLUSIONS: TACTYS arthroplasty can be proposed for people who have been treated long enough with unsuccessful conservative treatment. Infection rate is still the highest complication, which can evolve in invalidating arthrodesis. It should be proposed exceptionally if the PIP joint arthritis causes invalidating functional pain.

Radiological imaging of the trapeziometacarpal joint: a historical and clinical perspective.

The opposable thumb provides both stability and mobility and is needed to accomplish different prehensile tasks. The trapezium is a complex bone, with a distal articular surface that is convex in the sagittal plane of the thumb and concave in the coronal plane of the thumb. The numerous additional articulations with the carpus and the oblique orientation to the main plane of the hand makes it difficult to evaluate the trapeziometacarpal joint using standard hand or wrist radiographic views. This review gives an overview of the different radiological views that have been described for the thumb with an emphasis on their historical origin and positioning during radiography. We also describe different measurements and classifications that can be obtained using different thumb radiographs.

Ivory Arthroplasty for Trapeziometacarpal Joint Arthritis in Men: Analysis of Clinical Outcome and Implant Survival.

Background: Trapeziometacarpal arthroplasties are designed to restore an adequate level of mobility, stability, and grip strength. In this article, pain and functional and radiographic outcome of Ivory arthroplasty in male patients are investigated. Methods: Between 2005 and 2012, the Ivory arthroplasty was inserted in 21 male patients with degenerative trapeziometacarpal osteoarthritis, of which 14 patients were found eligible for inclusion. Mobility, grip strength, patient self-assessment (pain; Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH]), and radiographic outcome were measured. Twenty-two female patients who received an Ivory arthroplasty between 2005 and 2007 were included and underwent the same evaluation. Age at primary surgery, survival rate of the implant, and clinical outcome were compared between the 2 groups. Results: In both groups, QuickDASH score and mean pain sensation improved significantly. The improvement in mobility obtained significance in the female group. In the male group, 7 arthroplasties failed (mean follow-up of 65 months). In the female group, 3 of the 24 arthroplasties failed (mean follow-up of 123 months). Kaplan-Meier survival analysis demonstrated a significant lower implant survival in the male group. Conclusions: Decrease in muscle mass and decline in grip strength that postmenopausal women tend to experience might explain the significant difference in implant survival between sexes. In 4 of the 7 failed arthroplasties in the male group, no surgical revision was required. Trapeziometacarpal arthroplasty, even after radiographic failure, still served as a spacer, avoiding collapse of the thumb base. Nevertheless, the failure rate of the Ivory arthroplasty in male patients is high, and an alternative treatment should be considered.

Endoscopic carpal tunnel release with or without suture: Does it make a difference? A case-control study.

A case-control study was conducted to compare wound healing with or without skin suture after endoscopic carpal tunnel release. The primary endpoint was esthetics on the Manchester Scar Scale (MSS). Patients were recruited between April 2016 and April 2017. Inclusion criteria comprised carpal tunnel syndrome with clinical and electromyographic confirmation on the Canterbury NCS (nerve conduction studies) Severity Scale. Age, gender, occupation, handedness, smoking status, and operated side were noted. In the first group (64 patients) the skin was not sutured. In the second group (44 patients) the skin was closed Ethilon™ 5-0 intradermal running suture. All 108 patients had 3 months' follow-up. Since data were not normally distributed, analysis was performed with the Mann-Whitney U test (MWU) for independent samples. There were no significant differences in age (p = 0,416), gender (p = 0.670) or occupation (p = 0.725) between groups. MSS score did not significantly differ between groups (MWU test; p = 0.529): sutureless, 6.64 ± 1.21; sutured, 6.45 + 1.09. Thus, sutureless wound closure can be a useful option in treating carpal tunnel syndrome by a single-portal endoscopic technique. That the wound remains open enables easy evacuation of any hematoma, avoiding pain due increased intra-tissular pressure.

Addition-Subtraction Osteotomy With Ligamentoplasty for Symptomatic Trapezial Dysplasia With Metacarpal Instability: A 10-Year Follow-Up.

PURPOSE: Symptomatic trapezial dysplasia with metacarpal instability in a nonarthritic joint can lead to a disabling condition characterized by decreased pain, mobility, and strength. Bony correction may be required in dysplastic joints, because soft tissue correction might be insufficient to stabilize the trapeziometacarpal (TMC) joint. We combined 2 techniques described previously, an abduction-extension osteotomy of the first metacarpal and an opening wedge osteotomy of the trapezium, including a ligament reconstruction (hemi-flexor carpi radialis). The aim of this study was to investigate the long-term results of this technique. METHODS: In this single-center, retrospective cohort study, we included patients treated surgically for primary instability of the TMC joint with trapezial dysplasia between 2003 and 2007. We measured pain (visual analog scale), mobility (opposition and retropulsion), patient-reported disability (Quick-Disabilities of the Arm, Shoulder, and Hand), and radiographic evaluation (Devers' angle) 10 years after surgery. Results were compared with preoperative data. RESULTS: We reviewed 17 thumbs retrospectively (mean follow-up, 12 years). One patient was converted to a TMC prosthesis. Key pinch improved significantly from 5.2 kg (±2.4 kg) at baseline to 6.3 kg (±2.1 kg) at 10-year follow-up. Quick-Disabilities of the Arm, Shoulder, and Hand score and Devers' angle were significantly better after 10 years compared with preoperative data. There was a mean visual analog scale score of 0.5 (±1.4) at rest and 2.3 (±2.6) during activities. Ten years after surgery, 5 patients had a stable Eaton score of 1. Four patients had progression to stage 2, and 5 to stage 3. CONCLUSIONS: Addition-subtraction osteotomy with ligamentoplasty has a positive long-term effect on symptomatic trapezial dysplasia with TMC joint instability. Although this operation did not protect the TMC joint from further wear, pain was acceptable for most patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The effectiveness of a Botulinum Toxin A infiltration in the management of bicipital cramps after arthroscopic biceps tenotomy.

A challenging complication of arthroscopic biceps surgery is the persistent painful cramping of the biceps. There is a paucity of data upon nonsurgical treatment of this debilitating complication. We pro- pose an intramuscular injection of botulinum toxin A (BTX-A) for painful bicipital cramping after tenotomy of the long head of the biceps brachii tendon (LHBT). Ten patients with a painful Popeye sign after tenotomy of LHBT, were treated with intramuscular injection of 100 IU of BTX-A. Mean patient age was 56 years and mean time from surgery to infiltration was 317 days. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was obtained. Pain was objectified by a visual analogue scale (VAS). Patient satisfaction was described as excellent, good, satisfactory, or poor, three and six months after injection. Mean VAS prior to infiltration was 6.8 and decreased significantly to 2.6 at follow-up. Mean QuickDash was 54.04 prior to infiltration and decreased to 19.84 at follow-up. Patient satisfaction was excellent in 9 and good in 1 patient. We report a significant pain reduction and functional improvement following BTX-A infiltration as treatment of painful bicipital cramping after tenotomy of LHBT.

Complicated Replanted Finger, 34 Years after Revascularization.

Merely a few reports of late failure (later than the 7th postoperative day) of a digital replantation can be found in the literature. Discussions of the factors that might cause a late failure are concise. To our knowledge, there are no reports of failure in literature as late as the case we are presenting. An 87-year-old white man was diagnosed with acute complications of a digital replantation, 34 years after initial surgery. Ultrasound examination and an arteriography demonstrated occlusion of the arterial anastomosis. The patient's surgical file revealed scars of former replantation surgery of both the index and the middle finger. In the latter, 1 artery and 2 veins were anastomosed. Considering the age and comorbidities of the patient, revascularization of the finger was not performed. Local wound care and analgesic drugs were prescribed. After initial deterioration and ulceration, gradual improvement was noticed. Total wound healing occurred at 3 months after the initial consultation. Compared with free flap surgery in general, finger replantations are at a higher risk of late complications because digital neovascularization is directly correlated to the contact surface area. This contact surface is usually larger in other free flaps. Furthermore, diseases that deteriorate circulation most likely affect the short- and the long-term survival of a digital replantation. From this point of view, performing both volar digital arterial anastomoses, whenever possible, might reduce early as well as late failure in replantation surgery.

Intra-Articular Osteotomy for Symptomatic Bennett Fracture Malunion.

Bennett's fractures are the most common fractures around the trapeziometacarpal joint but require specialized radiographs to be correctly diagnosed. If a fracture is missed at initial presentation, it may heal with an intra-articular gap, leading to joint incongruency and a painful trapeziometacarpal joint. We present a new technique to correct the intra-articular gap and restore joint congruency in the event of a symptomatic Bennett malunion with a gap of at least 2 mm. The joint is exposed through an anterolateral approach, and the malunion is marked with K-wires under fluoroscopic control. A closing wedge osteotomy with excision of the malunion site is then performed to restore joint congruency. The osteotomy is fixed with 3 interfragmentary screws, and the joint is immobilized for 2 weeks before passive mobilization is initiated. Hardware can be removed between 3 and 6 months postoperatively after consolidation of the osteotomy. We recommend this technique in active patients without trapeziometacarpal osteoarthritis who present with a painful Bennett malunion. Restoration of the joint congruency reduces pain and may prevent the development of posttraumatic osteoarthritis.

Ivory arthroplasty for trapeziometacarpal osteoarthritis: 10-year follow-up.

This prospective study investigates long-term functional outcome after total trapeziometacarpal joint replacement with the Ivory arthroplasty for trapeziometacarpal joint osteoarthritis. Clinical outcome, overall function, pain, and radiologic outcome after a minimum of 10 years were evaluated for 26 Ivory arthroplasty in 24 patients. Two patients had bilateral arthroplasties. The female to male ratio was 22:2, and the mean age was 71 years (range 57-83). The mean follow-up period was 130 months (range 120-142). Overall functioning as defined by the QuickDASH score and visual analogue pain score improved by 50% and 81%, respectively, when compared with the preoperative status. However, these outcomes deteriorated beyond 5 years after surgery. Long-term results suggest the Ivory arthroplasty to be a reliable treatment for trapeziometacarpal osteoarthritis since it improves overall function and reduces pain up to 10 years postoperatively. However, revision within 10 years after surgery was needed in four of 26 cases. Level of evidence: II.

Pulley Reconstruction for Symptomatic Instability of the Tendons of the First Extensor Compartment Following de Quervain's Release.

Background Surgical management of de Quervain's tenosynovitis is based on decompression of the first extensor compartment. A simple release of the first compartment can cause instability of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons in zone seven of the extensors. The WHAT test (wrist hyperflexion and abduction of the thumb) is very effective in diagnosing this instability. Patients and Methods In this retrospective monocentric study, we analyzed a case series of 10 patients all of whom underwent a reconstruction of the first extensor compartment using a retinacular graft because of symptomatic instability after decompression surgery. The reconstruction was a modified technique of the sixth compartment. Functional outcome and characteristics of the newly reconstructed pulley were examined by physical examination with the aid of ultrasound and internationally validated questionnaires. Results Four patients had a good-to-excellent functional outcome, all of those had a maximum of two surgical procedures performed on the first extensor compartment. Six patients presented poor functional outcome. In four of them, more than two surgical procedures were performed. Minor residual instability was noted in six cases, found in both the groups. Conclusion The reconstruction procedures on the first compartment seemed to be satisfactory in treating instability of the EPB and APL tendons after primary surgical release for de Quervain's disease. Level of Evidence Level IV, observational study without controls.

The Oblique Metaphyseal Shortening Osteotomy of the Distal Ulna: Surgical Technique and Results of Ten Patients.

Background Ulnocarpal abutment is a common condition following distal radius fractures. There are different surgical methods of treatment for this pathology: open and arthroscopic wafer procedure or an ulnar shortening osteotomy. We describe an oblique metaphyseal shortening osteotomy of the distal ulna using two cannulated headless compression screws. We report the results of 10 patients treated with this method. Materials and Methods Out of 17 patients, 10 could be reviewed retrospectively for this study. Patient-rated outcomes were measured using the VAS (visual analogue scale) for pain, PRWHE (patient-rated wrist and hand evaluation) survey, and Quick-DASH (disability of arm, shoulder and hand) survey for functional outcomes. At the review we measured the range of motion (ROM) of the wrist (extension and flexion, ulnar and radial deviation, pronation and supination). Grip strength, pronation, and supination strength of the forearm was measured using a calibrated hydraulic dynamometer. ROM and strength of the affected wrist was compared with ROM and strength of the unaffected wrist. Surgical Procedure Oblique long metaphyseal osteotomy of the distal ulna (from proximal-ulnar to distal-radial), fixed with two cannulated headless compression screws. Results The average postoperative VAS score for pain was 23.71 (standard deviation [SD] of 30.41). The average postoperative PRWHE score was 32.55 (SD of 26.28). The average postoperative Quick-DASH score was 28.65 (SD of 27.21). The majority of patients had a comparable ROM and strength between the operated side and the non-operated side. Conclusion This surgical technique has the advantage of reducing the amount of hardware and to decrease the potential hinder caused by it on medium term. Moreover, the incision remains smaller, and the anatomic metaphyseal localization of the osteotomy potentially allows a better and rapid healing.

Pulley Reconstruction As Part of the Surgical Treatment for de Quervain Disease: Surgical Technique with Medium-Term Results.

Background Simple decompression of the first extensor compartment is commonly used for treating de Quervain disease, with the possible complication of subluxation of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) over the radial styloid. To prevent this painful subluxation of the tendons, several methods of reconstructing the pulley have been proposed. Questions/Purposes The purpose of our study was to evaluate a new technique for reconstructing the first extensor compartment following a release for de Quervain disease. Patients and Methods A retrospective study (mean length 40.4 months) was performed in 45 patients. The outcome assessment involved two different questionnaires and ultrasound evaluation of any tendon subluxation. Results None of the patients required reoperation for tendon instability or incomplete decompression of the first extensor compartment. Two patients experienced clicking around the radial styloid after surgery. This was not related to the amount of volar migration of the tendons. Conclusions We believe the reconstruction proposed here is an effective method of preventing painful subluxation of the APL and EPB following a release of the first extensor compartment.

De Quervain Tenosynovitis Following Trapeziometacarpal Ball-and-Socket Joint Replacement.

Background One of the surgical treatment options for trapeziometacarpal (TMC) joint arthritis is a prosthetic ball-and-socket replacement. One of the complications in the postoperative setting is de Quervain tendinopathy. Purposes Although this complication has been reported following a resection athroplasty, we questioned whether lengthening of the thumb following the Ivory (Memometal, Stryker Corporate, Kalamazoo, MI, USA) ball-and-socket arthroplasty could be a causal factor. Methods In a prospective study regarding the overall outcome of the Ivory prosthesis, we analyzed 96 cases (83 patients; 69 female, 12 male, 8 bilateral) of primary implanted Ivory prosthesis and the incidence of de Quervain disease during the first year following surgery. We found a particularly high incidence (17%) of de Quervain tendinopathy the first year following this ball-and-socket arthroplasty. We measured the lengthening of the thumb radiographically in the group presenting de Quervain and the asymptomatic group and compared this measure between the two groups. Results We did not find any measurable or statistically significant difference between the groups regarding lengthening. Discussion These findings suggest that lengthening of the thumb following ball-and-socket arthroplasty is not a causal factor in the development of de Quervain tendinopathy within one year after surgery.