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Samuel George 1,2, Bismark Adjei 1, Paul McArthur 1,2

1 Whiston Hospital, Liverpool, UK; 2 Alder Hey Children's Hospital, Liverpool, UK

Introduction: Anatomical variations of the flexor pollicis longus(FPL) muscle are well described, the common two being an accessory head of FPL also known as Gantzer’s muscle described in 1813 and the anomalous tendon slips from the FPL to the flexor digitorum profundus(FDP) of the index and more rarely middle finger described by Linburg and Comstock in 1979. We present an anomaly not previously described in the literature where the FDP to the ring finger was found to originate from the FPL tendon, causing tight flexion contracture of both due to underlying muscle spasticity. Case Report: An 11-year-old boy with Leigh syndrome was under the care of our plastic surgery unit for flexion contractures of his upper limbs. He underwent botulinum toxin injections 4 weeks previously and was undergoing tendon lengthening/release on the right side. Of note, pre-operatively he had a very tight FPL and wrist flexors but also incidentally a severe flexion deformity of his ring little and fingers which resembled a claw hand. During surgical exploration and release of the muscles, an anomalous fusiform muscle was found originating from the tendon of the FPL, heading to the ring finger and flexing the distal interphalangeal joint. The accessory muscle was divided and improved the flexion contracture. Conclusions: Anatomically distinct from the anomalous tendon slips described by Linburg and Comstock, this accessory muscle actually originated from the FPL and inserted in the ring finger. While most anomalous muscles are asymptomatic, ours was causing symptoms particularly due to underlying muscle spasticity. The other clinical relevance of this is that the ring finger FDP usually supplied by the ulnar nerve was in this instance supplied by the median nerve.

Tamer Ali, Andrew Watts

Royal Devon and Exeter Hospital, Exeter, UK

Anomalous or accessory FDS muscles in the palm are rare, but when present they can be painful and interfere significantly with hand function. We present the case of a 28 year old male mechanic who presented with a painful swelling over his right thenar eminence following a road traffic accident. The patient’s right hand was gripping the steering wheel when he was involved in a low velocity head on collision. Shortly afterwards he noticed a swelling in his right palm over the first web space which increased in size with finger flexion. His grip strength was compromised and had reduced abduction of his index finger. Ultrasound and MRI scans were inconclusive. No intrinsic muscle rupture was detected and no mass lesion was detected. Hypertrophy of the index intrinsic muscles was suggested. The swelling increased in size and his overall hand function decreased, so surgical exploration was planned. At operation, the FDP tendon to the index finger and the intrinsic muscles were intact and of normal appearance. However, an accessory muscle was seen attached to the index finger FDS tendon in zone 3. A tendon ran proximally from this accessory muscle belly into the forearm. The accessory muscle was excised from the FDS tendon and the accessory tendon was sutured end to side on the existing FDS tendon. Postoperatively, the patient made a full recovery with reduced pain and significantly improved hand function. Anomalous and accessory muscles in the palm are anatomical curiosities until they become symptomatic. Accessory FDS muscles presenting in the palm are rare and only a few cases have been reported in the literature since they were first described in 1970 by Vichare. However, significant functional problems have been reported in conjunction with these anatomical variations, including pain, compression neuropathy, digital triggering and stiffness. Because of their rarity, their diagnosis is often delayed or initially missed. The authors show clear anatomical photographs of this accessory muscle along with an algorithm for investigating suspected anatomical variations.

Ji Hun Park, Tae Wook Kang, Seul Gi Kim, Young Woo Kwon, Jong Woong Park

College of Medicine, Korea University Anam Hospital, Seoul, South Korea

Background: Two major lunate types have been proposed on the basis of the absence (Type I) or presence (Type II) of medial facets. The first purpose of this study was to examine the reliability and reproducibility of the two methods of determining the lunate type: posteroanterior (PA) radiographic analysis (PA analysis) and capitate-triquetrum distance analysis (CTD analysis). The second purpose was to investigate the compatibility of the radiographic classification of lunate types with MR arthrography (MRA) findings. Methods: Plain radiographs of a total of 150 wrists were reviewed by three observers. The lunate types were independently evaluated twice using both PA analysis (Lunate Types I and II) and CTD analysis (Lunate Types I, CTD≤2mm; II, CTD≥4 mm; Intermediate, Others). The Cohen kappa and Fleiss kappa statistics were used for estimating the intra- and inter-observer reliabilities. The compatibility of the lunate types with the MRA findings, as assessed by each observer, was investigated. Results: The overall intra-observer reliability was 0.517 for the PA analysis and 0.589 for the CTD analysis. The overall inter-observer agreement of the three raters was 0.448 for the PA analysis and 0.581 for the CTD analysis. The PA analysis and MRA findings for the detection of medial facets of the lunate were compatible in 119 of the 150 patients (79.3%). Twenty-eight (90.3%) of a total of 31 incompatible wrists had a medial facet on the lunate on MRA (Type II), which was undetected on the PA analysis (Type I). On the CTD analysis, 76 (50.7%) of the total wrists were classified into the intermediate group; excluding them, 27 of 29 Type II lunates (93.1%) and 39 of 45 Type I lunates (86.7%) were compatible with the MRA findings. Conclusions: Both systems had moderate inter-observer and intra-observer reliabilities. Although the Type II lunates on both radiographic analyses showed a good compatibility with the MRA findings, clinicians should consider undetected medial facets in Type I lunates on PA analysis.

Ronit Wollstein 1,2, Aviv Kramer 3, Frederick Werner 4

1 New York University, NY, USA; 2 University of Pittsburgh, Pittsburgh, PA, USA; 3 Technion, Israel Institute of Technology, Israel; 4 SUNY, Syracuse, NY, USA

Purpose: In the musculoskeletal system, structure dictates function and the development of pathology. Interpreting wrist structure is complicated not only by the existence of multiple joints and ligamentous structures but also by variability in bone shapes and anatomical patterns. A previous study evaluated normal plain radiographs for lunate and capitate shape in the midcarpal joint. This study identified intracarpal measurements related to lunate and wrist type. Assuming that these disparate patterns will transfer forces differently, our purpose was to correlate the forces transferred to the distal radius and ulna with the morphological measurements in cadaver arms. Hypothesis: we will find significant correlations between force transfer and two distinct anatomical patterns. Methods: Radiographs from a database of 49 cadaver wrists previously tested for force transfer between the radius and ulna were examined. The percentage of the compressive force through the distal ulna and radius was determined by mounting load cells to the distal radius and ulna while 22.2 N tensile forces were individually applied to the extensor carpi ulnaris, the extensor carpi radialis and brevis, the flexor carpi radialis and the flexor carpi ulnaris. Each wrist was tested in neutral flexion-extension and radioulnar deviation. Results: There were 35 lunates type 1 with a mean ulnar force of 27.6% and 11 lunates type 2 with a mean ulnar force of 10.4% (3unclassified). There was a significant correlation between lunate type and percent of force transfer through the ulna p=0.0003. Percent force transferred to the ulna was weakly correlated with ulnar variance (p=0.003 R2 =0.17), capitate circumference (p=0.02, R2=0.12), the capitate –lunate contact (0.003, R2=0.18). The percent of capitate circumference contacting the lunate (p=0.06, R2=0.18) was borderline as was the distance between the radial styloid and scaphoid d2/w2 (p=0.08, R2=0.23). Conclusions: 1) In the intact wrist, ulnar variance is not a strong predictor of percent force transfer through the ulna. This has been published in a previous study. 2) While lunate type was significantly associated with percent transfer of force through the ulna, other intracarpal measurements were only weakly correlated. This may support that a type 2 wrist transfers forces differently through the wrist. 3) The reason for the lack of strong correlations between intracarpal structure and percent load transfer through the ulna may be related to variations in soft tissue structures such as the TFCC and radiocarpal ligaments which can participate in load transfer between the radius and ulna but may also vary with lunate type. 4) Further study is warranted to improve our understanding of the relationship between structure and biomechanics in the wrist.

Santiago Salazar Botero 1,2, Sophie Honecker 1,2, Hamdi Jmal 2, Nadia Bahlouli 2, Philippe A Liverneaux 1,2, Sybille Facca 1,2

1 Department of Hand Surgery SOS main CCOM University Hospital of Strasbourg, Illkirch, France; 2 Laboratory ICube CNRS UMR 7357 University of Strasbourg, Strasbourg, France

Objective: Nerve section is often present in patients with hand trauma. Section of the digital collateral nerves needs appropriate repair to regain sensibility to support physiological local forces to allow early motion in case of concomitant flexor tendon section. This study characterizes the mechanical behavior of digital collateral nerve to stablish their healthy mechanical properties. Methods: 44 digital collateral nerves were harvested using Brüner incisions. Digital collateral nerves were preserved in sodium chloride 0.9% at room temperature during the time between harvesting and mechanical tests (3 hours average). Each nerve was carefully glued and sutured to an emery paper frame and then positioned in the Instron® machine. A tensile test at 6mm/min was made for each nerve until rupture. A correlation and independence test were applied to the values to explore the relationships between groups (each finger: thumb, index, middle, ring fingr,little finger) and between density and Young modulus. Results: 44 nerves harvested from 9 cadaveric hands were tested and the mechanical characterization was done. The stress- strain curve and young modulus were shown. The mean values found for the digital collateral nerves were: Ultimate stress 13,14 +/-4,8, ultimate strain 30 +/-9,5 and Young Modulus 76,55 +/- 35,5. Nerves. The scanty number of samples did not allow to stablish a significant difference between fingers, neither was possible to stablish a correlation between density and Young Modulus. A linear regression model for the scatter plot of nerve specific modulus and specific stress showed a tendency to direct correlation between these variables. Conclusions: Digital collateral nerves biomechanics are the first step toward a development of a better nerve repair. Data acquired during the experiment can be used to improve simulations of nerves during training and surgical planning. Further studies should correlate the ex vivo data with non-invasive techniques as in vivo elastography.

Sarah Jiayu Too 1, Duncan Angus McGrouther 2

1 National University of Singapore, Singapore, 2 Singapore General Hospital, Singapore

INTRODUCTION: Allen Buckner Kanavel (1874-1938) was an American surgeon, best remembered for describing the cardinal signs of suppurative flexor tenosynovitis. His book ‘Infections of the Hand’, a milestone in Hand Surgery, was first published in 1912, with six editions following until 1939. This manuscript focuses on Kanavel’s dissections of the flexor tendon sheaths, deep palmar spaces, and his description of their boundaries. With international concern over antibiotic resistance, it is timely to reconsider the role of surgery preceding the availability of antibiotic medication. Therefore, better understanding of the way infections in the hands can spread is of paramount importance in managing our patients. METHODS: To determine the communications between each fascial space, Kanavel injected a solution of radio-opaque dye mixed with diluted Plaster of Paris from different entry points, such as the tendon sheaths, wrists, and deep palmar spaces. The solution was injected at different pressures into a formalin-hardened hand specimen to observe where infections would spread when the spaces ruptured. He then took X-rays (then the novel Roentgen rays) of the injected hand specimens and performed cross-sections to better delineate these spaces. These spaces described will be illustrated by MRI images of current cases. ANALYSIS: Kanavel’s methods were brilliantly innovative– his findings acted as a basis for current clinical practice and were the basis of many anatomy books that followed. He described two main deep spaces of the hand: the middle palmar and thenar spaces. The middle palmar space was bounded by the third metacarpal to the radial border of the fifth metacarpal bone, with a thin fibrous septum separating it from the tendons that lie anteriorly. The thenar space was said to be bounded by the adductor transversus posterolaterally, and the flexor tendons anteriorly. The septa between these two spaces are thick, firm, and essential in preventing spread of infections. We were initially drawn to his initial study as we noticed it was rare to come across infections of the hand that conformed to his boundaries of the deep fascial spaces in actual clinical practice. Many of the patients with palmar abscesses present with their flexor tendons encased within purulent discharge, instead of being separate from Kanavel’s middle palmar space. Similarly, several later papers had varying descriptions of the boundaries of the deep spaces. For example, Grodinsky (1941) performed dissections and injections on 92 hands describing many other spaces with indeterminate septa within. Kaplan (1965) observed that the “very firm septa” separating the thenar and middle palmar spaces were only seen in patients with Dupuytren’s contractures. One possibility for this discrepancy was that cadaveric studies were unable to replicate the erosive and inflammatory processes of an active infection. Another possibility would be inaccurate interpretation of the dissections, as the spaces were mainly illustrated through hand-drawn images by different artists. CONCLUSION: Kanavel’s classical description of infection spreading from one space to another, distally to proximally, gives understanding of where to evaluate. Modern imaging should be performed to delineate relevant spaces that are encountered during infections.

Jidapa Wongcharoenwatana, Panai Laohaprasitiporn, Saichol Wongtrakul, Roongsak Limthongthang, Panupan Songcharoen, Torpon Vathana

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Background: Arterio-venous loop (AV-loop) graft and free functional muscle transfer (FFMT) has been reported in brachial plexus injury (BPI) with concomitant subclavian artery injury which compromised donor arterial flow for FFMT. The donor vein for constructing AV-loop graft was small saphenous vein graft. Currently there is no anatomical study about size, length and number of branching of small saphenous vein. Objective: To study anatomy of small saphenous vein, size and number of its branches and its valves as a vascular graft option for use in AV-loop graft in FFMT reconstruction in BPI with concomitant subclavian artery injury. Methods: The anatomy of the small saphenous vein was studied in 30 legs of fresh and soft cadavers. There were 15 females and 15 males with mean age 56.97 years. The total length of small saphenous vein was measured over the complete length of the leg. We measured vessel length and diameters with vernier caliper (6" MITUTOYO vernier calipers .001" 530-312 accuracy +- 0.03 mm). Recorded location, size and number of branches. We used retrograde saline injection to locate valves direction. Statistical analysis was performed by SPSS 18.0 (SPSS Inc, Chicago, Ill) Results: The average length of small saphenous vein taken from distal edge of lateral malleolus to the point where small saphenous vein connect to popliteal vein was 31.34 cm, ranging between 22 and 44.5 cm. The average diameter of proximal and distal end was 0.6 and 0.52 cm, respectively. The average frequency of branches was 10.67, ranging between 7 and 15. The average size of branches was 0.25 cm. The distance from each branch to distal end ranging from 1.57 to 32.0 cm. Valves of small saphenous vein allow bidirectional flow. Conclusions: Knowledge on the anatomical variations and characteristics of the small saphenous vein can be helpful in clinical practice and surgical operations concerning patient with BPI patients who undergone AV-loop graft in FFMT.

Claudia Lamas-Gómez 1, Ariadna Da Ponte-Prieto, Manuel Llusà-Pérez 2, Camila Chanes-Puigros 1, Marta Almenara-Fernández 1, Laura Velasco-González 1

1 Hand Unit and Upper Extremity, Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; 2 Department of Human Anatomy and Embryology, Hospital Clinic. Universitat de Barcelona, Barcelona, Spain

Objetives: The vascularity of the radius and the union in distal radius fractures has been associated with injury of the blood supply with the surgical approach and/or techniques of osteosynthesis. This study aimed to describe the role of the Pronator Quadratus (PQ) muscle and the Anterior Interosseous Artery (AIA) in the vascularity of the distal radius and its relationship with the union in distal radius fractures. Methods: Sixteen adult hands from fresh cadavers were dissected. There were 8 male and 8 female with a mean age 72 years (range, 50-91 years). The specimens were injected through the brachial artery with Ward ́s latex. Dissections were performed using magnifying loupes and vascular anatomy was studied. Hands were processed using soft tissue digestion and bone clearing using Spalteholz technique. Results: The PQ muscle originates from the ulna by a strong aponeurosis. The muscle is attached to the flexor surface of the distal radius and also on its medial triangular area, proximal to the sigmoid fossa. The distal border of the muscle covered the distal radioulnar joint and is on average 14 mm (11-18 mm) from the lower articulating surface of the radius. The AIA is a terminal branch of the common interosseous artery (IA), but it occasionally arises from the ulnar artery. The AIA is accompanied by its venae comitantes and the anterior interosseous nerve, all of which lie on the flexor surface of the interosseous membrane, deep to the PQ muscle. The artery, along its course gives a series of perforating branches at intervals of 15 mm. The distal radius was supplied by three main vascular systems: epiphyseal, metaphyseal and diaphyseal. The palmar epiphyseal vessels branched from the radial artery, palmar carpal arch and anterior branch of the AIA. These vessels entered the bone through the radial styloid process, Lister ́s tubercle and sigmoid notch. Every specimen studied had one o more palmar metaphyseal arch that coursed through the PQ. Its proximal source was either the anterior division of the AIA (95%) or the AIA itseft (5%). In the metaphyseal area we found numerous periosteal branches originating deep in the PQ and the AIA. These branches provided the main supply to the distal radius. Vessels perforated the bone and formed an anastomotic network. In the diaphyseal area only the nutrient vessel provided intraosseous vascularity in the distal radius. Conclusions: Numerous metaphyseal branches arise from the deep PQ muscle and the AIA course towards the distal radius. These branches allow the union of the distal radius fractures and they make that the nonunion be an uncommon complication. The main vascular contribution takes place by deep fibers of the PQ, so that the superficial fibers can be surgically approached for a plate with a minimum risk of injury to the vascularity.

Hari Venkatramani 1, Nicholas G Rabey 2, Praveen Bhardwaj 1, Raja S Sabapathy 1

1 Ganga Hospital, Coimbatore, India; 2 John Radcliffe Hospital, Oxford, UK

Introduction Mutilating injuries to the upper limb pose a significant problem as an increasing number of young adults participate in high-risk activities. There remains a shortage of literature showing what might be achieved with delayed secondary neurotisation following severe extremity trauma. This case shows what may be achieved if challenging trauma is managed within an effective protocol and timely access to expertise. Case Report A 22-year old male sustained a subtotal amputation of his left arm requiring vein graft revascularisation. Other injuries included a divided axillary artery, fractured clavicle and ruptured musculocutaneous nerve with intact posterior cord of the brachial plexus, median nerve and ulnar nerve. Total ischaemia time was less than 4 hours. The patient made a good recovery and was discharged two weeks later. Three months post-injury the patient had full hand function and sensation and elbow extension, although he scored M1 for elbow flexion, M3 for trapezius function and M0 for shoulder abduction. He underwent a nerve transfer of a median nerve motor fascicle to the brachialis muscle and received physiotherapy and electrical neuromuscular stimulation post-operatively. At clinic 12 months following injury the patient scored M4+ elbow flexion and extension but M0 for deltoid. We carried out a nerve transfer of the posterior motor branch of triceps to axillary nerve. He has regained almost full shoulder abduction and returned to his usual pre-morbid employment. Discussion The high volume of severe trauma at our centre has enabled us to develop an effective trauma system which successfully manages candidates for limb salvage. However, when this patient presented there had been little published utilising delayed nerve transfer following mutilating upper limb injuries. As a result, we had to establish our own practice. We consider three months a reasonable time for secondary procedures as the skin should be supple and swelling-free. For proximal upper limb injuries the restoration of elbow function should take precedence, followed by shoulder stability and active abduction and external rotation. However, when we operated on this patient, the tissue scarring had made the nerve branch to biceps unavailable. Therefore, we chose to coapt a fascicle of the median nerve to the brachialis muscle branch within unscarred tissue. In this patient, the outcome resulting from brachialis reinnervation alone was excellent. On returning for review 12 months the patient still needed improvement in shoulder function. As we could not use the spinal accessory nerve transfer to suprascapular nerve, we utilised the nerve branch to triceps to reconstruct the axillary nerve. Physiotherapy and electrostimulation was given post-operatively and after 10 years the patient has regained almost full arm function. Conclusion This case is the first documented case showing an excellent functional outcome in a revascularised limb following nerve transfer at 12 months. We stress the importance of senior expertise and a clearly defined trauma protocol which minimises ischaemia time. Mutilating upper limb injuries present a challenge, but modern neurotisation techniques, even if delayed, can result in success.

Kazuya Tajiri, Shinichi Yagishita, Hiroyuki Nakanishi, Yu Hatuchi, Daiyu Tsuji, Yuki Hagihara

Municipal Tsuruga Hospital, Tsuruga, Japan

Swelling, heat sensation, redness, pain appeared in the right index finger of a 12 year old girl without attraction, in March 2017. At the first visit on the six day after onset, the X - ray was normal. On the same day, MRI findings was osteomyelitis in the middle phalanx. However, the serum inflammatory response was negative. Serum rheumatic response was also negative, but antinuclear antibody was positive at 320 times. Antibiotic treatment started. On the 12th day after onset of disease, the vicinity of the epiphyseal line of the middle phalanx became erosive. At this point, from literature search and pediatric consultation, we got a diagnosis of Microgeodic disease. The antibiotic was discontinued. Pain was relieved 2.5 weeks after onset. At 4 weeks after onset, the middle phalanx fractured and fixed with the splint. Bone fusion was somewhat late. There was no deformation healing, but the epiphyseal line of middle phalanx and distal phalanx closed. At 7 months after onset, the difference in bone length between bilateral middle phalanges was 2 mm. The finger healed without dysfunction. “Microgeodic” is a sort of nodule that is hollow inside. Redness and swelling of fingers and toes like frostbite. It is accompanied by mild pain and itching. Predilection age is elementary school age (6 - 12 years old). It is mainly in the middle phalanx. A bone resorption image is recognized in the X-ray image. The cause is unknown, it is thought to be a transient bone circulation disorder. Prognosis is usually good, it will heal spontaneously in about 6 months. In this case, owing to attaching a diagnosis at a relatively early stage, appropriate treatment could be done. Microgeodic disease was reported 24 papers in PubMed. Since the arterial arch of the hand is predominant on the ulnar side, it seems that this disease is many in the index finger.

Markus Pääkkönen 1, Max Mann 2, Wiebke Hülsemann 2

1 Turku University Hospital and the University of Turku, Turku, Finland; 2 Catholic Children's Hospital Wilhelmstift, Hamburg, Germany

Introduction Several classification schemes exist for congenital anomalies (e.g. Oberg-Manske-Tonkin [OMT]-classification), but none of these describe involvement proximal from the wrist other than radio-ulnar synostosis. One case of longitudinal cleavage of the upper extremity has been described in the literature. Materials and methods An otherwise healthy 8-month-old infant presented with congenital split right forearm. Results Starting from the elbow joint, the forearm is divided into a superior radial forearm with a thumb and an index finger and an inferior ulnar forearm with two fingers. X-rays showed a radius and two metacarpals in the radial forearm and a hypoplastic ulna and a single metacarpal supporting two digits in the shorter ulnar forearm. The elbow joint of the radial part had an active and passive extension lag of 60 and 50 degrees, respectively, and an active and passive flexion of 100 and 120 degrees, respectively. An ulnohumeral synostosis was present and the ulnar forearm showed no motion. Conclusions This is the first reported case of congenital forearm. A possible suggested ethiologic theory would be an error of limb bud specification in the 4th or 5th week of gestation. It has been suggested that the timing of an error in limb bud specification would determine the extent of duplication. An early insult would lead to a more proximal division of the upper limb. We suggest that the case is a forearm cleavage - less severe than a total of upper extremity cleavage, but more severe as a conventional cleft hand. We suggest that a new category – cleft forearm complex – be added to the OMT –classification.

Xuyang Song, Alexandria L. Case, Rory Carrol, Joshua M. Abzug

University of Maryland School of Medicine, Baltimore, Maryland, USA

Objective: Emergency room transfers to a higher level of care are a vital component of modern healthcare, as optimal care of patients requires providing access to specialized personnel and facilities. However, literature has shown that upper extremity orthopaedic transfers to a higher level of care facility are frequently unnecessary. Furthermore, these transfers have been shown to be higher during “off-hours” and weekends, and frequently involve patients who have unfavorable insurance status. The purpose of this study was to assess the appropriateness of pediatric orthopedic transfers to a tertiary care center and the factors surrounding them. Methods: All pediatric upper extremity orthopaedic transfers to our pediatric emergency department were evaluated over a four year period. A retrospective review was performed to assess the factors surrounding the transfer including patient demographics, time of transfer, day of transfer, insurance status, outcome of transfer, and diagnosis. Three independent variables were utilized to assess the appropriateness of the transfer: the need for an operative procedure, the need for conscious sedation, and the need for a closed reduction in the emergency department. Results: One hundred twenty eight pediatric orthopaedic emergency room transfers were evaluated, of which 98% of them involved an acute fracture. 25% (32/128) of the transfers occurred on the weekend, with over half (67%) of these transfers being initiated between 6PM and 6AM. Approximately half (48%) of the transfers involved patients with Medicaid. 58% (74/128) of cases required a procedure in the operating room and 30% (39/128) had a closed reduction performed in the emergency department. Conscious sedation was provided in the emergency department for 31% (40/128) of patients. Only 9% (12/128) of transfers did not require a trip to the operating room, conscious sedation, nor a closed reduction procedure in the emergency department. Conclusions: The majority of pediatric upper extremity orthopaedic transfers are warranted as they require operative intervention, a closed reduction maneuver, or conscious sedation in the emergency department. Pediatric upper extremity orthopaedic transfers do not seem to be influenced by the day of the week. Similar trends to those seen in adult upper extremity orthopaedic transfers are present regarding off hour presentations and high percentages of less desirable insurance statuses.

Charles Blevins 1, Karan Dua 2, Joshua M. Abzug 1

1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 SUNY Downstate Medical Center, Brooklyn, New York, USA

Objective: Closed reduction and percutaneous pinning (CRPP) is traditionally performed following full surgical prep and draping, which can be inefficient and wasteful of materials. The semi-sterile technique has been shown to have no difference in infection or complication rates when utilized for pediatric supracondylar humerus fractures. Therefore, the authors hypothesize the semi-sterile technique can be utilized for CRPP procedures of all pediatric upper extremity fractures. Methods: A retrospective review was conducted over a five-year period to identify all pediatric patients who underwent CRPP of an upper extremity fracture. During this period, there was a gradual transition from utilizing the full preparation and drape technique to the semi-sterile technique. Factors assessed included demographics, fracture type and location, and length of pin fixation. Qualities of intraoperative care were assessed including average length of surgery, room set up time, and room cleaning time. Additionally, parameters of postoperative care were recorded including average length of follow-up and complication rates. Simple statistics and unpaired t-tests were performed. Results: Two hundred twenty four patient records were reviewed including 162 in the semi-sterile group and 62 in the full preparation group. The average length of surgery was 32 minutes (range 11-110) in the full preparation group compared to 26 minutes (range 7-69) in the semi-sterile group (p=.007). The average room setup time in the full preparation group was 20.1 minutes compared to 18.4 minutes in the semi-sterile group. Furthermore, the average operating room cleaning time in the full preparation group was 18.8 minutes compared to 16.8 minutes in the semi-sterile group. When assessing the setup time, procedure time, and clean up times together, the combined average times were 71.1 minutes in the full preparation group and 61.3 minutes in the semi-sterile group, for a difference of 9.8 minutes. Two complications occurred in the full preparation group including one pin tract infection and one physeal arrest. Conclusions: The semi-sterile technique is a safe and cost effective alternative that should be used when performing CRPP of all pediatric upper extremity fractures. The full preparation technique increases operating room time and medical waste, and therefore should not be utilized when performing CRPP procedures.

Stefanie Zaner 1, Karan Dua 2, Nathan N O'Hara 1, Alexandria L Case 1, Joshua M Abzug 1

1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 SUNY Downstate Medical Center, Brooklyn, New York, USA

Objective: Phalangeal neck fractures are a common orthopedic injury seen predominantly in the pediatric population. The indications for operative treatment are currently evolving. The purpose of this study was to determine the variation among orthopedic surgeons in their practice habits when treating phalangeal neck fractures. Methods: Twenty-five pediatric orthopedic surgeons reviewed sets of posteroanterior (PA), oblique, and lateral finger radiographs of children less than 17 years of age. In each clinical vignette, the age and gender of the patient was included. Surgeons were provided with 12 clinical vignettes and were queried if they would; (1) treat the fracture with immobilization or intervention? (2) if operative intervention was chosen, would a CRPP or ORIF be performed? (3) and when the next follow-up visit would be if the fracture was nonoperatively treated. Additionally, surgeons were asked to complete a demographic questionnaire detailing their training and personal background. The analysis was completed using a mixed effect model with the respondent as the random effect. Results: This study found that for each advancing year of age, the surgeons are 13.8% more likely to treat the fracture surgically which was determined to be a linear relationship (P < 0.0001). Additional results showed that females were 38% more likely to be treated surgically (P < 0.0006). There is a trend that indicates female surgeons are more likely to operate than their male counterparts and that surgeons were less likely to operate if they worked in a dedicated children’s hospital. Conclusions: These is no consensus or standardization for treatment of phalangeal neck fractures in the pediatric population. Age and gender are the primary patient characteristics in determining if a phalangeal neck fracture is surgically treated. In order to provide the best outcomes with the least patient morbidity, more standardized treatment algorithms are needed.

Thomas Chang 1, Karan Dua 2, Alexandria L. Case 1, Nathan N O'Hara 1, Joshua M. Abzug 1

1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 SUNY Downstate Medical Center, Brooklyn, New York, USA

Objectives: Fifth metacarpal neck fractures are common fractures affecting the pediatric population. However, no true standardization exists regarding their treatment. The purpose of this study was to determine if variation exists amongst orthopedic surgeons in treating pediatric fifth metacarpal neck fractures and determine the factors regarding this variation. Methods: Twenty-five sets of images of pediatric fifth metacarpal neck fractures with posteroanterior (PA), oblique, and lateral views were identified. Fracture angulation measurements were made for the lateral and oblique views, with half of the images unmarked to assess the effect of marked angulation on treatment decision. Five images were duplicated to assess variability of a surgeon’s treatment choice. Each set of images was accompanied by the patient’s sex and age. The images, along with a brief demographic questionnaire, were evaluated by 25 orthopedic surgeons. A mixed effect model with the respondent as the random effect to determine which patient/radiographic factors were most associated with a decision to operate was performed. Results: Age and angulation were the factors found to be significantly associated with a surgeon’s decision to operate. Patient sex, cast status, and whether or not an image was marked had no association with a surgeon’s decision to operate. Greater than 50% of surgeons would choose surgical intervention if the degrees of angulation in the PA and lateral views were ≥55° and ≥47°, respectively. Age alone was also identified as an independent factor for choosing operative intervention, with 42% of surgeon’s operating on patients aged 17 years. Conclusions: Treatment of fifth metacarpal neck fractures in the pediatric population is not standardized. Worsening angulation above approximately 50 degrees and increasing age (adolescence) appear to be the most important factors when deciding to operate. Improved treatment algorithms based on outcomes studies are needed to determine the optimal treatment.

Seok Woo Hong, Jihyeung Kim, Kee Jeong Bae, Hyun Sik Gong, Goo Hyun Baek

Department Orthopedic Surgery, College of Medicine, Seoul National University, Seoul, Korea

Objective: The aim of this study was to verify the remodeling patterns of proximal phalangeal head after conservative and/or surgical intervention in patients with camptodactyly using radiograph. Methods: A total of 45 subjects and 21 patietns (Male 13, Female 8, mean age 15.11 ± 14.22 months) with camptodactyly were selected. The regular stretching exercises were performed in 31 subjects and the others got surgical correction. Flexor digitorum superficialis (FDS) tenotomy and volar plate release were done through surgical procedure. The two radiographic parameters were proposed for confirming the radiographic remodeling of camptodactyly called Beak triangle ratio and Beak angle. Both parameters were measured using finger true lateral radiographs at initial visit. The same procedures for measurement on finger were done two years after intervention. The extent of proximal interphalangeal joint (PIPJ) contracture on passive functioning was evaluated to determine clinical outcomes from conservative and surgical intervention. Results: The mean Beak triangle ratio before intervention was mean 0.327 ± 0.052 and mean 0.367 ± 0.053 after intervention (P < 0.001). Also the mean Beak angle before intervention was mean 56.05 ± 5.19 degree and mean 50.31 ± 6.21 degree after intervention (P < 0.001). The extent of PIPJ contracture also showed significant improvement (P < 0.001). Conclusions: Remodeling of proximal phalangeal head with camptodactyly after conservative and/or surgical intervention were confirmed on radiograph.

Wenhai Sun, Yachao Zhou, Shengbo Zhou, Yongkang Jiang, Bin Wang

Department of Plastic and Reconstructive Surgery, Shanghai 9th People’s Hospital, Shanghai Jiaotong University School of Medicine, China

Purpose To evaluate the outcomes and complications in a series of children with clinodactyly treated with our novel opening wedge osteotomy of the abnormal Delta phalanx. Methods We performed a retrospective review of 8 children with clinodactyly treated at our institution with a novel opening wedge osteotomy of the abnormal delta phalanx between 2007 and 2017. This κ shaped osteotomy included resection of the abnormal longitudinal physis and double opening wedge osteotomy. Preoperative and postoperative clinical angle, radiographic angle, digital range of motion, and pain were compared and complications were recorded. Results 10 digits in 8 patients were included in the study. All had greater than 28 degrees of preoperative clinical angulation (mean, 40 degrees). Mean age at time of surgery was 6 years; mean duration of follow-up was 24 months (range, 12-48 mo). All digits had significant improvement (mean, 34 degrees) in clinical and radiographic angles after surgery. This improvement was maintained at final follow-up in all digits. 5 patients had pain preoperatively and no patient had pain postoperatively. One digit had a recurrent deformity at final follow-up and 3 digits developed stiffness at the interphalangeal joint. Conclusions Our novel opening wedge osteotomy is an effective treatment for angulation in children with severe clinodactyly although the risk of interphalangeal joint stiffness still exists.

Shringari Mahadevaiah Venugopal, Bhaskaranand Kumar, Gudaru Jagadesh

B.I.R.R.D. (T) Hospital, T.T.D.,Tirupati, Andhra Pradesh, India

A Descriptive Study on Radial Club Hand Introduction: Radial club hand is a rare congenital anomaly of hand involving preaxial border of hand with incidence of 1 in 30000 to 1 in 100000. It is associated with deformities in forearm, arm and several other systemic anomalies. Its severity ranges from mild hypoplasia of radius to complete absence of radius. In Indian context there were very less studies describing anomalies and this study aims at describing this anomaly. Materials and methods: This study was a descriptive study aimed at describing Radial club hand anomalies and its association with other systemic anomalies during March 2014 to March 2016 collected from outpatient department of Balaji institute of surgery research and rehabilitation for the disabled hospital, Tirupathi, Andhra Pradesh, India. Results: We reported a total of 62 cases of radial club hand among which 24 were bilateral and 38 were unilateral. Male to female ratio was 2.1:1 and no significant history of environmental or familial factors was reported. Type 4 Bayne radial deficiencies were most common and type 5 Blauth hypoplastic thumb was most common finding. All the finger deformities were more pronounced in index finger and were least seen in little finger. Other systemic anomalies recorded were absence of kidney (6.4%) and atrial septal defect (9.7%), Tibial hemimelia, Spina bifida, hemangioma. Conclusion: This study had recorded unilateral involvement of radial club hand to be more prevalent than bilateral. Association of systemic anomalies was less with bilateral radial club hand.

Eva Matoušková, Mária Kučerová, Petr Havránek

Departement of Pediatric Surgery and Traumatology, Thomayer Hospital, Prague, Czech Republic

Objective: Ten years ago in our department miniinvasive percutaneous osteotomy for malunited phalangeal fractures was developed by senior author. Osteotomy in former fracture line is performed by larger injection needle. Presentation of the method and patient cohort is the aim of the study. Method: Altogether 4722 children in period of 9 years (1/2009 – 11/2017) with acute finger fractures were treated in our department, 252 of them operated on and in 17 patients osteotomy was performed. The osteotomy can be performed only if 1.the original fracture line is still visible on x-rays, 2.callus is presented. Under x-ray control the injection needle is inserted into callus which is step-by-step disrupted. Instead of a fine needle a small elevator from 2 – 3 mm incision can be used. After releasing peripheral fragment is reduced and stabilized by percutaneous osteosynthesis from a separate entry. There are several possibilities of stabilization: intramedullar implant, screw or external fixator. Results: From 17 patients with malunited fracture in all the osteotomy by injection needle was performed, in 3 additional use of a smooth elevator was necessary. Supracondylar fractures were recorded in 10 children, unicondylar in 3, diaphyseal in 2 and intraarticular basal injuries in other 2 respectively. Reduced fragments were stabilized by pre-bended K-wire (“ESIN-like method”) in 11, by a mini-screw in 4, by external fixator in 2. Functional and cosmetic effect was very good. Conclusion: A method of miniinvasive osteotomy of malunited phalangeal finger fractures is presented. Especially in delicate pediatric hand skeleton it can be a beneficial method bringing better results than classic orthopedic procedures. Our above mentioned method is due to miniinvasive osteotomy procedure as well as stabilization maximally sparing soft tissues and can promise better cosmetic and functional outcome.

Tetsuro Onishi1, Takanobu Nishizuka1, Shintaro Oyama1, Tomonori Nakano1, Hisao Ishii1, Katsuyuki Iwatsuki1, Shigeru Kurimoto1, Michiro Yamamoto1, Masahiro Tatebe1, Hitoshi Hirata1

1Nagoya University Graduate School of Medicine, Nagoya, Japan

Introduction Dysplasia Epiphysealis Hemimelica (DEH) is a rare developmental disorder characterized by hemimelic epiphyseal overgrowth of cartilage involving one or multiple epiphysis. Histological examination shows the picture of a benign osteochondroma. Most cases of this rare condition are reported in the lower limbs, and occurrence of upper limbs is relatively rare. However, when occurring in the hand, even when the lesion is small, the functional impairment, such as the axial deviation and the restriction of range of motion can become severer than other parts due to the intra-articular lesion. We report six cases of osteochondroma at epiphysis (DEH) in the hand who underwent surgical treatment. METHOD In this retrospective study, six patients (five male and one female) with a diagnosis of DEH were evaluated, they underwent surgery from 2009 to 2017 at the author’s institution. Affected sites were three middle phalanx of middle finger, one proximal phalanx of thumb and ring finger and a third metacarpal bone. The average age at surgery was 9.3 years old and ranged from 1 to 23 years old. The average follow-up is 17.8 months, ranged from 6 months to 47 months. We evaluated the site of occurrence, deformity, chief complaint, surgical procedure and outcome. RESULTS Sites of occurrence were the radial aspect of the proximal phalangeal epiphysis of one thumb, the radial aspect of the middle phalangeal epiphysis of one middle finger, the ulnar aspects of the middle phalangeal epiphysis of two middle finger, the ulnar aspects of the proximal phalangeal epiphysis of one ring finger and one proximal part of third metacarpal bone. The angular deformities were localized at the proximal interphalangeal joint of a ring finger, and the distal interphalangeal joint of two middle fingers. (Angulation: 27°, 11°, 22°, respectively) The complaints at diagnosis were a swelling bony mass that was increasing in size (2 cases), restricted range of motion (3 cases), angular deformity (3 cases), and a pain (1 case). At surgery, osteocartilaginous tissue was excised in all patients, and pathological examination showed an osteochondroma covered with cartilage in all cases. At follow-up, restricted range of motion in affected joint improved in all cases. However angular deformity remains in two cases (angulation: 17°, 11°, respectively). And recurrence was seen in the case of third metacarpal bone, so we performed resection surgery again. CONCLUSION We reported 6 cases of DEH occurred in the hand. If DEH occurs in hand, masses cause incongruity of the joint surface, angular deformity and restricted range of motion of the affected joint. It is necessary to perform the sufficient tumor resection after accurate diagnosis at early stage. After excisional surgery, there are reports of arthritic changes and recurrence, so careful follow-up is necessary.

Marta Bertoli 2, Philip Henman 1, Sahan Rannan-Eliya 1, Julie Allen 1, Volker Straub 3, Bríd Crowley 1

1 Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; 2 Northern Genetics Service, Institute of Human Genetics, Newcastle upon Tyne Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne UK; 3 Institute of Genetic Medicine, MRC Centre for Neuromuscular Disease, Newcastle University, Newcastle upon Tyne, UK

Objective: Arthrogryposis is a descriptive term referring to multiple congenital contractures. More than 400 acquired and genetic diseases are labelled as arthrogryposis. Because of their rarity and complexity coordinated patient management is often lacking. Multidisciplinary clinics are the ideal setting to provide coordinated and comprehensive care to patients with special needs. These clinics are organized to bring together professionals from several disciplines, with the aim to provide patient centered, comprehensive clinical care, and reduce the burden of multiple medical appointments for the families. A team approach to care has been shown to be beneficial in developing a treatment plan maximizing cognitive, physical, and social development for the child. We report a 9 year experience of an interdisciplinary arthrogryposis clinic. Materials and Methods: Our interdisciplinary arthrogryposis clinic involves participation from paediatric orthopaedic surgery, hand/plastic surgery, clinical genetics, physiotherapists and orthotics. Representatives from a patient support group are available. Patients are referred from a variety of specialties, eg foetal medicine, paediatric neurology, orthopaedics, genetics. This clinic provides: diagnostic work-up, treatment of associated anomalies, overall care coordination of paediatric patients with arthrogryposis. Genetic diagnostic technologies have evolved, from single gene analysis, to gene panels for specific disease groups and exome or genome sequencing for more complex cases. These assist accurate clinical evaluation and increase the chance of providing a precise genetic diagnosis and correct genetic counselling. Results: In our cohort of 66 patients, 55% have a recognized diagnosis( half have amyoplasia). Other diagnoses include conditions presenting with arthrogryposis as their main feature (Freeman-Sheldon syndrome; Beals syndrome), cases where congenital contractures are described, but are not a typical sign of the condition ( DiGeorge syndrome; Ohdo syndrome) or can be part of an unexpected diagnosis for a patient referred for contractures of extremities (16p11.2 deletion syndrome). Conclusion: An interdisciplinary approach reduces the number of appointments, provides patients with arthrogryposis with more specific diagnoses, coordinated orthotic and surgical management and informed physiotherapy. Not only is patient care facilitated but a stimulating and collaborative environment is created for all the clinicians to learn from each other and from the patients’ experiences. In time, this helps build the expertise of the group, enabling it to provide more valuable services to the families. The relationships with the families are strengthened, as is adherence to treatment programmes. Families are pleased to attend a single multidisciplinary clinic rather than be followed up at a number of separate, individual clinics, and they are reassured by the combined expertise available.

Alena Schmoranzova 1,2,3, Radek Kebrle 1, Tomas Hellmuth 1, Stepanka Docekalova 3, Eva Leamerova 2

1 Hand and Plastic Institute, Vysoke nad Jizerou, Czech Republic; 2 Department of Plastic Surgery, Faculty of Medicine, Charles University, Prague, Czech Republic; 3 Department of Plastic Surgery, Faculty of Medicine, Charles University, Hradec Kralove, Czech Republic

o Objective: Hypoplasia of the thumb occurs within a spectrum of hypoplasia along the radial side of the entire upper extremity It is a rare congenital deformity affecting 1 in 100,000 live births. Congenital absence of the thumb, resulting in a loss of its prehensile ability, significantly affects hand function. To function correctly, the thumb must be positioned so that it can oppose the adjacent medial fingers and grasp objects securely from an antiposed (abducted, slightly extended, and pronated) position. o Methods: We followed a groupe of patients in the period 2008-2017 29 children , 41 hands ,men 18x , women 11x 12 children have comorbidity radial club hand Most of them have had floating thumb problem o Results: At the age of four, 29 children came back , we rated parent´s satisfaction and child's hand function using simplified Percival score The result is good in general . The results, which were not entirely right, were evaluated and corrected o Conclusions:. Pollicization is complicated procedure that may have some pitfalls. Additional surgery may improve the function of the thumb The work is documented by video showing some results

Abbas Peymani 1,2,3, Anna Rose Johnson 2, Samandar Dowlatshahi 2, Iwan Dobbe 3, Joseph Upton 4, Geert Streekstra 3, Simon Strackee 1

1 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands; 2 Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 3 Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands; 4 Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.

Objective. Madelung deformity is a congenital wrist condition characterized by volar subluxation of the wrist and caused by premature growth arrest of the distal radius. Partly due to disease rarity, ambiguity remains with respect to criteria for disease classification and optimal treatment strategy. The purpose of this study was to evaluate the current literature concerning Madelung deformity to determine criteria used in clinical examination, surgical treatment options and operative outcomes. Methods. A comprehensive review of published literature from inception to 2017 was performed to identify all studies that described surgical intervention for Madelung deformity patients, adhering to the Meta-Analyses of Observational Studies in Epidemiology (MOOSE) guidelines. Studies eligible for inclusion described a corrective surgery for Madelung deformity and reported post-operative outcomes. Studies were evaluated by level of evidence and a novel self-developed quality assessment tool. Results. Twenty-five studies met our criteria for inclusion in this systematic review. All studies assessed pain, range of motion and aesthetic deformity, with eight studies also assessing grip strength. The primary indication for surgery was the presence of wrist pain. Radiologic criteria were used inconsistently and surgical interventions varied. All studies reported post-operative pain reduction in a majority of patients and nearly all studies reported an improved range of motion. The majority of studies reported complications with revision surgeries occurring in 40% of studies. Conclusions. Despite nearly 200 years of experience with Madelung deformity, there remains a paucity of information regarding the surgical decision making process due to a lack of uniformity throughout case series. Generally, various surgical procedures seem to be effective in regards to post-operative pain reduction and increase in range of motion. However, outcomes are reported in a non-uniform manner, prohibiting pooling of studies and comparison of surgical procedures. We propose multiple changes to serve as the basis for new clinical guidelines, increasing the quality of evidence in future studies to compensate for small patient sample sizes.

Karina Liv Hansen, Hans Tromborg

Hand/Orthopaedic Department, Odense, Denmark

Objective: In Madelungs deformity the Distal Radioulnar joint (DRUJ) is often involved in the pain pathogenesis especially in moderately to severely affected patients. The DRUJ is of is of great importance to the function of the (Shaaban 2004). We studied the functional outcome one year after Constraint Distal Radioulnar Joint Replacement in patients with moderate to severely affected DRUJ (ulnar tilt 37 degrees (from 32 to 60) and lunate subsidence 2mm (-2 to 5)). Methods: We included patients (n=9) who had an DRUJ replacement a.m. Aptis in the cohort. Disability of Arm Shoulder and Hand, grip strength, and EQ-5D were compared before and one Year after surgery. Statistics were performed with paired t-test without correction for repeated measurements. Results: Age of patients: 44(18) (Years (SD)). Patients had a relatively high DASH score before surgery of 50(24) this is relatively high compared to normal 10(14); DASH score dropped significantly to 24(8) this is an improvement of 26(12) (p<<0.01). Grip strength of the affected arm improved 13 (11) kg to 26 (10)kg (p<<0.01). EQ-5D was not significantly improved. One patient (included in the results) had a revision after 2 months and a new alloplasty before one year. Conclusions: Aptis DRUJ joint replacement improve Madelung patients upper extremity function (DASH) one year after surgery in a cohort of patients with moderately to severely affected DRUJ.

Sang Eun Park, Seok Jae Park, Myung Sup Go

Daejeon St. Mary's Hospital, Daejeon, South Korea

Objective : To report the usefulness and radiological and clinical outcome of intrafocal pinning for the severely displaced pediatric distal radius fracture. Methods : A retrospective review was performed for the patients treated with Kapandji intrafocal pinning for their distal radius fractures. At the final follow up, radiologic and clinical outcomes were evaluated. Results : This study included 15 pediatric distal radius fractures. The average age was 9 years (range 8-11years). The inclusion criteria included no physeal involvement, open physis and no cortical contact on initial pre-reduction plain X-ray. The average location of distal radius fracture was 3.3cm proximal to joint line (range, 2.5- 3.8cm). 12 of 15 cases had concomitant distal ulnar fractures located slightly proximal to distal radius fracture. In all cases, post-reduction X-ray showed less than 50% of cortical contact. 1 or 2 0.062 or 0.045 inch K-wire was inserted from dorsal to volar direction through fracture site. Radial to ulnar insertion was performed in cases with need to restore radial inclination. No ulnar fixation was made in all cases. Short arm splint was applied for 4 weeks and K-wires were removed at postoperative 5 weeks and protective physiotherapy was initiated. Postoperative X-ray showed more than 90% of cortical contact on average. Average follow-up period was 12.5 months (range, 5 to 27 months). At the final follow up, any type of malunion and physeal arrest occurred. The final range of motion was equal to contralateral side. In 4 cases, superficial pin-related complication occurred but resolved with K-wire removal. Conclusions: Based on our experience, Kapandji intrafocal pinning is a simple and reliable method for the treatment of severely displaced pediatric distal radius fractures. Especially this method is very useful for the fracture at the metaphysio-diaphyseal junction Key words ; Dstal radius fracture, pediatric, Intrafocal pinning

María L Manzanares Retamosa, Pedro Bolado Gutiérrez, Luis Landín Jarillo, Aleksandar Lovic Jazbec

Hospital Universitario La Paz, Madrid, Spain

Objective: An unusual form of congenital hand deformity is described. It consists of radial club hand deformity with associated anomalies in shoulder and scapula (Grade 5 according Goldfarb). First visit as two year old girl with the bizarre “hook like” deformity of the acromiovlavicular complex, shoulder dysplasia with bifid scapula, lack of elbow flexión together with radial club hand grade IV and aplasia of the thumb. When she appeared for the first time she was already operated in another hospital ( centralization Klug&Baine and pollicization Buck Gramcko) with rather fair result ( recurrence of the wrist deviation and stiff retropositioned thumb). Methods: Two mayor surgeries are carried out: - Double osteotomy of the clavicle and spine of scapula to correct the position of the shoulder. Bipolar transposition of the latissimus dorsi muscle to restore elbow flexion - Radialization of the wrist and osteotomy of the first MC. The objective of the second surgery was strongly conditioned by the first surgery. Results and conclusions:The patient had a favorable evolution ( 2002-2017).She is able to bend the elbow 90° and to reach the mouth.The morphology of the shoulder is still deficient although the function and stability is satisfactory. Volume augmentation using free contralateral latissimus with skin island was recommended to improve the symmetry.

Lisa Ng, Susan Stevenson, Brid Crowley

Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK

Introduction Constriction ring syndrome (CRS) is a congenital condition with an incidence of 1:2000 to 1:15,000 live births. Upper limbs and distal extremities are most frequently affected. It can present with complex deformities ranging from constriction grooves in skin to complete amputation. Patterson classified these deformities into simple ring constrictions, constrictions with distal deformity (with or without lymphoedema), constrictions accompanied by fusion of distal parts and uterine amputation. We report our experience in managing this complex condition. Methods A retrospective review of children with CRS of the upper limbs referred to a specialist centre was performed. Patient demographics, anatomy of constriction, Patterson classification, management and outcome were recorded. Results 23 patients with upper limb CRS were studied. (M:F ratio 11:12). 5 (22%) were born prematurely, 5 (22%) had other congenital anomalies and 9 (39%) had lower limb involvement also. 11 (48%) patients had bilateral hand involvement. Deformities observed ranged from distal lymphedema of the digits, skin constriction (and deeper), acrosyndactyly, amputations at multiple levels to complex combinations of all these. Surgical Intervention:18 / 23 underwent surgery, with 12 requiring multiple/staged procedures. Procedures included digital separation, release of acrosyndactyly, web deepening, stabilisation of distal lymphoedematous digit, excision of constriction rings and debulking of lymphoedema. The mean age at surgery in our cohort was 18.7 months of age. Optimization of skin condition at every stage is advocated. 2 cases specifically required urgent surgical procedures: i) constriction ring excision at mid humerus level, longitudinal fasciotomies and neurolysis of median and ulnar nerves in a premature infant with high ulnar and median nerve palsy; ii) excision of distal lymphoedema of the hand. Conclusion Specific aspects of our treatment approach include optimization of skin condition at each stage of treatment and excision of constriction rings on limbs without z-plasty using longitudinal fasciotomies. Not all patients require surgery but consider urgent surgical intervention if there is evidence of nerve or vascular compromise. The Patterson classification is a helpful guide, but in reality there is often a complex combination of deformities in multiple digits at multiple levels. Appropriately timed staged surgical intervention maximizes function in these complex patients. Functional and aesthetic improvement was observed in most patients.

Lisa Ng, Susan Stevenson, Brid Crowley

Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK

Introduction Hereditary multiple exostosis (HME) is a rare, autosomal dominant condition characterised by the formation of multiple osteochondromas in children, particularly around areas of active bone formation. The tibia, femur, pelvis and proximal humerus are commonly involved. 0.5%-5% may undergo malignant transformation to chondrosarcoma. Lesions can cause pain, nerve compression, short stature, vascular compromise and limb length discrepancy. Methods Hereditary multiple exostosis has an estimated incidence of 1: 50,000. HME affects the long bones predominantly, with hand involvement reported in 30-79% of patients. Few case series are reported in the literature. Here we report the case of a fifteen-year old patient with known HME who presented with a symptomatic exostosis of right ring finger proximal phalanx, restricting finger flexion and causing painful triggering. Primary resection was performed. Results Histology demonstrated an osteochondroma with no evidence of malignancy. At operation an exostosis was identified, invading the flexor sheath, distorting flexor tendons at the level of Camper's chiasma. Operative photographs display the findings. Follow-up at two and four months post-op demonstrated restoration of normal finger flexion. There was no recurrence at five-year review. Conclusion HME in the hand is rarely reported in the literature but may cause significant functional problems. Excision of lesions may be indicated to relieve symptoms and restore function. Regular follow-up is recommended for detection of early malignancy and recurrent lesions.

Soo Min Cha, Hyun Dae Shin

Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea

We observed an unusual type of volar Barton fracture in pediatric age and performed open reduction and internal fixation of the fragment, using the buttress plate in consecutive children. We report the radiological and clinical outcomes after follow-up for least 3 years. From March 2008 to September 2014, 9 consecutive children were treated by buttress plating. Their mean age at the time of injury was 14.1 years. All of the fractures were metaphyseal fractures in the coronal plane and typical Salter-Harris II fractures in the sagittal plane. After accurate reduction of the fragment, a cortical screw was inserted in the proximal area until the maximum compressive force against the fragment was obtained. Then, one or two locking screws were added adjacent to the initial cortical screw. No screw was fixed in the fragment. All evaluations were done at least 3 years postoperatively with a mean follow-up of 48.8 months. At final follow-up, the radial inclinations, volar tiltings, and ulnar variances were 23.2 ± 1.78° (98.7% of contralateral side), 9.4 ± 2.12° (98.4% of contralateral side), and –1.56 ± 0.88 mm (93% of contralateral side), respectively. All radiological parameters of the distal radius were not significantly different from the contralateral values. The flexion–extension arc was 140.56 ± 5.27°, the pronation–supination arc was 165.00 ± 8.29°. The grip strength was 26.67 ± 5.56 kg. All clinical outcomes except the flexion–extension arc were similar to those of the normal side, with statistical significance. A volar Barton type injury can occur in pediatric age involving the physis, and the buttress plating that is used in adults is also a useful treatment method. However, there is little information on this injury and it was difficult to compare treatment outcomes to other methods. Because of the rarity of the injury, a larger, multi-center. prospective comparative study is required to further explore appropriate treatment options, long-term outcomes, and complications.

Johannes Rois, Werner Girsch

Trauma Center Vienna Meidling, Vienna, Austria

Fractures of the lateral humeral condyle in children are the second most pediatric elbow fractures. The treatment for displaced fractures is reduction and stabilisation. Nonunion of a pediatric radial humeral condyle fracture can lead to pain, instability and progressive cubitus valgus with ulnar nerve neuropathy. In this case report we present a surgical technique for providing union of a long standing nonunion and correction of valgus deformity. A girl, at the age of 5 years, sustained a fracture of the lateral humeral condyl after a fall from a climbing scaffold. The fracture was treated conservatively. With the age of 15 years she was referred to our institution because of pain and elbow deformity. The clinical examination revealed tenderness over the lateral humeral condyl, normal neurovascular examination and severe valgus deformity. Elbow motion was 0°-130°, supination 80° and pronation 90°. The radiographs showed a nonunion of the lateral humeral condyle fracture with dislocation and deformity of the trochlea and capitellum. We decided to perform a two-stage surgical procedure. In the first step treatment of the nonunion and in the second step correction of the valgus deformity. The patient underwent free vascularized iliac crest bone-grafting (to minimize the risk of necrosis) to the lateral humeral condyle fracture nonunion with microvascular anastomosis and screw fixation of the fragment. After bony union we performed the planned corrective humeral osteotomy and plating for correction of the valgus deformity. The operations did very well, there were no postoperative complications. Together with plate removal 20 months postoperative, anterior transposition of the ulnar nerve was performed. At the last follow up radiographs revealed a healed lateral humeral condyle and lateral column and restored elbow axis. Elbow motion was 15° to 130°, supination 85° and pronation 85°. In this case report we present a successful technique for the treatment of a long-standing pediatric lateral humeral condyle nonunion. Although further effort is required, when faced with the outcome, the decision for a two-stage procedure with the use of a free vascularized bone-graft was the right one.

Sarah Tolerton 1, Belinda Smith 1, David Stewart 1

1 Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, The Children's Hospital at Westmead, University of Sydney, Sydney, Australia

Title: Patient and Parent Reported Outcomes Following Pollicisation Objective: Pollicisation of the index finger is an established procedure for treatment of Type IIIB to V congenital thumb hypoplasia. Comparing results is challenging due to disparate methods, timing and conduct of assessment. While functional performance following pollicisation is well reported in the literature, we aim to provide further insight into the patient and parent satisfaction with functional and aesthetic outcomes of surgery. Methods: Ninety pollicisations in 79 patients were performed by a single surgeon between 1989 and 2012. Questionnaires were distributed to patients and their families including the Patient/Observer Scar Assessment Scale, Abil Hands Kids, Child Occupational Self Assessment (COSA), PedsQL (8-12), Peds QL (13-18), QuickDash and SF36. Results: We report the subjective assessments of functional and aesthetic outcome following pollicisation. The various additional outcome measures and their interpretation in the setting of pollicisation surgery will be discussed. Conclusion: Despite recognised functional limitations following pollicisation surgery, the majority of patients and their parents are satisfied with the aesthetic and functional outcomes. The development of consensus outcome measures including patient and parent satisfaction is necessary for ongoing research in congenital hand surgery.

Hazem Alfeky, Paul McArthur

Plastic Surgery department, Alder Hey Children's Hospital, Liverpool, UK.

Acrocephalosyndactyly or Apert’s hand is a rare syndrome occurring once in every 45000 live births. It has been well described and classified by Upton into 3 types based on the configuration of the first web space with type 3 as the most severe form. The challenge in Acrocephalosyndactyly is often more than a first web space issue. The pattern of the proximal and distal synostosis is one of the key factors that determines the management and outcome. 42 Apert’s hands have been assessed and managed within MDT setting. All hand procedures were performed by a single surgeon over a period of 10 years. A new proposed classification system is presented. Follow up period ranged between 4 and 13 years. Outcomes were assessed by the hand therapy team as well as patient and family satisfaction. The difficulty in operating on Apert’s hand, and consequently the predicted outcomes, relates more to the degree and level of the synostosis, status of MCPs and absence or coalescence of the osseous elements of the hand more than the status of the first web space. A new classification system, based on clinical and the x ray findings, is proposed to help planning and predicting the outcomes of the surgery in Apert’s hand, in particular a realistic prediction of number of digits achievable.

Ahmet Savran 1, Kubilay Erol 2, Levent Kucuk 2, Erhan Coskunol 2

1 Katip Celebi University Ataturk Research and Training Hospital, Izmir, Turkey; 2 Ege University Medical Faculty Hospital, Izmir, Turkey

Hemophilia is one of the extrinsic causes of Compartment Syndrome. A patient of 6 months of age is administered our hospital with swelling and diminished circulation at left arm, after intra venous blood sampling for history of bruising and ecchymosis at different location of his body. Without any previous diagnosis for diathesis of hemorrhage, hemophilia is granted presenting as Compartment Syndrome. And Emergent fasciotomy is done, replacement of Factor VIII is started immediately. A Hand Surgeon must be alert for Compartment Syndrome in Hemophilia patients, especially in pediatric age group with limited anamnesis and orientation. And Preoperative management of bleeding diathesis must be done Co-operatively with Pediatrician.

A. F. Klenner 1, K. Klenner 2

1 Clinics St. Barbara, Hamm, Germany 2 Mariannen Hospital, Werl, Germany

Introduction: If severe Dupuytren´s disease is present, complications in operative treatment are increasing in relation to the level of contracture. Other pathological conditions exist, with a similar presentation of contracture of fingers. Preoperative treatment for all those conditions, aiming to minimize extension deficit is desirable. Aim/Method: In this concern, treatment is divided in invasive and non-invasive methods. Invasive treatment can be associated with severe complications and needs good compliance. Only few technical devices and solutions are described in the literature, most of them exist only at one hospital and are not available for the European or global market. Hence there was developed a non-invasive, pneumatic splint (PNEUMANUS), which addresses severe contractures of the fingers and is obtainable for everybody. Conclusion: PNEUMANUS is a new device, available on the market especially for the preop treatment of Dupuytren´s and other similar conditions described, avoiding the disadvantages of invasive solutions. It's simple to use and adaptive to even severe contractures. The acting forces can be fine-tuned at any time and the splint therefore fulfills the need to act smoothly on the tissues at cellular level. It provides patients with a magnitude of comfort and is highly accepted.

Kazuki Sato, Takuji Iwamoto, Noboru Matsumura, Satoshi Oki, Taku Suzuki, Akiko Torii, Tsuyoshi Amemiya, Ruriko Iigaya,Masaya Nakamura, Morio Matsumoto

Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan

Introduction: Costal osteochondral grafting is a technique to achieve anatomical and biological repair for articular defects. Although some small series of clinical application of this procedure for finger joint injury or articular cartilage defect with short-term follow-up have been reported, the longer time outcome is still unknown. The purpose of this study is to clarify the mid to long-term clinical outcomes of costal osteochondral autograft for finger joint ankylosis. Technique and Methods: Twenty-three finger joints (3 MCP joints and 20 PIP joints) in 23 patients with bony ankylosis after trauma or infection were treated with costal osteochondral autograft with at least 5-year follow up. There were 19 males and 4 females, ranging in age from 18 to 55 (mean, 33). Ample exposure of the joint was obtained through a dorsal approach. The periosteum was elevated in concurrent with the bilateral collateral ligaments and the volar plate. After resection of the joint the phalanx (metacarpus) were step-cut for the graft floor. Two pieces of the osteochondral graft were harvested from the 5th and 6th ribs through an ipsilateral transverse sub-mammary incision. The harvested grafts were then shaped to form a matching pair of articular surfaces of the MCP or PIP joint with adequate contour. The grafts were step-cut and stabilized using low profile screws. The finger was immobilized with a splint for a week, followed by range of motion exercises. Clinical outcomes including range of finger motion, the Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder and Hand questionnaire (DASH-JSSH), donor-site disturbances, and radiographic outcomes were evaluated after a mean follow-up of 75 months (range, 60-138 months). Results: Radiographs demonstrated complete union of the bony part of the graft to the floor in all of the patients by 8 weeks after surgery. Donor-site pain persisted only 3-4 days after surgery, and raised no particular problems even during sporting activity. One patient injured his operated finger while playing rugby football at 2 years after surgery and diagnosed with fracture of the transplanted PIP joint. He needed additional costal osteochondral grafting. Other additional surgeries were collateral ligament reconstruction in 4, corrective osteotomy of the phalanx in 2, and tenolysis in 1. Significant improvement in finger active extension/flexion was seen from a preoperative average of -24°/26° (arc: 2°) to -12°/75° (arc: 63°) at 1 year postoperatively (p < 0.001) and to -13°/73° (arc: 60°) at the time of final follow-up (p < 0.001). Mean preoperative DASH-JSSH score was initially 23.6, improving to 6.6 at 1 year postoperatively, and to 5.2 by final follow-up. Improvements in status at 1 year postoperatively and at the time of final follow-up were significant compared with preoperatively (p < 0.001 respectively). Conclusions: Costal osteochondral autograft for finger joint ankylosis or severe articular cartilage injury demonstrated anatomical and biological reconstruction and provided stable improvement of clinical outcome with a mean follow-up of 75 months.

Jiro Namba, Michio Okamoto, Koji Yamamoto

Toyonaka Municipal Hospital, Toyonaka, Japan

Introduction Generally, PIP flexion contracture associated with finger stenosing tendovaginitis is resolved by incision of A1 pulley which is a major obstruction site. In spite of the favorable result of A1 pulley release, sometimes certain degree of contracture did not go away due to remaining sliding disorder at other sites except A1. We reviewed whether excision of total or half slip of the flexor digitorum superficialis (FDS) tendon was practicable for primary or revision cases with refractory flexion contracture. Methods We identified 12 fingers in 12 patients who underwent FDS resection. The average age was 76 years old (62-91). 2 fingers had one prior A1 pulley release and 1 had 2 previous surgeries. Diabetes were involved in 4. The long finger was affected in 11 and index finger in one. The intraoperative findings on tendons were recorded. Clinical outcome was reviewed including ROM, grip strength, Visual analogue score (VAS). Results The mean preoperative PIP contracture was 28 degrees. The ulnar half slip of the FDS was excised in 4, both slips in 8 fingers. Intraoperative full extension was achieved in 11 cases, and no other soft tissue release like capsule and volar plate was conducted. All FDS tendons had longitudinal internal lesions and enlargement. The postoperative PIP contracture was 7 degrees, full extension was achieved in 7 fingers at a mean of 18 months postoperative. No case of swanneck deformity was recognized. VAS was 14 points, and grip strength was 86% against contralateral side. Total active arc motion was 241 degrees. Between half slip and total resection, total arc was significantly different with 219 / 252 degrees, as opposed to insignificance among the other variables. Conclusion Resection of hemi or total slip of FDS is an effective method for treatment of residual PIP contracture. In consideration of total arc motion in our cases at final follow up, total resection might provide wider space for flexor digitorum profundus to glide than half slip .

Bertil Vinnars

Dept of Orthopedic and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden

Objective To provide good access in contracture release of the elbow by using a skin flap at the volar side of the joint Method Contracture of the elbow joint is common after brain injury second to trauma or stroke. In an observational study by Kwah et al 35 % of patients developed a moderate to severe contracture 6 month after stroke. According to Ada et al the major independent contributors to contracture were spasticity for the first four months after stroke. Spasticity can cause contracture after stroke and will affect the biceps and brachilis muscles with shortening and contractue of muscle fibers. In standard orthopaedic and hand surgical textbooks release of the contracture is performed by dividing lacertus fibrosus, lengthening of the biceps tendon and cutting the aponeurosis of the brachialis muscle. The recommended skin incision is a transverse or lacy S. We have in several cases experienced that after release of the contracture and straightening of the arm the skin deficit will limit the extension of the joint. In a consecutive case of 5 individuals we have used a trasposition flap from the brachioradialis area covering the area of skin defect. Result In all patients skin healing has been uneventfull with good healing. The method provides good access to the area. Straightening of the joint can be performed to full extension with no limitation of skin defect. The flap can be designed as a pure skin flap or a fasciocutaneous flap. Conclusion A transposition flap on the volar side of the elbow joint provides good access to the joint in releasing elbow contracture second to brain injury. Ref: Ada L, O'Dwyer N, O'Neill E., Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: an observational study. Disabil Rehabil. 2006 Jul 15-30;28(13-14):891-7. Li Khim Kwah1, Lisa A Harvey2, Joanna HL Diong1 and Robert D Herbert1; Half of the adults who present to hospital with stroke develop at least one contracture within six months: an observational study; Journal of Physiotherapy 2012 Vol. 58

Xoan Daniel Garcia Fuentes, Maria Angeles Garcia Frasquet, Rodrigo Marcos Rabanillo

Hospital Universitario Virgen Macarena

OBJECTIVE We present a case report of a patient with Saddle Syndrome, adhesion of the intrinsics at the metacarpal head level associated with pain and functional impairment (described by Watson et al and Chicarilli et al.). This is a complex pathology that requires a high index of suspicion due to its difficult diagnosis. A relation between the clinical presentation and main diagnostic tests is established. METHODS Our patient is a 24 year old female that four years ago suffered a crushing by a weight of aproximately 120 kg on the ulnar surface of the palm, fourth and fifth finger of her right hand. She was evaluated by our unit presenting intense pain and permanent ulnar fingers flexum. During clinical exploration elastic retraction of metacarpophalangeal and interphalangeal joints were noted, as well as pain located in fourth intermetacarpal space and base of the phalanges. Positive Bunell test. Ultrasound, EMG/ENG and MRI were all normal. RESULTS After the suspected diagnosis of Saddle Syndrome the patient underwent surgery, permorming a zig-zag palmar approach and exploring the fourth intermetacarpal space. Adhesions were removed between lumbrical and palmar interosseus and dorsal and deep transverse metacarpal ligament, resecting its most proximal half. The symptoms resolved immediately after the surgery. The pain dissapeared and range of motion was recovered. CONCLUSIONS The presumtive diagnosis should be based on careful anamnesis taking the traumatic precedent and compatible clinica exploration into account. MRI should be performed on every patient although it is not often useful. Differential diagnosis of simulated hand pathology is essential. The diagnosis will be confirmed through surgical exploration.

Ronit Wollstein 1,2, Yotam Shuali Cohen 2, Miri Steier 3, Nariman Hazan 3, Nofar Ben Basat 2, Raviv Allon 2

New York University, Department Of Orthopedic Surgery, USA 2 Technion Israel Institute of Technology School of Medicine, Israel; 3 Lin Medical Center, Israel

Introduction:rnrnFragility fractures, constitute a major health problem and are a major risk factor for a subsequent fracture in osteoporotic patients. Studies have shown that multidisciplinary teams are most effective in prevention of these fractures, especially when the treating orthopedic surgeon is involved postoperatively.rn rnIn a previous evaluation of our medical system, we found that patients were unlikely to receive timely diagnosis of osteoporosis and/or proper evaluation and treatment for secondary prevention of fragility fractures. We have since begun the implementation of a multidisciplinary anti-osteoporotic clinic designed to treat and follow-up patients with prior fragility fractures of the distal radius. The purpose of this pilot study was to evaluate the short-term effect of this clinic on patients sustaining a distal radius fragility fracture (DRFF) in a large health maintenance organization.rnrnMethods: rnThis was a case-control retrospective study. Cases included all participants assigned to a tertiary, multidisciplinary, fracture prevention clinic. Controls were taken out of a series of surgically treated patients in the same health system that did not attend the multidisciplinary clinic. The clinical team consisted of a hand surgeon, an endocrinologist and an occupational therapist. The primary outcome measure was a second fracture during the follow up period.rnrnResults:rnThirty-eight patients were seen by the clinic. All patients went through rehabilitation with an occupational therapist according to their physical ability and healing progression. The average follow-up period was 20.5 months with a longer period for the untreated group. Cases received more pharmacological treatment for osteoporosis than controls. There were no new fractures in the treated group. There was no difference between the treated and untreated groups in fracture occurrence at 1-year follow-up.rn rnConclusions:rnIt is possible that we were underpowered to detect a difference in fracture occurrence rate. It is also possible that short-term follow-up is not enough for a fracture known to occur years before a second fragility fracture. rnrnThe evidence from this study may support the implementation of a multidisciplinary anti-osteoporotic clinic in reducing subsequent fractures and improving treatment rates following a minimal trauma fracture due to bone fragility, however further study is necessary to improve the ability to realize effective prevention of fragility fractures.

Jinrok Oh, Myunggi On, Hanbin Jin

Wonju Severance Christian Hospital, Wonju, Republic of Korea

Among the distal radius fractures (AO classification 23-B, C) involving the wrist joint, plain X-ray and computed tomography (CT) showed that when the main fracture was initiated from the distal part over the watershed line, it makes difficult to have a firm internal fixation using the conventional anatomical volar locking plate only. Also if the metal plate is positioned over the watershed line, it is high risk that friction between the distal portion of the metal plate and the flexor tendon tend to increase, resulting in the tendon rupture. In order to overcome this problem, using the conventional stabilization of the distal radius anatomical volar locking plate with the use of the 2.0 mm distal ulnar hook plate (Depuy-Synthes®) simultaneously, or two 2.0 mm ulnar distal plates, was able to get the satisfactory results in fixation of the fracture. We would like to report the clinical results and techniques for the treatment of distal radius fracture involving the watershed line or fracture starting from distal part of the watershed line.

Karan Dua 1, Nathan N. O’Hara 2, Andrea S. Bauer 3, Roger Cornwall 4, Christine A. Ho 5, Scott H. Kozin 6, Kevin J. Little 7, Scott Oishi 8, Apurva Shah 9, Suzanne E Steinman 10, Theresa O. Wyrick 11, Dan A. Zlotolow 6, Joshua M. Abzug 2

1 SUNY Downstate Medical Center, Brooklyn, New York, USA; 2 University of Maryland School of Medicine, Baltimore, Maryland, USA; 3 Boston Children's Hospital, Boston, Massachusetts, USA; 4 5 Children's Health, Dallas, Texas, USA; 6 Shriners Hospitals for Children, Philadelphia, Pennsylvania, USA; 7 Cincinnati Children's Hospital, Cincinnati, Ohio, USA; 8 Texas Scottish Rite Hospital for Children, Dallas, Texas, USA; 9 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; 10 Seattle Children's Hospital, Seattle, Washington, USA; 11 University of Arkansas Medical Sciences, Little Rock, Arkansas, USA

Objective: Distal radius fractures are the most common injury in the pediatric population, but radiographic examination and subsequent classification of these fractures are not standardized. A recent study found poor agreement among pediatric orthopaedic surgeons when diagnosing and treating these fractures. The authors hypothesize substantial variation also exists among pediatric hand surgeons when diagnosing and treating pediatric distal radius fractures. Methods: Ten pediatric hand surgeons who commonly treat pediatric distal radius fractures at different institutions reviewed 100 sets of posteroanterior (PA) and lateral pediatric wrist radiographs. The surgeons were asked to complete a questionnaire describing the fractures, the type of treatment they would recommend and the recommended length of immobilization. Additionally, the surgeons were asked when the next follow-up visit would be scheduled for, and whether or not they would obtain new radiographs at the subsequent and final follow-up visits. Kappa statistics were performed to assess the agreement amongst examiners with the chance agreement removed. Strength of agreement was determined based on guidelines outlined by Landis and Koch. Kappa values of <0.00 were considered poor agreement, 0.00 to 0.20 slight agreement, 0.21 to 0.40 fair agreement, 0.41 to 0.60 moderate agreement, 0.61 to 0.80 substantial agreement, and 0.81 to 1.00 almost perfect agreement. Results: Only fair agreement was present when diagnosing and classifying the distal radius fractures (K=0.312). Diagnoses included torus, greenstick, Salter-Harris II, and extra-physeal fractures. There was also only fair agreement regarding the type of treatment that would be recommended (K=0.242) and only slight agreement regarding the length of immobilization (K=.187). Only slight agreement was present regarding when the first follow-up visit should occur (K=.188), there was only fair agreement whether or not new radiographs should be obtained at the first follow-up visit (K=0.396), and if radiographs were necessary at the final follow-up visit (K=.368). Surgeons had slight agreement regarding stability of the fracture (K=0.139). Conclusions: The inter-rater reliability among pediatric hand surgeons of diagnosing pediatric distal radius fractures showed only fair agreement. Both pediatric orthopaedic surgeons and hand surgeons have wide variability in their treatment of pediatric distal radius fractures. Better classification systems of pediatric distal radius fractures are needed that standardize the treatment of these injuries in order to provide the best health outcomes with the least patient morbidity.

Chun-Jui Weng, Chun-Ying Cheng, Shih-Sheng Chang, Chih-hao Chiu, Alvin Chao-yu Chen, Kuo-Yao Hsu, Yi-Sheng Chan

Chang Gung Memorial Hospital, Taoyuan, Taiwan

Object: Nonunion of distal radius fracture is rare due to metaphyseal position, bony impaction when injury, cancellous bone content and less soft tissue disruption. No consensus about treatment to distal radius fracture nonunion. The aim of our study is to evaluate contributing factor, treatment and outcome to distal radius fracture nonunion. Methods: We retrospective review patients with distal radius fracture. Thirteen patients received surgery due to distal radius fracture nonunion or delayed union. We reviewed preoperative and postoperative radiograph and range of motion. Fracture type, grip strength compared to contralateral hand and functional score were also recorded. Surgical procedure included debridement, realignment, bone grafting and stable fixation. ORIF of ulna or Darrach procedure was performed for associating ulna fracture. Results: According to Frykman classification, three of them were class II, six were class IV, two were class V, and one for class I and VIII respectively. Initial treatment was splinting in 7 patients and surgery in 6 patients. Six patients received plate fixation and bone grafting, two received additional Darrach procedure, six received ORIF with Acumed locking plate, one received shortening of radius and ulna. Postoperative wrist range of motion increased compared to preoperative range of motion. Eleven out of thirteen patients had concomitant distal ulna fracture. No complication occurred except one developed delayed union of ulna. One patient had excellent grade in functional score, eight with good and four with fair. Conclusion: Nonunion of distal radius fracture is rare and difficult to treat. Associated distal ulna fracture may be risk factor for nonunion or delayed union. Surgical treatment leads to high union rate, low complication rate and fair to excellent function outcome.

Hiromichi Yasuoka

Tamana Central Hospital, Tamana-shi, Kumamoto, Japan

[ Hypothesis ] Surgical procedure ‘without pronator quadratus (PQ) detaching’ is superior to ‘with PQ detaching’, when comparing post-operative clinical outcomes after open reduction and internal plate fixation for distal radius fractures. [ Materials & Methods ]  Comparing the surgical procedures and post-operative clinical outcomes of 30 patients with extension type fractures of the distal radius.  Intra-articular fractures having displacement of articular surface and fractures having comminution of volar cortex were excluded from the study.  The cases were randomly separated into two groups.  One group received surgery ‘without PQ detaching’ (16 patients).  The second group received surgery ‘with PQ detaching’ (14 patients).  Post-operative outcomes were assessed at approximately 6 months after surgery using The DASH Outcome Measure, modified Mayo wrist score, range of motion of the wrist and grip strength.  Radiographic assessments were performed immediately after each operations and the last follow up appointment of the patients. [ Results ]  The DASH score were significantly better in the ‘without PQ detaching’ group than ‘with PQ detaching’ group.  DASH score: ‘without PQ detaching’ group average 3.03, range 0~15.91 vs ‘with PQ detaching’ group average 9.31, range 2.5~32.5 (P=0.01).  There were no significant differences between the two groups in the other assessed parameters. [ Summary points ]  No statistical difference was observed in the modified Mayo wrist score, range of motion of the wrist, grip strength, operation time and radiographic assessments between the two groups of patients.  In the demonstrated cases of extension type fracture of the distal radius, the procedure ‘without PQ detaching’ in open reduction and internal plate fixation presented significantly better subjective recovery results than the procedure ‘with PQ detaching’, when comparing patient-rated evaluation. [ Discussion ] When operating the distal radius fractures through a volar approach, the PQ is generally once detached from the surface of the distal radius. In order to preserve physiological function of PQ, some authors recommend not detaching it in operation. In the anatomical and functional literatures, it is stated that PQ has two distinct heads and the superficial head is the prime mover in forearm pronation, and the deep head is a dynamic stabilizer of the distal radioulnar joint. Therefore this study was planned to confirm the influence of PQ detaching to post-operative outcomes in practical clinical scene. Intra-articular fractures having displacement of articular surface and fractures having comminution of volar cortex were excluded from the study because there was a risk of insufficient reduction when the PQ muscle was preserved in operation. Although the number of recruited case was small because of strict criterion for enrollment, there was significant difference in the patient-rated evaluation. Superior patient satisfaction, resulting from surgical procedure which is spared pronator quadratus detaching, could be observed. It was supposed that the damage to the PQ muscle caused by detaching procedure resulted in impairment of the physiological PQ function which contributed to pronation strength in forearm rotation and dynamic stabilization of the distal radioulnar joint.

Michael Jakubietz, Rafael Jakubietz, Laura Mages, Rainer Meffert

University of Wuerzburg, Department for Trauma, Hand, Plastic and Reconstructive Surgery, Wuerzburg, Germany

Background Intraarticular fractures of the distal radius present a challenging problem for surgeons. While preoperative CT scans are considered helpful to understand the type of fracture and to choose an adequate approach, the role of postoperative CT scans is not yet clearly defined. The aim of this study was to analyze indications for postoperative CT scans and to evaluate its potential therapeutic consequence in regard to detection of complications and its influence on revision rates in intraarticular fractures. These findings were used to establish an algorithm to help identifying patients that benefit from a postoperative CT scan. Patients and Methods: 92 patients with intraarticular fractures were included. AO type C fractures were seen in about 90% of patients, with type C3 being present in 55% of the patients. According to Frykman´s classification type 7 and 8 fractures were found in 93%. Data was analyzed in regard to radiographic results, complications and indication for a postoperative CT scan. Results: Six patients underwent revision surgery. When analyzing data in regard to correlation of radiographs and CT Scans a statistically significant correlation was found. Conclusions A high correlation between both imaging techniques can be shown. In inconclusive radiographs, CT scans are recommended to rule out intraarticular screw placement or step offs. Due to the number of patients and the retrospective design, further studies are needed.

Hyun Il Lee 1, Min Jong Park 2

1 Department of Orthopaedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, South Korea; 2 Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea

Introduction: Malunion after distal radius fracture is common complication especially in elderly patients with osteoporosis. Although the relationship between functional outcome and radiologic parameter was well known in younger patients, it is still controversial whether patient-perceived outcome and disability in elderly patients are influenced by a radiologic outcome. We evaluated the actual complaint of the patient and their perceived outcome according to radiologic parameters in elderly patients who underwent conservative treatment. Patients and methods: We reviewed 167 elderly patients over 55 years old with unilateral distal radius fracture to investigate the effect of radiologic deformity on functional outcome and patient’s satisfaction. All fractures were treated with closed reduction and cast immobilization, and followed-up for mean 7.1 years. Their wrist pain was evaluated using the visual analog scale (VAS) and the functional subjective outcome was measured with the disability of the arm, shoulder, and hand (DASH) questionnaire via telephone survey. Overall satisfaction and concern over wrist appearance were part of the subjective assessment. Radiologic evaluations including dorsal tilt, radial inclination, radial length and ulnar variance were performed. Malunion was defined when radiologic parameters showed volar tilt < -10° or > 20°, radial length < 0 mm, or radial inclination <5°. Results: According to radiographic criteria, 51 patients (30%) showed malunion. Mal-united patients are slightly older than patients with acceptable alignment (62.9 versus 69.6 years old, P < 0.001 by Mann-Whitney test). Fracture patterns including AO classification and the incidence of ulnar side fracture were similar between two groups. Mean pain VAS was 0.4 for mal-united patients versus 0.8 for patients with good alignment and it was not statistically significant (P = 0.347 by Mann-Whitney test). Mean DASH score showed inferior score in the mal-united group (14.9 versus 11.1, P < 0.001 by Mann-Whitney test). However, this difference (value of 3) was not reached the clinically meaningful difference (value of 10). More patients in mal-united group recognized the gross deformity of their wrist than well-aligned patients (52.9% versus 25.9%, P < 0.001 by Chi-Square test). Mean satisfaction VAS was lower in mal-united patients as 80.5 (versus 90.5 in well-aligned patients, P < 0.001 by Mann-Whitney test). Mal-united patients answered that they would choose surgery more than cast if they encounter same condition (13.3% versus 7.2%) but it was not statistically significant (P = 0.2332 by Fisher’s exact test). When we analyze the subset of patients older than 70 years old, we could get a similar trend with the whole set of patients. Conclusion: Our study indicated that the conservative treatment of the distal radius in elderly patients could show a good functional and patient perceived outcome despite residual deformity at fracture union. However, mal-united patients showed slightly less satisfaction in their management even in older patients over the age of 70 years old.

Johannes Rois

Trauma Center Vienna Meidling, Austria

Fractures of the distal radius are the most common fracture in the upper extremity. Open reduction and palmar fixed-angle plating is nowadays the most common used treatment method for unstable distal radius fractures. The complication rate of this treatment reported in the literature vary between 8% and 40%. The most common cause of wrist disability after distal radius fracture is the distal radioulnar joint (DRUJ) involvement. The aim of this study is to find sustainable solutions and to offer practical tips and tricks to prevent this type of complications. Based on an own retrospective study with 127 cases on the topic of palmar plating of unstable distal radius fractures, and on the literature review the different complication types were studied and classified. Focussed on preventable complications they were classified into surgeon-related and surgeon-independent complications. The surgeon-related complications (malunion, tendon complications, screw length, intraarticular screw placement, secondary dislocation,...) were analyzed. Based on these results and also taking into account biomechanical studies, possibilities of avoidance of complications on the DRUJ will be offered by means of case reports. To prevent complications is not restricted solely to the surgical technique – approach, reduction, plate position, screw position, screw length – but begins with the preoperative assessment of the fracture which results in surgery planning. It will definitely not be possible to achieve a complete avoidance of complications that are associated with palmar plating of unstable distal radius fractures. Awareness of the possible complications and how to deal with them may help to minimize the complication rate and on the other hand to recognize complications at an early stage allowing timely treatment.

Masato Shigi, Takeshi Egi, Yusuke Sogabe

Osaka Saiseikai Nakatsu Hospital, Osaka, Japan

[Objective] Volar locking plate fixation generally leads to satisfactory postoperative outcomes in patients with distal radius fracture, but correction loss may occur in unstable cases, such as an association of osteoporosis. The purpose of this study was to investigate association between correction loss after surgical operation for distal radius fracture and osteoporosis. [Method] 35 patients (32 females and 3 males) who performed open reduction and internal fixation using volar locking plate for distal radius fracture at our facility between April 2016 and July 2017 over 50 year of age (mean age of 68 years, range 50-86) was evaluated retrospectively. All of them had gone through measurements of bone mineral density (BMD) of lumber spine and femoral neck measured by dual-energy x-ray absorptiometry as well as measurements of serum levels of N-terminal propeptide of type I procollagen (P1NP) as a bone formation marker and tartrate-resistant acid phosphatase 5b (TRACP-5b) as a bone resorption marker at the time of injury. And we collected data of ulnar variance (UV), volar tilt and radial inclination measured on plain radiography in the postoperative period as well as 3 months later. Statistical analysis was conducted using three steps. First, wrists were divided into two groups by degree of loss of correction (correction loss group and non-correction loss group). Age, sex, BMD and bone metabolism markers were compared between two groups using the nonparametric Mann-Whitney U test. Second, logistic regression analysis was performed to identify factors independently associated with loss of correction at 3 months after operation and to calculate odds ratios adjusted for other covariates. Third, receiver-operating characteristic (ROC) curve analysis was performed to assess the cutoff values and area under the curve values of the predictive factor. [Results] 14 patients (33 %) who had correction loss of UV more than 1 mm had mean percentage of the young adult mean (%YAM) of femoral neck of 60 % compared with 74 % among the non-correction loss group (21 patients). Univariate analysis demonstrated this difference of %YAM between two groups was statistically significant (p = .001). On the other hand, age, sex, mean %YAM of lumber spine and mean bone metabolism markers had no significant differences between two groups. We used logistic regression analysis to assess whether %YAM of femoral neck was predictive of correction loss independent of age, sex, and bone metabolism markers. That has revealed that lower %YAM of femoral neck was a risk factor for correction loss of UV (p < .05). ROC curve was produced to assess the ability of the predictive factor. The area under the curve (AUC) was 0.83. When the cut-off value of %YAM was 63 %, the sensitivity and specificity for the prediction of correction loss were 86 % and 79 %, respectively. [Conclusion] Osteoporosis had a negative effect on correction loss after volar locking plate fixation of distal radius fracture. For patients whose %YAM of femoral neck is below 63%, surgeons should identify high-risk patients and ensure stable internal fixation, close monitoring and careful postoperative therapy.

Youn Moo Heo 1, June Bum Jun 1, Sang Ki Lee 2

1 Konyang University Hospital, Daejeon, South Korea; 2 Eulji University Hospital, Daejeon, South Korea

Purpose: Radiocarpal dislocation (RCD) of the wrist is a very rare injury caused by high energy trauma. This injury is common to have a fracture of radial styloid of distal radius rather than a pure dislocation. And, it may sometimes has an avulsion fragment from volar rim of the lunate facet by short radiolunate ligament that origin at volar rim of the distal radius. The purpose of this retrospective study is to evaluate final results of RCD and to assess whether the repair of avulsion fragment is necessary in RCDs with avulsion fracture by short radiolunate ligament. Materials and Methods: From February 2008 to October 2016, we reviewed 1051 patients surgically treated for distal radius fractures or perilunate injuries. And 17 patients confirmed as RCD with follow-up over 12 months were enrolled in this study. There were 14 men and 3 women with a mean age of 40 years (range, 19-79 years). The mechanism of injury was motorcycle accident in 5 patients, vehicle accident in 4 patients, a fall from height in 5 patients, a fall from climbing in 1 patient, a fall from standing height in 1 patient, and industrial injury in 1 patient. Patients with RCD were divided into Group 1 and 2 using the classification by Dumontier et al. Additionally, we subdivided Group 2 as the following; 2A without avulsion fracture by short radiolunate ligament and 2B with avulsion fracture by short radiolunate ligament. In all RCDs, fracture of radial styloid were fixed with K-wires or plate. And pure injuries of palmar radiocarpal ligament were repaired primarily or using suture anchor and injuries of palmar radiocarpal ligament with repairable avulsion fragment were fixed with mini-screw. Carpal tunnel decompression was performed in 5 cases with median nerve symptom and additional external fixation was performed in 4 cases. Final results were evaluated using the Mayo Wrist Score and a patient-rated wrist evaluation. And a wrist range of motion and grip strength were assessed. Statistical analysis was performed with the Student’s t test. Results: All RCDs were included in Group 2 (4 and 13 patients in Group 2A and 2B, respectively). The RCDs (Group 2A/2B) was rated as excellent in 2 (1/1) patients, good in 8 (1/7) patients, fair in 4 (1/3) patients, and poor in 3 (1/2) patients according to the Mayo Wrist Score (p=0.09). The mean Mayo wrist score was 73.5 (range, 50–90). The mean patient-rated wrist evaluation score was 17.3 (range, 0–55). Total range of motion of the injured wrist obtained 86.9% and grip strength of injured site obtained 73.9% of the uninjured side. Conclusions: Common RCDs is a complex injury with fracture of radial styloid and injuries of radiocarpal ligament. Not only the fixation of fracture but also the repair of ligament is important to maintain the stability of the joint. Particularly, we think that relatively large avulsion fractures associated with injuries of palmar radiocarpal ligament are helpful in restoring the stability of the ligaments.

Kotaro Okamoto 1, Satoshi Takei 1, Takeshi Oki 1, Kiyohito Takamatu 2

1 Hankai Hospital Orthopedics, Japan; 2 Yodogawa Christian Hospital Orthopedics, Japan 

Introduction Fragility fractures such as proximal femoral and vertebral fractures affect both patient life expectancy and quality of life. Patients should be treated for osteoporosis at an early stage to prevent fragility fractures. Distal radius fractures (DRFs) and vertebral fractures comprise the osteoporotic fractures at the initial stage. However, DRFs do not affect life expectancy, suggesting that when patients presenting with DRFs are diagnosed with osteoporosis, it is a good opportunity to start treatment for osteoporosis. However, most patients presenting with DRFs are relatively young. Therefore, it is likely that they have not undergone a bone mineral density (BMD) test. Thus, they may miss the opportunity to undergo osteoporosis treatment at the initial stage. Purpose The purpose of this study was to investigate the current status of BMD examination and the treatment administered for osteoporosis in patients with DRFs at our hospital. Methods We investigated patients who were treated for DRFs at our hospital between 1 January 2010 and 31 December 2016, excluding patients aged <50 years and those with pathological DRFs. We determined the following factors: age at the time of developing DRFs, sex, affected arm, type of fracture, location of the injury, cause of the injury, method of treatment, history of osteoporosis treatment, history of fragility fractures and whether the patient underwent BMD tests before and after developing DRFs. Results One hundred and fifty patients (women250, men50) were included in the study; 250 of the wrists were of women and 50 were of men and of the 300 wrists, 117 were of the right hand and 179 of the left. The cause of injury was falling from a height in 75% of the cases, with most of them occurring inside the house. Operations were performed in 74% of the cases. At the time of developing DRFs, only 7% of the patients received treatment for osteoporosis and 8% had a history of fragility fractures. Only 3% of the patients had undergone BMD tests before developing DRFs, and 7% of the patients underwent these tests after the operation. After the operation, 13% of the patients received osteoporosis treatment. Discussion The examination rate for osteoporosis in Japan is approximately 5%. However, in patients with DRFs treated at our hospital, BMD examination rate before developing DRFs was even lower than that. In addition, BMD examination rate after developing DRFs was relatively low. Our results indicated that it is highly likely that we are overlooking patients who would benefit from early osteoporosis treatment. Conclusions In future, we need to increase BMD examination rate at the time of DRF diagnosis and start treatment in patients with osteoporosis at an initial stage to prevent additional fragility fractures that may affect their life expectancy.

Daichi Ota, Mikiro Kondo, Mikio Harada, Masatoshi Takahara

Center for Hand, Elbow and Sports Medicine, Izumi Orthopedic Hospital, Sendai, Japan

Objective: Cast immobilization after closed reduction is a standard treatment for distal radius fractures. The position of the wrist during immobilization is controversial.Our aim was to investigate the effectiveness and limitation of cast immobilization with the wrist of extension for the distal radius fractures in elderly patients. Methods: 33 patients with distal radius fractures (age: 60 years old and older, follow up periods: 8 weeks and longer), were included retrospectively. 26 out of the 33 patients underwent conservative treatment initially, 18 patients needed closed reduction, and 17 patients of the 18 (mean age: 76.8 (64-95), AO classification: A2,3;A3,7;C1,1;C2,6) were immobilized using cast with the wrist of extension. After manual closed reduction, cast were applied and were modeled to rigidly press the dorsal side of the wrist, including distal radius and proximal carpal raw toward the volar side. Thus the wrists were kept in extension. 2 cases were immobilized with above elbow cast and the others were immobilized with below elbow cast. The mean period of cast immobilization was 5.5 (4-10) weeks. The following clinical results were examined: complications, surgery after casting, bone union, and final outcomes of pain, range of motion (ROM), and grip strength. Radiographic findings were also evaluated, including volar tilt (VT),ulnar variance (UV),radial inclination (RI) and correction loss. Results: No complications such as cast trouble were reported. 13 cases were non-operatively followed, although 4 patients underwent osteosynthesis, using volar locking plate between 6 and 12 days after casting (mean 7.5 days). All patients obtained bone union. mean VT was -7.0 (-23~10)° initially, +6.5 (-4~15)° immediately after casting, and +2.7 (-13~33)° at the final follow up. The mean UV was +1.8 (-1.0~3.8) mm initially, +1.5 (0.0~3.0) mm immediately after casting, +3.0 (0.5~6.5) mm at the final follow up. mean RI was 20.4 (8~29)° initially, 22.2 (13~30)° immediately after casting, and 21.5 (12~28)° at the final follow up. The mean correction loss was 3.7° in VT, 1.5 mm in UV and 0.6° in RI. Three patients complained wrist pain at the final follow up and 2 of the 3 had ulnar wrist pain. Mean ROM was 57.3 (40-80)° of flexion, 60.3 (40-80)° of extension, 81.5 (80-90)° of pronation and 81.5 (60-90)° of supination. Mean rate of grip strength compared to the opposite side was 73.0 %. In the patients who underwent osteosynthesis, the mean VT was -30.0 (-37~-25)° initially, and +2.0 (-9~10)° immediately after casting. mean UV was +2.7 (0.4~6.4) mm initially, and +0.7 (0~2)° immediately after casting. mean RI was 17.8 (12~21)° initially, and 22.5 (21~24)° immediately after casting. Conclusion: Our radiographic results showed relatively low correction loss in cast with the wrist of extension, compared to the conventional cast. It suggests that cast immobilization with the wrist of extension is safe, economic, and effective treatment of distal radius fractures in elderly patients. We recommend this technique as the first choice of the treatment for distal radius fractures which have unacceptable dorsal tilt. However, surgery should be immediately performed if the fracture has unacceptable shortening or articular displacement after reduction.

Jin Young Kim, Dong Mo Kang, Jae Hyun Kim

Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyang, South Korea

We attempted to investigate how accurately an extra-articular fracture was identified by plain radiographs. We also presented what types of intra-articular involvement commonly were found in extra-articular fractures misdiagnosed as by plain radiographs. The standard plain radiographs (AP and lat), oblique views and CT scan were taken for 464 distal radius fractures. The diagnosis of an extra-articular fracture was made by plain radiographs. Based on the findings of CT scans, diagnosis rate and sensitivity of the standard radiographs with/without oblique views for extra-articular fracture were calculated. We also investigated whether the added oblique views improved the diagnosis rate of extra-articular fractures. The common types of intra-articular involvement which were not revealed in plain radiographs was presented. The incidence of an extra-articular fracture was 19%. Diagnosis rate of standard plain radiograph for extra-articular fracture is 48%, and sensitivity is 96%. When oblique x-rays were added, diagnosis rate was 68% and sensitivity was 100%. A dorso-ulnar articular fragment was the most commonly identified in the misdiagnosed extra-articular fractures. In conclusion, the incidence of extra-articular fracture of distal radius was much lower than that in previous literatures. A large part of extra-articular fractures diagnosed as by standard plain radiographs conceals intraarticular involvement. Thus, CT scan might be necessary or at least, oblique view should be added, not to miss the fractures requiring surgery.

Adrienn Lakatos, Balazs Lenkei, Zsolt Szabo

Hand Surgery Center Miskolc, Hungary

Operative treatment of low energy distal radius fractures in elderly is increasing. The functional results of these patients are similar to the results of the young patients. The purpose of this study is to search for the factors influencing the functional outcome in these cases. The operated distal radius fractures were checked for the year 2016. We found 237 operated distal radius fractures. 121 of them were involved in the study. The functional outcome was evaluated with the quickDASH score. We collected data about the fracture type, the reduction quality, and the age of the patient. For evaluating the reduction, we created a scoring system based on the remnant gap or step in the articular surface and the remaining angulation in the fracture. The mean follow-up was 12,3 months. AO type A, B, or C type fractures were evaluated separately. Functional outcome was not significantly influenced by the fracture pattern. Comparing the reduction quality of all the patients the results were the following: on average 0 quickDASH score for perfect reduction, 14 quickDASH points for gaps 1 mm or angulation less than 10 degrees, 21 points for more than 1 mm gap, step or angulation more than 10 degrees. The overall quick DASH score of these patients did not vary significantly in the different age groups (6,3 points for 61-70 years; 7,9 points for 71-80 years; 5,4 points for 80+ years). Based on our results we conclude, that age of the patient should not be considered as contraindication for operative treatment. It seems that it is not the fracture type that is important, but the quality of the reduction which is the main influencing factor of the final functional outcome.

Emygdio JL de Paula, Edgard Novaes França Bisneto, Renata Gregorio Paulos

Grupo de Mão e Microcirurgia do Hospital das Clínicas da Universidade de São Paulo, Brazil

Purpose: To present long-term follow-up for pediatric patients following correction of forearm deformity with the use of distraction osteogenesis after distal radius physeal arrest in the setting of trauma. Methods: Retrospective review of a single surgeon’s experience using a circular External Fixator to correct forearm deformity in eight patients whose average age at time of application was 10.7 years. At time of lengthening, the ulnar phisys was left intact allowing its growth. After skeletal maturity, all patients underwent to a second acute lengthening procedure to restore radial/ulnar relation if necessary. All patients were evaluated clinically with radiographs, physical examination, and functional outcome assessments including the Short-Form 12, Disabilities of the Arm, Shoulder and Hand, and Mayo Wrist score. Results: At the time of long-term follow-up, at a mean of 120 months, all patients were nearly pain free. All were willing to undergo the same treatment again. Wrist flexion increased 150, extension decreased 4°, radial deviation decreased 10°, ulnar deviation increased 12°, and pronation and supination both decreased 7° on average. The radius was lengthened an average of 4.5 cm, with an average preoperative ulnar variance of +4,5 cm and an average postoperative ulnar variance of -3 mm. Mean outcome scores were as follows: Short-Form 12 was 84, Disabilities of the Arm, Shoulder and Hand was 10, and Mayo Wrist was 76. No complications were observed Conclusions: The use of distraction osteogenesis in pediatric patients with severe forearm deformity and dysfunction after physeal arrest in the setting of trauma is a reasonable alternative in association to a later osteotomy, bone grafting, and internal fixation. It provides good correction of deformity (cosmetic aspect) and maintains functional range of motion .

Shotaro Kamijo, Keikichi Kawasaki, Kazutoshi Kubo, Tetsuya Nemoto, Hiroshi Nishikawa, Katsunori Inagaki

Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan

[Objective] Variable angle volar rim plate (Depuy-Synthes Company, abbreviated as “VA-VRP”) is designed for distal radius marginal fracture. Because of its design, VA-VRP can cause flexor tendon ruptures and carpal tunnel syndrome (CTS), whereas recent studies showed the incidence of CTS in other volar plates was 0-9.9%. In this study, we evaluated whether carpal tunnel release can be necessary when VA-VRP is used for marginal fractures. [Methods] We reviewed the cases of marginal fracture, under 10mm of the longitudinal size of volar lunate facet fragment, treated with VA-VRP at our department from 2014. We excluded two cases who underwent carpal tunnel release combined with plating. We divided cases into two groups based on symptom and electrophysiological test: S group; cases with CTS before removal of plate system and N group; cases without CTS. As radiographic parameters, we examined volar tilt (VT), ulnar variance (UV), radial inclination (RI), carpal translation (CTL), carpal height ratio (CHR), distance between the volar edge of the plate in distal end and tip of hook of hamate in CT which was taken 3 months after operation. We also examined range of motion, percent grip power, Mayo wrist score as clinical evaluation. We evaluated these parameters between two groups. We performed numerous nerve conduction tests in S group. [Results] Twenty-six cases matched our inclusion criteria: S group; three cases (incidence of CTS 12%) and N group; 23 cases. The mean age was 60.0 year-old in S group and 55.1 year-old in N group. The fracture types were all cases Colles type in S group, and Smith type three cases and Colles type 20 cases in N group. AO classification were C2: 1, C3: 2 cases in S group and B3: 1, C2: 4, C3: 17 cases in N group. The averages of Mayo wrist score were 78.3 ± 10.4 in S group and 87.1 ± 8.3 in N group. The averages of percent grip power were 70.0 ± 21.8 in S group and 85.3 ± 24.2% in N group. Radiographic parameters showed no significant differences between S and N groups. We removed the plate system in all cases soon after bone union and combined carpal tunnel release surgery at removal of the plate in S group. [Conclusions] There were no significant differences between S group and N group in radiographic and clinical parameters; plate position and fracture reduction, but the incidence of CTS in marginal fractures treated with VA-VRP was higher than those of other plates, and the clinical results in S group tended to be worse than those of N group. Further investigation is needed to elucidate causes of CTS by VA-VRP, and Carpal tunnel release at open fixation surgery could be necessary to prevent CTS by VA-VRP.

M. Wehrli, E. Bodmer, M. Marks, St. Schindele

Schulthess Klinik, Zürich, Switzerland

Objective Computer-assisted surgical planning, including patient-specific surgical tools, have the potential to improve the preoperative understanding of patient anatomy as well as enhance the intraoperative accuracy of corrective osteotomies for malunited radius fractures. Standard anatomical plates for corrective osteotomy of the distal radius are prone to malpositioning because of missing anatomical landmarks, which results in a less precise correction. As there are significant correlations between malpositioning and poor clinical outcome, patients might benefit from custom-made patient-specific implants. The objective of this project was to describe the outcome of a pilot series of patients treated with radius corrective osteotomy using a patient-specific implant. Methods Preoperative 3D planning requires a CT scan of both the malunited and contralateral healthy radius. Based on these data, patient-specific osteotomy guides and custom-made plates were designed and printed. Patients receiving a personalized plate for corrective osteotomy due to distal radius malunion were retrospectively assessed between 6 and 12 weeks and 6 and 12 months after surgery. Results We included five distal radius malunion patients with a mean age of 50 years. Four radius fracture patients were each treated conservatively and one patient underwent enucleation of a cyst located in the distal radius prior to osteotomy. The mean time between injury or treatment and the corrective surgery was 6 years. The average follow-up time was 9 months. At follow-up, all patients stated that they would have the surgery again due to considerably improved wrist function and subjective stability. All patients had improved pronation/supination and flexion/extension compared to before the corrective osteotomy. No adverse events were documented to date. In one case, however, we plan to remove the implant because of a screw tip irritation at the extensor tendon. Conclusions The first results of patients treated with a custom-made implant for corrective osteotomies of the distal radius are promising. These implants offer the surgeon greater accuracy in the preoperative planning and implementation of the surgical procedure. As a next step, we plan to analyze the safety and effectiveness of these implants, and believe that this “gadget” has the potential to evolve into an essential tool for hand surgeons.

Takeshi Sakai 1,4,5, Keikichi Kawasaki 3, Naoya Nisinaka 1,2, Ken Yamasaki 4, Kouji Kanzaki 1, Katsunori Inagaki 3, Kenichirou Teramoto 5, Hidechika Nakashima 5

1 Department of Orthopedic Surgery, Showa University Fujigaoka Hospital Kanagawa, Japan; 2 Showa University Research Institute for Sport and Exercise Sciences Tokyo, Japan; 3 Department of Orthopedic Surgery, Showa University School of Medicine Tokyo, Japan; 4 Higashitotsuka Memorial Hospital Kanagawa, Japan; 5 Kumamoto Kinou Hospital Kumamoto, Japan

Objective: Double-tiered subchondral support (DSS) of the dorsal and central joint, using a monoaxial locking plate (MLP) for fixation in which the screw insertion angle is predetermined, is convenient for treatment and stability of distal radius fractures. The fixation strength between the screw plate provides better outcomes. However, DSS is not effective in all cases, with postoperative correction loss being reported in some patients. This study investigated plate position and screw length in patients who had postoperative correction loss after DSS using an MLP. Methods: Among 156 patients with a distal radius fracture treated using an MLP (DVR, Zimmer Biomet), 30 patients having correction loss with volar tilt (VT) 5°, radial inclination (RI) 5°, or ulnar variance (UV) 2 mm were defined as the re-dislocation group. This included 27 patients with AO type C fractures, mostly comminuted. Distance of the most ulnar / most radial distal plate edges from the articular surface, and between the plate ulnar edge and DRUJ, were measured by frontal view radiography. Distance between the most distal plate and the joint surface was measured by lateral radiography. In addition, the support rates were defined as the distal first and second row screw lengths divided by the joint surface length. The results were compared with a non-dislocated group and analyzed by the t-test. Results: In regard to plate position, frontal radiograph measurements in the re-dislocated group:non-dislocated group were: joint surface - most ulnar, 4.6:5.2 mm; joint surface - most radial, 17.1:16.1 mm; and DRUJ - ulnar edge, 3.5:2.7 mm. Lateral radiograph measurements were: joint surface - most distal plate, 2.1:2.3 mm. There were no significant differences. The support rates were: first row, 57.8:62.8% and second row, 79.8:85.8%. The second row support rate was significantly different. Moreover, additional treatment such as external fixation was required in three re-dislocation group patients. Conclusions: Prevention of correction loss when using an MLP requires careful consideration of plate position. In addition, care must be taken with screw insertion during DSS to ensure support of the dorsal joint surface. Patients treated surgically may still require additional fixation in some cases.

Hiroaki Ogihara 1, Emi Makino 1, Takao Omura 2, Michihito Miyagi 2, Kaori Sugiura 3

1 Japanese Red Cross Hamamatsu Hospital, Japan; 2 Hamamatsu University School of Medicine, Japan; 3 JA Shizuoka Kohseiren Enshu Hospital, Japan

(Objective) Although much attention has been paid to avoid incidence of extensor tendon injuries by screw perforation through the dorsal cortex of the distal radius during dorsal fracture fixation with volar locking plate (VLP), we sometimes encounter cases with screw penetration through the dorsal cortex on plain lateral radiograph. Recent reports have emphasized on the high importance of dorsal tangential view (DTV) on detecting screw penetrations. The purpose of this study is to evaluate the relationship between the in vivo screw tip cortex distance in vivo distance (STCD) and the postoperative STCD measured using DTV. (Methods) Forty nine hand of 47 patients who underwent VLP for distal radius fracture during 2016 to 2017 at Hamamatsu Red Cross Hospital were included in this study. The patients consisted of 6 males and 41 females with an average age of 70 years old. In vivo STCD was calculated by measuring the distance from the volar to dorsal cortex by depth gauge, then subtracting by the actually inserted screw length. Postoperative STCD was measured using DTV by plain radiograph. The discrepancy between In vivo and postoperative STCD was analyzed. (Results) Out of 364 inserted screws, there were 84 screws which showed discrepancy between in-vivo and postoperative STCD. Out of these 84 screws, 54 were placed, 24 were radial and 4 were on Lister’s tubercle. There were 35 screws with a between in-vivo and postoperative STCD discrepancy of 1 t o2mm. Out of these 35 screws, 22 were placed ulnar and 13 were placed radial. 15 screws showed discrepancy between 2 t o3mm with 8 screws placed ulnar and 7 screws place radial. Finally, 2 screws showed discrepancy of more than 3mm occurring on ulnar and radial side. (Conclusion) There was a 23% in-vivo and postoperative STCD mismatch with the majority occurring on ulnar side of the distal radius. The cause of this discrepancy may arise from the technical error while using the depth gauge, is comminuted dorsal radial cortex, firm fixation of the plate using proximal cortical screw and limited standard anteroposterior and lateral view by fluoroscopic images. We should select even shorter screws from in-vivo measurement.

R. Fujitani 1, Y. Dohi 1, S. Omokawa 2, Hiroshi Ono 2, Y. Tanaka 3

1 Department of Orthopedics, Ishinkai-Yao General Hospital, Japan; 2 Department of Hand Surgery, Nara Medical University, Japan; 3 Department of Orthopedics, Nara Medical University, Japan

Objective Fluoroscopy is used as the gold standard intraoperatively for the estimation of articular congruency for distal radius fractures (DRFx). However, impacted intra-articular fragments are difficult to judge under fluoroscopy. The purpose of this study was to arthroscopically assess the articular reduction after fluoroscopic open reduction and internal fixation of DRFx with impacted intra-articular fragment Material and Method Since 2014 to 2017, a total of 176 consecutive patients with intra-articular fractures were enrolled. Computed tomography (CT) scanning was obtained for all acute DRFx if articular incongruity is present or suspected. From a list of CT scans, we identified 13 CT scans that had impacted intra-articular fragments according to the classification by Medoff R. There were 6 women and 7 men with an average age of 59 years (range, 24-76 y). A flexor carpi radialis approach to the distal radius was used, the fracture was reduced using standard extra-articular techniques, and reduction was verified by fluoroscopic image. Once the reduction was deemed satisfactory by fluoroscopic imaging, a volar locking plate was applied. After the plate fixation, the reduction was assessed arthroscopically. A standard radiocarpal and mid carpal arthroscopy was performed. Step and gap deformity were then measured using a calibrated probe at the point of maximum displacement, even if this represented a small portion of total fracture line. In the preoperative CT scanning, we recorded whether there was a volar rim fracture fragment and the number of intra-articular fracture fragments based on the classification by Medoff R. Pre and intraoperative radiographs were examined teardrop angle. Single linear regression analysis was conducted to elucidate the association between the intraoperative teardrop angle and intraoperative arthroscopic parameters. A p value of ≦0.05 was considered significant. Results A volar rim fracture fragment was found in 12 of the 13 patients. The mean number of intra-articular fracture fragments were 4.7 (range, 4-5). The intraoperative gap was averaged 1.2 mm. The average step off was 1.3mm, and the averaged gap + step off 2.5mm. The average teardrop angle were 38.1°at preoperatively and 48.8°intraoperatively respectively. Linear regression analyses revealed that the intraoperative teardrop angle had a significantly negative correlation with postoprerative gap + step off in arthroscopy (R2=0.30, p=0.05). Conclusion We found that 12 of 13 patients had an articular step-off of more than 2 mm with arthroscopy evaluation, although the articular surface appeared anatomically reduced under the fluoroscopy. Arthroscopic reduction and fixation for optimal treatment for impacted intra-articular fragments of DRFx might be needed. Almost patients had volar rim fragment and more than 4 of intraarticular fragment. Increase of the intraoperative teardrop angle significantly corresponded with decrease of intraoperative gap + step off in arthroscopy. The teardrop angle measurement may be useful in intraoperative radiographs as well as intraoperative arthroscopic assessment.

Kozo Morita

The Department of Orthopaedic Surgery, International Goodwill Hospital, Yokohama, Japan

Objective : In recent years, various type plates for the distal ulna fractures (DUF) are developped. but we don’t know which type of plate is better to fix DUF. The purpose of this study is to compare different mechanism plate fixation for DUF with concomitant the distal radius fractures (DRF). Methods : A retrospective study was conducted to identify patients who had been treated with plate fixation for unstable displaced DUF with concomitant ipsilateral DRF was also treated operatively. 23 patients were identified with an average age of 66.9 years (range, 52-86 years) and with follow-up averaging 14.4 months (range, 9-20 months). Fracture types were classified type1: 7, type2: 1, type3: 10, type4: 5 cases in Biyani’s classification. We clasiified the cases into 2 groups : treated with fixed angle plate (FAP) (Stellar hook plate, HOYA technology, Tokyo, Japan) (HP group: 11cases) or polyaxial locking plate (Aptus2.5 distal ulna plate, Medartis, Basel) (PLP group: 12 cases) . We performed statistical comparison about radiological and clinical assessments between 2 groups using Mann-Whitney U-test. Results : All distal radius and ulna fractures united. In the average radiological parameters, range of motion, grip strength, Mayo’s wrist scoring system, the results were both satisfactory and they weren’t statistically significant. There were no severe complication. Conclusion : Both plate fixation for unstable DUF in the setting of an associated DRF, resulted in union, retaining to excellent alignment ,wrist motion and clinical assessment. There were no statistic difference between the two plate fixations. Both plate fixaition could stabilized unstable DUF by subchondral support, and exercize same post-operative therapy similar to that in the case of unilateral DRF.

J. Canosa, Ch. Gordo, J. Domingo, C. Esteve

Orthopaedic SErvice, Hospital del Vendrell, Tarragona, Spain

INTRODUCTION: Distal radius fractures (DRF) in people older than 65 years should be considered as a first alarm signal of an underlying osteoporosis (OP). DRF that occut between 65 and 75 years old are located in the "optimal segment" fior the realization of a detailed and rigorous study of the hideen OP because these patients are in a state of health that allows ample possibilities of implantation of a global paln of intervention anb prevention of a second fractures. We conducted a propective study of 15 patients diagnosed of DRF and treated in our Service and analyzed parameters that show that all of them have multiples "osteoporotic factors" that had not been previously shown. MATERIAL AND METHOD: Serie of 15 patients diagnosed with DRF. Ages between 65 and 74 years old. We revised of comorbilidities (CM) already diagnosed. Review of the consumption of drugs that interact wiht phosphocalcic metabolism and related to increased risk of fractures (corticosteroids, hynotics amb proton pump inhibitors. Radiological study of spine has been performed. BMD indication as part of the initial study. RESULTS: 13 women and 2 men. CM. 8 diabetes, 5 thyroid disfunctions and 4 renal insufficiencies. Combined 8 patients registered 1 CM, 4 with 2, 2 wiht 3 and 1 with 4. Drugs: corticosteroids 2, hypnotics 5, inhibitos of the proton pump 10. Spinal X_Rays: 6 patients with 1 or several dorsal or lumbar fratures not previously diagnosed. BMD at the diagnosis time: femur Z less than -2.5 7 patients, lumbar inferior to -2.5. 5. CONCLUSIONS: It reveals necessary to consider patients older than 65 years diagnosed with DRF as a "osteoporotic patients" The environment of osteoporotic requires a detalied study in order to determine the existence of comorbidities related to bone fragility, the presence of vertebral fractures and the consumption of "osteopenci" drugs. These paciente must be categorized within the group of "complex chronic patients". From the complete study of all the exposed parameters we can make a "map" that will allow us to elaborate a multidisciplinary action plan in order to reduce the future risk of new fractures.

Jaesung Lee, Hyungseok Jung, Donghoon Lee

Chung-Ang University Hospital, Seoul, South Korea

Introduction: Only volar approach is not always enough to provide anatomical reduction of the articular surface and secure fixation of dorsal fragment. The purpose of this study was (1) to provide a surgical technique about combined volar and dorsal approach for complex intra-articular distal radius fracture and (2) to assess the clinical outcomes. Methods: Combined approach was performed to 19 patients (6 males and 13 females, mean age 55.8) with AO C2,C3 comminuted intra-articular distal radius fractures. All patients were enrolled the following inclusion criteria: (1) have a free articular fragment without connection with a metaphysis, (2) distal migration of dorsal fragment or (3) impacted bony fragment within a radiocarpal articulation. Also, patients could be available for a minimum of 1 year follow up. 7 patients were treated by combined volar and dorsal plate fixation and the other patients were treated by volar plate fixation and dorsal approach (intra-articular reduction and fragment excision). Quick-DASH score, Mayo wrist score (MWS), VAS, range of motion, bone union time and any complication were evaluated. Results: 15 patients were AO type-C3 fractures, and 4 patients were AO-type 2 fractures. Mean follow-up period was 29 months and 3 patients were lost. Overall Quick DASH score averaged 20 and Mayo wrist score averaged 75 of being 5 excellent, 4 good, 8 fair and 2 poor. VAS averaged 2.4. All 19 patients showed bony union, the average union time is 8.2 weeks. Mean volar flexion was 47, dorsiflexion was 65, supination was 71, and pronation was 76. The patients who underwent dorsal approach for fragment excision showed better range of motion. Conclusion: Combined volar and dorsal approach for AO type C2,C3 can be a good option for good functional outcomes and further study about indications when dorsal approach should be done will be needed.

Sang-uk Lee, Ki-tae Na, Won-woo Kang, Jong-yoon Lee

Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea

Objective: Complex regional pain syndrome (CRPS) is a severe complication that affect as many as 10% of all patients with distal radius fracture (DRF). The pathophysiology of CRPS still unclear. Vitamin D regulates calcium and phosphorus absorption and plays a central role in mineralization, growth and remodeling of bone. Vitamin D deficiency causes osteomalacia in adults and chronic deficiency leads to increased bone turnover rate and progressive bone loss. In CRPS type I, patch osteoporosis due to osteoclast hyperactivity is a common radiographic finding. However, the relationship of vitamin D and CRPS type I is still unknown. The purpose of this study was to prospectively investigate the serum levels of vitamin D between CRPS group and control group. And the influence of vitamin D and other factors on the incidence of complex regional pain syndrome type I after fracture after distal radius fracture (DRF). Methods : A total of 62 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. We excluded patients who had gastrointestinal disease or renal disease. Because these factors could affect vitamin D level. We also excluded patients who had been taking vitamin D or osteoporosis medication at the time of injury. We used Budapest criteria to diagnose CRPS type I. The Budapest criteria require continuing pain disproportionate to the inciting event, symptoms in at least 3 of 4 sensory, vasomotor, sudomotor/edema, and motor/trophic categories, 2 or more signs at the time of evaluation, and absence of a plausible alterative diagnosis. The CRPS group was defined as patient with CRPS type I after surgically treated DRF (22 patients), the control group was defined as patients without CRPS type I after surgically treated DRF (40 patients). The factors assessed for the development of CPRS I were age, gender, the body mass index, the serum vitamin D level, alkaline phosphatase. A multivariate logistic regression analyses were conducted to identify independent predictors of CRPS I development after surgery for a distal radius fracture as well as to identify confounding effects of variables. Statistical significance was accepted for p<0.05. Results: The age of two group was similar (mean and standard deviation [SD], 67.25 ± 12.09 years versus 67.23 ± 10.06 years). Body mass index and alkaline phosphatase between CRPS group and control group are similar also. (21.99 ± 5.03 cm/kg versus 23.76 ± 3.07 cm/kg, 130.64 ± 84.05 U/l versus 147.32 ± 103.28U/l) The CRPS group was slightly lower vitamin D level than the control group (18.70ng/mL ± 6.38 versus 20.04ng ± 9.33) without statistically significance (p=0.55). According to the multivariate analysis, sufficient vitamin D and low alkaline phosphase did not reduce the incidence of CRPS. Conclusion: This study demonstrated that in patients with a distal radius fracture, the serum vitamin D level is not associated with the incidence of CRPS I.

Ajmal Ikram

University of Stellenbosch, Tygerberg Hospital Cape Town, South Africa

Aims of study: Assess and compare the functional and radiological results in patients treated with the dorsal locking plate (DLP), Volar Locking Plate (VLP) and Fragment Specific fixation (FSF) of distal radius fractures Method: All patients who presented to our institution with complex intra- articular distal radius fractures had C.T scan of the radius according to the fracture pattern either had volar lock plating or Fragment specific fixation or dorsal locking plate fixation of the distal radius. Dorsal radius locking plate was used for following indications, 1. Dorsal Barton fractures 2. Comminuted dorsal rim fracture of the distal radius 3. Suspected SL ligament injury with distal radius 4. Early intra-articular mal-united fractures needing intra-articular osteotomy These patients were then asked to be followed up at 2 weeks, 6 weeks, 3 months 6 months and 12 months. The radiological parameters, i e radial height, inclination and tilt were compared as well as the functional outcomes by means of DASH score. Incision size and tourniquet times were recorded. Complications were reviewed. Results: Currently we have included 12 patients each group. At 12 months the average DASH scores are 11. Tourniquet time is comparable in VLP and DLP group and longer in FSF patients. The radiological parameters are statistically comparable. We will be presenting our early results. Conclusion: Fixation of the distal radius fractures with dorsal plate allows direct visualization of joint cartilage to obtain anatomic reduction and assessment of intercarpal ligaments. Earlier dorsal radius implants had high complications but the new design and locking screws may allow stable fixation to get early range of movements as with other methods of fixation

Belén García-Medrano, Clarisa Simón Pérez, Blanca Ariño Palao, Gonzalo Martínez Municio, Miguel Ángel Martín-Ferrero

Hospital Clínico, Valladolid, Spain

INTRODUCTION The DRUJ instability, secondary to a distal radius fracture, causes pain in the ulnar border of the wrist, weakness and restriction of the range of motion. The severity of the fracture pattern and the magnitude of its displacement have been described as risk factors for DRUJ injury. MATERIAL AND METHOD Recording of fractures of distal radius, surgically synthesized with volar plate, in the period 2013-2015. Those that presented a fracture of the ulnar styloid base and / or sigmoid cavity were selected. Preoperative characteristics: epidemiological (age, sex, dominance, etiological mechanism), radiological (AO and Frykman classification, ulnar variance, volar tilt, radial inclination, radial translation, sagittal translation, DRUJ gap), postoperative (VAS, range of motion, grip / clamp strength, signs of DRUJ instability, malunions, ulnar styloid pseudoarthrosis). RESULTS 24 patients, 92% women, 11 of them with a sigmoid cavity fracture, 69 years on average, 22 low energy trauma. Classification: 71% of the fractures are included among the types AO A2, B3 and C3; 67% between types 2, 7 and 8 of Frykman. Mean preoperative radiological measurements: ulnar variance +2.42; volar tilt 20.69°; radial inclination 15.63°; sagittal translation 0.23; radial translation 0.17; DRUJ gap 1.39. Postoperative: VAS 1; 71.15º palmar flexion; 78,46º dorsal flexion; radial deviation 23,85º; ulnar 24.62º; 92% completed prono-supination; 4 cases of DRUJ crepitus and 2 of pain; grip strength 18.77 kg, clamp 6.31; 17% malunions and 46% pseudoarthrosis of the ulnar styloid. CONCLUSIONS The initial radiological study of a distal radius fracture can guide the risk of postoperative DRUJ instability. Although if radius reduction is correct, the percentage of secondary clinical instability decreases significantly.

Seoung-Joon Lee, Se-Bong Oh, Jung- Ho Lee

Department of Orthopedic Surgery, Konkuk University, School of Medicine, Seoul, South Korea

Objective : Distal radioulnar joint (DRUJ) instability commonly occurs in association with distal radius fractures. Injury of the triangular fibrocartilage complex (TFCC) associated with distal radius fracture can result in DRUJ instability. When treating a distal radius fracture, it is important to detect TFCC injury to prevent DRUJ instability. The purpose of this study is to evaluate the instability of DRUJ in distal radius fractures through dorsal stress radiography comparing the affected and unaffected wrist. Methods : 49 Patients who had distal radius fracture fixed with volar locking plate was enrolled. Patients with both radius fracture, previous distal radius fracture or those with distal radio-ulna osteoarthritis were excluded. Dorsal stress radiograph was evaluated on both injured wrist (affected) and non-injured (unaffected) wrist. Under general anesthesia, dorsal stress radiography of DRUJ was performed on unaffected wrist. After fixing distal radius fracture with volar locking plating, dorsal stress radiography of DRUJ was performed. Ulnar head translation ratio (UTR) was measured through the dorsal stress radiograph. Arthroscopic exam was done on all of the affected wrists to classify TFCC injury according to Palmer classification. Ulna styloid fracture was also classified to evaluate the correlation with UTR. We performed Pearson’s correlation analysis, logistic regression and Wilcoxon rank sum test using R program Results : 49 patients (Male; 14, Female; 35) were participated in this study. The average age was 59.1 years (19 to 86). UTR of affected wrist was significantly associated with TFCC injury palmer type Ib with age and gender-independent manner. Ulna styloid base fracture was significantly associated with UTR of affected wrist when only adjusted with age or gender. And as UTR difference between the affected and unaffected wrist enlarged it revealed significant tendency of DRUJ instability due to TFCC injury palmer type Ib. Conclusion : UTR difference between the affected wrist and unaffected wrist shows a strong correlation in detecting peripheral TFCC injury. We think that UTR measured from dorsal stress radiography of DRUJ in distal radius fracture patient could be a useful tool to evaluate the instability of DRUJ.

Daniel Vilcioiu 1,2, Dragos Zamfirescu 2, Florin Safta 1, Fabian Klein 1, Alexandru Firicel 1, Carol Birisiu 1, Ioan Cristescu 1

1 Clinical Emergency Hospital of Bucharest, Romania; 2 Zetta Clinic, Romania

Objectives. The current study investigated the incidence of complications after volar plating for distal radius fracture. We present our protocol in management of this complications and compare the results Material and methods. Between october 2016 and august 2017 a total of 57 patients treated for distal radius fracture were investigated. The patients, women and men, were older than 24 years and were observed for at least 12 weeks after surgery with a volar locking plate.   Results. The fracture consolidation rate was 100% but we found complications in 8.7% of the cases. The complications included carpal tunnel syndrome, volar escape, and tendon rupture or irritation (extensor pollicis llongus and flexor pollicis longus). Conclusions. The use of volar locking plates for surgical fixation of distal radius fractures has become very popular. However, several complications associated with this type of surgery have been reported. The implant should be well positioned, the screws should have appropriate length and some special tips and tricks should be used.

Kanwal Cheema, Raghunandan Kanvinde

Ysbyty Gwynedd, Bangor, Wales, United Kingdom

Objective: Open reduction and internal fixation is commonly accepted to be the ‘gold standard’ when treating distal radial fractures with radio-carpal joint disruption as absolute stability is provided and they have few complications. Methods/Results: In this case, a 63 year old female with rheumatoid arthritis had fallen sustaining an intra-articular distal radial fracture managed with a volar locking plate. The post-operative radiographs were satisfactory as were those taken during routine follow-up appointments. However, she presented to us after a further fall 8 years later that had resulted in failure of the plate and a consequent comminuted fracture at the distal radius. The hardware was removed, the fracture was reduced and an 8 hole volar locking plate was used to hold the reduced position. The post-operative radiographs were satisfactory and she has made a good recovery with full return of function. Conclusion: Mechanical failure of distal radius volar plates is a rarely reported complication, and all previous cases have reported failure within 12 weeks of fixation. To the best of our knowledge, late failure for this type of fixation has not previously been reported. This case study highlights late hardware failure as a potential complication that surgeons should be aware of when considering the options for fixation and when undertaking this commonly performed procedure. This is of particularl importance in those with poor bone quality as severe comminution at the time of re-injury may ultimately require wrist arthrodesis, a procedure requiring prolonged rehabilitation to allow continued function with a limited range of movement.

Karim Latrach Tlemsani, Teka Maher, Sabeur Saadi, Hamza Kefi, Yadh Zitoun, Faouzi Abid

University Hospital of Mahdia, Tunisia

Objective Dupuytren’s disease is a benign fibroproliferative disorder that paradoxically progresses to permanent flexion deformity of palmar joints and functional impairment. Despite the development of non-operative techniques, regional selective fasciectomy remains the gold standard. Methods In a retrospective study, a total of 25 patients, including 20 men and 5 women, were submitted from January 2007 to December 2011 with the diagnosis of Dupuytren's disease. All of them have exclusively performed regional selective fasciectomy. We managed 93 rays. Surgical treatment was indicated whenever the hand cannot be placed flat on a table. The mean follow-up duration was 18 months. We used Revised Tubiana’s Staging System and URAM scale to evaluate functional outcomes. Results The mean age was 57 years old with male predominance. Surgical treatment was performed in only 28 hands including 44 rays. The outcomes were excellent in 25 hands treated and good in the 3 remaining. All treated rays have been improved with a gain, at least, for one stage. A complete improvement (stage 0) was achieved for all the rays initially rated at I and II which are 35. The nine rays preoperatively rated at stage III have all gained 2 stages (passage to a stage I). In our series, we noticed only 5 cases of early complications quickly curbed. Late complications were dominated by algodystrophy with a total of 4 cases. We reported only one case of proximal interphalangeal joint stifness. No recurrence was recorded. Conclusion The management of Dupuytren contracture relies yet on surgical procedure. Selective fasciectomy offers better functional results with lower rates of complications and recurrence. However, the functional outcome remains significantly correlated with the preoperative status of the disease.

Ireneusz Walaszek 1, Elżbieta Gawrych 2, Justyna Rajewska-Majchrzak 2, Karolina Rosołowicz 1

1 Department of General and Hand Surgery Pomeranian Medical University, Szczecin, Poland; 2 Department Of Pediatric Surgery and Oncology Pomeranian Medical University, Szczecin, Poland

Dupuytren's contracture is a proliferative connective tissue disease, which affects the palmar aponeurosis. Although it is considered to be primarily a disease acquired in adulthood a few pediatric cases have been reported in literatur. The 16 year-old patient presented to our out-patient clinic with a decade-long history of right little finger contracture. The patient was otherwise symptom-free, but according to the patient’s parents the contracture has been progressively increasing in severity and they were anxious to exclude malignancy. Examination revealed a 90 degree contracture at the proximal interphalangeal (PIP) joint with a palpable, fibrous cord, approximately 3-5mm thick and 3 cm long extending along the ulnar aspect of the affected finger. There was no sensory or vascular impairment nor was there limitation in the PIP joint The ultrasound examination revealed a typical solid, hardened, fibrotic mass in the subcutaneous tissue. The patient underwent a local fasciectomy, which was performed in a typical manner. During the procedure a typical fibrous cord, attached proximally to lateral digital sheet and distally to Grayson”s ligament, was exposed and excised. Digital nerves and arteries were also identified. After the removal of fibrotic corda a full extension of pip joint was obtained and no need for arthrolysis was accounted. The excised mass was sent for histological examination which confirmed the diagnosis of Dupuytren's fibromatosis. The surgical incision healed with no complications. At a 6-month follow-up no recurrence of was noted. It is a worth to highlight the fact that the patient was qualified for surgery despite the absence of symptoms. Such a procedure, other than in the case of adult patients, was dictated to excude the development of the neoplasm instead of contracture. Dupuytren's contracture is a rare disease in children, and each tumor of soft tissue in young patients should raise oncological alertness. In such case, surgical treatment along with subsequent histological examination seems to be mandatory , particularly with the short history of the growth.

Sonja Elisabeth Pelzmann

Institute for Physical Medicine and Rehabilitation, Wilhelminenspital, Vienna, Austria

OBJECTIVE: Application of orthoses are an essential part of treating patients with Dupuytren´s disease, especially after surgery, collagenase injection treatment or as an conservative option. The goals of treatment are the retrieval of normal range of motion and an adequate hand function. Research on the effectiveness of orthosis and their use is poor. This review provides a synthesis evaluating the scope of research on use and implementation of orthosis treatment in clinical practice. METHOD: Multiple electronic databases and journals which are handling with orthosis treatment in this disease were searched for available information. The studies were classified using the Oxford Level of Evidence and the Structured Effectiveness Quality Evaluation Scale (SEQES). RESULTS: Different types of orthosis with different utilization are applied in the 31 analyzed studies (two RCTs two CCTs, one Delphi study, five review reports, 13 ODs, eight expert opinions). The sample size of the studies had a range from four to 268 patients. The Level of Evidence (Oxford) of included articles ranged from Ib to V. The ratings of the SEQES-Score ranged from six to 43. The authors gave information about wearing of orthosis in a range of two weeks to six months. In general, evidence for the effectiveness of hand therapy in range of motion, physical function, and satisfaction was not found. CONCLUSION: The effect of orthosis treatment is rarely investigated or researched in common with the surgical or the pharmacological intervention. Thus is difficult to determine the effect of the method of orthosis treatment and the contribution on treatment outcomes. The nonexistent heterogeneity of disease history, small sample size of studies, and short follow-ups are also reasons for these results. There is a need for more high quality studies examining the methods of orthosis treatment in regards to effectiveness. LEVEL OF EVIDENCE: V

Rasmus Wejnold Jørgensen, Lars Solgård, Jens-Christian Vedel, Claus Hjorth Jensen

Hand Clinic, Department of Orthopedics, Herlev-Gentofte University Hospital of Copenhagen, Denmark

Objective Complications following fasciectomy for Dupuytren’s Disease (DD) include digital nerve injury, wound healing complications, necrosis, hematoma formation and infections. The purpose of this study was to evaluate the number of postoperative complications, and hematomas in particular following fasciectomy for DD. Methods 362 patient charts were retrospectively reviewed. Postoperative events were recorded. Student T-test was used for numerical values. Chi-Square and Fisher’s Exact test was used for binomial outcomes. P<0.05 was considered statistically significant. Results No patients had ongoing treatment at the time of follow up (1-3 y). The mean age at follow-up was 67.6 years (SD 9.1, range 34-95 y). There were 43 wound defects (11.9 %), 27 hematomas (7.5 %), 14 recurrences (3.9 %) and 11 infections (3 %) postoperatively. Those with postoperative hematoma had a mean of 9.75 (SD 4.2) outpatient visits postoperatively, those without had 3.71 (SD 2.8), P<0.0001. Infections occurred in 2.3 % of patients without postoperative hematoma and in 16.7 % of patients with postoperative hematoma, P=0.0065. There were no differences in wound defects or recurrence rates when comparing patients with postoperative hematomas to those without, P>0.05. The use of anticoagulants, the use of tobacco or whether the patients were operated on by junior doctors under supervision did not vary on any parameters, P>0.05. Operating on three or more fingers in one setting compared to one or two fingers resulted in more postoperative outpatient visits (P=0.007), wound defects (P=0.049), and hematomas (P=0.012). Conclusions Operating on three or more fingers leads to more complications and should be avoided when possible. A postoperative hematoma results in significantly more postoperative outpatient visits and more infections.

C Simón-Pérez 1, J Alía-Ortega 1, B García-Medrano 1, JI Rodríguez-Mateos 2, M Brotat-Rodriguez 3, H Aguado-Hernandez 1, MÁ Martín-Ferrero 1

1 Hospital Clínico Universitario de Valladolid, Valladolid, Spain; 2 Hospital Universitario Rio Hortega Valladolid, Spain; 3 Hospital Rio Carrion Palencia, Spain

Purpose: To determine the recurrence rate, possible adverse reactions and factors influencing recurrence and progression of Dupuytren’s Disease (DD) treated with Collagenase from Clostridium Histolyticum (CCH). Methods: Prospective study, 71 patients with DD treated with CCH from 2011 to February 2013, with a minimum follow-up period of 4 years. Clinical, functional, patient satisfaction, drug safety and factors influencing recurrence and disease progression were evaluated. Results: In all patients, the rupture of the cord was achieved after the injection, reducing joint contracture. In 5 patients (7%) we verified the existence of disease recurrence during the follow-up. In 11 patients (15.5%) there was a disease progression with a significantly lower degree of finger retraction than prior to injection, except in one patient. Three patients have been surgically operated, with no surgery difficulty; the rate of recurrence and progression was higher in grades III and IV of Tubiana, in proximal interphalangeal (PIP) punctures, and was earlier in patients younger than 65 years. Conclusions: The recurrence or progression of DD is mainly observed in young patients with greater severity of the disease and at the PIP level. Patients with the lowest rates of recurrence and progression were those with a single cord in the metacarpophalangeal (MCP), a grade II of Tubiana and were older than 60 years.

Steven Roulet, Jacques Guéry, Jacky Laulan

Hand Surgery Unit, Department of Orthopedic Surgery 1, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours, France

Objective : The objective of this study was to evaluate the results of treatment of Dupuytren disease by extended fasciectomy with the McCash open-palm technique. Methods: In 2003, 40 consecutive operated patients were assessed by an independent evaluator. Twelve patients were Tubiana stage 1, 16 stage 2, 9 stage 3 and 3 stage 4. They were again examined in 2016 by a second evaluator who was unaware of the clinical results in 2003. Results: Forty cases were evaluated. There had been no peroperative or postoperative complications. At the first assessment, mean follow-up was 7.32 years (range, 4.26 to 12.5 years). Recurrence occurred in 7 patients (17.5%) and extension of the disease in 15 (37.5%). Mean extension lag was 19.3°. Average improvement in finger extension was 53°. Thirty-four patients (85%) considered that their result was stable over time. On the second evaluation, 21 patients were examined with a mean follow-up of 21.50 years (range, 18.7 to 26.3 years). None of them had been re-operated and no extension of the disease was observed. No recurrence occurred in patients who had no recurrence in 2003. However, the disease had worsened in five patients (23.8%) of whom 3 already had a recurrence in 2003. Mean finger extension lag was 31.8°. Twenty patients (95.2%) had no functional impairment, and one (4.8%) a moderate disability. Twenty patients (95%) considered that their result was stable over time. Eighteen patients (85.7%) were very satisfied and 3 (14.3%) satisfied with the procedure. Three patients would not repeat the procedure, including two who experienced recurrence. Conclusions: CRPS was the primary cause of failure and poor results. The number of operated rays was the only statistically significant factor of poor outcome and overall loss of mobility, especially for the proximal interphalangeal joint.

Takuya Yokoi 1, Takuya Uemura 1, Kenichi Kazuki 2, Ema Onode 1, Kosuke Shintani 1, Mitsuhiro Okada 1, Hiroaki Nakamura 1

1 Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; 2 Gakuen-minami clinic, Nara, Japan

The ratio of the lengths of the second and fourth digits (2D:4D) has been described as reflecting endogenous prenatal androgen exposure. In general, 2D:4D is lower in men than in women and has potential as a biomarker or predictor for various diseases, athletic ability, and academic performance. Dupuytren disease has digital flexion contractures and is known to predominate in men, but the pathogenesis of the disease remains unclear. To clarify the relationships between Dupuytren disease and endogenous androgens, we performed a retrospective analysis of hand radiographs to investigate 2D:4D in Dupuytren disease. The study included male patients with Dupuytren disease (n = 22) and a control group (n = 18) of male patients with carpal tunnel syndrome. Only unaffected hands, without contractures or osteoarthritis, were evaluated for the purpose of radiographic assessment. The lengths of the phalanx and metacarpal bones in the second and fourth digits were measured by 2 independent observers who each performed 2 sets of measurements separated by a minimum 1-week interval. The 2D:4D was calculated separately for the phalanges and metacarpals, and a combined (phalanx + metacarpal) 2D:4D was also calculated. The reliability of the observer measurements was established using the intraclass correlation coefficient, and both the intra- and interobserver reliability showed excellent agreement. We found that compared with control group, the Dupuytren disease group had significantly lower phalanx and combined 2D:4D. These findings suggest that endogenous prenatal androgens could contribute to the development of Dupuytren disease, leading to its characteristic clinical presentation predominantly in men and affecting the ulnar rays.

Kazuya Odake1, Masaya Tsujii1, Takahiro Asano1, Haruhiko Satonaka1, Akihiro Sudo1

Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Japan

Objective Pathophysiology of Dupuytren’s disease (DD) remains unclear. Thrombin is a multi-functional serine protease and a potent inducer of fibrogenic cytokines in various cells. Osteopontin (OPN), one of ECM proteins, can also modulate a variety of cellular activities associated with various chronic inflammatory disease including myocardial fibrosis after ischemic heart disease, liver cirrhosis and lung fibrosis. Additionally, the thrombin-cleaved form of OPN is well correlated with various inflammatory disease activities. We herein presented that myofibroblast expressed OPN, especially of thrombin-cleaved form, and fibroblasts derived from Dupuytren’s fascia were differentiated into myofibroblasts by the administration of thrombin. Methods The study group was composed of 25 patients (4 women and 21 men) who underwent resection of the palmer fascia for DD. The patients’ mean age was 69.1 years (range, 58 to 82 years). All patients signed an informed consent document, and the study was approved by the institutional review board. The palmer apponeurosis resected in carpal tunnel release were used as control. Immunohistochemical studies were performed on serial sections with antibody against αSMA, OPN and thrombin cleaved-form of OPN. For the determination of effect of thrombin on DD, cells isolated from nodules and cords were starved in serum-free medium overnight prior to treatment with thrombin, 1 U/ml. After 24 hours, expression of αSMA and OPN were analyzed in total proteins collected from cells using western blotting. Results Morphometric analysis in immunohistochemistry showed that expression of αSMA was significantly correlated with that of OPN in the nodules of Dupuytren’s fascia. In addition, there was respective expression of OPN and αSMA in 16 (67%) and 5 (20%) in cord of Dupuytren’s fascia. Furthermore, thrombin-cleaved OPN was also immunolabeled on similar areas with OPN in nodules of Dupuytren’s fascia, considered that the majority of OPN’s expression was thrombin-cleaved form in the nodules centered in the pathology. In vitro study, the proportion of myofibroblasts in cell cultures from nodule was 11.3%, compared with 4.6% in cord (P=0.011). Palmer fascia from control contained only 1.9% cells with expression of αSMA. After treatment of thrombin, expression of αSMA and OPN were clearly upregulated in the cells from nodules as well as cords, although there were weak expression of these molecules without application of thrombin. Conclusion The present study showed myofibroblast expressed OPN and thrombin cleaved-form in the nodules as well as cords of Dupuytren’s fascia, with significant correlation of αSMA’s expression. Lenga described that OPN was required for the differentiation and activity of myofibroblasts based on the experiment using OPN-null fibroblasts. Thus, OPN could involve in the pathologic progression by modulating the activity of myofibroblast in DD. In addition, our in vitro study showed the application of thrombin induced myofibroblast transformation from fibroblast of the nodules as well as the cords. Besides, expression of OPN was clearly upregulated in the cells from both nodules and cords. Thrombin in bleeding with the surgery may participate in the pathology of progression and recurrence by direct effect or indirect pathway via cleavage of OPN.

Fernando Menvielle, Macarena Layús, Sergio Daroda, Rodeolfo Cosentino, Paul Pereira

Clínica de la Mano, GAMMA, La Plata, Argentina

Objective The aim of this study was to evaluate the results of Percutaneous Needle Aponeurotomy (PNA) for primary Dupuytren’s contracture in relation to the maintenance of the total passive extension deficit (TPED) improved and to do a subjective evaluation of the results with the Disabilities of the Arm, Shoulder and Hand questionnaire (Dash). Material and Methods A review of all patients with Dupuytren’s contracture treated with PNA from 2008 to 2014 was performed. Patient demographics and digits affected was recorded. Pre-operative, immediate postoperative and final follow up total passive extension deficit was measured with standard goniometer and stratified by Tubiana classification system. Recurrence, defined as an increase of the passive extension deficit of 30° or more compared to the immediate postoperative measurement, and other complications were also noted. Statistical analysis was performed using paired t-test (statistical significance p-value <0.05). All patients completed the DASH questionnaire. 57 digits in 43 hands were treated with PNA. 38 patients were male and 2 were women. Average age was 62.6 years. Results The mean follow up was 42.6 months, ranging from 9 to 68 months. The average preoperative TPED was 79.6° and the average immediate postoperative was 8.16° (90% correction) p= 0.042. The average TPED at final follow up was 13.3° (83% correction) p=0.000.The results in relation to the maintenance of the TPED improved at the proximal interphalangeal joint were worse than those at the metacarpophalangeal. Two patients experienced a slightly diminished sensibility on one side of the finger. There were no flexor tendon injuries. Recurrence was observed in 11 digits of which 9 were reoperated in an average time of 33 months with a range of 10 to 52. The mean results of Dash questionnaire was 3.2% Conclusions PNA is a safe and effective technique in the treatment of Dupuytren’s contracture. Long term correction is better maintained in metacarpophalangeal than proximal interphalangeal joints.

Taichi Saito, Yasunori Shimamura, Shunji Okita, Toshifumi Ozaki

Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

Objective: Patient satisfaction is an essential measure of quality of care for Dupuytren’s contracture. Previous research demonstrated that patient satisfaction improves after fasciectomy for Dupuytren’s contracture. However, the relationship between functional recovery and satisfaction is not clear. The purpose of this study is to reveal the correlation between functional recovery and patient satisfaction after surgery. Methods: We observed 22 patients with 27 hands who had total fasciectomy from 2007 to 2016. A zig-zag (Bruner’s) incision was performed with 13 hands and a longitudinal incision with Z-plasty was performed with 14 hands. We examined grip strength, range of motion (ROM), patient satisfaction with hand function, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores and complications. We used Spearman coefficients to determine the correlation between objective measures of function and patient satisfaction. We also constructed receiver operating characteristic curves to identify optimal cutoffs in hand function that correspond with patient satisfaction. Results: Patents were followed for an average of 67 months after surgery. At the final follow-up, averaged grip strength and total extension deficit (TED) were improved from 31.0 kg to 36.2 Kg, and 78.7° to 17.6°, respectively. DASH was also improved from 7.3 to 0.8. After surgery, 72% of patients were very satisfied. One patient had a reoperation for recurrent Dupuytren’s contracture. TED after surgery was correlated with patient satisfaction. TED of 40° after surgery corresponded with very good satisfaction (sensitivity: 67%, specificity: 85%). Lack of improvement in grip strength was not correlated with postoperative patient satisfaction. The method of skin incision was also not correlated with satisfaction. Conclusions: Hand function was improved after fasciectomy. Most patients were satisfied with hand function and appearance. ROM corresponded with patient satisfaction in the postoperative period. The results of this study can help to adapt postoperative hand therapy protocols and goals to improve patient satisfaction.

Joachim Ganser, Moritz Scholtes

Department of Hand and Plastic Surgery, Kantonsspital Münsterlingen, Switzerland

Objective: Treatment for Dupuytren contracture in one or more finger rays with Collagenase Clostridium Histolyticum (CCH) becomes increasingly popular. With the last 4-7 years experience also adverse effects are being reported. These are local and systemic ones and allergic or non-allergic ones. As Dupuytren contracture is a localized disease (even in its manifestation as Morbus Ledderhose or Peyronie disease) and in itself not life-threatening, this study’s focus was set on systemic adverse effects possibly threatening the patient’s life or general medical condition. Methods: A retrospective study of 63 patients was performed based on patient charts, complete photo documentation and a subjective questionnaire. Patients were treated for Dupuytren contracture of one or more finger rays by injection of CCH between November 2014 and September 2017. Since January 2017, the majority of patient got two concurrent doses of CCH. Initial follow-up was performed until 6 weeks post injection. Patients were contacted in September 2017 and were invited to clinical follow-up. Results: Of the 63 patients, 47 (75%) returned the questionnaire and 17 (27%) followed invitation to clinical follow-up. Adverse effects, mainly seen within 2 days after injection, included either isolated or in combination: extensive ecchymosis up to the axilla and even one distant ecchymosis (eyelid), severe aseptic inflammation of the lymphatics, headache, pain in all extremities, chill, and dizziness. These complaints lasted up to 2 weeks. 1 frozen shoulder after CCH injection into the ipsilateral hand took 8 months to heal. 1 pulmonary embolism from a deep venous thrombosis of the lower leg occurred 3 weeks after injection. A bilateral basal pneumonia in an otherwise healthy and active patient, retrospectively diagnosed as probable pulmonary embolism, occurred 6 weeks after injection. 1 patient with known coronary heart disease died 6 weeks after injection, the cause of death was not further investigated. Conclusions: As a clearly visible effect, at least the local and distal ecchymosis after Collagenase Clostridium Histolyticum (CCH) injection could be related to affection on the vascular wall or to a disturbance of the blood coagulation system. Concerning pulmonary embolism and sudden death several weeks after injection, an adverse effect on the vessels or a coagulation disorder could be a possible explanation. Most of the adverse effects were not related to allergic reactions. On the other hand, the nature, the extent and the degree of the adverse effects was not related to the amount of CCH (one or two doses). Nevertheless, patients afflicted by a more severe adverse effect were not offered a second or third CCH injection of another or recurrent Dupuytren cord. Confronted with the major adverse effects we saw after CCH injection, we would like to propose further research regarding its systemic effects on vessels and the coagulation system.

Luca Lancerotto, Chris Garrard, Dominique Davidson

Edinburgh Hand Unit, Department of Plastic Surgery, NHS Lothian, UK

Objective: Percutaneous needle fasciotomy (PNF) is a minimally invasive option to treat Dupuytren’s palmar cords, but carries some risk of injury to digital nerves (DN). We performed an anatomical study to identify danger zones where extra care is advisable. Methods: the palm of 6 hands was dissected to investigate the relative position of DNs and longitudinal fibers of the palmar aponeurosis. Results: the index radial and little finger ulnar DNs lie along the outer boundaries of the palmar aponeurosis. The common DN to middle and ring fingers runs between the respective tendons, not crossing longitudinal fibers. The common DN to ring and little fingers originates from the ulnar nerve lateral to the little finger flexors and moves to the radial side where it lies proximally to the transverse fibers. It crosses tendons deeply and longitudinal fibers superficially mid-way between the distal margin of the carpal tunnel and the transverse fibers. The common DN to index and middle fingers less predictably crosses the flexors of the middle finger distal to the carpal tunnel. The 3rd ray pretendineous band does not exactly lie above the tendons, and the crossing with the band can be more distal. The DNs to the thumb emerge from the carpal tunnel at the intersection between the radial margin of the palmar aponeurosis and the distal border of the FPB, along which they proceed. Conclusions: we identified two “danger zones” for nerves during PNF. One more constant, where the common DN to the middle and ring fingers crosses the longitudinal fibers of the 5th ray. One more unpredictable, for the common DN to the index and middle fingers. PNF in the 1st web space should be safe if performed within and at some distance from the distal margin of the FPB and a line along the radial margin of the index finger.

Issei Nagura 1, Takako Kanatani 1, Yoshifumi Harada 1, Masatoshi Sumi 1, Atsuyuki Inui 2, Yutaka Mifune 2, Ryosuke Kuroda 2

1 Department of Orthopaedic Surgery, Kobe Rosai Hospital, Kobe, Japan; 2 Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan

Objective The technical instruction leaflet for collagenase injection recommends a “2-3mm depth” of injection, however, there is little supporting evidence. We consider that collagenase injection into the middle of the cord is optimal to avoid the possible complications of skin laceration or flexor tendon rupture. This study investigated using the long axis images of ultrasonography as a tool to determine the appropriate injection depth. Methods Sixteen male patients with Dupuytren’s contracture with a mean age of 72.2 years (range; 57-87 years) were included in this study. All patients showed fixed flexion contracture (FFC) of the MCP joint caused by a palpable cord. We marked the collagenase injection point on the skin above the cord and added two injection points proximally and distally with a 2mm distance. Then we measured the distance from the skin to the middle of the cord by high resolution ultrasonography with long axis images (SNiBLE; Konica Minolta, Tokyo, Japan). Results The average distance from the skin to the middle of the cord was 2.4mm (range; 1.8-3.0). There was no difference of the distance among the three points. Conclusions Injection of CCH to an adequate depth is very important not only to obtain the maximum effect of collagenase but also to avoid possible complications. By using ultrasonography, we demonstrated that the distance from the skin to the middle of the cord was comparable to that described in the technical manual for the CCH injection namely “2-3mm depth injection is recommended”. Using long axial images was practical for the measurement of the three injection points at one time.

Wan-Sun Choi 1, Kwang-Hyun Lee 2, Kyeong-Jin Han 1, Joo-Hak Kim 3, Chang-Hun Lee 4, Sung-Jae Kim 5

1 Ajou Univerisity School of Medicine, Suwon, South Korea, 2 Hanyang University College of Medicine, Seoul, South Korea, 3 Myongji Hospital, Goyang, South Korea, 4 Eulji Medical Center, Eulji University College of Medicine, Seoul, South Korea, 5 Hallym University Dongtan Sacred Heart Hospital, Dontan, South Korea

Introduction: To date, there have been few reports on the nationwide population-based epidemiology of Dupuytren’s disease (DD). We investigated the prevalence and incidence of Dupuytren’s disease in South Korea using the large dataset provided by the Korean Health Insurance Review and Assessment Service. This study is the second nationwide epidemiological study of DD after the study in Taiwan. Materials and methods: Records of patients diagnosed with DD between 2007 and 2014 were extracted from the large dataset by diagnostic code searching (International Classification of Disease 10th revision code M72.0) and were included in the study. We calculated the prevalence and incidence of DD based on the total population of South Korea provided by the Korean Statistical Information Service. Diseases associated with DD and the trends in surgery for DD were also analyzed. Results: A total 16630 patients were diagnosed with DD during the study period. The mean annual prevalence was 32.2 per 100,000 population (41.8 per 100,000 for men, 22.5 per 100,000 for women). The mean annual incidence was 1.09 per 100,000 population (1.80 per 100,000 for men, 0.38 per 100,000 for women). The common diseases associated with DD were hypertension (30.5%), diabetes mellitus (26.7%), hyperlipidemia (20.4%), ischemic heart disease (7.9%), and cerebrovascular disease (4.6%). The mean annual proportion of the patients who had surgery for DD was 5.24% of all DD patients. Conclusions: The prevalence and incidence of DD in South Korea were as small as 1/1000–1/100 of the western countries; however, it was slightly larger than that in Taiwan.

Sinolichka Djambazova 1, Dusanka Grujoska 2, Darko Petreski 3, Natalija Cokleska 4

Hospital for Orthopedic Diseases University, Skopje, Macedonia

Prospective study of needle fasciotomy for Dupuytrens contracture with two-year follow-up Objective Needle fasciotomy is a relatively new alternative in selected cases of Dupuytrens contracture. The advantage of needle fasciotomy is a very short recovery combined with high cost effectiveness compared to open surgery. The purpose of this study is to report results of needle fasciotomy in respect to reduction of contracture, complications and early recurrence after two years. Methods This study is a prospective study of patients with Dupuytren’s contracture treated with needle fasciotomy. The indication was contractures of the MCP joint and specifically in stages I and II with well defined fibrosis. Needle fasciotomy is a procedure where the contracted Dupuytren’s tissue is divided transversely along multiple points so that the finger can stretch out straight again. The procedure is performed with a needle through the skin and the sharp, small bevel of the needle is used to cut the Dupuytren’s tissue beneath the skin. We also administer a corticosteroid injection to the treatment area at the time of the procedure. Stretching, exercises and extension splinting during the recovery phase are important to gain maximum benefit from the procedure. The patients were evaluated preoperatively and per-operatively at one, two, four, eight, twelve, twenty-four weeks, after one and after two years. 87 patients with 98 fingers were operated. One of the operated fingers had recurrence after needle fasciotomy. Median age was 59 (44-74) with 79 man and 8 women. Results No cases of flexor tendons lesions, hematomas or infections were registered. The degree of the contracture, grip strength, pain, complication, recurrence, need for re- operation and sick leave were recorded. The patients were allowed to use the hand for their work or daily activities directly after the procedure. Conclusions Needle aponeurotomy does not involve incisions to the skin of the hand, so there is less tissue damage, less swelling, less pain, less down time and quicker healing. Needle aponeurotomy does not require a hospital admission or sedation. Needle fasciotomy is a good alternative to fasciectomy in cases with well defined fibrosis because of these preliminary good results and low morbidity.

Franco Bassetto, Regina Sonda, Erica Dalla Venezia, Diego Faccio, Cesare Tiengo

Plastic Surgery Department, Padova, Italy

Objective Several pathogenetic hypothesis were described but no one seems to be singularly responsible for fascia proliferation in Dupuytren’s disease. The surgical approach aim to treat the macroscopic manifestation of finger retraction, often with aggressive approach needed in the most advanced disease stage. It became necessary to investigate the cellular Dupuytren develop to find out new therapeutic approach to permit a more sparing surgery and to treat all severe cases. In fact some clinical studies assess as, in addition to fascia, palmar skin and fat-derived cells may be a potential source of cells causing the Dupuytren disease. Based on this observation, the introduction of the fat graft palmar replacement by lipofilling technique joint to traditional aponevrectomy have shown promising long term good result. Matherial and Method A retrospective study was performed on patients treated for Dupuytren recurrence by aponevrectomy joint to a fat graft from abdominal region. 30 patients, with a medium follow up of five years, were treated in our Centre for Dupuytren disease. An aponevrectomy was performed in all cases according to traditional surgical approach with complete removal of affected fascia. At the end of the skin closure all the surgical site and the unaffected neighboring rays were filled by fat graft harvested from the abdomen (mean 12cc of fat graft for each patient). Primary endpoint of the treatment was to evaluate the skin texture, scar quality, the tendon and finger gliding, pain, discomfort and all technique-related complication and a secondary endpoint was to observe the recurrence of the disease Results The patients were evaluated long-term for a stable result. Three cases are actually at five years of follow up. Five cases were submitted to ecography evaluation. All cases are submitted to clinical evaluation in term of maintenance of low contraction grade, mobility, pain, sensibility, strength, scar condition. Only three cases presented recurrence after two years and slide tendon and finger functionality revelead a satisfactory result. Ecography evaluation at six months and one year demonstrated also the permanence of fat pad under superficial skin layer, providing a sliding tendon good environment and, overall, a barrier from affected surrounding fascia. Discussion Fat grafting is a common procedure in reconstructive and aesthetic surgery and commonly defined as “lipofilling”. It’s commonly employed in several clinical field for its filler role in volume replacement both overall for its stem cell content known as adipose derived stem cell (ADSC) and its capability to provide numerous cytokines. Furthermore, for such reason, several clinical experience were based on its utilisation also in severe Dupuytren treatment even for providing a viable subcutaneous fat capable to protect the neurovascular and tendon structure even for its possible role in modulating the fibroproliferative diathesis. Preliminary satisfactory results have represent a stimulating challenge to introduce this procedure as scheduled with possible future perspectives of numerously clinical data collecting, specific examination, long term follow up, molecular studies and useful guidelines for therapeutic purpose.

David J Hunter-Smith, Jessie Xu, Theodore Lam, Daniel Reilly, Michael P Chae, Vicky Tobin, Warren M Rozen

Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston Victoria, Australia; Monash University Plastic and Reconstructive Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria, Australia

Objective: Determine the safety and efficacy of injectable collagenase clostridium histolyticum (CCH) for advanced Dupuytren’s Disease Methods: Patients presenting with advanced Dupuytren’ Disease (Tubiana grade 3 or 4) of the 2nd through 5th rays that were unsuitable for or declined surgical management were offered treatment with collagenase injections. Baseline demographic and medical data were collected. In addition, total passive extension deficit (TPED) and patient-reported outcome measures (PROMS) were recorded prior to treatment, and at 6 weeks post-manipulation. Patients underwent a standard treatment protocol of injection D0 and manipulation D7 under local anaesthetic on an outpatient basis. Results were collected prospectively and analysed using paired t-test. Results: 33 patients (25 males, 80.7%) with a mean age of 68.4 years (range 49.8-87.1) have been treated to date. In 43% of cases the disease represented a recurrence. There was a significant improvement in TPED across all injected rays (p<0.001). In addition, patients demonstrated highly significant improvement in function and quality of life on Southampton (p=0.0004) and URAMS (p=0.000001) questionnaires. No major complications were encountered. Conclusions: Our data suggest that collagenase, as a treatment option, is safe to use in patients with advanced Dupuytren’s Disease. It demonstrates significant improvements in objective and subjective measures of hand function. Whilst surgery remains the mainstay of management for advanced disease, CCH is a viable alternative for patients in whom surgery is not appropriate.

Ioannis Antoniou, Kostas Banios, Vasilis Kontogeorgakos, Zoe Daliliana, Konstantinos Malizos, Sokratis Varitimidis

Department of Orthopaedic Surgery, University of Thessalia, Larissa, Greece

Objectives: Dupuytren's contracture affects significantly appearance and function of the hand. In advanced stages use of the hand is difficult and sometimes includes risks. Operative treatment includes percutaneous division of the palmar fascia, partial and total excision of the palmar fascia. The aim of this study is to present complications and the long term outcome in a large group of patients in whom the disease was treated with resection of the contracted palmar fascia, only in the affected rays. Methods: From 2000 to 2015, 214 patients (170 men and 44 women) with Dupuytren's contracture were treated with excision of the contracted palmar fascia in the affected rays, Mean age was 67 years (from 37 to 86). The dominant hand was affected in 136 patients. The ring finger was most commonly affected (139 patients). Eighty eight patients presented with two or more finger rays affected. The procedure was performed under anesthesia with axillary block and with a tourniquet application. All diseased tissues (contracted fascia, skin, digital ligaments) were dissected and excised with great caution in the affected rays. Excision of the contracted tissues at the proximal phalanx was carried out in all patients to restore or improve range of motion Check rein ligaments in the PIP join were divided if there was stiffness of the joint. When skin was contracted and infiltrated by the disease, it was removed and the wound was left open to close by secondary intention. Non diseased palmar fascia of the adjacent finger rays was not excised. Results: Mean postoperative follow up was 9 years (from 2 to 15 years. Preoperatively, average extension deficit in the MCP and PIP joint was 38 and 32 degrees respectively. Postoperative values at the final follow up were 10 degrees in both joints presenting improvement of 28 and 22 degrees. Complications occurred in 56 patients (26%) and included 15 recurrences, 13 cases with complex regional pain syndrome, 1 amputation of the distal phalanx of the ring finger, 3 arthrodeses, 6 wound infections, 4 injuries of digital nerves that needed immediate repair, 7 sensory neuroapraxias that resolved after six months and 7 cases with cold intolerance which improved and resolved at two years postoperatively. Conclusions: Excision of the affected-contracted palmar fascia is effective in the treatment of Dupuytren's contracture. Although it is technically demanding in the advanced stages of the disease, it remains the most effective type of treatment in these late stages. Complications (early and late) are frequent with the most serious being a digital nerve injury, infection, complex regional pain syndrome and recurrence of the disease. Early complications needed immediate and appropriate treatment to obtain a satisfactory outcome.

Eva-Maria Baur, Robert Zimmermann, Verena Müller, Waltraud Mair

University Clinic of Plastic, Reconstructive and Aesthetic Surgery, lnnsbruck, Austria

In our clinic we are looking for the results after two minimally invasive treatments for Dupuytren disease in a prospective non-randomized study since 2011. With the upcoming possible treatment with collagenase the “”old fashioned" therapy with percutaneous needle fasciotomy (PNF) becomes a big revival. The purpose of the non-randomized prospective study was to Iook for differences regarding the two possible treatments. The results after 12 to 24 months was already presented. Now we get the results with a follow-up minimum of three years. In our clinic we propose and perform both treatments, the decision is taken together with the patient. Since more than 5 years we (try to) follow-up the patients regarding the results preoperative, after 3 weeks, 3, 6, 12, 24, 36, … months; regarding function, scars, and recurrence (worsening of contracture in comparison to 3 weeks postop at least for 20°). In the study since 1/2012 to 9/2016 we get overall 108 patients, overall we treated 185 minimal-invasive in this time. As a lot of people are not coming to the late clinical controls we start a recall to bring them back to the clinic. Now we got the following results with minimum FU of 36 months: Patients treated with Xiapex: 15 patients – 5 recurrences (2 in MCP and 3 in PIP joint) PNF: 23 patients – 6 recurrences (1 in MCP and PIP joint, 5 in PIP joint) Post “operative" treatment is night-splinting for 6 weeks. We report our results of both groups. As in our first report in 2014 and 2015 within results from 1 to 2 years postop, we cannot find a real difference between both groups. We report also the pros and cons of the two different treatment options. The groups are still very small, comparing to all the patients are treated, but it is very difficult to bring the people back to the clinic, if they don’t feel the need of further treatment (with or without a recurrence), but we are still trying to get more people back.

Özge İpek 1, Mustafa Nazım Karalezli 2, Oğuzhan Şamil Erciyes 2, Nevres Hürriyet Aydoğan 2, Kılıçhan Bayar 1

1 Muğla Sıtkı Koçman University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Muğla, Turkey; 2 Muğla Sıtkı Koçman University, Faculty of Medicine, Department of Orthopedics and Traumatology, Muğla, Turkey

Objective: Dupuytren’s disease (DD) is a common benign fibromatosis of the palmar fascia causing chronic contracture of the fingers. The exact etiology of DD have not been entirely identified. The general aspect is that a combination of risk factors can influence in genetically predisposed patients. These include diabetes, smoking, older age, menopause, alcohol consumption and male gender. The objective of this study was to investigate the etiologic factor of associated with DD. Methods: This study was planned as a descriptive study. Ethics committee approval was obtained for the research. A total of 120 patients who received the diagnosis of DD by the orthopaedic surgeon. All patients signed an informed consent form. A sociodemographic form was prepared by researchers used to evaluate etiologic factors of DD. All patients completed the questionnaire which related to gender, dominant hand, affected fingers, smoking and drinking alcohol habits and history. Results: A total of 50 patients with DD (16 female, 34 male) were participated voluntarily in the study. The average age of participants was 61.26±11.85 years. The mean height was 1.62±0.07 m, the mean body weight was 68±12.03 kg and the mean body mass index was 25.4±3.8 kg/m2. Weight, height and body mass index were not statistically correlated with DD. Both hands were affected in two cases (4%). In our study the most affected finger is 4th finger (n=30, 60%). 80% of participants used his/her right hand dominantly. No correlation was found between the dominant hand and the affected side (p = 0.45). The average duration of DD was 1.44±0.5 years. 14% of participants were smokers. No significant relation was found between smoking and DD in our study (p= 0.23). None of participants had drinking alcohol habit. This study found no correlation with drinking alcohol with DD in our population. Conclusions: Results show that the prevalence of DD was significantly higher among men than among women. The most affected finger is 4th finger. Our study found no correlation with smoking with DD. Further research must be undertaken to clarify the relation with the etiologic factors in large population with DD. In conclusion, a large-scale research is necessary to determine the etiology and in order to confirm the relationships between etiologic factors and DD.

Eric Camprubí Garcia, Silvia López Marne, Jose Moranas Barrero

Hospital Universitari de Bellvitge, Barcelona, Spain

Objectives: The objectives of the study are to asses: clinical success, recurrence rate, nondurability of response, progression of disease and occurrence of adverse effects (AEs) after a minimum follow-up of 3 years. Methods: All patients with Dupuytren’s contracture affecting at least one metacarpophalangeal (MCP) joint or one proximal interphalangeal (PIP) joint who received one or more CCH injections from 2012 through 2017 were included. The criteria for inclusion were palm and / or digital palpable cord, with contracture due to Dupuytren's disease (<20º), without contraindication to the injection and the acceptance of the CCH treatment by the patient. The Tubiana’s classification was used to quantify the initial severity of the contracture prior to treatment. Each cycle of treatment consisted of a single injection of 0.58 mg of CCH into the cord followed by a finger extension the next 24 or 48 hours. Patients were followed at day 30, 90 and once annually for 2 years after the first injection. Demographic and disease characteristics at baseline were recorded. At each visit, MCP and PIP joints were measured and changes in contracture were determined. Demographics and disease characteristics of treated joints were summarized. Incidence rates of recurrence, progression and worsening were calculated for all joints, by joint type and by joint severity. AEs to CCH injections were also summarized. Statistical analysis was performed by using SPSS v19.0 (IBM Corp., Armonk, NY, USA).. Results: We have followed the criteria defined in the CORDLESS study to classify the results into success, relapse or low response; obtaining overall results of 79.17% success, 10.42% recurrence and 10.42% low response to treatment. Of 79.17% of the successes, 84% corresponded to the MCP articulation and of these 50% to the 4th finger. All patients with grades I-II of Tubiana. Of 10.42% of the recurrences, 75% was presented in the 5th finger with a recurrence rate of 20% MCP and 16.6% IFP. 80% of these cases corresponded to the degree II of Tubiana. The average time of onset of recurrence was 6.6 months and in all cases, it was detected during the first year. Finally, of 10.42% with low response, the majority of cases were presented in the art PIP (80%) and in the 5th finger, reaching a low response rate of 50% in these cases. The majority of cases (80%) stage II of Tubiana. The side effects that have been observed more frequently have been pain at the injection site, hematoma, local edema, ecchymosis, skin laceration and lymphadenopathy. Conclusions: Collagenase treatment for Dupuytren's disease is effective, with a low complication rate and lower healthcare costs than surgery. The best results are obtained in the treatment of the art MCP of the 3rd and 4th fingers, with Tubiana I-II grades. The worst results are obtained in the treatment of the PIP art of the 5th finger and in the II degree of Tubiana. Recurrences usually appear between the 6th month and the year of treatment. With a greater selection of cases to treat, we can achieve results similar to those of open surgery.

Grigorios Kastanis, George Belivasakis, Petros Kapsetakis, Eirini Trachanatzi, Idomeneas Makrigianakis, Nikolaos Bounakis

General Hospital of Heraklion- Venizelio, Greece

Objectives: Dupuytren's disease is a fibroproliferative disorder of unknown origin causing palmar nodules and flexion contracture of the digits. The treatment of choice is surgical excision of the affected palmar fascia. The rate of postoperative complication is reached up to 17-19%. The purpose of this study is to analyze the functional outcomes and the rate of complications in patients with Dupuytren’s and concomitant Diabetes mellitus disease who undergoing surgical treatment with needle versus open fascietomy. rnMaterial & Methods: Between 2013-2016 38 patients (25 male- 13 female) with an average age 59 years old (48-69) were operated for Dupuytren’s contracture. 9 patients had diabetes mellitus type 1 and 29 type 2. The second digit was involved in 2 (5,2%) cases, the third digit in 7 cases (18,4%), the fourth digit in 8 cases (21%) and the fifth digit in 10 (26,3%) cases. In 4(10,5%)cases the contracture affected both middle and ring finger and in 7(18,4%) cases the ring and little finger. 22 patients were Tubiana type III, and 16 patients type IV. In 18 patients (11 Tubiana III and 7 Tubiana IV) was performed needle fascietomy (group A) and in 20 patients (11 Tubiana III and 9 Tubiana IV), open fascietomy(group B). A short arm splint was applied postoperatively to maintain the hand and fingers in extension. After the edema subsided, the splint was removed and rehabilitation initiated. All patients continued to use the extension splint at night for two more months.rnResults: The mean follow-up period was 28,2 months (range 14 to 38 ). In group A 9 patients (50%) had excellent results, 6 (33,3%) had good results and 3 (16,7%) had fair results. Mean Quick DASH score for this group at the final follow-up was 6.8. Complications rate was: 2 cases with digital nerve injury and 1 case with neuroma, 3 cases with hematoma and 2 cases with recurrence. In group B 11 hands (55%) had excellent results, 5 (25%) had good results and 4(20%) hands had fair results. Mean Quick DASH score for this group at the final follow-up was 4,5. Among the complications: 1 case with chronic regional pain syndrome, 2 cases with hematoma, 3 cases with infection, 1 case with recurrence. rnConclusion: Dupuytren’s disease appears in patients with diabetes mellitus in percent 25%. The contracture of the digits causes disability frequently in manual worker especially in late stage of the disease. Percutaneous needle fascietomy is a minimally invasive treatment modality with low rate of complications versus to open fascietomy especially in patients with diabetes mellitus.rn

David J Hunter-Smith, Robert Capstick, Rachael Leung, Angela Lei, David Nour, Warren Rozen

1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health; 2 Monash University Plastic and Reconstructive Surgery Group

Objective: In order to better inform patients we aimed to determine the morbidity of established interventions for Dupuytren’s Disease Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines . We included published complications following treatment with radiotherapy, fasciotomy, collagenase, fasciectomy, aponeurotomy, and dermofasciectomy that assessed the treatment of primary Dupuytrens disease. 35 studies were finally included; evidence level 2 (6), level 3 (10) and level 4 (19). Results: A total of 3104 participants (mean 76 per study) were included. The mean follow up was 21.5 months. Study types included retrospective cohort (20), prospective cohort (9) and RCT (6). Calculated rates for infection, haematoma, nerve injury/neuropraxia, wound complications, and CRPS/neuropathy for all treatment types is reported. Conclusions: The quantification of complication rates following treatment for primary Dupuytren disease may facilitate decision making and patient counselling.

Stefano Galli

Orthopaedic Clinic - University of Brescia, Brescia, Italy

Objective: Regarding Dupuytren’s disease, in the literature of the last decades the lack of precise definitions concerning the therapeutic procedures, the lack of a single evaluation system of functional results, which can be applied to all available therapeutic procedures, the lack of a clear definition of recurrence and, consequently, of a relative staging system, has generated much confusion. These problems have become evident mainly thanks to the new interest in Dupuytren's disease caused by recent non-invasive therapeutic applications (Collagenase of Clostridium Histolyticum). The International Consensus Conferences of Rome 2013 (Felici et oth, 2014; Kan et oth, 2017) laid the foundations for an appropriate diagnostic-therapeutic framework that will allow the comparison of the results of future cases. We propose a new, and possibly simple, staging system that permit to evaluate clinical postoperative results and recurrence of contracture at follow-up . Methods: We considered as firm points results elaborated by the International Consensus Conference of Rome of 2013: to assess an extension deficit, the measurement of the passive extension deficit (PED) of each treated joint should be used, considering each joint as a separate entity. Time 0 is defined as the period between 6 weeks and 3 months after treatment. A PED of more than 20° for at least one of treated joints, in the presence of a palpable cord, compared to the result obtained at time 0 represented the definition of recurrence. But we considered that some authors in literature consider recurrence a PED of more than 30°. Furthermore a detailed definition for correction of contracture remains not clear too. Clinical studies of collagenase clostridium histolyticum provide a good example of how this can be accomplished (Peimer et oth., 2015). Finally we considered salvage procedures in which PED is not evaluable. Results:We firstly considered the single joint residual PED at time 0. We defined: T0 a successfully treated joint, or excellent result, if residual PED is 0° to 5°; T1 a measurably treated joint, or good result, if residual PED is > 5° but < 20°; T2 a not effectively treated joint, or poor result, if residual PED is 20° or more; T3 a joint treated with salvage procedures (as amputation, arthrodesis, corrective osteotomy). Than we considered recurrence rate at follow-up time, compared to results evaluated at time 0. We defined: R0 no recurrence; R1 a progression of the contracture < 20°; R2 a progression of contracture from 20° to 29°; R3 a progression of contracture of 30° or more. Example: MF5 T0R1: metacarpophalangeal joint of the fifth ray, with excellent result at time 0, with a progression of contracture < 20° at follow-up. Conclusions: We think that this staging system can be a useful instrument for evaluation treatment results and recurrence rate of Dupuytren’s disease and can be applied to all available therapeutic procedures actually described.

Bertille Charruau, Steven Roulet, Jacky Laulan

CHRU , Service de Chirurgie Orthopédique et Traumatologique, Tours, France

Introduction. The Kaplan’s interval is the most common lateral approach for elbow surgery but involves a neurological risk. The approach, between extensor carpi radialis brevis and longus muscles, initially described for surgical treatment of the radial tunnel syndrome, allows a visual checking of the radial nerve and branches. For more than 20 years, we used this lateral approach for elbow arthrolysis and/ or synovectomy. Material and methods. The modified lateral surgical approach and its anatomical relationships have been assessed by an anatomical study in 1994. The exposure between the two extensor carpi radialis muscles, allowed to locate the radial nerve and its deep branch and permitted, together with a proximal extension of this interval, an excellent exposure of anterior capsule. Since then, this approach has been systematically used for arthrolysis and/or synovectomy. Results. It has been used in 43 patients, 30 men and 13 women whose mean age was 40.56 years (17-84). It always allowed, eventually in combination with a medial approach, a peroperative recuperation of a total or subtotal elbow extension, without neurologic complication. In association with the posterolateral approach, between anconeus and extensor carpi ulnaris muscles, it allowed a subtotal synovectomy. Discussion. The « classic » lateral approach goes distally through the lateral epicondylar muscles, approximately between extensor carpi radialis and extensor digitorum communis. The exposure of anterior aspect of the articulation imposes to cut the distal part of the extensor carpi radialis longus and the anterior part of the lateral epicondylar muscles, in practice the extensor carpi radialis brevis. This approach is distally limited by the deep branch of the radial nerve. The absence of visual control of the nerve, despite some tricks (short incision and pronation of the forearm), involves an important neurologic risk. The approach, between extensor carpi radialis brevis and longus, is different of the Kaplan exposure because the extensor carpi radialis brevis is left in place with the other epiconylar muscles. So, it is slightly more anterior than the Kaplan’s interval. It allows checking of the posterior interosseous nerve and a better exposure of the anterior aspect of the elbow. Conclusion. This surgical approach is more efficient to expose the anterolateral aspect of the elbow and less risked than the Kaplan approach. Initially described for the surgical treatment of radial tunnel syndrome, it must be recommended for elbow arthrolysis and synovectomy.

Isidro Jiménez, Pedro J. Delgado

Hospital Universitario HM Montepríncipe, Madrid, Spain

Proximal radioulnar synostosis is a rare but highly disabling posttraumatic complication in periarticular elbow injuries. Surgical treatment is an option for functionally limiting proximal radioulnar synostosis however, the approach can endanger local neurovascular structures especially if the synostosis affects the level of the bicipital tuberosity. The Sauvé-Kapandji technique was as a combination of arthrodesis of the distal radioulnar joint and ulnar resection-osteotomy proximal to the arthrodesis to restore pronation and supination of the forearm. In proximal radioulnar synostosis we already have the arthrodesis so we just have to achieve the nonunion of the proximal radius. We report two cases of proximal radioulnar synostosis with a preoperative prono-supination range of motion of 0 and 15º treated by a reverse Sauvé-Kapandji procedure resecting a 1-cm section of the radial shaft distal to the bicipital tuberosity and leaving the synostosis in place. An improvement in prono-supination arc of motion of 82.5º was achieved at two years of follow-up with no complications associated to the technique. According to the results published in the limited available literature and our own results, we believe that the reverse Sauvé-Kapandji procedure could be a valid option in the treatment of proximal radio-ulnar synostosis in cases where an aggressive excision of the bone bridge may result in a fatal iatrogenic injury to the local neurovascular structures.

Arun Hariharan 1, Christine Ho 2, Andrea Bauer 3, Charles Mehlman 4, Nathan O'Hara 1, Paul Sponseller 5, Joshua M. Abzug 6

1 University of Maryland Orthopaedic Associates, Baltimore, USA; 2 Texas Scottish Rite Hospital for Children, Texas City, USA; 3 Boston Children's Hospital, Boston, USA; 4 Cincinnati Children's Hospital Medical Center, Cincinnati, USA; 5 John's Hopkins Hospital, Baltimore, USA; 6 University of Maryland School of Medicine, Baltimore, USA

Objectives: Transphyseal humeral separations (TPHS) are rare injuries with only case reports and small series reported in the literature. The purpose of this study was to assess the various injury patterns, treatments, outcomes, and complications in a large series encompassing multiple institutions. Methods: A retrospective review was conducted at five pediatric institutions to identify all transphyseal humeral separations in patients 0-3 years of age from January 1991- December 2016. Patient demographics, mechanism of injury, Child Protective Services involvement, diagnostic modality, time to surgery, configuration, and complications were recorded. Frequencies and means were recorded for demographic and epidemiological analysis. Results: Seventy-nine patients aged 0-46 months, with a mean of 17.6 months, were identified. The most common mechanism of injury was accidental trauma (62%), followed by non-accidental trauma (27%), Cesarean section (7%), and vaginal delivery (4%). Child Protective Services were involved in 39 cases (49%). Additional injuries were noted in 19 patients; most commonly additional fractures including the humerus, ribs, and skull fractures. All patients had elbow radiographs, while four patients also had an ultrasound and/or an MRI. Time to surgery was greater than 24 hours in 62% of patients (n=49). Intra-operatively, 87% of patients underwent an arthrogram (n=69), 78% of patients had lateral pins only (n=62), 80% had two pins for fixation (n=63), and two patients underwent an open reduction. Ten complications were noted, including decreased range of motion (n=4) and cubitus varus/valgus (n=6) (8%). No cases of avascular necrosis or physeal arrest were found. No loss of reductions occurred. Conclusions: Transphyseal humeral separations have excellent outcomes in the vast majority of patients. We recommend high suspicion for non-accidental trauma with transphyseal humeral separations as Child Protective Services involvement was required in over half of the non-birth related injuries. The most common complication was distal humeral deformity; patients should be followed beyond pin removal to evaluate for residual deformity. This multicenter analysis provides the largest demographic and outcomes data pertaining to transphyseal humeral separations. It is important to consider non-accidental trauma for all of these injuries that do not occur during the birthing process.

Guiliana Rotunno 1, Mark Shasti 2, Alexandria L Case 1, Joshua M Abzug 1

1 University of Maryland School of Medicine, Baltimore, USA; 2 University of Maryland Orthopaedic Associates, Baltimore, USA

Objectives: Healthcare costs continue to increase, even for common orthopaedic procedures, such as closed reduction and percutaneous pinning (CRPP) of supracondylar humerus fractures in the pediatric population. Providers must investigate causes of monetary burdens placed on patients. One such cause may be location of care. The purpose of this study is to quantify the direct cost of CRPP for supracondylar humerus fractures to determine if there is a significant difference of cost between a tertiary care center and a community hospital. Methods: A retrospective chart and radiographic review of 136 supracondylar humerus fractures treated with CRPP over six years (2010-2016) was performed (74 male, 62 female). Fractures treated at a tertiary care center (n=106) accounted for 78% of the cohort and those treated at a community hospital (n=30) accounted for 22%. The primary outcome measure was the total operating room cost. Statistical analysis was completed using a two-sided T-test. Results: The data indicated that the average cost of treating supracondylar humerus fractures via closed reduction and percutaneous pinning is no different between tertiary and community care centers (p=0.4). The average cost of CRPP procedures at the tertiary care center was $2,292.93 (CI: $1,782.21-$2,803.65). The average cost of percutaneous pinning procedures at the community hospitals was 2,378.28 (CI: $2,169.48-$2,587.08). Conclusion: The average cost of closed reduction and percutaneous pinning of supracondylar humerus fractures is similar at various locations, with costs charged at a tertiary care center being largely the same as those charged at a community hospital. The current study suggests that the location of common outpatient or short stay pediatric orthopaedic procedures does not influence its cost.

Gonzalo Luengo Alonso, Leandro Ramos Ramos, Veronica Jimenez Diaz, Miguel Angel Porras Moreno, David Cecilia Lopez, Lorena Garcia Lamas

Hospital 12 de octubre , Madrid, Spain

Background Patterns of elbow unstable fracture-dislocations include transolecranon fracture-dislocations, among others. This pattern of is not that frequent, and occurs when a high-energy direct blow is applied to the dorsal aspect of the forearm with the elbow in mid-flexion. Objectives Analyze functional and clinical outcomes of this group of fractures treated surgically. Study Design & Methods Retrospective study of trasnolecranon fracture-dislocation surgically treated at our center (2007-2016). A total of 15 fractures were included. Patients with non-follow up, less than 6 months follow-up and ipsilateral acute fractures were excluded. Results Mean age was 62.53 (SD 19.2). Seven men and eight women. Average time to surgery was 5.27 days, and surgical time 92 minutes (SD 36.58). Associated fractures were present: 9 radial head, 2 coronoid process. Final range of movement was excellent: mean elbow flexion about 125-130 degrees, with only 5-10 extension loss. Pronation was complete in almost every single patient, as well as supination. Mean follow up was more than three years. There were no major complications associated to surgical treatment. Hardware removal was necessary in four cases due to discomfort. Finally, functional scores were very good: Mean DASH was 36.38 and Mayo Clinic Score was 100. Conclusions Transolecranon fracture-dislocations have good functional outcome if treated correctly, as there is no ligament injury. Surgical treatment allows earlier recovery and most of the times almost same range of motion as they had before the fracture.

Ana M. Far-Riera, Carlos Perez-Uribarri, Matias Esteras Serrano, José María Rapariz Gonzalez

Hospital Son Llatzer, Palma De Mallorca, Spain

1.- Aim Analyze the resutls of radial head prosthesis in three different patterns of instability: elbow triads, variation of Monteggia and comminutted no reparable head fractures. 2.- Background Surgical management of comminuted radial head fracture include excision of the radial head, reduction and internal fixation and arthroplasty. In our hospital we indicate radial head arthroplasty in fractures types III and IV of Mason with valgus instability or Essex Lopresti injury. 3.- Methods We made a descriptive retrospctive study of radial head fractures. Since 2005 to 2010 twenty-one radial head prosthesis were implanted in our hospital. We followed up 19 cases, during 54 months, 11 of them were women, with an average of 56 years. We had 9 elbow triads, 5 variation of Monteggia fractures and 5 radial head fractures associated with instability. 4.- Results Clinically, 12 patients achieved excellent results (6 triads, 3 variation of Monteggia and 3 radial head fractures associated with instability), and 7 achieved good results. According to the pattern of fracture, patients with elbow triad and Monteggia presented excellent results, and patients with radial head fractures associated with instability had good results. At DASH score we obtained an average of 11. Radiologically, 13 patients did not developed osteoarthritis in capitellum and 8 did not developed it in the ulno-humeral joint. Five patients developed heterotopic ossification. In 14 patients the neck was reabsorbed. Only 2 patients presented stem loosening, both long stem. No instability was noted. 5.- Conclusions In our series stress shielding was developed only during the first year, remaining stable thereafter. On our experience we can conclude that unlike other studies, we have found a low incidence of radiolucency and complications, and that all elbows have proved to be stable. The limitations we had in this study were those of a retrospective study, and a low number of patients. A more longer term study could be requiered to get more reliable conclusions.

Takuji Iwamoto, Tsuyoshi Amemiya, Taku Suzuki, Satoshi Oki, Noboru Matsumura, Kazuki Sato

Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan

Objective: An olecranon osteotomy approach is the most common method recommended for intra-articular distal humeral fractures. This approach provides good exposure of the articular surface, enabling accurate articular reduction for intra-articular distal humeral fractures, however, this approach is associated with several complications, including symptomatic hardware prominence, nonunion or delayed union of the olecranon, and loss of osteotomy reduction. The purpose of this study was to assess the outcomes of the lateral para-olecranon approach for the treatment of intra-articular distal humeral fracture. Methods: Ten patients (4 males, 6 females) with a mean age of 55 years (range 23-85) were retrospectively reviewed. There were three C1, and seven C2 fractures according to the AO/ASIF classification. Type B3 and C3 fractures were excluded from this study because antero-lateral approach or olecranon osteotomy approach were indicated to visualize the anterior fragment. The triceps was split between the lateral triceps expansion and the central triceps tendon, and the anconeus muscle was incised from the proximal ulna. The lateral half of the triceps along with anconeus was retracted laterally as a single unit. After that, the medial half of the triceps muscle was released from the medial intermuscular septum and dorsal aspect of the distal humerus. The distal part of the humerus could be visualized from medial and lateral windows by retracting the medial half of the triceps. The articular fragment was anatomically reduced and fixed temporarily with Kirschner wire, and the reconstructed distal articular block was then fixed to the humeral shaft with double locking plates. Results: Technical difficulties during surgery were not encountered in this case series. No articular step-offs of more than 1 mm were seen on postoperative radiographs. Postoperatively, average elbow flexion was 128° (range, 110° to 145°), and extension was –12° (range, –22° to 0°) at the average follow-up time of 11.7 months (range, 8‒20 months). Eight patients had normal muscle strength against full resistance (manual muscle testing grade 5), and the other two patients had slightly reduced muscle strength (grade 4). Subcutaneous prominence of the hardware was observed in two cases, and removal of the implant was required. Transient postoperative ulnar nerve palsy was observed in two cases, but they resolved within 6 months. There were no cases of postoperative infection or heterotopic ossification. The average (± standard deviation) Mayo Elbow Score was 94 ± 5.8 points at the final follow up. Conclusions: The lateral para-olecranon approach is useful for the management of type C1 and C2 distal humeral fractures, preserving extension strength and providing satisfactory clinical outcomes, with no risk of olecranon osteotomy-related complications.

Osamu Soejima

Department of Orthopaedic Surgery, Fukuoka Sanno Hospital, School of Medicine, International University of Health and Welfare, Japan

Hypothesis: The pathologic entity of recalcitrant tennis elbow (lateral epicondylitis of the elbow: LEC) would be the impingement syndrome of the lateral elbow related to the radial head abutment during supino-pronation as the impingement syndrome of the shoulder. We hypothesize that the radial head of patients with LEC has poorer mobility. Thus, it is critical to release the tension of the radial head, therefore both the capsule and a part of the annular ligament must be resected during the surgery. Methods: 71 elbows in 68 recalcitrant LEC patients (26 males and 42 females) who underwent mini-open modified Boyd’s procedure were evaluated clinically, ultrasonographically, MRI findings, and histologically. The average follow-up period was 14.2 months. Results: JOA-JES score improved from 33.9 to 92.2. From the ultrasonographic analysis, the severe LEC group had poorer radial head mobility than the mild LEC group. From the MRI and histological evaluations, the degree of the MRI signal changes and histological character were correlated but the histological changes (e.g. fibrosis or angiogenesis) were randomized. Conclusions: The abutment of the radial head to the ECRB origin during the supino-pronation was confirmed, and the decrease of the elasticity in the ECRB origin and the inhibition of the normal radial head motion were observed in the ultrasonographic evaluations. The Degree of the MRI signal changes and histological character were correlated but the histological changes (e.g. fibrosis or angiogenesis) were randomized. Recalcitrant LEC has a progress cycle (micro tear → angiogenesis → remodeling → fibrosis). As this cycle progresses, the decrease of the elasticity in the ECRB origin and the inhibition of the normal radial head motion would occur like the impingement syndrome of the shoulder (Latera elbow impingement syndrome: LEIS). Thus, the key-point of the surgical concept for the recalcitrant tennis elbow is not only the debridement of the degenerative tissue at the ECRB origin but also the decompression of the peri radial head at the lateral elbow (Peri radial-head decompression: PRD). References: 1. Soejima O, Iwamoto R, Matsunaga A: Surgical treatment of lateral epicondylitis; Results of arthroscopic versus open procedure. FESSH, 2014 2. Muraoka K, Soejima O: Pathogenesis of the lateral epicondylitis; Ultrasonographic analysis. ASSH, 2016 3. Soejima O: New pathologic entity of tennis elbow: Lateral elbow impingement syndrome (LEIS). ASSH, 2017

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

BACKGROUND: Nowadays, the Wide-Awake approach is commonly used in hand surgery. However, it is rarely used in elbow surgery. Lateral and medial epicondylitis surgery mostly performed with tourniquet control under local, brachial plexus block or general anesthesia. The purpose of this study was to compare the perioperative pain and clinical outcomes of surgical treatment using Wide-Awake approach for lateral or medial epicondylitis. MATERIAL AND METHOD: 88 patients (93 elbows) underwent surgery for lateral (51 elbows, 48patients) or medial epicondylitis (42 elbows, 40patients). Patients were divided into two groups (lateral, medial epicondylitis) and then each group was subdivided into two groups based on their anesthesia method and tourniquet use. 1. Lateral epicondylitis (LE) (n=51 elbows, 48patients): 26 elbows were in wide-awake group (WA), who received epinephrine-contained lidocaine as a local anesthetic agent, without tourniquet and 25 elbows were in the local anesthesia group (LA) who received lidocaine alone as a local anesthetic agent with a 250-mmHg tourniquet application 2. Medial epicondylitis (ME) (n=42 elbows, 40patients): 20 elbows were in the wide-awake group (WA), who received epinephrine-contained lidocaine as a local anesthetic agent, without tourniquet and 22 elbows were in the general anesthesia group (GA) and a 250-mmHg tourniquet application The outcome was assessed regarding the pain using the visual analog scale (VAS), Roles & Maudsley score, and Nirschl & Pettrone grade. Results: Overall elbows (91%) achieved satisfactory results. There were no perceived outcome differences between any of these individual groups at final follow-up (p > 0.05). The perioperative pain(preoperative surgical site injection, Intraoperative, postoperation) during the first 1week after surgery were higher in LE(LA) group than LE(WA) group(p < 0.05). The postoperative pain during the first 1week after surgery were higher in ME (GA) group than ME (WA) group (p < 0.05). Conclusions: a Wide-awake approach to Lateral and Medial Epicondylitis offers better comfort for patients and reliable technique that eliminates the need for general anesthesia, removes the need for a tourniquet.

Minho Lee, Hyun Sik Gong, Seong Cheol Park, Sehun Kim, Goo Hyun Baek

Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Objective To determine whether olecranon fractures have osteoporotic features such as age-dependent low bone attenuation and low-energy trauma as a cause of injury. Methodology In a total of 114 patients (53 males and 61 females) with acute olecranon fracture, we retrospectively reviewed elbow CT scans and medical records for the causes of injury (high or low-energy trauma). Their mean age was 57 years. Bone attenuations were measured on the central part of the olecranon on sagittal CT images avoiding the fracture and on the distal humerus (distal metaphysis and medial and lateral condyles) on coronal CT images. We compared bone attenuations and causes of injury in each gender between younger (< 50 years) and older (≥ 50 years) patients. Multiple regression analysis was performed to determine the effect of age and gender on bone attenuation. Results Mean bone attenuations in older male or female patients were significantly lower than those in younger patients except in the medial condyle in men. The proportion of low-energy trauma in older male patients was significantly higher than that in younger male patients. In female patients, low-energy trauma was predominant in both younger and older patients. Age and female gender were found to have significantly negative effects on bone attenuation. Conclusions This study demonstrates that olecranon fractures have osteoporotic features, including age-dependent low bone attenuation and low-energy trauma as a predominant cause of injury. Our results suggest that osteoporosis evaluation should be considered for patients aged 50 years or more with an olecranon fracture.

Alexandria L. Case, Carissa Meyer, Ebrahim Paryavi, Joshua M. Abzug

University of Maryland School of Medicine, Baltimore, Maryland, USA

Objective: Supracondylar humerus fractures are the most common pediatric elbow fracture. As children can be difficult to examine and many may have associated neurovascular injuries that can alter timing of treatment, the purpose of this study was to assess adequacy and accuracy of documentation regarding neurovascular injuries. Methods: A retrospective chart review was performed to identify all pediatric supracondylar humerus fractures in children under the age of 15. Data collected included patient age, type of fracture (Type I, II, III extension, flexion), clinician type (Emergency Department or Orthopaedic surgeon) and level of training, motor exam documentation (anterior interosseous nerve (AIN), radial nerve and ulnar nerve function) and presence of a nerve palsy. Linear regression was used to analyze documentation with regards to patient age and clinician level of training. Results: Thirty patients were identified during the study period, including three patients with associated nerve palsies (two AIN and one radial nerve palsy). In all cases, the nerve palsy was not recognized by the ED physicians or the orthopaedic resident(s) prior to the orthopaedic attending’s evaluation. In patients with a nerve palsy, motor documentation continued to be incomplete or failed to document a nerve palsy in >50% of notes even after attending documentation of the nerve palsy. Incomplete motor exam documentation occurred in 97% of ED notes. There was no correlation between motor exam documentation and year of orthopaedic residency training. Documentation by orthopaedic residents was significantly improved as patients increased in age (p=0.046). Documentation was complete in 90% of patients aged six years or older. There was no correlation between improved motor documentation and correctly identifying a nerve palsy (odds ratio=0.88, p=0.43). Conclusions: Inadequate or incorrect documentation may occur at any step of the evaluation process and may persist despite appropriate documentation by an attending surgeon. Motor exam documentation improved with patient age and reached 90% for patients six and older, implying that barriers exist to appropriate neurologic examination in young children. Improved education of emergency department physicians and orthopaedic residents is important to provide specific and age-appropriate neurologic examinations in young children with skeletal trauma. Proper documentation is necessary to improve recognition and monitoring of neurologic status in pediatric patients with supracondylar humerus fractures.

Karan Dua 1, Andrew Fischer 2, Raymond A. Pensy 2, W. Andrew Eglseder 2, Joshua M. Abzug 2

1 SUNY Downstate Medical Center, Brooklyn, New York, USA; 2 University of Maryland School of Medicine, Baltimore, Maryland, USA

Objective: “Terrible triad” injuries of the elbow consist of a posterior elbow dislocation with concomitant fractures of the coronoid process of the ulna and radial head. The purpose of this study was to evaluate the usefulness or lack thereof of placing a static external fixator to be used as a removable brace when treating patients with terrible triad injuries. Methods: A retrospective review was performed of patients treated for a terrible triad injury at a Level-1 trauma center over a 15-year period. Patient demographics were examined and outcome data was recorded regarding complication rates and post-operative range of motion (ROM). Statistical analysis was performed using two-tailed Fisher’s exact and t-tests assuming unequal variances. Additionally, data was analyzed when matching for age, body mass index (BMI), and presence of concurrent injury. Results: Ninety-three terrible triad injuries were reviewed including 13 that were treated with open reduction and internal fixation (ORIF) plus a static external fixator and 80 treated with ORIF alone. Patients treated with ORIF and an external fixator were older than those treated with ORIF alone (average 51 vs. 45.7 years). In the ORIF with external fixator treatment group, 61.5% had concurrent injuries compared to 33.8% of patients who underwent ORIF alone. Twenty percent of patients treated with ORIF alone needed a reoperation compared to only one of the 13 patients (7.7%) initially treated with ORIF plus an external fixator. Patients initially treated with ORIF and an external fixator had greater forearm pronation/supination and elbow flexion earlier in the rehabilitation period, but less elbow extension. The average arc of motion was greater in patients treated with ORIF and an external fixator later in the rehabilitation period. In obese patients (BMI ≥ 30), ORIF plus an external fixator allowed for significantly better forearm supination at the first and second follow-up evaluations. Patients <40 years of age with no concurrent injury treated only with ORIF had significantly better forearm rotation. Conclusions: The addition of a static external fixator when performing ORIF of terrible triad injuries serves to function as a rigid brace, which can be unlocked for supervised physical therapy leading to better postoperative ROM and lower reoperation rates, especially in obese patients.

Masao Okamoto

Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan

【Purpose】 To determine the incidence of ectopic ossification (EO) after double-plating fixation of comminuted fractures of the distal humerus and to characterize the extent of EO and the consequential functional impairment. 【Materials & Methods】 Fifteen patients with comminuted distal humeral fractures underwent open reduction and double-plating fixation between 2005 and 2017. Twelve men and three women were included in this study, with the average age of 41 years (range: 21–60 years). One fracture was AO type A3, three type C2, and five type C3, and eleven patients had open fracture. Definitive internal fixation was applied 16 days post-injury (range: 4–36 days), and a grafting of autogenous bone block was required in eight patients. Ten patients were transferred for rehabilitation 49 days post-operation, and the others were discharged on day 22. The average follow-up period was 3 years and 7 months (range: 6 months–9 years). The Mayo Elbow Performance Score (MEPS) system was used for all clinical evaluations. Radiographic changes were evaluated nearly every week post-operatively for 2 months and at final follow-up. 【Results】 Bony union was achieved in all the patients. According to the MEPS system, the results of the functional recovery were noted to be excellent in four, good in seven, fair in three, and poor in one patients. At the final follow-up, the average flexion was 119° and the loss of extension was 21°, producing an arc of motion of 98°. EO was shown on radiograph in ten patients and started to appear 26 days post-injury (range: 8–39 days). Five patients who did not present EO within 6 weeks post-injury showed similar findings at the final follow-up. We classified the extent of EO as Type I (slight), Type II (moderate), or Type III (severe). Among the ten patients, one patient was classified as Type I, who showed no changes at 7 months post-injury. Four patients were classified as Type II, with one underwent arthrolysis and the others remained contracture due to EO. Five patients were classified as Type III, with one being reported as excellent according to the MEPS system due to spontaneous reduction of the EO and the other three patients included one with ankylosis who underwent arthrolysis, and the remaining one patient resulted in severe contracture. There was an improvement in the mean flexion–extension arc of the four patients who underwent arthrolysis from 34° to 100° at the final follow-up. 【Discussion】 In ten (67%) patients, EO was shown on radiograph, which was more than expected compared to previous reports. The reasons for this discrepancy following comminuted fracture are manifold: a high-energy trauma, delayed definitive fixation, high rate of bone grafting, and so on. Because most cases of EO appear by 6 weeks post-injury, careful radiographic follow-up and various modalities for prophylaxis against EO post-injury deserve consideration. Although even severe EO may rarely diminish spontaneously, more moderate EO usually results in functional impairment. Therefore, surgical treatment should be considered at the appropriate time.

Sho Kohyama 1, Yuki Hara 1, Akira Ikumi 1, Eriko Okano 1, Yasumasa Nishiura 2, Masashi Yamazaki 1

1 Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan; 2 Tsuchiura Clinical Education and Training Center, Tsukuba University Hospital, Tsuchiura, Japan

Objective In osteochondritis dissecans (OCD) of the elbow, the state of the interface between the articular cartilage and the subchondral bone affects the prognosis and selection of treatment options; however, techniques that can precisely predict this preoperatively have not been developed. If subchondral bone visualized by computed tomography (CT) and articular cartilage visualized by magnetic resonance imaging (MRI) are fused three dimensionally and evaluated, the instability of the OCD lesion can be predicted, thereby enabling preoperative selection of appropriate treatment. Therefore, we sought to develop a preoperative evaluation and surgical simulation for OCD of the elbow using three-dimensional MRI-CT fusion images. Methods We enrolled 6 patients who had visited our hospital after April 2017 and were diagnosed with OCD of the elbow. Preoperative CT and MRI of the elbow were performed. A 320-row detector imager (Aquilion ONE, TOSHIBA, Japan) was used to obtain 1-mm thick slices during CT and to generate a 3D model of the humerus. A 3 Tesla imager (MAGNETOM Verio 3T, SIEMENS, Germany) was used for MRI. Images were obtained using 3D double echo steady sequence, with 0.4-mm thick slices. To widen the humeroradial joint space and clarify the articular cartilage outline, 7 kg of axial traction was applied to the elbow during MRI. Three-dimensional models of the humerus and articular cartilage were constructed. The CT and MRI images were integrated for further evaluation and surgical simulation. Materialise Mimics Innovation Suite (Materialise, Belgium) was used for 3D model construction. Materialise 3-matic (Materialise, Belgium) was used for MRI-CT fusion and surgical simulation. Using fusion images, the International Cartilage Repair Society (ICRS) classification, the gold standard for intraoperative OCD lesion evaluation, was predicted based comprehensively on articular cartilage shape (normal or irregular), existence of cartilage fissure or defect, and existence of isolated subchondral bone lesion. The proprieties of MRI-CT fusion; average distance error of fusion images; expected ICRS classification; selected treatment options; expected surgical procedures; intraoperative ICRS classification; and actual surgical procedures used in each patient were evaluated. Results Three-dimensional MRI-CT fusion images were successfully constructed in all patients. The average distance error of fusion images was 0.89 (range 0.6-1.0) mm. The expected ICRS classifications were classes II, III, and IV in 1, 3, and 2 cases, respectively. Of the 6 patients, 4 underwent surgery and their expected ICRS classes were II, III, and IV in 1, 2, and 1 case, respectively. The two other patients elected to undergo conservative therapy. Preoperatively, subchondral drilling for a class II case and a class IV case and costal osteochondral autograft for 2 class III cases were simulated. The intraoperative ICRS classification accurately matched the imaging-based predictions (class II, 1 case; class III, 2 cases; and class IV, 1 case). Surgeries were conducted as expected based on the simulations (subchondral drilling in 2 cases and costal osteochondral autograft in 2 cases). Conclusions Using 3D MRI-CT fusion images, the instability of OCD lesions was accurately evaluated. Pre-surgical imaging can facilitate lesion severity determination and precisely simulate the surgical procedure.

Sang Ho Kwak, Min Uk Do, Seung Jun Lee

Pusan National University Yangsan Hospital, Korea

Objective In lateral epicondylitis, even in the absence of apparent instability, subtle instability can be found under anesthesia. We wanted to ascertain: (1) how many elbows surgically treated with lateral epicondylitis showed subtle instability during examination under anesthesia (EUA), (2) how effective magnetic resonance imaging (MRI) was in predicting subtle instability, and (3) if any difference existed in demographic and preoperative clinical data between elbows with and without subtle instability during EUA, Methods Eighty-eight elbows (87 patients) diagnosed with intractable lateral epicondylitis underwent surgical treatment. No elbow showed apparent instability with conventional physical examination. Under general anesthesia, the elbows were examined for subtle instability via fluoroscopy and divided into an unstable and stable group. We performed open extensor carpi radialis brevis excision and lateral ulnar collateral ligament reconstruction for the unstable group and extensor carpi radialis brevis excision for the stable group. The MRI images were reviewed by two radiologists and demographic data were assessed retrospectively. Pain and functional scores were recorded preoperatively and 12 months after the surgery. Results Thirteen elbows (unstable group, 14.8%) had subtle instability in EUA while 75 elbows (stable group, 85.2%) did not. Lateral collateral ligament (LCL) complex injury was noted on 23 elbow MRIs. Twelve elbows showed subtle instability among 23 elbows with abnormal MRI (positive predictive value, 52.2%) while 55 elbows did not show subtle instability among 56 elbows with normal MRI (negative predictive value, 98.2%) The preoperative visual analog scale score was higher in the unstable group than in the stable group (p<0.001). Other demographic factors showed no significant differences between both groups. Conclusions Subtle instability resulting from LCL complex injury was noted in elbows with lateral epicondylitis. This could be visualized with fluoroscopic EUA and preoperative MRI could be used to exclude subtle instability. Surgeons should consider checking for subtle instability, especially when pain is severe and MRI indicates instability.

Young Hak Roh 1, Hyun Sik Gong 2, Goo Hyun Baek 2

1 Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea; 2 Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Objective: Both obesity and diabetes mellitus are well-known risk factors for tendinopathies. We retrospectively compared the efficacy of single corticosteroid injections in treating lateral epicondylitis in patients with and without metabolic syndrome (MetS). Methods: Fifty-one patients with lateral epicondylitis and MetS were age- and sex-matched with 51 controls without MetS. Pain severity, Disability of the Arm, Shoulder, and Hand score, and grip strength were assessed at base line and at 6, 12 and 24 weeks post-injection. Results:The pain scores in the MetS group were greater than those in the control group at 6 and 12 weeks. The disability scores and grip strength in the MetS group were significantly worse than those of the control group at 6 weeks. However, there were no significant differences at 24 weeks between the groups in terms of pain, disability scores and grip strengths. After 24 weeks, three patients (6%) in the control group and five patients (10%) in the MetS group had surgical decompression (p = 0.46). Conclusions: Patients with MetS are at risk for poor functional outcome after corticosteroid injection for lateral epicondylitis in the short term, but in the long term there was no difference in outcomes of steroid injection in patients with and without MetS.

Hyun Il Lee 1, Jong Pil Kim 2, Jae Woo Shim 3, Min Jong Park 4

1 Department of Orthopaedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, South Korea; 2 Department of Orthopedic Surgery, College of Medicine, Dankook University, Cheonan, South Korea; 3 Department of Orthopaedic Surgery, Hallym University, Kangdong Sacred Heart Hospital, Seoul, South Korea; 4 Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea

Introduction Thickened synovial plica in radio-capitellar joint has been reported as cause of lateral-side elbow pain. However, there are few reports containing detailed descriptions of physical examination and MRI finding to aid diagnosis. Purposes of this study were to characterize clinical manifestations of this syndrome and to investigate clinical outcome of arthroscopic surgery. Method We analyzed 20-patients who were diagnosed as plica syndrome and underwent arthroscopic debridement between 2006~2011. Diagnosis was made based on physical examination and MRI finding and arthroscopic finding confirmed. Patients with lateral epicondylitis were excluded. Elbow symptom was assessed by pain visual analog scale (VAS), Mayo elbow performance score (MEPS), and DASH score at minimum 2-years after surgery. Measured thickness of plica in MRI was compared with normal data in literature. Results Plica was located on anterior in one patient, on posterior in 15-patients and on both sides in four patients. Radio-capitellar joint tenderness and pain with terminal extension were observed in 65% of patients, respectively. MRI showed enlarged plica consistent with intra-operative findings. Mean thickness of plica in MRI was 3.7±1.0mm and it was significantly thicker than normal value (P<0.0001). Lengths (mediolateral length=9.4±1.6mm and anteroposterior length=8.2±1.7mm) were also longer than normal values (P<0.0001). The pain-VAS was decreased from 6.3 to 1.0 after surgery. MEPS and DASH score was improved from 66 to 89 and from 26 to 14, respectively. Conclusion Specific finding of physical examination and MRI image could give clues in diagnosis of plica syndrome. Painful symptom had been successfully relieved after arthroscopic debridement.

C Chanes Puiggrós, J Martínez Zaragoza, A Petrica, L Trigo Lahoz, X Crusi Sererols, C Lamas Gómez

Department of Orthopaedics and Traumatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain

INTRODUCTION Heterotopic ossification (HO) can cause stiffness after an elbow injury. Its prevalence can range from 3% in simple dislocations to 45% in distal humeral fractures, however its prevalence in radial head fractures is not well defined. MATERIAL AND METHODS We retrospectively reviewed 51 radial head arthroplasty after non-synthesizable radial head fractures. We studied the demography, Mason type, posterior dislocation, concomitant coronoid or olecranon fractures, ligamentous injuries, time to surgery, site and size of HO and articular balance. We used Hastings-Graham functional classification and Brooker radiographic classification. RESULTS 51 patients with average age of 53.7 years. 34 Mason type IV, 15 type III, 2 type II. 51% associated to posterior dislocation. 53% of the patients developed HO: 100% of those with both coronoid and olecranon fractures, 87.5% of those with isolated radial head fractures and 35% of patients with concomitant coronoid fractures. The average size of the calcifications was smaller in isolated radial head fractures (7.5mm) and larger those with both coronoid and olecranon fractures (18.4mm). The HO was mostly located anteriorly. 38% of patients developed OH in only 1 site and 61.5% in 2 or more. Posterior dislocation, gender, age, Mason type, time to surgery or mechanism were not found to influence HO formation. Average follow-up was 20 months (6-125). CONCLUSION In concomitant coronoid and olecranon fractures associated with radial head replacement it is very likely to develop HO. It is also very prevalent in isolated radial head fractures but it usually consists in bone islands that will not affect function. Some factors expected to increase HO formation like posterior dislocation, time to surgery or high energy trauma did not influence in our study.

Takuro Wada, Takashi Oda, Akira Saito

Saiseikai Otaru Hospital, Otaru, Japan

Objective: Literature regarding the outcomes of revision arthroscopic surgery for tennis elbow is limited. The purposes of the study were to report clinical outcomes for a cohort of patients with chronic tennis elbow who underwent revision arthroscopic release of the extensor carpi radialis brevis (ECRB) tendon. Methods: From January 2003 to December 2016, 146 arthroscopic surgeries for chronic tennis elbow were performed by a single surgeon. Among them 5 patients had persisted elbow pain following a primary surgery and underwent revision arthroscopic surgery. Indications of primary surgery included failure of a minimum of 6 months of conservative treatment such as rest, activity modification, counterforce bracing, nonsteroidal anti-inflammatory medications, and corticosteroid injection. Operative treatment consisted of an arthroscopic inspection, debridement of the ECRB tendon origin, and resection of the radiocapitellar synovial plica if interposed in the joint. The mean age of 5 patients was 48 years; four were male and one was female. The average duration between primary and revision surgery was 11 months and the average follow-up period after revision surgery was 18 months. Outcome was evaluated on the basis of visual analogue pain score, range of motion of the elbow, grip strength, Japanese Elbow Society (JES) score, DASH score and patient satisfaction. Arthroscopic findings of the revision surgery were also evaluated. Statistical analysis was performed using a paired Student t test, with statistical significance set at p< 0.05. Results: Significant improvements were seen in terms of postoperative pain (p < 0.05), active extension and flexion (p<0.05), grip strength (p<0.05), the JES score (p < 0.05), and DASH (p<0.05). All of 5 patients satisfied with the operative results. Arthroscopic findings of the revision surgery included insufficient release of the ECRB origin in three patients and persisted impingement of the posterolateral synovial plica in two patients. Conclusions: Rate of revision arthroscopic surgery for tennis elbow was 3%. Incomplete release of the ECRB origin or synovial plica was considered to be a cause of persisted pain. Revision arthroscopic surgery resulted in reliable pain relief and improvement in elbow function in patients with persisted elbow pain following primary arthroscopic tennis elbow surgery.

Matias Núnez 1, Alberto Castellón 1, Ignacio Fernández 1, Felipe Hughes 1, Enrique Johow 1, Rodrigo Pérez 2

1 Instituto de Seguridad del Trabajo, Viña del Mar, Chile; 2, Universidad Andres Bello, Viña del Mar, Chile

Objective: To describe the functionality in patients undergoing cupulectomy versus radial head arthroplasty. Materials and Methods: A descriptive, comparative study was carried out. We reviewed 17 clinical records between January 2013 and December 2016. We were able to contact 14 patients, of whom 7 underwent a cupulectomy, and 7 patients with radial head arthroplasty. The procedures were performed by 5 different surgeons of the upper extremity team of our center. They were evaluated clinically and radiologically. For the classification of fractures the Mason classification was used, and the DASH and Broberg - Morrey scales were used for the functional evaluation. Results: No significant differences were found in relation to wrist pain, ulna valgus, instability or in the sensation of loss of strength. Patients submitted to cupulectomy, compared to those who underwent arthroplasty, had a higher frequency of arthritis of the elbow 100% vs 71% respectively. Patients undergoing arthroplasty had a higher incidence of functional limitations in their daily lives (85% of cases) versus 57% undergoing cupulectomy. Regarding the DASH assessment, the patients of this last group presented a lower average of disability (19.17 points vs. 25.58 average points in arthroplasty), as well as a greater presence of good results in terms of the Broberg - Morrey scale (57 % of cupulectomies Vs. 42% of arthroplasties). Conclusión: We can conclude that cupulectomy turns out to be a better surgical option, in stable lesions, due to the lower incidence of functional limitations. Faced with an unstable lesion, arthroplasty remains a good therapeutic option.

Takeshi Egi 1, Masato Shigi 1, Yusuke Sogabe 1, Masahiko Tohyama 2

1 Osaka Saiseikai Nakatsu Hospital, Osaka, Japan; 2 Osaka Rosai Hospital, Sakai, Japan

Objectives: When treating osteochondritis dissecans (OCD) of the capitellum, it is important how to manage to perform treatment with the pathological stage/condition. The objective of this study was to examine the postoperative results of removal of intra-articular loose body and abrasion of capitellum in patients with a relatively small affected area during the OCD fragment detached phase. Methods: From 2007 to 2016, we conducted a retrospective study which included 19 patients (1 female; 18 males) who suffered OCD with loose body. Mean age at the time of the procedure was 16 years (range, 12-35 years). Mean postoperative follow up period was 14 months (range, 3-24 months). All patients presented disability of upper arm extremities because of pain on motion, scratching and limitation of range of motion. The position where the loose bodies were present was preoperatively evaluated using three-dimensional computed tomography (3DCT). The bodies were classified into three locations (posterior to the olecranon fossa, lateral to the radial head region, or anterior to the capitellum region), a portal was selectively established with respect to the position of the body, and the bodies were arthroscopically extracted. In the case of the capitellum, this method was applied to patients with diameter of approximately 10 mm by CT and MRI. The remaining hyaline cartilage of the capitellum and the regenerated fibrocartilage that were found to be stable upon probing were left as they were, whereas those that were unstable were resected. Abrasion was performed by subchondral bone exposed with bleeding. Debridement was performed when osteophyte formation was observed on the tips of olecranon and/or coronoid process. Results: Loose bodies were noted anteriorly only in eight patients, posteriorly only in four, posteriorly and laterally in four, and anteriorly and posteriorly in three. The total number of loose bodies was as follows: anteriorly, 17; posteriorly, 14; laterally, eight (total: 39). Osteophyte formation was observed in the olecranon (five patients), olecranon fossa (two patients), and coronoid process (two patients). Regarding the range of motion, the preoperative average extension of -16±14 and flexion of 123±14 degrees significantly improved to post-operative average extension of -2±5 and flexion of 134±9 degrees. Average gain of motion was 27 degrees after the procedure. Regarding the Mayo Elbow Performance Score, the preoperative average of 73±9 points (range, 55-85 points) significantly improved to post-operative average of 98±6 points (range, 85-100 points). Regarding the Quick DASH score, the preoperative average of 11±8 points (range, 2.3-30 points) significantly improved to post-operative average of 0.4±1 points (range, 0-4.5 points) . Conclusion: This procedure provided pain relief, free from scratching, improvement of approximately 27 degrees range of motion and both objective and subjective excellent outcomes. These findings indicate that by targeting only patients with lesions up to 10 mm in diameter, and by selectively approaching the location where the loose bodies are present, it is possible to efficiently perform minimally invasive operative treatment. When the lesion is large, because this method does not maintain reconstruction of the joint surface well, osteochondral graft transplantation should be indicated.

Reza Sh. Kamrani 1,2

1 Tehran University of Medical Sciences; 2 Joint Reconstruction Research Center of TUMS

Objective: articular fracture of distal humerus is an uncommon fracture with significant complications. We report results of 14 patients treated by open reduction and pin and plate fixation technique. Methods: we used pin and plate fixation when screw fixation alone was impossible or inadequate to fix this fracture. We fixed fragments with k wires and augmented theme with a small plate. We reviewed all those patients. Results: 14 patients with distal humerus articular fracture were treated by pin and plate fixation. average age was 36.4 and mean follow up was 41.5 months. The average quick Disabilities of the Arm, Shoulder and Hand (DASH) score was 19.5 points and the mean points for Mayo Elbow Performance Index was 142.6. Mean Final arc of motion was 142.6 degrees which was 70 percent of uninjured elbow. Conclusions: Distal humerus articular fracture is sometimes difficult to fix with conventional methods. We used pin and plate technique and believe that this can lead stable fixation and early ROM with acceptable results.

Kensaku Kuga 1, Takashi Masatomi 2, Yoshinori Takemura 3, Narihito Kodama 3, Shinji Imai 3

1 Japan Comunity Health care Organization Shiga Hospital, Shiga, Japan; 2 Yukioka Hospital Hand Surgery Center, Osaka, Japan; 3 Shiga University of Medical Science Hospital, Shiga, Japan

(Objective) To evaluate the clinical outcome of total elbow arthroplasty for ankylosed elbow joint due to rheumatoid arthritis. (Methods) We reviewed five patients with ankylosed elbow joint due to rheumatoid arthritis, who underwent an unconstrained total elbow arthroplasty. All patients were women, and their mean age at the time of the surgery was 56 years old (range, 41 to 66). Although they had no pain, their daily activities were limited severely because of ankylosed elbow joint (Steinbrocker functional classification classⅣ). An unconstrained total elbow arthroplasty was performed for obtainment of elbow joint motion. The clinical outcomes were assessed according to Mayo Elbow Performance Score, radiological findings and complications. (Results) We followed all the patients at least more than 18 months . Mayo Elbow Performance Score with mean values improved from 45 to 87 points at the latest follow-up. The overall result was excellent for two patients and good for four. The mean flexion angle of ankylosed elbow joint was 92°at pre-operation. An average of elbow flexion was 130°, extension -55°, pronation 58°and supination 35°at latest follow-up. The patients’ daily activities of living, such as face-wash and eating, were improved greatly with much satisfaction postoperatively. There were no cases with implant loosening or periprosthetic fracture. (Conclusions) Total elbow arthroplasty for the patients with ankylosed joint due to rheumatoid arthritis is useful option. Since elbow flexion and forearm pro-supination are obtained , activities of daily living will improve.

Cristóbal Greene 1,2, Guillermo Droppelmann 1, Arturo Verdugo 1

1 Clínica MEDS, Santiago, Chile; 2 Hospital DIPRECA, Santiago, Chile

Introduction: Patients looking for care because of lateral epicondylitis is high with near a 3% of population experiencing a elbow injury and up to 40% of tennis player during their lifetime. Kocaushear and Nirsch suggested 4 stages in epicondylitis with a partial or complete tear of the tendon in stages 3 and 4. The importance of recognizing a tear tendon is based that in this cases other treatments could be adviced (PRP, Shockwaves, Surgery)(4). Hypothesis: With two clinical findings in phisycal examination you could diagnose extensor tendon tear in patients with Lateral Epicondylitis. Method: Patients with clinical history of lateral Epicondylitis were evaluated in an outpatient clinic. Clinical findings that were stablished to be associated with extensor tendon tear were fail to resist wrist dorsal extension against resistance (New Test) and nocturnal pain. In all patients the Cozen test was recorded. After evaluation all patients were studied with ultrasonography, the radiologist was blind to the clinical evaluation. Statistical analysis was made with Fisher’s Exact Test. Results: 38 patients were evaluated. There were no statistical difference between the Cozen Test and ultrasound with a tendon tear (p=0,157). There where statistical differences between the “New Test” with an ultrasound with a tendon tear (p=0,007). Statisitical diference was also significant with nocturnal pain an a tendon tear in the ultrasound in patients with Lateral Epicondylitis. Conclusion: The “New Test”, fail to resist wrist extension against ressistance and nocturnal pain correlates with the presence of a tendon tear in the ultrasound evalaution in patients with Lateral Epicondylitis

Kosei Ando, Kodama Narihito, Yoshinori Takemura, Kento Kuga, Yoichirou Kuyama, Shinji Imai

Shiga University of Medical Science, Otsu, Japan

(Objective) To evaluate the clinical outcomes of the elbow dynamic reconstruction by latissimus dorsi muscle transfer after resection of malignant bone and soft tissue tumors in upper arm. (Methods) All the patients were male with a range of 17 to 62 years old. Mean follow-up was more than 2 years. Two patients were affected with osteosarcoma, three with undifferentiated pleomorphic sarcoma (UPS), and one with liposarcoma. All the patients were underwent a latissimus dorsi muscle transfer in upper arm after curative wide resection of the sarcomas together with brachial, biceps, and/or triceps muscles. Clinical outcomes were postoperatively evaluated with elbow range of motion (ROM), muscle strength with manual muscle testing (MMT), International Symposium on Limb Salvage (ISOLS) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications. (Results) Elbow ROM was a mean of 95 degrees (range, 80-120). MMT of elbow flexion or extension was 3-4 in all the cases. ISOLS score was a mean of 90% (range, 63-100). DASH score was a mean of 13.2 points. Two cases of subcutaneous hematoma were found on the surgical defects after resection of latissimus dorsi muscle. (Conclusions) Curative wide resection in bone and soft tissue sarcoma means composite resection of both of the tumors and the upper arm muscles such as brachial, biceps, and/or triceps. Consequently, a latissimus dorsi muscle flap was useful for not only coverage of large soft tissue defect but also reconstruction of functional muscles against the serious loss of elbow function. Our clinical results have shown that a latissimus dorsi muscle transfer is an acceptable surgical option in dynamic elbow reconstruction with muscle strength of upper arm.

IM Kurinnyi, OS Strafun, AS Lysak

State institution "Institute of Traumatology and Orthopedics of NAMS of Ukraine", Kyiv, Ukraine

Results of treatment of 37 patients (19 men and 18 women) with neglected dislocations and fracture-dislocations of the elbow joint, including 29 patients with the "unhappy triad of the elbow joint" were analyzed. The patients' age was 38,5 ± 11,7 years in average. Patients were divided into four groups according to the type of lesion and time from injury: Group 1 - untreated patients (17), up to 4 weeks after injury; Group 2 - previously operated patients (9), with no signs of dislocation, but with pain, instability and contracture in the elbow; Group 3 - chronic instability or dislocations of the elbow joint (11 patients). In group 1, after elimination of dislocation, restoration of the anterior capsule integrity was performed with synthesis of the coronoid process of the ulna and head of the radius and suture of the damaged ligaments. In patients of 2 group arthrolysis of the elbow joint and restoration of ligaments were performed. In group 3, after elimination of dislocation or subluxation, anterior capsule plastic and radial head arthroplasty (in case of bone defects) were performed. In patients with Essex-Lopresti injury we also made ulnar shortening osteotomy. After surgery, we applied a posterior cast immobillisation on the upper extremity with elbow extended in 30 degrees. Rehabilitation started from the first day after the operation, and included immobilization in extension (30º) for night and flexion of the elbow (over 90º) during the day period. The average duration of such rehabilitation was 4,52 ± 0,89 weeks. Further development of movements we provide with increasing load on the elbow joint. In 12 patients with compression-ischemic neuropathy of the ulnar nerve transposition and neurolysis were also performed. Results: According to MEPS scale we obtained excellent and good results in group 1 in 84% of cases. In groups 2 and 3 with neglected injury we received excellent and good results in 53% patients, fair - in 31% and poor - in 16% of cases.

IM Kurinnyi, OS Strafun, AS Lysak

State institution "Institute of Traumatology and Orthopedics of NAMS of Ukraine", Kyiv, Ukraine

Fractures of the head of the radius are about 20% of all fractures of the elbow joint. In 5 to 10% of cases, fracture of the radial head is complicated by dislocation of the forearm We have analyzed the surgical treatment of patients with fractures of the proximal parts of the radius. The total number of observations was 47, of which 22 were men and 25 women. The average age of patients was - 36,9314,7 years (varied from 7 to 71 years). Patients were hospitalized at different time after the injury - from 3-4 days to 6 months. Therefore, all patients were divided into 2 groups: 1 group - patients with fresh trauma (up to 4 weeks after injury) - 24 patients (51.1%), and 2 group - patients with delayed injury (more than 1 month after injury) - 23 patients (48.9%). In both groups of patients, depending on the severity of the injury, three types of surgical interventions were performed: open reposition and metal osteosynthesis in 28 patients (59.6%), radial head arthroplasty - in 5 patients (10.6%), head resection or fragments removal - in 14 cases (29.8%). The results of the treatment are analyzed in the period from 7 months to 3.5 years after the surgery. It was found that excellent and good treatment results according to MEPS were obtained in 79.2% cases (19 patients) in first group of patients (who performed surgery within 1 month after injury), and fair in 20.8% (5 patients). In patients with delayed injury (second group of patients) excellent and good results were obtained in 60.9% of cases (14 patients), fair - in 30.4% (7 patients), poor - in 8.7% (2 patients) cases . Based on the analyzed material - reconstructive surgical interventions on the radial head should be performed within the first 4 weeks after the injury.

Kayo Tsuzawa 1, Keikichi Kawasaki 1, Yukio Ueno 2, Katsunori Inagaki 1

1 Department of Orthopaedic Surgery, Showa University School of Medicine, Japan; 2 Ohta Nishinouchi Hospital, Japan

Supracondylar fractures of the Humerus are the most common fractures in children and sometimes involve complications such as vascular injury, nerve injury, malunion and cubitus varus. Avascular necrosis (AVN) after supracondylar fracture of the humerus is a rare but important complication. We report five cases with suspicion of AVN after supracondylar fracture of the humerus. Retrospective data were collected for the patients with supracondylar fractures of the humerus treated at our hospital and our affiliated hospitals from 2001 to 2015. Five cases were suspected AVN after supracondylar fracture of the humerus, two of them were male and three were female. Age at the injury was range from 3 to 7 years. Three cases were Gartland type 3 fracture and underwent surgical treatment. Two cases treated by closed reduction and casting, one was a nondisplaced Gartland type 1 fracture. Their treatments of period were from 12 to 71 months. The X ray check-up at 6.8 months on an average showed suspicion of AVN of medial condyle of the humerus. One postoperative patient had slight motion pain, but others had no clinical symptoms after all. Etiel et al. reported 5 cases with AVN of trochlea after supracondylar fracture of the humerus. They reported this complication are caused by the loss of blood supply of the trochlea and seen in displaced fractures but also in nondisplaced fractures. The lateral vessels considered to be interrupted by tamponade because of the fracture hematoma in intact capsule in nondisplaced fractures. In other reports Hegemann’s disease, osteochondrosis after sport activities and fishtail deformity are also thought to be caused by vessel interruption of growth plate at the trochlea and they presents late clinical symptoms; motion pain, loss of range of motion of the elbow, cubitus varus and so on. Our cases have no clinical symptoms, but AVN of the trochlea is rare and should be considered in late presentation of pain or loss of motion after treatments of supracondylar fractures of the humerus. Long-term follow-up could be necessary in the treatments of supracondylar fractures of the humerus in children.

Pierluigi Tos 1, Simona Odella 1, Bruno Battiston 2, Federico Palumbo 1, Sara Razza 1

1 Asst Pini-CTO, UOC Chirurgia della Mano e Microchirurgia Ricostruttiva, Milano, Italy; 2 AOU Città della Salute e Della scienza di Torino UO Ortopedia e Traumatologia, Chirurgia della Mano, Torino, Italy

OBJECTIVE Elbow ankylosis is a predictable complication in severe complex traumas of distal humerus of the proximal radius and ulna in which, in addition to rigidity, there is an important joint impairment but no prosthetic replacement is indicated. In young and motivated patients, the retrieval of range of motion can be restored by fascia lata interposition arthroplasty. The purpose of the work is to produce our experience of a case study of four patients who had surgery between 2009 and 2016 with this method. METHODS Four patients had surgery: we performed arthrolysis using a medial access performing epitroclea osteotomy and fascia lata interposition (age 35, 40, 45 and 50 years - 2 women and 2 men). In three cases at the end of surgery and legaments reconstruction, the use of the external fixator was necessary, while in one case the elbow had good residual stability and was not protected. The minimum follow-up was 8 months, the maximum 7 years. Twice the affected side was the dominant one. As for etiology, there were three post-traumatic cases and one post coma. The ankylosis was present at 90 ° in three patients and at 70° in the other. Patients were evaluated with MEPS. Once the fascia lata was an autograft from the triceps of the patient. The other three times the grafts were from bank tissue and folded on herself. Techniques are reported. RESULTS There were no major complications. In all patients, a degree of satisfactory, pain-free range of motion was achieved, three of theme could lead the hand to the mouth and the last patient 5 cm from the face. There have been no cases of secondary instability. Two cases have been classified as good (80 MEPS score) and two as discreet (70 MEPS score); the ROM were between 50 and 100 degres. CONCLUSION Arthroplasty of the elbow with fascia lata or triceps band interposition is a viable alternative in those patients with severe functional limitations that have no indication for an elbow prosthesis. The loss of movement of this joint is poorly tolerated and constitutes an important functional impairment for a young patient

Zacharias Christoforakis 1, Petros Kapsetakis 1, Spyros Gigourtakis 2, Gregory Chlouverakis 3, Anastasia Pitikaki 2, George Kontakis 1, George Koumantakis 4, Ioannis Galanakis 1

1 Orthopaedic Department, University Hospital of Heraklio, Greece; 2 Physiotherapy Private Practice, Heraklio, Greece; 3 Medical School, University of Crete, Greece; 4 401 General Military Hospital of Athens, Greece

Objective: to functionally and objectively evaluate patients undergoing surgical repair of distal biceps tendon rupture by anatomic reattachment of the tendon with a bone tunnel technique and using a single anterior incision. Methods: 16 male patients operated by the same surgeon have been retrospectively evaluated. Operative technique involves initially the passage of a guide wire from the anatomic footprint of the tendon attachment on the radial tuberosity towards the dorsal surface of the forearm. Then, a tunnel of one cortice is created with a cannulated dril over that guide wire. A no5 Ethibon suture, previously attached on the tendon stump, is driven via the guide wire on the dorsal forearm. By pulling the suture, the tendon is advanced into the tunnel. Final tensioning and securing of the tendon is attained by tightening the suture over a gauge on the skin of the dorsal forearm. The study consisted of patients more than 1year from surgery all of whom had a clinical assessment and elbow ROM measurements, a self-reported subjective outcome evaluation via specific questionnaires (satisfaction scale, DASH, Oxford Elbow Score, Mayo Score, VAS) and an objective analysis by using an isokinetic device (HumacNorm, CSMi) based on a concrete protocol. The latter comprised isometric and isokinetic torque measurements of elbow flexors – extensors and supinators – pronators (the isokinetic in a slow speed of 60º/sec and a rapid one of 120º/sec), as long as endurance of the above muscle groups. Both elbows of each patient were evaluated and t paired statistical analysis of the results was done comparing injured with non-injured side. Results: three patients had bilateral tendon surgery and eight had their dominant arm affected. Mean age at the time of surgery was 47 years (24-60) and the average follow-up was 62 months (range 12-174). 94% of patients were highly satisfied, with DASH and OES scores of 2,5+/-10 and 47,2+/-2 respectively. All patients reported no pain at all. The only statistically significant difference was detected in testing isokinetic elbow flexion at the speed of 60º/sec, giving an advantage, regarding peak torque, for the noninjured side (noninjured, 53.62+-15.69 Nm; injured, 49.77+-13.96 Nm; P=0.043). For the rest of torque and endurance measurements a slight superiority of the uninvolved elbow was noted but this did not reach significance. Conclusion: our technique gives satisfactory and reproducible results for active patients requiring surgery after distal biceps rupture, and makes up a reliable and cost-effective alternative to other modern techniques arising last decades for addressing this rare injury. Keywords: distal biceps repair; bone tunnel; single insicion; functional; isokinetic assessment

Verónica Jiménez-Díaz 1, David Cecilia-López 1, Lorena García-Lamas 1, Raúl Barco-Laakso 2, Jose Ramón Sañudo-Tejero 3

1 Hospital Universitario 12 de Octubre, Madrid, Spain; 2 Hospital Universitario La Paz, Madrid, Spain; 3 Universidad Complutense de Madrid, Spain

Objective: The aim of the present study is to describe the proximal origin of extensor muscles (ECRB, EDC, ECU, anconeus) around the lateral epicondyle, as well as the proximal origin of lateral colateral ligament and its relationship with the surrounding muscles. Methods: 25 cadavers preserved in formaldehyde, 11 men and 14 women were dissected. Dissections were carried out in 48 elbows, 25 were right elbows and 23 were left elbow; two left elbows could not be dissected because of bad preservation of soft tissues due to poor perfusion. Skin and subcutaneus tissue were removed of elbow and forearm. Fascial tissue was also removed exposing the muscle bellies. All muscles were desinserted distally and a distal to proximal dissection was carried isolating each muscle belly till its proximal origin in the epicondyle. Length, width and the estimated area of each of them were measuring. Likewise, the proportional size with respect the perimeter of the lateral epicondyle was calculated. The proximal origin of lateral colateral ligament was also studied. Length and width of the lateral epicondyle were measured, estimating its perimeter and its area. Results: The mean width of the proximal origin of the extensor muscles was 6.67 ± 1.39mm for ECRB, 7.38 ± 1.11mm for EDC, 5.25 ± 0.8mm for ECU and 7.71 ± 1.06mm for anconeus. Mean length was 8.8 ± 1.06mm for ECRB, 9.23 ± 0.99mm for EDC; 6.82 ± 1.06mm for ECU and 10.98 ± 1.28mm for anconeus.The area was 59.5 ± 18.61mm² for ECRB, 68.74 ± 15mm2 for EDC, 34.96 ± 11.64mm2 for ECU and 85.03 ± 16.16mm for anconeus. Perimeter that occupies each muscle with respect to the epicondyle was about 3.38 ± 1.12mm for ECRB, 4.19 ± 1.1mm for EDC, 2.82 ± 1.13mm for ECU and 7.39 ± 1.36mm for anconeus. Multivariate analysis showed that there were differences in gender, being those parameters greater in men. Anconeus muscle have the greatest length, width and surface area occupied by the perimeter of the epicondyle followed by EDC, ECRB and ECU. The proximal origin of the lateral ligament presents dimensions of 7.65 ± 1.04 mm in length, width of 3.92 ± 0.83 mm an area of 30.02 ± 7.45 mm2. The lateral epicondyle has an average length of 18.35 ± 1.63 mm, width of 11.7 ± 1.85 mm, perimeter of 36.91 ± 5.8 mm an area of 111.07 ± 38.05 mm2. These parameters present a positive correlation with arm and forearm length; once again there are differences in sex, being greater values in men. Conclusions: Proximal origin of LCL is underlying the proximal origin of ECU around the lateral epicondyle. Proximal extensor origins around the epicondyle have been isolated, being able to measure length, width and area, as well as to estimate the relative length with respect to the perimeter of the lateral epicondyle. Muscles are placed bordering the lower half of lateral epicondyle in a semicircumferential form following the order from anterior to posterior: ECRB, EDC, ECU and anconeus.

Hiroyasu Ikegami, Takanori Shintaku, Shu Yoshizawa, Hideaki Ishii, Takeo Mori, Yoshiro Musha, Takao Kaneko

Department of Orhopaedic Surgery, Toho University, Tokyo, Japan

Objectives: Treatment of unreconstructible comminuted fractures of the radial head remains controversial. Radial head arthroplasty is an alternative treatment for unreconstructible comminuted fractures with traumatic elbow instability. The purpose of this study was to evaluate the results of the bipolar radial head prosthesis after more than ten years. Methods: Fifteen patients (seven females and eight males; mean age, 47 years old (26-71) with an unreconstructible comminuted radial head fracture and associated elbow injuries were treated with a bipolar radial head prosthesis (Tornier). There were six Morrey type-III and nine Morrey type-IV injuries. Two of these injuries were isolated, and thirteen of them were associated with other elbow fractures and/or ligamentous injuries. The outcome was assessed using the Mayo Elbow Performance Index (MEPI) at a mean follow-up of thirteen years and six months (10 to 18 years). Results: There were eight excellent results, four good, and three fair according to the MEPI. The mean elbow flexion arc was 105 degrees and forearm rotation arc was 155 degrees. All elbow joints remained stable and no implant required revision. There was no evidence of overstuffing of the joint. Six patients had radiographic changes of lucency around the neck and stem of the prosthesis that was not associated with pain, five patients had heterotopic ossification, and three patients had proximal migration of the prosthesis against the capitellum. Conclusions: Arthroplasty with a bipolar radial head prosthesis for unreconstructible radial head fractures associated with elbow joint instability had satisfactory results during midterm of follow-up. However, high prevalence of radiographic changes suggesting osteolysis is noted and more than twenty-year follow-up is necessary to use this prosthesis.

Sang-uk Lee, Ki-tae Na, Do-yeol Kim, Won-woo Kang, Jong-yoon Lee

Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea

OBJECTIVE Nonunion is one of the most common and challenging complications of distal humeral fractures. Recently, patients with severe bone loss or old age were recommended for arthroplasty rather than osteosynthesis, because of high failure rate and severe joint stiffness after osteosynthesis. However, the complication rates of arthroplasty is also high. Chronic kidney disease (CKD) affects calcium and phosphorus metabolism and interfere with bone union. We present a case of successfully treated CKD patient with distal humerus nonunion using an autogenous pillar bone graft. METHODS A 67-year old female got injured to her left elbow containing arteriovenous shunts when she slipped down 6 months ago. Patient was treated conservatively at local orthopaedic clinic. Despite a follow-up of more than 4 months, bone union could not achieved. When her first visited the outpatient department of our hospital, her elbow joint was marked deformed and range of motion was limited due to pain. Palin radiographs and CT-scan revealed nonunion and displacement of the distal humerus with several bone fragments around the fracture site. Surgery was done under pneumatic tourniquet control, despite the injured limb included arteriovenous (AV) shunts for hemodialysis. Large bone defect at humeral metaphysis obstructed anatomical reduction of distal humerus. Autogenous strut bone graft was inserted between the hole of distal fractured bone fragment and intramedullary canal of proximal fragment. And then the orthogonal locking plate fixation with corticocancellous bone graft was applied via the posterior campbell’s approach. RESULTS The duration of the postoperative follow-up period was 9 months, and the subject’s elbow motion values were 0°, 140°, 80° and 80° during extension, flexion, pronation and supination. The patient visual anaglog scale; QuickDASH score; and Mayo elbow performance score were all excellent, and bony union was achieved. No complications related with AV shunt were noted. CONCLUSION Anatomical locking plate fixation with autogenous pillar bone graft might be useful for treating distal humerus fracture or nonunion with metaphseal bone defect to restore alignment, anatomical length, bone defect, and contour for anatomical locking plate positioning.

Hiroyasu Ikegami, Takanori Shintaku, Shu Yoshizawa, Hideaki Ishii, Tako Mori, Yoshiro Musha, Takao Kaneko

Department of Orthopaedic Surgery, Toho University, Tokyo, Japan

Objectives: Fractures of distal humerus in elderly patients are difficult to treat, as diminished bone mineral quality and increased trauma-associated articular surfaces destruction may make stable joint reconstruction even more difficult. In active patients, internal fixation is still a primary choice because of use age of total elbow replacement, but disagreements have still existed on how to treat these fractures in elderly patients. The purpose of our study was to evaluate objective, subjective as well as radiographic results after total elbow arthroplasty (TEA) for the fractures of the elbow. Methods: Between 2000 and 2008, 25 cases (man 6, woman 19) underwent TEA for the fractures of the elbow and were followed for a mean of 8 years (5-13). The mean age at operation were 76 years old (66-86). We examined treatment results of each case according to operation method, length of stay in hospital and an external fixation period. Results: Among nine cases operated within three weeks from injury, there were 6 trauma of rheumatoid patients, 2 comminuted fracture distal humerus, and one breast cancer terminal pa- tient. As for 16 cases that underwent operation after three months or more from injury, they were 9 non-unions after transcondylar fractures of the humerus, 5 trauma of rheumatoid patients, and 2 old fracture dislocations of the elbow. The used TEA systems were ten K-NOW, unlinked type, and 15 linked type (Coonrad-Morrey 13, Snap-in type K-NOW 2). Bone transplantation was performed to ten examples. The length of stay was 1 to 4 weeks (avg. 13 days), and the excursion acquisition training started 2-14 days after the operation (avg. five days). The external fixation period was 3 days to 6 weeks. As for the fresh cases, JOA Score was 83-92 points (avg. 87). As for old trauma cases, JOA Score was 31-43 points before surgery (avg. 37) and 82-90 points after surgery (avg. 86). Conclusions: In case of comminuted fracture of elderly people or rheumatoid patients, the frac- ture of the distal humerus is difficult to treat even when it is fresh, still more when it becomes old trauma. As we reported, even for fresh cases TEA can be one of the choices. For old cases, espe- cially in case of elderly or rheumatoid patients, TEA can provide a better and more stable result than ORIF (open reduction and internal fixation), considering the long term of bony and soft tissue incongruence, wear of the cartilage of a humeroulnar joint, and the period of social rehabilitation.

Yutaka Kubota, Keikichi Kawasaki, Hiroki Nishikawa, Sadaaki Tsutsui, Tetsuya Nemoto, Kazutoshi Kubo, Katsunori Inagaki

Showa University School of Medicine, Tokyo, Japan

[objectives] The authors present the treatment result of Monteggia fracture in children in particular the cases with ulna Acute plastic bowing(APB) [materials and methods] 26 children with Monteggia fracture treated in our department since 2001 were retrospectively reviewed. Among them,7 cases presented with APB and 19 cases were without APB. In the APB group, (2 male, 5 female), average age of 7.4 years (5-13), injury mechanism was fall in all the cases. 5 cases were referred to our hospital from local doctors and 3 cases among them had non-displaced olecranon fractures as a complication. All cases were Bado type 1. Mean time to operation from injury was 2.1 days (0-7). 4 cases were treated with manual reduction and 3 cases underwent operation. Different operative procedures were performed: one case underwent manual reduction of an ulna and removal of annular ligament emboly, one case underwent intramedullary nailing and radioulnar joint fixation after open reduction of the ulna, and one case required plate fixation and radioulnar joint fixation after ulna osteotomy. The mean post-operative follow-up period was 10.6 months (3-25). We compared the treatment results of the APB group with the non-APB group. [results] None of the cases in the APB group presented with re-dislocation of the radial head. The mean elbow joint ROM was flexion 139.3°, extension 2.9° ,pronation 87° , and supination 90°. Among the five referred cases, three patients did not have ulna APB pointed out. Ulna bone union was achieved and radial head dislocation was not presented in all the cases in the non-APB group. The mean elbow joint ROM was flexion 135.9° extension 2.5° pronation 86.6° and supination 90.3°. In both groups, none of the cases had functional impairment and there were no significant differences in the treatment results between the two groups. [conclusions] We experienced relatively high prevalence (7 cases: 26.9%) of ulna APB. Furthermore, there were 3 cases with non-displaced olecranon fractures, so called Hume fracture. We suspect that in case of a fall on the outstretched arm, ulna APB occurs due to the axial load, and furthermore olecranon fracture occurs consequently by the impact to the humeral olecranon fossa. In 3 of the 5 referred cases the ulna APB was not diagnosed. We recommend an accurate radiographical examination of forearm in both sides. When examining a dislocation of the radial head without an ulna fracture, it is necessary to suspect the possible existence of APB

Ki Jin Jung, Jae-Hwi Nho, Byungsung Kim

Soonchunhyang University Hospital, Cheonan, South Korea

Objective Analyze the results of various radial head arthroplasty in the treatment of complex fractures associated with elbow joint instability. Material and methods Retrospective design study of 12 patients, 7 men and 5 women with a mean age of 50 years (24-76) who suffered radial head fractures (Mason III) in the context of an unstable elbow injury. Mean follow-up was 17 months (12-60). Radial head replacement was performed with Ascension(®) Modular Radial Head [MRH], Modular Evolve prostheses(Wright Medical Technology and Judet bipolar Tornier SAS and associating repair of concomitant lesions. The Mayo scale Elbow Performance Score (MEPS) was used to perform the functional assessment. A radiological evaluation was performed at the last follow-up and the complications were recorded. Results Mean motion arcs were 131° in flexion-extension and 155° in pronation-supination. At final follow-up, 89% of results were satisfactory according to the MEPS. The 40% of patients had radiographic signs of lucencies around the stem, although most of them were asymptomatic. None of them needed a second surgical procedure. The lateral ulnohumeral space was 3.3mm and medial ulnohumeral facet was 2.7mm. There was one patients with ectopic ossification. Discussion Radial head implants are an adequate treatment option for restoring stability in complex radial head fractures. The associated injuriesto bones and ligaments and the measures taken to repair them influence the prognosis. Periprosthetic osteolysis could be associated with the presence of pain, so it is necessary to perform long-term studies to test the potential complications of this finding.

Rhyou In Hyeok

Semyeong Christianty Hospital, Pohang, South Korea

Purpose this study was to compare the outcomes of patients who underwent open or arthroscopic release in patients with both lateral and medial epicondylitis that did not respond to conservative management. Materials and methods from 2011 to 2016, 11 patients with lateral and medial epicondylitis who did not respond to conservative management for more than 6 months were included. 4 patients underwent arthroscopic release, and 7 underwent open surgery. Preoperative and postoperative clinical results were measured MMES, DASH, grip power and VAS. Results the final MMES was 85, DASH 12.22, VAS 2 in arthroscopic release, and final MMES was 75.8, DASH 24.23 and VAS 1 in open surgery Conclusion arthroscopic or open surgery of the patients with lateral and medial epicondylitis did not show any significant difference at final follow-up. However, arthroscopic release is more advantageous in case of cosmetic side or immediate post-operative pain

Rhyou In Hyeok, Lee Jung Hyun

Semyeong Christianity Hospital, Pohang, South Korea

Introduction The study of conservative and surgical treatment of distal biceps tendinopathy and associated biceps tendon partial rupture. Materials and methods Twenty - one cases with distal biceps tendonitis and partial rupture were studied in 20 patients who visited our clinic from June 2010 to August 2017. The mean age was 57.1 years (39 ~ 69 years), 14 males and 6 females. The mean duration of symptom at the time of first visit was 6.2 months (0.2 ~ 14 months). Ultrasonography and MRI were performed for patients with severe symptoms. According to the severity of the symptoms, splint immobilization, oral NSAIDs, and ultrasound - guided steroid injection were performed. Surgical treatment was performed if the patient did not respond to conservative treatment for 3 to 6 months or longer. Results There were 9 cases of partial rupture of the distal biceps tendon associated with distal biceps tendinopathy on imaging studies. Conservative treatment showed symptomatic improvement in 15 of 21 cases. In 3 cases with a relatively mild symptom, anti-inflammatory analgesics and intermittent splinting showed good result. In 12 cases, symptoms improved after ultrasonography - guided steroid injection. Surgical treatment was performed on 5 cases that did not respond to conservative treatment. All 6 cases that underwent surgery had distal biceps partial rupture. The symptoms resolved after 3 months after surgery in 4 cases, and 15 months after surgery in 1 case. Conclusions Conservative treatment of distal biceps tendonitis may promise good results. However, in case of partial tear of the distal biceps tendon and refractory to conservative treatment, surgical treatment may be needed

Isabella Fassola, Kay Krüger, Benedict Kunz, Jens Hahnhaußen, Wolfgang Ertel, Senat Krasnici

Department of Orthopedic, Trauma and Reconstructive Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany

Introduction: The dislocation of the elbow joint associated with fractures of the radial head and ulnar coronoid process is known as Terrible Triad Injury (TTI). The purpose of this study was to evaluate the results from the surgical treatment of terrible triad injuries of the elbow in our institution. The purpose of this study was to evaluate the results from the surgical treatment of terrible triad injuries of the elbow in our institution. Material and methods: We retrospectively reviewed 21 consecutive patients treated for TTI of the elbow, including 5 polytrauma patients. In 17 cases CT scan images were available in addition to the standard radiographic images to support the preoperative planning. Included in this series were twelve males, nine females aged on average 53.3 years. The reported mechanism of injury was fall on the outstretched hand (47.6%), bike accident (23.8%), fall from height (23.8%) and sport accident (4.8%). The fractures of the radial head were classified according to Mason in type I (5 cases), type II (5 cases), type III (10 cases) and type IV (1 case). The fractures of the coronoid process of the ulna were classified according to Regan and Morrey in type I (7 cases), type II (11 cases), and type III (3 cases). The elbow dislocation was posterior in 85.7% of cases. In 76.2% of cases the injury was associated with an ipsilateral fracture involving the olecranon (31.3%), the lateral epicondyle of the humerus (31.3%), the medial epicondyle of the humerus (6.3%), the extra-articular proximal ulna (12.5%). In addition, a trans-scaphoid-perilunate dislocation and a triquetrum fracture were diagnosed in 12.5% and 6.3% respectively.   The average interval between the trauma and the definitive treatment was 5.1 days (min 1, max 10). Initial treatment after closed reduction of the dislocation was splint immobilization (71.4%) and temporary external fixation (28.6%). The surgical approach was via a combined lateral and anterior approach in 7 cases (33.3%), a lateral approach in 6 cases (28.6%), combined lateral and medial approach in 5 cases (23.8%). In the remaining 3 cases, a combined medial and anterior or isolated medial or isolated longitudinal posterior approach (4.8% of cases each) was used. The treatment of the radial head and of the coronoid fracture was mostly surgical (85.7% and 61.9%, respectively). The LUCL and the MCL were repaired in 42.9% and 23.8% of cases, respectively (suture or anchor). The average follow-up was 16.6 months (range 1-38.2). Results: Average results were: arc of flexion-extension 76 degrees (range 55-110), flexion 109 degrees (range 85-140), extension loss 32 degrees (range 30-40), arc of prono-supination 130 degrees (range 110-150), pronation 82 degrees (range 75-90) and supination 47 degrees (20-75). Average DASH was 19.5 (range 6.7-39.2) and average MEPS was 80.0 (range 70-85) Two (9.5% of cases) complications occurred: one rigidity and one delayed union of the radial head. Both required surgical revision. Heterotopic ossification was present in 3 cases (14.2% of cases). Conclusions: The surgical treatment for the terrible triad of the elbow generally provided satisfactory results.

Dawid Mrozik 1,2, Agnieszka Jackiewicz 1,2

1 HANDPROJECT Clinic, Gdańsk, Poland; 2 SWISSMED Private Hospital, Gdańsk, Poland

BACKGROUND: Lateral epicondylitis or tennis elbow is a noninflammatory, degenerative condition of the origin of the ECRB or EDC, clinically associated with overuse and characterized by: absence of inflammatory cells, profusion of disorganized collagen and fibroblastic hypertrophy, disorganized vascular hyperplasia with avascular tendon fascicles, nutritional flow is compromised, making it difficult for tenocytes to synthesize the extracellular matrix necesary for repair and remodelling. A principal aim in treatment of tendinosis is to establish a biologic healing response. THE PURPOSE of this study was to evaluate the long-term results, safety and effectiveness of using RF-based microtenotomy to treat lateral epicondylitis of the elbow. MATERIAL and METHOD: It was prospective, nonrandomized, two-center clinical study. Into the study were involved 49 patients (28 men and 21 women) with symptomatic epicondylitis lateralis (tennis elbow) for at least 6 months and had failed conservative treatment. The average age of patients was 44,9 years (range: 26-57). Dominant limb was involved in 89% of the patients. As operative method we used bipolar microtenotomy of extensor carpi radialis brevis and/or common extensor tendom using TOPAZ Microdebrider device (ArthroCare, EU). Before operation was done VAS, DASH and clinical examination. Postoperative clinical assessment: 2 and 14 day. Follow-up: 12 and 24 months after oparation: VAS, DASH, USG, clinical examination. USG: LOGIQ e GE Healthcare device with a 7,7-15Mhz linear transducer RESULTS: The dominant arm was involved in 89% with unilateral involvement. There were no perioperative or postoperative complications related to the procedure. The mean VAS decreased from 8,8 before operation to 2,6 (p=0,001). Postoperative DASH value was 21,6. There were found ultrasonography abnormalities 24 months after operation: - focal hypoechoic area: 36 patients (74%) - focal anechoic area: 16 patients (33%) - cortical irregularity of the lateral epicondyle: 34 patients (70%) - tendon thickening: 13 patients (27%) - intratendinous calcifications: 11 patients (22%) - increased vascularity: 9 patients (18%) CONCLUSIONS: 1. RF-based microtenotomy appears to be a safe and effective method for treating patients with chronic tendinosis. 2. Microtenotomy is a technically simple procedure to perform and is associated with a rapid and uncomplicated recovery. Pain relief was achieved rapidly in all patients and diminished even further with time. 3. Ultrasonography is a widely and inexpensive imaging study for assessing tendons providing useful information on the severity and stage of tendon pathology.

I M Kurinnyi, O S Strafun, A S Lysak

State institution "Institute of Traumatology and Orthopedics of NAMS of Ukraine", Kyiv, Ukraine

Purpose. To evaluate the results of surgical treatment of nonunions and defects of the distal humerus. Methods. The surgical treatment of 63 patients (41 men, 22 women) with the consequences of treatment of fractures and nonunions of the distal humerus were analyzed. The average age of patients was 48.4 ± 15.6 years. All patients had been operated previously, but due to various reasons, consolidation of the distal humerus did not occur. Patients were hospitalized in 6.8 ± 5.4 months after injury. During clinical investigation all of them had pathological mobility at the level of nonunion, movements in the elbow joint were significantly limited. In 17 cases, the treatment of patients began with the skin defects substitution at the level of the elbow joint. At the first stage of treatment, osteosynthesis of the distal humerus was performed with bone plastics. Technically, this stage was rather complicated due to a significant violation of the anatomical relationships between the bones, presence of thick scar tissues, adhesions and defects in the bone in the area of injury. After the first stage surgical intervention, an early rehabilitation with two removable splints in the position of flexion and extension, was carried out. As a rule, the range of movements in the elbow increased to a satisfactory level. After 1 year or more, the 2nd stage of treatment was performed - removal of the metal fixators and mobilization of the elbow joint. After bone consolidation and improvement of anatomy of distal humerus the range of movements in the elbow joint was improved to a 90 degrees or more. After the operation, an early rehabilitation treatment was also carried out using cast in full extension at night and a sling in flexion for a day time. Results After the first stage of surgical treatment (osteosynthesis and bone plastics) on the MEPS scale, good results were obtained at 55.6% and satisfactory - 44.4% of patients. After the 2nd stage (mobilization of the elbow joint), good results were observed in 79.4% of cases, and satisfactory - in 21.6%. The main factor limiting the ability to renew movements in the elbow joint was the degree of preservation of the shape of the articular surfaces of the distal humerus. Conclusions. Osteosynthesis with bone plastics and mobilization surgeries in cases of severe injuries of distal humerus allowed to obtain good results of treatment in 79.4% of cases.

Hiroki Nishikawa 1, Keikichi Kawasaki 1, Kazutoshi Kubo 1, Tetsuya Nemoto 1, Sadaaki Tsutsui 1, Yutaka Kubota 1, Katsunori Inagaki 1, Jun Ikeda 2, Takuma Kuroda 2, Yukio Ueno 3

1 Showa University Hospital, Tokyo, Japan; 2 Showa University Northern Yokohama Hospital, Kanagawa, Japan; 3 Ohta-Nishinouchi Hospital, Fukushima, Japan

Objective: Humeral condylar fractures in the elderly are challenging to treat due to fragility of the bones, and have high rates of delayed or nonunion due to small contact area of the fragments, small proportion of cancellous bone and the fact that it is intra-articular. Recently, surgical treatment with locking plates is becoming more common. We report the treatment results of humeral condylar fractures in the elderly operated at our hospital and affiliated hospitals with locking plates. Methods: We retrospectively reviewed 38 patients over the age of 65 who were operated with locking plates in our department and in our affiliated hospitals between May 2005 and November 2015, and were followed up over at least three months. Mean age at the time of injury was 77.0 (65-93). Results: The mean postoperative follow up period was 19 months, and bone union was achieved in 33 patients. However, there were two cases of nonunion, one case of condylar necrosis and two cases of postoperative re-displacement of which one case underwent revision surgery. The mean postoperative ROM of those cases with bone union was 123.8 degrees of flexion and -15.1 degrees of extension, and the mean Mayo elbow performance score (MEPS) at the latest check-up was 91.1. Comparison between the age groups of sixties, seventies and eighties revealed that older groups had progressively smaller arc of motion and lower MEPS at the latest check-up. No case acquired infection. Complication of numbness of the ulnar nerve area was seen in one case, transient radial nerve palsy in one case and heterotopic ossification in one case. Conclusions: Treating humeral condylar fractures in the elderly with locking plates are often reported to have good results, and our results were similarly good. However, some cases developed nonunion, condylar necrosis and postoperative re-displacement, which suggest the need for careful indication and accurate operative techniques for this treatment. Primary total elbow arthroplasty for humeral condylar fractures in older patients is also achieving good results in our department and this may be an efficient alternative for some types of fractures, although careful consideration is needed for its indication.

T Tawonsawatruk 1, P Tuntiyatorn 2, T Kanchanathepsak 1, I Watcharananan 1

1 Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2 Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Abstract Background: PRP contains several growth factors which can improve functional outcomes in tendinopathies especially for the Tennis elbow. However, there is no previous report on the clinical use of PRP injection in cases with previous corticosteroid injection. Hypothesis: PRP injection can improve the elbow function of the elbow tendinopathy in patients who have a history of previous corticosteroid injection. Methods: Six-teen lateral epicondylitis (Tennis Elbow) patients who had a recurrent symptom or failure treatment from previous corticosteroid injection therapy were included into this study. Autologous PRP was injected to the ECRB origin for all patients under ultrasound-guidance in order to improve the accuracy of the injection to ECRB location. Means follow up time, VAS score, Quick DASH score, Mayo elbow score and patients’ satisfaction score were comprehensively collected both before and after PRP injection to evaluate functional outcomes. The result: Three patients were loss of follow up, then only 16 patients were analyzed in this case series. Means follow up time was 16.94 months. VAS score, Quick DASH score, Mayo elbow score were significantly improved after treatment (8.78 and 1.78, 47.35 and 5.48, 65.42 and 96.25 respectively P<0.0001). All patients satisfied with treatment demonstrating by the patient satisfactory score. There was no complication from skin allergy after PRP injection. Interestingly, there was no patients underwent surgery at last follow up. Conclusion: Ultrasound guided PRP injection can improve functional outcomes in the lateral epicondylitis patients who had previous failure from corticosteroid injection. Keywords: Platelet rich plasma, Recalcitrant lateral epicondylitis, Recurrent lateral epicondylitis, Corticosteroid, Ultrasound-guided injection

Muhammad A Quolquela

Tanta University, Department of orthopaedics, Tanta, Egypt

Objective Tennis elbow or lateral epicondyltis is a common patient presentation in any office of orthopaedic practice. Most patients respond well to non operative measures as anti-inflammatory drugs, splints and local cortisone injections. Very few patients are candidates for surgery usually as a release of the common extensor origin at the lateral epicondyle. This kind of surgery is fraught with complications as persistence of pain due to adhesions and inflammatory reactions at the surgery site together with weakness of wrist extension due to lengthening of the extensor carpi radials longus muscle (the main wrist extensor) .Weakness of wrist extension has a deleterious impact on hand grip strength as the former is a conjuncture to finger flexion. Denervation of the lateral epicondylar region through division of branches of posterior cutaneous nerve of the forearm (PCNF) was proposed as a simpler procedure to alleviate pain without drawbacks of muscle release. Methods During the last five years, 21 patients having tennis elbow and not responding to non operative treatment for at least 9 months were subjected to denervation procedure. They had an average age of 29 years old. Dominant arm was involved in 18 patients. On a scale of pain severity from 0 (no pain) to 10 (most excruciating pain), patients reported an average of 7. Patients lost an average of 25º to full elbow extension with full flexion. Hand grip strength averaged 60% of the other side. Mayo elbow performance score (MEPS) was evaluated to be 60 points on the average. Through a longitudinal incision along the upper arm a hand breadth proximal to the lateral epicondyle, main trunk of PCNF was severed, ligated with non absorbable suture and buried through a slit in the fascia covering the triceps lateral head to avoid neuroma formation. Results Average postoperative follow up was 3.5 years. On the 0 to 10 pain scale, 94 % of the patients reported no pain at all and the rest reported an average of 3. Loss of full elbow extension averaged 8º. MEPS averaged 90 points. Average hand grip strength improved to 88% of the other side. Conclusions Denervation of the elbow through division of the posterior cutaneous nerve of the forearm for management of tennis elbow is a simple safe procedure with apparently better outcome compared to the classic common extensor release at the lateral epcondyle.

Young Ho Lee 1, Jung Eun Lee 2, Jihyeung Kim 1, Hyun Sik Gong 3, Goo Hyun Baek 1

1 Seoul National University Hospital, Seoul, South Korea; 2 Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea; 3 Seoul National University Bundang Hospital, Gyeonggi-do, South Korea

Purpose: In the treatment of simple transverse fracture of olecranon, it is known that tension band wiring technique is effective. However, complex transverse fracture of olecranon, the Schatzker type B fracture, which has the articular impacted-depression fragment, loses the anterior bony buttress against the compression force of the articular surface of the trochlea, so that tension band wiring technique will be able to cause secondary reduction loss. Therefore, for using a stable tension band wiring technique, the anterior buttress of olecranon notch should be restored. The purpose of this study was to report the clinical outcome of tension band wiring fixation of complex transverse olecranon fractures. Patients & Method: We treated the complex transverse fracture of olecranon which had joint-impacted fragment from 2010 to 2016. Articular impacted-depression fragment was restored anatomically to proximal or distal segment using longitudinally inserted absorbable pins. After switched to simple transverse fracture of olecranon in this way, bone defect was supplemented with autologous iliac bone graft followed by fixation by tension band wiring using eyelet pins. The functional evaluation of the elbow joint was measured by MEPS (Mayo Elbow Performance Score) and the range of the motion of the elbow joint was evaluated, and the radiologic outcomes were evaluated in simple X-ray. Results: All olecranon fractures were united without secondary reduction loss in the average 6 weeks. Two patients showed joint subsidence of 1.2 mm and 2.2 mm respectively, but they did not report subjective discomfort. The mean elbow joint flexion range was 132 degree and the mean elbow joint extension range was 4 degree. There was no migration of the implant in the final image, and there were no symptoms by metal implants. The mean postoperative first year MEPS score was 94, 25 of the 26 cases (96%) achieved a good or excellent outcome. Conclusion: In the complex transverse fracture of olecranon which has the joint-impacted fragment, tension band wiring fixation after conversion to a simple transverse facture by anatomical restoration of articular fragments using absorbable pins supplemented with autologous bone graft is considered as good option.

Koji Fujita 1, Takuro Watanabe 2, Yuta Sugiura 2, Akimoto Nimura 1, Atsushi Okawa 1

1 Tokyo Medical and Dental University, Tokyo, Japan; 2 Keio University, Kanagawa, Japan

Objective The importance of postoperative rehabilitation is well-acknowledged in the field of hand surgery. Daily rehabilitation supervised by trained hand therapists is ideal, but daily hospital visits can be burdensome. Home-based self-rehabilitation is recommended; however, doctors are not aware of when and how it should be performed. In this study, we developed a tablet-based application (app)for home-based rehabilitation of patients with postoperative carpal tunnel syndrome. The app reminds patients to perform daily finger rehabilitation exercises and enables doctors to confirm compliance remotely from the hospital. Methods The study was approved by the institutional review board in Tokyo Medical and Dental University. Three patients who underwent carpal tunnel release surgery for severe carpal tunnel syndrome with thenar muscle atrophy were included. We developed an app that stimulates palmar abduction of the thumb, consisting of a game that is played by sliding the thumb to receive points. Prior to starting every game, range of motion in the thumb was automatically measured. The game then started the range of thumb motion slightly wider than the pre-measured range so the patients unconsciously abducted their thumb. Usage status and all parameters including speed, score, and range, were confirmed remotely. Prior to surgery, the patients were educated on how to use the app, and they began using it two weeks postoperatively. They received feedback from their doctor during each postoperative hospital visit. Results All patients used the app postoperatively on a daily basis for three months. Compared to preoperative values, speed and range of thumb motion improved. These results showed the potential usefulness of a tablet-based app that promotes home-based rehabilitation. Rapidly developing network technology enables us to monitor patients’ physical activities outside of the hospital, which was not easily accessed before and also promotes adequate postoperative movement through tablet or smartphone-based apps. We hope to develop new apps for adaptable hand diseases to reduce the physical and economic burdens on both patients and medical staff. Conclusion We developed a tablet-based rehabilitation app for postoperative patients with carpal tunnel syndrome. This app promoted home-based rehabilitation and could confirm the results remotely.

Ahmet Fahir Demirkan 1, Ali Kitis 2, Umut Eraslan 2, Hande Usta 2, Merve Kalpak 2

1 Pamukkale University, Medical Faculty, Department of Orthopaedics and Traumatology, Denizli, Turkey; 2 Pamukkale University, School of Physical Therapy and Rehabilitation, Denizli, Turkey

OBJECTIVE: The aim of this study was to investigate the effect of early physiotherapy program on range of motion (ROM) and grip strength in zone I extansor tendon injuries. METHODS: Thirty-two patients aged from 16 to 66 (36.56±12.95) years who were diagnosed with zone I extansor tendon injury between 2014 and 2017 were included in this study. Injury severity was assessed with Modified Hand and Forearm Injury Severity Scoring (MHISS). All cases were followed-up every week for wound care, edema control, pain control and active joint motion exercises for uninvolved joints from the first postoperative week. A static volar finger splint was used for involved distal interphalangeal (DIP) joint for 8 weeks. Active blocking exercises were started when splint was removed at 8th week. At 9th week tendon gliding exercises and at 10th week mild resistence exercises were started. The physiotherapy program continued for 12 weeks. The descriptive information of the cases were recorded. ROM (by distance measurements) at 8th and 18th weeks after injury, and the grip strengths at 12th and 18th weeks were evaluated. At postoperative 12th week, the disability and symptom status was evaluated with the Turkish version of Disabilities of the Arm, Shoulder and Hand Score (Q-DASH). The results were analyzed by Paired Samples t test. RESULTS: Sixteen cases were female (50.0%) and 16 cases were male (50.0%). 29 cases had right hand dominancy (90.6%) and 3 had left dominancy (9.4%). Sixteen cases (50.0%) had injury on dominant and 16 (50.0%) had on nondominant side. 19 cases were followed by conservative treatment (59.4%) and 13 (40.6%) had a surgery. The mean MHISS score was 8,56 ±2,72 and Q-DASH score was 26,89±16,09. At 18th week, flexion of the 3rd, 4th and 5th fingers were significantly higher when compared to the 8th week results (p<0.05). However, there was no significant difference in hand and pinch grip strength at 12th and 18th weeks (p>0.05). There was no extension deficit. CONCLUSIONS: As a result of this study, at 18th week finger ROM was more than 8th week. But there was no difference in grip and pinch strengths. In order to be able to interpret the results more clearly we think that in the larger sample groups, evaluations in the late period and long intervals are needed. Keywords; extansor tendon, rehabilitation, functional status

Anna Pantouvaki, George Velivasakis, Petros Kapsetakis, Grigorios Kastanis

General Hospital of Heraklion - Venizelio, Greece

Objectives: Perilunate injuries affect both soft tissues and bony element and account 5-7% of all wrist injuries. The early surgical management is the treatment of choice, following a rehabilitation program in order to gain normal function of the wrist. The purpose of this study is to describe the functional outcomes after use deep friction massage together with manual therapy of this type of injury. Material & Methods: Two patients with average age 40 years after a traffic accident had sustained trans-Scaphoid volar dislocation of lunate of the right wrist. The patients underwent surgery treatment and they started rehabilitation therapy after an average time of 7 weeks from the surgery. Physical therapy included conventional intervention with ultrasound, ice and deep friction massage directed to the ulnar and radial collateral ligaments as well as to the extensors apparatus of the wrist plus the dorsal capsular - ligamentous complex of the wrist. Deep friction massage was performed three times per week for 3-5 minutes in areas described above. Mobilization techniques were utilized to promote pain -free wrist and finger mobility. The patients followed a supervised physiotherapy treatment three times a week for one hour. The rehabilitation program included also an individualized exercise regimen performed three to five times daily according to given instructions at intensity and number of repetitions. Results: The mean follow-up was approximately 12 months. The results were based upon Quick Dash Score, Mayo Wrist Score, and range of motion. The patients were measured at the start of the rehabilitation program, at 3, 6, 12 months. The Quick Dash Score was 4,5 and 6,8 while the Mayo Wrist Score was 80 and 75 .The final range of motion at one year , were: extension 40°/45 - 41°/ 46° , flexion 60°/65°- 59°/67°, radial deviation 21°/24°- 23°/25° and ulnar deviation 30°/32°- 30°/34°. The motions were pain free and the patients return to the previous status of functionality after one year. Conclusion: The combination of deep friction massage, manual therapy, and exercise as well as ultrasound and ice intervention proved successful to these patients. Deep friction massage may contribute to painful syndromes in the tendon and ligament complexes that cross the injured joint due to decrease of the inflammation process and pain, while mobilization techniques may increase the range of motion rapidly due to effective joint alignment coupled with active exercises.

Ishan Radotra, Benjamin Baker, Stuart W McKirdy

Department of Plastic Surgery, Royal Preston Hospital, Preston, UK

Severe flexure contractures of the hand cause pain, palmar hyperhidrosis, ulceration, and nail plate deformities. Non-operative management includes splinting, that can be very painful, and botulinum toxin injections, which provide only a temporary solution. Surgical treatment includes soft tissue release, tendon transfers, and release of the flexor and intrinsic muscles, but may not be acceptable to patients with anticipated functional recovery due to permanent effect on hand function. We present the first documented case in the literature of flexion contractures of the hand managed using the Inflatable Carrot orthosis. In a patient with unsatisfactory results from botulinum toxin injections and for whom surgical intervention was not considered in their best interests, the inflatable carrot provided an alternative non-surgical solution for management. We demonstrate efficacy with medical photographs and objective measurements with no associated complications. Awareness of this alternative orthosis amongst hand surgeons will broaden our armamentarium for this difficult clinical problem.

Agnes Sturma 1,2, Laura A Hruby 1, Cosima Prahm 1, Johannes Mayer 1, Oskar C Aszmann 1,3

1 Christian Doppler Laboratory for Restoration of Extremity Function, Medical University of Vienna, Vienna, Austria 2 Master Degree Program, Health Assisting Engineering, University of Applied Sciences FH Campus, Vienna, Austria 3 Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria

Objective: Successful motor function recovery following nerve transfers depends on the re-innervation of the new target muscle by regenerating axons as well as adequate motor learning. As this learning process is cognitively demanding for the patient, a structured rehabilitation program is needed. Our objective was to evaluate such a protocol in a pilot study. Methods: Five patients after severe injuries of their brachial plexus were included. On all patients nerve transfers were performed to restore biological upper extremity function. Muscle strength was assessed with the British Medical Research Council (BMRC) muscle scale before surgery and after completion of rehabilitation. Explorative statistics were applied. All patients did undergo a structured rehabilitation regime in three phases. In the first months after neurotization no active movements are possible and therapy therefore focused on enhancing cortical representation of upper extremity motor areas. This included motor imagery as well as mirror therapy. As soon as the patients could activate the re-innervated muscles, the second phase started. Here, otherwise undetectable motor activity was visualized using surface EMG biofeedback. Patients were educated on what activation patterns to use as, after motor nerve transfers, muscular activation requires thinking about the movements the nerve was initially responsible for. Subsequently, they were educated to also think about the intended movements. The third phase started when patients could initiate movements that were easily detectable with naked eye. Here the focus lied on relearning the original movement pattern. This was done by asking the patient to execute the intended motor task without co-contraction of the muscles the donor nerve had originally innervated. This cognitively demanding task was supported using surface EMG. This allowed patient and therapist to see a visualization of the activity of both muscles and thereby receive precise feedback on performance. Finally, fine motor tasks and activities of daily life were trained. Results: All patients completed rehabilitation and had an improved muscle strength. While all patients had a severely impaired elbow flexion with BMRC grade 0 (n=4) or grade 1 (n=1) before surgery, function clearly improved to BMRC grade 3 (n=3), grade 3+ (n=1) and grade 5 (n=2). In the 4 patients with impaired deltoid function, a similar improvement was seen. Additionally, all patients regained a better triceps function. Two patients had no function in the forearm and hand before surgery and regained some muscle strength. Full hand function, however, could not be achieved. But one patient, who had impaired wrist and hand function before surgery, could regain full muscle strength and functionality. Conclusions: As all patients completed the rehabilitation program, it can be considered feasible. The functional outcomes were better than or equal to those described in literature. Although many factors influence the outcome after neurotization, the structured rehabilitation programm can be considered as supportive. It can help in the cognitively demanding process of establishing new motor patterns.

Stefanie Wieschollek, Karl Josef Prommersberger, Rainer Schmitt, Karl Heinz Kalb, Georgios Christopoulos, Roland Geue

Klinik für Handchirurgie, Campus Bad Neustadt, Germany

Hypothesis: Evaluation and understanding of location, dislocation, humpback deformity and misalignment of scaphoid fractures is essential for the decision of the following treatment. Therefore a CT scan in the long axis of the scaphoid (CTsc) is more significant and reliable than a CT scan in the plane of the wrist (CTw) . Methods: We tested the interobserver reliability of those two CT scan methods. 42 patients with scaphoid fractures had a CT scan in the long axis of the scaphoid (CT-scaphoid). CT reformations along planes relativ to the wrist (CT –wrist) were made. Those 84 cases were anonymised and put in a random order. They were presented to 4 clinical observers (2 handsurgeons and 2 radiologists) for fracture evaluation regarding: localisation, humpback deformity, offset (radial/ulnar and palmar/dorsal) and classification by Herbert. Additionaly the surgeons shoud decide for palmar or dorsal approach, open or percutaneous technique. Statistical analysis was made between 2 and 4 observers, using Cohen´s kappa coefficient, Pearson coefficient, Fleiss´ kappa, interclass correlation coefficient (Shrout and Fleiss) and Spearman-Rho coefficient. Results: Observer CT w CTsc Localization Cohen´s kappa 2 0,609 0,730 Fleiss´ kappa 4 0,442 0,695 Humpback Pearson coefficient 2 0,037 0,760 Shrout and Fleiss 4 0,047 0,938 Offset r/u Spearman-Rho 2 0,271 0,395 Shrout and Fleiss 4 0,652 0,661 p/d Spearman-Rho 2 0,431 0,597 Shrout and Fleiss 4 0,759 0,885 Herbert Cohen´s kappa 2 0,371 0,559 Fleiss´kappa 4 0,321 0,533 Approach Cohen´s kappa 2 0,483 0,545 Technique Cohen´s kappa 2 0,362 0,413 Interpretation: 0-> no correlation; 1->high correlation Summary: - regarding evaluation of humpback deformity there was a significantly higher interobserver correlation in CTsc than CTw - regarding evaluation of localisation, offset, Herbert classification, approach and technique there was a slightly higher interobserver correlation in CTsc than CTw - in all evaluated parameters the interobserver reliabilty was slightly higher in the CT scan in the long axis of the scaphoid For evaluation and understanding of scaphoid fractures the CT scan along the long axis of the scaphoid is more significant and reliable than the scan in the plane of the wrist and therefore preferable.

Michaela Huber, Rebecca Woehl, Johannes Maier, Christoph Palm

Department of Trauma Surgery and Emergency Department, University Medical Center Regensburg

Objectiv Scaphoidectomy and midcarpal fusion can be performed using traditional fixation methods like K-wires, staples, screws or different dorsal (non)locking arthrodesis systems. The aim of this study is to test a new locking plate and to compare the clinical findings to the data revealed by CT scans and semi-automated segmentation. Methods This is a retrospective review of eleven patients suffering from scapholunate advanced collapse (SLAC) or scaphoid non-union advanced collapse (SNAC) wrist, who received a four corner fusion with a plate (Aptus 4CF) between August 2011 and July 2014. The clinical evaluation consisted of measuring the range of motion (ROM), strength and pain on a visual analogue scale (VAS). Additionally, the Disabilities of the Arm, Shoulder and Hand (QuickDASH) and the Mayo Wrist Score were assessed. A computerized tomography (CT) of the wrist was obtained six weeks postoperatively. After semi-automated segmentation of the CT scans, the models were post processed and surveyed. Results During the six-month follow-up mean range of motion (ROM) of the operated wrist was 60°, consisting of 30° extension and 30° flexion. While pain levels decreased significantly, 54 % of grip strength and 89% of pinch strength were preserved compared to the contralateral healthy wrist. Union could be detected in all CT scans of the wrist. While X-ray pictures obtained postoperatively revealed no pathology, two complications were found through the 3D analysis, which correlated to the clinical outcome. Conclusion Due to semi-automated segmentation and 3D analysis it has been proved that the plate design can keep up to the manufacturers’ promises. Over all, this case series confirmed that the new plate can compete with the coexisting techniques concerning clinical outcome, union and complication rate.

Takahiro Asano 1, Masaya Tsujii 1, Kazuya Odake 1, Yoshinori Makino 2, Ryu Iida 2, Akihiro Sudo 1

1 Department of Orthopaedic Surgery, Graduate School of Medicine, Mie University, Mie, Japan; 2 Nagai Hospital, Mie, Japan

Objective Triangular fibrocartilage complex (TFCC) injury, especially at the fovea, is a serious complication leading to chronic pain of wrist joint associated with the distal radius fracture. The prevalence were reported based on the evaluation using arthroscope and MRI, although these are impractical to be routinely performed. The purpose of this study is to find the predictor in X-ray of TFCC foveal tear in analysis of the relationship between X-ray parameters of distal radius fracture and foveal tear of TFCC on computed tomography (CT) arthrography. Methods Thirty-six wrists of 35 patients (8 men and 28 women; mean age, 69 years) were surgically treated with volar locking plates for distal radius fracture. Immediately after the surgery, 5ml non-ionic contrast material was injected within the distal radioulnar joint under the fluoroscopy. Within 10 minutes after the injection, the CT was taken using a helical CT unit (Aquilion 64, Toshiba, Tochigi, Japan). We determined the foveal tear of TFCC on the slice of coronal and radial view centered on the ulnar styloid process. Furthermore, radiological parameters were measured on X-rays after the surgery, including radial inclination (RI), volar tilt (VI), radial translation (RT), and radial translocation of the ulnar styloid (UT). The radiological parameters were statistically assessed between the patients with (group T) and without foveal tear on CT arthrography (group N) using Mann-Whitney U test and multiple logistic regression analysis. Results Out of 36 wrists, 21 wrists (61%) were diagnosed as foveal tear of TFCC on CT arthrography, of which 10 did not have ulnar styloid fracture. In group T, the mean value of RI, VI, RT, and UT was 13.8°,-12.3°, 3.7 mm, 2.6 mm, respectively, in which the degree of RT and UT was significantly greater than the value (17.7°,-6.2°, 1.7 mm, and 0.2 mm, respectively) in group N. Additionally, multiple logistic regression analysis revealed that translocation of fractured ulnar styloid was an independent risk factor of TFCC foveal tear. Conclusion CT arthrography immediately after the surgery could be easily performed without additional pain due to the injection, because of the anesthesia for the plate fixation. As a result, the clear images made us diagnose foveal tear of TFCC in 61% patients of this series. In addition, the radial translocation of ulnar styloid fracture was shown to be an independent risk factor of the foveal tear. Distal radius fracture accompanied with greater ulnar styloid dislocation should be carefully treated, including cast and surgical treatment for foveal tear of TFCC.

Pascal Ducommun, Urs Hug

Division of Hand and Plastic Surgery, Lucerne Cantonal Hospital, Switzerland

Introduction Wrist pain is frequent and can be caused by a diversity of pathologies. Depending on the symptoms conventional X-rays, MR, CT or ultrasound are the imaging possibilities for evaluation of wrist pain. Fractures, osteoarthritis and inflammatory diseases might be sufficiently diagnosed with x-rays or ultrasound. Despite this armamentarium the etiology can not always be found. SPECT/CT (Single photon emission computed tomography/ computed tomography) is used additionally, especially in the hand. Abnormal scintigraphic uptake in asymptomatic joints and bones are described, but remains unclear in its significance. Objective The aim of this study is to evaluate the prevalence and prognostic value of abnormal uptake in bone SPECT/CT in asymptomatic wrists. Patients and Methods 44 patients (18 women, 26 men) with pain in the symptomatic wrist (SW) and asymptomatic contralateral wrist (AW) were examined with SPECT/CT and included in this study. Dual phase planar and SPECT/CT images of the symptomatic and asymptomatic wrists were obtained between July 2014 and September 2016 and retrospectively evaluated regarding presence, localization, intensity and origin of uptake using a four-point grading scale. Furthermore clinical investigation on the asymptomatic wrist with higher uptake in SPECT/CT was performed after one year. Results 31 (70%) patients showed increased uptake in the SW and 14 (32%) in the contralateral AW. Mean uptake grade in the SW was 1,48 (range 0 - 3) and 0,48 (range 0 - 2) in the AW. The SW showed significantly (p <0.01) more locations with increased uptake and significantly (p<0.01) higher uptake grades compared to the AW. In the AW abnormal uptake was observed in osteoarthritis (n=8), mechanical overload (n=5) or traumatic (n=1). In the SW abnormal uptake was related to osteoarthritis (n= 13), osteoarthritis (n= 5) mechanical overload (n= 14), carpal boss (n= 4) or other etiologies (n=7). No patient of the follow-up group (n=14) had spontaneous pain in the primarily asymptomatic wrist but in 50% patients local pain could be triggered during wrist examination and matched exactly with the initially increased uptake observed in SPECT/CT. Conclusion Increased uptake in SPECT/CT in asymptomatic wrists can be found in one third of patients and are often low to intermediate. The majority of uptake in asymptomatic wrists do not have a clinical relevance in short time follow-up and can therefore be neglected.

D. Bakker 1,3, G. A. Kraan 1, N. M. C. Mathijssen 1, J. W. Colaris 2, G. J. Kleinrensink 3

1 Reinier de Graaf Groep, Department of Orthopaedic Surgery, Delft, The Netherlands; 2 Erasmus Medical Centre, Department of Orthopaedic Surgery, Rotterdam, The Netherlands; 3 Erasmus Medical Centre, Department of Neuroscience, Rotterdam, The Netherlands

Objective Injuries of the scapholunate interosseous ligament (SLIL) are considered to be the most frequently diagnosed cause of carpal instability. In order to improve the post-operative rehabilitation process, it is necessary to obtain a better understanding of the biomechanical properties for commonly used reconstructions like capsulodesis. Therefore, the aim of this cadaveric study was to assess the stress strain relation of the wrist during palmar flexion and to determine the type of failure after capsulodesis. Methods Ten cadaver wrists were used for this study. To obtain the stress strain relation, a differential variable reluctance transducer (DVRT) was placed on two intervals, on the scaphoid and the lunate, and on the dorsal intercarpal complex and Lister’s tubercle. To quantify palmar flexion a digital goniometer was attached at the dorsal aspect of the hand. All wrists were cycled five times through a neutral position to 70° arc. Results The mean strain on the dorsal intercarpal reconstruction at 70° palmar flexion was 0.8mm. (SD±0.6). No failure of the dorsal intercarpal reconstruction was seen during all tests. The maximum strain on the dorsal intercarpal complex was 3.9mm. (SD±1.7) at 70°. Conclusions The stress strain relation shows that the dorsal intercarpal reconstruction undergoes a minimal amount of strain. Furthermore, no failure of the dorsal intercarpal reconstruction occurred. These findings supports the concept that the capsulodesis stabilizes the scaphoid and lunate. The slight strain on the dorsal intercarpal complex suggests that a faster start of the post-operative rehabilitation process might be possible.

Kazutoshi Kubo 1,2, Boran Zhou 2, Yu-Shiuan Cheng 2, Kai-Nan An 2, Steven L. Moran 2, Peter C Amadio 2, Xiaoming Zhang 2, Chunfeng Zhao 2, Katsunori Inagaki 1

1 Orthopedic Surgery Department Showa University School of Medicine, Tokyo, Japan; 2 Mayo Clinic, Minnesota, USA

Carpal tunnel pressure is considered a key factor in the etiology of carpal tunnel syndrome because disease condition in most of carpal tunnel syndrome results in tunnel pressure elevated. We believe that measuring carpal tunnel pressure leads to help to diagnose carpal tunnel syndrome as well as to understand carpal tunnel syndrome comprehensively. Numerous approaches have been conducted to measure carpal tunnel pressure. However, most techniques are invasive and take time and effort. We have developed an innovative approach to non-invasively assess the tunnel pressure by using the ultrasound surface wave elastography (USWE) technique. In a previous study it was shown that the shear wave speed propagating in a tendon increased linearly with increasing tunnel pressure enclosed the tendon in a simple tendon model. This study aimed to examine the relationship between the carpal tunnel pressure and the shear wave speeds inside and outside the carpal tunnel in a human cadaveric model. A total of 10 fresh frozen human cadaveric forearm hands were used to study. The result showed that the shear wave speed inside the carpal tunnel increased linearly with created carpal tunnel pressure, while the shear wave speed outside the carpal tunnel remained constant. These findings suggest that noninvasive measurement of carpal tunnel pressure is possible by measuring the shear wave speed propagating the tendon in the carpal tunnel. After fully establishing this technology and being applicable in clinic, it would be useful in the diagnosis of carpal tunnel syndrome. For that reason, further validation with this technique in both healthy controls and patients with carpal tunnel syndrome is required.

Keitaro Fujino, Katsunori Ohno, Atsushi Yokota, Kenta Fujiwara, Masashi Neo

Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan

Objective: When we evaluate the thenar muscles using ultrasound, with the transducer directly contacting the skin, the morphometry may easily change with transducer pressure on the curved surface of the thenar region. The aim of this study was to compare reliability and measurement between water bath technique (WBT) and the direct contact method (DM) in ultrasound quantification of thenar muscles and to determine whether measurements were influenced by transducer compression. Method: This study included 40 healthy adults (19 men and 21 women; mean age, 37.8 years; range, 23 - 56 years). The abductor pollicis brevis (APB) of 80 hands was measured with axial ultrasound scans using WBT and DM. Subjects were in relaxed sitting position with the elbow in 90°flexion, forearm in supination, hand in neutral position, and thumb in maximum abduction. WBT was performed in a plastic container filled with water. The forearm and hand were immersed in the container. The transducer was placed adjacent to the skin surface without touching it. DM was performed with sufficient transmission gel in the same container. For ultrasound evaluation, the transducer was placed onto the skin with the least compression possible. A line was drawn between the radial sesamoid of the thumb and the scaphoid tuberosity. An axial image was acquired at the midpoint of the line and the transducer was adjusted to find the location where the flexor pollicis longus tendon was brightest. Thickness and cross-sectional area (CSA) of the APB were calculated with the measurement function of the ultrasound device. In axial images, APB thickness was calculated on a perpendicular line at the most volar point of the first metacarpal. APB CSA was measured simultaneously in the image. All subjects underwent third ultrasound examinations by two examiners a week apart. Interclass correlation coefficients (ICC) were calculated to estimate inter- and intraobserver reliability. Bland-Altman analysis was performed to compare the agreement between measurements by WBT and DM. Limits of agreement were defined as the mean difference ± 1.96 standard deviaion (SD). Result: Thickness and CSA of the APB by both methods showed almost perfect interobserver reliability (ICC range, WBT 0.90 - 0.94, DM 0.87 - 0.94) and intraobserver reliability (ICC range, WBT 0.91 - 0.95, DM 0.90 - 0.95). The mean ± SD (WBT/DM) of APB thickness was 5.76 ± 0.90/5.83 ± 0.90 mm and CSA values were 0.88 ± 0.20/0.91 ± 0.21 cm2. In the Bland-Altman analysis, measurements by WBT were found to overestimate the APB thickness by an average (limits of agreement) of 0.05 ± 0.38 mm, 0.01 ± 0.07 cm2, respectively. Conclusion: Ultrasound quantification of thickness and CSA of APB by both methods showed almost perfect reliability. Although compression by the transducer cannot be completely avoided, the clinical difference may be very small. This result indicates that use of sufficient transmission gel and careful transducer compression on the curved surface of the thenar area will have little influence on measurements of APB thickness and CSA.

Leen Vanlaer 1, Loïc Vercruysse 2, Pieter Caekebeke 1, Arne Decramer 2, Joris Duerinckx 1

1 Ziekenhuis Oost-Limburg, Genk, Belgium; 2 AZ Delta, Roeselare, Belgium

Correct implant position is essential to obtain good results in ball-in-socket trapeziometacarpal total joint arthroplasty. Adequate placement of the cup in the trapezium can be challenging, but is one of the most important factors to prevent postoperative complications. The purpose of this study was to determine if intra-operative fluoroscopic control improves cup position. We evaluated cup centring and cup inclination on postoperative radiographs of 114 trapeziometacarpal joint prostheses. Half of the cups were placed with visual inspection only, the other half was positioned with intra-operative fluoroscopic control. The mean difference in cup centring was not statistically significant between both groups. Mean cup inclination was significantly better in the fluoroscopy-assisted group. Between patient variability was significantly less in the fluoroscopy-assisted group, both for cup inclination and cup centring. The use of intra-operative fluoroscopy results in a better inclination of the cup. It also decreases variability in cup position, providing more consistent radiographic results with less outliers.

Diego Junqueras, Pablo Orellana, Francisco Melibosky, René Jorquera, Peter Cobb, Juan José Valderrama

Clinica Indisa, Chile

Introduction: The fracture of the distal end of the radius is the most frequent fracture of the upper extremity with an annual incidence of 16.2 per 10,000 people. Its surgical treatment with blocked volar plates is currently the gold standard in most fractures. However, it can present complications such as extensor tendon injury and the presence of intra-articular screws. To prevent these complications, the projections of intraoperative radioscopic support "Skyline and Facet View" have been described in recent years, to improve their research and modify their position. The objective of this work is to determine the usefulness of the intraoperative radioscopy using the projections mentioned, to identify screws in an inadequate position, comparing them with a postoperative TAC of control. Patients and Method: A retrospective review of clinical records and image files was performed, where 4 hand surgeons independently and blindly evaluated the "Skyline and Facet View" radiographic images of 24 patients operated for distal radius fracture. Screws were identified in the dorsal or intraarticular position, respectively, and then compared with the postoperative CT Results: There was a low interobserver concordance between what was recorded in fluoroscopic images by each surgeon and the findings in the postoperative CT scan. In addition, low values ​​of diagnostic accuracy are obtained for Skyline View and acceptable values ​​for Facet View. A low detection capacity of dorsal screws in the 1st and 2nd extensor compartment of the wrist was also observed. Conclusion: Our study shows that intraoperative fluoroscopy with Skyline and Facet View projections has low reproducibility and diagnostic accuracy compared to that observed in the control with CT. We believe that the use of this tool should be in a complementary way during the surgical act, keeping in mind its limitations in complex wrist fractures.

Hongje Kang, Daejin Nam, Seng Hwan Kook

Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea

To compare the results of Ultrasonography guided percutaneous A1 pulley release and blind percutaneous A1 pulley releases techniques in a patient with trigger finger, a retrospective study was performed. From February 2012 to February 2016, 34 patients (45 fingers) underwent blind percutaneous A1 pulley release, and 26 patients (30 fingers) underwent ultrasonically guided A1-transcutaneous transcutaneous dissection from August 2014 to February 2016. The mean age was 56 (38-65) years of blinded percutaneous releases techniques, and 54 (35-60) years of ultrasound-guided percutaneous release. The blind percutaneous incision was performed in 8 cases of thumb, 9 cases of 2nd finger, 9 cases of 3rd finger, 6 cases of 4th finger and 2 cases of 5th finger. Ultrasonically induced percutaneous incision was performed in 5 cases of thumb, 2 cases of 2nd finger , 8 cases of 3rd finger, 8 cases of 4th finger and 1 case of 5th finger. The residual postoperative trigger symptom and VAS score were confirmed, and the range of motion of the joint was compared. At the last follow-up, in all cases with ultrasound-guided percutaneous release trigger symptom had disappeared, but three patients who underwent blind percutaneous incision underwent revision surgery for postoperative trigger symptom. The duration of pain after the procedure was 2.0 ± 0.5 days from 0 to 17 days, at the last follow-up, all were recovered. The VAS score was 2 points in the ultrasonography group and 4 points in the blind group at the 2nd week after surgery, at the 4th week after surgery, the VAS score was 1.2 points in the ultrasound group and 2.3 points in the blind group. In the 3 months after the operation, 1.1 points in the ultrasound group and 1.4 points in the blind group. There was a statistically significant difference at 2 and 4 weeks after surgery. No rupture of the tendon was observed, and no other complications such as nerve injury or surgical site infection were observed. The range of motion showed complete recovery in all cases after the procedure, but complete restoration of the range of motion was not obtained when the joint stiffness remained originally. All patients with the procedure was satisfactory, and responded that he would choose the treatment through this method in the future. As conclusion, ultrasound-guided percutaneous A1 pulley release as surgical treatment for trigger finger is considered to be a treatment with low risk of complications such as nerve injury and tendon rupture and highly satisfied after treatment.

Seung-Han Shin, Yong-Suk Lee, Yang-Guk Chung

Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea

Background: Forearm pronation is known to aggravate the ulnar impaction via the increase of ulnar plus variance. However, currently the ulnar variance is measured on two-dimensional (2D) images, and thus does not reflect the effect of dorsal translation of the ulnar head in pronation. Therefore, the actual ulnocarpal distance in pronation could be different in three-dimensional (3D) space. Materials and Methods: We investigated wrist 3D-computed tomography (CT) images of 21 patients, which were taken once with the forearm pronated and then with the forearm supinated. The shortest distance between the ulnar head and the lunate (ulnolunate distance) was measured. Dorsal translation of the ulnar head from its anatomic position in the center of the sigmoid notch was measured using a technique described by Lo et al (radioulnar ratio, RUR). Comparison between pronation and supination and correlation analysis between ulnolunate distance and dorsal translation of the ulnar head were performed. Results: The mean ulnolunate distance was significantly greater in pronation (2.2 mm) than in supination (1.6 mm). The mean dorsal translation of the ulnar head (RUR) also was significantly greater in pronation (0.13) than in supination (-0.14). When those who had greater ulnolunate distance in pronation (n = 18) were analyzed, the difference of ulnolunate distance in pronation and supination had significant correlation with the difference of dorsal translation of the ulnar head in pronation and supination Conclusion: The actual ulnolunate distance in 3D space is greater in pronation, due to dorsal translation of the ulnar head. Dorsal translation of the ulnar head in pronation may be a necessary and protective mechanism which prevents ulnolunate impingement.

Soo Min Cha, Hyun Dae Shin

Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea

Purpose: We evaluated the relationship between the area around the distal radioulnar joint (DRUJ) according to the ulnar variances and the cross sectional area (CSA) using magnetic resonance images (MRI) in this prospective study of patients with carpal tunnel syndrome (CTS). rnMethods: From among a total of 243 patients who had been diagnosed with CTS between March 2012 and February 2017 at our hospital, 41 patients with positive ulnar variance were enrolled in group 1. As control groups, 39 healthy volunteers who underwent MRI evaluations were included in group 2 (neutral ulnar variance) and group 3 (negative variance). Basic demographic data, including age, gender, and body mass index (BMI) were recorded for all three groups. An area encompassing the contents of carpal tunnel (nerves/tendons) was designated as area “A,” and the area just beneath the subcutaneous fat was designated as area “B” at the levels of the lunate (L) and pisiform (P) on axial MRI. Ratios of these areas (“A/B at L” and “A/B at P”) were evaluated in terms of their correlations with ulnar variance. rnResults: Mean age, gender, and BMI were not statistically different among the groups, respectively. Within each group, there was no difference between “A/B at L” and “A/B at P”, respectively. When comparing the three groups, “A/B at L” and “A/B at P” were all significantly decreased in group 1 than in other groups. Regardless of the group, ulnar length negatively correlated with both “A/B at L” and “A/B at P” ratios.rnConclusions: We found a positive relationship between decreased CSA around the DRUJ and positive ulnar variance on radiologic investigation. These findings show the importance of variance in the positive ulna variance to the development of CTS.rn

Jamila Hussein Eriksen 1, Niels Søe Nielsen 2, Dimitar Ivanov Radev 2, Charlotte Strandberg 2, Merete Juhl Kønig 2, Eva Balslev 3, Lisbeth Vesterløkke 2, Helle Raagaard Larsen, Nana Vermehren 4, Gudlaug Rosa Sigurdardottir 2, Britt Ebstrup 2

1 Nordsjællands Hospital, Hillerød, Denmark; 2 Gentofte Hospital, Denmark; 3 Herlev Hospital, Denmark; 4 Alexis-Hamlet Hospital, Denmark

Objective: There are still many questions regarding the origins of the clinical dorsal wrist ganglion. In this study we seek to discover the processes that initiate and maintain this disease by closely examining the patient history coupled with the exact location and pathology of the tissue. By learning more, it is our hope that treatment of the disease, which has shown to relapse in 5-10% of lege artis operated patients, can be improved. Our hypothesis is that the clinical dorsal ganglion is a result of a change in mesenchymal cells to mucin-producing cells and that there is a connection to the female gender, anatomy, former trauma to the wrist and the occupation of the patient. Methods: The prospective cohort study will examine approximately 40 patients with clinical dorsal wrist ganglion included consecutively over 1-2 years. Excluded are those formerly operated with clinical ganglion excision in the same wrist region. The included patients will undergo a preoperative evaluation with x-ray, MRI and ultrasound of the wrist before excision of the tissue by the same surgeon. The tissue removed is examined by the same pathologist for its components. Results: Preliminary results show that the clinical dorsal ganglia are located primarily dorsal to the scaphoid, lunate and capitate joints and volar to the extensor tendons. Most are cystic structures with surrounding inflammatory changes. Of the 6 patients included in the study to date, only 1 patient has shown signs of having a mucin-producing cyst. The remaining 5 patients have presented cysts that are synovial in origin. Conclusions: Little is known of the ætiologi and pathogenesis of the clinical dorsal ganglion. Our hypothesis is that the cysts develop as a result of change of mesenchymal cells to mucin-producing cells. Our preliminary results have shown that the cysts are mainly synovial in origin. Further study is needed in order to reach a conclusion which may change the public view of what the clinical dorsal ganglion is.

Benjamin Degeorge, Lionel Athlani, François Dap, Gilles Dautel

Centre Chirurgical Emile Gallé, Nancy University Hospital, Nancy, France

The Tactys implant is a new total anatomic gliding and modular prosthesis for the proximal interphalangeal arthrosis. 33 implants in 27 patients with a mean age of 67 years were operated. Surgical approach was mid-line dorsal trans-tendinous. All patients were evaluated (pain, range of motion, strength, function, X-rays) by an independent examiner. The mean follow-up was 21 months (range 12–30). Pain decreased from 7,4 to 1,6 on VAS scale. Flexion–extension range of motion increased from 32,1° to 59,2 and pinch strength from 1,8 to 2,4KgF. Four patients were reoperated on: 3 dorsal tenoarthrolysis and 1 swan neck deformity correction. Asymptomatic peri-prothesis calcification were noticed in 39% of cases on X-rays. There were no signs of implant migration or loosening. The modularity of the Tactys prosthesis seems to maintain range of motion of the PIP joint. It is a reliable alternative to other conventional PIP implants.

Francesco Smeraglia, Sergio Russo, Giovanni Balato, Maria Rizzo, Massimo Mariconda

University Federico II, Naples, Italy

Objectives The goal of this study is to prove the efficacy of Pyrodisk which is a biarticular convex disc made of pyrocarbon designed to act as an interposition spacer after minimal resection of the TMC joint. The implant and TMC joint are stabilized by a hemi- transfer of flexor radialis carpi passed through the implant itself. Study Design & Methods This is a prospective case series analysing 27 consecutive Pyrodisk implants in 25 women for advanced osteoarthritis of the TMC joint (Eaton II or II). Function assessment were made preoperatively and at 1, 3,6 and 12 months postoperatively, and annually thereafter. We obtained the DASH score, VAS score, Kapandji test, patient's satisfaction and pinch strength. Furthermore we requested an x ray to each follow up visit. Results All patients experienced a reduction in the DASH score 1 month postoperatively. The VAS score for pain and the opposition of the thumb also showed significant post- operative improvement. Further positive changes in the DASH score, VAS score for pain, and key pinch strength occurred progressively over the first postoperative year, whereas the opposition of the thumb steadily improved from the first to the sixth postoperative month. All the patients except one were satisfied with surgery. One patient had improvement in the DASH score but she still experienced an high VAS score and reduction of the pinch. She had a slightly hyperextension of the metacarpophalangeal joint. After 4 years she underwent further surgery (trapeziectomy and Ceruso's artrhoplasty). Conclusions Partial trapeziectomy with pyrocarbon arthroplasty may prove to be a successful option for the treatment of trapeziometacarpal joint osteoarthritis. Further long-term comparative studies are warranted.

Jean Louis Bovet 1, Marion Bricout 1, Moujoud Morchikh 1, Hugues Tiemdo 1,2

1 Polyclinique Jean Villar, Bordeaux, France; 2 Clinique Charles de Gaulle, Douala, Cameroun

Objective : Failures of a total TM prosthesis are mainly due to cups non embedment. In this cases many authors suggest the ablation of the implant followed by trapezectomy. We present a way to preserve the trapezium and thereby preserve thumb length, stability, and grasp. This technique is not indicated if the trapezium is fractured. Methods : 37 patients are included in this series, 2 cup loosening and 35 cup non embedment. The series includes 25 Electra , 4 Maia, 3 Arpe, 3 Isis, 2 others implants. It starts from 2005 All the cases had the same procedure. Through a dorsal approach, ablation of the implant avoiding a metacarpal corticotomy is performed. The reconstruction of the trapezium is made by filling it with bone chips from the ipsilateral radius .The first metacarpal basis is resurfaced through the interposition of a CMI pyrocarbon implant. The void created inside the first metacarpal is filled by the CMI stem sometimes completed with apatite. The cicatricial carpo-metacarpal capsulae is tightened with resorbable suture , any complementary ligamentoplasty is employed. Immobilisation is done for 3 weeks . Results : Evaluation was done on X rays, pain, satisfaction, mobility, grasp. Owing to belated beginning 18 cases could not be rewieved. Radiologic evolution shows a corticalisation in contact with pyrocarbon of the chips grafted inside the trapezium. None extrusion of the stem inside the first metacarpal was noticed, none osteophytes or calcification found in the neojoint. Clinically the main fact is the preservation of thumb opposition tests and grasp force (diagram 3) Complications : (diagram 4) none on the donor site, 3 neuritis of the radial sensory branch, 2 SDD Conclusion : This technic is easy to drive, in one time surgery, in one on only operative site. Since for such difficult cases one reprise is already too much, it stands out to become in our practice a "gold standard " for that situations.

Jean Louis Bovet 1, Hugues Tiemdjio 2

1 Clinique jean Villar Bruges Bordeaux France;2 Clinique Charles de Gaulle Douala Cameroun

Objective : Tow lesions close to the articular corticalis of the first metacarpal basis could not be treated without sacrifying the TM joint . This poster will show a combined treatment using after curettage of the tumor a filling of the bone with bone chips from the ipsi lateral radius and the use of a Maia prothesis to reconstruct the TM joint . Method : The first report is a case of Chondroma in right hand of a female secretary aged 45 , without any signs of arthrosis. Pain was the main complaint and leads to discover it . The second report is a giant cyst lacunae combined with arthrosis of the TM joint on the right hand of a physiotherapist aged 63 starting to retire from his job .Pain was the main complaint, the arthrosis was known but neglected and certainly related to his hard massage job. Technic applied was the same for both cases : Under loco regional anesthesia, dorsal incision, full curettage of the lesion, taking chips from the ipsi lateral radius to feel the defect , insertion of the Maia stem amoung the chips in a press -fit manner , and then completion of the procedure on the trapezium .Splinting was applied for 3 weeks . Autoreeducation was enough without need of physiotherapy. Caution was asked in everyday life for 3 months . Hard works authorized only after 6 months Results : Evaluation was done at 1 month , 3 month , 1 year , last control is 8 years for the chondroma and 5 years for the cyst. Both recovered a complete opponens and antepulsion of their thumbs. Pain have totally disappeared. No complaint due to surgery. No complications on the donor site. Any radiological recidive of the lesions . Full incorporation of the bone grafts. No signs of implant descellement. Conclusion: Combination of bone grafts and articular reconstruction allows to keep a normal function, without shortening the thumb , and preserving the trapezium.

Annelien Brauns, Pieter Caekebeke, Joris Duerinckx

Ziekenhuis Oost-Limburg, Genk, Belgium

It has been suggested that in trapeziometacarpal total joint arthroplasty, the trapezial cup should be positioned parallel to the proximal articular surface of the trapezium (PAST). This suggestion was based on the radiographic measurement of the range of motion of healthy joints. The goal of this study was to biomechanically test this statement. 5 fresh frozen cadavers hands were mounted in a test jig. An Arpe metacarpal stem and medium offset neck were implanted. 3D-printed trapezium cups with different inclinations relative to the PAST (neutral, 10°; 20°; 30°, 40°) were implanted. The stability of the prosthesis was tested through its entire range of motion for the different cup inclinations. We assessed is which positions and with which inclinations the prosthesis dislocated.This is important information to determine ideal cup position.

Damian Sutter 1,2, Dzhuliya V. Dzhonova 2, Jean-Christophe Prost 3, Cedric Bovet 3, Yara Banz 4, Jean-Christophe Leroux 5, Robert Rieben 2, Esther Vögelin 1,2, Jan A. Plock 6, Paola Luciani 5,7, Adriano Taddeo 1,2,8, Jonas T. Schnider 1,2,8

1 Department of Plastic, Reconstructive and Hand Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland; 2 Department for BioMedical Research, University of Bern, Switzerland; 3 University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Switzerland; 4 Institute of Pathology, University of Bern, Switzerland; 5 Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zürich, Switzerland; 6 Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Switzerland; 7 Department of Pharmaceutical Technology, Institute of Pharmacy, University of Jena, Germany; 8 contributed equally

Study Vascularized composite allotransplantation (VCA), the transplantation of a hand, face, abdominal wall or uterus is an emerging field. Thus far, over 120 upper extremity transplantations in at least 75 patients have been performed around the globe within the past few years. Most recipients are otherwise healthy individuals. After transplantation however, they are in a need for life long systemic immunosuppression to prevent graft rejection. This therapy comes at the cost of considerable morbidity and even mortality preventing a wider clinical application of vascularized composite allograft. Contrary to solid organ transplants, their composition of different tissue types makes them highly immunogenic and particularly challenging to treat. On the other hand, hand and face transplants are accessible for visual inspection, allowing treatment of an acute rejection episode to be initiated promptly. In addition, local treatment is also used to treat rejection episodes. Expanding on this concept, VCA offer the unique opportunity for local delivery of immunosuppressive treatment directly to the graft, possibly without the need for systemic treatment altogether. In this study, we developed a vehicle to locally deliver rapamycin to an allograft. We hypothesize that locally delivered rapamycin using this system may lead to immunomodulation of the graft microenvironment with improved graft survival, minimization of immunosuppression and expansion of regulatory T cells. Methods Drug release pattern of in situ forming implant loaded with 5 mg rapamycin (Rapa-ISFI) was analyzed in vitro and in vivo. The effect of Rapa-ISFI on VCA rejection was analyzed in the Brown-Norway-to-Lewis hindlimb allotransplantation model. Rapa-ISFI was injected in the groin on the transplanted (group A) or contralateral non-transplanted side (group B). Control group consisted of absence of immunosuppression (group C). Rejection was graded macroscopically and histologically. Rats were followed until grade 3 rejection or for 100 days. Tacrolimus levels and regulatory T cells and chimerism levels were analyzed in blood throughout the experiment using LC-MS and flow-cytometry. Results In vitro and in vivo analysis of the Rapa-ISFI showed sustained release with subtherapeutic systemic drug levels. All the untreated rats (group C) died within 30 days. Rapa-ISFI significantly prolonged graft-survival with 83.3% of the rats in group A (p=0.0007 versus group C) and 50% of group B (p=0.007 versus group C, p=ns versus Group A) reaching the 100 days end-point. Rapa-ISFI injection induced an initial burst-release of rapamycin, constant levels between day 23 and 58 and undetectable levels (i.e., <1.5 ng/mL) afterwards. Rapamycin in VCA-skin in groups A and B showed similar tissue levels. Rapa-ISFI treatment promoted the expansion of Helios-negative regulatory T cells and peripheral chimersim both in the peripheral blood and in the transplanted skin. Conclusion We show a novel approach for drug delivery in VCA. The treatment is able to promote VCA survival and induce the expansion of T regulatory cells as well as myeloid chimerism.

Lea Estermann 1, Elvira S. Bodmer 1, Miriam Marks 2, Daniel B. Herren 1

1 Department of Hand Surgery, Schulthess Klinik, Zurich, Switzerland; 2 Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland

Objective The Amandys® implant is an interpositional pyrocarbon implant for wrist arthroplasty. For patients with well-aligned wrists and competent capsuloligamentous structures, this implant offers a good alternative to more invasive procedures involving a total wrist prosthesis or total fusion. Based on the few case series showing promising results of pain relief and patient satisfaction, we began using Amandys® mainly for revision surgery after failed wrist procedures. We noted complications with this implant after a short follow-up period, which led to further revision surgery. The objective of this analysis was to investigate possible factors explaining the problems we encountered with this implant. Methods This retrospective analysis focused on five consecutive patients who underwent wrist interposition arthroplasty with the Amandys® implant (i.e. index revision surgery). The indication for this procedure was persisting wrist pain after proximal row carpectomy (PRC) in three patients, scapholunate advance collapse (SLAC Stage III) in one patient, and Kienböck’s disease (Stage IIIb) in the last patient. All patients underwent clinical and radiographic examinations to determine total range of motion, improvement in the level of pain and carpal bone alignment after 6 weeks, 3, 6 and 12 months post-surgery. Results Due to persisting postoperative wrist pain in two patients, we had to remove the Amandys® implant and perform wrist fusion after 12 and 23 months respectively. These patients had undergone PRC prior to the index revision surgery. Of these two patients, one required an additional intervention before the wrist fusion to excise the proximal part of the hamate bone due to osseous impingement (as detected by SPECT/CT scan). The patient with Kienböck’s disease is scheduled to undergo revision surgery because of persisting pain and loss of strength. The last two patients (with a SLAC and PRC wrist, respectively) were satisfied with their hand function. The 6-month postoperative mean wrist flexion was 21° (range: 0 - 45°) and mean wrist extension was 37° (range: 20 - 50°). Conclusions Based on our small patient series, we could not confirm the results from previously published studies. Our failure rate after interposition arthroplasty with the Amandys® implant is high, particularly for PRC patients. We hypothesize that PRC, in conjunction with a certain degree of intrinsic ligament destabilization, may primarily lead to proximalization of the hamate. This process could provoke an impingement with the implant, resulting in subsequent pain and failure of this procedure. In cases of obvious distal carpal row instability, additional stabilization may therefore be considered. More patients are needed to find the optimum indication for this implant, and we encourage further reports on this issue.

Magne Røkkum, Trygve Holm Glad, Rasmus Thorkildsen, Ole Reigstad

Oslo University Hospital, Norway

Arthrodesis has been the final treatment of destroyed and painful wrists. Pain relief may be good, although several patients complain of residual pain and complications that require reoperation. In addition, many people experience that stiffness reduces hand function. We have rearticulated 8 fused wrists with the Motec cement-free total wrist prosthesis with metal-on-metal articulation. There were 4 women and 4 men of median age 53 (41-67) years. The causes of arthrodeses were SLAC (3) and SNAC (1) wrist, seq. radius fracture (2), Madelung’s deformity and hand replantation (1). The indication for rearticulation was impaired function in all, as well as significant pain in 5 wrists. The rearticulation took place median 5 (2-13) years after arthrodesis. Mobile CMC 3-joints were fused simultaneously. The patients were followed up median 2 (2-11) years after rearticulation. No peroperative complication was seen. In one patient, X-ray showed radiolucent lines developing between the distal fixation screw and the diaphysis of the third metacarpal, where a part of a screw was left. No lucencies were found in the capitate and no migration of the component was seen. Radiologically, excellent bone integration of all components was observed. At the last check, median flexion/extension was 60 (45-90) degrees divided on 20 (10-32) degrees of flexion and 40 (30-60) degrees of extension. Median ulnar/radial deviation was 25 (20-40) degrees. Six wrists were painless, while two had some tenderness. All patients were very pleased with the improved function, the mobility and the reduced pain. Although the follow-up is short, the results of rearticulation of fused wrists with the Motec prosthesis are promising. Fixation of the prosthesis is not more difficult than in the primary situation. All patients achieved enough wrist mobility to get close to normal hand function. The surprising pain relief may be explained elimination intercarpal and CMC 3 joints. Patients with functional problems and pain following wrist fusion should be considered for rearticulation.

Stéphane Barbary 1, Thomas Apard 2, Jean-louis Bovet 3, Jacques Teissier 4

1 Centre Chirurgicale ADR, Nancy, France; 2 Center of Echo Handsurgery, Versailles, France; 3 Orthopole, Bruges, France; 4 Orthosud, Montpellier, France

It’s a prospective study. 50 Maia prosthesis has been implanted between January and July 2015 for the treatment of thumb arthritis Dell stage 2 or 3. The implant is a ball and socket dual mobility prosthesis with hemispherical cup and press-fit fixation and hydroxy-apatite coated. The surgical technique (dorso-radial approach) and the average duration of intervention (40 minutes) was the same as for the placement of a conventional trapezio-metacarpal prosthesis. The thumb column was immobilized for 3 weeks then rehabilitation was gently encouraged. At the minimal 2 years follow up, we observed : one early dislocation ( 2 months) because of a surgical error (cam effect) solve by the excision of the palmar horn of the first metacarpal, no trapezial/metacarpal fracture, no infection and no failure of the implants. The score pain VAS decrease from 7/10 to 1,5/10, the mobility was similar or increase in any direction after surgery, the most of unfixed Z deformations were corrected, the pinch grap increase of 30% and the rate of patient satisfaction was very high. In conclusion, at 2 years follow-up, the pain release, the mobility, the pinch grap, the patient satisfaction, was comparable as the assess of the classical single mobility Maia prosthesis. However, with 1 dislocation on 50 patients, because of a technical error, the dual mobility seems to be better than single mobility in short outcome. A prospective comparative study with more patient should be conducted.

Gauthier Menu, Etienne Boyer, François Loisel, Daniel Lepage, Laurent Obert

Orthopedic, Traumatology, and Hand Surgery Unit, CHRU Besancon - University of Bourgogne – Franche-Comte, Bd. Fleming, 25030 Besancon, France

PURPOSE: The new generation of ISIS TMC total joint arthroplasty is a modular, semi retentive, uncemented ball-and-socket hydroxyapatite-coated implant. It was introduced in 2007 for the treatment of symptomatic trapeziometacarpal (TMC) osteoarthritis. The primary outcome of this retrospective study is to report the medium- to long-term joint survival of this prosthesis in patient who have been operated on both sides. Our secondary outcomes are the clinical and functional results. METHODS: This multicenter retrospective study involved 12 patients who underwent 36 Isis TMC prosthesis implantations from June 2007 to September 2016, and who had a minimum of 12 months’ follow-up. Indications for the procedure were painful bilateral TMC joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Clinical and radiological assessment was recorded prospectively: before surgery and in the first year by the surgeon, and at 5 years or more after surgery by an independent operator). We compared the means of the Kapandji index (assessing the thumb range of motion and opposition), the grip strength, the pinch strength, ADL, QDash, before surgery and at the latest follow-up. Clinical and radiological complications were registered. RESULTS: we included 36 prostheses in the survival analysis with a mean follow-up of 48.2 months (range, 12-111 months). No prostheses required revision surgery and no implant failed. No dislocation was pointed. A total of 32 bilateral arthroplasties from 12 patients were included in the clinical analysis. The mean age at surgery was 60.4 years (range, 42-80 years) and the median follow-up was 48.2 months (range, 12-111 months). At 5 years' follow-up, the mean Quick Disabilities of the arm, shoulder, and hand score improved from 75.6± 3.5 to 8.8 ± 0.5. The mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. Opposition, defined by the Kapandji score, was almost normal (9.6 of 10; range, 5-10), as was the final mean key pinch and grip strength, which improved by 25% and 44%, respectively. CONCLUSIONS: In our series, the bilateral procedure for Isis prosthesis in TMC osteoarthritis has proven to be a reliable and effective implant. Mean motion and strength increased whereas pain decreased after surgery and these results remained constant within the follow-up period.

Gauthier Menu, Etienne Boyer, François Loisel, Daniel Lepage, Laurent Obert

Orthopedic, Traumatology, and Hand Surgery Unit, CHRU Besancon - University of Bourgogne - Franche Comte, Bd Fleming, 25030 Besancon, France

PURPOSE: The new generation of ISIS TMC total joint arthroplasty is a modular, semi retentive, uncemented ball-and-socket hydroxyapatite-coated implant. It was introduced in 2007 for the treatment of symptomatic trapeziometacarpal (TMC) osteoarthritis. The primary outcome of this retrospective study is to report the medium- to long-term joint survival of this prosthesis in males patients only. Our secondary outcomes are the clinical and functional results. METHODS: This multicenter retrospective study involved 13 males patients who underwent 17 Isis TMC prosthesis implantations from December 2010 to September 2015, and who had a minimum of 14 months’ follow-up. Indications for the procedure were painful TMC joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Clinical and radiological assessment was recorded prospectively: before surgery and in the first year by the surgeon, and at 5 years or more after surgery by an independent operator). We compared the means of the Kapandji index (assessing the thumb range of motion and opposition), the grip strength, the pinch strength, ADL, QDash, before surgery and at the latest follow-up. Clinical and radiological complications were registered. RESULTS: We included 17 prostheses in the survival analysis with a mean follow-up of 36.7 months (range, 14-69 months). No prostheses required revision surgery and no implant failed. No dislocation was pointed. A total of 17 arthroplasties from 13 males patients were included in the clinical analysis. The mean age at surgery was 65.4 years (range, 54-80 years) and the median follow-up was 36.7 months (range, 14-69 months). At 5 years' follow-up, the mean Quick Disabilities of the arm, shoulder, and hand score improved from 78.7 ± 501 to 8 ± 1.2. The mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. opposition, defined by the Kapandji score, was almost normal (8.5 of 10; range, 5-10), as was the final mean key pinch and grip strength, which improved by 32% and 45%, respectively. CONCLUSIONS: In our series, the Isis prosthesis of the thumb TMC joint has proven to be a reliable and effective implant in males patients. Mean motion and strength increased whereas pain decreased after surgery and these results remained constant within the follow-up period.

Gauthier Menu, Etienne Boyer, François Loisel, Daniel Lepage, Laurent Obert

Orthopedic, Traumatology, and Hand Surgery Unit, CHRU Besancon - University of Bourgogne - Franche Comte, Bd Fleming, 25030 Besancon, France

PURPOSE: The new generation of ISIS TMC total joint arthroplasty is a modular, semi retentive, uncemented ball-and-socket hydroxyapatite-coated implant. It was introduced in 2007 for the treatment of symptomatic trapeziometacarpal (TMC) osteoarthritis. The primary outcome of this retrospective study is to report the medium- to long-term joint survival of this prosthesis. Our secondary outcomes are the clinical and functional results. METHODS: This multicenter retrospective study involved 24 patients who underwent 29 Isis TMC prosthesis implantations from November 2006 to July 2009, and who had a minimum of 5 years' follow-up. Indications for the procedure were painful TMC joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Clinical and radiological assessment was recorded prospectively: before surgery and in the first year by the surgeon, and at 5 years or more after surgery by an independant operator). We compared the means of the kapandji index (assessing the thumb range of motion and opposition), the grip strength, the pinch strength, adl, qdash, before surgery and at the latest follow-up. Clinical and radiological complications were registered. RESULTS: We included 29 prostheses in the survival analysis with a mean follow-up of months. No prostheses required revision surgery and no implant failed. No dislocation was pointed. A total of 29 arthroplasties from 24 patients were included in the clinical analysis. The mean age at surgery was 63 years (range, 42-84 years) and the median follow-up was 80 months (range, 60-120 months). At 5 years' follow-up, the mean quick disabilities of the arm, shoulder, and hand score improved from 77.2 ± 2.5 to 11.9 ± 1.4. The mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. Opposition, defined by the kapandji score, was almost normal (9.6 of 10; range, 5-10), as was the final mean key pinch and grip strength, which improved by 25% and 42%, respectively. CONCLUSIONS: In our series, the Isis prosthesis of the thumb TMC joint has proven to be a reliable and effective implant. Mean motion and strength increased whereas pain decreased after surgery and these results remained constant within the follow-up period.

Gauthier Menu, Etienne Boyer, François Loisel, Daniel Lepage, Laurent Obert

Orthopedic, Traumatology, and Hand Surgery Unit, CHRU Besancon - University of Bourgogne - Franche Comte, Bd Fleming, 25030 Besancon, France

PURPOSE: the new generation of ISIS tmc total joint arthroplasty is a modular, semi retentive, uncemented ball-and-socket hydroxyapatite-coated implant. It was introduced in 2007 for the treatment of symptomatic trapeziometacarpal (TMC) osteoarthritis. The primary outcome of this retrospective study is to report the medium- to long-term joint survival of this prosthesis in patients with scaphotrapeziotrapezoid osteoarthritis. Our secondary outcomes are the clinical and functional results. METHODS: This multicenter retrospective study involved 20 patients who underwent 21 Isis TMC prosthesis implantations from September 2010 to march 2016, and who had a minimum of 18 months follow-up. Indications for the procedure were painful scaphotrapeziotrapezoid joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Clinical and radiological assessment was recorded prospectively: before surgery and in the first year by the surgeon, and at 5 years or more after surgery by an independant operator). We compared the means of the kapandji index (assessing the thumb range of motion and opposition), the grip strength, the pinch strength, adl, qdash, before surgery and at the latest follow-up. Clinical and radiological complications were registered. RESULTS: We included 21 prostheses in the survival analysis with a mean follow-up of 46.9 months (range 18-111). No prostheses required revision surgery and no implant failed. No dislocation was pointed. A total of 21 arthroplasties from 20 patients were included in the clinical analysis. The mean age at surgery was 66.4 years (range, 54-84 years) and the median follow-up was 46.9 months (range, 18-111 months). At 5 years' follow-up, the mean quick disabilities of the arm, shoulder, and hand score improved from 70.3 ± 3.2 to 13.2 ± 1.5 the mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. Opposition, defined by the Kapandji score, was almost normal (9.45 of 10; range, 5-10), as was the final mean key pinch and grip strength, which improved by 30% and 46%, respectively. CONCLUSIONS: In our series, the Isis prosthesis in patients with scaphotrapeziotrapezoid osteoarthritis has proven to be a reliable and effective implant. Mean motion and strength increased whereas pain decreased after surgery and these results remained constant within the follow-up period.

Gavrielle Kang 1, Mabel Leow 2, Tay Shian Chao 2

1 Tan Tock Seng Hospital, Singapore; 2 Singapore General Hospital, Singapore

This study aims to identify differences in demographics, clinical and laboratory data between wrist septic arthritis and other non-septic arthritides in patients admitted for wrist inflammation. A retrospective review of inpatients managed by the Hand Surgery Service from May 2012 – April 2015 was conducted. 77 patients were included. Non-septic arthritis patients were more likely to have chronic kidney disease, pre-existing gout, or both. All septic arthritis patients had normal serum uric acid levels, and two or more raised inflammatory markers (white cell count, C-reactive protein, and erythrocyte sedimentation rate). In patients with isolated wrist inflammation, the mean C-reactive protein in the septic arthritis group was significantly higher compared to the non-septic arthritis group (mean difference 132 mg/L, 95% CI 30.9 – 234).

Clara Vella, Samuel George, Zahid Hassan

Whiston Hospital, Liverpool, UK

Hypothesis: To evaluate practice and recurrence rates of surgically treated DMC in a single-centre where DMC excision is performed by both plastic and orthopaedic surgeons; comparing practice to the suggested operative-triad outlined by Shin and Jupiter(1). Methods: A retrospective review of all patients with surgically treated DMC, under the care of plastics or orthopaedic surgery, from April 2012-April 2016 was performed. Data was collected from an online database of operative records, outpatient follow-up letters and histology reports. The areas that were analysed were patient demographics, grade of surgeon, documentation of osteophyte debridement and synovectomy, methods of closure, follow-up period, recurrence and complications. Results: A total of 136 cases were included; 66.2% were female patients with an average age of 58.9 (range 16-90). 73 (53.7%) were treated by plastic surgeons and 63 (46.3%) by orthopaedic surgeons. There was a total 14 (10.3%) documented recurrences; the average recurrence rates for plastic surgery were 13.7%, compared to the orthopaedic surgery recurrence rate of 6.4%. All three of the suggested triad were documented as performed in 4(2.9%) cases – with a 100% cure rate. Debridement of osteophytes was documented in 39 (28.7%) cases, 31 (79.5%) of which were under the care of the plastic surgeons. Synovectomy was documented in 13 (9.6%) cases, 9 (69.2%) of which were under the care of the plastic surgeons. 114(83.8%) cases underwent direct closure and 16(11.8%) had local flaps. Plastic surgeons sent more samples for histology at 84.9% when compared to orthopaedic surgeons, 36.5%. The follow up period ranged from 1 week to 12 months but on average plastic surgeons followed their patients up for longer, with a mean follow-up period of 8.6 weeks, while orthopaedic surgery had a mean follow-up of 3.6 weeks. The complication rate for plastic surgeons was 23.3% while orthopaedic surgeons had a complication rate of 19%. Conclusion: The study has shown discrepancies in practice and outcomes between plastic and orthopaedic surgeons. The difference in complications and recurrence rates cannot be commented on due to the large difference in follow-up periods between the two groups. Discussions regarding the introduction of a universal proforma to be used by both plastic and orthopaedic surgeons ensuring all surgeons are performing Shin and Jupiter’s triad of skin excision, osteophyte debridement and synovectomy which have a 100% reported cure rate(1) will promote treatment consistency and pave the way for further research into the optimal technique for digital mucous cyst excision. References: 1. Shin EK, Jupiter JB. Flap advancement coverage after excision of large mucous cysts. Tech Hand Up Extrem Surg. 2007 Jun;11(2):159-62.

Isidro Jiménez 1, Pedro J. Delgado 2, Ricardo Kaempf de Oliveira 3

1 Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain; 2 Hospital Universitario HM Montepríncipe, Madrid, Spain; 3 Instituto da Mão, Complexo Hospitalar Santa Casa and Hospital Mãe de Deus, Porto Alegre, Brazil

Our purpose was to study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cyst using the Zitelli modified bilobed flap. Thirty-three cases were surgically treated from January 2006 to June 2015. Demographic data, comorbidities, location and size of the cyst, time to wound healing and complications were assessed. No punctures or injections were performed prior to surgery. The surgery was performed under a digital nerve block using 1% mepivacaine and a digital tourniquet was applied as described by Salem. The first dressing was performed five to seven days after surgery placing a non-adherent dressing and an aluminum DIP immobilization splint was used for two weeks. The mean mucous cyst size was 7.1 x 5.8 mm and the most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. In one case donor area skin necrosis on the very distal part of the first lobe occurred but healed by secondary intention. In two of cases a superficial infection was diagnosed and treated successfully by oral antibiotics. There were no major complications. The mucous cyst recurred in one of 33 cases The Zitelli bilobed flap is an exceptional flap to provide good quality skin coverage over the DIP joint in a short time period. Its geometrics landmarks facilitate the technique learning curve for young surgeons. The Zitelli bilobed flap can provide good quality skin coverage over the DIP joint in a short time period.

P. Martínez-Galarza 1, A. Toro-Aguilera 1, V. Arcediano 2, H. Alfaro 3, M. Pascasio 4, E. Povedano 5, I. Dot 6

1 Hand and wrist unit, Fundació Sanitària Mollet, Barcelona, Spain; 2 Vascular Surgery Department, Fundació Sanitària Mollet, Barcelona, Spain; 3 Socio-Sanitary Hospital, Fundació Sanitària Mollet, Barcelona, Spain; 4 Physical Therapy Department, Fundació Sanitària Mollet, Barcelona, Spain; 5 Occupational Therapist, Hospital Sant Joan de Deu, Barcelona, Spain; 6 Intensive Care Unit, Hospital del Mar, Barcelona, Spain

Purpose: We would like to expose the multidisciplinary approach after this rare and devastating situation in two different patients: a 73 and 52 years old woman. Methods: Challenges of managing people with multimorbidity in today’s healthcare systems force professionals to face patients under multiple considerations as previous quality of life, patient expectations and family support. We present a 73 years old lady type 2 diabetes insulin-dependent with a severe peripheral neuropathy and nephropathy, allergic to penicillin, who suffered a septic shock after an acute 7mm obstructive pyelonephritis. After pigtail ureteral stent placement and imipenem/linezolid intravenous treatment the patient didn’t improve and evolved to a multiorgan collapse because of E.coli bacteraemia. She was treated by noradrenaline up to 14 mcg/kg/min, dialysis and mechanical ventilation. The patient survived but unfortunately presented a symmetrical peripheral gangrene. The second case is a 52 years old lady with a Chron disease, who also suffered a septic shock after an intestinal resection surgery. After a suture failure and a polymicrobial infection she developed a septicaemia and was started on broad-spectrum antibiotics, dopamine and noradrenaline in the medical intensive care unit. A peripheral four limbs dry gangrene was established. Results: The first case got a 4 limb amputation. Lower limbs were resected by vascular surgery in a transtibial short below knee amputation. After 2 months, hand and wrist unit proceed with a bilateral wrist disarticulation. Due to her medical conditions, the patient is in a wheelchair and uses hand external cosmetic prosthesis. The 52 years old lady was treated by a transtibial short below knee amputation of both legs. After 6 weeks she had a transmetacarpal amputation of the left hand and a multidigital amputation of the right hand. At present time, the patient is able to walk with prosthesis and she was protetized from the dominant hand. Conclusions: This is an extremely rare side effect from inotropic use in a septic shock. A multidisciplinary approach has to be done to manage this anecdotal situation. Four limb amputations is a reasonable treatment once the gangrene is well established.

Thomas Henne

Kreiskrankenhaus Osterholz-Scharmbeck, Germany

Introduction: About 35.000 people are victims of animal bites in Germany every year. 80% of them never see or need a doctor. Nevertheless specially cat bites are a therapeutic problem, because they are like inoculation injuries and are in up to 50 % infected. Though the clinical course without intervention cannot be predicted due to multiple variables ( microbiological settlement of cat`s oral cavity, immunbiological state of the patient ). The therapeutic range starts with watchful waiting and raise up to operative revision in every case. We present a seton drainage as a new tool for treatment of cat bites. Method: A monofile non resorbable seton is led through the cat bite in the subcutaneous tissue, stitched out one inch proximally and fixed by a false knot, though that the cat bite wound cannot close. After a wound dressing soaked with an alcoholic desinfection solution the related upper extremity is immobilized by a splint. Moxifloxacin is given as antibiotic. The wound is controlled day by day. After clinical recovery of inflammation the setons were removed, antibiotics run 2 days longer. Return to work is possible 2 days later. Results: Up to now 22 patients with hand or forearm bite injuries ( cat 19, dog 1, Degu ( southamerican hamster ) 1, rat 1 ) were treated according to the procedure described above. The patients came to hospital between 6 and 48 hours after injury ( rat bite after 2 weeks ). Clinical findings were pain ( 22 ), local swelling ( 22 ), local inflammation ( 22 ), lymphangitis ( 6 ) and fever ( 3 ). In 20 patients wounds healed without complications. One patient, presenting himself 48 hours after cat bite, required operative intervention 24 hours later and one patient developed an abscess of the related finger 6 weeks later. A definitive evaluation of the method needs greater numbers of patients.

Deepak Samson, Matthew Jones, Andrew Mahon

University Hospital Coventry and Warwickshire, Coventry, UK

Objectives: Fractures of the trapezium are rare and easily missed. . As these injuries are often imperceptible on plain radiographs, diagnosis in the ED setting is challenging. We report a case of an isolated fracture of the Trapezium which was picked up as a non-union five months after the injury following persistence of symptoms. To our knowledge successful fixation of a non union of the trapezium has not been reported in the literature. This case highlights the importance of a high index of suspicion in the face of continuing symptoms and the judicious use of cross sectional imaging . Methods: A 49 year old man fell from his mountain bike at speed and presented to his local secondary care hospital with an injury to the base of his left thumb. There was pain and swelling at the base of the thumb with painful restriction of movements. Initial radiographs were deemed to be normal and he was treated as a soft tissue injury with a period of immobilisation followed by physiotherapy. The patient was referred to us four months later as the pain and weakness were persisting. A thorough retrospective perusal of his history and imaging to date was carried out. A review of his initial plain radiographs and MRI scans indicated a fracture of the left trapezium and a CT scan was obtained to further characterise the anatomy of the fracture. We performed a open reduction and internal fixation through a Wagner approach with headless compression screws. Results: At three months from injury, the patient had complete resolution of his symptoms and had gone back to mountain biking. Range of movement had improved remarkably and he was pain free. Plain radiographs confirmed union across the fracture site. Conclusion: These are rare and challenging injuries to diagnose and can often be missed. Open reduction and internal fixation, even after delayed diagnosis and late surgery, can result in good functional outcome.

Mateus Saito, Renata Gregorio Paulos, Priscila Rosalba Domingos de Oliveira, Thiago Felipe dos Santos Barros, So Yeon Kim, Marcelo Rosa de Rezende, Rames Mattar Junior

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

Objective: Report the first case of infectious tenosynovitis caused by bacteria from the genus Paenibacillus Methods (CLINICAL CASE) Female patient, 23 years old, professional Judo athlete. At the time of infection she was in her second month rehabilitation from an left knee anterior cruciate ligament reconstruction. Her main complaint was pain and edema of her right hand for the past 10 days. She denied any type of trauma, fever or chills. When she came into the our service she had already been seen in two different hospitals and was treated as inflammatory tendinitis caused by overuse. She had clear Kanavel signs in her middle, annular, and small finger of her right hand. She had intense pain when palpated on the volar side of the distal third of the forearm. Her neurological exam was normal. An incision was made at the distal palmar crease of the anular and small finger, with another incision at the distal interphalangeal joint level of the same fingers. We observed intense synovitis in the pulleys of the flexor tendons but did not observe purulent drainage, even after a irrigation catheter was placed and the tendon sheath irrigated. The tissue in the A1 pulley and the proximal portion of the A2 pulley of the small finger, was friable, as well as the subcutaneous tissue around them. Samples of these tissues were sent for culture analysis. Another 4cm longitudinal incision was made over the flexor radialis carpus, proximal to the palmar crease at the wrist and the Parona’s space was explored. We found clear serous liquid. Results:Leucocyte count: 8390; C reactive protein: 57.2 mg/ L. The culture analysis of the tissue was positive for Paenibacillus spp. The patient was admitted for ten days, was prescribed Oxacillin and Ceftriaxone. At discharge, she was prescribed oral Levofloxacin and had good clinical remission of the signs and symptoms. Conclusion: This is the first case report on pyogenic tenosynovitis caused by Paenibacillus. Even though it was an isolated case, it alerts health professionals of the fact that this can be an agent that causes pyogenic tenosynovitis in the hand in healthy patients.

Marco Borsetti, Federica Bergamin, Claudia Cerato, Alessandra Clemente, Ezio Gangemi, Silvia Germano

Departement of Plastic Surgery, Hand Surgery and Microsurgery

Objective Osteomyelitis of the hand is uncommon, but prompt diagnosis and treatment are important, because hand stiffness, contractures, and even amputation can result from missed diagnoses or delayed treatment. In recent years, treatment of these infections has become challenging owing to increased virulence of some organisms and drug resistance. The principles of management are good surgical debridement and culture-guided antimicrobial therapy but in the hand, duration and mode of antibiotic administration are still uclear and evidence is lacking to guide the decision whether to send atypical cultures during surgical debridement. Our purpose was to validate a protocol of treatment. Methods We retrospectively identified 28 adult patients undergoing surgical debridement of bone infections of the upper extremity in which cultures were sent. Descriptive statistics were used to describe patient characteristics, infection diagnoses, number of cultures sent with corresponding rates of positivity. The treatment involves a combination of: surgical debridment with tissue coltures, antibiotic treatment of 4weeks' duration (intravenous and/or oral) first and guided by swabs results after and flaps to cover or to fill the defect. Patient were evaluated at one year with x-ray to esclude persistence of infection. Results The most common bacteria implicated remains Staphylococcus aureus and Streptococcus species. Methicillin-resistant S aureus infections have become prevalent. The protocol adopted was able to eradicate the infection in all cases. The functional result depends on duration of the disease before surgery and on type of bone involved (metacarpal, phalanx). Conclusion The continued emergence of antibiotic-resistant bacteria and the development of only a few new classes of antibiotics over the past 50 years have made the treatment of acute hand infections problematic. Identifying the cause of the infection and initiating prompt and appropriate medical or surgical treatment can prevent substantial morbidity. We have introduced a protocol of treatment with optimal cure rate e good funcional preservation.

Alberto Castellón, Matías Núnez, Ignacio Fernández

Instituto de Seguridad del Trabajo, Viña del Mar, Chile

Acute osteomyelitis is a diagnostic and therapeutic emergency, whose Early diagnosis and timely treatment improve prognosis and minimize the risk of progression to chronicity and complications. Knowledge about the use of bone grafts has demonstrated clinical success in musculoskeletal surgery. The clinical achievements and the ability to solve highly complex pathologies are directly related to the possibility of having allografts or bone autografts. The surgeon who faces a reconstructive and rescue problem must choose the graft to use that has the greatest integration potential, according to local conditions and minimize the risk of complications, especially in thumb injuries where the fist and clamp maneuver are of vital importance for activities of daily living. The following case correspond to a 63-years-old male, with no known morbid history or allergies. Smoker +. Two weeks of evolution of pain in the right thumb plus volume increase and erythema, secondary to a puncture wound in the kitchen area while on board. Physical exam, right thumb with erythema, increased phlegmonous volume, associated with functional impotence. Radiological studies were requested to complement the study, where an osteolytic lesion involving the entire distal phalanx is observed. Patient is hospitalized for surgery and intravenous antibiotic treatment. Surgical cleanliness was performed with dorsal approach to proximal, with loss of almost the entire distal phalanx and almost complete infectious involvement of the extensor tendon. As well as commitment of the capsule and the joint. 3 cultures samples and 2 biopsies of perilesional and bony tissue are taken. It is left in treatment with intravenous Clindamycin, with poor response. Antibiotic treatment is adjusted according to the result of cultures (Proteus vulgaris and Enterobacter), to Moxifloxacin 400 mg every 24 hours and new surgical toilets Confirmed the infectious etiology with cultures and biopsy (nonspecific acute osteomyelitis, suppurative associated with an acute nonspecific acute peritendinitis), it was decided to leave cement spacer with antibiotic COPAL G + C, debriding devitalized tissue and removing remnants of base of distal phalanx. On the fourth day after the last procedure, discharge and ambulatory control were decided in 9 days, continuing with antibiotic treatment orally. In medical control, it was decided to perform phalangisation by means of a structural bone graft technique of the anterior iliac crest, in addition to sample taking of secretion and tissue culture. Graft is carved and fixed with transient axial Kirschner wire, and 28 mm trimed compression screw step. He is immobilized with Jackson splint. It evolves favorably and it is decided high with ambulatory control. The following week, the last culture is rescued, being positive for negative coagulase staphylococcus, being evaluated by an infectious agent, who suggests maintaining behavior without antimicrobials. Two weeks after structural bone grafting, the patient is referred to Occupational Therapy and physical therapy. At 9 weeks postoperatively, he presented advanced signs of consolidation, with a well-tolerated grip and grip maneuver. It is decided to register as a patient together with a multidisciplinary team, reintegrating to differentiated tasks in their work.

Mihaela Perţea 1,2, Sorinel Luncă 1,3, Oxana-Mădălina Grosu 2

1 University of Medicine and Pharmacy “Gr. T. Popa” Iași, Romania; 2 Clinic of Plastic and Reconstructive Microsurgery, “Sf. Spiridon” Emergency Hospital Iași, Romania; 3 Surgery II Department, Regional Institute of Oncology Iași, Romania

Objectives Septic arthritis is not a very common pathology. The incidence of septic arthritis is 5-10 cases per 100000 inhabitants. It occurs as a result of a pathogenic agent contamination in one of the joints, most often a bacterial one. The etiology may be various: wounds, neglected fractures, vicious treated or unrecognized due to an atypical clinical picture that a septic arthritis can take. Symptoms occur later enough, so the disease is detected when tissue destruction is massive. Methods Our study is based on a group of 4 patients: a woman and three men, aged between 45 and 76 years old, all with a recent history (between 3 weeks and 1 month) of closed fracture of distal radius. The treatment in all four cases was cast immobilization. It should be noted that all the patients were diagnosed with insulin-requiring diabetes. Clinically, the onset of the septic arthritis is with very intense pain, erythema and swelling in the wrist, symptoms which did not remit under conservative treatment with anti-inflammatory. Paraclinical tests showed important leukocytosis (maximum of 40.000), thrombocytosis (maximum of 1.100.000) and a moderate anemia (up to 7.1). Ultrasound exam showed, in all four cases, fluid collection in the wrist (left wrist of the woman and right wrist of all the men). Operatively, we found a purulent content (a quantity between 50 and 300 ml), extended in the carpal tunnel and palm in two cases. The bacteriological exam found the presence of Methicillin-resistant Staphylococcus aureus in all four cases. Targeted antibiotics were administered. Local treatment was difficult and long-standing in two cases, using negative pressure therapy (VAC therapy) associated with continuous lavage. Only in one case we managed to obtain a quality granular bed which allowed the coverage with a split-thickness skin graft. In the other one, due to the associated diseases, the general status of the patient worsened, so the amputation was necessary. In the last two cases, we managed to close the wounds by direct suture. Results The results were relatively good only in three cases. The physiotherapy after the complete healing was mandatory and the patients remained with wrist flexion deficits betwwen 10 and 30 degrees and limited wrist extension between 15 and 35 degrees. In one case (the youngest patient) the diabetes mellitus and associated diseases exacerbated the patient’s condition in the infectious general status, so that the amputation was necessary from the upper third of the forearm. Conclusions Although quite rare, the septic arthritis must be a well-known condition and considered in the differential diagnosis with other diseases. Neglected, it can lead to serious complications with long-suffering period of hospitalisation and, in the extreme cases, with loss of limb segment. Key-words: arthritis, VAC, infection.

Torbjörn Vedung

1 Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; 2 Department of Orthopedic and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden

Objectives Mycobacterium Senuense is a newly described previously unknown species, closely related to the Mycobacterium terrae complex. It was isolated 2008 from a Korean patient with a symptomatic pulmonary infection. It is an arbitrary name formed from the initial letters of Seoul National University, the organization that carried out the taxonomic investigation of the type strain. Mycobacterium Senuense has recently been found in slaughter pigs in Uganda, but has never been reported as a soft tissue infection in humans. Mycobacterium infections in the hand are rare but may occur. Methods A 40-year-old female chef accidently cut her long finger while preparing pork tenderloin. The wound healed but the long finger developed a relatively fast-growing tumour along the flexor tendon sheath. When she was admitted to the hospital six months later, the whole volar aspect of the finger was engaged by the tumour. MRI showed massive synovitis along the flexor tendons with multiple rice bodies. There were no signs of malignancy, and she went on to surgery. Results Despite meticulous dissection, it was impossible to find any remnants of the flexor tendon sheath. Only parts of the A5 pulley remained intact. The underlying tendons were almost unaffected, although a bit rugged on their surface. As soon as the skin had healed, two external plastic rings were placed over the proximal and middle phalanx respectively, to prevent bowstringing. Histology showed unspecific granulomatosis and synovitis. Special cultures found Mycobacterium Senuense. A six months treatment with Klaritromycin and Etambutol followed. The resulting bowstringing was very mild, probably due to subcutaneous scarring. Conclusions Mycobacterium Senuense can cause soft tissue infection in humans. Bacteria in pigs may be transmitted to humans through wounds. The infection seems to destruct the flexor tendon sheath. Early postoperative mobilisation and treatment with external rings over the proximal and the middle phalanx can prevent most of the expected bowstringing after a complete loss of the flexor tendon sheath.

Bismark Adjjei, Hazem Alfeky, Irfan Khan, Chris West, David Bell

Whiston Hospital, Liverpool, UK

Introduction and Aims The World Health Organisation recently raised an alarm concerning moving towards a world without effective antibiotics (The post-antibiotic era) urging medical specialities to review their practice and, where appropriate, change them to stem the tide. Prophylactic antibiotics are frequently used by plastic surgeons in hand trauma as a prophylaxis. However, there is no solid evidence for that. The aim of this audit is to review the current practise and measure it to the guidelines. Material and Methods A review of 300 hand soft tissue laceration cases were included. All open fractures and complex soft tissue injury were excluded. The antibiotics prescription was measured against the guidelines and the recommendations of a two recent meta-analysis studies to define the role of prophylactic antibiotics in upper limb lacerations. Results In two recent meta-analyses, Jennifer Lane et al. and Murphy et al, showed that prophylactic antimicrobial use has no significant effect on the infection rate compared to placebo or no antibiotics in patients with small soft hand lacerations. Our current practise shows that there is a trend to prescribe prophylactic antibiotics where there is no clear indication. Conclusion Not withstanding current evidence, there is a trend to routinely supply simple hand laceration patients with prophylactic antibiotics. There is a need to review our practise and define a clear guidance on the role of antibiotic prophylaxis in hand trauma patients.

Judit Réka Hetthéssy, Noémi Szakács

Semmelweis University, Department of Orthopedics, Budapest, Hungary

Introduction, backround: Synovial chondromatosis is a rare disorder characterized by the development of multiple cartilaginous nodules in the synovial membrane of joints, bursae or tendon sheaths as a result of subsynovial connective tissue metaplasia. It usually affects larger joints (knee, hip, elbow and shoulder), the wrist and hand is an exceptionally rare localization. Because of its low prevalence and nonspecific symptoms, synovial chondromatosis may pose differential diagnostic difficulties for the treating clinician, which may lead to a delay in treatment. As synovial chondromatosis is rare in the pisotriquetral joint, other diseases including infection, tenosynovitis, autoimmune disease, triangular fibrocartilage pathology may be suspected at first. Based on imaging studies, the differential diagnoses include rheumatoid disease, osteochondritis dissecans, crystal arthropathy, tuberculous arthritis, trauma-related osteochondral proliferations, periosteal chondroma, synovial sarcoma, psoriatic arthropathy, pigmented villonodular synovitis and degenerative joint disease. A misdiagnosis may lead to complications down the line as over time the presence of intraarticular bodies may lead to degenerative arthritis with associated pain and loss of function. Spontaneous regression is rare in this disorder, and is not to be expected. There have also been a very small number of reported cases of sarcomatous transformation of synovial chondromatosis. For these reasons, recommended treatment is synovectomy and removal of loose bodies by open surgery. Objective: Our objective was to call attention to this rare disorder, and to aid both the diagnostic and differential diagnostic process of clinicians to avoid the above complications. Case Report: We present a case of synovial chondromatosis arising from the pisotriquetral joint. A 56-year-old female patient was referred to our department with persistent ulnar sided wrist pain on the left side, two years following minor trauma and chronic overuse. She complained of increasing swelling over the pisotriquetral joint and flexor carpi ulnaris tendon, she noticed the apperance of a mass which had become increasingly painful over the previous 3 months and there was a limitation in the range of motion also (F/E 20/40). Radiographs demonstrated calcification over the pisiform and the ulnar styloid process, MRI and CT scan suggested synovial proliferation with calcification or atypical pigmented villonodular synovitis. Surgical excision revealed numerous loose bodies surrounded by a 25x15x10 mm area of soft tissue. Histological examination demonstrated mature hyaline cartilage surrounded by fibrous tissue and partly lined by synovium, which was consistent with synovial chondromatosis. 9 months after the excision there was no recurrence, the pain decreased immediately after surgery and the range of motion increased continuously. Conclusion: Synovial chondromatosis is a rare disorder, and misdiagnosis may lead to complications down the line. Clinicians should keep this disorder in their mind when faced with an atypical chondromatous lesion.

Michio Sano 1, Tomokazu Sawada 1, Kazuhiro Hagiwara 1, Takao Omura 2, Ryo Okabayashi 3

1 Department of Orthopaedic Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan; 2 Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan; 3 Department of Orthopaedic Surgery, JA Enshu Hospital, Shizuoka, Japan

Hypothesis Whether dynamic compression plate (JMM-KYOCERA OSR plate) could hasten bone union after radius osteotomy for Kienbock’s disease in comparison with locking plate. Methods During 2011 and 2016, We performed radius shortening wedge osteotomy for Kienbock’s disease in 8 hands of 8 patients. The patients consisted of 4 males and 4 females. Their average age was 46.1 years old. The follow up period ranged from 6 to 39 months. The Lichtman classification revealed five Stage3a cases and 3 were 3b. After the shortening wedge osteotomy, the radius was fixed with locking plate in 5 patients (Synthes LCP-T plate;3, Japan Unitec Stellar I plate;2) and dynamic compression plate in 3 patients. The bone union was evaluated using plain X ray film, when bridging callus was comfirmed both sides of radial cortex in both A-P view and lateral view. The statistical analysis was performed using non-parametric method (Mann-Whitney U test). Result The bone union was confirmed at 5.9 ± 1.9 months after surgery with locking plates, while it was 2.5 ± 0.5 with compression plates.(p<0.05) Four patients treated with locking plates required LIPUS application for promoting bone union, in contrast to no patients requiring additional treatment in compression plate group. We considered that dynamic compression plate was more useful than the ordinary locking plates because of the accelerated bone union and for no LIPUS necessity. Discussion Various operative methods have been performed for Kienbock’s disease. Osteotomy of radius is one of the established methods. At first, we used locking plate until 2012. We changed the locking plate to OSR dynamic compression plate in 2012. As a fixation method after osteotomy, sufficient fixing force can be obtained even with locking plates, but OSR plate was more useful for crimping osteotomy site during operation. Since crimping force can be applied by the osteotomy site, we consider that we could shorten the period until bone union. Summary Dynamic compression plate (JMM OSR plate) is very useful for the fixation of radius after osteotomy for Kienbock’s disease.

Young Ho Shin 1, Jae Kwang Kim 1, Joo-Yul Bae 2, Shin Woo Choi 1

1 Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; 2 Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, South Korea

Objective: The purpose of this study was to compare radial osteotomy with non-operative treatment in terms of radiologic and clinical long-term outcomes in Kienböck's disease. Methods: We systematically reviewed long-term follow-up (more than average 10 years) retrospective studies of radial osteotomy and non-operative treatment in Kienböck's disease. A systematic search was conducted across 3 databases (CENTRAL, PubMed, and Embase) and relevant articles were selected. Data regarding patient demographics, treatment details, and radiologic and clinical outcome were abstracted from the selected studies. Results: Seventeen studies (five studies of non-operative treatment and 12 studies of radial osteotomy) were included. Before treatment, the mean age of patients and mean proportions of wrists with Lichtman stage III or higher were not significantly different between the two groups. The mean proportions of wrists which showed aggravation and no change of the Lichtman stage after treatment were not significantly different between the two groups. However, the mean proportion of wrists which had pain more than moderate degree at final follow-up was significantly lower in radial osteotomy group (5.7% (range, 0.0% to 18.2%)) than in non-operative treatment group (23.2% (range, 17.4% to 35.3%)). In addition, the total arc of wrist motion at final follow-up was significantly higher in radial osteotomy group (107.4° ± 10.0° (range, 93.0° to 126.0°)) than in non-operative treatment group (88.8° ± 13.2° (range, 68.5° to 103.5°)). Conclusions: Systematic review of long-term follow-up studies showed that radial osteotomy was not superior to non-operative treatment in terms of disease progression according to Lichtman stage. Nevertheless, radial osteotomy was reported to have better outcomes with respect to the extent of pain and range of wrist motion.

Ki-tae Na, Sang-uk Lee, Do-yeol Kim, Jong-yoon Lee, Won-woo Kang

Incheon St. Mary's Hospital, The Cathlic University of Korea, Incheon, South Korea

Objective It has been known that treating early stage Kienbock's disease with vascularized bone graft inhibits disease progression and prevents collapse of lunate. Various modified techniques are used, but the possibility of damage to the blood vessels and the availability of sufficient blood flow have always been a problem. Here, we present the surgical technique of fourth and fifth extensor compartment artery & ulnar artery dorsal branch vascularized bone graft. Methods The surgical procedure At first, fifth extensor compartment artery was found in the dorsal aspect of distal radius. Then the distal aspect of the fourth extensor compartment artery & ulnar artery dorsal branch was found. After identify feeding vessel, vascularized bone from radius were harvested by the saw. Sufficiently dissected around the dorsal branch of ulnar artery to avoid compression of the ulnar artery dorsal branch during the insertion of vascularized grafting bone in the bone defect of lunate. After bone grafting, the tourniquet was released to check viability of graft. At last, scaphoid and capitate were temporary fixed by K-wire to avoid weight bearing on lunate during the period of revascularization. Results Case 1 73 year old female patient with kienbock disease (Lichtman stage IIIA) were treated with this technique. Preoperatively, her wrist range of motion was decreased, and she complained wrist joint pain. Radiographic examination showed sclerotic change and collapse of lunate. VAS score improved seven to three, and range of motion improved after surgery. Case 2 48 year old female patient with kienbock disease were treated. She has complained wrist pain for two years without trauma history. She had tenderness over the dorsal wrist, but range of motion of affected wrist was nearly normal during physical examination. Radiography showed Lichtman stage IIIA kienbock disease. After surgery, VAS score improved five to three. And DASH score was improved. Case 3 50 year old male patient, who have a history of ipsilateral wrist extensor tenorrhaphy at local hospital two years ago, visited the clinic to evaluate signal change on MR images. He complained wrist pain. Simple X-ray showed necrotic change and diffuse bone marrow edema for lunate. After surgery, patient improved range of motion. However, pain was unchanged after 6 month follow-up. Conclusion Fourth and fifth extensor compartment artery & Ulnar artery dorsal branch vascularized bone grafting technique provide multiple feeding vessels and lesser variations, and enough length of attached vessel. As a result, this technique provide safe and easy technique for kienbock disease.

Ryogo Nakamura 1, Hirofusa Ichinose 2, Etsuhiro Nakao 1, Takaaki Shinohara 1, Masahiro Tatebe 3

1 Nagoya Hand Center, Nagoya, Japan; 2 Fujita Health University, Aichi, Japan; 3 Nagoya University, Nagoya, Japan

Wrist swelling is a frequent clinical manifestation of Kienböck’s disease but no study has reported the site and pathology of wrist swelling in this disease. The aim of this study is to elucidate the site and pathology of wrist swelling in Kienböck’s disease. Dorsal and palmar soft tissue thickness of the wrist were measured on standard lateral radiographs of the wrist in 26 patients with Kienböck’s and 30 subjects without intraarticular lesion. Axial MRI views were examined to detect the site of swelling. The dorsal capsular ligament in three patients with Kienböck’s disease underwent histological examination. X-ray Measurements could not detect a difference in the average thickness of the dorsal and palmar soft tissue thickness in the control group. Radiographic study confirmed dorsal wrist swelling in 24 of 26 (92%) patients examined comparted to the contralateral unaffected wrists. However, the average palmar sogt tissue thickness of affected wrists was similar to that of unaffected wrist. MRI demonstrated thickening of the dorsal capsular ligament and extensor layer with synovial proliferation. Histological examination revealed non-specific chronic inflammation. Dorsal wrist swelling in Kienböck’s disease is a common manifestation and constitute a part of pathology of Kienböck’s disease, although further study is required to clarify the relation between wrist swelling and etiology of Kienböck’s disease.

Johanne Korslund 1, Rasmus Thorkildsen 1, Ole Reigstad 1, Magne Røkkum 1,2

1 Upper Extremity and Microsurgical Unit, Division of Orthopaedic Surgery, Oslo University Hospital, Norway; 2 Institute Of Clinical Medicine, University of Oslo, Norway

Triscaphoid arthrodesis for advanced Mb Kienböck, follow up after 7 years Objective: Patients with grade IIIA Mb Kienböck/lunate malacia is a therapeutical challenge. To postpone more extensive surgery we have offered these patients a triscaphoid arthrodesis. We present our long term results after a partial wrist fusion. Material and method: Since 2004, 15 (11 male) patients, median 33 (19-44) years with Mb Kienböck and minimum 3 year follow-up were treated with a triscaphoid arthrodesis. They were all grade IIIA and preoperative radiographs showed no radioscaphoid arthritis. We used a dorsoradial incision, and cartilage was removed in the scapho-trapezial-trapezoidal joint and bone was transplanted from the radius (12) or iliac crest (3) and the fusion was secured by 1.1 mm K-wires. Postoperative the patients wore a cast for 8 weeks, K-wires were routinely removed after 12 weeks, and the patients were then encouraged to use the wrist without any restrictions. All patients had unilateral disease. 9 had surgery done in non-dominant wrist (9 left). At final follow-up AROM, grip strength and key pinch was measured and compared to the uninjured side. The patients completed the Q-DASH, PRWHE and graded pain (VAS) at rest and activity. New radiographs of both wrists and a CT of the affected wrist were taken. Results: There were no per- or post-operative complications. All arthrodesis healed. 1 patient emigrated and one patient was satisfied, but did not attend follow-up. During the follow-up period 3 of 15 received a wrist arthroplasty due to increasing pain and progression of wrist arthritis. At final follow-up 7 (3-13) years after surgery the patients reported a median Q-DASH and PRWHE = 10 (0-52) and 14 (2-68) and median VAS pain score = 0 (0-6) at rest and 1 (0-6) at activity. AROM was 50% of AROM in their healthy wrist. Grip strength was reduced by approximately 20% compared to their healthy wrist. Key pinch was similar to the healthy side. New radiographs demonstrated intercarpal degenerative changes in 4 patients, whilst CT scans showed degenerative changes (intercarpal and radioscaphoid) in 8. The patients were satisfied with the procedure and felt it had improved both hand function and pain level compared to their preoperative status. Conclusion: Advanced lunate malacia/Mb Keinböck is not easily treated. A triscaphoid arthrodesis can be an alternative, at the expense of wrist motion and strength. The procedure has postponed total wrist fusions or arthroplasty surgery in the majority of the patients in our study, and might slow the degerenative prosess in the wrist. CT scans revealed more degenerative changes and should be included in the follow-up of this complicated disease.

Ronit Wollstein 1,2, Yahav Levy 1, Raviv Allon 1, Idit Lavi 3, Aviv Kramer 1

1 Technion, Israel Institute of Technology, Haifa Israel; 2 New York University, NY NY USA; 3Department of Community Medicine and Epidemiology, Carmel Medical Center, Israel

Purpose: Fragility fractures of the distal radius are commonly treated by the hand surgeon, and constitute a risk factor for a subsequent fragility fracture. In general osteoporosis and its main complication -fractures have an enormous impact on global health systems. It is therefore imperative to be able to screen for fragility fractures. Prevention includes treatment of osteoporosis and fall prevention. Currently, screening uses dual-energy X-ray absorptiometry (DXA), which has limited ability to predict fractures. Our purpose was to evaluate the current literature for a method that may form a screening test better able to predict fragility fractures. Methods: A review of studies evaluating osteoporosis and fragility fractures was performed. Multiple modalities were reviewed. Ultrasound (US) had sufficient data on fracture prediction to perform a meta-analysis, therefore prospective US cohort studies were analysed. Six study populations, with 29,299 individuals, 87,296 person-years of observation and including nine hundred and ninety-two fractures were analysed. Results: US was a good predictor of any fracture occurrence with an increased risk of 1.45 (95% CI 1.21-1.73) to fracture. The ability to predict a hip fracture was 1.52 (95% CI 0.94-2.48). MRI is sensitive and specific for osteoporosis but its use for screening has not been sufficiently evaluated. Computed tomography seems to have the ability to predict fracture occurrence. Conclusions: US has not taken the place of DXA as a screening tool for osteoporosis, perhaps due to operator dependency and difficulty in standardization of testing. CT has been shown to have the potential for fracture prediction, however may be problematic as a screening tool due to cost, radiation and availability. MRI has not yet been thoroughly evaluated. More study taking into account cost, accessibility, technical challenges and sensitivity and specificity of the tool is needed.

Antonio García-Jiménez 1, Àlex Grau 2, Laura Noguera 2, Santiago Castañeda 1, Bernardo Uran 1, Javier Ochoa 1, Ignacio Proubasta 2, Ignasi Gich 2, Judit Martínez 2

1 SSIBE - Hospital de Palamós, Palamós, Spain; 2 Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

Perilunate dislocation is a severe and disabling injury that necessitates urgent emergency reduction and stabilization to prevent late complications such as vascular necrosis, chronic instability and arthritis. Acute perilunate injuries may be misdiagnosed and treated conservatively in 25% of cases. The recognition of the three arcs or lines of Gilula in the posteroanterior projection (PA) x-ray is crucial for a correct diagnosis. The objetive of our study was to evaluate the intraobserver and interobserver reliability of Gilula lines in the diagnostic of perilunate dislocation. Six observers evaluated 30 carpal x-rays (15 with a diagnosed perilunate dislocation and 15 without carpal injuries). There were 2 orthopedic residents, 2 orthopedic surgeons and 2 hand surgeons. They all had to classify that x-rays as pathological or normal, attending only to Gilula's lines. A statistical calculation of the interobserver and intraobserver variability was performed using the Kappa coefficient. The intraobserver agreement was very good (Kappa 0,867-1,000) in residents and in hand surgeons, and moderate or good (Kappa 0,553-0,795) in orthopedic surgeons. The interobserver agreement was very good (Kappa 0.875) among the hand surgeons, while it was good among orthopedic surgeons and residents (Kappa 0.679 and 0.751 respectively). The interobserver agreement was greater among residents and hand surgeons (Kappa 0.875, very good agreement) than among residents and orthopedic surgeons (Kappa 0.702, good agreement). We can conclude that the observation of Gilula's lines is a good diagnostic method in case of suspicion of perilunar dislocation, with good intraobserver and interobserver agreement in orthopedic residents, hand surgeons and orthopedic surgeons.

Shohei Omokawa 1, Iida akio 1, Kenji Kawamura 2, Takamasa Shimizu 2, Tadanobu Onishi 2, Yasuhito Tanaka 2

1 Department of Hand Surgery, Nara Medical University; 2 Department of Orthopedic Surgery, Nara Medical University

Objective: Although standardized criteria for evaluating the distal radioulnar joint (DRUJ) instability have not been established, DRUJ ballottement test remains a key component of diagnosing peripheral tears of the triangular fibrocartilage complex (TFCC) at the ulnar foveal insertion. This prospective cohort study investigated the reliability and diagnostic accuracy of the DRUJ ballottement test in detecting the TFCC foveal tears. Methods: The study enrolled 50 consecutive patients with ulnar wrist pain (25 with foveal tears and 25 without tears, 27 men and 23 women, mean age was 41 years) and 25 healthy volunteers (mean age 36 years). Two observers independently performed the DRUJ ballottement test; the test was repeated by one observer. These data were used for reliability analysis. Interobserver and intraobserver reliability were analysed with Cohen’s kappa statistics. First time assessments during the initial hospital visit were used for analysis of diagnostic accuracy of the DRUJ ballottement test. DRUJ instability grade was assessed with Nakamura’s criteria (grade 0: stable DRUJ; grade 1: less stable than intact contralateral side; grade 2: absence of an endpoint in either the dorsal or palmar direction; grade 3: no endpoint in either direction). Results: Regarding the DRUJ instability grade, there were 18 of the 25 patients with foveal tears had grade 2 instability, and 19 of the 25 patients without foveal tears had grade 0 or grade 1 instability. There were 23 volunteers in grade 0. Kappa values for intraobserver and interobserver reliability of the instability grade were 0.85 and 0.8, respectively. Regarding the accuracy analysis by comparing the test results between the 25 patients with and without TFCC foveal tears, the sensitivity and specificity of the DRUJ ballottement test were 96% and 40%, respectively, when a positive result was defined as grade 1. When a positive result was defined as grade 2 (absence of endpoint in either the dorsal or palmar direction), the sensitivity and accuracy specificity were 76% and 76% respectively. The comparison between the 25 foveal tears patients and 25 healthy volunteers revealed that the sensitivity and specificity were 96% and 88%, respectively, when a positive result was defined as grade 1. When a positive result was defined as grade 2, the sensitivity and specificity were 76% and 100%, respectively. Conclusions: Comparing injured and contralateral wrists provided reasonable reliability and high sensitivity in detecting TFCC foveal tears. When the test result is grade 1 in a clinical setting, acquisition of imaging techniques would be recommended to diagnose tears of the radioulnar ligaments. We found perfect specificity when comparing patients with healthy volunteers, but the test was not specific in a population of patients with ulnar wrist pain. Because absence of endpoint alone is not a specific finding to diagnose radioulnar ligament tears, exclusion of other disorders with DRUJ instability such as ulnocarpal abutment syndrome is needed to confirm the foveal tears in patients with ulnar wrist pain.

Lisa Reissner, Gabriella Fischer, Pietro Giovanoli, Maurizio Calcagni

Division of Hand and Plastic Surgery, University Hospital Zurich, Switzerland

Objective: The human hand is used in a great range of activities of daily living. In recent years, researchers and clinicians increasingly focused attention towards the assessment of hand movements. However, there is still very little knowledge about hand and finger kinematics during ADL. The aim of the study was to analyse the motion patterns during the task of opening a yoghurt in healthy volunteers. Method: Twenty healthy volunteers (10 male, 10 female), mean age 28 (SD 4.7), years were performing a set of basic motion tasks and the functional task “opening a yoghurt”. Each volunteer was assessed twice on two different measurement days. The active range of motion (AROM) and the mean angle during the opening phase were calculated for the wrist, the radioulnar joint and the joints of the small finger. Furthermore, the AROM of a joint during the functional task was expressed in percentage of its maximum range of motion calculated from the basic motion tasks. Results: There was a wide range of joint angles among different volunteers. The AROM ranged between 17°-85° / 21°-58° and 17-79° for flexion angle of the MCP of the small finger, the wrist and the pronation-supination of the radioulnar joint, respectively. Some individuals had the wrist, metacarpophalangeal (MCP) 5 or proximal interphalangeal (PIP) 5 joint in extended position, while others preferred in the same joints in flexed position with a mean angle up to 60°. The exploitation of the maximum range of motion was between 5-84%. A significant higher AROM in wrist flexion of 44° (p<0.001) was found for the female group compared to 32° of the male subjects. Furthermore, the female group had a mean flexion angle of 30° (p=0.043) in the MCP of the small finger during the opening phase, while the male group had the corresponding joint in a more flexed position of 41°. Conclusion: Individuals seem to use different strategies to fulfil the analysed task. In the group, that performed the functional task without contact of the small finger to the object (extended/abducted small finger), five out of six cases were women whereas mostly male subjects tended to “roll” the hand over the small finger to open the yoghurt. This study reveals that gender differences might influence motion pattern during the analysed ADL. The individual preference has to be considered for the determination of the required range of motion of this daily activity.

Angela Reger, Marion Mühldorfer-Fodor, Karl-Josef Prommersberger, Jörg van Schoonhoven

Klinik für Handchirurgie Bad Neustadt, Bad Neustadt / Saale, Germany

Objective: This study investigates in vivo if an isolated fusion of a single DIP-joint influences the grip force and the load distribution of the hand when gripping a clylindrical object. Methods: Ten patients who had one single DIP joint fused due to posttraumatic joint destruction, but without other structural lesions of the Hand, were included in this study. On average 55 (17-121) months postoperatively, patients returned for a manugraphy analysis. Patients performed grip force tests, using three clyinders covered with a pressure sensor matrix and with 100 mm, 150 mm and 200 mm circumferences to measure the total grip force and the load distribution pattern of both hands. The grip force and the load distribution applied by each of the four fingers were compared for the affected and the healthy hand. Due to the small number of patients, only descriptive statistics were provided. Results: Two patients had the index finger involved; both omitted the affected finger during gripping evidently. Their total grip force was 57%, 62% and 60% of the healthy opposite side, for the small, middle and large cylinder resepctively. Eight patients had a Fusion of the middle finger DIP. All of them had an apparent load Peak at the finger tip III while using the 150 mm cylinder, six patients had such load peaks additionally on at least a second cylinder size. Their total grip force was 94%, 101% and 94% compared to the healthy side. If the dominant hand was affected, the hand was even stronger than the healthy, non-dominant hand. Analyzing the load applied exclusively by each finger, there was a different pattern apparent for the DIP joint II and DIP joint III fusions: the operated index finger showed a considerable force loss, but also the other fingers were weaker than those of the healthy side. Patients with a DIP joint fusion of the middle finger applied considerable less force with the middle and ring finger, but the index and small finger performed with the same or even higher finger force compared to the healthy side. Conclusion: Although this study investigated a small study group, DIP joint fusion of the index finger seems to affect the total grip force more than DIP joint fusion of the middle finger. This confirms the results of some previous experimental studies and might be contributed to the "Quadriga-effect" of the finger flexors.

Ali Arnaout 1, Paul Caine 1, Elizabeth Mawby 2, Christopher Powell 1

1 Department of Plastic, Burns and Reconstructive Surgery, Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK; 2 Department of Physiotherapy, Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK

Objective: Extensor Pollicis Longus (EPL) division is a common injury that is routinely managed in hand surgery. The literature on the subject, despite this, is limited and rarely discussed in isolation from finger extensors injuries. There are two accepted rehabilitation regimes accepted for EPL mobilisation, post repair. 1) The utilisation of early active movement regimes, 2) the most commonly practised regime in European units, is splinting, EPL repairs in a static splint or mobilising in a dynamic extension outrigger for 4 to 6 weeks followed by active mobilisation for further 2-4 weeks. We decided to assess the outcome of our EPL repairs in zone 1 and 2, through an intra-patient controlled range of movement outcome measures. Methods: Prospective data was collected by the departmental hand specialist physiotherapists, between February 2013 and September 2015 for anyone identified as a complete zone 1 or zone 2 EPL ruptures that were repaired. Total Active Movement (TAM), which calculates the active range of movement as a percentage of movement of the unoperated thumb at the metacarpophalangeal joint (MCPJ) and the interphalangeal joint (IPJ) and White’s criteria (1956) was used to compare the range of movement outcome post repair. All therapists within the department were taught how to measure thumb range of movement (ROM) according to department guidelines using standardised positioning and equipment. Results: Total sample size N=20 patients, followed through to discharge at 8-weeks post mobilisation. ROM started 25-35 days after surgery 90% (N=18). Excellent ROM [=TAM] on discharge 25% (N=5), Good ROM [>75% TAM] 30% (N=6), Fair [50-75% TAM] 40% (N=8), Poor ROM [<50% TAM] 5% (N=1) Over half (55%) of cases therefore, achieved 75% ROM of the control thumb on discharge, and 95% achieved over >50% ROM on discharge. 66% of patients required less than 3 sessions, and 80% of patients were discharged after fewer than 8 treatment sessions. Conclusions: Over half of the patients regained >75% of the ROM of the unoperated thumb within only 2 or 3 physiotherapy sessions. Stuart el al 1965, and Mowlavi et al 2005 both reported no long-term superiority of mobilization protocols over immobilization. The reported NHS tariff for a physiotherapy session is £81(€91.37) for the initial session followed by £40(€45)/session; extrapolating this data, immobilising post EPL repair and discharge in 66% will cost £161(€181.61) 3 sessions, while for early active, it’s suggested they will have between 8-12 weeks of physiotherapy costing between £361-521(€407-587.45) leading to an increased cost of 124-224% per patient without any long-term benefit. Although greater ROM represents restoration closer to pre-injury movement, it does not necessarily reflect the restoration of function. However, it has been reported in literature the versatility of the thumb in adapting to a reduced range of movement in one joint by increasing range in another joint, preventing functional loss. It will be useful for future projects, to assess the time of returning to work post-injury, and any difficulty with function or pain, using PRWHE (Patient Related Wrist and Hand Evaluation), ideally with a larger sample size.

Abby Choke 1, Ou Yang You Heng 3, Alyssa Toh LiYu 2, Wong Yoke Rung 2, Muntasir Choudhary 1, Duncan Angus McGrouther 1,2

1 Department of Hand Surgery, Singapore General Hospital, Singapore; 2 Biomechanics Laboratory, Singapore General Hospital, Singapore; 3 Department of Orthopedics Surgery, Singapore General Hospital, Singapore

Objectives Spiral fractures of the metacarpal are common and indicated for surgical fixation due to its unstable nature. We aim to study the fracture pattern and characteristics following a biomechanically induced torsional force on a chicken humerus model. We hypothesize that the speed of the torsional force is related to the length of the spiral, and that secondary fracture lines always propagate along the ‘spiral component’ of the fracture. Methods 30 fresh frozen chicken humerus bone were dissected and divided into three groups of 10. The bones were mounted onto a customized jig and subjected to torsional load using the Instron 3343 Mechanical Tester. The bones were tested at 3 different speeds (2,3 and 4 seconds) based on their group. The fracture pattern, angle, length, and degree of comminution were analyzed. Results 24 bones failed in a spiral pattern along the shaft of the bone. 6 bones that failed at the metaphysis were excluded. For the first observation, we noticed that all spiral fractures have two components: a helical line that traverses the circumference of the bone and another longitudinal line that connects both ends of the helical. This creates the characteristic spikes at two bony ends. A linear pattern was observed for the different torsional rate applied - the faster the torque, the smaller the fracture angle (R2=0.9957) and the longer the fracture length (R2=0.9778). The appearance of secondary fracture lines was not related to the torsional rate and always propagate at a sharp angle to the original fracture line. Conclusion A thorough understanding of fracture characteristics is important for the surgeon to plan the fracture fixation. As spiral fractures of the metacarpal have a broad and irregular configuration, anatomical reduction by screws and plates should be well planned to prevent fracture propagation or comminution.

Thea Birch Ransby 1, Lisa Bay Johansen 2, Helene Nørgaard 2, Nanna Rolving 3

1 Faculty of Health, Aarhus University, Aarhus, Denmark; 2 Department of Physical and Occupational Therapy, Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark; 3 University Clinic of Innovative Patient Pathways, Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark

Objective: The aim of the study was to assess the responsiveness of the Assessment of Motor and Process Skills (AMPS) in a population of patients undergoing rehabilitation following finger or hand surgery, as this has not previously been investigated.   Methods: Patients are included from the Department of Physical and Occupational therapy at Silkeborg Regional Hospital in the period October 2017 to March 2018. A total of 50 patients, who have been referred for specialized occupational therapy rehabilitation following finger or hand surgery, will be included. At baseline and follow-up (after 8-10 weeks) all patients are assessed with AMPS, Canadian Occupational Performance Measure (COPM), hand grip strength and joint range of motion using standardized methods. Responsiveness to change is evaluated using an anchor-based method, comparing AMPS scores with the scores on the Global Rating Scale. The area under the ROC curve will be calculated, and an area under the curve of 0.7 is considered acceptable. Convergent and discriminative validity of the AMPS will be assessed across the different instruments used. Thus we expect a higher correlation between AMPS and COPM and lower correlation between AMPS and hand grip strength and range of motion.   Results: Patient inclusion was initiated as planned in October 2017. We expect the last follow-up to be completed in May 2018. Results will be presented at the FESSH conference.   Conclusions: Rehabilitation following finger or hand surgery is often evaluated using only instruments assessing bodily function, e.g. hand grip strength and joint range of motion. However, considering the ICF rehabilitation framework, outcome measures should focus more on activity and participation. Furthermore, many patients requiring finger or hand surgery are still at the labor market, which underlines the importance of a valid assessment of their abilities in terms of activity and participation. This study will provide valuable knowledge in terms of whether AMPS is a valid tool for measuring improvement on these parameters in a population for which AMPS has not traditionally been used.

Shingo Abe 1,3, Kunihiro Oka 1, Yoshihito Ootake 2, Yuusuke Tennma 2, Yuuta Hiasa 2, Yoshinobu Sato 2, Satoshi Miyamura 1, Atsuo Shigi 1, Tsuyoshi Murase 1

1 Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Japan; 2 Nara Institute of Science and Technology, Ikoma, Japan, 3 Toyonaka Municipital Hospital, Toyonaka, Japan

Objective It is important to analyze dynamic forearm rotational motion for the patient with forearm rotational restriction or instability during forearm rotation; however, in-vivo three dimensional (3D) forearm rotational analysis is difficult to obtain. We have conventionally performed forearm computed tomography (CT) in three rotational position (full supination/ pronation, and neutral rotation) and created virtual dynamic forearm rotation using the computer software (CT method). The purpose of this study was to create a new intensity-based 2D-3D registration (2D-3D method) to measure real forearm rotational motion and validate the accuracy of this method. Methods We performed biplane fluorography for forearm dynamic rotation and acquired 2D dynamic image data; the forearm CT was performed and created 3D static image data. Digital reconstructed radiograph (DRR), which was projected image of 3D CT data in arbitrary direction containing intensity information of radiolucency, was created for each the radius and ulna. The DRR of the radius and ulna was registered on the corresponding bone on fluoroscopy images for each frame based on similarity metric which calculated intensity information. All the registration procedure was implemented through an automatic matching algorithm written by MATLAB software. Consequently, 6 degree-of-freedom (DOF) of rotation and translation for each the radius and the ulna during forearm rotation were calculated and visualized. For validation study, we manufactured the upper arm phantom (Kyoto Kagaku, Japan) composed of bones, soft-tissue, and 8 stainless spheres with diameter 1.5mm implanted on the radius and the ulna. We manually rotated the phantom for 10 seconds and performed biplane fluorography with 12.5 frame/sec, acquiring total 125 frames of biplane fluorography. We defined the radiostereometric analysis (RSA method), which calculated 3D bone position based on 3D position of stainless spheres, as ground truth. Because the density of spheres on the images help to increase the accuracy of registration, we removed the density of spheres from the images using the impainting technique which replace the density of the spheres to average density of surroundings. We executed 2D-3D method using the images without the stainless spheres. To assess accuracy of 2D3D method, we compared 6 DOF of rotation and translation for the radius and ulna between 2D-3D method and RSA method. One healthy male volunteer performed forearm rotation and analyzed by both the 2D-3D method and the conventional CT method. We compared radiation dose between the 2D-3D method and CT method. Results The absolute value of rotation error were 0.36 ± 0.59° for the radius, and 0.55 ± 0.73° for the ulna. The absolute value of translation error were 0.26 ± 0.28 mm for the radius, and 0.18 ± 0.18 mm for the ulna. Radiation dose was 1.58 mGy for 2D-3D method, which was lower than conventional CT method (4.05 mGy). Conclusion We achieved highly accurate in-vivo forearm rotational analysis using intensity-based biplane 2D-3D registration technique with high temporal and special resolution. In addition, the radiation dose of the current 2D-3D method was lower than conventional CT method.

Stefanie Hensler 1, Pascal Behm 3, Stephen J. Ferguson 3, Daniel B. Herren 2, Stephan Schindele 2

1 Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland; 2 Department of Hand Surgery, Schulthess Klinik, Zurich, Switzerland; 3 Swiss Federal Institute of Technology (ETH), Zurich, Switzerland

Objective Many activities of daily living are dependent on sufficient motion and good stability of the proximal interphalangeal (PIP) joint. However, there is no well-established, objective and adequately precise method for measuring full three-dimensional finger joint kinematics, including lateral stability of the PIP joint. There are associated technical challenges including the limited space for marker localization, ensuring visibility of all markers during the entire motion task, and the processing of large data volumes. Therefore, our objective was to adapt a three-dimensional motion capture system for measuring lateral stability of the PIP joint, and conduct pilot trials with this system in healthy volunteers as well as in a patient after surface-replacing arthroplasty to establish its reliability. Methods A machine-vision optical tracking system (CamBar B2 C4, Axios 3D GmbH, Oldenburg, Germany) was used for motion analysis measurements. Four retroreflective markers (3 mm diameter) were clustered on each of two rigid plates, which were mounted onto the proximal and intermediate phalanx by compression cuffs to limit relative skin motion. A frame was constructed to fix the proximal phalanx during the measurement. A lateral bending moment in the PIP joint was generated by a pulley system with free hanging weights of 40, 90 and 170 grams. Lateral deflection of the intermediate phalanx provides a relative quantitative measure of radial and ulnar instability of the PIP joint. Data were analysed using MATLAB R2016b (The MathWorks Inc., Massachusetts, USA). Measurement reliability was evaluated with a test-retest (intraclass correlation coefficient (ICC)) method in ten healthy volunteers. Initial measurements of lateral stability were also performed in a 68-year-old PIP osteoarthritis patient who underwent surface-replacing arthroplasty (CapFlex-PIP, KLS Martin Group, Tuttlingen, Germany) five years ago. Results Reliability measurements demonstrated stable and continuous motion data recording of the PIP joint and adjacent segments, which allowed the calculation of representative deflection angles. The test-retest repeatability was high with an ICC of 0.83. System handling was easy and the measurement time of approximately 20 minutes per subject was short. The first patient test confirmed these observations; the patient had a stable PIP joint with both radial and ulnar deflection angles of less than 2 degrees, which corresponded to the subjective clinical assessment of lateral stability. Conclusions The current system provides a simple, fast and precise measurement of PIP joint lateral stability as well as reliable and repeatable kinematic data. It will be used in a comparative study to test the hypothesis that a surface-replacing implant leads to higher 1-year postoperative PIP joint stability compared to silicone arthroplasty.

Per Linnertz 1, Johanna Prieto Ek 2, Birgitta Rosén 1

1 Department of Translational Medicine – Hand Surgery, Skåne University Hospital, Lund University, Malmö Sweden; 2 Department of Health Sciences, Lund University, Sweden

Background:The STI™- test (shape-texture-identification) is used to evaluate one aspect of tactile gnosis in nerve disorders, and it has proven good methodological properties. Aim: A new version of the STI™-test was recently introduced. The aim of this study was to test the concurrent validity in STI²™ in patients with affected sensibility and in a population with uninjured hands. Method: Using a cross sectional design this study compared STI²™ to the original version based on 20 persons (40 tested fingers) with subjectively affected sensibility following hand injuries and one healthy group including 20 persons (80 tested fingers). The agreement between the two versions of the instrument was calculated. Results: Of the 112 tested fingers there was a complete agreement between the versions in 74 % (n=83) of the cases. The measurements showing complete agreement including the accepted 1.2 points margin of error of the instrument was 92 % (n=103). The result showed that there is no significant deviation between the two versions of the STI™ test. Conclusion. Since STI²™ proved good concurrent validity we conclude there is enough evidence to implement the new instrument in the hand therapy tool box.

Spyridon Gigourtakis 2, Zacharias Christoforakis 1, Petros Kapsetakis 1, Anastasia Pitikaki 2, Georgios Koumantakis 3, Antonia Baxevani 2, Tzagkarakis Eustratios4 , Bounakis Nikolaos 5

1 Orthopaedic Department, University Hospital of Heraklio, Heraklio, Crete, Greece; 2 Physiotherapy Private Practice, Heraklio, Crete, Greece; 3 Physiotherapy Department, 401 General Military Hospital of Athens, Athens, Greece, 4 Orthopaedic Surgeon, Private Practice, Heraklio, Crete, Greece 5 Orthopaedic Department, General Hospital of Irakleion Venizeleio - Pananeio, Heraklio, Crete, Greece

Objective: Dynamometric assessment of muscle groups with tendon disorders is performed to interpret their mechanical profile and to assess treatment effects. Accurate functional assessment of muscular strength is fundamental. A same-day test-retest reliability study, for the muscle groups of elbow flexion, extension, forearm pronation, supination and grip strength, following distal biceps tendon rupture was performed. Methods: A sample of 16 male patients, who underwent the same technique surgery, from the same surgeon, for the repair of rapture on the distal biceps tendon, where assessed one year plus postoperatively. The assessment included the use of an isokinetic device, "Humac Norm Isokinetic Extremity System", CSMi and a "Digital Hand Held Dynamometer", “Biometrics Ltd“. The protocol of isokinetic device assessment included: isometric flexion, at 90° elbow flexion, 3 reps; isometric extension, at 90° elbow flexion, 3 reps; isometric supination, at 0° and 45° of pronation, 3 reps for each position; concentric flexion-extension, speed test 60°/sec, 5 reps; concentric flexion-extension, speed test 120°/sec, 5 reps; concentric pronation-supination, speed test 60°/sec, 3 reps; concentric pronation-supination, speed test 120°/sec, 3 reps. The protocol of grip strength assessment included the isometric maximum grip strength measurement, 3 reps. The assessment included both right and left upper limbs, with random side selection. The selection of isokinetic speeds were based on the characteristics of the sample. The slow speed (60°/sec) was selected for the purpose of gaining highest torque without the fatigue of a slower speed. The more rapid speed was selected for best representing functionality. Eccentric testing was not performed, to ensure the safety of the re-attached tendon. Lastly, the grip strength evaluation was performed to assess whether surgery affected the total capability of hand grip. Results: Patient mean (range) age at the time of surgery was 47 (24-60) years and measurements were conducted 62 months (range 12-174) postoperatively. The protocol included reliability measurements for 26 contractions: 10 isometric and 16 isokinetic concentric, involving both upper limbs. The proposed method was found to be equally reliable for both the isometric and isokinetic concentric contractions. Intraclass Correlation Coefficients (ICCs Model 3,1) ranged between 0.92-0.98 for the isometric and between 0.87-0.98 for the isokinetic assessments. Standard Error of the Measurement (SEM) % values ranged between 3.79-13.56 % for the isometric and between 4.68-14.06 % for the isokinetic assessments. All testing has been successfully completed by all subjects and the procedures involved in the assessment protocol were easy to comprehend. Better stabilization and isolation of the assessed muscle groups, with elimination of the effect of gravity was achieved with the isokinetic dynamometer. Conclusions: The application of a dynamometric evaluation of elbow and hand muscles has been tested in a population of subjects with distal biceps tendon rupture. Contrary to what has been done so far, all muscle groups involved were evaluated under both static and dynamic contractions. We believe it has a clinical applicability in assessing the muscle changes that occur in people undergoing surgery that affect upper limb strength. These are the preliminary results of a project in progress.

Harry Belcher

Independent Hand Surgeon

Outline: the assessment of power is an important part of the assessment of a hand in medicolegal practice. The most widely used method is the measurement of grip-strength using a Jamar dynamometer, which is an adjustable hand-held device that measures grip strength over five widths. The power that can be applied over the five settings of the dynamometer usually exhibits a skewed bell-shaped curve; the maximum power being almost always achieved at either setting 2 or 3. It has been observed that the performance of patients is variable and inconsistent due to the effects of injury as well as anxiety about the assessment. An extended test protocol has been developed to mitigate these effects whilst retaining the ability to detect submaximal effort. Methods: the extended protocol was undertaken in 100 consecutive patients who had suffered unilateral upper limb injuries undergoing medicolegal assessment at a median interval of 26 months from injury. Information collected included demographic data and a quick-DASH score (QDASH). The whole limb impairment (WLI) was calculated from the examination findings. The dynamometry test protocol comprised two tests at each Jamar position. The sequence starts from the first and narrowest position on the uninjured hand, followed by the first position on the injured hand, the second position on the uninjured hand, etc. Following the 5th test on the injured hand at the widest handle setting, the sequence is reversed. The largest value for the two attempts at any given side and position was used for the purposes of analysis. The data is analysed for consistency of performance, variation over the five settings and deviation from the expected curve pattern derived from a normal population. Results: The population had a median age of 42 years, WLI of 4% and QDASH score of 42. The median difference in maximum power between injured and uninjured sides was 25%. This difference was correlated with the WLI (R=0.43, p<0.001) and QDASH (R=0.53, p<0.001). Maximum power was exerted at postion-2 in 81% of uninjured hands compared with 65% in injured hands (p<0.05) Patients were less consistent in test performance with their injured compared with uninjured hands (median values of 9.4% vs 6.7%, p<0.001). The curves achieved by injured hands were significantly albeit slightly more dynamic (20.1% vs 18.2%, p<0.01) and deviated more from the expected curves than the injured hands (9.8% vs 6.9%, p<0.001). Conclusion: injury causes loss of power and changes in dynamometry performance. Analysis of curve physiology allows the identification of statistical outliers. Whilst some results can be explained on the basis of the injury sustained, others cannot, suggesting that these test results cannot be relied upon as a true reflection of capacity.

Spyridon Gigourtakis 1, Antonia Baxevani 1, Anastasia Pitikaki 1, Georgios Koumantakis 2, Georgios Manolarakis 3, Matthaios Matthaiakis 4, Constantinos Koutsojannis 5

1 Physiotherapy Private Practice, Heraklion, Crete, Greece; 2 401 General Military Hospital of Athens, Athens, Greece; 3 Orthopaedic & Ortho-Trauma Surgeon Private Practice, Heraklio, Crete, Greece; 4 Orthopaedic Surgeon Private Practice, Heraklio, Crete, Greece; 5 University of Patras, Computer Engineering and Informatics Department, Patras, Greece

Abstract Purpose: The purpose of the study was to establish the concurrent validity and test-retest reliability of the Grip Force Measurement System (GFMS), as a specialized system of the grip force of the palm and its individual fingers. Methods: Grip strength testing was performed on 12 injured participants. Three trials were completed for the right and left hand on the Biometrics E-LINK EP 9, using a repeated measures design. The maximal voluntary grip force perpendicular to the surface of the handle was estimated immediately afterwards, using a glove with 349 sensors (Tekscan, USA-Grip Force Measurement System), while holding the digital biometrics dynamometer at the same time. Six more trials (three for each hand) were tested using GFMS, during holding a cylindrical handle. Individual digit and palm forces were studied. Each subject was properly positioned and the same verbal orders were given. Six participants repeated the testing later, for test-retest reliability of the Grip Force Measurement System. Main Findings: The study presents initial evidence on the test-retest reliability of the Grip Force Measurement System. In addition, a repeated measures analysis of variance (ANOVA) with one within participants factor of systems (Biometrics versus Grip), was conducted to determine whether differences in strength scores existed between systems. Differences were considered significant at the 0.05 level of significance. Conclusion: The results indicate that the Grip Force Measurement System is reliable and comparable to the Biometrics E-LINK EP 9, when used for measuring grip strength. The human hand grip force is commonly assessed using hydraulic or tensometric hand dynamometers, but the Grip Force Measurement System allowed identification and analysis of the force of the palm and its individual fingers. The total hand grip force was measured by 349 resistive sensors located in a glove. Fourteen sensing areas were placed on the phalanges of the hand, and the remaining ones on the palm. Ηowever, due to small sample, future studies into the reliability and validity of the Grip Force Measurement System should be conducted

Özge Buket Cesim, Başak Karadağ, Elif Cimilli, Burcu Semin Akel, Çiğdem Öksüz

Hacettepe University, Ankara, Turkey

Purpose: DASH is an useful questionnaire for measuring functional disability in upper extremity disorders of Turkish patients and is used to determine functional activity profile of patients with different upper extremity injuries. The aim of the study is to investigate activity profile with DASH questionnaire thereby determining the distribution of items in Turkish population with distal radius fractures. Methods: Forty five patients (32 females, 13 males) with distal radius fractures completed the Turkish version of Disability of the Arm, Shoulder and Hand (DASH) questionnaire which response options are range from 1 to 5 (1: no difficulty; 2: mild difficulty; 3: moderate difficulty; 4: severe difficulty; 5: unable). The DASH scores are between 0 and 100 in which a high DASH score indicates severe disability. Assessments were done at the first session of the patients by authors. Incomplete DASH questionnaires (more than three items missing) were excluded from the study. To determine the distribution of items and most unanswered questions, frequency analysis was done with SPSS 21 programme. Results: The age interval of the patients were between 21 and 65 years with the mean age of 49,17 ± 13,75 years. The mean score of DASH questionnaire was 45,84 ± 24,35 (minimum 6,89, maximum 87,03). Most unanswered items were ‘garden or yard work’ (by 10 female patiens), ‘sexual activities’ (by 6 female and 2 male patients), ‘prepare a meal’ (by 4 female and 2 male patients) and ‘make a bed’ (by 1 female and 5 male patiens). ‘Open a tight or new jar’ (by 44 patients), ‘do heavy household chores (e.g. wash walls, wash floors)’ (by 41 patients) and ‘carry a heavy object (over 10 lbs)’ (by 40 patients) items were considered difficult for these patients. Not at all difficult items were ‘manage transportation needs’ (by 30 patients), ‘use a knife to cut food’ (by 22 patients) and ‘sexual activities’ (by 20 patients) for these patients. Conclusions: Our results showed that patients with distal radius fractures have specifically difficulties in bilateral activities which require strength. On the contrary, these patients have no difficulties in activities which is not specific to the upper extremities. Unanswered items may be the reflection of culturel and physical environment. In Turkish population most males do not perform activities related home management such as making a bed. Due to the majority of females patients, we may found that unanswered acitivities mostly indicated by female patients. Nevertheless we think that unanswered questions -except questions which include home management activities- such as sexual activities or garden or yard work, reflect both genders in Turkish population. We believe that identifying activity profiles which are specific to patient groups guide treatment programmes.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Background: A Morel-Lavallée lesion is a closed degloving injury associated with severe trauma. The lesions classically occur over the greater trochanter of the femur. Occasionally over the lumbar, scapula, or knee can result in identical lesions. Once these lesions became established and encapsulated, then conservative management is rarely successful. In that case, surgical intervention such as open drainage, repeated debridement, and vacuum sealing drainage may be required. However, this surgical treatment could be insufficient. Herein, we describe good results of fasciocutaneous rotation flap for the intractable Morel-Lavallée lesion. Methods: Since 2012, 6 patients underwent fasciocutaneous rotation flap for intractable Morel-Lavallée lesion over the greater trochanter (n=2), lumbar (n=1), and buttock (n=3). The patients' age, sex, the cause of the defect, wound dimensions, the timing of flap coverage, operative time, and postoperative complications were recorded. Results: All the flaps survived completely without the additional procedure. The mean operative time was 48minutes(range 35 to 58). The dimension of the defects ranged from 3cm×5 cm to as large as 5cm×8 cm. There was no significant complication in any of the patients. Conclusion: The fasciocutaneous rotation flap for Morel-Lavallée lesion has the advantages of reliable, easy to perform and fast operation times. Therefore we recommend this flap for the reconstruction of an intractable Morel-Lavallée lesion.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Background and aims. The sacral region is one of the most frequent sites of a pressure sore. Sacral pressure sores remain challenging to orthopedic surgeons who are unfamiliar with microsurgical techniques. Herein, we present our experience in reconstruction of sacral defects with the use of fasciocutaneous rotational and parasacral perforator flaps. Methods. 15 sacral pressure sores, patients underwent surgical reconstruction of sacral defects with a fasciocutaneous rotational (n=7) and parasacral perforator flaps (n=8). The patients' age, sex, the cause of the sacral defect, wound dimensions, the timing of flap coverage, operative time, and postoperative complications were recorded. Results. All the flaps survived completely except for one patient who had partial necrosis of the flap, which necessitated another rotation flap for coverage. There was no significant operation related mortality in our study. The average follow-up period was 12.6 months (range, 3-18 months). The dimension of the sacral defects ranged from 3cm×4 cm to as large as 7 cm×12 cm. The mean operative time was 62minutes (range 48 to 75). The overall flap survival rate was 93% (14/15). There was no recurrence of sacral pressure sores during the follow-up period. Conclusions. In our experience, fasciocutaneous rotational and parasacral perforator flaps are easy and reliable in reconstructing sacral pressure sores. Therefore, we recommend these flaps for orthopedic surgeons who are unfamiliar with microsurgical techniques.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Background: Soft tissue coverage of lower extremity defects is a challenging for an orthopedic surgeon. Perforator flaps are widely used in reconstructive surgery. Herein, we describe our experience with the use of medial sural artery perforator (MSAP) based propeller flap for reconstruction of defects of the upper one-third of the leg and around the knee. Methods: Since 2012, six patients have undergone MSAP based propeller flap reconstruction. The patients' age, sex, the cause of the defect, wound dimensions, the timing of flap coverage, operative time, and postoperative complications were recorded. Results: All the flaps survived completely except one who had developed marginal necrosis of the flap, which was managed with secondary intention healing. The defect site was upper one-third of the leg in 4 cases and around the knee in 2 cases. The mean operative time was 65minutes (range 55 to 90). The dimension of the defects ranged from 4cm×5 cm to as large as 5 cm×12 cm. There was no significant complication in any of the patients. Conclusion: MSAP based propeller flap has the advantages of relatively constant perforator anatomy, faster operation times, without sacrifice gastrocnemius muscle and sural nerve. Furthermore, this flap is reliable and easy to perform. Therefore, we recommend this flap in selected cases for reconstruction of defects of the upper one-third of the leg and around the knee.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Background and aims. Perforator flaps increasingly use in orthopedic reconstructive surgery. Freestyle local perforator flaps allow flap harvesting in any anatomical region. Although an advantage of Freestyle local perforator flaps, it is difficult to identify the location of the perforators. We report our clinical experience with Freestyle local perforator flaps in various orthopedic reconstructive surgery and describe how to use a preoperative handheld Doppler and color Doppler ultrasound for the detection of the perforator. Methods. From March 2011 to December 2016, 46 patients underwent the reconstruction of soft tissue defects using freestyle local perforator flaps. The defect area included the elbow (4), sacral/gluteal (11), trochanteric (2) thigh (6), knee/popliteal (6), leg (8), ankle (8) and plantar foot (1). Preoperatively, we used a handheld Doppler and color Doppler ultrasound to locate the perforators. The mean age of patients was 48.6 years. The mean follow-up period was 6.5months. Results. Except for 5 cases (thigh: 1, leg: 2, ankle: 2), all remaining flaps survived. The donor sites were closed primarily in 33 of 46 patients, and 13 patients required skin grafts (elbow: 1, knee/popliteal: 2, leg: 4, ankle: 5 and plantar: 1). All the perforators except two (leg: 1, ankle: 1) were found intraoperatively. Handheld Doppler and color Doppler ultrasound assessment had a 92% true-positive rate. The time required to complete the procedure varied from 0.5 to 2.5h depending on each case. There was no complication at the donor site in any patient. Conclusions. By using handheld Doppler and color Doppler ultrasound, we could easily identify the perforators. Freestyle local perforator flaps have the advantages of using similar tissues in reconstruction, not damaging another area, not sacrifice main vessels, and the donor site can be primary closed. Freestyle local perforator flaps provide a useful option for the reconstruction of various orthopedic soft tissue defects.

Satoshi Usami, Kohei Inami

Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, Tokyo, Japan

Objective: A posterior interosseous artery perforator flap is used for small defects, leaving no functional disturbance at the flap donor site. The purpose of this study is to describe our experience with the transfer of this flap for fingertip defects and the evaluation of postoperative function. Methods: Thirteen flaps were used for 16 fingertip reconstructions in 13 patients from April 2014 to December 2016. All patients were men without one female, and their mean age was 45.2 years. Of the 16 digits, two were thumbs, three were index fingers, seven were middle, three were ring, and one was little. Three patients had two finger defects covered at a time with one bridge flap, and five flaps were harvested in true perforator flap style. As the postoperative flap evaluations, Semmes-Weinstein and two point discrimination was used for sensory recovery, and numbness, hypersensitivity and cold intolerance for peripheral nerve disturbance. Moreover, patient’s satisfaction (excellent, good, fair, poor) and the time for return to work was assessed as the item of patient-based outcomes. Results: Flap size was from 2.5×2.0 cm to 7.5×3.0 cm with mean 10.4cm2. Two flaps were congested postoperatively, but bloodletting for two days improved flap congestion. Eventually, all flaps were survived without two flaps. Partial necrosis were observed in these flaps, but they eventually became epithelialized after conservative treatment using ointment. Over the mean follow-up of 10.6 months, static and moving two-point discrimination were 9.4 and 6.8 mm, and in Semmes-Weinstein, blue were six, purple were six and red were four. In the sensory disturbance, numbness was remained in 31% patient, hypersensitivity in 38% and cold intolerance in 44%. Patients returned to work approximately two months after surgery. There were no complications at the donor sites. As conclusive satisfaction, excellent was 38%, good was 62%, and there was no patient who complained about treatment by this flap. Conclusions: A posterior interosseous artery perforator flap was a useful choice for fingertip reconstruction without donor site morbidity, and the patients were able to return to daily living quickly. This flap consists of thin skin and subcutaneous tissue not of glabrous skin, but offers an acceptable sensory recovery and a desired patient’s satisfaction.

Rosana Raquel Endo 1, Flavio Faloppa 2, João Baptista Gomes dos Santos 2, Carlos Henrique Fernandes 2, Luiz Carlos Angelini 1, Luis Renato Nakachima 2, Marcela Fernandes 2

1 Hospital do Servidor Público Municipal de São Paulo, Brazil; 2 Hospital São Paulo UNIFESP/Orthopedic Surgery Department, Hand Surgery Department, Brazil

Due to the scarcity of data in the Brazilian literature regarding the hand surgeon's performance in microvascular surgeries, we performed a statistical analysis with the data obtained through an anonymous questionnaire carried out during a specialty congress. Through it we approach technical, demographic, epidemiological and financial aspects to obtain pertinent conclusions. 143 brazilians hand surgeons answered the questionnaire. Only 10 (7%) did not receive microsurgery training during medical residency. 90 (72.6%) stated that they already performed reimplants 67 (49.6%) performed microsurgical flaps. 65 (63,1%) relataram que os dedos amputados chegam ao hospital em condições inadequadas. Quanto ao tempo o qual os dedos amputados chegam ao hospital, 53 (53,0%) responderam receber em tempo hábil.We did not find in the medical literature data regarding the hand surgeon's performance in microvascular surgeries in Brazil, but the results obtained were similar to those found in the North American literature with drawings similar to ours.

Renata Gregorio Paulos, Bruno Alves Rudelli, Renee Zon Filippe, Gustavo Bispo dos Santos, Ana Abarca Herrera, Andre Araujo Ribeiro, Marcelo Rosa de Rezende, Teng Hsiang Wei, Rames Mattar Jr

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

OBJECTIVE: To analyze the histological changes observed in venous grafts subjected to arterial blood flow as function of the duration of the postoperative period to optimize their use in free flap reconstructions. METHODS: Twenty-five rats (7 females and 18 males) underwent surgery. Surgeries were performed on one animal per week. Five weeks after the first surgery, the same five animals were subjected to an additional surgery to assess the presence or absence of blood flow through the vascular loop, and samples were collected for histological analysis. This cycle was performed five times. RESULTS: Of the rats euthanized four to five weeks after the first surgery, no blood flow was observed through the graft in 80% of the cases. In the group euthanized three weeks after the first surgery, no blood flow was observed in 20% of the cases. In the groups euthanized one to two weeks after the first surgery, blood flow through the vascular loop was observed in all animals. Moreover, intimal proliferation tended to increase with the duration of the postoperative period. Two weeks after surgery, intimal proliferation increased slightly, whereas strong intimal proliferation was observed in all rats evaluated five weeks after surgery. CONCLUSION: Intimal proliferation was the most significant change noted in venous grafts as a function of the duration of the postoperative period and was directly correlated with graft occlusion. In cases in which vascular loops are required during free flap reconstruction, both procedures should preferably be performed during the same surgery.

Marcelo Rosa de Rezende, Mateus Saito, Renata Paulos, Samuel Ribak, Ana Abarca Herrera, Alvaro Baik Cho, Rames Mattar Jr

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

Objective: The reverse sural flap has often been used for cutaneous coverage of the distal region of the leg and ankle. When the flap is performed in 2 stages, the vascular pedicle is exteriorized and later resected. Our goal was to assess the reverse sural flap performed in 2 stages regarding its viability and lower morbidity along the flap-donor area. Methods: Eleven patients with cutaneous coverage loss found in the area between the distal third of the leg and ankle were subjected to cutaneous coverage surgery with reverse-flow sural flap with exteriorized pedicle, without violation of the skin between the base of the flap pedicle until the margin of the wound. After a minimum period of 15 days with flap autonomy, the pedicle was resected. The flap dimensions, its viability before and after the pedicle ligature, and the distance from the intact skin between the flap base and the margin of the wound were evaluated. Any losses were measured as a percentage of the total flap size. Results: The respective length and width of the flap were, on average, 7.45 cm x 4.18 cm. All flaps survived. There was partial loss of flap in 3 cases ranging from 20 to 30%. The average distance of the intact skin between the pedicle base and the margin of the wound was 5.59 cm (min: 4 cm/max: 8 cm). Conclusion: Our results show that the 2-stage reverse sural flap ensures good flap survival and a lower morbidity.

Miguel Moron, Thuan Ly, Claudia Meuli-Simmen, Itai Pasternak

Clinic for Hand, Reconstructive and Peripheral Nerve Surgery, Cantonal Hospital of Aarau, Switzerland

Introduction Soft tissue defects over the posterior aspect of the elbow can result from various causes, bursitis olecrani being one of the most common. There is a large variety of treatment strategies to address this problem, ranging from secondary wound healing to coverage with a flap. We report six selected cases, all of which were treated with a different flap. Methods We chose exemplary cases from our institution which warranted different sorts of soft tissue coverage due to defects over the posterior aspect of the elbow. Results Six patients whose ages ranged from 49 to 70 years were selected (4 male, 2 female). All defects could be closed by a flap. The flaps we used were; perforator flap and split skin graft (n=1), local bridging perforator flap (n=1), pedicle radialis flap (n=2), local bridge flap (n=1), reverse lateral upper arm flap (n=1). We observed no flap loss and all defects could be covered. Complications were one split skin graft loss and one postoperative hematoma. Conclusions Depending on the size of the defect, general medical condition and comorbidities treatment strategies are modified. There are numerous possibilities when choosing the ideal flap in each individual case, each comprising its own advantages and disadvantages. Decision pathways, operative technique, advantages and disadvantages are presented and discussed for each of these exemplary cases.

J Braga Silva

PUCRS University, Porto Alegre, Brazil

Hypothesis: The perforator pattern of vascularization of the dorsal forearm is a subject that is well studied, and based in these anatomic features non-debilitating flaps can be performed successfully in this region with good results in cases of complex injuries to the dorsum of the hand. We describe here our option for reconstruction of these kind of lesions, presenting our cases and results. Methods: Twenty patients underwent reconstruction of defects in their distal forearm, wrist or hand, using a dorsal forearm adipofascial turnover flap. Twelve males and eight females, with ages ranging from 26 to 80 years were treated. Regarding etiology, eight patients suffered trauma (including 4 crushing injuries), nine had a tumor, and three had burns. One half of patients showed bone exposure and the other half showed tendon exposure. In 18 patients, the lesion occupied the entire length of the back of the hand, and the other two were associated with more than 50% involvement of its surface. Radial artery injury was observed in six patients and ulnar artery injury in two (7%). Results: The flaps survived in all patients. In one case, there was necrosis in less than 25% of the length of the flap. In all patients, the normal gliding motion of the involved tendons and joints was gained, and the cosmetic result in the donor site was quite acceptable.

Andrzej Zyluk

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland

Degloving injury consists in tearing out the soft-tissue integument from skeleton of the hand, with accompanied nerves and vessels. The whole hand degloving has bad reputation and one of worst prognosis, even worse than total hand amputation. The range of possible salvage procedures in these cases is limited and their outcomes are unsatisfactory. One of the suitable methods is wrapping the skinned hand with pedicled or free greater omentum flap, retrieved from the abdominal cavity. The article reports outcomes of the treatment of 5 patients at a mean of 8 years after total degloving of their hands and coverage with omental flaps. All flaps healed uneventfully, but in none of the patients the whole length of the fingers was preserved. Division of stumps of 3 fingers was possible in one patient, two others had three-digital hands and remaining two had only separated thumb. Dexterity of injured hands was limited with a mean of score DASH questionnaire of 43 points. Quality of life as measured by SF-36 questionnaire was fair (58 and 53 points in physical and mental domain, respectively). Regardless this, all patients were satisfied with achieved outcomes and all returned to work, which was a confirmation of the effectiveness of the method used in their treatment.

Panai Laohaprasitiporn, Saichol Wongtrakul, Roongsak Limthongthang, Panupan Songcharoen, Torpon Vathana

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University Bangkok, Thailand

Background: Free functioning muscle transfer (FFMT) is a standard treatment in late brachial plexus injury (BPI) and failed primary nerve surgery. FFMT procedure required good donor arterial flow for arterial anastomosis. However, concomitant BPI and subclavian artery injury are not uncommon which required alternative method to restore sufficient arterial flow for FFMT. Objective: To preliminarily report results of arterio-venous loop (AV-loop) graft for FFMT in BPI patients with subclavian artery injury Material and Method: We performed a longitudinal descriptive study in adult BPI patients with concomitant subclavian artery injury proven by computed tomography angiogram. We excluded patients with good intraoperative thoraco-acromial and/or thoracodorsal arterial flow, which could perform FFMT without AV-loop graft. Results: Ten patients were enrolled into study. Three patients were excluded due to good intraoperative thoraco-acromial arterial flow in two patients and large amount of adhesion around external jugular vein in one patient, which couldn’t proceed to the index surgery. Seven patients with an average age of 39 years were included in this study. Most of the patients were male who sustained total arm type BPI from motorcycle accident. Four patients underwent one-stage operation (arterio-venous loop graft and free gracilis muscle transfer in the same operation) and three patients underwent two-stage operation. The success rate was 100% and 33% in one-stage and two-stage operation, respectively. There were increased in operative time, blood loss, blood transfusion rate and length of hospital stay in two-stage operation. All successful cases regained gracilis motor power grade I-III within 10-13 months. Conclusions: Arterio-venous loop graft with free functioning muscle transfer could be an option for late reconstructive surgery in BPI patients with insufficient donor arterial flow.

Hiroyuki Gotani, Hirohisa Yagi

Department of Hand and Microsurgery, Osaka Hospital of Sea Affairs and Relief Association, Japan

(Introduction) We recently have used dorsal ulnar artery perforator flaps (DUAPF) or fascial flaps to cover the tendons and nerves during initial treatment as well as to repair soft tissue defects after elimination of scars during secondary tendon or nerve release in cases of incomplete amputation of forearm and wrist laceration. The flap was first reported by Becker and Gilbert et al. and uses the dorsal ulnar artery as the pedicle. Our clinical experience with the flap is reported. (Materials and Methods) Fifteen patients of complex hand injuries were studied. The injury was caused by an electric saw in five patient, a press in eight, and so-called “spaghetti wrist” by self-laceration in two. The patients ranged in age from 16 to 47 years old (mean: 30 years). The DUAPF was used during the initial surgery in 6 patients and during secondary tenolysis or neurolysis in 9. The DUAPF was prepared as follows. First, a small skin incision, about 2 cm long, was made over the ulnar axis 2 cm proximal to the pisiform bone, and the flexor carpi ulnaris muscle was pulled with a retractor. The dorsal ulnar artery, which serves as the vascular pedicle, was then identified. Ideally, the ulnar axis should be at the center of the flap, and the flap should reach the palmaris longus muscle tendon on the palmar side and the ring finger extensor muscle on the dorsal side. Its length should be determined on the basis of its positional relationship with the site of the defect, taking into consideration that the length of the rotatable vascular pedicle is 2 to 4 cm with the pisiform bone at the center. (Results) The vascular pedicle could be identified in all cases. In six cases, a DUAPF was used in the initial treatment because as a result of debridement, etc., associated with the crush injury and contamination, the skin remaining immediately above the tendon and nerves had poor circulation. A DUAF was used as the pedicle flap in all cases, and as the fascial flap in three of them. Severe adhesion of the flap to the underlying tissues was not observed postoperatively, and none of the patients required secondary neurolysis or tenolysis. The postoperative results assessed according to Chen’s classification were Grade 4 in one patient, Grade 3 in three, Grade 2 in seven, and Grade 1 in four. (Discussion) Treatment of forearm injuries becomes difficult if severe scar tissue occurs at the site of the injury on the palmar side and the tendons or nerves adhere to the skin. It therefore seems best to use a flap with good circulation to cover the site in the early stage whenever possible. Our approach is considered useful because the soft tissue defect around the hand joint, including the carpal canal and the dorsum of the hand, can be covered with a pedicle flap, the main artery can be spared, and the operation itself is easier than with other flaps.

Iva Neshkova, Michael Jakubietz, Silvia Bernuth, Karsten Schmidt, Rainer Meffert, Rafael Jakubietz

Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Clinic Wuerzburg, Wuerzburg, Germany

Objective Soft tissue reconstruction of the hand is often challenging to the reconstructive surgeon. The intricate anatomy of the hand requires a durable soft-tissue -envelope to with gliding capacity crucial for tendon excursion . Commonly used fascial flaps for the dorsum of the hand are free flaps – e.g. temporal fascia flap, ALT fascia flap. We report on a modification as a “fascia only “ distally based interosseus posterior flap (PIA flap). Methods The distally based PIA flap was used in 7 patients to reconstruct soft tissue defects of the hand. In one patient the flap was pulled through the metacarpal gap to cover a palmar defect at the MCP level. Contrary to the standard technique only the deep fascia was included in the flap. A split thickness skin graft was transferred primarily. The donor site was closed in a straight line scar. Results 6 flaps survived completely. In one patient a distal tip necrosis required repeated debridement and a split thickness skin graft. In 3 patients secondary procedures such as bone grafting and tenolysis were carried out. No thinning was required. Conclusions This study reports on the use of a fascial flap without including a skin paddle. As only vascularized fascia is transferred, this flap is very thin and thus allows an aesthetically pleasing reconstruction of dorsal hand defects. Although the series is small we have not found an increased rate of complication. In comparison to the temporal artery fascia flap or the lateral arm fascia flap, harvesting the PIA flap is technically easier and can be done under plexus anesthesia only. The straight forearm scar is aesthetically more pleasing than a large skin grafted area over the extensor muscles. The thin and pliable nature of this pedicled flap is beneficial for reconstructing dorsal hand defects.

Luciano Ruiz Torres, Renata Gregorio Paulos, Luiz Sorrenti, Marcos Leonhardt, Teng Hsiang Wei, Tulio Diniz Fernandes, Marcelo Rosa de Rezende, Rames Mattar Junior.

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

Objective: Distal third of leg and foot coverage was in the 1980’s a strong indication for microsurgical reconstruction with free flaps. After perforator arteries concept better understanding, many new and reappraised flaps were developed and applied to this particular area on avoiding microvascular flaps application: propellers and high reverse sural flaps are examples. As these series progresses in many centers, their assessment showed that failure rates are significant. The authors applied the pedicle medial plantar artery flap in other areas than plantar one and the purpose of this study was to analyze its use in non weight-bearing areas of lower limb. Methods: From 1995 to 2017 we have operated 21 patients with soft tissue defects of posterior heel, medial lower tibia, ankle, Achilles tendon surgery dehiscence and one proximal tibia. Age varies from 21 to 85. Sixteen patients were men. Most patients were operated due to trauma, except for two patient by pressure sores, two patients due sarcoma and two due osteomyelitis. We assessed viability of the flap, complications in donor area and patient satisfaction. Results: All the flaps healed uneventfully. There was no flap necrosis (total or partial). In 5 patients, partial width skin graft over the donor area didn't take completely. They were treated only by dressing changes with complete wound healing. There was no need for secondary surgery except for two patients: one that extruded active bioglass and needed debridement and another one that had problems after debulking (only one in this series). All patients are satisfied. The unaesthetic grafted donor site was hidden under the foot. Only one of them asked for a flap debulking. Conclusions: In these case series anatomy was constant, flap was reliable with no failure and there was reasonable donor site morbidity on medium term follow-up. To our understanding this is a rare series on non-weightbearing area coverage with MPA flap.The authors consider MPA as option on small to moderate defects of posterior heel, medial ankle and medial distal tibia. It worked well as a unique flap, as a rescue of other partial flap failures and in association to other pedicled local flaps when microvascular surgery was not best option due to clinical or local considerations.

Andrea Marchesini, P. Pugliese, P. P. Pangrazi, L. Senesi, Michele Riccio

A.O.U. Ospedali Riuniti di Ancona, Department of Reconstructive Plastic Surgery, Hand Surgery, Ancona, Italy

Objective: The loss of substance in the hand dorsum, both due to traumas and soft tissue cancer, can be classified as simple or complex. In the first case only the skin is involved while two or more tissues are involved in the second case. Such tissutal losses are likely to impose severe deficit to patients as they limit the ability of wrist and fingers extension which is a biomechanically essential functional task in order to grant a proper hand’s grip. Due to the importance of such functional area various authors proposed and largely employed a ‘one stage functional reconstruction’ in the multi-tissutal loss of substance by means free or pedicled composite flap [1-3]. Such treatments have been integrated, in the last years, by the use of dermal substituted and more recently by new methods of regenerative surgery [4]. Authors propose a review of their cases which reveals a treatment flowchart allowing for a reduction of the costs associated to the reconstruction for the patients involved. Materials and method: Authors provide a review of hand dorsum and wrist trauma cases treated at their unit from 2006 to 2016. The sample is made of 40 patients of which 14 received a one-stage reconstruction of the hand dorsum by means of a radial forearm composite free flap, 2 were treated with free ALT flap, 8 were treated with pedicled radial forearm flap and the remaining 16 had their hand dorsum reconstructed with dermal substituted and regenerative surgery. Valuations are based on the number of surgical procedures that patients received, the numbers of days they were at hospital, and the quality of their functional recovery in terms of TAM, sensitivity, Quick-Dash e Posas score. Results: From our preliminary results all patients were satisfied with their reconstruction and recovered a good or excellent function a part from two cases of poor recovery. Conclusions: Based on the results a treatment flowchart will be proposed which merges traditional and innovative reconstructive techniques depending on the specific tissue involved in the loss of substance. [1]Reid CD, Moss LH. One-stage flap repair with vascularized tendon grafts in a dorsal hand injury using the “Chinese” forearm flap. Br J Plast Surg 1983;36:473–9. [2] Yajima H, Inada Y, Shono M, Tamai S. Radical forearm flap with vascularized tendons for hand reconstruction. Plast Reconstr Surg 1996;98:328–33. [3] Caroli A, Adani R, Castagnetti C, et al. Dorsalis pedis flap with vascularized extensor tendons for dorsal hand reconstruction. Plast Reconstr Surg 1993;92:1326–30. [4] Adani R, Rossati L, Tarallo L, Corain M. Use of integra artificial dermis to reduce donor site morbidity after pedicle flaps in hand surgery. J Hand Surg Am. 2014 Nov;39(11):2228-34. doi: 10.1016/j.jhsa.2014.08.014. Epub 2014 Sep 26.

Horst Zajonc, David Braig, Jan R. Thiele, Vincenzo Penna, G. Björn Stark, Steffen U. Eisenhardt

Clinic for Plastic and Hand Surgery, University Clinic of Freiburg, Freiburg, Germany

Background: There are only relative indications for distal digital replantation in zones 1 and 2 according to Tamai. In contrast to primary closure for fingertip amputations, replantation is a complex procedure that requires skills in supermicrosurgical techniques, as vessels with diameters between 0.3–0.8 mm are connected. In addition the time spent in hospital and the time off from work are longer. Distal digital replantation is thus only indicated, if the expected functional and aesthetic benefits surmount those of primary closure. Patients and Methods We retrospectively analysed all fingertip amputations in zone 1 and 2 according to Tamai between 9/2009 and 7/2014 where we attempted distal digital replantation. The success of replantation, wound healing and functional results were evaluated according to Yamano. Results We performed 11 distal digital replantations in the study period. There were 6 total amputations, 4 subtotal amputations and 1 avulsion of the digital pulp. Revascularisation with long-term reattachment of the amputated tissues was possible in 8 cases (73%). In 3 cases (27%) secondary amputation closure was necessary. The mean operating time was 3 h 56 min. 6 patients, which had a successful replantation, were available for follow-up examinations after a mean period of 19 months. 5 patients were satisfied with the result and would again prefer replantation over primary amputation closure. 4 patients reported a good function of the replanted digits and did not complain about any limitations in their use. 2 patients complained about restricted function. All patients could return to their previous places of employment and were free of pain. Of the 12 affected digital nerves 11 nerves had a 2-point discrimination (2-PD) of ≤15 mm, 3 of them had a 2-PD between 7 and 10 mm and 4 of them of <6 mm. Soft tissue atrophy was obvious in 3 replanted digits and nail deformities in 2 patients. Conculsions Distal digital replantation is complex and technically challenging. It leads to high patient satisfaction with only minimal functional limitations, if successful. Due to the good results that can be obtained by these procedures, fingertip replantation should be attempted, if operative risks are minimal and if requested by the patient.

Jin Yong Shin, Jung Hoon Lee, Si-gyun Roh, Suk-Choo Chang, Nae-Ho Lee

Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, Jeonju, South Korea

Introduction Traumatic injuries and soft tissue defects in the fingertips are challenging problems for hand surgeons. Many surgical techniques for the reconstruction of fingertip injuries have been described depending on the type of injuries. The most frequently considered procedure is the reverse digital island flap, which is useful for the repair of various fingertip injuries. Although usually surgical detachment procedures have been performed about 14 postoperative days (POD), we introduce early detachment technique as a effective surgical method. Methods 15 patients undergone a heterodigital island flap from 2013 to 2017 were included in this study. We performed 15 reconstructive procedures using a heterodigital island flap to cover the defects. Through our medical charts, we investigated the patient's medical history, vector, level of injury, severity, hospitalization period and time to surgery after injury. In all patients who had heterodigital island flap surgery, we performed surgical delay about 3 POD and detatchment between 7 to 10 POD. Result The 15 patients included 10 males and 5 females, with an average age of 44.87 years. They have undergone surgical delay about 3 POD and detachments on 7 to 10 day after surgery. 15 flaps completely survived and there were no severe complications. Patient’s mean hospital days from day of surgery to discharge were 10 days. Conclusion Early detachment of heterodigital island flap is effective technique for defect of fingertip. All patients who underwent early detachment techniques returned their activities of daily living earlier.

SangHyun Lee, SungJin An, HeeJin Lee

Department of Orthopaedic Surgery, Medical Research Institute, Pusan National University Hospital, Pusan, South Korea

In cases of multi-level amputation of the hand, unsuccessful replantation leads to severe loss of hand function, as well as psychological sequelae resulting from the physical appearance. We report the outcomes of replantation in eight patients with multi-level amputations of the hand between June 2006 and December 2016. In four of the eight patients, all injured fingers survived. The average finger motion recovery was 40.6%. Mean static two-point discrimination was 3.0 cm at finger level and 4.9 cm at palm level. The average grip strength in the affected hand was 65.6% of that of the contralateral hand. According to Chen’s criteria, four patients had good results, three had fair results, and one had poor results. The replantation of multi-level amputations of the hand is challenging, but a good understanding of the surgical procedure can produce good results.

Hyeonwoo Kim, Ji Ung Park, Jun Ho Choi, Julong Hu, Sung Tack Kwon, Byungjun Kim

Seoul National University Hospital, Seoul, South Korea

Background: Fascia free flaps have been widely used in the soft tissue reconstruction of the hands. Fascia flaps are thin, pliable, and provide gliding surface. We have achieved good postoperative results using serratus anterior fascia free flaps (SAFF) in patients with skin malignancy in the nail units, hands, and forearms. Methods: Seven patients with skin malignancy had wide local excision followed by reconstruction with SAFF and skin graft between April 2017 and November 2017 by a single surgeon. All patients were operated in semi-lateral position with vertical incision on their upper lateral flanks. Flaps were harvested with great caution to prevent long thoracic nerve injury. The fascia was anastomosed with recipient vessels under microscope, then covered with skin graft. . Results: Five patients had subungual type of malignant melanoma. Two patients had squamous cell carcinoma on their wrist and forearm, respectively. The serratus anterior fascia flaps were successfully harvested on each donor site in all seven cases. There were no identifiable injury of long thoracic nerve during the operation. The lack of skin paddles made monitoring of the flaps difficult but all the flaps survived without major complications. Conclusions: SAFF is a reliable option in the soft tissue reconstruction of the nail unit and hand, especially when a thin and pliable flap is required. Donor site complications like injury of long thoracic nerve can be minimized with careful dissection during harvest of serratus anterior fascia flap.

Hugo Maschino 1, Germain Pomares 2, François Dap 1, Gilles Dautel 1

1 Centre Chirurgical Emile Gallé, Nancy, France; 2 Institut Européen de la Main, Luxembourg

Objective : -The aim of this presentation is to report the technique applied to reconstruct a metaphysiary-shaft defect of the 4th metacarpal bone in a 22 years old women after tumoral resection. Methods : -Xray and IRM showed typical aspect of aneurysmal cyst of the left 4th metacarpal bone, with typical septa and formation of fluids levels. The lesion concerned metacarpal shaft preserving articular surface proximally and distally. -After submission of patient’s disease history and imaging in oncologic consultation meeting, decision was made to perform a resection and reconstruction in a one stage surgery program. -Preoperative status asked the question of preservation of distal epiphysis in this particular case and in order to determine metacarpophalangeal joint preservation or reconstruction in one surgical approach, we chose to perform free medial femoral condyle flap. This choice was emphasized by intermetacarpal space invasion leading to possible poor revascularization possibilities, justifying the use of a vascularized bone transfer. Results : -After resection distal articular surface was preserved, the length of the defect and the orientation of articular surface was first maintained by intermetacarpal Kirschner wire fixation. -Flap harvesting was made on the contralateral side and measured 4x1 cm, the length enabled to preserve epiphyseal structure and bone anatomy and length. One artery and two veins were found, pedicle length was sufficient to perform terminolateral anastomosis on radial artery and terminoterminal anastomosis of the two veins on venae comitans of radial artery into anatomical snuffbox. -Bone fixation used multiple wire and this solution allowed early active motion, after 2 weeks. Donor site was reconstructed by fitted bone allograft without fixation. -Good results and quite complete flexion-extension range were observed during the follow-up, except minor intrinsic muscles deficit in progress of recovery. At 2 months bone consolidation was complete. Conclusion : -Free medial femoral condyle flap in its extra-articular version seems to offer an alternative to other bone vascularized transfer, minimizing donor site morbidity in cases of metacarpal reconstruction, it also offers an on demand solution when we have to decide peroperatively between articular conservation or reconstruction.

Roderick Dunn 1, Alexandra Crick 2, Stuart Watson 2

1 Odstock Centre for Burns and Plastic Surgery, Salisbury, UK; 2 Canniesburn Plastic Surgery Unit, Glasgow, UK

Objectives This is a case series of 20 free thinned extended lateral arm flaps to the hand and wrist. This paper describes the technique, planning and modifications to the standard lateral arm flap which enable skin distal to the lateral epicondyle to be included in the flap safely. Method This is a prospective case series from 2005 to date. All cases were performed by the author. The method for raising the flap, particularly the inclusion of skin distal to the lateral epicondyle, is described, along with lessons learned. Results Twenty free thinned extended lateral arm flaps were used in 20 patients, 12 primary and 8 secondary. Eleven flaps were performed for trauma, 2 for burns reconstruction, 3 in blast injuries and 4 for infection. All flaps survived completely. No secondary thinning was required, and all flaps tolerated further secondary procedures under the flap when required. All patents regained a high level of function post-operatively. Conclusions The free thinned distal lateral arm flap is very useful small flap for hand and wrist reconstruction, both primary and secondary. The skin is suitably thin for the hand, is a good colour match for normal hand skin, and it can be raised again safely for secondary procedures such as tendon, nerve or joint reconstruction. It is robust enough withstand early use in non-compliant patients. Lessons learned and the evolution of the technique are described, including how to include the much thinner skin distal to the lateral epicondyle safely, flap planning, pedicle length, and selection of appropriate recipient vessels. It is a reliable flap, is easier to thin than alternative fasciocutaneous flaps, and provides a very good skin and colour match for hand reconstruction with an acceptable donor site.

Cheng-Hung Lin, Chew-Wei Chong, Yu-Te Lin, Chung-Chen Hsu, Shih-Heng Chen

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taipei, Taiwan

Introduction: Fingertip injuries constitute a significant portion of cases that present to Hand Surgery service. These injuries are commonly associated with soft tissue loss. Conventional cross-finger flap is the workhorse flap for resurfacing of pulp loss. The authors described a laterally based cross-finger flap for reconstruction of soft tissue defect of the fingers. This modification enables coverage of volar or dorsal soft tissue defect at the distal, middle or proximal phalanx. Patients and Methods: From March 2015 to January 2017, a total of 10 patients (11 fingers) underwent laterally based cross-finger flaps and two patient (two fingers) underwent extended laterally based cross-finger flap. There were 10 men and two women, and the age of the patients ranged from 24 to 46 years. Results: The flap dimensions ranged from 13 x 7 mm to 43 x 13 mm. Eleven of the 13 flaps survived completely. The two flap failures were attributed to injury of the donor fingers, rendering the blood supply of the flaps unreliable. All donor sites were closed primarily without the need for skin grafting, negating the problem of donor site morbidity associated with harvesting of skin graft. Conclusion: The laterally based cross-finger flap is a versatile flap with less donor site morbidity and better aesthetics than conventional cross-finger flap. The authors described the design of the flap, as well as the pearls and the pitfalls, in doing a laterally based cross-finger flap.

Alexandru Georgescu, Ileana Matei, Irina Capota, Marius Pruna, Maria Nedu

University of Medicine Iuliu Hatieganu Cluj Napoca, Romania

Objective Coverage of complex tissue loss in the hand after severe traumas by crushing or avulsion is very challenging. These defects involve generally all the anatomical structures. The difficulties in repairing such a compromise hand are primarily related to the necessity to obtain an as good as possible functionality. The key of obtaining a good functional rehabilitation is to perform, whenever is possible, both the reconstruction and coverage as an all-in-one procedure. Material and Methods We take into account the cases with very complex injuries involving all the structures of the hand. In 70% of our cases we used local or regional perforator flaps, and in 30% of cases free flaps. In case of need to cover soft tissue defects over repaired fractures, vessels, nerves and tendon lesions, we prefer to use-whenever is possible-local or regional perforator flaps; if the skin defect is to big, a free flap is preferred. For composite skin and bone defects we use generally composite flaps including bone. For amputations or devascularized segments with skin defects, a free flow-through flap is used. For amputations of different segments, and especially of the thumb accompanied by skin defects, we cover the defect with a free flow-through-flap which is used in mean time to revascularize one or more toe transfers. Results All the hands treated by this protocol survived. The failure rate of the flaps was comparable with the one in the literature. By using local/regional perforator flaps we experienced no complete necrosis, but only a transitory venous congestion (20%) followed by a superficial necrosis in 5% of cases. We lost 2 free flaps out of 45 (4.4%). We obtained a satisfactory functional rehabilitation of the reconstructed hand in 10% of cases, a good one in 40% of cases, and a very good one in the remaining 50%. Conclusions In complex injuries of the hand the modality of reconstruction is up to the team experience. The use of local/regional perforator flaps has a very good indication in small and medium skin defects, and only in the purpose of coverage. The use of free flaps remain the gold standard in solving big composite defects. The emergency all-in-one reconstruction and the beginning of kinetotherapy as soon as possible after surgery are the key stone of a good functional recovery

Alexandru Georgescu 1,2, Ileana Matei 1,2, Octavian Olaru 2

1 University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; 2 Rehabilitation Hospital Cluj Napoca, Romania

Objective The coverage of simple or complex tissue defects in hand and wrist is generally very challenging because of the complexity of the lesions, which involve not only the skin but also most of the anatomical structures. The repair as complete as possible of all the important functional structures and the beginning as soon as possible of the functional rehabilitation represent the keystone of obtaining a functional hand. Material We take into account the cases with very complex injuries involving all the structures of the hand, amputations in absence of amputated segments and complex tissue defects. In 70% of our cases we use local or regional perforator flaps, and in 30% of cases free flaps. In case of need to cover soft tissue defects over repaired fractures, vessels, nerves and tendon lesions, we prefer to use-whenever is possible-local or regional perforator flaps; if the skin defect is to big, a free flap is preferred, as for example the antero-lateral thigh (ALT) or toraco-dorsal (TD) perforator flap. For composite skin and bone defects we use generally composite flaps including bone; our preferred flap is serratus anterior or latissimus dorsi, or both, with rib. For amputations or devascularized segments with skin defects, a free Chinese or ALT flow-through flap is used. For amputations of different segments, and especially of the thumb, but in absence of the amputated segment/s, accompanied by skin defects, we prefer to do an all-in-one reconstruction, by covering the defect with a free flow-through-flap which is used in mean time to revascularize one or more toe transfers to reconstruct the missing fingers Results The failure rate of the flaps in our hands is comparable with the one in the literature, i.e. not more than 5%. By using local/regional perforator flaps we experienced no complete necrosis, but only a transitory venous congestion (20%) followed by a superficial necrosis in only 5% of cases. We lost only 2 free flaps out of 45 (4.4%). We obtained a satisfactory functional rehabilitation of the reconstructed hand in 10% of cases, a good one in 40% of cases, and a very good one in the remaining 50%. We consider that these good results are related to our strategy, i.e. the all-in-one reconstruction whenever is possible and the beginning of the kinetotherapy very early after surgery. Conclusion In complex injuries of the hand and wrist, the modality of reconstruction is up to the team’s experience. The use of local/regional perforator flaps has a very good indication in small and medium skin defects, and only in the purpose of coverage. The use of free flaps remains the gold standard in solving big composite defects.

María L Manzanares Retamosa, Pedro Bolado Gutiérrez, Luis Landín Jarillo, Aleksandar Lovic Jazbec

Hospital Universitario La Paz, Madrid, Spain

Objective: The prevalence of clavicle fractures ranges between 2.5 to 15% of all fractures and non-union rate ( bone shortening and defects) between 0.1 and 5.8%.The oncologic resections are another source of this type of injuries. Early, safe and effective reconstruction is a must in such a cases, in order to provide an adequate treatment and rehabilitation of any underlined condition as brachial plexus injury, spine injury or any direct upper limb lesion. Methods: Although the microsurgical reconstruction of the clavicle non-union is rarely indicated from the beginning of the treatment it could be the most efficient option for patients who’s upper limb function recovery is strongly conditioned by the proper shoulder stability. We present 8 cases with a free fibula flap carried out between 2011-2016. The analyzed data were: etiology of the defect, associated comorbidities, secondary surgeries, recipient of the anastomosis , osteosynthesis, recovery period and functional evaluation of the shoulder and upper extremity before and after the treatment. Results:Four cases were fracture sequelae with multiple previous surgeries, two tumor resections and two post-surgical clavicle excisions. All of the patients with the exception of the tumoral cases showed important comorbidity (five brachial plexus palsies and one trapezius palsy) that needed nerve transfers and tendon/muscle transfers as a part of the surgical treatment. ORIF was performed in all the cases using anatomical plates and screws. Two cases presented supraclavicular hematoma as postsurgical complication. All the patients started immediate physical therapy and reached bone consolidation within two months after the surgery. There was notorious improvement of pain and the shoulder stability permitted to apply an adequate surgical protocol of the nerve lesions without interfering with the rehabilitation. Screws and plate were removed in six cases for cosmetic reasons. All the patients were back to their original activities. Conclusions: The reconstruction of clavicular defects with a free fibula flap is reliable, straightforward procedure that transform the complex pseudoarthrosis of the clavicle into much “easier to heal”, “fracture-like” conditions, that immediately restore the original shape and stability of the shoulder. It is highly recommendable in the cases where other surgical procedures have to be done simultaneously or as secondary surgery in order to achieve satisfactory functional recovery.

Martina Greminger, Urs Hug, Elmar Fritsche

Luzerner Kantonsspital, Hand- und Plastische Chirurgie, Luzern, Switzerland

The Interossea posterior system is well known as a source for pedicled or even free flaps in hand surgery. In contrast, the Interossea anterior system is not established yet. There is only few literature, and many flap books do not even mention the use of Interosseous anterior flaps. Also the medline database includes only few publications regarding these flaps. In the past 8 years we performed 8 Interossea anterior flaps, 3 pedicled flaps and 5 free microvascular flaps. Flaps were performed in patients with traumatic hand injuries either immediately or early elective, or in a secondary intervention after hand trauma. We registered one partial loss of a free flap. In most cases, donor site could be primarly closed and donor site morbidity was generally low. There are various opportunities to cover small or medium sized defects of the hand. Up to date the Interosseous anterior flap is unreasonably unknown and rarely performed. We show the anatomy, the flap harvesting technique and point out advantages of these flaps in comparison with other flaps of the forearm.

Soo Joong Choi, Jinsoo Park, Seungjin Lee

Hallym University Sacred Heart Hoaspital, Anyang, South Korea

Objective The best form of reconstruction of the soft tissue defects of the hand is replacing like with like. However, small but not very small defect is difficult to be covered by local flap. We tried to cover them by various small free flaps and reporting the results. Methods We performed retrospective review of 12 hand trauma patients treated by small free flaps. There were 11 men and one woman,their ages ranged from 15 to 71 years(mean 46.3 years). The size of defects were from 1x2 to 3.5x9 cm(mean 10.0 cm2). 7 radial artery superficial palmar branch(RASP) flaps and one medialis pedis flap were used for volar defects of fingers and 3 partial big toe flaps for finger tips or side and one medial sural artery perforator (MSAP) flap for dorsum of fingers. Results All the flaps survived completely.The glabrous skins of RASP,medialis pedis and partial big toe flaps and pliable MSAP flap matched well in color and texture with the recipient sites with minimal donor site morbidity . Conclusion Appropriate selection of small free flap is very useful for functional and cosmetic restoration of the soft tissue loss of the hand.

Jorge G. Boretto, Javier Bennice, Gerardo L. Gallucci, Ignacio Rellan, Agustin Donndorff, Pablo De Carli

Hospital Italiano de Buenos Aires, Argentina

Objective The anterolateral thigh (ALT) free flap is currently one of the most useful options for the reconstruction of cutaneous defects in different locations. A long pedicle, reliable anatomy, suitable vessel diameter, the availability of different tissues with large amounts of skin, make this flap versatile with the possibility of customized its applications. The purpose of this study was to evaluate the versatility and customization of the ALT free flap in a series of patients with coverage defects in both, the upper and lower limbs. Methods A retrospective review from a single orthopedic service at a level I Hospital was performed. Inclusion criterion were: patients with defects in different locations of the extremities to whom this flap was made as a reconstructive treatment. All were treated by the same surgeon. In the preoperative period, demographic variables, causes of the defect, size and location of the defect and time between the defect and surgery were analyzed. From the surgical technique, the type of flap, the suture performed and the type of closure of the donor site were analyzed. Finally, during the postoperative period, the survival of the flaps and the complications of the flap and the donor site were evaluated. Results During a 6 years’ period, 12 ALT free flaps were performed. Seven men and five women with an average age of 44 years (range 13-78) were included. The defects were caused by oncological resection in 9 patients and trauma in 3. In 4 cases the defect was in the upper extremity and in 8 cases in the lower extremity. The average time between the defect and the reconstructive surgery was 8 days. Eight flaps were fascio-cutaneous, one flap was compound with fascia lata and 3 were cutaneous. Three out of twelve were thinned before insetting and two were inset as flow-through. In 5 cases the arterial anastomosis was end to end and in 8 end to side. Venous anastomosis was end to end in 10 cases and end to side in 2. The size of the flap varied from 6 to 20 cm in length and from 3 to 12 cm in width. The survival rate of the flap was 92%, presenting failure only in one case. One patient required revision of the pedicle for lack of Doppler signal and suffered partial necrosis. The donor site presented no complications and primary closure was performed in all cases except for 2 that required closure with skin graft. Conclusions The ALT free flap is a valid and very useful resource for the coverage of defects of different etiologies in the upper and lower limbs since its versatility allows it to customized it successfully in varied defects in both, location and size.

Hazem Alfeky 1, Paul McArthur 1, Yasser Helmy 2

1 Whiston Hospital, Liverpool, UK; 2 Alazhar University Hospitals, Cairo, Egypt

Background: Distal digital replantation remains one of the demanding microsurgical procedures due to the difficulty of vascular anastomosis. Venous congestion is the most commonly encountered problem after replantation due to the difficulty of venous anastomosis in traumatic injuries. Heparin, among other drugs, is commonly used to facilitate venous drainage and prevent thrombosis. However, systemic heparin can be contraindicated in some patients. The senior author has experience of subcutaneous heparin injection for venous congestion in thirteen patients Methods: An amount of 1 ml (25,000 U) of calcium heparin for subcutaneous injection was diluted with 2.4 ml of physiologic saline to prepare a solution containing 1000 U in each 0.1 ml. Initially, 1000 U (0.1 ml) of this calcium heparin solution was injected subcutaneously into the tip of congested replanted digits. This was repeated twice daily until venous congestion improved Results: all the congested replanted digits survived without systemic side effects. There were no local side effects of the treatment. The PT and APTT have shown slight increase but they remained within the normal range. Haemoglobin levels have dropped slightly but no patients were at any risk of developing anaemia or needed blood transfusion. Conclusions: Subcutaneous heparin injections can salvage the replanted digits when venous congestion is a warning flag for replantation failure. It is safe and very efficient in patients where systemic heparin cannot be administered. However, this article shows the results in only thirteen patients which is a small number to show the efficacy, safety and side effects. Keywords: Replantation, Heparin, Injection, Salvage

Ahmet Savran 1, Ozgun Gunturk 2

1 Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey; 2 Gaziantep Dr. Ersin Arslan Education and Research Hospital, Gaziantep, Turkey

26 years of male patient has administered our hospital with hypothenar mass and distal ulnar nerve symptoms. Previous penetrating injury at the wrist at the past medical history and scar is inspected at the dorsal side of the mass. Doppler US is reported as pseudo aneurism of ulnar artery. Resection of the mass and vein grafting is perform with Ulnar neurolysis is performed. Total relief of the symptoms is observed at the postoperative 3 months. Hypothenas hammer syndrome is a rare condition of the hand. Our aim is to share our experience in treatment of this diagnosis.

Soo Min Cha, Hyun Dae Shin

Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea

We investigated the anti-adhesive effects of a temperature-sensitive poloxamer/alginate mixture (Guardix-SG®) through a prospective randomized controlled study for carpal tunnel release surgery. The 47 patients who received the infusion were classified as Group 1, and the 51 patients who did not were classified as Group 2. Basic demographic factors and preoperative clinical status were evaluated. At the postoperative 18 months, the degree of clinical recovery and adhesion around the median nerve for both groups were evaluated and compared using sonography. The clinical outcomes, which were assessed using the six-item carpal tunnel symptoms scale, were not significantly different between the groups. However, sonography showed that adhesions around the median nerve were significantly less common in the infusion group. Although the anti-adhesive effects of the temperature-sensitive Guardix-SG® were apparent upon radiological investigation, its use was not associated with a significant difference in clinical outcome on the short-term period follow-up.

Tomas Kubek 1,2, Pavel Novak 1, Libor Streit 1,2, Jiri Vesely 1,2

1 Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital Brno, Czech Republic; 2 Faculty of Medicine, Masaryk University, Brno, Czech Republic

Objective: Authors present unique case report of combined amputation and burn injury of the hand. Methods: 48-years-old man suffered amputation injury to his left hand while working with circular saw. Unfortunately, amputated part fell into a fireplace, which resulted in second and third degree burns on dorsal aspect of the hand and fingers. Replantation was performed 5 hours after the accident. The procedure was supplemented by escharotomy. Gentle tangential necrectomy and debridement was performed in two steps during first two weeks. Defects after necrectomy were covered by skingrafts in third postoperative week. Patient started with active rehabilitation 3 weeks postoperatively. Results: Replantation of the hand with third degree burns was successful. No complications occurred during hospital stay, all wounds were healed within 40 days. Results of rehabilitation in early postoperative period were promising. Unfortunately, the patient failed to cooperate and did not come for follow up. Conclusions: Despite the initial concerns of the surgical team, third degree burns were not an obstacle to successful hand replantation.

Raquel Bernardelli Iamaguchi, Marco Aurélio de Moraes, Renan Lyuji Takemura, Gustavo Bersani Silva, Jairo Andre de Oliveira Alves, Alvaro Baik Cho, Teng Hsiang Wei, Marcelo Rosa de Rezende, Rames Mattar jr

University of Sao Paulo, Brazil

Objetive: Vascularized fibula flap is a standard technique for reconstruction of complex and long defects in lower and upper limbs, mostly in traumatic and oncologic defects. Although, the crescent knowledge in bone reconstruction with microsurgery, the fibula flap still remains one of the most difficult free flaps and complications, including the loss of viability of the vascularized bone and pseudarthrosis remains a challenge. This study evaluated the risk factors fof complications that can influence results in vascularized fibula flap. Methods: A cross-sectional study was conducted with consecutive inclusion of all patients undergoing vascularized fibula flap for upper and lower limb reconstruction at our institution, between July 2014 to July 2017. Patient demographics (age, gender and comorbidities), location and size of bone defect, operative technique, intraoperative and postoperative complications were studied. Statistical analysis were performed with SPSS 20.0 (SPSS Inc ®, Chicago, IL, EUA). All tests were two-tailed, and statistical significance was defined as p < 0.05. Qualitative data were analyzed by Pearson chi-square test or Fisher exact test. Mann-Whitney U-test was used for quantitative nonparametric data. Results: A total of 23 vascularized fibula flaps were performed in 23 patients. Of these, 14 patients were male and 9 female. The indications for bone reconstruction were defects cause by: trauma in 13 patients, tumor in 7 patients and congenital pseudarthrosis of the tibia in three patients. The type of bone tumor were: giant cell tumor in three cases, osteosarcoma in two cases, B-cell lymphoma in one case and adamantinoma in one case. The most common anatomical area of bone lesion was leg in eight cases, followed by forearm in six cases. Obese patients (BMI ≥ 30kg/m2) were significantly associated with an increase in early complications (p= 0,046). Although a high rate of complications, our overall success rates are similar to those in the literature, with 13% total flap loss. Conclusion: Obesity is a risk factor for complications in vascularized fibula flap in orthopedic surgery.

Sang Hyun Woo

W Institute for Hand and Reconstructive Microsurgery, W Hospital, Daegu, South Korea

We present 12 cases in which palmaris longus tendocutaneous arterialized venous free flaps were used for the reconstruction of the collateral ligament in compound defects of digits. There were nine cases involving the interphalangeal joint of the fingers and three of the interphalangeal joints of the thumb. The venous flaps survived completely in 10 of the 12 cases. In 11 cases, there were excellent functional results for joint stability, pain, total active motion and pinch power. In all 12 cases, a pain-free joint with excellent stability was achieved after surgery. The palmaris longus tendocutaneous arterialized venous free flap is a good option for reconstruction of composite defects of the collateral ligament of the interphalangeal joint.

Dong Geun Lee

Chungbuk National University Hospital, Cheongju, South Korea

Introduction Soft tissue defect of the heel is caused by several causes, such as trauma and tumor. Especially in traumatic case of the heel defect , the difficulty of the reconstructive problems is that composite tissue problems often present such as soft tissue and Achilles’ tendon defect. For example, a 54-year-old man with right tibiofibular open fractures had wide soft tissue defect and crushing injury on foot including posterior heel composite tissue defect. After undergoing closed reduction and external fixation of the fracture, there was substantial soft tissue defect on right lower leg area. The soft tissue defect except posterior heel defect was covered with split thickness skin mesh graft. The reason for exception of heel in coverage was that the heel defect included a necrosis of Achilles’ tendon. What should treatment be for this heel composite tissue defect? One month after the latest surgery, the surgical debridement was preformed on the heel wound. And Promptly, reconstruction was performed with anterolateral thigh perforator flap including strip of fascia lata. The purpose of this article is to address such complex problems and to provide a solution for complex soft tissue defect of the posterior heel. Methods and materials The patient was a 54-year-old man with right tibiofibular open fractures having a wide soft tissue defect and crushing injury on foot including posterior heel composite tissue defect. As the reconstruction method, I used microsurgical composite anterolateral thigh perforator flap with tendon transfer using fascia lata. The dimension of the flap was 4 X 6 centimeters sized. The dimension of the transferred fascia lata was 9 X 6 centimeters sized. Before the tendon transfer, the fascia lata was rolled to provide a more strength as a tendon. With a microscopic assistance, the vascular pedicles were anastomosed. Especially the artery was anastomosed with T-shaped pattern not to inhibit the orginal arterial flow of the foot. Results and conclusions The flap was survived without any problem. After 3 monthes following surgery, physical therapy was started for enhancing the power of the Achilles’ tendon. In soft tissue heel defect including the Achilles’ tendon loss, I believe that this method will be one of the best choice.

Hazem Alfeky 1, Esam Tamman 2

1: Whiston hospital, Liverpool, UK. 2: Alazhar University Hospitals, Damietta city ,Egypt.

Proximal hand and forearm amputations are devastating injuries. the prediction of the success is always uncertain due to multi factorial risk factors including the mode of injury, level of amputation, presence of contamination and the extent of the damage to the neuro-vascular tree. General patient status and co-morbidities affect the outcomes as well. There is not any reported algorithm or guidance that can help predict the outcomes of plantation. We present our experience of a series of 17 post traumatic proximal hand and forearm replantations over a 5 year period in 3 major trauma centres . A management guidance is proposed to help deciding whether the process will be successful regarding the immediate survival and the long term functional outcomes and cost effectiveness.

Nasa Fujihara 1, Yuki Fujihara 1, Jennifer M. Sterbenz 2, Melissa J. Shauver 2, Chung Ting-Ting 3, Kevin C. Chung 2

1 Department of Hand Surgery, Nagoya University, Nagoya, Japan; 2 Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA; 3 Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Objective: Economic conditions affect surgical volumes, particularly for elective procedures. In this study, we aimed to identify the effects of the 2008 US economic downturn on hand surgery volumes to guide hand surgeons and managers when facing future economic crises. Methods: We used the California State Ambulatory Surgery and Services Databases from January 2005 to December 2011, which includes the entire period of the Great Recession (December 2007 to June 2009). We abstracted the monthly volume of five common hand procedures using ICD-9 and CPT codes. Pearson’s statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure. Results: The total number of operative cases was 345,583 during the study period of seven years. Most common elective hand procedures, such as carpal tunnel release and trigger finger release had a negative correlation with the unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation. Conclusions: The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. A strategy for mitigating this may be to take advantage of economies of scale, the principle that increased volume reduces unit cost. Consolidating hand surgery services at regional centers may make for a more “economy proof” environment.

Steven Roulet, Guillaume Bacle, Bertille Charruau, Charles Agout, Emilie Marteau, Jacky Laulan

Hand Surgery Unit, Department of Orthopedic Surgery 1, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours, France

Objective : Carpal boss is a symptomatic bony protrusion on the dorsal surface of the wrist, at the base of the second and/or third metacarpal. The goal of this study is to assess reliability and safety of the simple resection of the exostosis. Methods: 29 carpal bosses have been operated. The surgical technique was consistent with Cuono and Watson's description : the bony abnormality was resected until the dorsal edge of normal cartilage. There were 16 females and 13 males. The mean age at surgery was 33 years. The chief complaint was: isolated pain in 13 cases; pain associated with aesthetic blemish in 13 cases; and isolated aesthetic blemish in 3 cases. A cyst was present in 10 cases. 25 patients were contacted for telephone interview by an independent investigator on average 8 years after surgery. Results : No recurrence was reported, seven patients (28%) reported a discrete persistent swollen scar. One patient reported daily pain and impairment 5 years post-surgery, in relation with carpometacarpal instability, requiring fusion. Sixteen of the 24 patients who did not undergo fusion (67%) were free of pain; the others reported episodic pain of a mean 2.3/10 on VAS (range, 1 to 4), which they all attributed to climatic factors. Twenty patients (83%) felt no functional impairment and 4 (17%) some impairment for unusual activities. None complained of metacarpal instability. Patients considered themselves cured in 15 cases (60%) and improved in 9 cases (36%) and unchanged for the patient treated by fusion. None considered their condition worsened by surgery. All patients would undergo the same surgery again. Conclusions : In this series, there was no recurrence of carpal boss, but 1 surgical complication with carpometacarpal instability, probably due to excessive bone resection. Other studies based on simple resection reported failure rates ranging from 4.7% to 50%. Doubts regarding simple resection include small series and short follow-up; the present series is one of only two in the literature to report at least 25 patients and is the only one with a mean follow-up of at least 8 years. Simple exostosis resection is sufficient to effectively treat carpal boss. Fusion should be reserved for the rare cases of secondary metacarpal instability.

Roberta Sartore, Filippo Zanotti, Vito Zanella, Leone Pangallo, Massimo Corain

Hand Surgery Department, Verona University Hospital, Verona, Italy

An aneurysm is as a progressive dilation of the normal diameter of a vessel in the amount of 50% or more. Aneurysms of the hand are rare lesions, caused mostly by recreational or occupational trauma, iatrogenic injury and atherosclerosis. Most of them are false aneurysms. Surgical treatment is suggested to treat symptoms and avoid possible complications like paresthesia, distal embolization, cold intolerance and rupture. We present here a general overview of this pathology and our clinical and surgical experience in its treatment. From October 2016 to September 2017, we treated five cases of arterial aneurysms of the hand. The patients were 3 men and 2 women, with a mean age of 68 year-old (38-84). Two cases involved ulnar artery at the palm (one of them was a recurrence), 1 case was a lesion in the superficial palmar arch, 1 case involved the 3rd common palmar digital artery and 1 case involved the artery in the 1st interdigital space. Two cases were traumatic and 2 spontaneous, whereas the fifth case was of unknown origin (probably post-traumatic, following omolateral wrist fracture). Every patient referred pain and a developing pulsating mass over the site of the lesion, but there was only one report of distal paresthesia in the III and IV fingers (last case). All patients were investigated with ultrasonography, in 2 cases an MRI with contrast was performed and in 1 case a CT with contrast was performed: in every case we found a complete arterial dilation and one case had a complete thrombosis of the vessel (3rd common palmar digital artery). Every patient underwent surgical treatment of aneurysmectomy. Three of them had a subsequent end-to-end anastomosis and 2 a vascular ligation.The mean follow-up was 8 months (2-13). The aneurysmectomy was performed without complications in every patient. We had no complications with the end-to-end anastomosis in terms of patency of the suture and distal ischemia; even in the 2 cases of vascular ligation there was no report of distal ischemia. We had no complications of wound healing or infection, in 1 case the patient lamented a scar pain problem, solved with skin massage. The number of arterial hand aneurysms, even though uncommon lesions, is increasing due to many factors, weather traumatic (working or recreational) or iatrogenic, causing direct or repetitive blows to the vessels. Surgery is the treatment of choice for hand and forearm aneurysms, but high microsurgical expertise is needed. Complete diagnostic assessment is mandatory before surgery to give patients the right surgical indications (avoiding misdiagnosis) and achieve good results.

Ellada Papadogeorgou, Nikolaos Daniilidis

Interbalkan Medical Center, Thessaloniki, Greece

Objective: To describe the rescue procedure of an amputated upper limb at the level of the wrist, prioritizing solely the revascularization of the hand during the first operation, because of the delayed admission of the patient. Methods: A 34 years old male with left hand amputation at the level of the wrist and the palm, caused by a severe crush injury at work, was admitted to our emergency department 6 hours after the accident and after having already had a failed operative attempt of the hand’s revascularization in another hospital. During surgery priority was given to the successful anastomosis of the ulnar and the radial arteries, which had been ligated and thrombosed after suturing retrospectively. After the successful revascularization of the hand, adequate numbers of veins were anastomosed, median and ulnar nerve stumps were tagged and flexor and extensor tendons were sutured en block. Multiple fractures and dislocations of the hand and the wrist were temporary stabilized with an ex-fix system and k-wires. Ten days later, a second operation took place during which all tendons were sutured, the ulnar and the median nerve were reconstructed with sural nerve grafting and the palmar skin defect was covered with local flaps and free skin grafts. The dorsal surface was left uncovered and VAC was applied. After one month, skeletal and extensor tendon reconstruction was performed. The dorsal skin defect was covered with groin flap, which was separated after three weeks. After this point the patient followed an intensive rehabilitation program. Defatting and refinement of the scars followed and two years later a rotational osteotomy of the thumb together with opposition tendon transfer was also performed. Results: Three years post-traumatic the patient has satisfying range of wrist motion and full ROM of the IP joints of the digits. He retains the extrinsic function of his injured hand, thumb’s opposition is functional and he has protective sensibility. He is completely independent in daily activities and very satisfied with the final result. Conclusions: Complex trauma often demands modification of the usual surgical practice, in order to obtain the best possible result. In this case the usual sequence of tissue reconstructions during replantation was modified according to the circumstances, based on critical thinking and experience.

Han-Vit Kang 1, Jin-Hyung Im 2, Myeong-Kyu Lee 3, Joo-Yup Lee 1

1 Department of Orthpedic Surgery, the Catholic University of Korea, South Korea; 2 Department of Orthpaedic Surgery, Gyeongsang National University Changwon Hospital, South Korea; 3 Korea Public Tissue Bank, South Korea

Objective Peripheral nerve injuries affect a large proportion of the global population, often causing significant morbidity and loss of function. Processed nerve allografts offer a promising alternative to nerve autografts in the surgical management of peripheral nerve injuries where short deficits exist. The aim of this study was to compare the effect of the detergent-processed nerve allografts by a novel protocol utilizing nuclease with another protocol in a rat model. Material and method Two established models of acellular nerve allograft produced by two different detergent-process were compared with each other in a 15-mm rat sciatic nerve defect. Twelve Adult male rats, weighing 225-250 g (Harlan Sprague-Dawley), were utilized as donors for two different detergent-processed nerve allografts. Twenty-four adult male rats were divided into two groups of 12 animals each. In group I, sciatic nerve defects were repaired with 15-mm detergent-processed nerve allografts which were conventionally processed and decellularized using a detergent as described by Hudson et al. In group II, newly developed detergent-processed nerve allografts described by Wilshaw et al utilizing nuclease were used. At 12 weeks postoperatively, we analyzed the muscle mass, evoked muscle force and ankle contracture angle as functional parameters and histomorphometric findings to compare the effect of nerve regeneration. Result No significant difference was observed in muscle mass(Group I ; 58.02±7.01%, Group II ; 57.99±4.85%, p=0.99), evoked muscle force(Group I ; 46.05±19.55%, Group II ; 58.89±16.15, p=0.1) and ankle contracture angle(Group I ; 28.82±4.96°, Group II ; 31.27±5.62°, p=0.29). Also, population of axons that successfully crossed interposed nerve graft was not significantly different. Conclusion A novel method for detergent-processed nerve allografts described by Wilshaw et al utilizing sodium dodecyl sulphate(SDS; Sigma) and nuclease was not inferior to conventional Hudson method and it could substitute existing method.

Woan-Yi Chan, Gabriel FIeraru

Royal Devon and Exeter Hospital, UK

Objective It is important to be aware of a junior doctor’s potential limitations and knowledge regarding hand injuries and relevant anatomy to ensure no injuries are missed. We developed rapid and easy methods to form a general idea about a new junior doctor’s knowledge about hand anatomy, hand trauma and initial management and identify potential pitfalls and learning needs. Methods Over a 9 month period, junior staff performing a rotation at our plastic surgery department were asked to complete a short questionnaire on three commonly presenting plastic surgery trauma scenarios: 1. laceration on the hand; 2. hand fracture; 3. pretibial leg injury. Each case was presented using a printed photo or X-ray followed by questions to elicit descriptions of taking a relevant medical history and performing a clinical examination as well as forming a management plan. Candidates were asked to provide written answers individually without the use of any books or internet resource. No time limit was given. On returning their questionnaires, all candidates were provided with a short individual session to discuss their answers. This was followed by another interactive session to test hand anatomy knowledge and practical skills. The candidates were asked to put on an examination glove from the ward and draw the nerve innervations areas and tendon zones on it. Results 8 people completed the questionnaires. Two 5th-year medical students, two locum doctors and four trainees. None had previous plastic surgery experience. However, the trainees ranged from no previous surgical experience to two years basic surgical training. Although some incomplete answers were given, no questions were answered completely incorrectly. The medical students and two most experienced trainees gave the most extensive answers. However, the latter provided answers with a more relevant clinical approach and gave a more thorough management plan. They were also fastest in returning their questionnaires. The examination glove was found to be readily available and versatile to test and teach hand anatomy and skills. As well as anatomical landmarks, trainees could advance their knowledge on local flaps, incision lines for wound explorations and carpal tunnel release. Moreover, they could keep the glove to remind oneself of the teaching. Informal feedback, in particular from the locum doctors and medical students, was good as it provided an opportunity to refresh and consolidate their knowledge and skills required for working in the department. Conclusion Using a short questionnaire and readily available examination glove can rapidly and inexpensively assess a new junior doctor’s basic knowledge and skills on hand trauma and identify potential learning needs to be addressed during their rotation.

Abbas Peymani 1,2, Samandar Dowlatshahi 1, Austin Chen 1, Sabine Egeler 1, Simon Strackee 2, Samuel Lin 1

1 Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands

Objective. Both plastic surgeons and orthopedic surgeons operate on the hand. However, extensive differences in training exist between the services in terms of exposure, technique, and anatomical expertise. Comparable studies have shown significant differences in complication rates, operating time and length of stay of other specialties. In this study, the National Surgical Quality Improvement Program (NSQIP) was used to compare outcomes after surgical procedures of the hand. Methods. A retrospective analysis of the NSQIP database (2005-2015) was performed to identify all patients undergoing hand surgery. Relevant Current Procedural Terminology codes were used to categorize procedures into three groups: tendinoplasty, fracture repair, and amputation. Patient characteristics, operating time, length of hospital stay, and post-operative complications were examined and compared. Results. A total of 8723 hand procedures were identified, 5277 performed by orthopedic surgeons and 3446 by plastic surgeons. Total hospital length of stay after tendinoplasty and fracture repair was significantly lower for orthopedic surgery. After covariate adjustment, there were no significant differences in operative time, wound complications, unplanned readmissions, and unplanned reoperations. Conclusions. This study shows similar outcomes after tendinoplasty, fracture repair, and amputation when comparing orthopedic and plastic surgery. Future outcome comparison studies should investigate other anatomical regions and procedures for which overlap of services exists.

Abbas Peymani 1,2, Mahyar Foumani 1, Iwan Dobbe 2, Simon Strackee 1, Geert Streekstra 2

1 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands; 2 Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands

Objective. Proximal row carpectomy (PRC) is used in the treatment of various post-traumatic and degenerative disorders of the wrist. Previous studies have aimed to investigate the biomechanics of the wrist after PRC almost exclusively in static cadaveric models, bringing about several disadvantages, including the need to artificially load tendons and the disruption of ligaments. The purpose of our study was to investigate the effects of PRC on wrist joint kinematics in patients. Methods. We measured cartilage thickness, contact surface area, volume of the capitate and shape of the capitate during motion in the operated and unaffected wrists of 11 patients. Mean follow-up was 7.3 years after proximal row carpectomy. Results. Radiocapitate cartilage thickness in the operated wrists did not differ significantly from radiolunate cartilage thickness in the unaffected wrists. The radiolunate surface area was significantly less than the radiocapitate surface area. The volume of the capitate was significantly increased in the operated wrists. The shape of the capitate changed significantly in two of three orthogonal directions. Conclusion. The combination of remodelling of the capitate, increase in its surface area and intact cartilage thickness could help to explain the clinical success of proximal row carpectomy, highlighting the adaptive capacity of the wrist after major anatomical changes.

Thierry Dubert 1,2,3, Cedric Girault 3, Alexandre Kilink 1, Marc Rozenblat 3, Yves Lebelle 3,4, Emmanuel H. Masmejean 5, Christian Couturier 6, Julie Dorey 7, Gregory Katz 8

1 Ramsay Générale de Santé, Clinique Jouvenet, Paris, France; 2 Ramsay Générale de Santé, Hôpital Privé Paul d'Egine, Champigny sur Marne, France; 3 Groupement de Coopération Sanitaire du Réseau Prévention Main Ile de France, Paris, France; 4 Ramsay Générale de Santé, Clinique de l’Yvette, Longjumeau, France; 5 Hôpital européen Georges-Pompidou (HEGP) – APHP, Head of hand, upper limb & peripheral nerve surgery service, Paris, France; 6 Espace Médical Vauban, Paris, France; 7 School of Medicine, Chair of Innovation management & Healthcare Performance, Paris-Descartes University, Paris, France

Objective: There is growing evidence that a good doctor-patient relationship can increase patient’s ability to tolerate pain, facilitate recovery and reduce patient’s anxiety and depression. To date, there is no evidence of such correlation for surgeon- patient relationship. It is our hypothesis that, besides surgical expertise and skills, a positive patient-surgeon relationship may play a significant role in improving clinical outcomes, help return to work (RTW) and reduce time off work (TOW). If this hypothesis is confirmed, improving the quality of patient-surgeon relationships would have a significant economic impact by reducing costs for payers as well as for the patients themselves. This could be of paramount importance for hand and upper extremity surgery considering that hand injuries and musculoskeletal disorders (MSD) form a huge economic burden for both patients and society mostly because of temporary or definitive limitations to return to work (RTW). Methods: A total of 219 patients aged 18 to 55 years on sick-leave because of trauma or MSD of the upper limb were enrolled in a prospective longitudinal observational study conducted in eight Hand trauma centres in France. To measure the Patient’s health condition at enrolment we used 3 validated questionnaires: QuickDASH for disability, HADS for anxiety and depression, and the BICF-CS for hand lesions. To measure patient-surgeon relationship, we used the QPSR which is the only patient-reported questionnaire specifically designed to measure the impact of patient-surgeon relationship on return to work after surgery. The reliability of the QPSR was reported as satisfactory, with an intra-class Pearson’s correlation coefficient of 0.86, and good psychometric properties in patients with hand trauma and MSD. After 6 months, RTW and TOW data were collected. Statistics for all collected variables were computed and correlations between collected data and RTW were studied. Additionally, regression models were developed to identify the drivers of RTW and TOW. Results: Only two drivers of RTW and TOW where identified: Patients who had more severe lesions were 28% less likely to return to work (odds ratio [OR]=0.717, 95%CI=[0.549; 0.937]). More interestingly, patients with a low or middle-low QPSR score had 95% and 71% less chance to return to work, respectively. The quality of the patient-surgeon relationship was strongly correlated with RTW and TOW. Overall, 74% of patients who returned to work had a high or middle-high QPSR score, whereas 64% of patients who did not return to work had a low or middle-low QPSR score. All items of QPSR questionnaire were significantly correlated with RTW (all p-values <0.05). Conclusions: According to the present study, the quality of patient-surgeon relationship, as measured by the QPSR score, is strongly correlated with RTW and TOW. We believe that improving patient-surgeon relationship may play a significant role in improving clinical outcomes, help return to work (RTW) and reduce time off work (TOW) following hand trauma and MSD.

Mihaela Perţea 1,2, R. Issa 2, Oxana-Mădălina Grosu 2

1 University of Medicine and Pharmacy “Gr. T. Popa” Iași, Romania; 2 Clinic of Plastic and Reconstructive Microsurgery, “Sf. Spiridon” Emergency Hospital Iași, Romania

Objectives: Prof. Lalonde revolutionizes hand surgery by introducing local anesthesia without sedation and without tourniquet. Good results, safety technique and patient’s full satisfaction made us ask ourselves “what are the limits of this technique?” and try to reduce the amount of anesthetic recommended by the author on a number of hand surgical interventions. Material and method: Our personal experience is based on 96 patients, aged between 20 and 77 years, 38 women and 52 men with various pathologies of hand and fingers. The study included 36 patients (23 men and 13 women) with Dupuytren disease in different evolution stages, 27 patients (14 men and 13 women) with carpal tunnel syndrome, 17 patients (8 men and 9 women) with trigger finger and 10 patients (7 men and 3 women) with acute pathologies like zone 2 flexor tendonsand digital neurovascular bundles injuries.In all the cases we used local anesthesia with lidocaine 1% and epinephrine (1:100.000 concentration). In 60% of the cases we used the recommended doses in the literature and, in the other 40%, of the cases, we decreased the doses between 5% and 40%. The most important decrease was noticed in 20 out of the 27 cases of carpal tunnel syndrome. We always respected the injection points recommended in the literature. Results There were no operatively incidents or accidents, nor skin necrosis or other complications related to the effects of adrenaline. Patient’s satisfaction was highest in all the cases and the economies were large due to short-term (several hour) hospitalization. Only 10 cases required 24 hours hospitalization caused by associated diseases in some older patients. Conclusions Wallant technique is safe, easy, less expensive, assuring the necessary comfort for both the patient, as for the surgeon allowing a dissection in similar conditions of visibility as an exsanguinated surgical field obtained using a tourniquet. The possibility of decreasing the dose of used anesthetic will bring an additional advantage to this surgical technique. Key words: local anesthesia, hand, surgery

João Paulo Mussi, Christophe Camps, Alexandre Durand, Christophe Duysens, Rainer Andrea Falcone, Thomas Jager

Institut Européen de la Main, France

Objectives: The treatment of the pan-arthritic wrists in the young patients due to traumatic injuries is challenging even for experienced surgeons, especially when both lunate fossa and capitate head are committed with considerable arthritis being the most acceptable option is the total wrist fusion. We present a case report of an alternative technique of proximal row carpectomy associated with a bifocal osteochondral graft to treat a SNAC wrist type IV in a young patient. Methods: We performed in a 23 years-old male patient a proximal row carpectomy associated with a bifocal osteochondral graft from the lateral femoral condyle to resurface an important arthritic degeneration of both capitate head and lunate fossa due to a sequel of an open trans-styloid trans-scaphoid perilunate fracture-dissociation. Pre-operatively, he had 20kg of grip strength (50% compared with the contralateral side), 65 degrees of flexion-extension motion (35/30) and pain of intensity of 10/10 in the visual analogic scale. Results: At the 18-month follow-up, the patient is pain-free with the 60 degrees of flexion-extension motion (30/30), 22kg of grip strength (61% when compared with the contralateral side), completely integrated graft and no signs of degeneration of the resurfaced area at this follow-up period Conclusion: We conclude that, despite being only one case, the resurface of the capitate head and lunate fossa by osteochondral graft can be an alternative for young patients with advanced arthritis preserving some motion of the wrist.

Francisco Simões Deienno, Trajano Sardenberg, Raffaello de Freitas Miranda, Denis Varanda, Andréa Christina Cortopassi, Paulo Roberto de Almeida Silvares

Hospital das Clínica de Botucatu, São Paulo Estate University, UNESP, Brazil

Objective: Evaluate, through a systematic literature review, whether there is or not a need to suspend anticoagulants (warfarin, aspirin and clopidogrel) to perform elective procedures of wrist and hand surgeries. Methods: The search for articles was performed by using a combination of keywords in the databases available without scientific design restraints. A series of articles with five or more surgeries performed without suspending antithrombotic medication was selected and examined in terms of severity of the complications, serious (need for surgical treatment) and minor complications (no need for surgical treatment). Results: Six articles were identified and examined; 360 wrist and hand surgeries were performed in patients receiving warfarin or aspirin and clopidogrel, two serious (0.5%) and 24 minor complications (6.6%) were reported; 1973 surgeries were performed in patients who did not use antithrombotics, showing no serious complications and 13 minor complications (0.6%). Conclusions: The studies in this review allow us to suggest that there is no need for antithrombotic discontinuation in patients undergoing wrist and hand surgeries. However, further randomized studies are needed to properly elucidate this question

S. Rodríguez Paz 1, A. Oriol Segura 1, A. Rañé Tarragó 1, R. Galtés Fuertes 2, N.H. Sarma 3, P. Kumar 3, FJ. Peris Prat 1, G. Dargallo Carbonell 1

1 Parc Hospitalari Martí i Julià of Salt - St. Catherine Hospital, Girona, Spain; 2 Faculty of Health Sciencies at University of Vic-Central University of Catalonia, Manresa, Spain; 3 Rdt Hospital Bathalapalli, Anantapur, India

OBJECTIVE The surgical treatment for long-term sequelae after snake bite is not described at the scientific literature. We expose a surgical treatment based on fasciectomy, the macroscopic and microscopic features and the results of 2 cases of wrist fixed dorsiflexion contracture after indian cobra bites. METHODS A collaboration with the Bathalapalli Hospital in India through an international foundation is being developed for the last 8 years and the two patients were reported during this collaboration. Both were victims of a local cobra bite named Naja Naja at the dorsal area of the left wrist. The first patient is a 43-year-old woman with a 8-year history of 70 degrees dorsiflexion contracture. Opposition of the thumb was impossible. The second one is a 23-year-old woman with a 6-year history of 64 degrees dorsiflexion contracture and opposition of the thumb with only the index finger was possible. They didn’t developed systemic chronic affection but joint stiffness, muscle wasting and reduced muscle power were reported. Paresthesias or local pain were not documented. RESULTS Women underwent elective surgery with a dorsal wrist incision. A retraction of the soft tissue under skin was found, with fibrotic bundles but without infiltration of the rest of structures (extensor tendons were absolutely respected). The fibrotic tissue was excised and a dorsal capsulotomy was arranged. The histopathology reported bundles of fibro-collagenous tissue with degenerated and hyalinized areas, fibroblasts and occasional lymphocytes were seen between the collagen bundles. Women achieved a 70 and 64 degrees improvement in the range of motion respectively after the surgery and the rehabilitation programme. This allowed the thumb to touch the tips of the fingers in both patients and to grasp objects in the second pacient. CONCLUSIONS The treatment of the chronic musculoskeletal disability following a snakebite is not well known, whereas it’s widely described the acute treatment. Our work could be the first mention in the scientific literature. The snakebite in upper limbs causes a systemic and local response to the toxin and it developes a fibrotic contracture of the soft tissues near the bite area. This long-term sequelae can be treated with a fasciectomy of the fibrotic tissue and a dorsal capsulotomy with good results. Despite the limited number of cases, we believe thay his surgery provides an opportunity for disabled patients with this kind of affectation.

James D Bedford 1, Joseph J Dias 2, Vivien C Lees 3,4

1 Manchester University Foundation Trust, UK; 2 University of Leicester, UK; 3 Manchester Hand Institute, UK; 4 University of Manchester, UK

Objective The ultimate priority of all nations' healthcare systems is to prevent and treat the illnesses of their populations. Changes to health service provisions in high income countries aim to improve cost efficiency, productivity, and patient safety. In contrast in India, a low income country, a key governmental priority is to deliver universal, equitable healthcare, where the prevailing trend had been of worsening health inequalities. Hands for Life, a UK charity of hand surgeons, has visited a rural commune in central India for the last seventeen years, providing surgical care for patients with hand disabilities due to leprosy, burns, and congenital hand differences. We wanted to compare the economics of providing this surgical camp with the costs of performing the same work in our own system (the UK National Health Service). We also sought to reflect critically on the team working aspects of providing hand surgery in an austere environment, and consider what lessons can be brought back to practices in high-income countries in order to improve efficiency, clinical effectiveness, resource use and patient safety. Methods The activity undertaken at a week-long hand surgery camp in India in November 2015 was analysed. The surgical log was coded according to ICD-10 diagnosis and OPCS procedural codes. These are translated into HRG codes which determine remuneration within the English NHS. The economic “value” of the surgical work performed in India was appraised. Basic data was collected on the clinical outcomes of adult hand surgery patients by a local hand therapist trained by our visiting surgeons. The non-technical aspects of providing surgical care at the camp were qualitatively analysed. Results Forty-nine procedures were performed over four consecutive days by four hand surgeons, following a multidisciplinary pre-operative clinic. Procedures were split between those for leprosy (17), burn contracture (18), congenital hand difference (5) and other diagnoses (9). The overall cost of delivering the camp (including travel for the surgical team, theatre consumables, and infrastructure costs) was EUR 7350. If the camp workload had been delivered in the NHS, the income from the work would have been EUR 132 500. The non-technical aspects identified included: * Constant/ fixed team composition, eliminating errors due to handover and increasing role clarity and effectiveness of communication * Availability of senior surgeons for expert decision-making, surgical assistance, training and mentorship * Streamlining of administrative tasks to eliminate redundant and unnecessary steps, while preserving a “core” bundle of essential documentation, including consent, surgical notes, photography, and WHO safe surgery checklists * Clear briefings attended by all members of the surgical team, with emphasis on candour / contribution by the whole team to identify safety or logistical issues. Discussion Reflecting critically on the difference between high- and lower-income health systems allows lessons to be learned for practice in wealthier systems, which may have additional benefits in terms of increasing productivity and thus economic efficiency. Delivering such camps gives opportunity for teaching local professionals, appears to benefit the local community and also appears to be very good value for money.

Aurelio Portincasa, Liberato Roberto Cecchino, Luigi Annacontini, Fedele Lembo, Domenico Parisi

Plastic surgery Department, University of Foggia, Italy

Objective: Soft tissue deficiencies represent a challenge for the Reconstructive Surgeon if associated with exposed tendon and absent paratenon in order to select the proper procedure due to possible tendon adhesions, poor range of motion (ROM), poor cosmesis and donor site morbidity. The Integra Bilayer Dermal Regeneration Template (Integra Lifesciences, Plainsboro, NJ, USA) is a dermal inductor used in reconstructive surgery, including the incidental coverage of tendons. Integra dressing’s post-operative functionality of the tendons, anyway, has not been well documented yet. We present our results on the Integra use for soft tissue reconstruction overlying tendons with loss of paratenon in the upper extremity soft tissue defects. Methods: We reconstructed 52 patients (45 men and 7 women) with exposed tendons due to trauma (n = 47), cancer excision(n = 2) or chronic wounds (n = 3) using the Integra dressing. Results obtained in a prospective manner including age, gender, wound location, wound size, time to final closure, operative time, follow-up length, split-thickness skin graft percentage taking and active post-operative ROM. Medline engine was used for a literature research of current surgical techniques for the treatment of exposed tendons and the results compared with our results. Results: All 52 patients healed with an average split-thickness skin graft take rate of 92.5% (SD 6.1; range 80 - 100%). 10 patients dropped out of follow-up. 42 patients at the follow-up achieved an average ROM of 91.2% (SD 6.5; range, 80 - 100%). Conclusions: The Integra dermal regeneration template offers an ideal, efficient operative technique with minimal morbidity, assuring good morpho-functional results. Thus, the Integra dressing may offer an alternative, valid option for immediate tendon coverage in the upper extremities reconstruction.

Petros Mikalef, Manish Gupta, Rajive Jose, Mark Herron, Dominic Power

Birmingham Hand Centre, UK

Objectives: Cognitive simulation provides a readily accessible and low cost alternative to traditional methods of procedural skill acquisition that can supplement traditional experiential learning. The technique involves knowledge assessment, visualisation, sensory perception, and kinaesthetics supporting the development of psychomotor and decision making skills. OrthOracle is an on line training resource that provides a structured learning platform for complex surgical procedures. The aim of this study is to explore the use of OrthOracle as a model for wider development of cognitive simulation training in hand surgery. Methods: A complex surgical task was deconstructed to key component steps and a value assigned to each representing its importance. Consensus on the grading scale was reached by a committee of hand surgeons. Trainees in hand, orthopaedic and plastic surgery were recruited to undergo cognitive simulation training and assessment using standardised techniques. Baseline information regarding previous training and operative experience was recorded prior to simulation and trainees were asked to score themselves in key areas based on their experience. 50% were provided with free access to the OrthOracle training platform as prelude to assessment. All cognitive simulation assessments were undertaken by consultant hand surgeons and scores assigned using the approved grading scale. Results: Trainees performed better in the cognitive simulation tasks when they had higher levels of experiential learning. Trainees with OrthOracle priming performed better than their counterparts. Conclusion: Service pressures, shortened training hours and greater numbers of trainees have limited the effectiveness of the traditional cognitive apprenticeship model of surgical training where a trainer would scaffold the trainee allowing progressive autonomy and skill acquisition in a controlled and supervised environment. Alternative training methods include cadaveric training, computer simulations and virtual reality but are limited by cost and availability. Cognitive simulation is a cheap and effective alternative training tool. The high quality images and supplementary procedural training material on the OrthOracle platform can be developed for the purpose of cognitive simulation in hand and orthopaedic surgery.

Lorenza Caggiati, Henk P Giele

University of Oxford, UK

Background: Psycholgists and body language specialists explain that hand holding is determined by dominance in a relationship. However, we seek to determine the scientific basis of hand holding. Purpose: This study is aimed to study the scientific basis of holding hands. To determine if placing the hand in front is a mere consequence of physiological adjustment or relates to psychological dominance. Material and methods: Couple observations were performed in three cities (Oxford, Venice and Rome) as well as in magazines and web-sites. A total of 300 couples were analyzed by considering body height, sex and age. Couples with at least one subject obese or afflicted with evident neurologic or musculoskeletal disease were excluded. The study cohort included also couples of two adults, two children or one adult and one child. These preliminary findings were then correlated to those obtained in 30 couples of voluntaries by observing their holding hands in normal conditions and after putting the shorter one on a step (16-18 cm). Results: In 92% of cases, the taller person puts the hands in front. This was particularly evident when the difference in height was greater than 10 cm. In 26/30 couples, to move the shorter person on the step provoked the inversion of the hanging behaviour. Conclusion: our findings disagree with the common opinion that the position of the hands during hanging depends upon psychic dominance. Our findings suggest that in most cases the taller puts the hand in front of that of the shorter because he extends the arm and naturally he is taken to pronate it. In turn, the shorter has to flex the arm to reach the hand of the taller partner and he physiologically pronates it.

Sze-Ryn Chung, Robert Yap Tze-Jin, Andrew Yam Kean Tuck

Department of Hand Surgery, Singapore General Hospital

Camitz abductorplasty is the most commonly used tendon transfer in patients with severe carpal tunnel syndrome with significant muscle wasting and loss of opposition. This procedure requires a long incision in the palm to harvest a strip of palmar aponeurosis to lengthen the palmaris longus tendon, allowing it to reach the abductor pollicis brevis insertion. Several complications have been attributed to this extensive dissection in the palm. We describe a minimally invasive palmaris longus abductorplasty using a strip of flexor carpi radialis tendon graft to achieve the necessary length. This can be done together with endoscopic carpal tunnel release in patients with severe carpal tunnel syndrome. In our experience, this operation achieves the same results as the Camitz transfer with less scarring and less risk of complications.

Karim Latrach Tlemsani, Sabeur Saadi, Khezami Mounira, Rafrafi Abderrazak, Lotfi Nouisri

The Main Training Military Hospital Tunis, Tunisia

Objective Ulnar neuropathy at elbow is the second most common peripheral nerve compression syndrome after the median nerve at the wrist. The surgical management of this affection proposes several procedures. The purpose of this study is to assess the long-term results of a series of 39 patients suffering of cubital tunnel syndrome exclusively treated with anterior subcutaneous transposition in order to provide predictive elements of outcome. Methods In a retrospective study, 39 patients with the diagnosis of cubital tunnel syndrome were submitted to anterior subcutaneous transposition, from January 1998 to December 2007. Preoperative clinical severity and postoperative assessment and satisfaction were appreciated using the British Medical Research Council scale after a mean follow-up duration of 18 months. All patients performed anterior subcutaneous transposition. Results According the British Medical Research Council scale, the patients were distributed into 3 groups: 18 patients had a beginning form with a mean scale of S2M4, 12 a medium form with a scale of S2M3 and 9 severe form with a mean scale of S2M2. Postoperative results were reported using Bishop rating system. Outcome was good in 18 patients (S4M5), fair in 15 (S3M4) and poor in 6 (S2M2). Neither surgical complications nor recurrences were recorded. The main finding was the significant correlation between preoperative neurological status and the postoperative outcome. Conclusion The nerve decompression, in the context of cubital tunnel syndrome, with anterior subcutaneous transposition have proven it efficiency in term of surgical safety and functional outcome even in advanced stage of the disease. A randomized prospective study, including several surgical techniques, could confirm our findings.

Ronit Wollstein, Duffield Ashmead, Lois Carlson,Haruko Okada, Jonathan Macknin, Steven Vantler Naalt

1 New York University, NY, USA: 2 The Hand Center, CT, USA

Purpose: Trigger finger (TF) and carpal tunnel syndrome (CTS) are common hand conditions that often occur together with an unclear relationship. While some studies conclude that trigger fingers occur as a result of carpal tunnel release (CTR), others found that they present concurrently. We believe that the reason trigger fingers tend to develop following CTR is due to an underlying tendency that is exacerbated by post-operative edema. It is possible that when a carpal tunnel release is done, the bursae within the carpal tunnel become edematous. This edema may extend distally and cause friction at the Al pulleys. The purpose of this study was to evaluate the prevalence and timing of trigger finger development after open CTR. Methods: Retrospective review of 497 patients who underwent open CTR by a single surgeon. Two hundred and twenty-nine charts were included in the study for analysis. Patients were further assessed for age, gender, handedness, BMI, workers compensation status and history of diabetes or hypothyroidism. We also analyzed the specific digit involved and the timing to the development of triggering after CTR. Results: Thirty-one patients developed triggering after carpal tunnel release (13.5%). Mean population age was 52.5 (14.0). Follow up ranged from 1-53 months with a median follow up of 6 months (IQR = 2,13). The thumb was the most common digit to trigger (42.22%). followed by the ring finger 24.44% (11 cases), middle finger 22.22% (10 cases), 8.89% little finger (4cases), and index finger 2.22% (1 case). Trigger thumb occurred at a median of 3.5 months (3,6 months) post-operative while other digits occurred at a median of 7.5 months (4,10.25) after surgery (p=0.022). No clear risk factors to trigger finger development after CTR were identified. Conclusions: 1) In tandem with recent literature, our results suggest that a trigger thumb develops more frequently and earlier than other trigger digits after an open carpal tunnel release. 2) Further study can reveal the mechanism of combined occurrence and may enable specific treatment such as local anti-inflammatory medication following carpal tunnel surgery. 3) We suggest educating prospective carpal tunnel surgery patients that the risk of trigger thumb and trigger digits following CTR is high.

Samuel George 1,2, Zahid Hassan 1,2

1 Whiston Hospital, Liverpool, UK; 2 Alder Hey Children's Hospital, Liverpool, UK

Introduction: Various anomalies of the palmaris longus have been described throughout history dating back to the 16th century. A well-known variation is agenesis which is prevalent in 12.8% of people. The muscle can also be digastric, duplicated, bifid or reversed. Symptomatic presentation of these variations are extremely rare and ee present a case of median nerve compression caused by a bifid reversed palmaris longus in a 9 year old girl which is the youngest reported case in the literature. Case Report: A 9-year old girl and active gymnast presented to us with an eight-month history of worsening left wrist pain and swelling with paraesthesia in the median nerve distribution, exacerbated by physical activity. She was a keen gymnast but there was no history of trauma to the affected limb. Clinically she had a bluish swelling on the distal volar wrist with very little active or passive wrist movement. After failure of conservative treatment, she was investigated with an ultrasound scan and Magnetic Resonance Imaging(MRI). The ultrasound scan and the MRI revealed an epifascial/reversed palmaris longus which was originating from the FDS perimysium and inserting in the flexor retinaculum and palmar aponeurosis. We present high resolution radiographic images and comparison with the contralateral limb demonstrating this. Surgical exploration revealed a bifid reversed palmaris longus as described causing displacement of the median nerve. The entire muscle was excised and the median nerve and carpal tunnel were released. At 3-month follow-up the patient had full resolution of symptoms, and now had full range of movement. She has gone back to full physical activity and gymnastics. Conclusions: Surgeons need to be aware of the possible variations of the palmaris longus muscle both when operating on a limb as well as when assessing patients in clinic as they’re appearances can mimic vascular malformations while the symptoms can be mistaken for chronic compartment syndrome. A good history identifying exacerbating factors and appropriate investigations as well as awareness of anomalies can ensure these patients are treated quickly and effectively.

Takakazu Hirayama, Masaaki Shindo

Department of Orthopedic Surgery, Shindo Hospital, Asahikawa City, Hokkaido, Japan

Objective: To report a new technique using the roof of the cubital tunnel as a ligamentofascial sling to maintain anterior position during ulnar nerve transposition. Methods: Operative Technique: The roof of the cubital tunnel is formed by a ligamentofascial band composed of the cubital tunnel retinaculum and antebrachial fascia that extends from the olecranon to the medial epicondyle. This technique creates a non-compressive ligamentofascial sling using the released band. An 8- to 10-cm curved, longitudinal incision is centred over the cubital tunnel. The medial antecubital cutaneous nerve is identified and preserved. The ulnar nerve and its vascular bundle are identified just proximal to the ligamentofascial band and dissected distally from the posterior aspect of the band. The band is incised medially to raise a 3-cm wide and 3-cm long flap based on the medial epicondyle, and tailored to wrap around the ulnar nerve and its vascular bundle. The origin of the flexor-pronator muscles is identified, and a 3-cm incision is made to the fascia overlying the muscles along this line. After the ulnar nerve and its vascular bundle are transposed anteriorly to the medial epicondyle, the band is loosely attached to the incised fascia overlying the flexor-pronator muscles to function as a sling. A bulky elbow dressing is maintained postoperatively and patients are encouraged to resume elbow motion immediately. Patients: Twenty-three elbows in 21 patients were assessed for primary chronic cubital tunnel syndrome without restriction of excursion or fixed deformity. Of the 23 elbows, 12 had no specific aetiology (idiopathic) and 11 showed ulnar nerve (sub)luxation. According to McGowan’s classification of severity, 6 elbows were grade I (minimal), 12 were grade II (intermediate), and 5 were grade III (severe). Results: Seventeen elbows were available for direct follow-up and 6 were contacted for a telephonic survey. The mean follow-up period was 3 years (range, 4 months to 9 years). According to the Messina grading system, 91% of the elbows had excellent or good results and only 9% had fair results. Pain was completely relieved in all 23 elbows, with improved sensation and motion. Patients with excellent or good results recovered sensitivity and muscular activity within several months. However, severely affected elbows showed little improvement. None of the cases required secondary surgery or had postoperative posterior nerve subluxation, and no injury to the medial antebrachial cutaneous nerve was observed. Conclusions: Posterior subluxation after anterior transposition is an uncommon but serious complication. Our new technique addresses this complication at the time of surgery. The ligamentofascial sling provides a wide, non-compressive flap, without tenting or kinking of the nerve. This prevents nerve instability, without restraining excursion during elbow motion. This procedure is indicated for primary chronic cubital tunnel syndrome, but is contraindicated in patients with an insufficient ligamentofascial band or an elbow with a severe fixed deformity.

Amaris Lim, Dawn Chia

Hand and Microsurgery Section, Department of Orthopaedics, Tan Tock Seng Hospital, Singapore

Objective: Distal radius fractures may distort carpal tunnel anatomy, and are a relative contraindication to endoscopic carpal tunnel release (eCTR). This study aims to evaluate the anatomical considerations of eCTR in patients with previous distal radius fractures, and compare the use of open release (OCTR) and eCTR in these patients. Methodology: This is a retrospective study conducted in a tertiary hospital in Singapore between May 2008 and February 2016. This study included all patients aged above 16, with a history of distal radius fractures, who underwent CTR. Parameters studied included patient biodata, risk factors for CTS, AO classification and treatment of the fractures, as well as CTR treatment outcome. Statistical analysis was conducted using the chi-squared test. Results: Among 5292 patients who had a history distal radius fractures, 40 had carpal tunnel syndrome requiring surgical release. Of these, 67.5% underwent OCTR, and 32.5% underwent eCTR. The eCTR patients most commonly had AO Type A fractures (66.7%), while the OCTR patients most commonly had Type C fractures (46.2%). 53.3% of the eCTR patients had their fractures treated conservatively, while 80.0% of the OCTR patients had undergone open reduction and internal fixation (ORIF). Within the eCTR cohort, radiological parameters post-fracture-healing were as follows: average volar tilt -2.6°, average radial height 8.49mm, average radial inclination 17.2°, and average ulnar variance -0.28°. The post-operative results of both the eCTR and OCTR patients were comparable. All patients experienced improvement in CTS symptoms at final follow-up. Conclusion: We recommend that eCTR can be used in the treatment of patients with previous distal radius fractures who now present with CTS.

Chul-Hyung Lee, Cheol-U Kim, Deuk-Hee Jung

Daejeon Sun Hospital, Daejeon, South Korea

Introduction Carpal tunnel syndrome is the most common nerve compression disorder in the upper extremities. Several variations of the thenar branch have been reported. Therefore, careful attention should be paid to the damage of the thenar branch when performing carpal tunnel release. There are few reports about iatrogenic thenar branch injury. We report a patient suffering from thenar branch injury after carpal tunnel release. The patient underwent delayed thenar branch repair at 138 days after carpal tunnel release, and the nerve function was restored. Case description A 49-year-old female patient with tingling of both hand in January 2016 underwent an electromyography with a positive Tinel and Phalen sign on physical examination. Electromyography showed bilateral carpal tunnel syndrome. Bilateral carpal tunnel release was performed with longitudinal incision. Symptoms improved but, the patient complained of discomfort in the left thumb at the 12 week follow-up. At the 16 week follow-up, the left thenar compartment showed weakness, and atrophy was observed. In electromyography abductor pollicis brevis innervated by thenar branch showed no motor conduction. On the 138th day after carpal tunnel release, median nerve exploration was performed. Adhesion of surgical site was not severe, and release was sufficient. The proximal part of the disconnected thenar branch was attached to the released transverse carpal ligament. The thenar branch was carefully detached from the transverse carpal ligament. The distal part of the disconnected thenar branch was searched in the thenar compartment and the adipose tissue between the muscle was observed and the adipose tissue was carefully removed to find the nerve tissue that entered the thenar compartment. The pathway of disconnected thenar branch was transligamentous variation. Both sides of the disconnected thenar branch had a contracture, so that direct repair was performed with tension slightly. At 6 months post-operative follow-up, the patient said that the power of the thumb was better and the electromyography showed motor conduction. At last follow-up, the patient had no atrophy and the electromyography was restored similar to that before carpal tunnel release. Discussion Several variations of the thenar branch have been reported. Our case is transligamentous variation. Especially in the case of this type of variation, care must be taken when releasing the carpal tunnel. If the branch is damaged, I think it’s better to repair it. There are some reports that delayed nerve repair has poor results. In our case, delayed repair was performed at 4 months after nerve injury, but motor function was restored. Even if the timing is delayed, I think it would be better to try repair. There was concern about slight tension on the repaired thenar branch, which might adversely affect the recovery, but the patient recovered normal function. If direct repair is not possible or if tension is predicted to be too strong during direct repair due to contracture, nerve graft may be considered. After nerve repair, the patient showed improvement after 6 months. In this case, it is good to observe the recovery of nerve function through electromyography every 3 months after surgery.

Shin Woo Choi 1, Jae Kwang Kim 1, Young Ho Shin 1, Joo-Yul Bae 2

1 Asan Medical Center,University of Ulsan College of Medicine, Seoul, South Korea; 2 Gangneung Asan Hospital,University of Ulsan College of Medicine, Gangneung-si, South Korea

Purpose: The purpose of this study was to investigate whether psychological status is associated with the symptom severity or functional disability of carpal tunnel syndrome (CTS) patients. Patients and Methods: Sixty patients diagnosed with CTS and treated with carpal tunnel release (CTR) were asked to complete a self-administered questionnaire consisting of three validated measures obtained before and 3 months after surgery. The Boston Carpal Tunnel Questionnaire (BCTQ) was administered to assess symptoms (BCTQ-S) and functional disabilities (BCTQ-F), and the Center for Epidemiologic Studies Depression Scale (CES-D) and Pain Anxiety Symptoms Scale (PASS) were administered to assess depression and pain anxiety. The preoperative scores obtained on the questionnaires and those obtained 3 months after CTR were compared. Bivariate and multivariable regression analyses were performed to determine whether the variance of CES-D and PASS scores are associated with the variance of symptom severity or functional disability of CTS patients. Results: The CES-D and PASS scores significantly improved after surgery. In a multivariable linear regression model, the CES-D and PASS scores were significantly associated with the BCTQ-S scores both before and 3 months after surgery. In addition, the changes in CES-D and PASS scores were significantly associated with the change in BCTQ-S scores. Conclusion: The depression level and pain anxiety of CTS patients were significantly improved at 3 months after CTR. The depression level and pain anxiety were significantly associated with the CTS symptoms both in preoperative and postoperative period. In addition, the improvement of depression and pain anxiety were associated with the improvement of CTS symptoms. Thus, our findings indicate that the depression and pain anxiety of CTS patients are associated with the symptom severity of CTS.

Takao Omura 1, Tomokazu Sawada 2, Michihito Miyagi 1, Yukihiro Matsuyama 1

1 Hamamatsu University School of Medicine; 2 Shizuoka City Shizuoka Hospital

Objective Cubital tunnel syndrome (CuTS) is symptomatic ulnar nerve dysfunction at the level of the elbow resulting from a combination of compression, traction, and friction. In Japan, the most common cause for CuTS is osteoarthritis (OA) with the prevalence rate of 64%, followed by Constriction of arcuate ligament of Osborne (9%). Due to this etiology, the prevalence of patients with female CuTS is much lower in comparison with female CTS patients. The purpose of this study is to identify the prevalence and the characteristics of female CuTS patients. Methods 99 patients who presented sensory disturbance of the little finger plus ulnar half of the ring finger and operated under the diagnosis of CuTS at Hamamatsu University School of Medicine were included in this study. All the patients were examined with a plain radiographic for the prevalence of OA of the elbow and all the subjects except one, who had a pace maker of the heart received motor conduction velocity (MCV) recordings. The prevalence of female patients, the cause, the initial severity of CuTS and MCV were analyzed in comparison with the male patients. Results There were 20 female and 79 males, and the prevalence of female patients was 20.2%. The average age was significantly higher in the female patients (64.8 ± 2.5) in comparison with the male patients (59.2 ± 1.5). The most common cause was OA in 11 females (prevalence rate 55%) and in 64 males (81%), followed by trauma of the elbow in 6 females (30%) and 7 males (12.7%) which was significantly different between the two groups. Interestingly, the average age of patients with OA was significantly higher in female patients in comparison with the male patients (70.4±3.03 vs 62.2±.52).According to McGowan’s classification, there was no significant difference in the severity of CuTS. Two females (10%) and 6 males (7.6%) were classified as grade I, 11 females (55%) and 75 males (41%) were classified as grade II and 7 females (35%) and 32 males (41%) were classified as grade III. There was also no significant difference in the preoperative MCV measured between the elbow which was 27.9±3.4m/s in females and 32.1±1.6m/s in males. Conclusions According to Adkinson et al, the prevalence of female patients operated for CuTS was 52% in Florida State, which could be reflecting the cultural or racial difference between the United States and Japan. Our results showed that the prevalence of female CuTS patients are much lower in Japan and that they are significantly older, with lower incidence of OA in comparison with male patients.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

BACKGROUND: Open carpal tunnel release (OCTR) and cubital tunnel release (OCTR) is a common procedure in nerve decompression surgery. This study aimed to compare the efficacy and patient satisfaction of wide-awake local anesthesia, no tourniquet (WALANT) technique versus traditional anesthesia method with the arm tourniquet in OCTR and OCTR MATERIAL AND METHOD: 46 patients (62 hands) underwent OCTR, and 38 patients (42 elbows) underwent OCuTR. Patients were divided into two groups (OCTR, OCuTR) and then each group was subdivided according to their anesthesia method and arm tourniquet use. 1. OCTR (n=46patients, 62hand): 20 hands were in wide-awake group (WA), who received epinephrine-contained lidocaine as a local anesthetic agent, without tourniquet, 22 hands were in the local anesthesia group (LA) who received lidocaine alone as a local anesthetic agent with a 250-mmHg tourniquet application and 20 hands were in the general anesthesia group (GA) and a 250-mmHg tourniquet application. 2. OCuTR(n=38patients,42elbows): 20 elbows were in the wide-awake group(WA), who received epinephrine-contained lidocaine as a local anesthetic agent, without tourniquet and 22 elbows were in the general anesthesia group(GA) and a 250-mmHg tourniquet application. Perioperative discomfort was assessed using a visual analog scale (V.A.S). The Michigan Hand Outcomes Questionnaire was used at OCTR to determine hand-specific disability. The subjective outcome was assessed with the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire at OCuTR. Adverse events during surgery were also recorded. Results: There were no perceived outcome differences at six weeks as evidenced by the Michigan Hand Outcomes Questionnaire between any of OCTR individual groups (p > 0.05). The perioperative pain(preoperative surgical site injection, Intraoperative, postoperation) during the first 1week after surgery were higher in OCTR(LA), (GA) group than OCTR (WA) group(p < 0.05). There were no perceived outcome differences at final follow up as evidenced by the quick DASH score between any of OCuTR individual groups (p > 0.05). The perioperative pain(preoperative surgical site injection, Intraoperative, postoperation) during the first 1week after surgery were higher in OCuTR (GA) group than OCuTR (WA) group(p < 0.05). Conclusions: a Wide-awake approach for open Carpal and Cubital tunnel release surgery offers better comfort for patients and reliable technique that eliminates the need for general anesthesia, removes the need for a tourniquet.

Ilka Anker 1, Gert S. Andersson 2, Malin Zimmerman 1, Helen Jacobsson 3, Lars B. Dahlin 1,4

1 Department of Translational Medicine – Hand Surgery, Lund University, Malmö, Sweden; 2 Department of Neurophysiology, Lund University, Skåne University Hospital, Lund; 3 R&D Centre Skåne, Skåne University Hospital, Lund; 4 Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden

Objective: Ulnar nerve entrapment at the elbow is common, but the knowledge about the outcome of revision surgery for recurrent or persistent entrapment is scarce. The outcome of subcutaneous (SCT) and submuscular (SMT) ulnar nerve transpositions, both primary and revision surgeries, due to ulnar nerve entrapment at the elbow was studied with the aim to identify predictors of revision surgery. Methods: All cases with an ulnar nerve entrapment at the elbow that were surgically treated at our department between 2004 and 2008 were retrospectively studied. Out of the 285 primary surgeries, 43 ulnar nerve transpositions (15 SCT and 28 SMT) and out of 52 revision surgeries, 44 ulnar nerve transpositions (7 SCT and 37 SMT), were identified. Medical records, including electrophysiological evaluations performed by a neurophysiologist, were reviewed and the postoperative outcome was graded as: 1) cured/improved and 2) unchanged/worsened symptoms, based on a simple patient-reported and surgeon-evaluated outcome, which correlates to patient-rated outcome measures, such as QuickDASH, at one year post-surgery. Results: Revision surgery cases had a high frequency of concomitant systemic diseases (p<0.001), musculoskeletal conditions (p=0.029) and carpal tunnel syndrome (p=0.048) compared to the primary surgery cases. Both primary (79%) and revision SMT (76%) cases had a high frequency of ulnar nerve subluxation. Primary SMT cases had a higher frequency of an ulnar nerve disorder observed through electrophysiological examination (p=0.045), while revision SMT cases had normal electrophysiological findings or a reduced ulnar nerve conduction velocity (not significant; p=0.10). The general satisfactory rate was 79-93% of the cases undergoing primary transposition surgery and the corresponding values after revision transposition surgery were 73-86%. Conclusions: Patients who have comorbidity with other systemic diseases, other musculoskeletal conditions or a concomitant carpal tunnel syndrome have a higher risk to be affected by ulnar nerve entrapment relapse needing revision surgery. Assessment should be made by the treating surgeon whether the ulnar nerve shows a tendency to perioperative subluxation at the primary surgery for ulnar nerve entrapment at the elbow. If such a subluxation is present, transposition of the ulnar nerve in the same surgical séance is suggested to minimize the need of revision surgery.

Sang Ho Kwak, Jung Yun Bae, Sang Woo Kang, Seung Jun Lee, Kuen Tak Suh

Pusan National University Yangsan Hospital, Korea

Objective Simple decompression, which is a treatment option for idiopathic cubital tunnel syndrome (ICTS), is an effective and safe procedure; however, nerve traction and instability are potential problems. Although several technical modifications have been developed for anterior transposition and medial epicondylectomy, few have been reported for simple decompression except for Osborne’s modification (the repair of Osborne’s ligament beneath the ulnar nerve after decompression). In this study, we compared Osborne’s modified simple decompression (MSD) with conventional simple decompression (CSD) and wanted to assess how the repair of Osborne’s ligament affects the ulnar nerve length (UNL), determine whether there are differences in the ultrasonographic grade of ulnar nerve instability (UNI) before and after each technique (MSD and CSD), and assess whether there are significant differences in the clinical outcome between the two techniques at 24 months postoperatively. Methods Between 2013 and 2015, we performed surgical treatment on 80 patients presenting with cubital tunnel syndrome. We excluded patients with previous trauma (n=8), limited range of motion (<90°, n=2), severe degenerative arthritis (n=5), revision surgery (n=2), and a systematic disorder (n=7). Patients treated conservatively (n=4) or followed for <24 months (n=6) were also excluded. Finally, 46 patients diagnosed with ICTS were included in the study. Twenty-eight patients (24 men, 4 women; mean age, 51.1 years) underwent MSD and 18 patients (11 men, 7 women; mean age, 55.9 years) underwent CSD. In the MSD group, UNL was measured from the intermuscular septum to the first motor branch intraoperatively. Measurements were performed during full elbow flexion and extension before and after the repair of Osborne’s ligament. UNI during elbow motion was classified using ultrasonography as Grade 0, Grade 1, and Grade 2 instability preoperatively and at 24 months postoperatively. Visual analogue scale (VAS) score; quick disability of the arm, shoulder, and hand score (quick DASH); grip power; pinch power; McGowan grade; and Wilson and Krout criteria were recorded preoperatively and at 24 months postoperatively. Results The UNL during full elbow flexion was significantly reduced after the repair of Osborne’s ligament, in the MSD group (after repair, 11.7 ± 1.7 cm; before repair, 12.4 ± 2.4 cm; p <0.001). At 24 months after the surgery, the MSD group had a lower grade of UNI than the CSD group (p=0.019). The VAS score, quick DASH score, grip power, pinch power, McGowan grade, and Wilson and Krout criteria were not significantly different at 24 months postoperatively. Conclusions UNL during elbow flexion was significantly reduced after the repair of Osborne’s ligament, and the MSD group had a lower grade of UNI compared to the CSD group. In addition, the clinical outcome was similar between the two groups through 24 months of follow-up. Therefore, considering the possibility of nerve traction and instability after CSD, MSD could be used as a possible surgical option to treat ICTS.

Myung Ho Lee, Hyun Sik Gong, Min Ho Lee, Seung Hoo Lee, Jihyeong Kim, Goo Hyun Baek

Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea

Objective: Studies suggest that vitamin D supplementation improves myelination and recovery after nerve injuries. The purpose of this study was to evaluate whether vitamin D supplementation could be helpful for better surgical outcomes in patients with both carpal tunnel syndrome (CTS) and vitamin D deficiency. Methods: We retrospectively reviewed 84 vitamin D deficient women with CTS who underwent carpal tunnel release and then received daily supplementation of 1000 IU vitamin D for 6 months. At baseline and 6 months postoperatively, serum vitamin D levels were measured as were symptom severity in terms of the Disabilities of the Arm, Shoulder and Hand (DASH) score, neurophysiologic severity with motor conduction velocity (MCV), and grip and pinch strengths. We evaluated whether improvement of vitamin D level at 6 months was associated with better surgical outcomes. Results: The mean vitamin D level improved from 12.0 to 24.5 ng/mL at 6 months postoperatively. Fifty-nine patients (70%) became vitamin D non-deficient (≥ 20 ng/mL) and 25 were still vitamin D deficient (< 20 ng/mL). Patients who were not deficient in vitamin D levels at 6 months had greater improvement of mean DASH score than patients who were still vitamin D deficient (-21 vs. -10, P = 0.023). There were no differences in MCV and grip and pinch strengths between the two groups. Vitamin D levels at 6 months were found to have significant correlation with the mean DASH score at 6 months (r = -0.349, P = 0.003) and also with the mean improvement of DASH score (r = -0.263, P = 0.041). Conclusions: This study suggests that correction of vitamin D deficiency is helpful for better surgical outcome in women with CTS and vitamin D deficiency. Further randomized comparative studies are necessary to determine whether vitamin D supplementation is helpful for vitamin D non-deficient patients.

Ema Onode 1, Takuya Uemura 1, Kosuke Shintani 1, Takuya Yokoi 1, Mitsuhiro Okada 1, Kiyohito Takamatsu 2, Hiroaki Nakamura 1

1 Osaka City University Graduate School of Medicine, Japan; 2 Yodogawa Christian Hospital, Japan

Objective: Adhesion neuropathy of the median nerve with persistent wrist pain can be a challenging problem. Current opinion dictates that coverage of the median nerve with well-vascularized soft tissue is important after secondary neurolysis. In the present study, we introduced a novel method using a radial artery perforator (RAP) adiposal flap for coverage of the neurolysed median nerve to minimize reformation of scar adhesion. Methods: Eight patients, who had previously undergone median nerve surgeries, repair of a median nerve laceration or primary open carpal tunnel release, were included. Because all had substantial median nerve hypersensitivity at the wrist, the secondary neurolysis with RAP adiposal flap was performed. In short, after careful neurolysis of the scared median nerve, the RAP adiposal flap was elevated and rotated to envelop the nerve without sacrificing of the radial artery. The average age was 65 years (range 42 - 89 years). The average interval between the prior nerve surgery and re-exploration was 19 months. The visual analogue pain scale score, presence of a positive tinel sign at the wrist, wrist range of motion, scores of the quick Disabilities of the Arm, Shoulder and Hand (DASH) were examined both preoperatively and at the final follow-up. The average follow-up was 13 months (range 4 – 28 months). Results: The RAP adiposal flap size ranged from 750 to 1200 mm2 (average 1088 mm2) and was enough to cover the exposed median nerve. After surgery, the positive tinel sign on the wrist disappeared in all patients and the mean visual analog pain scale score decreased. The fat pads remained beneath the skin and were detected in magnetic resonance imaging at the final follow up exam. Average arc of wrist motion and average score of the quick DASH improved postoperatively. There was no recurrence of median nerve adhesion neuropathy. There was a slight pigmentation of the skin and a mild surface infection but no major complications. Conclusions: This is the first report of the application of the RAP adiposal flap for the coverage of the neurolysed median nerve, modified to be thinner and softer than the RAP adipofascial flap. The results of interposing the RAP adiposal flap between dysesthetic volar wrist skin and the neurolysed median nerve have been successful in terms of both pain relief and restoration of hand function.

Carlos Henrique Fernandes 1, João Baptista Gomes dos Santos 1, Luis Renato Nakachima 1, Marcela Fernandes 1, Giana Giostri 2, Trajano Sardenberg 3, Henrique Ayzemberg 4, Jeffferson Braga Silva 5, Rodrigo Guerra Sabongi 1, Estevão Juliano Lopes 1, Jaime Piccaro Erazo 1, Thais Silva Barroso 1, Eduardo Murilo Novak 2, Suzilaine Ramos de Oliveira 2, Denis Varanda 3, Andrea Christina Cortopassi 3, Valdir Steglich 4, Tiago Salati Stangarlin 4, Flávio Hermano Bezerra Araujo 4

1 Hospital São Paulo/Universidade Federal de São Paulo, Brazil; 2 Hospital Universitário Cajuru/PUCPR, Brazil; 3 Hospital das Clinicas da Faculdade de Medicina de Botucatu – UNESP, Brazil; 4 Instituto de Ortopedia de Traumatologia de Joinville, Brazil

Objectives Traumatic lesions of the hand can correspond to 10 to 30% of all the services provided in the emergency room. Our objective was to study the characteristics of accidents involving trauma in the hand, wrist, forearm and elbow, performed during Carnival party in 2017. Method A questionnaire was drawn up in which data were collected on the patient's age and gender, whether or not there was use of licit or illicit drugs, characteristics of the trauma, type of agent causing the trauma, type and anatomical location of the lesion. The questionnaire was sent to all 31 Hand Surgery Training Centers accredited by the Brazilian Society of Hand Surgery for data collection. Results A total of 104 consultations were performed in 5 hospitals. The majority of the patients were male (61.5%), with a mean age of 36.14 years. Twenty patients (19.23%) had previous use of some type of drug before the accident. Regarding the etiology of trauma, the following were the direct traumas (31.73%) and falls (25%). The most frequent diagnosis was fracture, 52 (44.44%) and the distal radius fracture was the most common (14.52%). Conclusion Despite the importance of this research for the specialty of Hand Surgery, there was little adherence to the collection of these data. We believe that there is a need for financial support for this type of research so that we can have the participation of a larger number of hospitals with complete coverage of the Brazilian territory.

Carlos Henrique Fernandes, Lia Miyamoto Meirelles, Marcela Fernandes, Luis Renato Nakachima, João Baptista Gomes dos Santos, Flavio Faloppa

Hospital São Paulo/Universidade Federal de São Paulo/ Hand Surgery Unit, Brazil

Objective: An intra-individual comparison of surgical results between the open and endoscopic release was performed in patients with bilateral carpal tunnel syndrome, each of the hands operated by one of the technique. Material and Methods: Fifteen patients (30 hands) were evaluated in the preoperative, second week, first month, third month and sixth months in the postoperative period. The patients were evaluated by Boston questionnaire, visual analog pain scale (VAS) and grip strength. A comparative study was performed between the endoscopic and open surgeries at each of the follow-up times, and the evolution of each surgery over time. Results: Evaluating the symptoms between endoscopic and open release in each of the follow-up times (pre-operative, 2nd week, 1st month, 3rd month and 6th month), for the strength, only the tripod strength suffered difference in the 6th month, in the other follow-ups there were no differences. There were no differences in pain scores. The Boston questionnaire showed differences in the 1 st and 6 th months in the SSS(symptom severity score) and no change in the FSS (functional status score). Both surgeries behave in a similar way, as well as all the requirements measured over time. Discussion: Although many articles compare the different techniques, few were compared in patients operated bilaterally. The advantage is that we eliminate the individual variation to evaluate the measures between the different techniques. Conclusion:We concluded that using the intra-individual evaluation we did not find differences between open and endoscopic release in the evaluation of pain intensity, Boston protocol score and strength measurement.

Young Hak Roh 1, Hyun Sik Gong 2, Goo Hyun Baek 2

1 Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea; 2 Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Objective: The aim of this study was to compare the efficacy of a corticosteroid injection for the treatment of carpal tunnel syndrome (CTS) in patients with and without Raynaud’s phenomenon. Methods: In a prospective study, 139 patients with CTS were treated with a corticosteroid injection (10 mg triamcinolone acetonide); 34 had Raynaud’s phenomenon and 105 did not . Grip strength, perception of touch with a Semmes-Weinstein monofilament and the Boston Carpal Tunnel Questionnaires (BCTQ) were assessed at baseline and at six, 12 and 24 weeks after the injection. The Cold Intolerance Severity Score (CISS) questionnaire was also assessed at baseline and 24 weeks after the injection. Results: The two groups had similar baseline BCTQ scores, but the scores in the Raynaud’s phenomenon group were significantly higher than those in the control group at 12 and 24 weeks after the injection. Throughout the 24-week follow-up, there were no significant differences in the mean grip strength between the groups, whereas the mean Semmes-Weinstein monofilament sensory index for the control group was significantly higher than that of the Raynaud’s phenomenon group. The mean CISSs were not significantly different between the groups at baseline and at 24 weeks. After 24 weeks, 11 patients (32%) in the Raynaud’s phenomenon group and 16 (15%) in the control group required carpal tunnel decompression (p = 0.028). Multivariable analysis indicated that concurrent Raynaud’s phenomenon (odds ratio (OR) 2.6) and severe electrophysiological grade (OR 2.1) were independently associated with a failure of treatment after a corticosteroid injection. Conclusions: Although considerable improvements in symptoms will probably occur in patients with Raynaud’s phenomenon who have CTS, they have higher risk of poor functional outcomes and failure of treatment than those without Raynaud’s phenomenon.

Alexander Schuetz

Sporthopaedicum Straubing - Regensburg, Straubing, Germany

Introduction: The most common peripheral neuropathy in upper extremities is caused by the idiopathic carpal tunnel syndrome (CTS). In Germany, if invasive decompression surgery is needed, it is usually performed with an open carpal tunnel release operation (OCTR) and not with endoscopic carpal tunnel release (ECTR). The ECTR is suspected to show a flat learning curve and to be technically more demanding than the OCTR. Worldwide, the one-portal technique by Agee has become a standard procedure in minimal invasive operations. We wanted to verify the learning curve and any early complications while establishing this technique in our clinic. Methods: From April to November 2017, in a pilot study, 52 patients with idiopathic CTS were operated in a single center by one surgeon using the one-portal ECTR-procedure. The operative time was measured, as well as any remaining hematoma (score: 0=none-5=revision necessary) at the time of stitch removal 12 days after surgery. The postoperative pain level was evaluated by using the VAS score (0-10). Regression of the typical CTS symptoms such as nocturnal numbness and pain (NMP) was also monitored. Results: In the first 30 patients, greater variabilities in the operative time from 6 to 27 min. were recorded. In this period, 2 ECTR-procedures were converted into an open surgical approach, owing to unclear intraoperative conditions. In the first third of 52 patients (1-17), the average operative time was 11.8 min., in the second third (18-35) 8.0 min. and in the last third (36-52) 5.5 min. were needed. There was a trend to greater postoperative hematomas and pain in the first 2/3rd. of the patients. Operative revisions, due to complications like hematoma, were not observed. There were no complications assessed, such as iatrogenic nerve or tendon injuries. By all patients, the NMP disappeared immediately post-operatively. Summary: In the present study, at least 30 endoscopic operations were needed, to achieve a stable and representable process, in order to establish the one-portal ECTR-procedure. By all 52 patients that were included, no major complications or surgical revisions were observed. Thus, these results do not confirm the assumed prolonged learning process while establishing this endoscopic technique in our clinic.

Chae Seungbum

Daegu Catholic University Medical Center, Daegu, South Korea

Abstract Background This study aim is to know the usefulness of the ultrasonography in diagnosis of carpal tunnel syndrome and possibility of replacement of the ultrasonography in diagnosis of the carpal tunnel syndrome instead of electrophysiologic study. Method Fifty one patients with unilateral carpal tunnel syndrome confirmed using Carpal Tunnel Syndrome-6 for the diagnosis of carpal tunnel syndrome were enrolled. Ultrasonography was performed on both wrists by single radiologist who didn’t know the affected side. Electrophysiologic study was perform on the both side by single examiner without any information of the affected side. The cross-sectional area and the ratio of those between the inlet and the outlet was measured on the median nerve of the both side. We compared the accuracy of the ultrasonography and the electrophysiologic study in the diagnosis of carpal tunnel syndrome. Result In patients diagnosed with carpal tunnel syndrome by the carpal tunnel syndrome -6, sensitivity and specificity of ultrasonographic measurement of the median nerve inlet diameter for diagnosing carpal tunnel syndrome was 0.818 mm2 and 0.864 mm2, and cutoff value was 0.105mm2 respectively. Also, the sensitivity and specificity of ultrasonographic measurement of the inlet and outlet diameter for diagnosing carpal tunnel syndrome was 0.886 and 0.886, and cutoff value was 1.29 respectively. The sensitivity and specificity of the nerve conduction study was 0.841 and 0.818, respectively. There were no significant difference in diagnosing carpal tunnel syndrome by ultrasonography or nerve conduction study. Conclusion We conclude that ultrasonographic studies are highly accurates in the diagnosis of carpal tunnel syndrome and the electrophysiologic studies are not necessary in most cases. Keywords : Carpal tunnel syndrome, Diagnosis, Ultrasonograohy, median nerve

Kaori Sugiura 1, Takao Omura 2, Michihito Miyagi 2, Hiroaki Ogihara 3, Tomokazu Sawada 4, Yukihiro Matsuyama 2

1 JA Shizuoka Kohseiren Enshu Hospital, Japan; 2 Hamamatsu Univercity School of Medicine, Japan; 3 Japanese Red Cross Hamamatsu Hospital, Japan; 4 Shizuoka City Shizuoka Hospital, Japan

Objective: Carpal Tunnel Syndrome (CTS) is the most common peripheral compression neuropathy primarily affecting postmenopausal women. Trapeziometacarpal (TMC) arthritis is also commonly seen in postmenopausal women and is currently estimated to affect 1/3 of the women population. Although association between carpal tunnel syndrome and TMC arthritis has been suggested, it is not known how much of the patients with carpal tunnel syndrome have radiographically apparent TMC arthritis. The purpose of this study is to examine the prevalence and the characteristics of CTS in patients with TMC arthritis. Methods: We studied 73 patients (94 hands) who had undergone carpal tunnel release with the clinical and electrophysiological diagnosis between January 2012 and June 2017. The patients consisted of 29 men and 65 women, ranging from 44 to 92 years old, with a mean of 67.2 (44~89)years old. The mean follow up period was 10 months. The diagnosis of TMC arthritis was made based on plain radiographs, and the severity of the arthritis was determined using Eaton’s clacification. Joints with stage2 and beyond were considered to as positive finding of osteoarthritis (TMC+ group). Manual muscle testing (MMT) on abductor pollicis brevis (APB) muscle and distal motor latency (DML) detected on APB was examined for the evaluation of CTS. The characteristics of TMC+ group were compared with the TMC stage 1 and less (TMC-) group. Results: The prevalence of TMC arthritis was 43% in patients with CTS. The mean age for the TMC+ group was 72.0(53~89)years old. According to Eaton’s classification, twenty-four hands were classified as stage2, nine hands were stage3 and eight hands were stage4. TMC- group consisted of fifty-three hands (57%), with a mean age of 63.6(44~83) years old. With electrophysiological study, the mean preoperative DML was 7.29ms for TMC+ group and 7.73ms for TMC- group with 17 and 13 undetectable compound muscle action potential (CMAP) in TMC+ and TMC– group. There was no statistical difference between the two groups. Similarly, the mean postoperative DML was 4.82ms for TMC+ group, and 4.72ms for TMC - group, with 8 and 7 CMAP undetectable hands, showing also no statistical difference. However, the mean final MMT of APB was 3.87 in TMC- group, while 3.12 in TMC+ group. Furthermore, in cases with severer stage of TMC arthritis (Eaton stage3,4), the mean postoperative MMT of APB was limited to 2.76, which was statistical significance in comparison with the TMC- group. Conclusions: We conclude that the prevalence of CTS and TMC arthritis was 43% and that the presence of TMC arthritis in patients with CTS negatively affects the postoperative recovery of the APB muscle.

Ryosuke Ikeguchi, Souichi Ohata, Hiroki Oda, Hirofumi Yurie, Hisataka Takeuchi, Sadaki Mitsuzawa, Bungo Otsuki, Shuichi Matsuda

Department of Orthopedic Surgery, Kyoto University, Japan

Objective Non-surgical treatment is the primary option for hand disease, but the effects of conservative treatment on carpal tunnel syndrome (CTS) are uncertain and the factors predictive of outcome are unclear. The purpose of this study is to investigate the efficacy and prognostic factors of splinting therapy for CTS. Methods From 2006 to 2016, 80 hands of 77 patients diagnosed with CTS were treated with splinting therapy (average age 65.2 years old). Each hand was treated with a nocturnal-wear custom-fabricated wrist splint for eight weeks. The outcomes were investigated retrospectively and logistic regression analysis was used to examine the prognostic factors for the effectiveness of splint treatment. The independent explanatory variables were patient age, disease duration, nocturnal symptoms, physical findings (Phalen test, thenar muscle atrophy and Tinel’s sign), electrophysiological findings ( distal latency and amplitude) and CTS severity. Results Subjective symptoms disappeared in 10 hands (12.5%), improved in 55 hands (68.75%) and worsened or did not change in 15 hands (18.75%). The efficacy rate of splinting therapy was 81.25%. With regard to the prognostic factors, there was a significant relationship between ineffectiveness and patient age when patient age was greater than 80 years; the odds ratio was 0.11 (p=0.0027). There was no significant relationship between ineffectiveness and disease duration, Phalen test, thenar muscle atrophy, distal latency, amplitude or disease severity. Conclusions Splinting treatment for CTS is minimally invasive, and the current study shows that splinting therapy is effective in about 80% of cases. In patients over 80 years of age, however, it does not lead to improvement. CTS severity, physical findings and electrophysiological examination cannot predict the effectiveness of splinting treatment. For CTS patients under 80 years of age, splinting treatment is considered to be the first choice regardless of disease severity.

Andrzej Zyluk, Paulina Zyluk-Gadowska, Piotr Puchalski, Zbigniew Szlosser

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland

Outcomes of surgery for carpal tunnel syndrome may differ in relation to certain factors like age, duration of symptoms, clinical and electrophysiological severity. The objective of this study was an investigation into the hypothesis that several factors are predictive of results of surgical treatment of the condition. The pre- and postoperative records of 1,117 patients: 909 women (81%) and 208 men (19%) with a mean age of 63 years were analysed. The whole group was divided into subgroups, depending on the variables analysed: sex, age, duration of symptoms, clinical and electrophysiological severity of and presence of comorbidities. The effect of these variables on outcomes of surgery at 6 months was investigated. Results. None of the considered variables had a substantial impact on the results of carpal tunnel release which were sufficiently satisfactory at any circumstances. Slightly poorer outcomes in grip strength were observed in elderly patients, with clinically severest condition and with concomitant comorbidities.

Andrzej Zyluk, Paulina Zyluk-Gadowska, Piotr Puchalski, Zbigniew Szlosser

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland

Clinical presentation of carpal tunnel syndrome may differ in relation to certain factors like sex, age, duration of symptoms and severity of compression. The objective of this study was an investigation into the hypothesis that several distinct factors are predictive of the clinical profile for the condition. The records of 1,117 patients: 909 women (81%) and 208 men (19%) with a mean age of 63 years, were analysed. The whole group was divided into subgroups, depending on the variables analysed: sex, age, duration of the condition, severity of symptoms, severity of electrophysiological abnormalities and occurrence or lack of comorbidities. Results. Of all the considered variables, the Levine symptom scores had the greatest impact on the condition’s clinical profile: the higher scores the more severe pain, poorer sensation, weaker grip and worse hand function. Also, ages greater than 80 years had a significant negative effect on most of the considered parameters. None of the remaining analysed variables had a substantial impact on the clinical profile of the condition.

Gyeong Min Kim, Seungjae Shim, Kyu Bum Seo

Jeju National University Hospital, Jeju, South Korea

Introduction Carpal tunnel syndrome is the most common compressive neuropathy in the hand. And lipoma is one of the most common soft tissue tumors. But lipomas are rarely present in the hand, and carpal tunnel syndrome due to compression of lipomas is rarely reported. Case Description A 66 - year - old woman with diabetes mellitus was visited to our clinic with complaints of numbness and mass of the left hand. On physical examination, the mass was palpable near the thenar muscle of the left hand and there was no tenderness. There was no weakening of the grip strength. Electromyography and nerve conduction study were suspected to be median nerve neuropathy at the distal part of the transverse carpal ligament in the left hand. On magnetic resonance imaging of the left hand part, a lobulated mass with fat-like signal intensity was observed and was surrounded by flexor tendons. The proximal portion of the median nerve showed high signal intensity on T2-weighted images and suspected neuropathy. After the incision, a yellow mass that was compressing the median nerve was observed. The mass and epineurium were carefully detached and completely resected. Histological examination confirmed the lipoma. The numbness of the patient's left hand has improved and is currently on follow-up. Discussion If physical examination, electromyography, and nerve conduction study have abnormal findings on one side, it is necessary to consider the possibility of carpal tunnel syndrome due to other causes such as space occupying lesion. In this case, consideration of ultrasonography, magnetic resonance imaging, and other tests will be helpful for accurate diagnosis and treatment.

JuiTien Shih

Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan

Objective : Carpal tunnel syndrome (CTS) is a common and sometimes challenging condition, which causes pain; paresthesia; tingling of the thumb, index and long fingers; and even thenar weakness in the hands. The endoscopic transcarpal ligament (TCL) released is effects but need more time for nerve regeneration in previous studies. In recent years, platelet-rich plasma (PRP) has proven to bean alternative as it encourages nerve regeneration. Methods : From 2012 to 2014, we rolled 32 patients with CTS, the mean aged was 57.6 ( range 50-68 years). There were 24 female and 8 male patients in our series and they all underwent endoscopic TCL release with PRP injection. Results: We hereby describe a patient with CTS showing significant improvements early in electrophysiological parameters after receiving endoscopic TCL release with PRP injections. The results revealed significant improvements in the distal motor and sensory latencies as well as the sensory nerve action potential and compound muscle action potential amplitudes of the both median nerves. Conclusion: In summary, patients with CTS underwent arthroscopic TCL release with PRP injection get more early recovery of symptoms and nerve.

Kiyohito Takamatsu 1, Akira Kawabata 1, Yasunari Awa 1, Megumi Ishiko 1, Ema Onode 2

1 Dept. of Orthop. Surg. Yodogawa Christian Hospital, Osaka, Japan; 2 Dept. of Orthop. Surg. Osaka City University, Osaka, Japan

Introduction For a detailed evaluation of patients with thoracic outlet syndrome (TOS), we had previously performed three-dimensional computed tomography (3DCT) after brachial plexography. Recently, we focused on patients with TOS of traction type who complained of symptoms in the sitting or standing position but not in the position assumed during the Wright’s maneuver provocation test. Furthermore, the results of first rib resection surgery in these patients were reported to be poor. Dynamic 3DCT in different positions enhanced the definition of the brachial plexus anatomy and enabled a dynamic assessment of the compressed brachial plexus. For further examination of TOS, this method also enabled evaluation of the relationship between the clavicle and the rib, which is impossible to assess using typical brachial plexography. Purpose The purposes of this study were to assess the narrowest costoclavicular space using 3DCT after brachial plexography and evaluate changes in the costoclavicular space in the supine position with/without upper limb traction, thus revealing the costoclavicular relationship in the sitting and standing positions. Materials and Methods TOS was suspected based on patient history, symptoms, neurological findings, provocation test results, and electrophysiological examination findings. Patients with other conditions associated with neuropathy (e.g., hypothyroidism and diabetes mellitus), bilateral conditions, and clinical findings of neuropathies, such as cervical radiculopathy and polyneuropathy, were excluded. Brachial plexography and 3DCT were performed in 10 female patients with a mean age of 35.3 years. First, brachial plexography was performed, following which dynamic 3DCT was performed not only in the resting supine position but also in the supine position with upper limb traction to assess the costoclavicular relationship in the standing and sitting positions. The 3DCT images were assessed, with special attention given to reconstituting the images in the oblique sagittal view, and cross sections of the brachial plexus in 3DCT were observed. In these reconstituted images, we specified the narrowest costoclavicular space and assessed the distance between the clavicle and the rib as well as the thickness of the subclavius muscle. These values were compared between the affected and healthy sides. Results On the affected side, the narrowest space was the second rib–clavicular space in nine cases and the second intercostal–clavicular space in one case. On the healthy side, it was the second rib–clavicular space in seven cases, the first intercostal–clavicular space in one case, and the second intercostal–clavicular space in two cases. The mean values for the narrowest costoclavicular space at rest were 31.1 mm on the healthy side and 26.7 mm on the affected side, and the values with limb traction were 23.9 and 21.1 mm, respectively. In addition, the mean ratio of the values of thickness of the subclavius muscle to costoclavicular space with limb traction were 21.5% on the healthy side and 25.4% on the affected side. However, there were three cases with ratios of >30%. Conclusion In patients with TOS who complained of symptoms in the sitting or standing position, the narrowest space was mainly the second rib–clavicular space and not the first rib–clavicular space.

Yong-Suk Lee, Jin-Woo Kang, Seung Han Shin, Yang-Guk Chung

Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of South Korea

Objective Carpal tunnel syndrome is one of the most common clinical problems hand surgeon encounters. In recent days, mini-open techniques (limited longitudinal incision techniques) have been popular method to release carpal tunnel. The purpose of our study is to compare the results of percutaneous (our method) and mini-open carpal tunnel releases among patients with primary idiopathic carpal tunnel syndrome. Method We performed a comparative prospective study on two different methods of carpal tunnel release in 60 wrists of 46 patients since March, 2016 until Feb, 2017. Thirty-one wrists underwent percutaneous carpal tunnel release using hook knife, and 29 wrists underwent mini-open release. Percutaneous releases were performed through a small transverse incision just proximal to wrist crease using a curved hemostat and a hook knife under local infiltration of lidocane at day surgery center. Primary outcome is the severity of symptoms of carpal tunnel syndrome and functional status scores. Secondary outcome is the severity of postoperative pain in the scar & pillar. The postoperative functional statuses were evaluated with Quick DASH and Boston questionale at the 2nd weeks, 6th weeks, 3rd months, 6th months, and 12th months. Results All except 2 cases (29/31, 93.5%) of percutaneous carpal tunnel release and all but for 2 cases (27/29, 93.1%) of mini-open release patients showed complete symptomatic recoveries and were satisfied with the final result (p>0.05). One of patients with no resolution had overlapping thoracic outlet syndrome, which made patient’s symptom unresolved. The two patients with unsatisfied results had bilateral carpal tunnel releases using different methods and preferred mini-open method. Twelve patients among 14 patients who underwent bilateral carpal tunnel release (one wrist with percutaneous method and the other wrist with mini-open) preferred percutaneous method due to less scar and pillar pain. The final Quick DASH scores were 18.03 (percutaneous) VS 23.04 (mini-open). The final function score of Boston questionale were 1.60 (percutaneous) VS 2.01 (mini-open) and the final symptom score of Boston questionale were 1.56 (percutaneous) VS 2.09 (mini-open) respectively. There were no significant complications during both percutaneous and mini-open procedures. Conclusion Compared to mini-open method, percutaneous carpal tunnel release is a preferable method with less postoperative pain and good functional outcome.

Tatsuki Ebata, Ikuo Nakai, Akira Kogure, Ken-ichiro Goto

Sakura Orthopaedic Hospital, Sakua, Japan

Objective: Carpal tunnel syndrome (CTS) is the most common upper extremity entrapment neuropathy. Nerve conduction studies are used for the diagnosis of CTS. As the severity of CTS progresses, the nerve conduction velocity in the carpal tunnel reduces. The compound muscle action potential of the abductor pollicis brevis (APB-CMAP) demonstrates progressively increased latency and decreased amplitude. In the most advanced stages of CTS, APB-CMAP finally becomes undetectable and the motor conduction velocity cannot be measured. The purpose of the present study was to investigate the epidemiology (risk factors) of CTS in relation to APB-CMAP. Materials and Methods: Seven hundred eighty-six hands of 572 idiopathic CTS patients whose latencies of APB-CMAP ≥4.5 ms between 2012 and 2017 were included in the present study. The diagnosis of CTS was established based on neurological and electrophysiological examinations. Secondary CTS patients, including those undergoing hemodialysis and those associated with other neuropathies or diabetes, were excluded. Patients had a mean age of 60.7 years. Among the 572 patients, 136 were men (23.8%) and 436 were women (76.2%); 542 patients were right-handed (94.8%) and 30 were left-handed (5.2%). Results: Among 786 hands, 191 hands were of men (24.3%) and 595 were of women (75.7 %). The number of hands of women was 3.1 times greater than that of men. Four hundred forty-six hands (56.8%) were dominant and 340 (43.2%) were non-dominant. The number of dominant hands was 1.3 times more than that of non-dominant hands. In 290 patients with bilateral CTS, dominant hands had statistically significantly greater undetectable APB-CMAP rates (83 hands, 28.6%) than non-dominant hands (52 hands, 18.0%). In 162 patients with bilateral CTS and bilateral detectable APB-CMAP, the average latency of APB-CMAP of dominant hands (7.00 ms) was statistically significantly greater than that of non-dominant hands (6.29 ms). The number of hands of patients aged 60–69 years was the highest (227 hands, 28.9%), and the number of hands of patients aged 50–59 years was the second highest (222 hands, 28.2%). The patients aged 70–79 years had the highest undetectable APB-CMAP rates (29.7%). The hands of patients aged 80 years and older had the second highest undetectable APB-CMAP rates (27.6%). Conclusions: There are some possible risk factors of idiopathic CTS. Being a woman is one of them. In the present study, women were 3.1 times more susceptible to CTS than men. This may be because estrogen plays a part in the development of CTS. Dominant hands tended to develop CTS and were more susceptible to progression than non-dominant hands. The cause of CTS may be related to overuse of the hand, as repetitive motion at work. The age distribution curve of CTS peaked in the sixties and fifties. The most serious CTS occurred in seventies. Therefore, age is also an important factor of CTS. A combination of these risk factors appears to contribute to the development of CTS.

HL Stark, B Crowley

Royal Victoria Infirmary, Newcastle-upon-Tyne, UK

Objective Carpal tunnel syndrome in adults with congenital hand anomalies is infrequently described. We present two cases of carpal tunnel syndrome in adults with congenital hand anomalies. Method A review of case notes and operative records. Results Case 1: 19 year old female with right radial dysplasia and hypoplastic thumb Manske grade IIIA. Clinical and neurophysiological findings consistent with right median nerve compression at wrist level Case 2 : 64 year old male with bilateral ulnar dysplasia with absent ulnar digital rays in both hands. Clinical and neurophysiological findings consistent with left median nerve compression at wrist level. Surgical treatment, carpal tunnel decompression, was undertaken in both cases. Operative findings were similar in both patients. The median nerve and carpal tunnel were located more radial than normal. The ulnar artery and nerve were found more centrally in the proximal palm. The median nerve was adherent to the overlying flexor retinaculum and deep aspect of the thenar muscles. Dense palmar aponeurotic bands compressed the median nerve distal to the carpal tunnel causing an hour-glass constriction of the nerve (see photographs of operative sequence case 1). Conclusion Our cases highlight the anomalous anatomy that may be found when undertaking carpal tunnel decompression in patients with congenital hand anomalies. We advocate brachial plexus block or general anaesthetic for this surgery. The skin incision should enable extension proximal to the wrist to facilitate identification of nerve anatomy. Awareness of this allows the hand surgeon to make an appropriate operative plan.

Amirouche Dahmam, Gero Meyer zu Reckendorf, Jean-Luc Roux

Institut Montpelliérain de la Main, Montpellier, France

Introduction: A direct approach is the standard procedure for the treatment of recurrent carpal tunnel syndrome. However, this may be technically challenging due to adhesions and an increased risk of iatrogenic injuries. Endoscopic release of the median nerve within the carpal tunnel has become a well-controlled procedure, providing better anatomical vision than the conventional technique, thanks to the advances in technology. The aim of this work is to study the interest and feasibility of endoscopic release in the event of carpal tunnel recurrence. Material and Method: Seven patients (5 women and 2 men) with a mean age of 61 years old (38-92), presented a clinical symptomatology of carpal tunnel syndrome after an average of 6 years (6 months - 15 years) following initial surgery for median nerve release, by mini-open surgery in 6 patients and endoscopic surgery in one patient. An ultrasound was performed to rule out an endocanalar cause. Electromyography was positive in all patients and confirmed the recurrence. All patients were treated under regional anesthesia with endoscopic carpal tunnel revision surgery. They were informed of the risk of conversion to open surgery and all were reviewed and clinically evaluated. Results: Endoscopic release was successfully performed except in one case in which the anterior carpal retinaculum did not deviate sufficiently in its distal part due to its thickness. We undertook an open conversion to complete the release. In all cases, the following anatomical elements, the median nerve, flexor tendons and the superficial palmar arch were visualized in order to protect them before section of the anterior carpal retinaculum. All patients were satisfied and reported an improvement in symptomatology, as well as the recovery of sensitivity and strength. Discussion: Recurrence after carpal tunnel surgery is rare and should trigger a search for incomplete release in the majority of cases. Open surgery is the most commonly used technique and some authors advocate neurolysis of the median nerve associated with a protection flap as required. The interest of endoscopy is to visualize all the anatomical parts such as the median nerve, flexor tendons and the superficial palmar arch, in order to protect them before safely cutting the anterior retinaculum on its ulnar side, unlike with the open approach. Neurolysis exposes the patient to a risk of iatrogenic nerve damage. We believe that, for a first recurrence, it is sufficient to perform a simple release without any associated procedures. This study shows that endoscopic release of recurrent carpal tunnel can be safely performed with good results. Mastering the endoscopic technique is essential and reverting to open surgery must be the rule for cases with difficult visibility.

Amirouche Dahmam, Jean-Luc Roux, Gero Meyer zu Reckendorf

Institut Montpelliérain de la Main, Montpellier, France

Endoscopic release of the median nerve according to Agee's original technique is limited to section of the flexor retinaculum without endocanalar exploration. We present a video of the modified Agee technique the purpose of which is to explore the carpal tunnel, including its contents and walls. The procedure is performed under locoregional anesthesia with a tourniquet at the root of the arm. As soon as the endoscope is introduced into the carpal tunnel, the median nerve is located and section of the retinaculum is only performed afterwards. Once the retinaculum has been divided, exploration becomes easier. By longitudinal rotational movements of the endoscope we may visualize the following anatomical elements: the retinaculum margins confirming its complete section, the median nerve and its motor branch on the radial side, the long flexor of the thumb in its sheath outside, the flexor tendons of the 4th and 5th fingers with their lumbrical muscles on the ulnar side, the uncus of the hamatum and finally, behind the flexor tendons, the anterior capsulo-ligamentous parts of the carpus. On a continuous series of 100 carpal tunnels, the median nerve was always visualized before section of the retinaculum and the motor branch was visualized 82 times. Release of the motor branch was performed under endoscopy in 27 cases who presented thenar atrophy or a compressive anatomical element. In most of these cases, endocanalar vision associated with passive flexion/extension movements of the first metacarpal, revealed shearing of the motor branch due to fibrous reinforcement of the flexor fascia, this arch was sectioned. The long flexor of the thumb was individualized 87 times, the flexors of the 4th and 5th fingers with the lumbrical muscles 68 times. In 18 cases we found degenerative tendon lesions with a rough hamate. The anterior part of the carpus was visualized by passing the endoscope under the flexor tendons. A synovial cyst was found in one case. This film shows that the endoscopic technique offers endocanalar anatomical vision with better quality than the classical open technique. It proves that complementary procedures, such as neurolysis of the median nerve and its motor branch, associated with section of the retinaculum are possible by endoscopy. This experience has led us to believe that, just as with wrist arthroscopy for the carpus, endoscopy will become a standard means of exploring the carpal tunnel.

Petra Brinskelle, Saskia Kotschar, Birgit Michelitsch, Daniel Georg Gmainer, David Benjamin Lumenta

Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria

Introduction To adequately describe the treatment for a given morbidity and its recurrence following a previous therapeutic intervention, agreement on the definitions is a prerequisite to evaluate and describe the state-of-the-art. There exist no common definitions on the recurrence of carpal tunnel syndrome and no previous such review was performed. Methods Following ethical board approval and prospective registration in the Prospero database, we used a literature search with the terms carpal tunnel syndrome and recurrence in the PubMed database, including publications from 1972 onwards, and sub-searched within previous reviews of carpal tunnel syndrome for additional literature. Inclusion criteria for screening of publications were the mentioning of included patients/hands, level of evidence, type of surgical incision, follow-up duration, recurrence rate with standard deviation, symptom-free interval, and time-to-recurrence. Exclusion criteria were reviews, and case reports. Symptoms on recurrence were also screened for numbness, weakness, tingling, and nightly pain. Two independent reviewers used a standardized reporting sheet, in case of disagreement a decision was reached following a joint discussion. Results The initial search retrieved 177 publications, and a PRISMA flowchart derived to demonstrate the included literature. The common denominator of the included publications will be presented at the conference. Discussion Contesting the definitions non-uniformly used across studies dealing with carpal tunnel syndrome and its recurrence we suggest a common denominator to adequately describe the term recurrence in the context of the most common peripheral neuropathy of the upper extremity.

Nahoko Iwakura 1, Hisanori Fukaya 1, Yoshihito Takatsuki 1, Yasushi Terayama 2

1 Tokyo Women's Medical University, Japan; 2 Hasuda Hospital, Saitama, Japan

Objective Some patients with hemodialysis-associated carpal tunnel syndrome (HD-CTS) do not experience improvement in nerve conduction velocity (NCV) after carpal tunnel release. The purpose of this study was to investigate the relationship between structural changes in magnetic resonance imaging (MRI) and changes in NCV before and after surgery for HD-CTS. Methods Sixteen hands belonging to 14 hemodialysis patients (nine male and five female patients) who had previously undergone endoscopic carpal tunnel release (ECTR) for CTS were enrolled in the study. Recurrent cases of CTS were excluded. Patients were divided into two groups: those who experienced improvement in NCV (I group), and those who did not experience improvement in NCV (NI group) two years after surgery. MRI of the carpal tunnel was performed prior to and 12 months after surgery. The cross-sectional area of the carpal tunnel and median nerve at the hook of hamate level, and distance from the volar side of the carpal bone to the flexor pollicis longus (FPL), flexor digitorum superficialis (FDS), and flexor digitorum profundus (FDP) were measured and compared before and after ECTR. Further, the difference between time points was calculated for each measurement and compared between the study groups. Results Fourteen hands (12 patients) were in the I group and two hands (two patients) were in the NI group. The mean patient age was 67±7.5 and 70±7.1 years, and the mean duration of hemodialysis was 18.7 and 23.5 years for the I and NI groups, respectively. In both the groups, the cross-sectional area of the carpal tunnel and median nerve and the distance from the bone to the tendon increased after ECTR. The difference in the cross-sectional area of the median nerve before and after surgery was 9.0±3.5 mm2 in the I group and 2.0±1.4 mm2 in the NI group, significantly greater in the I than the NI group. Conclusions Equivalent to previous reports on idiopathic CTS, we found the median nerve and carpal tunnel at the hamate level to be expanded and the flexor tendons shifted to the volar side following ECTR for HD-CTS. Our results suggest that if MRI does not indicate that the median nerve has become sufficiently large within 12 months of ECTR, the NCV two years after surgery is unlikely to have improved.

Sergio Daroda, Ezequiel Fernández, Facundo Zabaljáuregui, Fernando Menvielle, Rodolfo Cosentino, Clara Benedetti, Paul Pereira

Clinica de la Mano GAMMA, La Plata, Argentina

Objetive: Our aim is to present the results of the open release of the suprascapular nerve in the coracoid notch, by an upper shoulder approach. Methods: Thirty patients with entrapment of the suprascapular nerve were included in a retrospective analysis from 2010 to 2016. All the patients were operated on by the same surgeon with an open release of the transverse ligament in the coracoid notch through a superior approach. The average age was 52.1 years and 60% of the patients were women. All the patients had pain at the posterolateral region of the shoulder, and in 2 cases there were hypotrophy of the supraspinatus muscle. The average duration of the symptomatology last for 15.1 months (range 1-48 months) prior to the surgery. All the cases were studied with shoulder x-rays (antero-posterior and profile) and magnetic resonance. An electromyogram of the brachial plexus was performed in all the cases by the same physician, being positive in 100% of the cases. They were evaluated using the Visual Analogue Scale (EVA) of pain, ASES scale (American Shoulder and Elbow Society) and the patients were asked if they were satisfied or not. Results: The average follow-up was 31.4 months (range of 12-72 months). The diagnoses associated to the entrapment of the suprascapular nerve were: rotator cuff injury (11 cases), direct trauma (5 cases), subacromial bursitis (4 cases), osteoid osteoma of the scapula (1 case), thoracic operculum syndrome (1 case) and pure entrapment (8 cases). 93% presented immediate relief of symptoms. One patient remained in pain for 1 month and another for 4 months. The average preoperative EVA was 8.43 and the postoperative EVA was 0.86. All the patients were satisfied with the treatment. The average preoperative ASES scale was 22.32 and the postoperative scale was 84.86. Conclusions: We consider that the release of the suprascapular nerve in the coracoid notch produces a complete relief of the symptoms, and a functional recovery that allows the patient to resume his daily tasks at an early stage.

Ki-tae Na, Sang-uk Lee, Won-woo Kang, Jong-yoon Lee

Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea

Objective Clinical manifestations of thoracic outlet syndrome are vague pain or symptoms in upper extremity. Hence, the diagnosis is often delayed or misdiagnosed as cervical HNP, shoulder pathology or peripheral neuropathy. For this reason, many patients spend time and money for unnecessary or ineffective treatments. There is no definite treatment guideline that helps decide when to perform surgery or when not to. We report the outcomes of thoracic outlet syndrome when treated by conservative care or surgical intervention. Methods Twenty-seven cases diagnosed as thoracic outlet syndrome were reviewed retrospectively between January 1999 and March 2013. Eleven patients (41%) had surgery and sixteen patients (59%) had conservative care in outpatient clinic. Light exercises of upper extremity such as stretching of neck and shoulders were recommended at initial visit. After two or three months of conservative care, clinicians reassessed the patients to determine whether doing the surgery or not. Surgical method included anterior and middle scalenectomy, neurolysis of brachial plexus, and resection of first rib. As the case of cervical rib syndrome, resection of cervical rib was performed as well. The outcomes were assessed based on the follow-up duration, postoperative improvement and the results of conservative treatment. Results Mean age was 45 years (range, 22-68 years) at their first clinic visit. Nine patients (81%) were improved to nearly normal within 6.5 months (range 2-21 months), two patients (19%) had mild discomfort after the surgery. We performed anterior and middle scalenectomy in all cases, first rib resection in four cases, and cervical rib resection in three cases. No post-operative complications were noted in this series. Among sixteen patients treated by conservative methods, eleven (69%) were free of symptoms, and five (31%) showed no significant improvement in symptoms. Conclusion Conservative treatment is an effective method for thoracic outlet syndrome patients at initial clinic visit. If ineffective, surgical methods may require. Thorough exploration of brachial plexus and anterior and middle scalenectomy are most helpful for successful outcomes. Other pathologic lesions such as cervical rib or space-occupying lesion must be removed for the complete decompression of brachial plexus.

Belén García-Medrano 1, Clarisa Simón Pérez 1, Blanca Ariño Palao 1, Julián Alía Ortega 1, Benedicta Catalán Bernardo 2, Miguel Martín-Ferrero 1

1 Orthopaedic Surgery, Hand Unit, Hospital Clínico, Valladolid, Spain; 2 Neurophysiology Department, Hospital Clínico, Valladolid, Spain

Introduction: Recently, increasing evidence has revealed the beneficial effects of PRP on axon regeneration and neurological recovery in animal or vitro studies. Demostrated and defended its positive effect during carpal tunnel release (CTR), according to our previous researchs. Objectives: Compare perineural and intraneural PRP infiltration after carpal tunnel release. Material and Method: Prospective, experimental study including 60 patients with severe and very severe CTS. Local addition to the median nerve of 3 cm3 of PRP previously activated, during surgical neurolysis, after opening of the annular carpal ligament. 3 groups: simple CTR, with perineural PRP, and intra-epineurum infiltration. Primary outcomes: pain and paresthesias (Boston test). Secondary outcome measures: Durkan, Phalen, Tinel test, grip and clamp strength; cross-sectional area, perimeter, and vascular ultrasound measures of the median nerve; motor and sensory electrophysiological study. Results: Evaluation at 6 months. 100% refers a clear improvement in their symptomatology (EVA, Boston test) and pain relief; feeling of pressure in the immediate postoperative period in intraneural infiltration; occasional residual pulp paresthesias in 29%; progressive improvement in the grip and clamp force was observed, faster in PRP groups (56% before the third month). The magnification of the tunnel perimeter as well as its diameter and the reduction in the vascularization before the tunnel are statistically significant in both PRP groups. EMG control quantifies an acceleration in conduction velocity with reduction in latency. No statistically significant improvement of results in intraneural group. Conclusion: PRP accelerates and improves the functional outcome in the most complex cases of compressive neuropathy. But the function of the blood-nerve barrier of perineurium and endoneural vessels could limit the difference between the peri and intraneural PRP addiction.

Marcello Cunha, Jose Pistelli, Antonio Emanoel Miachon, Marcio Cunha

Hospital Albert Einstein, São Paulo, Brazil


Masatoshi Takahara, Shuji Toyono, Mikiro Kondo, Hiroshi Satake, Michiaki Takagi

1 Izumi Orthopaedic Hospital, Sendai, Japan; 2 Yamagata University, Yamagata, Japan

Aim: Carpal tunnel syndrome (CTS) is a common complication following distal radius fracture. The onset is various, including past, acute, late or subclinical. The aim of this study was to investigate the onset and course of carpal tunnel syndrome associated with volar locking plate fixation for the distal radius fracture. Materials and Methods: During the past 2.5 years, 130 cases underwent volar locking plate fixation for the distal radius fracture. Of the 130 cases, 101 were selected as the subjects of this study, because they were above 18 years old and had preoperative distal latency of the median nerve. 17 cases preoperatively had numbness of the hand, including the two cases that had had the numbness before the fracture. The delayed distal latency (> 4.0 msec) of the median motor nerve was shown in 22 cases. According to the presence or not of the numbness and delayed distal latency, we diagnosed preoperative CTS as the following four: 1) past onset: numbness before fracture, 2) acute onset: numbness immediately after fracture, 3) subclinical: no numbness with delayed distal latency, and 4) none: no numbness or delayed distal latency. Two cases had past onset CTS, 15 had acute onset CTS, 17 had subclinical CTS, and 65 had no CTS. All cases underwent volar locking plate fixation and nine cases concomitantly did endoscopic carpal tunnel release (ECTR). The mean follow up period was 6.7 months. We examined the results of numbness. Results: Two cases with past onset CTS underwent concomitant ECTR and the numbness was relieved. Six cases with acute onset CTS underwent concomitant ECTR and the numbness was disappeared in four and relieved in two. Nine cases with acute onset CTS did not underwent concomitant ECTR and the numbness was disappeared in all except one case who had progressed numbness and underwent ECTR 4 months after plate fixation. The numbness was disappeared in all of 17 cases with subclinical CTS while only one cases had concomitant ECTR. Of 65 cases with no CTS, two cases postoperatively had numbness and delayed distal latency, and were diagnosed as delayed onset CTS. Discussion: We found the following three onsets of symptomatic CTS associated with volar locking plate fixation for the distal radius fracture: past (2 %), acute (15 %), and delayed (2 %). We indicated concomitant ECTR for past CTS, acute CTS with the distal latency of 4.0 msec and more, and subclinical CTS with the distal latency of 6.0 msec and more. After the plate fixation, three (3 %) patients developed symptomatic CTS: one with subclinical CTS had severe numbness and two with no CTS had delayed CTS. The fact that the incidence of postoperative symptomatic CTS after volar locking plate fixation was only 3 % suggested that preoperative distal latency of the median nerve was helpful.

Malin Zimmerman 1,2, Marianne Arner 3, Ingela Carlsson 1,2, Simon Farnebo 4, Lars Dahlin 1,2

1 Department of Translational Medicine – Hand Surgery, Lund University, Skåne University Hospital, Malmö, Sweden; 2 Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden; 3 Department of Hand Surgery, Södersjukhuset (KI SÖS), Stockholm, Sweden; 4 Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden

Objective Carpal tunnel syndrome (CTS) is more common amongst women. Our aim was to investigate any gender differences in symptoms before and outcome after open carpal tunnel release. Methods All (n=10770) open carpal tunnel releases, registered in the Swedish National Quality Register for hand surgery (HAKIR) between 2010 and 2016, were included. Outcome was assessed by QuickDASH questionnaires and eight VAS-questions assessing pain, stiffness, weakness, numbness/tingling, cold sensitivity and ability to perform daily activities preoperatively and at three and 12 months postoperatively. Results In the study population 67% (n=7169) were women with an age of median 54.0 years (IQR 42.0-66.0; men median 59.0 years IQR 48.0-70.0; p<0.0001). VAS and QuickDASH data were available in 33% (n=3600) preoperatively, in 26% (n=2826) at three months and in 19% (n=2037) at twelve months. Preoperative QuickDASH scores were higher in women (median 54.5; IQR 38.6-68.2) than in men (median 43.2 IQR 27.3-59.1; p<0.0001) and they scored higher than men at three (25.0 IQR 11.4-45.5 vs. men median 18.2 IQR 6.8-36.4; p<0.0001) and at 12 (women: 18.2 IQR 4.5-40 vs. men: 11.4 IQR 2.3-34.1; p<0.0001) months after surgery. Women had a bigger decline in their QuickDASH scores over the 12 months of follow-up (median 27.3 IQR 11.4-40.9) than men (median 20.5 IQR 9.1-36.4; p=0.002). Women scored higher on load pain, weakness, ability to carry out daily activities, opening a tight or new jar, doing heavy household chores, carrying a shopping bag/briefcase, using a knife to cut food and ability to do recreational activities, where some force or impact is taken through the arm at all three occasions. For pain with movement without load, numbness/tingling, washing your back, severity of pain and difficulty sleeping women scored higher than men before surgery and at three months after surgery, but the differences had disappeared after 12 months. Scores for pain at rest, stiffness, interference with social activity and interference with work were higher in women preoperatively, but no differences were found at three and 12 months postoperatively. Men scored higher on cold sensitivity at three and 12 months after surgery, but no differences were found before surgery. Women rated numbness/tingling higher than men preoperatively, but at three months postoperatively the score was higher for men. At 12 months, no differences were seen between men and women. Conclusion From a large National Quality Register, we conclude that women with CTS generally rate their symptoms higher than men in QuickDASH, and for some tasks evaluated by VAS, before and after open carpal tunnel release, but the improvement is relatively higher in women. Tasks requiring more grip strength are scored higher by women than by men, which remain after carpal tunnel release. Gender differences should be considered when evaluating patients before and after carpal tunnel release.

Silviu Marinescu 1, Ana-Maria Boiangiu 1, Anca Ruxandra Oporanu 1, Ruxandra Mihai 1, Carmen Giuglea 2

1 “Bagdasar-Arseni” Clinical Emergency Hospital, Bucharest, Romania; 2 Saint John's Clinical Emergency Hospital, Bucharest Romania

Objective: This paper aims to present our experience in managing the 23 patients of the mass casualty fire of 30th October 2015 that were brought to our hospital, out of which all had thermal injuries of the hands and upper limbs. Methods: Escharotomies were performed upon admission on the upper limbs of 15 patients with circumferential deep burns. 17 patients out of the 23 were treated by enzymatic debridement of their hands, in the first 12-84h since injury, while 2 were treated by surgical excizion and grafting, starting 4 days since injury. 70% of the burns treated by enzymatic debridement were grafted and 100% of those treated by surgical excision. Results: We achieved complete coverage of the burned hands at 10 to 25 days since injury. 5 patients out of the 23 died, 8 patients were treated abroad. The remaining patients were treated afterwards with compressive garments, silicone dressings, steroid injections, laser therapy, with very good results. 3 patients needed additional surgeries, performed at 1 year after injury (scar excision, grafting, web space corrections). Conclusions: In the case of a mass casualty fire, immediate attention goes to increasing the survival rate of the patients and less to the management of essential functional areas, such as the hands. We believe both can be taken care of simultaneously, by enzymatic debridement, which is a fast, selective and efficient method of removing the burn eschar, with minimal effort, man power and blood loss, an asset in a mass casualty incident.

Kana Kataoka 1, Soya Nagao 1,2, Hiroko Shiraishi 1, Koji Tanimoto 1, Yoshiaki Tomizuka 1, Masahiro Nagaoka 1, Yasuaki Tokuhashi 1

1 Nihon University School of Medicine, Tokyo, Japan; 2 Itabashi Medical Association Hospital, Tokyo, Japan

[Introduction] To perform carpal tunnel release low-invasively and safely, preoperative diagnosis of a space occupying lesion (SOL) in the carpal canal was extremely important to improve the postoperative outcomes and to avoid the complications and recurrence. The purpose of this study is to establish the diagnostic algorithm to detect SOL for carpal tunnel syndrome (CTS) preoperatively. [Materials and Methods] Seventeen hands in 16 cases were treated for CTS accompanied by SOL. There were 9 male and 7 female, with a mean age of 60.4 years (range of 18-84 years). Affected hands were 5 right hands, 10 left hands, and 1 bilateral hands. Variety of SOL, diagnostic imaging method, and correlation between imaging and operative findings were investigated in all cases. [Results] The origins of SOL were synovitis in 6 hands, calcification in 4 hands, bifid median nerve in 3 hands (2 cases), gout nodule in 2 hands, cystic lesion in a hand and lipofibromatous hamartoma in a hand. Calcification and gout nodule are detected preoperatively by plain radiographs and additional computed tomography (CT) in all cases. Other lesions were discovered by ultrasonography in all cases and additional magnetic resonance imaging (MRI) in some cases preoperatively, however they were not found by any radiographic examinations. Additionally, each lesion had a specific finding in ultorasonographic examinations respectively, and easily diagnosed the origins. [Conclusions] The combination with plain radiographs and ultrasonography was easy, time-saving and cost-effective method for screening of SOL associated with CTS. Additional CT and/or MRI should be examined as necessary, if SOL is detected by plain radiographs and ultrasonography.

Emanuele Pamelin 1, Belinda Cedron Novoa 1, Alessandra Scalese 1, Riccardo Budroni 2

1 Hand Unit I - IRCCS Istituto Ortopedico Galeazzi Milan, Italy; 2 Ortopedia e Traumatologia Osp. San. Francesco Nuoro, Italy

Objective: Many sports are associated with a variety of peripheral nervous system (PNS) injuries specific to that sport. The sports most commonly reported with PNS injuries are football, hokey, soccer baseball, cycling and winter activities. Among the different winter activities Alpine skiing have shown an unusual entrapment of the ulnar nerve at Guyon’s canal. Matherials and methods: we report seven cases of alpine skiers suffering weakness of interossei, 4th and 5th loumbricals, adductor pollicis and abductor digiti minimi secondary to the deep motor branch of the ulnar nerve entrapment. Four men and three women, with average age 45 years (28-62) have been evaluated after intense and repeated sport activity. All the patients underwent physical examination of the peripheral entrapment before imaging and EMG and Nerve Conduction Studies. Results: all the skiers have shown a Type II compression according to the Shea and MaClain classification with the site of compression located in the distal portion of the Guyon’s canal at the origin of abductor digiti minimi and Pitres-Testut, Froment and Wartemerg sign positivity. No sensory nerves involvement have been demonstrated. MR images studies demonstrated no masses or ulnar artery thrombosis or hamate’s hook occult fractures. Conservative treatment have been proposed by resting and activity avoidance combined with splinting regimen and NSAIDs and modalities to decrease inflammation and pain. Conclusion: ulnar motor branch entrapment is a rare but typical PNS inyurie occuring in repeated ulnar deviation of the wrist owing to the extrinsic load of the ski pole in the traction phase.

Tugba Karaaslan, Ela Tarakci, Hayri Omer Berkoz

Istanbul University, Istanbul, Turkey

Objective: Carpal tunnel syndrome (CTS) is the most common type of trapped neuropathies that occurs when the median nerve is exposed to pressure within the carpal tunnel at the level of the wrist and post-surgical rehabilitation of patients is of great importance. The aim of our study was to investigate the efficacy of mirror therapy applied early after carpal tunnel open surgery on the reduction of pain and improvement of sensation and function. Methods: In the randomized controlled study with 35 patients who appropriate the inclusion criteria to investigate the efficacy of MT patients were divided into two groups by simple drawing method. In the control group (n=17), the classical physiotherapy program was applied when the post-operative immobilization period ended, MT was applied to the mirror group (n=18) in addition to this treatment for 20 minutes and a total of 10 sessions in the immobilization period. Patients who were scheduled for operation due to CTS, evaluated that pain (VAS), sense (monofilament test, esthetiometer), function and symptoms (BCTQ, MHQ, 9-hole peg test) before surgery, 3 weeks and 6 weeks after surgery. The SPSS 20.0 statistical program was used in the data analysis of the study and the level of significance was accepted as p<0,05. Results: There was no statistically significant difference between the groups in terms of demographic features and symptoms at the beginning (p˃0,05). There was a statistically significant difference in pain at rest (p = 0.004) and pain at night (p = 0.037) in favor of mirror group in the 2nd and 3rd measurement results, but there was no significant difference in other parameters (p˃0,05). There was no statistically significant difference in sensory test scores between the groups (p˃0,05). While there was a statistically significant difference in favor of the control group in the first and second measurement results (p = 0,018) and in the second and third measurement results (p = 0,032) in the 9 hole peg test, no significant difference was found in other parameters p˃0,05). There was no statistically significant difference between the Boston Carpal Tunnel Questionnaire and Michigan Hand Outcomes Questionnaire scores between the groups (p˃0,05). Conclusions: The data obtained from the study indicated that the improvement in the related parameters, the early introduction of mirror therapy to carpal tunnel open surgery after classical methods has been started after immobilization with physiotherapy exercising compared, there was no significant difference between the groups, however, in the reduction of pain in CTS patients, in the improvement of the sense of light touch and in the improvement of function. In the repeated measurements, both groups showed that the treatment had a positive effect at post operative 6th week.

Konstantinos Tolis 1, Kalliopi Diamantopoulou 2, Dimitrios Vasileiou 1, Emmanouil Fandridis 1, Frantzeska Zampeli 1, Sarantis Spyridonos 1

1 Hand surgery,Upper limb and Microsurgery Department, General Hospital KAT, Athens, Greece; 2 Pathologic Anatomy Department, General Hospital KAT, Athens, Greece

Objective : Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Etiologies can be numerous but rarely a vascular cause is referred in medical literature. We present a case of chronic CTS due to a post traumatic aneurysm of the superior palmar arc. Methods: A 63 years old woman was referred to our clinic for further evaluation of a large mass at the center of her left palm, with simultaneous symptoms of median nerve entrapment. Her medical history was free of chronic diseases. She reported a fall from a ladder two years before presentation, when a large hematoma covered most of the palmar area. Tinel sign was positive for carpal tunnel syndrome, as well as the neurophysiologic studies. Under brachial plexus anesthesia and tourniquet, a z-plasty incision extending from the carpal tunnel area to the distal transverse palmar line revealed a large, dark red mass. The median nerve was decompressed at the carpal tunnel. After careful dissection and identification of the palmar arc the mass was removed en bloc. No digital blood insufficiency was documented intraoperatively. The wound was closed and a short palmar plaster cast was used for rest. Results : The plaster cast was removed after two weeks. The histopathology of the specimen revealed organizing and recanalizing thrombi, consisting of anastomosing channels, leading to aneurismal type dilatation of the vessel lumen. Relief of symptoms continued progressively during one year follow up. Discussion : An aneurysm of the superior palmar arc is an extremely rare cause of CTS. A careful preoperative examination, followed by accuracy in surgical resection will provide a postoperative normal digital blood circulation.

Lia Miyamoto Meirelles 1, Carlos Henrique Fernandes 1, Benno Ejnisman 2, Moises Cohen 2, João Baptista Gomes dos Santos 1, Flávio Faloppa 1

1 Hospital São Paulo - Universidade Federal de São Paulo - Department of Orthopedic Surgery - Hand Surgery Unit, Brazil; 2 Hospital São Paulo - Universidade Federal de São Paulo - Department of Orthopedic Surgery - Centro de Traumatologia do Esporte

The increase in the number of athletes in sports for people with disabilities (henceforth, SPD) has been growing all over the world. Surveys conducted with these athletes showed alterations in the median nerve in ultrasound and electrical studies. We did not find research on the clinical signs and symptoms of Carpal Tunnel Syndrome (STC) or the need for some type of treatment in SPD. The goal of this study was to evaluate the clinical signs and symptoms of CTS in SPD, as well as the need for clinical and/or surgical treatment. This study was observational and transversal. It included athletes in SPD that involved palmar grip or hand support in the flat position and flexion of the wrist when supporting the weight of the body, regardless of wheelchair use. In the evaluation, we investigated the complaint of nocturnal paraesthesia, Tinel's signal on the wrist and the Phalen maneuver. To measure the symptoms, we applied the visual analog scale for pain, as well as the Boston and the CTS-6 questionnaires. We evaluated 75 SPD athletes, totaling 147 hands (73 right hands, 74 left hands). The mean age was 32.2 years, ranging from 14 to 53 years. 29 (38.67%) were weightlifters, 15 (20.00%) were (sitting) volleyball player, 14 (18.66%) wheelchair fencers, 13 (17,33%) wheelchair basketball players, 2 (2.67%) capoeiristas (a Brazilian martial art) and 2 (2.67%) table tennis players. No athlete reported presence of nocturnal paraesthesia or pain in the hands. The Tinel Sign was present in the right hand of 4 athletes (5.47%) and in the left hand of 4 athletes (5.40%). The Phalen maneuver was present in the right hand of 12 athletes (16.43%) and in the left hand of 8 athletes (10.81%). The presence of two symptoms or signs occurred only in 5.6% of right hands and in 4.2% of left hands. The median score of the Boston Questionnaire for right (resp. left) hands was 11.75 (11.36), whereas the mean CTS-6 score for right (resp. left) hands was 1.08 (1.06). The few athletes who reported some signs and/or symptoms of CTS showed no interest in performing complementary tests or some type of treatment. Our results show that changes -- found in complementary tests -- in the shape and electrical conduction of the median nerve in SPD athletes do not lead to clinical manifestations that require clinical or surgical treatment.

Dawid Mrozik 1,2, Agnieszka Jackiewicz 1,2

1 HANDPROJECT Clinic, Gdańsk, Poland; 2 SWISSMED Private Hospital, Gdańsk, Poland

Background: Compression of the ulnar nerve in the cubital tunnel is the second most frequent entrapment neuropathy of the upper extremity after carpal tunnel syndrome. None of the described techniques have proved to be superior in randomized prospective trials. We therefore present our series of endoscopically decompression of the ulnar nerve at the elbow to determine the effectiveness of this procedure. Methods: It was prospective, non-randomize two-center clinical study. In 45 patients: 25 men and 20 women (age's range 28-77) with clinical McGowan grade I (6 patients), II (29 patients), and III (10 patients) and electrophysiological signs of cubital tunnel syndrome, 21-cm of the ulnar nerve was released through a 2-cm long skin incision. Diagnosis was based on history, clinical examination (i.e. pain over medial epicondyle, sensory loss, positive Tinnel's sign, weakness or atrophy of the muscles innervated by the ulnar nerve, and positive elbow flexion test) and confirmed by neurophysiological studies (nerve conduction velocity and electromyography). A 4-mm, 30° standard endoscope and Wolf retractor were used during the procedure, and the mean postoperative follow-up examination was 12 months. Results: There were no visible nerves and vessels injured during the procedure. The main postoperative complication was hematoma in 4 patients that resolved after conservative management. There was no elbow extension deficit after surgery and surgical wounds all healed within a week. Grip strength showed a highly significant increase after surgery. Outcomes were excellent in 27 of 45 cases and good in 13 of 25 cases. Grip strength showed a highly significant increase after surgery compared to the non-operated hand (p<0.005). The mean DASH score was decreased significantly about 65% (from 74,8 before operation to 26,3 after procedure) (p<0,005). 88% patients were satisfied with the procedure. Conclusion: Endoscopic technique for treating cubital tunnel syndrome is a safe and reliable procedure, characterized by a short incision, minimal soft tissue manipulation, less scar sensitivity and early postoperative mobilization. It demonstrates promising benefits against conventional approaches (complete release and good visualization), and reduced complication profile (painful scarring and elbow contracture). Endoscopy is a widely imaging study for assessing nerves providing useful information on the severity and stage of nerve pathology.

Mark Mikhail, Roisin T Dolan 1, Michelle Baker 1, Ciara Deall 1, Ravi Knight 2, David Wilson 3, Henk P Giele 1

1 Department of Plastic and Reconstructive Surgery; 2 Department of Neurophysiology; 3 Department of Radiology Oxford University Hospitals NHS Trust, Oxford, UK

Objectives Thoracic outlet syndrome (TOS) is a symptom complex caused by compression of one or more of three neurovascular structures: the brachial plexus, subclavian vein, or subclavian artery, between the first rib and clavicle. A paucity of standardised objective diagnostic criteria renders accurate diagnosis of thoracic outlet syndrome (TOS), and reliable indicators for surgical intervention, challenging. The aim of this study is firstly, to correlate symptoms, pre-operative clinical provocative tests, radiological and neurophysiological studies with findings at surgical exploration and outcomes. Patients and Methods We performed a retrospective review of a prospectively maintained database comprising patients presenting consecutively to a quaternary level centre for surgical management of TOS. All patients were clinically assessed by the senior author (HG) at the Nuffield Orthopaedic Centre or John Radcliffe Hospital, Oxford University Hospitals NHS Trust between April 1997 and November 2017. Each patient was assessed as follows: 1. Clinical history 2. Clinical tests for vascular compression (Adson’s manoeuvre, Reverse Adson’s test, Wright’s hyperabduction test, Falconer’s test) and for neural compression (Roos’s test, Spurling’s test, Morley’s compression test and Tinel’s sign over the supraclavicular area). 3. Radiological investigations (MRI of cervical spine and brachial plexus, plain film x-ray of the c-spine) and 4. Neurophysiological studies. Surgical outcomes (resolution of symptoms, recurrence rate) were assessed at latest follow-up using Derkash’s classification category. Outcomes were then correlated with pre-operative clinical examination/investigations to identify predictive accuracy of these screening modalities. Results One-hundred and twenty-five patients (n=125) underwent thoracic outlet exploration (+/- decompression with neurolysis, +/- arteriolysis +/- excision of scalenus muscles +/- excision of cervical/ first rib) on one-hundred and sixty limbs. There was a female preponderance in this cohort (n=94, 75%) and age ranged from 22-75 years (mean: 41 years). At latest follow=up (minimum of 3 years), recurrences were noted in n=18 patients (14%) and n=99 patients (79%) reported Derkash’s full/good outcomes. Morley’s compression test was the most commonly positive provocative test (82%), MRI demonstrated pathology in 49% of patients and nerve conduction studies were suggestive/positive in 36%. Patients with > 4 pre-operative positive clinical tests demonstrated highest Derkash’s outcome scores. Conclusions Thoracic outlet syndrome is a diagnosis of exclusion and presents with atypical symptomatology in the majority of cases. Standardised clinical diagnostic criteria are less useful in this setting. We identified the quadriad of 1.positive Morley’s test, 2.positive nerve conduction studies, 3. positive findings on MRI and 4. presence of cervical rib, associated with highest diagnostic accuracy and complete resolution of symptoms. Future studies should focus on the diagnostic work-up of TOS.

Avshalom Carmel

Laniado Hospital, Netanya, Israel

Background: CTR can be achieved by open or endoscopic techniques alike. Currently, most hand surgeons use "mini open" (less then 3 cm skin incision) technique. some cut the transverse carpal ligament (tcl) with sccisors in a "semi blind" way, thereby potentially exposing the median nerve to harm. Different tools (carpaltomes) were developed in order to enhance safety but most are single use tools or expensive. objective: to describe a surgical technique using new equipment: smilley meniscotome and cannula trocar for mini-open CTR and show safety and preliminary short term results. Method : A retrospective chart review. I used a newly developed canula/trocar tool. This tool is based on a modified tool that I used for 12 years in more than 700 ctr operations with reported good results . the tool is a simple cannula and trocar of 5 mm diameter and 13 cm length that serve as a guide for a smiley meniscotome that cuts the canal roof. I will report my experience with the first 50 patients operated. patients were evaluated after 2 weeks for short term results and complications, focusing on reported sensory loss or symptom aggrevation (potential nerve damage). Result : preliminary results were good and will be reported Conclusion: this is a safe and simple way to perform mini open CTR. It is low-cost. Estimated <5euro per procedure.

Claudia Bauer, Reinhold Stober

Handchirurgie Kantonsspital Olten, Switzerland

Objective: In a previous retrospective review we provided data on long term patient satisfaction after supraclavicular first rib resection for Thoracic Outlet Syndrome (TOS) by postoperative assessment using the Quick DASH questionnaire (mean score 21 after mean follow-up of 11 years in 87 patients). Objective of the current prospective study is to systematically evaluate the outcome after supraclavicular first rib resection for TOS using validated questionnaires pre- and postoperatively. Method: All patients scheduled for supraclavicular first rib resection for TOS are assessed pre- and postoperatively (3-12 months) by Quick DASH and CBSQ (Cervical Brachial Symptom Questionnaire). Results: 20 consecutive patients are included by now. Of 11 patients pre- and postoperative questionnaires are available by now. Mean Quick DASH score before operation was 74, mean CBSQ score 95. During mean follow-up of 8 months (range 3 -12 months) Quick DASH score dropped from 74 by 34 points to 40. Concerning the CBSQ, score more than halved (dropped from 95 by 57 points to 38) indicating significant improvement after supraclavicular first rib resection. Poorer scores are associated with higher age, multiple operations, opioid use and coincidence of chronic pain syndromes. All but one patient would do the operation again. Reported subjective improvement ranges from 10 to 100%. Conclusion: The most pronounced improvement seems to occur in the first 3, rarely up to 6 months after supraclavicular first rib resection for TOS. Quick DASH and CBSQ yield valuable instruments in evaluating the outcome. Supraclavicular first rib resection can offer consistently good results with high patient satisfaction in carefully selected patients.

Lucy Homer, Samuel George, Irfan Khan

Whiston Hospital, Liverpool, UK

Introduction and Aims The few reports in the literature about digital nerve repair techniques are mostly regarding the use of allografts and conduits. We present a novel technique that can be used to bridge nerve gaps of up to 1.5 cm to achieve a primary, tension-free repair. Patients and Methods A V-Y advancement flap, of the overlying skin and soft tissue is used to achieve advancement of the underlying neurovascular bundle to approximate the ends of the nerve. This was raised similar to the Venkataswami flap used for fingertip injuries but designed more proximally. We present the case of a 48 year old male right hand dominant company director who suffered a complex circular saw injury to his left thumb and index finger with tissue loss to both fingers, a defect of the extensor pollicis longus (EPL) tendon and a 13mm defect in the radial digital nerve of his index finger. Results The technique enabled us to achieve a tension-free coaptation of the digital nerve and close the soft tissue defect. A Foucher flap from his left index was used to reconstruct the left thumb after an EPL turnover flap and this did not affect the nerve repair on the index finger. Follow-up at 3 months showed full recovery and in particular the index finger had similar sensation and 2-point discrimination when compared to the contralateral side. Photographs of all stages are presented. Conclusions A tension-free coaptation is the goal of any nerve neurorrhaphy and we know from the literature that achieving a primary closure will give you better outcomes when compared to a graft or conduit. We present a simple, yet effective technique to treat the moderate <1.5cm nerve defects saving the more expensive, less reliable conduits and grafts for the larger defects.

Karan Dua 1, Catherine Miller 2, Joshua M Abzug 3

1 SUNY Downstate Medical Center, Brooklyn, USA; 2 University of Maryland Medical Center, Baltimore, USA; 3 University of Maryland School of Medicine, Baltimore, USA

Objective: Obstetric brachial plexus injuries (OBPI) can have mental health implications on parents coping with this injury to their newborn. Previous studies have reported increased rates of depression in mothers of children with an OBPI and parents having unresolved feelings of sadness and anger. The presence of post-traumatic stress disorder (PTSD) and depression are well established in parents of babies that require a neonatal intensive care unit (NICU) stay. The purpose of this study was to assess the mental health of parents with newborns with an OBPI as compared to parents of NICU babies and babies in the healthy newborn nursery. Methods: Three groups of parents were prospectively given a 10-minute self-reported survey: 1) Newborns with OBPI; 2) Newborns in the healthy newborn nursery without OBPI; 3) Newborns in the NICU. The survey consisted of demographic questions, the PHQ-9 and PCL-S screening tools, and parents’ exposure to community violence, family support, and use of drugs or alcohol. The PHQ-9 is a 10-item depression survey that asks respondents to rate their mood symptoms on a Likert scale and the PCL-S is a 17-item PTSD survey that rates symptoms on a Likert scale. Results: 51 parents were enrolled including 41 mothers and 10 fathers. 33 mothers took the PHQ-9 portion of the survey and 4 screened in for depression (15.4% for NICU, 0% for newborn nursery, 9% for OBPI). 41 mothers took the PCL-S portion of the survey and 18 screened in for PTSD (46% for NICU, 0% for newborn nursery, 45.5% for OBPI). Of the 10 fathers, two in the OBPI group screened in for depression. Conclusions: The birth of a child with an OBPI can be very difficult to cope with for parents. The rate of PTSD is equal, being nearly half (46%), between mothers with newborns with OBPI and children in the NICU. These rates are significantly higher than the national average of 3.5% for PTSD following pregnancy. PTSD is treatable and possibly preventable with appropriate psychosocial care following newborn delivery. In contrast, untreated PTSD in parents with a child with an OBPI can affect the entire family and society. OBPI clinics should be staffed similarly to the NICU with clinical social workers that can appropriately screen and treat parents with PTSD symptoms. Orthopaedic surgeons who treat OBPI should be aware of the mental health implications on families and employ an interdisciplinary team to address these needs.

Joshua M Abzug 1, Charles Mehlman 2, Jun Ying 3

1 University of Maryland School of Medicine, Baltimore, USA; 2 Cincinnati Children's Hospital Medical Center, Cincinnati, USA; 3 University of Cincinnati College of Medicine, Cincinnati, USA

Objective: Brachial plexus birth palsy (BPBP) is quite common, however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known and unknown risk factors, and evaluate the length of stay (LOS) and costs of children with an associated BPBP injury. Methods: Data from the 1997-2012 Kids’ Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and cost was also performed. Multivariate logistic regression analysis was utilized to assess the association of BPBP with its known and unknown risk factors. Results: The incidence of BPBP has steadily decreased from 1997-2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number one risk factor for the development of a BPBP injury, (OR 166.01). Hypotonia is a newly recognized risk factor for the development of BPBP (OR 1.93). Fifty-five percent of infants with BPBP still have no known risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay costs are approximately 40% higher. Conclusions: The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the number one risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer length of stays and hospital costs compared to children without a BPBP injury.

Steven M. Koehler, Ronnie L. Shammas, Fraser J. Leversedge

Department of Orthopaedic Surgery, Duke University, Durham, NC, USA

Purpose: To assess outcomes of ulnar nerve decompression and anterior transposition at the elbow using a pedicled adipofasical flap. Methods: A retrospective cohort of patients who underwent primary or revision ulnar nerve decompression and anterior transposition using an adipofascial flap for a preoperative diagnosis of ulnar neuropathy at the elbow at a single center between 2006-2016 was examined. Pre-and post-operative visual analogue scale scores, modified McGowan classifications, complications, and physical exam findings were used to assess patient outcomes. Results: 22 patients underwent ulnar nerve decompression with anterior transposition using an adipofascial flap, and 16 patients were eligible for inclusion in the study. 11 cases were primary nerve procedures and 5 patients were revision ulnar nerve surgery with a mean postoperative follow-up time of 352 days (range: 122-701). There was a significant mean improvement in global intrinsic strength when comparing pre- and post-operative measures (3.7/5 v. 4.6/5, p<0.05 ). 50% of patients had improvement in their two-point discrimination postoperatively. Following the operation, all patients experienced a significant reduction in their VAS pain scores (4/10 v. 0.6/10, p<0.05). 12 of 16 of patients were classified as demonstrating an improvement in their modified McGowan classification score, while 4 out of 16 were classified as having no change. No patient had a worse post-operative score. All patients maintained preoperative elbow range of motion. There were no perioperative complications. Conclusions: Use of the adipofascial flap for anterior transposition of the ulnar nerve at the elbow generally provided patients with significant improvement in measured clinical outcomes, even in the revision setting. Ulnar nerve sensation and global intrinsic strength improved postoperatively, corroborating the initial published report that analyzed this technique. In patients for whom ulnar nerve decompression with or without anterior transposition is indicated, anterior transposition using an adipofascial flap may be a valuable technique for improving nerve function and for improving overall patient outcomes.

Constantinos Kritiotis 1,2, Jan Friden 3, Sabrina Koch-Burner 3, Christiana Fakonti 4

1 Manchester Hand Centre, Salford Royal NHS Foundation Trust, Manchester, UK; 2 Iasis Private Hospital, Paphos, Cyprus; 3 Swiss Paraplegic Centre, Nottwil, Switzerland; 4 Paraplegic Department, Nicosia General Hospital, Nicosia, Cyprus

Background : Hand Surgery in Tetraplegic patients has been described as the ultimate method of rehabilitation. It has been around and evolving for more than 50 years and it can significantly improve the upper limb function in selected tetraplegic patients, providing these patients with an extra level of independence. We present the story as well as our first results of our service since it was created three years ago. Methods : Following lectures in the Paraplegic Department of the Nicosia General Hospital as well as the Cypriot Paraplegic Organization, fifteen patients were reviewed for prospective surgery. The patients were evaluated using the ICSHT (International Classification for Surgery of the Hand in Tetraplegia) and three patients that were suitable candidates decided to go ahead with surgery. In these three patients four procedures were carried out, two posterior deltoid to triceps transfers as well as two grip reconstructions. Results : No complications were noted. In the case of triceps recosntruction, both patients recovered a significant strength in their reconstructed triceps and were able to use their transfers for independent mobilization. Especially one of the two patients used a hoist for his transfers prior to the procedure and now he can transfer independently using a sliding pad. The grip reconstruction procedures were done in an ICHST grade two patient (who was one of the patients that had the triceps reconstruction) and an ICHST grade four patient. Mean operating time for both procedures was 5.5 hours. Both patients had a change of dressings the next morning and started a targeted rehabilitation program. Both patients saw an increase in the functionality of their operated hands and a significant increase in their COPM scores Conclusions : Hand surgery reconstructive procedures should be offered in every suitable tetraplegic patient. The triceps reconstruction using the posterior deltoid to triceps transfer can significantly improve these patients' ability to transfer and the grip reconstruction can increase the functionality of their hands.

Hirofumi Yurie 1, Ryosuke Ikeguchi 1, Tomoki Aoyama 2, Akira Ito 2, Mai Tanaka 2, Junichi Tajino 2, Souichi Ohta 1, Hiroki Oda 1, Hisataka Takeuchi 1, Sadaki Mitsuzawa 1, Shizuka Akieda 4, Koichi Nakayama 3, Shuichi Matsuda 1

1 Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 2 Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 3 Department of Regenerative Medicine and Biomedical Engineering Faculty of Medicine, Saga University, Saga, Japan; 4 Cyfuse Biomedical K.K., Tokyo, Japan

OBJECTIVE: The treatment of the peripheral nerve injuries with nerve defect include end-to-end suturing, autologous nerve graft and nerve conduit. Recently, the implantation of neural stem cell, undifferentiated bone marrow stromal cells (uBMSCs), or fibroblasts to the nerve conduit has been shown as a beneficial effect on peripheral nerve regeneration. However, the seeding efficacy and viability of the implanted cells remain unclear. And, synthetic nerve conduits are associated with a risk of infection and low biocompatibility. So as previously reported, we created a scaffold-free Bio 3D conduit from normal human dermal fibroblasts. To promote peripheral nerve regeneration, we have made a Bio 3D conduit from uBMSCs. So, in the current study, we examined the efficacy of the peripheral nerve regeneration using a Bio 3D conduit from uBMSCs (uBMSCs group) compared to the control group from fibroblasts. METHODS: Primary uBMSCs were isolated from bone marrow of femurs of female Lewis rats and fibroblasts were from subcutaneous tissue of the skin. Using Bio 3D printer, we have made Bio 3D conduits from both cells in same procedure as we previously reported. These conduits were interposed to the rat sciatic nerve at the mid-thigh level with a 5 mm nerve gap. Eight weeks after surgery, several assessment were conducted. Data were analyzed by using student t test. Values of P < 0.05 were considered statistically significant. RESULTS: Electrophysiological studies revealed significantly higher compound muscle action potential in the uBMSCs group both in the gastrocneminus and pedal adductor muscle compared to the control group (P < 0.05). Morphometric studies revealed that the uBMSCs group exhibited a significantly greater myelinated axon number compared to the control group (P < 0.05). In the uBMSCs group, the nerve gap was bridged successfully and Bio 3D conduit was maintain tube-like structure around the regenerated axons at eight weeks after surgery. Immunohistochemical examination revealed abundant angiogenesis in the regenerated nerve and uBMSCs composing Bio 3D conduit were positive for S-100 in the eight weeks after surgery. CONCLUSION: In the present study, we created scaffold-free Bio 3D conduits from uBMSCs and confirmed peripheral nerve regeneration in a rat sciatic nerve model compared to the control group. Recent studies have demonstrated uBMSCs facilitate peripheral nerve regeneration because uBMSCs differentiated into Schwann cell-like cells and produce various types of neurotrophic factors. The immunohistochemistory suggested uBMSCs composing Bio 3D conduit differentiated into Schwann cell-like cells. And the stability of the tube-like structure even in the eight weeks was advantageous for axonal regeneration. There are several limitations associated with the current study. First, the 5-mm nerve gap was not long enough to assess the efficacy of the Bio 3D conduit from uBMSCs. Second, the duration of the observation period after transplantation was insufficient to evaluate nerve function. In the present study, we confirmed that Bio 3D conduit from uBMSCs contribute to peripheral nerve regeneration. Further studies of Bio 3D conduit are needed for clinical applications.

B Jagannath Kamath, Premjit Sujir, Mithun Pai Arkesh

Kasturba Medical College, Mangalore, Manipal University, India

AN INNOVATIVE NERVE REPAIR SIMULATION Introduction Traumatic nerve injury and its repair or reconstruction are an integral part of hand surgery. Unpredictability and the critical time have been the hallmarks of results of Nerve repairs. Clinical and Investigative modalities to confirm the success or failure of results take time. With the advent of the nerve transfers the training has acquired a new Importance. An ideal stimulatory exercise in micro neural repair should not only mimic the technical challenges but should also allow the trainees to evaluate their own techniques. Apart from the tension at the anastomotic site the important factor for favourable outcome during repair is the ability of obtaining the coaptation of fascicles. We are describing a simple method of simulation of nerve repair emphasising the method of evaluating the fascicular coaptation following the repair. Method The method that is being described involves preparing the 2 conduits of desirable size using the sterile disposable hand towels available in operation theatres. The conduits are cut into a size of 2.5 cms to mimic the proximal and distal cut ends of nerve to be repaired. Three or four pieces of small hollow plastic tubes of length 2.5 cms obtained by trimming the middle thirds of the cotton ear buds to simulate the fascicles. Three or four such white coloured tubes are inserted into one of the Conduits (proximal segment) and through the other conduit (distal segment) the same number of different coloured plastic tubes are inserted to mimic the 2 segments of nerves for simulated repair. The 2 segments can now be transfixed using a nerve apporximator to suture the anterior wall . The trainees are now allowed to bring about simulated repair keeping in mind the fascicular alignment. Once the repair is complete we know use the Android flexible HD Camera with a diameter of 3.5 mm, to evaluate the degree of coaptation at the anastomotic site of the simulated repair. The flexible camera is placed at a distance of 1-1. cms from each of the white coloured plastic tubes, and the image is captured on the laptop using the appropriate App. The overlap of the coloured circles on the white circles on the monitor, and the configuration of the overlap will give the evaluator an idea of the degree of coaptation. This can even be evaluated depending on the overlap as Grade 4 (100- 75%), Grade 3 (75-50%), Grade 2( 50-25%), and Grade 1 ( less than 25%). It will thus be possible to evaluate the coaptation obtained for each of the fascicle in the simulated repair to assess the competence of the trainee Conclusion The above described method of nerve repair is not only simple but also allows the evaluation of degree of coaptation of the fascicles following the simulated nerve repair.

Mohamed Elsaid Abdelshaheed

Faculty of medicine, Mansoura university, Mansoura, Egypt

Objective Lipofibromatous hamartoma (LFH) is a rare and benign fibro-fatty tumor of the peripheral nerves. Only a handful of cases are available in the literature with the median nerve is the most common site of affection. Cases with LFH of the digital branches of the median nerve have also been documented. Different lines of treatment of LFH were described according to the clinical presentation. Methods Here, I am presenting two cases of LFH of the digital branches of the median nerve undergone intraneural fascicular dissection and mass excision. Results Good results were obtained in the form of disappearance of numbness and regain of intact sensation. Conclusions Intraneural fascicular dissection and mass excision is a good option for management of lipofibromatous hamartoma of the digital branches of the median nerve.

Renata Paulos, Emygdio José Leomil de Paula

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

Objectives: To describe the use of pronator teres motor branch as a donor nerve for achieving fingers flexion in a tetraplegic patient. Although it is used as a donor nerve in brachial plexus lower trunk lesions, it is the first description of its use in tetraplegia. Methods: a 29 years-old tetraplegic patient had both upper limbs operated on one year after injury. Upper limb function was classified as group 4 ICSHT at both sides. We performed bilaterally transfer of the supinator motor branches to posterior interosseous nerve and transfer of one branch of the pronator teres to the anterior interosseous nerve. During the procedure, we identified on each side two branches destinated to the pronator teres muscle, and we used just one as a donor nerve. At the right side, we identified the branch to the flexor digitorum superficialis along with the AIN and it was included in the suture. Results: Patient didn’t lose the ability to pronate his forearms immediately after surgery. Five months after surgery, he presented some movements of his left hand (M2 finger extension). Eighteen months after the surgery, he has on the left side M4 fingers extension and M3 fingers flexion (FPL and FDP) and on right side M3 fingers extension and M2 fingers flexion (only FDS). Conclusion: Pronator teres motor branch can be an option of donor nerve to achieve fingers flexion in tetraplegic patients.

Amir Adham Ahmad, Sellakkuddy Selvaganesh, Vaikunthan Rajaratnam

Khoo Teck Puat Hospital Singapore

Outcome of nerve allografts in nerve injuries of the hand – single unit experience Nerve injury results are still to be improved. The nerve gap bridging needs nerve graft. The nerve auto-graft is still the gold standard. The donor site morbidity, delay in mobilization and limited availability are still significant clinical problems. Nerve allograft is an off the shelf option negating the above issues with the auto graft. Method – We are doing a prospectective interventional study in our unit using processed allografts which do not need immune suppressive therapy as there is no cellular lines in that. Axogen allograft from 1-2mm to 4-5mm size grafts varying from 15mm to 70 mm are used in this study. All the operations were done using microsurgical techniques and the measurements were taken to the nearest mm. All the data collected by interviewer administered questionnaire. The analysis done using excel spread sheets. Results – Majority of our patients were foreign workers and there was difficulty in following them up due to less turn over in follow up visits. We were able to review around 50% of them. All had insurance cover and no one had previous nerve injury of the related nerve. More patients were digital nerve injuries and the clinical outcome (Sensory nerve - 76%, Motor nerves -71%, Mixed Nerves - 54%) was satisfactory in majority. Conclusion – It has given good outcome without donor site morbidity. Chances of immediate mobilization for pure nerve injury patients were possible. But cost is a concern.

Bauback Safa 1, Jaimie T. Shores 2, Yasser El-Sheikh 3, Timothy R. Niacaras 4, Leon J. Nesti 5, Ian Valerio 6, Dominic M Power 7, Mehir J. Desai 8, Gregory M Buncke 1

1 The Buncke Clinic, San Francisco, USA; 2 Johns Hopkins University, Baltimore, USA; 3 North York Hospital, Toronto, Canada; 4 JPS Health Network, Forth Worth, USA; 5 Walter Reed National Military Medical Center, Bethesda, USA; 6 Ohio State University, Columbus, USA; 7 Queen Elizabeth Hospital, Birmingham, UK; 8 Vanderbilt University Medical Center, Nashville, USA

Objectives Processed nerve allografts (PNA) have been shown to be safe and effective option to repair nerve gap injuries in a growing number of clinical studies. The RANGER registry is an active database designed to collect outcomes data for processed nerve allografts (Avance® Nerve Graft, AxoGen) on sensory, mixed, and motor nerve repairs. The registry has continued to collect long term follow-up and has also expanded to include data from additional centers. Here we report on meaningful recovery of the expanded cumulative registry for injuries spanning 70 mm and on higher thresholds of recovery in PNA repairs with long term follow-up as compared to historical controls for nerve autograft and tube conduit. Methods The RANGER database was queried for nerve repairs in the upper extremity using PNA that reported a minimum of 6 month of quantitative outcome data. Reported sensory and/or motor assessments included 2-point discrimination, Semmes-Weinstein Monofilament (SWMF) testing, range of motion, strength test. Reported outcome data were incorporated into the MRCC scale for sensory and motor function. Meaningful recovery was defined as ≥ S3/M3 on the MRCC scale. Higher thresholds of recovery, defined as S3+/M4 or greater, were evaluated in repairs reporting a minimum of 15 months of follow-up. Demographics, outcomes and covariate analysis were performed to further characterize the sub-groups. Results The current RANGER® registry has sufficient quantitative outcomes data on 303 repairs (255 sensory and 48 mixed/motor nerve injuries). Mean age of the cohort was 42 ± 16 (18 – 81) years. Mean gap length was 22 ± 14 (3 – 70) mm with an average follow up time of 11 months. Meaningful recovery was observed in 85% of all repairs. Further analysis by nerve type observed meaningful recovery in 85% of sensory and 79% of mixed nerve repairs. Among repairs reporting longer term follow-up, mean follow-up 22 ± 7.3 (15 –42) months, 79% reported higher thresholds with S3+/M4 or greater. No related adverse events were reported. Conclusions Processed nerve allografts continue to be a safe and reliable off-the-shelf alternative for the reconstruction of nerve deficits. Quantitative data demonstrate meaningful recovery in 85% of all repairs. Repairs with longer term follow-up demonstrated higher levels of recovery at 79%. These results compare favorably to historical outcomes for autografts and exceed those for conduits. The registry remains ongoing and will continue to expand to further collect outcomes data on processed nerve allografts.

Bauback Safa 1, Andrew Watt 1, Paul Sibley 2, Robert Hagan 3, Mark S Rekant 4, Harry Hoyen 5, Brendan Mackay 6, Gregory Buncke 1

1 The Buncke Clinic, San Francisco, USA; 2 Hand and Upper Extremity Surgery, Allentown, USA; 3 Neuropax Clinic, St Louis, USA; 4 The Philadelphia Hand Center, Philadelphia, USA; 5 MetroHealth System, Cleveland, USA; 6 Texas Tech University, Lubbock, USA

Introduction Inflammation, scar formation, and adhesions are inherent following injury or surgical intervention. When peripheral nerves are involved, resultant scarring and inflammation around nerves can lead to poor outcomes and make re-access difficult in the event of secondary surgical procedures. Placental membranes, historically used as wound dressings and coverings, while containing beneficial biological properties lack the qualities ideal for surgical applications as an interpositional barrier. Human umbilical cord is a naturally resorbable and permeable membrane that’s shown to modulate inflammation, separate tissue layers, and contains essential extracellular matrix molecules and endogenous growth factors. Avive® Soft Tissue Membrane (AxoGen, Alachua FL, USA) is processed human umbilical cord membrane (cord membrane) intended for use as a soft tissue covering. This material is designed to overcome specific shortcomings of placental membranes and remains intact at least 16 weeks making it ideal for use during the critical time of scar formation and maturation. Here we report on the use of cord membrane as an interpositional barrier for exposed peripheral nerves. Methods Case evaluation was conducted on the utilization of cord membrane during peripheral nerve surgery when post-operative scar and inflammation were a concern. Following relevant consents, data was collected in cases where cord membrane was used during a surgical procedure on an exposed nerve. Information on injury, placement, and outcomes were collected. Data was reviewed to evaluate clinical application and outcomes after use in peripheral nerve surgery. Results This series included 13 patients undergoing surgical procedures with exposed nerve in the zone of injury. The average age was 45(11-62) years. Pre-operative and surgical procedures were based on institution’s standard of care. Procedures included nerve decompression, reconstruction after traumatic injury, and planned reconstructive procedures. A majority of these nerves were in the upper extremity (radial, median, ulnar nerves). After exposure and neurolysis, cord membrane was hydrated and placed as a covering over the nerve. In eight cases, sutures (6-0/8-0) were used to secure in place. All surgeons reported the membrane conformed well, easily positioned, and remained intact. The average follow-up was 6 months. There were no reported complications /revisions and patients are recovering as expected. Additional follow-up is on-going. Conclusions Processed human umbilical cord membrane can be used as a soft tissue covering during nerve surgery. This series included multiple injury types where the potential of post-operative scar and inflammation were a concern. Placement was successful in all cases. There were no reported complications or revisions and patients continue to recover as expected.

Curt Deister, Stefanie Villender, Anne Engemann, Brian Romot; Erick DeVinney

AxoGen, Alachua, USA

Introduction: Inflammation is a normal component of wound healing and can result in increased scar formation and adhesions. Placental tissues have been studied as possible mediators of inflammation but their use as an implant for internal surgical applications has suffered from inherent limitations in mechanical properties. This work describes minimally processed placental membranes, isolated from human umbilical cord membrane that retain the beneficial placental properties of the tissue, with its known potential for reducing inflammation and adhesion formation. Processed umbilical cord membrane provides ideal mechanical properties appropriate for a surgical implant while remaining in the wound throughout the wound healing cascade. Methods: Human umbilical cord membrane tissue was obtained and minimally processed following established procedures. Proteins were quantified using Milliplex® kits and analyzed using a Luminex 200TM. Resorption rate was determined by subcutaneous implant in a rat model followed by macroscopic and histological evaluation of resorption at 16 weeks. Thickness was determined by use of a push-gauge as the average of 3 sites along the graft. Tensile strength was measured at a rate of 25.4 mm/min. Suture retention strength was measured with 6-0 suture, bite depth of 3-6mm and a rate of 25.4mm/min. Results: Protein quantification included identification of 28 proteins detected at either higher (13), similar (5) or lower (10) levels compared to unprocessed controls. Proteins found at relatively high levels included several interleukins, TIMP-4 and several growth factors including EGF, FGF, PDGF, VEGF and TGF-β3. Macroscopic and histologic evaluation methods determined that approximately 75% of the implant was resorbed at 16 weeks. Average thickness of the processed umbilical cord membrane was 176µm compared to <25µm for placental amnion. Mean tensile strength of processed umbilical cord membrane was 12.3N and the mean force required for suture pull out was 1.47N. Conclusions: The results of these studies demonstrate that minimally processed umbilical cord membrane retains the inherent properties of native tissue, when implanted remains present for at least 16 weeks, is approximately 8 times thicker than placental amnion, and possesses sufficient mechanical properties to allow normal handling and use in the surgical environment.

Zeynep Tuna 1, Deran Oskay 1, Oktay Algin 2, Orhan Murat Koçak 3

1 Gazi University Faculty of Health Sciences Department of Physiotherapy and Rehabilitation, Ankara, Turkey; 2 Atatürk Education and Research Hospital, Ankara, Turkey; 3 Kirikkale University Faculty of Medicine Department of Psychiatry, Turkey

Obstetric Brachial Plexus Injury (OBPI) may cause permanent disability through into adulthood. Persistent disability is recently thought to result from central problems rather than peripheral ones. However, studies investigating the cortical changes after OBPI are very poor. Therefore, aim of this study is to investigate the cortical activity during impaired movements by functional magnetic resonance imaging. Five adult patients with right upper trunk involvement and 5 age-matched healthy volunteers participated in the study. Participants watched videos of 2 movements (hand to mouth and neck) of either side inside the scanner with the integrated eyeglasses. Statistical Parametric Mapping (SPM) was used for statistical analysis. The cortical activity level during action observation in the patient group was significantly lower in the control group (p <0,05). Areas of difference were middle temporal gyrus, premotor area and inferior parietal lobule. Region of Interest (ROI) analysis showed that the signal change in these areas was significantly lower in the patient group than in the control group (p <0,05). Observing right and left arm movements in the patient group resulted in similar activity in the cortex (p> 0,05). In conclusion, OBPI causes neuroplastic changes in the cortex, although it is a birth injury and involves peripheral structures. The motor representation of some movements does not appropriately develop as those patients have to grow up into adulthood with significant input lack. Therefore, it is concluded that even if the patients observe the correct pattern of the movements, the motor representation is still impaired in the associative areas.

Karan Dua 1, Lucas Fishman 2, Nathan O’Hara 2, Raymond A. Pensy 2, Walter A. Eglseder 2, Joshua M. Abzug 2

1 SUNY Downstate Medical Center, Brooklyn, New York, USA; 2 University of Maryland School of Medicine, Baltimore, Maryland, USA

Introduction: Injury to major peripheral nerves can occur as a result of direct penetrating trauma or crush injuries and subsequently require surgical intervention. Previous studies have mainly reported on digital nerve injuries, whereas the purpose of this epidemiologic study was to characterize patients who have undergone surgical repair of major peripheral nerves at a Level-1 trauma center over a 15-year period. Methods: A retrospective review was performed, assessing all patients who underwent major peripheral nerve repair at a level-1 trauma center over a 15-year period. Patients who underwent digital nerve repair were excluded from the study. Demographic data, type of nerve injured, mechanism of injury, and if the injury occurred as a result of poly-trauma were recorded. Qualities of the nerve repair were assessed including the type of repair and nerve gap distance. The epidemiology of injuries was described using univariate analysis. Nominal logistic regression was used to estimate the effect of model variables on the type of surgical procedures performed. Results: One hundred sixty-four patients were identified that underwent major peripheral nerve repair. Of these patients, 74.1% were male, 55.1% were African American, and the mean age was 31.0 years (SD: 12.0). The most common mechanism of injury was a laceration (36.0%), followed by a gunshot wound (17.7%), and then motor vehicle accidents (16.5%). The most commonly injured nerve was the ulnar nerve (n=39, 23.5%), followed by the median nerve (n=38, 22.9%), and then the radial nerve (n=29, 17.5%). The overall reoperation rate was 9.8%. 20% of patients who underwent either autograft or allograft repair required a reoperation. Nerve gap distance was the only significant predictor of the type of surgical repair performed (p<0.0001). Age (p=0.42) and gender (p=0.65) did not have a significant influence on the type of surgical repair performed. Conclusion: Ulnar and median nerves are the most commonly injured major peripheral nerves. Nerve gap distance was found to be the most significant predictive factor in deciding which repair technique was utilized. Patients who underwent autograft and allograft repair were more likely to require a reoperation.

Ulrike Schnick, Richarda Boettcher

Unit for reconstructive Surgery in Brachial Plexus Injuries, Tetraplegia and Cerebral Disorders, Unfallkrankenhaus Berlin, Germany

Objectives: Active elbow and shoulder function are prerequisites for the usability of an affected arm and should be reconstructed. Intra- and extraplexal neurotisations are established surgical techniques. A long term follow-up of several years is necessary to record definite results. Constant assessments of follow-up are required to compare results. Methods: 79 patients with brachial plexus injuries were treated by 95 operations between January 2010 and November 2017. In 53 cases different neurotisations like transfers of intercostal nerves to axillary nerve (15), intercostal nerves to musculocutaneus nerve (21), accessory nerve to suprascapular nerve (30), triceps branch to axillary nerve (19) and modified Oberlin transfer (18) were performed. Neurotisations of musculocutaneus, axillary and suprascapular nerves were usually combined in one surgical session.One year between operation and follow-up was the minimum of this evaluation. Range of motion and muscle force of shoulder and elbow were reported. Comparison with the literature showed limited comparability due to different assessments. Results: Follow-up of 39 patients until December 2016 was included. Shoulder abduction of ≥40° was achieved in 9/12 cases by transfer of intercostal nerves to axillary nerve with median MRC of 3 and in 9/12 cases by transfer of a triceps branch to axillary nerve with median MRC 4. Transfer of accessory nerve to suprascapular nerve led to a satisfying shoulder function in 18/22 cases - mainly in combination with reconstruction of axillary innervation. Elbow flexion of ≥ 90° and MRC ≥ 3 was successful in 12/17 cases by transfer of intercostal nerves to musculocutaneus nerve. A better success rate was achieved by modified Oberlin transfer(12/13). Median muscle force rated 4/5 MRC in all transfers for the musculocutaneus nerve including intercostal transfers and for the neurotisation of axillary nerve by triceps branch. Elbow flexion and shoulder function were both reconstructed in 32 patients. 19/27 (70,4%) of the assessed patients achieved a combined MRC ≥ 3 strength movement of shoulder and elbow. Thus they regained a suitable upper extremity which allowed to use grip and grasp by residual lower plexus innervation or further reconstructive procedures. Conclusion: Nerve transfers are a successful method to regain function in partial or complete plexus injuries. They are the first choice in treatment of root avulsions and long-stretched lesions. In addition pain is significantly reduced by shoulder stabilisation. Better results have been attained by intraplexal neurotisations like Oberlin procedure and transfer of triceps branch to axillary nerve than by extraplexal neurotisations as intercostal transfers. This is probably due to the shorter distance to the recipient muscle. According to other studies short latency between trauma and surgery has a prognostic value. An early and comprehensive diagnostic is determinative for success. In combination with extended contralateral transfers and/or free muscle transfers it might be possible to gain useful results for the whole arm including a simplified grip and grasp.

Femke Mathot 1,2, Nadia Rbia 1, A.T. Bishop 2, S.E.R. Hovius 1, A.Y. Shin 2

1 Erasmus Medical Center, Rotterdam, The Netherlands; 2 Mayo Clinic, Rochester, Minnesota, USA

To optimize the biological support and to enhance the functional outcomes of clinically available nerve replacement treatments (the Avance Nerve graft and the NeuraGen Nerve guide), we attempted to seed adipose derived Mesenchymal Stem Cells (MSCs) on the surface of these nerve substitutes. Subsequently, we studied the MSC viability, the optimal seeding time and the distribution of the MSCs throughout the nerve substitutes. In this study we used human adipose derived MSCs that are well described and characterized. An MTS assay was used to examine the viability of MSCs after different time intervals when a 2mm segment of Avance Nerve Graft or NeuraGen Nerve Guide was added to their environment (3 samples per group per time point). MSC seeding was obtained with a dynamic seeding method using a bioreactor, preserving the inner ultrastructure of the nerve substitutes. Cultured MSCs in growth medium were transferred to conical tubes containing either a 10mm Avance nerve graft or a 10mm NeuraGen nerve guide. An amount of 1 million MSCs per nerve substitute was used. The conical tubes were rotated in the bioreactor for 6, 12 and 24 hours after which cell counts were performed of the remaining ‘free floating’ MSCs in the medium in order to calculate the amount of MSCs attached to the nerve substitutes. For each time point 10 Avance Nerve Grafts and 6 NeuraGen nerve guides were used. The distribution of the MSCs was mapped with live/dead and Hoechst staining. Hoechst stain was also used to observe the distribution of cells on the inside of the graft, by staining fixed cross-sectional sections of multiple segments of the nerve substitutes. Compared to the samples containing only MSCs or only medium, neither the presence of the Avance Nerve Graft nor the NeuraGen nerve guide negatively influenced the viability of the MSCs. For the Avance group, a seeding efficiency of 18% was obtained after 6 hours, increasing to almost 70% after 12 hours after which the efficiency decreased to 65% after 24 hours. For the NeuraGen group, the seeding efficiency increased from 52% after 6 hours to 94% after 12 hours and decreased to 53% after 24 hours. Live/dead stain on all time points showed an equal distribution of viable MSCs over the entire surface of both nerve substitutes. The Hoechst stains showed the same equal distribution on the surface of the nerve substitutes, and revealed that the MSCs were absent on the inside of the nerve substitutes and thus did not migrate into the nerve substitutes. Our study has shown that MSCs are able to survive in the presence of the Avance Nerve graft and the NeuraGen nerve guide. With an optimal seeding time of 12 hours, we successfully seeded viable MSCs onto both nerve substitutes without harming the inner ultrastructure. Seeded MSCs did not migrate into the nerve and remained on the surface of the grafts. This study shows that our methods have great clinical potential to improve and individualize peripheral nerve repair in the future.

Safiye Özkan 1, Zeynep Hoşbay 2, Müberra Tanrıverdi 2, Atakan Aydın 1

1 Istanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey; 2 Bezmialem Vakif University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, İstanbul, Turkey

Objective: Many scales have been developed to assess daily living activities and clinical functions of the patients on the brachial plexus palsy. “"Brachial Plexus Outcome Measure (BPOM)" was developed in 2012 by Emily Ho, activity and substance containing a total of 14 self-rating scale consisting of the components. Our aim in this study, make an intra-inter rater reliability of BPOM scale, is used to make clinical trial in patients with brachial plexus palsy. Methods: The scale was translated into Turkish by following the appropriate translation step. The demographic data of patients were recorded. The ratings were repeated after 2 weeks. Inter- and intra-rater reliability in items was examined by using weighted kappa statistics. Results: In our study, 18 female (37,5%), 30 male (62,5%) 48 patients were included. Mean age was 8,68±2,432, mean birth weight was 4054,86±538,504 gr. The mean intra-rater agreement in items was excellent (kappa 0.810) in the raters. Fit statistics showed too much variation in the rater, who also had only good (kappa 0.450) agreement in items. The mean inter-rater agreement in items was fair; kappa 0.620, between the experienced raters and kappa 0.50 between raters. Conclusions: The BPOM is a valid and reliable measurement for assessing functions in children with OBPP in Turkey. Overall, the agreement was higher in the more experienced raters, indicating that reliable measures of the BPOM.

Zeynep Hoşbay 1, Safiye Özkan 2, Müberra Tanrıverdi 1, Ömer Berköz 2

1 Bezmialem Vakıf University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Turkey; 2 İstanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Turkey

Objective: We aimed to learn the relationship between range of motion of shoulder and mallet classification, also seperately evaluated mallet scores which are abduction, external rotation and internal rotation in children with obstetric brachial plexus palsy (OBPP). Methods: All datas of children with OBPP had shoulder tendon transfer operation called Modified Hoffer Tecnique were recorded from their file and parents. Range of motion was measured with goniometer by physiotherapist and function of shoulder evaluated with Mallet Classification. Parameters were analysied with SPSS packet program with descriptive, frequenciency and Pearson correlation analysis. The p<0.05 was accepted significantly statistically. Results: Fifty-four (64.3%) boys and 30 (35.7%) girls totally 84 children with OBPP included in the study. When looked at demographics; 47 (56%) have right involvement, 42 (50%) have C5-7 involvement type by Narakas, mean age was 7.30±2.35, and birth weight was 4138.42±512.54. The correlation analysis performed using the results of this study found a positive, moderate, statistically significant correlation between the Mallet total score and mallet abduction (r=0.305; p<0.01) and external rotation (r=0.531; p<0.01) scores, and the Mallet abduction scores and range of motion of abduction (r=0.414; p<0.01), and the mallet internal rotation and range of motion of internal rotation (r=0.298; p<0.01). A negative correlation was found between the children’s the mallet external rotation with mallet internal rotation scores (r= -0.623; p<0.01) and range of motion internal rotation (r=-0.345; p<0.01). Conclusions: The results show us; after shoulder tendon transfering increased external rotation and abduction, however limitation of internal rotation caused the Mallet Classification having wide range of motion. In future studies will focus on evaluating internal rotation with glenohumeral and scapulathorasic joints, seperately.

Safiye Özkan 1, Zeynep Hoşbay 2, Müberra Tanrıverdi 2, Ömer Berköz 1, Türker Özkan 1

1 Istanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey; 2 Bezmialem Vakif University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey

Objective: We aimed to investigate the relationship between involvement type and upper limb functions of children with obstetric brachial plexus palsy (OBPP). Methods: Demographic characteristics and physical measurements of children with OBPP were recorded. The upper limb functions were evaluated by Brachial Plexus Outcome Measurement (BPOM) scale which that developed by Emily Ho, and contains 14 items. The BPOM has 2 subtitle – activity scale (AS) and self evaluation scale (SES). The AS scored by functional movement scale (1-5). High score, 5 means completes task with normal movement pattern, and lower score, 1 means cannot complete task. The AS has 11 items, totally scored between 11-55. The SES scored by visual analog scale which that 0-10 line. Three lines, first one “my arm works ..”, second one “my hand works …” and third one “my arm and hand looks …” are evaluated apperance and functions from children eyes. Lower score, 0 means bad and poor, high score, 10 means good and excellent. Totally 3 lines scored between 0-30. Results: Forty-eight (18 (37.5%) girl, 30 (62.5%) boy) children with OBPP were included in the study. Mean age was 8.68±2.43 (min-max=4.5-14), when looked at involvement type of children 3 (6.3%) has C5-6, 19 (39.6%) has C5-7, 9 (18.8 %) has C5-T1 and 4 (8.3 %) children has C5-T1 + Horner Syndrome, and the means of BPOM subtitle scales are seperately, AS was 42.21±8.01 (min-max=17-52) and SES was 20.54±7.39 (min-max=2-30). The only statistically significant difference was found in involvement type between the BPOM AS (z= -.495; p<0.01) while no differences were found in other correlations between the scores and characteristics (p>0.05). Conclusions: There is no statistically significant differences between AS and SES scale because of we are thinking that extremity is not participate in activity cause from body imagination, sociocultural levels of children and their parents. In our opinion; in future studies will study to develop on body imagination and participation.

Teodor Stamate 1, Camelia Tamas 1, Radu Budurca 1, Mariana Stamate 2, Ionut Atanasoae 1, Ionut Topa 1

1 University of Medicine and Pharmacy “Gr.T.Popa”, Iasi, Romania; 2 Laboratory of Neurophysiology – Neurosurgery Hospital, Iasi, Romania

Objective Axillary vascular lesions associated with brachial plexus injury pose difficult decisional problems about the moment and the type of microsurgical reconstruction. Treating this kind of lesions at the same operative time has some strong advantages and should be regarded as standard. Methods 82 cases of brachial plexus injuries were selected from which 27 had associated axillary neuro-vascular lesions and were treated by a mixed team: vascular surgeon – microsurgeon. Axillary artery reconstruction was done with saphenous vein interposition grafts in 25 cases and with PTFE grafts in 2 cases. In 21 cases vascular reconstruction was performed immediately and in 6 cases after 24-48 h, delayed emergency. Nerve lesions were located at the level of cords in 19 cases, retroclavicular in 3 cases and supraclavicular lesions in 5 cases. Retro- and infraclavicular nerve lesions were treated primarily in 19 out of 21 cases by external neurolysis and neuroraphy, the reconstruction for the other 2 being through secondary nerve grafting. Spraclavicular lesions especially in elongation and avulsion injuries required secondary reconstruction through combined methods: nerve grafts, nerve transfers (intercostals ± phrenic) and palliative muscular transfers (one pectoralis major, two latissimus dorsi and two triceps). Patients were reviewed at 6, 12 and 36 months postoperatively. The mean age of the patients was 29 years. The average posttraumatic interval prior to surgery was 6-9 months. Muscular reinnervation was evaluated according to BMRC scale. Emergency repair patients presented M3-4 results on BMRC scale in comparison with secondary reconstruction patients with rezults M1-2. Results Neurological recovery was better in primary cases than in secondary reconstructions and nerve dissection was more difficult in these late cases due to scarring and the risk of iatrogenic vascular lesion. Emergency repair of both vascular and nervous lesions is mandatory. Even if the evaluation of the nerves lesions dimensions is difficult in emergency, the clinical experience of the surgeons in replantations and reconstructions of the severe damaged tissue, allows - in many cases - a reasonable evaluation of nervous tissue which is going to be sacrificed or not. Lesions evaluation in combined surgical approach with vascular surgeon and microsurgeon is the best surgical attitude towards this kind of trauma avoiding scared tissue and allowing good anatomy viewing and restoration. Primary reconstruction avoids difficult scar tissue dissection, large nerve graft reconstruction Conclusions In conclusion combined neuro-vascular axillary lesions should be treated by a mixed team – vascular surgeon + microsurgeon – with primary repair of all structures as stated by G. Brunelli. Except for elongation lesions, the other type of brachial plexus injuries associated with axillary vascular lesions worth repairing in immediate emergency after vessel repair or in delayed emergency (5-7 days) after patient stabilisation, can lead to better clinical results than secondary reconstruction. This strategy avoids iatrogenic injury to the vascular graft possible and the difficult dissection in secondary brachial plexus repair.Primary repair by mixed surgical team guarantees the best functional results in complex cases.

J. Braga Silva, G. M. Marchese, C. G. Cauduro, M. Debiasi

PUCRS University, Porto Alegre, Brazil

Objective: systematic review aims to gather evidence regarding the use of nerve conduits for peripheral nerve repair peripheral nerve injuries are a major public health problem. Nerve conduits have been developed in the recent years, although it is still not clear if they should replace nerve grafting and neurorhaphy. Methods: the following electronic databases were searched: MEDLINE, Cochrane Library (CENTRAL) and Embase. Study selection and data extraction followed the PRISMA guidelines. The systematic review of the literature retrieved 6767 articles. Only 27 studies were retained accounting for 1022 patients: 10 randomized controlled trials, 15 case series and 2 cohort studies. Results: ten different types of tubes were described and a variety of evaluation methods were used to assess outcomes in terms of efficacy (motor and sensory recovery) and complications. The Semmes–Weinstein monofilament test and the static and moving 2-point discrimination test were the most commonly applied tests to evaluate nerve recovery. In general, outcomes showed no significant difference between groups. Conclusions: synthetic conduits had more complications. Despite major methodological limitations in the studies, we can conclude that use of nerve conduits is preferable over suture repair and nerve grafting, as the functional recovery rates are above 80%. The choice of conduit is based on the surgeon’s expertise, but use of synthetic conduits is discouraged due to their higher complication rates. 

Panupan Songcharoen, Panai Laohaprasitiporn, Saichol Wongtrakul, Torpon Vathana, Roongsak Limthongthang

Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Background: Limiting source of donor nerve for primary nerve transfer has long been a great obstacle for restoration of function in total arm type brachial plexus injury (BPI) patients. Contralateral donor nerve transfer is an optional treatment for functional restoration of the injured limb. Ulnar nerve has advantage for transferring to contralateral side without using interposition nerve graft and its consistent vascular supply for vascularized nerve transfer. Objective: To report long-term (over 10 years) functional outcomes after vascularized contralateral ulnar nerve transfer to median nerve in 2 total arm type BPI patients. Material and Method: Two patients with total arm type BPI underwent vascularized contralateral ulnar nerve transfer to median nerve and end-to-side anastomosis of distal ulnar donor nerve stump to median nerve. Functional recovery of injured limb and residual deformity of donor limb were recorded during follow-up period. Results: Two patients were male sustained motorcycle accident at the age of 17 and 32 years old. The index surgery was performed at 7 and 6 months, respectively, after the injury. Motor recovery of wrist flexor was regained to Medical Research Council (MRC) grade 2 at 2 years and grade 3 at 6 years follow-up. MRC grade 1 of finger flexion was detected at 6 years follow-up. One patient has been followed for 16 years and found recovery of wrist flexor to MRC grade 4. The thumb and finger flexor were recovered to MRC grade 3. All of the patients had initial sensory deficit along donor-side ulnar nerve distribution with claw deformity. However, sensory deficit and claw deformity gradually recovered in all of the patients at 3 ½ years after surgery. Conclusions: Vascularized contralateral ulnar nerve transfer to median nerve with end-to-side anastomosis of distal ulnar nerve to median nerve can be a treatment option for total arm type BPI patients with limiting donor nerve.

Shigeya Suzuki 1, Masashi Abe 1, Kio Suzuki 1, Yosuke Usui 2, Takao Omura 3, Yukihiro Matsuyama 3

1 Fujieda Municipal General Hospital, Fujieda, Japan; 2 Mizutani Pain Clinic, Shizuoka, Japan; 3 Hamamatsu University School of Medicine, Hamamatsu, Japan

Objective: Intraoperative monitoring during hand surgery using WALANT (wide awake, local anesthesia, no tourniquet) is a powerful technique which is now utilized worldwide. However, when performing peripheral nerve surgery, tumescent injection of lidocaine with epinephrine into the area surgical field will also block the objective peripheral nerve adjacent to the injected area and is not an ideal method when the peripheral nerve is preferred to be intact and un-anaesthetized. Here, we report a novel ultrasound guided selective nerve block for ‘Intraoperative monitored peripheral nerve surgery ’. Methods: We performed ultrasound guided selective nerve block in three cases. Two cases were on cubital tunnel syndrome patients and one case was on a schwannoma arising from the median nerve. For cubital tunnel decompression, radial nerve, medial cutaneous nerve of the forearm, medial cutaneous nerve of the arm was blocked and the ulnar nerve was left intact in order to perform intraoperative monitoring. During operation, elbow flexion test was performed to ascertain the degree of decompression. The extent of ulnar nerve release was determined by the diminished symptom by elbow flexion test. For enucleation of the schwannoma arising from the median nerve, radial nerve, ulnar nerve, musculocutaneous nerve, medial cutaneous nerve of the forearm was blocked and the median nerve was left intact. 0.15% ropivacaine 4ml was used for each nerve block. 1:100,000 epinephrine was injected into the surgical field and no tourniquet was used. Results: Cubital tunnel decompression; In one patient, elbow flexion test became negative after Osborne ligament was released whether as in another patient, elbow flexion test persisted until the anterior nerve transposition was complete. Schwannoma enucleation; The intact median nerve enabled us to monitor the appearance of numbness or pain during incision of the nerve sheath until enucleation. The patient could feel the tactile sensation, when an intact fascicle was touched. This lead us to minimize the damage to the nerve fascicles and there was no neurological deficit postoperatively.Conclusions: Peripheral nerve can be monitored intraoperatively with our novel ultrasound guided selective nerve block anesthesia. Our technique enables more precise and safer surgery on peripheral nerve.

Bauback Safa 1, Jaimie T. Shores 2; John V. Ingari 2, Renata V. Weber 3, Mickey Cho 4, Jozef Zoldos 5, Timothy R. Niacaras 6, Leon J. Nesti 7, Wesley P. Thayer 8; Gregory M. Buncke 1

1 The Buncke Clinic, San Francisco, USA; 2 Johns Hopkins University, Baltimore, USA; 3 Multi-Disciplinary Specialists, Rutherford, USA; 4 San Antonio Military Medical Center; Fort Sam Houston, USA; 5 Phoenix, USA; 6 JPS Health Network, Fort Worth, USA; 7 Walter Reed National Military Medical Center; Bethesda, USA; 8Vanderbilt University Medical Center; Nashville, USA

Introduction: Severe trauma to the upper extremities often results in the transection of mixed and motor peripheral nerves. Without surgical management, these transection injuries result in functional loss that can seriously affect the patient’s overall quality of life. Clinical data demonstrate that PNA is safe and results in positive functional outcomes for the reconstruction of nerve gaps up to 70 mm in length. However, these studies mostly report on sensory outcomes. The RANGER® Registry is an ongoing observational study on the use and outcomes of processed nerve allografts (Avance® Nerve Graft, AxoGen, Inc.). Here we report on motor recovery outcomes for nerve injuries repaired acutely or in a delayed fashion with PNA and comparisons to historical controls in the literature. Methods: The RANGER® database was queried for acute mixed and motor nerve injuries in the upper extremities, head and neck area having completed greater than six months of follow-up. All subjects with sufficient assessments to evaluate functional outcomes were included. Meaningful recovery was defined as ≥M3 on the MRC scale. Demographics, outcomes and covariate analysis were performed to further characterize this sub-group. Results: The sub-group included 33 subjects with 36 nerve repairs. The mean ± SD (minimum-maximum) age was 39±19 (16-77) years. The median time to repair was 8.5 (0-133) days. The mean graft length was 34±20 (10-70) mm with a mean follow up of 594±441 days. No significant differences were found in subject age, pre-operative interval or follow-up length among subgroups (P> 0.05, ANOVA test). Meaningful motor recovery was observed in 75%. When looking at higher thresholds of recovery, 53% of these demonstrated M4 or greater recovery in repairs with at least 1 year of follow-up. The cohort was also divided and analyzed in three subgroups based on gap length: 10-25 mm, 26-49 mm and 50 mm or greater. Meaningful recovery of motor function was reported in 69%, 77% and 86% of repairs in these subgroups, respectively. Subgroup analysis showed no differences between gap lengths or mechanism of injury. There were no related adverse events reported. Conclusion: Processed nerve allografts provided functional motor recovery when used for mixed and motor nerve repairs. Outcomes compare favorably to historical controls in the literature for nerve autograft and exceed those for hollow tube conduit. Processed nerve allograft may be considered as an option when reconstructing major peripheral nerve injuries.

Sergii Strafun, Oleksii Dolhopolov, Serhii Bezruchenko

State Institution «The Institute of Traumatology and Orthopedics by the National Academy of Medical Sciences of Ukraine”, Ukraine, Kyiv

The microsurgery technique development has considerably extended the possibilities of functional recovery in case of ischemic severe injury of upper limb. During the period of 11 years 25 patients operated with injuries of peripheral nerves and posttraumatic ischemia of upper limb. Depending on the stage of ischemia process, the patients were subdivided into 3 clinical groups. The first clinical group included 9 (36%) patients with compartment syndrome and neurovascular injuries. The second group - 10 (40%) patients with injured peripheral nerves of upper limb in reactive-recovery period of ischemic contracture. The third group – 6 (24%) patients with Volkmann’s ischemic contracture in residual period and injured peripheral nerves of upper limb. Patients of all clinical group underwent precise clinical and instrumental examination to exclude sensitive and functional disorders of upper limb as well as sonography and MRI examination in dynamics. Among the 9 patients of the first group the most frequent was the suture n.medianus and/or n.ulnaris in the middle and lower part of forearm 6 (66.7%). In 2 (22.2%) patients the suture was performed at the edge of the middle and lower parts of shoulder. In one case (11.1%) there was a suture of finger nerves at the level of palm. Special conditions for recovery of these nerves were adjustment of performance of fasciotomy wounds with approaches to neurovascular batches. In 5 (55.5%) patients with compartment syndrome the damage of peripheral nerves was combines with comminuted fractures of bones of upper limb. In these patient’s recovery of nerves has been performed after elimination of acute ischemia signs (3 weeks) and osteosynthesis by external fixation. Among 10 patients of the second group in 5 (50%) cases we performed neurolysis of n.medianus and/or n.ulnaris. In 3 (30%) the suture of the abovementioned nerves was performed. Plastic by n.suralis has been performed in 2 (20%) cases. Peculiarity of neurolysis of the abovementioned nerves was that it has been performed almost along the whole ischemic compartment. In some cases, the area of neurosis exceeded 9-12cm. While suturing the peripheral nerves we observed big areas (over 4cm) of intra-stem neuromas. In process of nerve plastics we tried to put the transplants of n.suralis out of limit of ischemia diseased compartments. In the third group all 6 patients underwent plastics of peripheral nerves. It should be mentioned that even if a size of an initial defect of nerves was up to 2cm, after resection of neuromas in proximal and distal parts the size increased to 4-6cm, requiring plastics by transplants of n.suralis. Long term results of treatment were assessed according to AOOS as modified by Kurinnyi I.M. (1996), for the period over 2 years. In 14 (56%) patient the achieved result was excellent, in 8 (32%) was good, in 3 (12%) it was satisfactory. The total increase of the function of ischemic upper limb in average was over 40%, being sufficient for medico-social adaptation of this complicated category of patients.

M Yavari, D Royeentan, H Mahmoudvand

Shahid Beheshti University of Medical Science, Tehran, Iran

there is a very small chance of success for nerve reconstruction in the patients with old total brachial plexus palsy who refer after two years or suffer from flail upper extremity after the failure of prevues operation. for these individuals, the surge has to find a recipient motor nerve in order to perform free gracilis muscle transplantation. in this study, contralateral medial pectoral nerve from the intact side was transferred to the damaged side as a recipient nerve, then in the second operation, approximately 15 month later, free gracilis muscle transfer was performed. the gracilis muscle was removed and transferred to provide the elbow and finger flexion. in a retrospective study (Over 10 years) we reviewed 68 patients, for whom this method has been performed, after 1 year , the result were investigated using MRC grading system. five patients did not participate in the study. muscle power of M3 and M4 was regained in 26 and 21 patients, respectively contralateral pectoral nerve transfers followed by the free muscle transplantation can be used as a good option for patients with ld total racial plexus palsy

Onur Seyrek 1, Burcu Semin Akel 2

1 Hacettepe University, Faculty of Health Sciences, Department of Physical Therapy And Rehabilitation, Ankara, Turkey; 2 Hacettepe University, Faculty of Health Sciences, Department of Occupational Therapy, Ankara, Turkey

Objective Guitar players are at high risk of facing neuromuscular and musculoskeletal injuries. Guitarists are experiencing and reporting pain more than other instrumental musicians. The pain and discomfort they have may be due to neurovascular entrapment. In this study, we aimed to relieve the symptoms caused by neurovascular entrapment by using myofascial releasing techniques. Methods A 38-years-old guitar player with the diagnosis of Thoracic Outlet Syndrome had stiffness and coldness at the right hand for 6 months. Inspection of the upper limbs bilaterally showed vasomotor changes. Pain was present during forearm supination at 1 cm lateral to the extensor muscles’ belly. Symptoms aggravate while playing and patient had poorer performance due to the symptoms. Demographic information and painful movements were noted. Posture analysis of static erect posture and static guitar holding was made. Upper extremity neurovascular entrapment was assessed with Roos, Wright’s, Adson’s Tests and Suprascapular maneuver before and immediately after the session. The myofascial releasing session included releasing of right anterior and middle scalene, sternocleidomastoid, levator scapula, upper trapezius, pectoralis major and minor, subscapularis, teres major and minor, latissimus dorsi muscles and lateral and medial intermuscular septum of the right arm. Results The patient was playing guitar for 15 years amateurly and 3 years professionally. Average daily practicing time was 3 hours. Coldness was present at all fingers and ulnar side of the hand. Static erect posture analysis showed forward and right lateral tilt of head, shoulder protraction, right shoulder elevation, left rotation of torso, right rotation of pelvis, external rotation of hips. Static posture analysis on guitar showed tibial and femoral external rotation, left rotation and lateral flexion of torso, right shoulder protraction and elevation, excessive thoracic kyphosis and head-neck flexion, right lateral tilt and rotation of head. Before the session Roos and Wright’s tests were positive for neurovascular entrapment. Patient graded the pain at Roos Test as 6/10 on visual analog scale. Adson’s Test and Suprascapular Maneuver was negative. Pain during forearm supination was 3/10. After the session Wright’s Test was negative and pain at Roos Test reduced to 2/10. Pain during forearm supination was absent. Coldness reduced at the ulnar side of the hand but not at fingers. Conclusion Asymmetrical posture while playing guitar for years may cause stiffness following muscle chains from bottom to top. Assessment of the playing posture made us think, constantly depressing upper body with thoracic kyphosis cause tightness at quadratus lumborum and abdominal muscles. Right laterally rotating and tilting head makes sternocleidomastoid muscle overactive. To balance the force generated by tight abdominals and forward head posture, upper trapezius, anterior and middle scalene will be overloaded. Tightness at abdominal muscles and right shoulder protraction compromises pectoral muscles and reduce subacromial space. Possible entrapment sites were between scalene muscles and under pectoralis minor. The immediate relief of symptoms contributes to the muscle chains mechanism. Therefore, myofascial releasing would be an effective approach to the guitar players who have neurovascular entrapment caused by soft tissues. Long-term follow up with larger sample is needed to provide further proof.

Ryo Okabayashi 1, Takao Omura 2, Takato Ohishi 1

1 Iwata City Hospital, Iwata, Japan; 2 Hamamatsu University School of Medicine, Hamamatsu, Japan

Objective Humeral shaft fracture associated with radial nerve palsy post-injury mostly occurs in distal third of the shaft. However, it is sometimes difficult to decide whether these cases should be treated conservatively or surgically. The purpose of this study is to analyze the relationship between the location of humeral shaft fracture and the recovery of radial motor nerve paralysis. Methods Medical records of 11 patients who underwent open reduction and internal fixation for humeral shaft fractures with radial nerve paralysis which developed prior to injury between 2010 and 2017 were reviewed. The patients consisted of 3 male and 8 female with an average age 54.7 years old (21 to 90). Location of humeral shaft fracture, the distance from the proximal edge of the olecranon fossa to the fracture location measured using plain radiograph, the fracture type, the period from surgery to the recovery of extensor carpi radialis (ECR) and extensor digitorium communis (EDC) by MMT of 3 or more and the status of the radial nerve during operation were investigated. Children under fifteen years old were excluded from this study. Results The fracture locations were one each at the proximal third and middle third, and 9 at the distal third. The average distance from the proximal edge of the olecranon fossa to the fracture location was 69.1mm(42~92mm). Four patients had spiral, 2 had oblique 1 had transverse, and 4 had comminuted fracture. The average recovery period for the recovery of MMT 3 in ECR was 3.7 months and 4.6 months for EDC. There was one case of an open fracture, which took five months for the recovery of ECR and 12 months for the recovery of EDC. There was no significant difference between the recovery period and the fracture type. Seven cases were surgically explored and all of their radial nerves were in continuity. Conclusion The recovery of the radial nerve paralysis does not depend on the fracture type and in most of the cases, the recovery of ECR can be achieved in less than 4 months.

Joshua M. Abzug 1, Alexandria L. Case 1, Orlando Merced-O'Neill 2, Eric DeVinney 2

1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 AxoGen, Inc., Alachua, Florida, USA

Introduction: Tension at nerve repair sites is associated with impaired nerve regeneration and thus poor clinical outcomes. Additionally, lacerated nerve ends that have edema, scar, and/or hemorrhage, without exposed axons, limit the potential growth of regenerating axons. Thus, it is often necessary for nerve ends to be trimmed prior to direct repair or nerve grafting. The purpose of this study was to determine what effect trimming nerve ends has on the tension at the repair site. Methods: The common digital nerves to the 2nd, 3rd, and 4th webspaces were exposed in six cadaveric hands. Each nerve was then sharply lacerated. Subsequently, with the aid of a digital caliper, one nerve was trimmed 2 mm (equivalent to trimming 1 mm of each cut end of a nerve) and one nerve was trimmed 5 mm (equivalent of trimming 2.5 mm of each nerve stump.) The nerve trimming distance (0, 2, or 5 mm) was randomized in each hand. Following transection and trimming, the nerves were reapproximated, such that they were just “kissing” and the tension required to do so was measured with a tyrolean tensiometer. The tension required to make the nerve ends oppose each other was measured 10 times for each nerve. Statistical analysis was then performed. Results: Tension at the nerve repair site significantly increased as more nerve was trimmed. The average tension required to oppose the nerve when no trimming occurred was 1.3 N. Tension increased to 3 N when 2 mm of nerve was trimmed. When 5 mm of nerve was trimmed, the tension increased to 7.1 N (p<0.05). Conclusion: Removing the damaged nerve tissue plays a critical role in preparing a transected nerve for repair. As one trims a lacerated nerve to expose “good” nerve ends, significantly more tension is required to permit a direct repair. The exact threshold of acceptable tension at a nerve repair site remains unknown. However, it is important to recognize that if significant trimming of the nerve ends is performed, one may want to consider utilization of a nerve conduit or nerve graft to minimize the tension at the site of the nerve repair.

Sergio Daroda, Facundo Zabaljauregui, Fernando Menvielle, Rodolfo Cosentino, Paul Pereira

Clínica de la Mano GAMMA, La Plata, Argentina

Objective: The main purpose of this poster is to show the preliminary results in our first patient using the Great Occipital Nerve as a donor nerve in brachial plexus reconstruction. The secondary objectives are to describe the path, the relations and peripheral nerve length and its mobilization to reach the suprascapular nerve. Materials and methods: Eight cadaveric specimens were used with dissections of the two Great Occipital Nerves (GON) with a total of 16 GONs. They were dissected from the outlet at the rachis up to its surface emergence. Length measurements were registered between these points; the topographic point of its emergence in the nape skin was identified. Also the mobilization from this point to the inner scapula angle was recorded. Finally, the number of axons before and after the exit of the motor branches for the nape muscles was histologically studied. A 25-years-old patient with a total preganglionar brachial plexus palsy was operated on with a nerve transfer from the great occipital nerve to the supraescapular nerve using a nerve graft. The time from the injury to the surgery was 18 months. Results: Anatomical results: Six and 2 specimens out of 8 were males and females respectively. The length from its exit between the first and second cervical vertebrae and its emergence in the nape skin was 62 mm average. With lateral nerve mobilization, a distance of 27 mm to the medial border and superior angle of the scapula was reached. Also the length to the suprascapular notch was measured obtaining an average distance of 73 mm. Clinical result: after one postoperative year the patient shows an M3 activity of the supra and infraespinatus muscles confirmed by electromyography. Conclusions: Using the mobilization, the GON can be reached close to the suprascapular notch. This is an alternative to neurotize the suprascapular nerve and to free the accessory nerve for another transfer. Even though the sample is very low, we believe the GON can be a new source of nerve donor motor for brachial plexus reconstruction.

C.K. van der Sluis, J.M. van Bodegom, K. Postema, P.U. Dijkstra

University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands

Introduction: A brachial plexus injury (BPI) has a restricting effect on the function of the arm. As a result, the non-affected arm performs more daily tasks or perform tasks unilaterally which normally are executed bilaterally. This could lead to overuse injuries of the non-affected arm, neck or upper back. Objective: To assess the prevalence of overuse injuries of the non-affected arm, the neck and/or upper back in patients with BPI compared to a control group. Secondary objectives were to investigate factors predicting pain and disability. Patients: Patients were recruited from three outpatient departments of rehabilitation medicine in the northern region of the Netherlands. Eligibility criteria were: Having a unilateral brachial plexus injury (not due to plexus neuralgia), aged 18 years or older, date of injury more than 1 year ago, understanding written Dutch language, no co-morbidities influencing upper limb function Methods: Musculoskeletal pain was defined as pain in the muscles, tendons and/or bones not caused by an accident, sports injury, infection or joint disease. Prevalence of MSC was defined as the proportion of individuals with MSC in the preceding year. A survey was distributed by mail. The questionnaire comprised personal, work-related, social and pain specific questions: Upper Extremity Work Demands (UEWD), Pain Disability Index (PDI), Utrechtse Coping List (UCL) with active, avoidance, and support seeking questions and the RAND-36 with subscale health perception, mental health and pain. Results: Seventy-nine patients (mean age 51 years; 65% men) and 114 controls (mean age 50 years; 63% men) participated. The prevalence of MSC was significantly higher in the BPI-group (52%) compared to the control group (38%, P=0.041). Patients with BPI experienced more disability in participation (P=0.005). Mental and general health (RAND36), upper extremity work demands (UEWD) and coping styles (UCL) were similar in participants with BPI and the controls. Presence of MSC was associated with worse self-reported mobility of the affected arm, an active coping style, and lower mental and general health. Higher disability was associated with the presence of MSC, worse self-reported mobility of the affected arm , female sex and a shorter time since injury. Discussion and conclusions: The high prevalence of MSC in individuals with BPI indicates that patients with BPI are at risk for developing musculoskeletal complaints in the non-affected arm, neck or back. The self-reported functional mobility of the affected arm seems to be a useful predictor for clinical practice, since it predicted MSC as well as disability. The influence of coping styles on MSC in patients with BPI needs further attention.

Franco Bassetto 1, Manfredo Atzori 2, Matteo Cognolato 2,3, Diego Faccio 1, Gianluca Saetta 4, Arjan Gijsberts 5, Valentina Gregori 5, Mara Graziani 2,5, Francesca Giordaniello 2,5, Andrea Gigli 5, Francesca Palermo 2,5, Peter Brügger 4, Barbara Caputo 5, Henning Müller 2, Cesare Tiengo 1

1 Clinica di Chirurgia Plastica, Azienda Ospedaliera Universitaria di Padova, Padova, Italy; 2 Department of Business Information Systems, University of Applied Sciences Western Switzerland, (HES-SO Valais), Switzerland; 3 Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland; 4 Department of Neurology, University Hospital of Zurich, Zurich, Switzerland; 5 Department of Computer, Control, and Management Engineering, University of Rome “La Sapienza”, Rome, Italy

Objective This work presents the Megane Pro project, which has three main objectives: first, to improve hand prostheses by reproducing eye-hand coordination in prosthetic hands; second, to better understand phantom limb sensation and the neurocognitive effects of hand amputations; third to better integrate surgical procedures with prosthetics. The overall aim is thus to improve the capabilities and quality of life of amputees, who are - despite recent scientific progress – still affected by the limited control of prosthetic hands. Phantom limb sensation is a good predictor of how well amputees can control a robotic prosthesis, but little is known about the mutual interactions between different types of sensation and the use of a prosthesis. Methods The data acquisition setup for detecting hand movements includes 12 surface electromyography electrodes, a pair of eye tracking glasses equipped with a scene camera and a laptop. The acquisition protocol includes four exercises and a set of neurocognitive tests. The first exercise aims at improving robotic hand prostheses control. The subjects are asked to repeat 12 times several hand grasps on a set of various objects. The movements are collected from the hand movement taxonomy literature and they are presented to the subjects as videos. The grasps are repeated both as static and functional movements. The second, third and fourth exercise aim at better understanding phantom limb sensation and the neurocognitive effects of hand amputations. They include the repetition of executed and imagined movements as reported in Sirigu et al., the classical apparent motion paradigm with body parts introduced by Shiffrar and Freyd, and an experiment based on imagined and executed movement of the hand in presence of an obstacle, aimed to study obstacle shunning. The neurocognitive experiments are enriched with gaze and sEMG measures. Phenomenal characteristics of individual phantom limb sensations are assessed by structured interviews such as the interview on phantom sensations (RAM SIPS) and the phantom and stump phenomena interview. The multimodal data are analysed with statistical and artificial intelligence methods. Results The results highlight the usefulness of the acquisition setup and protocol both for prosthesis control and for neurocognitive research. Surface electromyography, eye tracking and computer vision allow to obtain more complete data. The acquisition protocol allows for a qualitative and quantitative assessment of painful, not painful and residual phantom limb sensations and examines the properties of a phantom limb when brought “in contact” with material objects. The results suggest that the interaction between sensory-motor imagery and the visual observation of objects in the environment might critically influence the properties of a phantom limb. Conclusions This paper provides an interdisciplinary insight into hand amputations and hand prosthesis control. A proper integration between surgical procedures, neurocognitive analyses, multimodal data acquisition and artificial intelligence algorithms can make current prostheses more autonomous, restoring eye-hand coordination, leading to naturally controlled robotic hands with better performance. The experiments are highly informative regarding phantom limb properties, both painful and painless, and when a phantom gets “in contact” with external objects.

Cesare Tiengo, Arianna Gatto, Andrea Monticelli, Franco Bassetto

Plastic Surgery Department, Padova, Italy

Objective: Peripheral nerve injuries following traumas are an epidemiologically relevant problem due to their poor outcome. They still need an appropriate and effective management. In the last decades, improvements in the field of biomaterials and nanotechnologies have offered a suitable alternative to more invasive methods such as autografts or allografts, leading to the production of far more sophisticated scaffolds which are able to interact with cells and macromolecules on a nanoscale. Prompted by an in depth review of current biomaterials and nanotechnologies, by the encouraging results of various in vitro studies on a novel MWCNT-PhMO_PLLA(4-methoxyphenyl-functionalized-multi walled-carbon nanotubesand PLLA-nanofibers)-based scaffold, we tested this material, combined with an external CNTfree-PLLA-wide mesh supporting structure, in vivo on a murine model of injuried sciatic nerve. Our study aimed to evaluate its effectiveness when used as a wrapping sheat compared to the actual gold standard, the epineurial suture. Moreover, we aimed to demonstrate its biocompatibility, its ability to prevent adhesions and collateral sprouting and the absence of Wallerian degeneration downstream the injury. The latter would be the real improvement compared to wraps actually on the market which have only a protective function, preventing from adhesions as well. Materials and methods: The right sciatic nerve of 7 mice was transected, repaired with an epineurial suture and then wrapped with our novel wrapping sheat. Other 3 mice underwent sciatic nerve transection and epineurial suture repair to be used as controls. All of them were monitored for the following 30 days and tested through functional tests, such as De Medinaceli test, Open Field test, Walking Track test and EMG. On the 30th day nerves and muscles were taken to be histologically analyzed. Results: Results from De Medinaceli, Open Field and Walking Track tests were statistically different between CNT-PLLA mice and sutured mice. The CNT-PLLA group showed a faster and greater improvement in all the performed tests. Friedman's test indicated improvement in the CNT-PLLA group has been far more relevant. Electrophysiology confirmed the absence of Wallerian degeneration and the presence of a biphasic compound muscle action potential (CMAP). Histology showed no adhesions and no fibrotic reaction. Muscle showed a certain grade of atrophy albeit higher among the suture group. Conclusions: Statistical analysis highlighted the better results gained by CNT-PLLAgroup in functional tests. Electromiography excluded the presence of denervation downstream the suture site and confirmed the CMAP is restored. Therefore histology confirmed that no foreign body reaction has occured and adhesions and neuromas have been avoided and showed a higher grade of atrophy in the suture group. Our MWCNT-PhMO-PLLA nanofibers based scaffold has proved to prevent Wallerian degeneration, being fully biocompatible and protective from adhesions ande neuromas at the same time.

Viviana Maja Rosero 1, Katalin Dévay 1, Zsuzsanna Aranyi 2

1 Merenyi Gusztav Hospital, Budapest, Hungary; 2 Department of Neurology, Semmelweis University Budapest, Hungary

Objective: To assess with high resolution ultrasound penetrating nerve injuries before or after nerve reconstruction. Methods: Between 2016 and 2017, consecutive patients with complete or incomplete penetrating nerve injuries were included in the study prospectively. All patients underwent clinical, electrophysiological, and B-mode and color Doppler ultrasound examination. The size of the scar / neuroma at the injury site was measured, and correlated with the degree of reinnervation where reconstruction was carried out and sufficient time has elapsed. Intraneural blood flow was quantified. Results: 30 patients with 34 injured nerves were included in the study. Most of the nerves were treated with epi- / perineural nerve suture. The earliest time point for assessment was 2.5 months, the latest was 30 years after the injury. No significant correlation was found between the degree of reinnervation and the size of the scar / neuroma. However, in a number of cases ultrasound has shown findings which prompted surgical intervention / revision. These included unrecognized neurotmesis, complete misalignment of the sutured stumps, and suture neuroma. A consistent finding was marked intraneural blood flow, not normally detected in intact nerves, proximal to the injury site. The hypervascularization was seen in all nerves, both in untreated and treated injuries. Conclusions: Hypervascularization of the nerves proximal to injury site appears to be an essential element of nerve regeneration after penetrating nerve injuries. We hypothesize that hypervascularization reflects neovascularization triggered by axonotmesis. Ultrasound may also provide important information with respect to the therapeutic pathway.

Dalia Mohamed, Dominic Power

The Hand and Peripheral Nerve Research Network, Institute for Translational Medicine, Birmingham, UK

Objective: Randomised controlled trials involving interventions in an emergency setting are notoriously difficult. Successful recruitment and retention of participants into research studies is critical for optimising internal and external validity. Balancing service pressures and the administrative burden necessary for robust trial methodology creates challenges that must be reconciled to maintain recruitment targets Methods: The CoNNECT study is a randomised controlled interventional trial with three arms evaluating the role of tension in a digital nerve repair model. The study centre is a tertiary referral hand trauma service with approximately 600 new attendances resulting in approximately 350 hand trauma cases each month. Recruitment is through a 2-stage eligibility screening process with final confirmation of eligibility after surgical exploration of the wound. At this stage the nerve to be repaired is randomised with stratification for age. Repair is then completed with microsurgical suture, Neurolac protection of a suture repair or with a Neuralac-assisted tension free co-aptation with remote sutures. The complexity of the trial design requires co-ordination between several different clinical areas and co-operation between junior medical staff, hand co-ordinators and research nurses. Interim recruitment audit in the early phase of the trial identified missed recruitment opportunities. A bespoke electronic patient record for hand trauma has been re-engineered to provide automated prompts during initial assessment of all patients with potential nerve injuries. Results: The E-hand system was designed at the Birmingham Hand Centre for the assessment and management of hand injuries. Referral, assessment, surgery and therapy data is compiled in a single system that generates workload data for co-ordination of the patient pathway. Activity reports provide accurate data on trial recruitment and missed potential trial patients. Redesign of the assessment tool to create an automated alert regarding trial eligibility and confirmation of inclusion criteria has resulted in optimisation of trial recruitment. Patients can be provided with trial information that they can review in advance of a planned day surgery admission for surgery and the research team are alerted to the date and time of attendance for surgery. Conclusion: Randomised controlled trials in trauma surgery are complex and there are challenges created by the short time available between presentation and surgery. Rotating junior staff are the first point of contact for new trauma patients and clinical pressures may limit trial recruitment. Redesign of the E-hands management system has ensured trial recruitment is optimised and that there is compliance with Good Clinical Practice guidelines.

Belén García-Medrano 1, Nuria Mesuro Domínguez 2, Clarisa Simón Pérez 3, Fernando Moreno Mateo 1, Manuel Garrosa García 3, Miguel A Martín-Ferrero 1, Sara Gayoso del Villar 3, Manuel José Gayoso Rodríguez 3

1 Orthopaedic Surgery, Hand Unit, Hospital Clínico, Valladolid, Spain; 2 Otorhinolaryngology Department, Hospital Clínico, Valladolid, Spain; 3 Cell biology and Histology department, Faculty of Medicine, University of Valladolid, Valladolid, Spain

INTRODUCTION: When a gap occurs in a lesion of peripheral nerve, the repair is possible by using a prothesis to bridge the gap between proximal and distal nerve ends. Many and of variegated origin prostheses have been employed, but none has rendered convincing results. The morbidity and limitations of the nowadays most employed treatment, opens the way to the search of surgical and biological alternatives. OBJETIVE: To obtain segments of decellularized human nerve by a new chemical method as a basis for the manufacture of biocompatible prostheses useful in the repair of human nerve injuries. MATERIAL AND METHODS: Nerves from organ donors were decellularized by a chemical method patented by one of us (MJ Gayoso, P201531544) without detergents. These prostheses were subsequently implanted, after anesthesia, in receiving Wistar rats, in which a 7 mm defect was made in a sciatic nerve. The implants were maintained for a period of 2, 4, 8 and 16 weeks. After the implant period the animals were subjected to Sciatic Functional Index (SFI) test and after anesthesia sacrificed by intracardial perfusion to complete the histological study using light and electron microscopy. RESULTS: Our decellularization method manages to eliminate Schwann cells, perineural and endoneural cells, preserving the extracellular matrix due to the absence of detergents. Functional test revealed poorer functional recovery in implanted rats as compared with our previous studies using allogenic grafts. Likewise, we have observed a greater graft rejection in this xenogenic grafted rats than with allogenic grafts. DISCUSSION: Our method of decellularization seems adequate for the development of allogeneic prostheses for clinical use. A biological study has been initiated to establish which part of the defensive reaction that leads to rejection of the human prosthesis by xenogene implanted rats is due to interspecies response. This defensive reaction is expected not appear in an allogenic graft implanted in human nerves.

Isabel Guy 1, Daniel Guerero 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2

1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK

Objectives: Injury to the infraclavicular brachial plexus is an uncommon complication of dislocation at the glenohumeral joint that results in a devastating loss of upper limb function and debilitating neuropathic pain. The patterns of injury and associated injuries are poorly defined in this injury group. Recognition of injury patterns can guide management and prognosis. Methods: We reviewed all cases of brachial plexus injury presenting to a regional peripheral nerve injury service during a three year period from 2012-2016 with at least 12 months follow up at final review. Medical records, therapy records, imaging and neurophysiology reports were reviewed and recorded in a database derived from a prospective peripheral nerve injury workload database where injuries were coded after first assessment. Demographic and injury details were recorded and a consensus on nerve injury grade was achieved by 2 reviewers and with senior author review where no consensus was reached. Results: 2500 new patient episodes have been recorded since 2012. Database interrogation identified 110 infraclavicular brachial plexus injuries during a 3 year period to 2016 with at least 12 months follow up. Following exclusion of high energy injuries, stabs, gunshots and iatrogenic injuries there were 52 injuries classified as low energy and a sub-group of 40 cases of confirmed glenohumeral dislocation were included in the final analysis. There were 26 female and 14 male patients in this sub-group with a mean age of 61 years (range 24-86). 13 patients sustained a greater tuberosity avulsion fracture and 11 patients sustained rotator cuff tears. There were 5 vascular injuries. Nerve injury classification data was complete in 36 patients (90%). Review of the injury patterns identified axonopathy of all 3 cords (medial, lateral and posterior) in 21 cases (58%) although 2 had sparing of the axillary nerve. The medial cord was most commonly injured in 78% of cases. In 5 cases (14% of classified injuries) there was a medial cord injury with additional involvement of the lateral head of the median nerve but sparing of the musculocutaneous nerve and the posterior cord. This group has not been previously described and the outcome for the hand is generally poor due to loss of the intrinsic muscles and limited reinnervation of the extrinsic finger flexors. Conclusion: Defining injury patterns can help to evaluate outcomes after brachial plexus injuries and assist in providing a prognosis. Early recognition of an injury sub-group with medial cord and lateral head of median nerve involvement (medial cord plus median nerve) and sparing of the posterior cord and musculocutaneous nerve may provide an opportunity for consideration of novel targeted nerve transfer surgery to restore hand function despite the long reinnervation distances necessary to reach forearm and hand motor targets.

Daniel Guerero 1, Isabel Guy 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2

1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK

Objectives: Axonopathy of the medial cord of the brachial plexus results in poor functional outcome for the hand due to loss of extrinsic digital flexion and paralysis of the hand intrinsic muscles. Nerve transfers for hand function are limited in efficacy due to the long reinnervation distances from intact proximal donor muscles to the distally placed denervated motor targets. Methods: Review of a clinical series of low energy infraclavicular brachial plexus injuries identified a sub-group of patients (14% of injuries) with involvement of the medial cord and lateral head of the median nerve with sparing of the musculocutaneous nerve and the posterior cord. Review of outcomes in this subgroup identified early prognostic predictors of poor recovery. A cadaveric feasibility study was designed to evaluate the use of an in-situ reverse innervated motor to sensory vascularised nerve transfer as an early intervention option to staged pedicled transfer of the neo-innervated motor nerve to a range of distal targets. Results: The medial cutaneous nerve of the forearm (MABCN) arises as a direct branch from the medial cord of the brachial plexus and has no branches in the upper arm. Following axonopathy of the medial cord there is Wallerian degeneration of the sensory axons in the MABCN. Mobilisation of the distal end at the proximal forearm enables a loop to be created and distal to proximal retrograde innervation may be achieved using the nerve to brachialis, the medial head of triceps branch, the nerve to supinator or the extensor carpi radialis branch of the radial nerve. Staged transfer of the vascularised motor graft can be achieved following axonotomy of the proximal end of the MABCN from the medial cord after reinnervation. A number of distal targets for these motor axons can be reached within the 9-12 month window necessary for a successful reinnervation. Targets include the anterior interosseous nerve, the flexor digitorum profundus branch of the ulnar nerve and the motor fascicle of the ulnar nerve in the distal forearm. Conclusions: A novel staged motor nerve transfer using a reverse innervated in-situ vascularised sensory nerve graft can be used to reinnervate distal targets following medial cord brachial plexus injury.

Isabel Guy 1, Daniel Guerero 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2

1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK

Objectives: Axonopathy of the medial cord of the brachial plexus results in poor functional outcome for the hand due to loss of extrinsic digital flexion and paralysis of the hand intrinsic muscles. Nerve transfers for hand function are limited in efficacy due to the long reinnervation distances from intact proximal donor muscles to the distally placed denervated motor targets. Methods: A review of a clinical series of low energy infraclavicular brachial plexus injuries identified a sub-group of patients (14% of injuries) with involvement of the medial cord and lateral head of the median nerve with sparing of the musculocutaneous nerve and the posterior cord. Review of outcomes in this subgroup identified early prognostic predictors of poor recovery. A cadaveric feasibility study was designed to evaluate the use of an in-situ reversed innervated motor to sensory vascularised nerve transfer as an early intervention option to staged pedicled transfer of the neo-innervated motor nerve to a range of distal targets. Results: The lateral cutaneous nerve of the forearm (LCNF) arises as a direct branch from the musculocutaneous nerve after the innervation of brachialis. In a patient with a functioning biceps the supinator branches from the posterior interosseous nerve can be sacrificed and used to reinnervate denervated targets, however they are too short for a direct nerve transfer. A cadaveric study was performed to identify the proximal branching patterns of the LCNF. There are no branches within the arm and before 5cm distal to the lateral epicondyle. Mobilisation of the distal LCNF and reverse innervation from the supinator branches through an anterior approach can provide a means of reinnervation of mid and proximal forearm motor targets when performed early as a prelude to staged distal transfer following reinnervation. Early prognostic prediction of poor outcome following medial cord brachial plexus injury can prompt use of this early transfer in isolation or in combination with a brachial to a medial antebrachial cutaneous nerve transfer for restoration of function to the digital flexors and the hand intrinsic muscles. Conclusions: A novel staged supinator motor nerve transfer using a reverse innervated in-situ vascularised sensory LCNF nerve graft can be used to reinnervate distal targets following medial cord brachial plexus injury.

Simona Odella 1, Stefania Raimondo 2, Arianna Lovati 3, Alessandro Crosio 4, Anna Maria Biondi 5, Francesco Locatelli 1, Stefano Geuna 2, Pierluigi Tos 1

1 Reconstructive Microsurgery and Hand surgery Unit, ASST Pini-CTO Milano, Italy; 2 Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Orbassano, Italy; 3 IRCCS Isituto Galeazzi Cell and Tissue Engeneering Laboratory, Italy; 4 AOU City of Health and Science of Turin UO Orthopedics and Traumatology, 2 Hand Surgery, Italy; 5 AOU City of Health and Science of Turin, Muscolo-Scheletal Tissues Bank, Italy

OBJECTIVE Peripheral nerve injuries are more than 70% of upper limb trauma. In the case of large defects, end to end suture is not possible and conduit is not enough to obtain good results, thus the gold standard is the autograft, however this solution presents disadvantages: donor site morbility and longer surgery time. Allograft could be another alternative but nerves from donors frequently cause immunogenic response. Starting from 1980, several authors are looking for the correct way to decellularize nerves preserving both the extracellular matrix and basal lamina to improve nerve regeneration. In Italy, a recent law prohibits to commercialize human tissue for profit, thus the use of marketed human-derived devices is forbidden in the case of nerve injuries that need a graft. The purpose of this study is to find an easy, cost effective, standardized and reliable protocol for the allogeneic nerve decellularization to be stored in a nerve bank. METHODS From a literature review, we concluded that the best method to eliminate cells and to remove cell debris is the chemical one. This method is able to maintain preserved basal lamina and collagen that are indispensable for nerve regeneration. In our study, we propose two chemical-based protocols for the nerve decellularization: one chemical (TritonX100 + sodium dodecyl sulphate- SDS- detergent) in association to sonication cycles, the other also chemical (phosphate-buffered saline- TBP- detergent) in association to a DNAse. According to these protocols, we decellularized human (median and ulnar) and rat (sciatic) nerves. We processed and evaluated samples by means of histology and electron microscopy compared to commercial decellularized allografts. RESULTS The results showed that both of them could remove immunogenic components maintaining the basal lamina to improve nerve regeneration. . In particular, we found that the commercial specimens maintained some integral axons, many cellular and myelin debris within a preserved collagen structure and tissue organization. Differently, nerves decellularized with the chemical and sonication protocol showed a good tissue organization with oriented and intact collagen, but still present axons within the extracellular matrix. The best results were obtained by the chemical and DNAse protocol in which a rich matched connective matrix was maintained and no integral axons were present. CONCLUSION The purpose of this study is to identify an accessible method of decellularization that was also cost-effective, standardized and permitted to obtain a complete removal of immunogenic elements maintaining an intact basal lamina to help axon regeneration. Here, we identified the best procedure to obtain stable results even in long-term storage. In the next future, we will evaluate the nerve regeneration in an in vivo study through the implantation of decellularized allograft in a rat model.

Michele Riccio, Angelica Aquinati, Pier Paolo Pangrazi, Andrea Campodonico, Letizia Senesi

Department of Reconstructive Plastic Surgery-Hand Surgery, AOU “Ospedali Riuniti” Ancona, Italy

INTRODUCTION The use of autologous sural nerve grafts is still the current gold standard for the repair of peripheral nerve injuries with wide substance losses, even if this technique have some limits like a limited donor nerve supply, and morbidity of donor site. Despite good microsurgical techniques for repair of peripheral nerve lesions and the use of nerve grafts and nerve conduits for bridging the defects, functional nerve recovery is generally partial and unsatisfactory. At present, tubulization through the muscle vein combined graft, is a viable alternative to the nerve autografts although this technique is currently limited to a critical gap of 3 cm with less favorable results for motor function recovery. EXPERIMENTAL METHODS We present our experience regarding a new tubulization method, the amnion muscle combined graft (AMCG) technique. It consists in the combination of the human amniotic membrane hollow conduit with autologous skeletal muscle fragments for repairing the substance loss of peripheral nerves and recover both sensory and motor functions.rnWe also present the clinical and histological results of an experimental study on a rat model: Fourteen male Wistar rats were divided into two groups: 1.5 cm length gap on median nerve reconstructed by means of i) a reverse nerve autograft; ii) amnion-muscle combined conduits.rnFunctional recovery, evaluated using grasping test 30, 60 and 90 days after surgery, was observed in both groups. Moreover, the stereological analysis showed that, in amnion-muscle combined conduits group, regenerating median nerves have significantly more myelinated fibres with the same axon size, but significantly thinner myelin than autograft group. The experimental study on the rat model confirm the brilliant clinical results. RESULTS Follow-up ranged from 10 to 48 months. In a series of twelve patients with loss of substance of the median nerve (7 patients) and the ulnar nerve (5 patients) ranging 3–5 cm at the wrist and forearm, AMCG achieved excellent results graded as S5 in one case, S4 in seven cases, S3+ in three cases, and S3 in one case; M5 in one case M4 in seven cases and M3 in four cases according to the Sakellarides classification and the criteria of nerve injuries committee of the british medical research council modified by Mackinnin and Dellon. No iatrogenic damage due to withdrawal of a healthy nerve from donor site was done. CONCLUSION The clinical and experimental results suggest that the AMCG is a reasonable alternative to traditional nerve autograft in selected clinical conditions. Amnion conduit, peripheral nerve repair, upper limb nerve

M.J.O.E. Bertleff

Bergman Clinics, Naarden, The Netherlands

Objective Symptomatic neuroma may develop after a nerve dissection or bruising of a nerve following any trauma to a peripheral nerve, whether accidental or planned. Neuroma-induced neuropathic pain and morbidity seriously affect the patient’s daily life and functional status. The objective of this pilot study was to provide data to assess safety and effectiveness of the NEUROCAP®, a bioresorbable capping device, to protect a peripheral nerve end and separate the nerve from surrounding tissues in order to reduce the development of a symptomatic neuroma. Methods This prospective cohort study included ten upper limb non-reconstructable symptomatic primary or secondary end-neuroma patients at three hospitals in The Netherlands. Their neuroma was treated by surgical excision followed by capping of the transected proximal nerve end with the NEUROCAP®. This nerve capping device is a tube with one closed end consisting of the bioresorbable copolyester poly(DL-lactide-ε-caprolactone), which maintains its form for up to ten weeks and then slowly degrades within approximately sixteen months. Main outcome measures of the study were VAS Pain score, QuickDASH score, recurrence of symptomatic neuroma, adverse events and use of analgesics. Primary outcome assessment of all parameters was performed after 6 weeks, secondary outcome assessment was performed at 3, 6 and 12 months after surgery. Results 10 patients were enrolled (8 females and 2 males). Mean age was 39.3 ± 22.4 years. There were five patients with superficial radial nerve (SRN) neuroma enrolled, two with neuromas of dorsal branches of ulnar nerve, two median nerves and one radial nerve. Mean VAS Pain score at baseline was 69.1 ± 27.8 on a scale of 0-100. Preliminary results indicate that this decreased to 26.9 ± 25.3 at 12-month follow up. QuickDASH scores decreased from 64.9 ± 21.2 on a scale of 0-100 at baseline to 31.5 ± 15.2 at 12-month follow up. All patients reported to use analgesics at baseline, mainly comprising a combination of Paracetamol, Naproxen, Pregabalin and/or Oxycodon. At 12-month follow up, 8 out of 10 patients reported they were not using any pain medication and in 2 patients analgesics use was significantly reduced. There was one recurrent neuroma at 12-month follow up. Adverse events (AEs) mainly included minor sensory loss inherent to the treatment (2 patients). One patient had an AE, where the device was removed after a traumatic hit on the surgical area 3 months after implantation. There was one serious adverse event (SAE), where a patient developed seroma after the surgical area was hit on furniture several weeks after the implantation. The device was removed 2.5 months later. Assessment of the origin of this SAE is inconclusive as to whether is device-related. Conclusions This pilot study shows promising results regarding treatment with the bioresorbable NEUROCAP® device in peripheral symptomatic end-neuroma in up to 12 months of follow up. The pain reduction observed significantly improves patients’ quality of life and daily function. Result interpretation is however limited by the small study group size. Further information should be collected in a larger patient population.

Aline Yen Ling Wang 1, Charles Yuen Yung Loh 1,2, Huang-Kai Kao 3,4, Fu-Chan Wei 1,3,4

1 Vascularized Composite Allotransplantation Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 2 St Andrew's Center for Plastic Surgery, Chelmsford, Essex, UK; 3 Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 4 College of Medicine, Chang Gung University, Taoyuan, Taiwan

Introduction: Traumatic peripheral nerve neurotmesis occurs frequently and functional recovery is often slow and impaired. Induced pluripotent stem cells (iPSCs) have shown much promise in recent years due to its regenerative properties similar to that of embryonic stem cells. However, the potential of iPSCs in promoting the functional recovery of a transected peripheral nerve is largely unknown. This study is the first to investigate in vivo effects of episomal iPSCs (EiPSCs) on peripheral nerve regeneration in a murine sciatic nerve transection model. Material and methods: Episomal iPSCs refer to iPSCs that are generated via Oct3/4-Klf4-Sox2 plasmid reprogramming instead of the conventional viral insertion techniques. It represents a relatively safer form of iPSC production without permanent transgene integration which may raise questions regarding risks of genomic mutation. A minimal number of EiPSCs were added directly to the transected nerve. Results: Functional recovery of the EiPSC group was significantly improved compared to the negative control group when assessed via serial five-toe spread measurement and gait analysis of ankle angles. EiPSC promotion of nerve regeneration was also evident on stereographic analysis of axon density, myelin thickness, and axonal cross-sectional surface area. Most importantly, the results observed in EiPSCs are similar to that of the embryonic stem cell group. A roughly ten-fold increase in neurotrophin-3 levels was seen in EiPSCs which could have contributed to peripheral nerve regeneration and recovery. No abnormal masses or adverse effects were noted with EiPSC administration after one year of follow-up. Conclusion: We have hence shown that functional recovery of the transected peripheral nerve can be improved with the use of EiPSC therapy, which holds promise for the future of peripheral nerve regeneration, especially in the extremity.

Richarda Boettcher, Ulrike Schnick

Unit for reconstructive Surgery in brachial plexus injuries, tetraplegia and cerebral palsy, Unfallkrankenhaus Berlin, Germany

Objectives: After reconstructive surgery in brachial plexus surgery a long term follow up of several years is necessary to record definite results. Published data for these cases show quite different patterns in recording and measurement of the outcome. Therefore studies are of limited comparability. Mostly only one item (Range of motion, muscle force, pain or function) is reported. Until now no data are available showing the relationship between measurable force and ROM and usability of the arm in daily activities. Material and method: More than 50 patients after plexus lesions with different surgical treatment were long term observed. For shoulder and elbow function range of motion as well as muscle force were reported, while for the wrist and hand mostly functional items were examined. Comparing own results with the literature showed the limited comparability. Thus critical assessment of own results was limited. Results: Based on this experience a draft for a combined chart to report functional and measurable results in a short and effective way was developed. It considers range of motion for the most important functions, muscle force, functional items, pain and sensory quality. Due to limited ressources the chart include only aspects with practical importance for usability of the arm in daily life. Conclusion: The results in reconstructive brachial plexus surgery need to be comparable better with respect to function in daily life. Nevertheless measurable items are necessary to objectify the findings. A standardized chart to report long term results might help to support multicentric evaluation of defined surgical procedures or schemes of treatment and will be introduced for discussion.

Ivica Ducic 1,2, Erick DeVinney 2

1 Washington Nerve Institute, McLean, VA, USA; 2 AxoGen Inc, Alachua, FL, USA

Objectives: Harvesting nerve autograft or obtaining sensory nerve biopsy for diagnostic purposes is expected to cause permanent sensory deficits. In addition, donor site wound complications, neuroma pain and post-denervational paresthesia may follow, mandating additional treatments due to negative effect on patient’s quality of life. Systematic review is undertaken to define the incidence, healthcare cost-related sequela and available solutions for these complications. Methods: Literature search of available Pub-Med English reported studies was undertaken to address each of the three targeted goals. Results: Although various sensory upper and lower extremity nerve donor site grafts are utilized, sural nerve is reported as the most common nerve autograft or biopsy donor site. The complication rates of chronic pain (>6months) range from 11-40%, while mild pain symptoms may persist up to 5 years or more. Diabetic patients have greater risk for chronic postoperative pain (40%, up to 44 months). Allodynia was presented in 19% of patients, while dysesthesia ranged from 35-47%. Donor site wound infection or dehiscence are reported in 3-15% of patients. The extended operative time for autograft harvest was 30-75 min, with associated OR costs of $3200-$6500, and charges for prolonged stay, affected ambulation and pain management. If complication due to surgical site infection, wound dehiscence or neuroma management, health-care costs are reported in range of $9700, with $4-$22,000 cumulative hospital loses per incidence. Medical and interventional neuroma pain management have low long-term success rate as neither removed pain source-neuroma. In addition, overall 55% effectiveness of radiofrequency ablation is further troubled with high recurrence rate, while about 70% effective neuromodulation appears appealing, only about half are still effective beyond three year, with average of 39% complications. Aside from standard sterile surgical approach, previous reports of modified sural nerve biopsy aimed to minimize donor site complication, still failed to restore the original sensation. Even surgical removal of neuroma without reconstruction may have up to 20% of failure rate. Similar to other reports, sensory donor nerve reconstruction with Avance human nerve allograft appears the most promising as it restores the nerve continuity for up to 7 cm donor defects. Conclusions: Donor site morbidity due to nerve autograft harvest or diagnostic biopsy may be associated with morbidity and costly complications. The awareness of such events should aid surgeon and patient when choosing nerve autograft vs allograft reconstruction. Newest technologies utilizing human allograft enable us to restore the original donor nerve continuity, thereby eliminating neuroma recurrence, in addition to restoring original nerve function. Further prospective studies are suggested to reinforce presented evidence based-data.

Erick DeVinney 1, Anne Engemann 1, Curt Deister 1, Ivica Ducic 1,2

1 AxoGen Inc, Alachua, FL, USA; 2 Washington Nerve Institute, USA

Objectives: In the past few decades interest in nerve allograft technology has increased greatly. Numerous institutions have developed processing and preservation methodologies in an attempt to create a nerve graft that is safe, physically stable, immunologically tolerated, structurally intact, biologically active and conveniently stored. Unfortunately, achieving this has proven challenging, with only a few reaching commercialization. Nuances in tissue sourcing, processing reagents, processing conditions, quality controls, sterilization methods and storage conditions play a role in the final functionality of each type of nerve allograft. However, general statements are often made on availability, utility and functionality of nerve allografts as a group. To better characterize the similarities and differences between preparation methods, a review of the processes, their characterization assessments and critical factors to success was conducted. Methods: A systematic review of MEDLINE and EMBASE databases was conducted using a comprehensive combination of keywords and a search algorithm according to PRISMA guidelines. Identified candidates were evaluated based on key criteria, categorized and compared to examine key similarities and differences. Results: Since 1990, 16 institutions have developed and/or patented unique nerve processing methods. Globally, 3 of these methods have been successfully developed to a clinical stage. Processing methodologies were found to vary by tissue source, processing agents, structural preservation, growth factor content, growth inhibitor content, biological activity, mechanical integrity and sterility. The most prevalent method for reducing the immunologic burden is chemical extraction, with or without detergents. Tissue sources included rat, rabbit, porcine and human. Assessments of cellular extraction, growth factor preservation and growth inhibitor modification/removal were rarely performed, and varied greatly between processes. Preservation of basement membrane structure and laminin assessments were available for many, but not all processes. The degree of structural preservation as well as functional regeneration in both short and long gap models varied greatly by processing methodology. Improved functionality was significantly correlated with a greater degree of structural and laminin preservation as well as enzymatic removal of growth inhibitors. All processing methods demonstrated a favorable safety profile. Conclusions: Tissue source, processing methodologies, and both structural and bioactive laminin preservation play key roles in the utility of nerve allografts. While safety data and general utility data may be used interchangeably, functional data varied greatly between processing methods and should not be used interchangeably. Given the high degree of variability in the data examined, the tissue source and the processor and/or processing methodology used should be specified to avoid misinterpretation of relevant data.

Joaquim Forés 1, David Romeo-Guitart 2, Mireia Herrando-Grabulosa 2, Raquel Valls 3, Tatiana Leiva-Rodriguez 2, Elena Galea 4, Francisco Gonzalez-Pérez 2, Xavier Navarro 2, Valerie Petegniel 5, Assumpció Bosch 6, Mireia Coma 3, José Manuel Mas 3, Caty Casas 2

1 Hospital Clínic. University of Barcelona, Hand and Peripheral Nerve Unit, Spain; 2 Institut de Neurociències and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona (UAB), Centro de Investigación Biomedica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Barcelona, Spain; 3 Anaxomics Biotech, S.L, Barcelona, Spain; 4 Institut de Neurociències, Biochemistry and Mlecular Biology, UAB and ICREA, Spain; 5 Department of Brain Ischemia and Neurodegeneration, Tnstitute for Biomedical Research of Barcelona (IIBB), Spanish Research Council (CSIC), Institut d'investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; 6INc and Department of Biochemistry and Molecular Biology, UAB and CIBERNED, Spain

Here we used a systems biology approach and artificial intelligence to identify a neuroprotective agent for the treatment of peripheral rood avulsion. Base bon accumulated knowledge of the neurodegenerative and neuroprotective processes that occurs in motoneurons after root avulsion, we built up a protein networks and converted them into mathematical models. Unbiased proteomic data from our preclinical models were used for machine learning algorithms and for restrictions to be imposed on mathematical solutions. Solutions allowed us to identified combinations of repurposed drugs as potential neuroprotive agents and validated them in our preclinical models. The best one NeuroHeal, neuroprotected motoneurons, exert anti-inflammatory properties and promoted functional locomotor recovery. NeuroHeal endorsed the activation of Sirtuin 1which was essential for its neuroprotective effects. These results support the value of network-centric approaches for drug discovery and demonstrate the efficacy of NeuroHeal as adjuvant treatment with surgical repair for nervous system trauma.

Michele R Colonna 1, Vincent Casoli 2, Nikolaos Papadopulos 3, Francesco Stagno d'Alcontres 1, Konstantinos Natsis 4, Bruno Battiston 5, Paolo Titolo 5, Pierluigi Tos 6, Francesco Zanchetta 1, Alfio Costa 1, Pietro Micieli 1, Antonina Fazio 1, Gabriele Delia 1, Stefano Geuna 7

1 University of Messina, Department of Human Pathology of the Adult, The Child and The Adolescent, Messina, Italy; 2 Department of Hand Surgery, Plastic Surgery, Burn Surgery, CHU University of Bordeaux, Centre François-Xavier-Michelet, Groupe Hospitalier Pellegrin, Bordeaux, France; 3 Department of Plastic Surgery And Burns, Alexandroupoli University General Hospital, Democritus University of Thrace, Alexandroupoli, Greece; 4 Aristotle University of Thessaloniki School of Medicine, Department Of Anatomy And Surgical Anatomy, Thessaloniki, Greece; 5 Azienda Ospedaliero Universitaria Citta della Salute e Della Scienza di Torino, Depatment of Traumatology, Turin, Italy; 6 UOC Hand Surgery And Reconstructive Microsurgery Unit, Asst G Pini-cto, Milano, Italy; 7 University of Turin School of Medicine, Italy

Protecting distal muscle effectors from atrophy is a major challenge in patient’s care after proximal nerve trunk injuries (particularly ulnar nerve) and several distal motor nerve fiber transfers have been suggested for this purpose. More recently, sensate fiber protection has proven effective in this task, avoiding harm to motor donors. The present study was designed to test whether through an easy dissection, the radial sensate dorsal branches to the 1st space were capable to reach in the palm the deep motor branch of the ulnar nerve to perform a comfortable coaptation. Moreover, a histomorphometric analysis was planned to show whether anatomical structures (diameter, cross-sectional area, number and density of fascicles and axons) of the donor sensate branches reached the standards proposed by the literature for efficient nerve transfer. An anatomical study was undertaken on 16 fresh cadavers from the Anatomy Labs of Bordeaux and Thessaloniki Universities and from the International Center for Learning Orthopaedics in Arezzo (Italy). The study was approved by the Review Board for Anatomical Research of the Italian Association for Surgery of the Hand and by the Ethics Committee Academical Authorities. Through a careful subcutaneous dissection of the sensate radial nerve branches to the 1st web, the largest branch was cut at the metacarpal head level. A blunt dissection was then performed through the first interosseous muscle to reach on the volar aspect the terminal branches of the deep motor branch of the ulnar nerve, identifying this as the site for coaptation, whether in end-to-end or in reverse end-to side fashion. At this site, samples were taken from both the radial donor and the ulnar recipient nerve to perform histomorphometric analysis. Nerve samples were fixed in glutaraldehyde 2.5% and processed to obtain semithin sections. Both qualitative and quantitative analysis were carried out on the specimens using a DM4000B microscope equipped with digital camera DFC320 and IM50 Image Manager System. The expected donor-to recipient fiber count ratio to identify a successful nerve transfer is known as 1:3. A smaller diameter, as well as fascicular cross-sectional area, fewer fascicles and axons, and a smaller axon density were found in the donor radial sensate branch compared to the recipient ulnar nerve branch. However, a ratio of 1:5,7 was found, which identifies the sensate branches of the radial nerve as potential good fiber donors to the ulnar motor branch in the palm.

Ishan Radotra 1, Natalie Jumper 1, N Campbell 2, Anuj Mishra 1

1 Department of Plastic and Reconstructive Surgery, University Hospital South Manchester NHS Foundation Trust, UK; 2 Department of Cardiology, University Hospital South Manchester NHS Foundation Trust, UK

Despite overall complication rates of 9.1% following implantable cardiac defibrillator (ICD) placement, brachial plexus injury is infrequently reported in the literature. We describe a 26-year-old female experiencing left arm pain, hand numbness and biceps weakness following revision ICD via subclavian vein approach. Nerve conduction studies identified severe partial left brachial plexopathy, which remained incompletely resolved after conservative management. Surgical exploration revealed lateral cord impingement by ICD loop fibrosis, necessitating neurolysis and ICD box repositioning. As increasing numbers of patients undergo cardiac device implantation, it is incumbent on practitioners to be aware of potential increases in the prevalence of this complication.

Daniel Ruter, Joseph Meyerson, Ian Valerio

The Ohio State University College of Medicine Department of Plastic Surgery, USA

Objective: Approximately 40,000 Americans are living with a major upper extremity amputation. An estimated 5-25% develop painful neuromas and up to 67% experience phantom limb pain which can severely limit prosthetic tolerance and increase narcotic usage rates. Targeted muscle reinnervation (TMR) is a surgical procedure that reroutes transected peripheral nerves to the motor unit of freshly denervated muscle. First primarily utilized to improve myoelectric prosthetic signal generation, TMR has recently been advocated for the treatment of painful neuromas. Our group will report on the advantages of targeted muscle reinnervation performed at the time of index amputation rather than as previously reported mainly at delayed setting. Primary focus on neuroma prevention and prevalence of phantom limb pain will be highlighted. Methods: A retrospective study of targeted muscle reinnervation performed on upper extremity amputees was performed. Data reviewed included reason for amputation, amputation level, patient age, postoperative neuroma and phantom limb pain rates, and time to prosthetic use. Results: Thirteen patients with upper extremity amputations were identified (2 forequarter, 5 trans-humeral, 6 trans-radial). Oncologic resection and skeletal trauma were the most common indications for amputation. Only two patients had TMR performed secondarily, all others were concurrent with amputation. Ages ranged from 22-63 years old with average follow up of 13 months (range 1-29 months). None of the 13 patients developed a painful neuroma. Phantom limb pain rates at 1, 3, 6, and 12 months were 46%, 33%, 25%, and 20%. Six patients currently use a myoelectric prosthetic and three more are undergoing assessment and fitting. Average signal capture rates are greater than 96%. Conclusion: Our data suggests that regardless of the cause of or level of amputation, upper extremity targeted muscle reinnervation prevents the formation of painful neuroma postoperatively compared to previous methods. Similarly, the prevalence of phantom limb is lower than reported rates in the literature and decreases precipitously over time. Throughout our entire cohort of targeted muscle reinnervation patients we have found significantly lower pain scores when compared to a control amputee population, leading to better tolerance of the prosthetic, and less narcotic use. In addition to the improved control of myoelectric prosthetics, the prevention of painful neuromas and reduction in phantom limb pain warrant the addition of targeted muscle reinnervation at the time of index amputation.

Abbas Peymani 1,2, Anna Rose Johnson 1, Samandar Dowlatshahi 1, Simon Strackee 2, Samuel Lin 1

1 Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands

Objective: Early recognition and treatment of traumatic upper extremity nerve injuries are paramount to optimize patient outcomes. Currently, a knowledge gap remains in regards to classification, distribution and variations in care delivery of nerve injuries treated in the emergency department (ED). The aim of this study is to evaluate racial, geographic and socioeconomic disparities in patients with upper extremity nerve injuries. Methods: We used the National Trauma Data Bank to investigate the prevalence of upper extremity nerve injuries seen in the ED. Statistical analyses were performed to determine factors associated with longer emergency room wait times. Additionally, variations in hospital trauma level status were investigated. Results: A total of 5742 patients with upper limb peripheral nerve injuries were identified. Patients had a mean age of 35.5 ± 17.8 and the majority were male (76.6%), Caucasian (56.3%) and had private insurance coverage (43.2%). Distribution of most commonly injured nerve in order of decreasing frequency included: ulnar (27.5%), radial (21.9%), median (19.9%) and digital nerves (19.4%). Average wait time in the ED was 249.2 minutes. Caucasians were more likely to have shorter ED waiting times compared to other racial groups (p<0.001). Level 1 Trauma Centers were associated with shorter ED waiting times (p<0.001). There was no association between insurance status and ED wait times. Conclusion: There are existing racial variations in the treatment of traumatic upper extremity peripheral nerve injuries. Further studies are necessary to gain an increased understanding of these trends in order to ensure prompt recognition, eliminate dispsarities in care delivery and optimize patient outcomes.

Romain Detammaecker, Lionel Athlani, Yohan Kim De Almeida, Sandrine Huguet, Francois Dap, Gilles Dautel

Department of Hand Surgery, Plastic and Reconstructive Surgery. Centre Chirurgical Emile Gallé CHU, France

Objective : The transfer of a triceps motor branch to the anterior branch of the axillary nerve is a young technique that helps to restore one of the main function of the upper limb : shoulder abduction by deltoid reinnervation. The aim of the study was to evaluate, with a minimum of 2 years follow-up, the clinical, functional and professional outcomes and also to find out any prognostic factors of this nerve transfer in isolated axillary nerve lesions and in post-traumatic C5 C6 brachial plexus avulsion. Methods : This was a retrospective single-center study with 19 patients (17 men and 2 women) operated by 6 surgeons from 2007 to 2014. Their average age was 30 years. All had deltoid paralysis confirmed clinically and electromyographically, with an important functional disorder and triceps graded minimum M4+ (British Medical Research Council scoring). At last follow-up, we measured pain score by Analog Visual Scale, range of shoulder motion in abduction (ABD) and external rotation (RE1), strength (BMRC), donor site morbidity, presence of co-contraction, Disabilities of the Arm, Shoulder, and Hand (DASH) score and the feeling of satisfaction. We questioned the patient about their professional situation, before and after the surgery. A subgroup analysis was also performed. Results : The mean follow-up was 74 months. 11 patients suffered from isolated axillary lesion, usually post anterior shoulder dislocation (or iatrogenic for 1 case). 8 patients had C5 C6 brachial plexus avulsion. The operation was undertaken 9,3 months after injury. At last follow-up, shoulder abduction strength was graded M3 in 73% and M4 in 63% and the external rotation strength was graded M3 in 84% and M4 in 74% and M5 in 37%. Abduction recovery averaged 128° and external rotation (RE1) averaged 62°. No donor site deficit was observed. The mean EVA was 1,3. A strong fatigability was rated at 1,7/3 to the effort. The amyotrophy improved in 79% of the cases to reach a minimum of 50% of the opposite side deltoid. The average DASH score was 28. 9 patients kept the same job. 7 needed a working reconversion. There were 14 good and excellent results. Conclusions : This study shows good outcomes in term of deltoid strength and shoulder range of motion, as good as those found in the literature in nerve transfer of one motor branch of the triceps to the anterior branch of the axillary nerve. The proposed nerve transfer constitutes a valid strategy in C5 C6 brachial plexus lesions but also in isolated axillary nerve lesions. The delay of surgery appears to be one of the most important prognostic factors. The addition of a second transfer from the accessory spinal nerve to the suprascapular nerve improves clinical and functional outcomes in C5 C6 lésions. The evaluation of the rotator cuff, before and after the surgery should also be done to improve our clinical outcomes.

Mikhail Novikov, Timur Torno, Andrey Fedorov, Armen Karapetyan

N. Solovjov’s Emergency Medicine Hospital and Yaroslavl State Children’s Hospital, Yaroslavl, Russia

In cases of complete brachial plexus palsy (BPP) with multiple spinal nerve avulsions extraplexal nerve transfers to selected targets is the only means to obtain useful function of the involved upper extremity. The Intercostal nerve (ICN) is a well-known donor for brachial plexus (BP) reconstructions. However, there are some controversies concerning the indications and different technique versions. Forty-eight patients with BPP underwent ICN transfers in our center (40 adults and 8 children). ICN transfers to the musculocutaneous (MC) nerve or its branches were performed in 37 cases. In 11 cases ICN were used for neurotization of free gracilis muscle transfer. In all cases only direct coaptations of ICNs and recipient nerves were used. The number of ICNs used depends on the target: main MC – 5 (adults) and 3 (children), branch MC to the biceps – 3(adults) and 2 (children), nerve of free gracilis muscle – 3 and 2. Branches of MC to brachialis muscle previously neurotized by ICNs were utilized in 5 patients with free gracilis muscle transfer. In our series only 4 (8%) patients did not obtain useful function after ICNs transfers. In 44 (92%) cases patients received sufficient muscle power M3-M4 (MRC). Our favorite method for complete BPP with multiple avulsions is the transfer of five ICNs to the main trunk of MC for reinnervation of both biceps and brachialis muscles followed by the use of the nerve branch to the brachialis muscle for free gracilis muscle transfer for finger flexion or wrist extension.

Young Ho Lee 1, Jung Eun Lee 2, Jihyeung Kim 1, Hyun Sik Gong 3, Goo Hyun Baek 1

1 Seoul National University Hospital, Seoul, South Korea; 2 Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea; 3 Seoul National University Bundang Hospital, Gyeonggi-do, South Korea

Introduction: Radial nerve palsy associated with humeral shaft fracture(HSF) is known to be the most common nerve lesion complicating long bone fractures. Although there have been some studies on the treatment and prognosis of the radial nerve palsy, but it is still controversial. Most of the patients were recovered without surgery, but there is some consensus of early surgical exploration of radial nerve concomitant internal fixation in HSF with radial nerve palsy after high energy trauma, open fractures or accompanying vascular injury. This study is to investigate clinical outcomes and prognosis of radial nerve palsy with transverse HSF showing distraction of fracture gap. Method: We retrospectively reviewed total 10 cases of the HSF patients who had radial nerve palsy immediately after trauma or who were transferred from other hospital for the same diagnosis from January 2001 to December 2014. All the cases were treated by open reduction and internal fixation with plate and screws, and radial nerves were explored under microscopy. There were 7 men and 3 women, and the mean age at the surgery was 32 years. The follow-up was more than 2 years and most common mechanisms of injury were traffic accidents. Results: Every fracture was transverse middle or middle-distal shaft of the humerus in all 10 patients. Mean distraction gap on initial or preoperative radiograph was 9 mm (range, 5 - 31 mm). Distracted-segmental injury of radial nerve was detected in all radial nerve exploration, and mean size of nerve defect was 10cm (range, 9-12cm). All injured nerves were treated with autologous sural nerve graft and all fractures were treated with plate. In every case, bone union was achieved, Recovery of motor function was 8 cases of M5 and 2 cases of M4 after nerve graft. Conclusion: In case of radial nerve palsy accompanying HSF with distracted fracture gap, there is a possibility of complete transection or long-segmental injury of radial nerve. Therefore, early exploration of radial nerve is recommended, and consider preparing for simultaneous nerve graft due to distracted-segmental injury of radial nerve.

Andreas Gohritz, Jan Fridén

Hand Surgery, Swiss Paraplegia Center, Nottwil, Switzerland

Loss of pinch power and thumb flexion can be caused by many traumatic or atraumatic origins, most frequently by carpal tunnel syndrome, flexor tendon injuries or anterior interosseous nerve (AIN) compression. A rare, but relevant differential diagnosis is an isolated flexor pollicis longus (FPL) nerve fascicle lesion. The objective of this paper is to illustrate this phenomenon with a clinical case and provide a discussion of its anatomical, clinical background and differential diagnosis of incomplete AIN syndrome in the literature. We present a 42-year-old otherwise healthy female patient who developed a weak thumb-to-index pinch and deficient right thumb flexion following the removal of osteosynthesis plates after a forearm fracture. Clinically,the flexor pollicis longus function was absent, yet index flexion and sensibility were unimpaired. Tendon rupture was excluded using a tenodesis test and the electro-physiological result of isolated interosseus nerve fascicle lesion was confirmed intraoperatively by inspection and electrostimulation. Tendon transfer using the extensor carpi radialis longus reconstruct strong thumb flexion during pinch. In conclusion, due to its specific location and anatomy, the FPL branch is more prone to isolated neuropathy, e.g. by injections or operations, than to other fascicles of the anterior interosseus nerve. When confronted with sudden and isolated thumb flexion deficiency, specialists should be aware of this rare phenomenon.

Davide Smarrelli

Humanitas-Gavazzeni Institute, Bergamo, Italy

We report our experience with cephalic or basilic vein wrapped around scarred median nerve. From 2008 from 2016 we reviewed vein wrapping for 15 median nerves. The autologous vein graft was harvested in the omolateral arm incided longitudinally and wrapped around the nerve scarring with the intima of the graft against the nerve. 11 cephalic veins and 4 basilica veins were harvested. Each patient underwent subjective and objective evaluations, VAS scale, and Semmes Weinstein test. We report excellent results on median nerve with decrease of pain in 12 cases within 5-20 days, 2 within 2 months and 1 after 10 months with important decrease of VAS from 7-9 to 0-1.The Semmes -Weinstein test showed in 10 cases recovery of complete sensibility at the end of follow up, while 5 patients showed decrease of sensibility, respectively 3 of superficial, 2 of protective sensibility. Wide neurolysis is always performed; no immobilization was applied encouraging early mobilization. 1 infection was observed; no defects in the donor area were observed Among several techniques, vascularized or free flaps, lipofilling, synthetic interposition, vein wrapping represents a reliable option: use of a vein of the same arm instead of saphenous vein as classically used, is surely less invasive for patients with a good coverage of scarred nerve, especially for big nerves. This technique is recommended mainly for treatment of recalcitrant nerve compression.

Atakan Aydin 1, Safiye Özkan 1, Zeynep Hoşbay 2

1 Istanbul Medical Faculty, Istanbul, Turkey; 2 Bezmialem Vakif University, Istanbul, Turkey

Objective: Muscle imbalance in a growing child can lead to bone and joint deformities. Obstetric palsy patients with incomplete recovery have glenohumeral joınt problems because of imbalance between shoulder adductor and internal rotator(IR) muscles & abductor external rotatuar(ER) muscles. Although shoulder internal rotation concracture preventing shoulder abduction and external rotation in the most common problem in obstetric palsy patients with partial recovery ; shoulder internal rotation limitation or external rotational conctacture is a worse condition preventing hand to belly and back functions hence limiting daily activities. An obstetric palsy child could have both shoulder external and internal rotation limitations and contractures at the same time.It is hard to explain this condition with muscles imbalance theory which is adductor and internal rotatory muscles are often out of balance with the abductor and external rotator muscle forces. May be, at incomplete recovery with C5,6,7 involvement, in every muscle unit, stem cells are differantiating to sarcomers which are short and less functioning causing contractures. Since to improve shoulder abduction and ER, tendon transfers are commonly used ,postoperative transient loss in internal rotation is expected. But some patients could not get preoperative IR functions , long after the operations. Also there are some nonoperated patients whose main problem is internal rotation limitations. We operated on these two group of patients to achieve better internal rotation function. Method: Fourteen patients had operation to improve shoulder ER and Abduction 3 years ago. Although their Abd and ER degrees improved dramatically; two years after the operation they had internal rotation limitation despite vigorous physiotheraphy. 15 patients did not have neither nerve nor palliative any operation before and had IR limitations preoperatively. During operation, posterior incision above spine of the scapula was performed, supraspinatus, infraspinatus and teres minor muscles ,and acromion bone were encountered. The intraoperative observationwas not only heavily scarred muscle fascias which needed relaxation but also shortenned external rotator muscles which needed release and lateralization with V-Y fashion so that passive shoulder internal rotation movements were possible. We did not cast or use orthosis for the patients postoperatively. At 3rd day postoperative rehabilitation program ,active range of motion exercises were initiated. All cases were evaluated by using range of motion measurement and Mallet scale. Results: Average age of the children was 6,3 years and The average follow­up period was 21 months. The preoperative values in terms of IR were 2º and postoperatively 20º. Degree of abduction was mean 136 before the surgery. After surgery, it decreased to 105º but with theraphy it catched up preoperative values. Degree of external rotation value was mean 85º preoperatively. After the treatment, the external rotation value was measured 66,2º. The mean Mallet score improved from 18 preoperatively to 20 postoperatively. Conclusion: Although shoulder abduction, ER problems are far more common in obstetrical palsy patients, there a group of patients which had internal rotation limitations either occured spontaneously or surgically. Facing with the reality we operated on these patients to achieve better hand to midline and back functions.

Anna Pittermann 1 2, Laura Hruby 2, Agnes Sturma 2 3, Oskar C. Aszmann 2

1 General Hospital Vienna, Austria 2 Medical University Vienna, Austria 3 University of Applied Sciences FH Campus, Vienna, austria

Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand and lead to numerous psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. Here we introduce a standardized psychological assessment procedure for bionic reconstruction in patients with complete brachial plexopathies. Method: Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted a semi-structured interview exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning, body image and deafferentation pain (VAS). Finally, the effect of bionic reconstruction on these parameters was analyzed over time. Results: Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. After bionic reconstruction the physical component summary scale increased from 30,80 ± 5,31 to 37,37 ± 8,41 (p-value = 0,028), the mental component summary scale improved from 43,19 ± 8,32 to 54,76 ± 6,78 (p-value = 0,018). VAS scores indicative of deafferentation pain improved from 7,8 to 5,6 after prosthetic hand replacement (p-value = 0,018). Conclusions: Bionic reconstruction provides hope for patients with complete brachial plexopathies, improves overall quality of life and reduces deafferentiation pain. Critical patient selection is crucial since high levels of adherence and compliance to a stringent prosthetic rehabilitation protocol determine optimal functional outcomes.

Richarda Boettcher, Ulrike Schnick

Unit for reconstructive Surgery in Brachial Plexus Injuries, Tetraplegia and Cerebral Disorders, Department for Hand-, Replantation- and Microsurgery, Unfallkrankenhaus, Berlin

The risk of iatrogenic nerve lesions associated to surgical treatment is not clearly quantified. For the radial nerve a frequency up to 10% according to fixation of a humeral fracture seems to be likely. In 25% of all radial nerve lesions including primary appearance a complete reinnervation will not spontaneously occur. The study aims to define the effect of consequent diagnostic and surgical improvement on the functional result. In a retrospective analysis all surgical treated patients between 01/2010 and 11/2017 with lesions of the radial nerve were identified. All cases with isolated lesions of the superficial sensory branch and all cases with compartment syndrome were excluded for the analysis. 89 patients received neurolysis, direct microsurgical repair, repair with grafts or muscle transfers. These cases were analyzed to define the rate of iatrogenic lesions according to the anatomical level, to identify risk factors for iatrogenic complications and to allow a statement concerning treatment and outcome. 48 lesions of the radial nerve at the axillary region and upper arm were treated surgically. Under them 20 (42%) lesions occurred according to further surgical treatment. Main causing procedures were intramedullary nail fixation, plate fixation and prosthesis of the shoulder. At the lower arm level including radial head 42 lesions of the deep motor branch were operated, among them 12 cases with clear iatrogenic cause. In this area plate fixation or removal were common reasons. Three cases showed previous radial head surgery. Previous schwannoma or lipoma resection was etiological in three cases. Treatment strategies were muscle transfers in 13 cases with good results and one missing follow- up. Isolated neurolysis, in some cases combined with correction of implants, showed reinnervation in all 10 cases, while two more cases were lost for follow-up. In 6 cases with microsurgical reconstruction by graft the result showed 1 missing reinnervation, 4 good results and 1 missing follow-up. For all 32 cases of iatrogenic radial nerve lesions 25 good results with functional benefit good be achieved. For two patients with additional palsies no changing of the findings was possible. In three cases the long term result is unknown. The summarized results show a high probability to improve reinnervation or functional outcome by surgical treatment. Patients with an evidence for structural nerve lesions after surgical treatment should be revised early with an option for all different treatment methods. With this postulate permanent radial palsies following surgical treatment can be avoided better than by “wait and see”. Furthermore a better awareness of the endangered radial nerve in different surgical procedures might be reachable by interdisciplinary co-working and better instruction

Isabel Guy 1, Daniel Guerero 1, Manish Gupta 2, Petros Mikalef 2, Dominic Power 2,3

1 Birmingham University, UK; 2 Birmingham Hand Centre, UK; 3 Institute for Translational Medicine, UK

Objectives: Tensegrity is an inherent property of biological tissues. Following nerve transection a nerve gap results and repair with microsurgical sutures may result in ischaemia, fascicle distortion and intrinsic scar formation as a result of stress concentration around sutures. A delay to repair results in a greater modulus of elasticity for a nerve. The increased strain is partially mitigated by creep, however it remains higher than for a fresh repair. Techniques to reduce tension at repair sites have been widely adopted, however little clinical evidence exists for increased neural regeneration. This cadaveric pilot study examines the effect of tensegrity on nerve gap after transection and evaluates different repair techniques using a validated grading tool and provides evidence to support the development of the STRAIN protocol for a prospective study of tension alleviation using allograft in acute nerve repair. Methods: A workshop was conducted using fresh frozen cadaveric upper limbs. The procedures were completed by consultant hand surgeons. The common digital nerves (CDN) to the 2nd, 3rd and 4th webspace were transected proximal to the distal palmar crease. The digits were cycled through 5 flexion and extension arcs and the resulting nerve gaps were noted. Repairs were completed using microsurgical suture techniques, allograft interposition suture to fill the gap or using collagen connector assisted repairs. The quality of repair was graded by the operator and the study team. The repair sites were then repeatedly cycled through a full range of flexion and extension. Disruptions at the repair site were noted and the repair was regraded following the mobilisation. Results: Twenty-four CDNs were studied. The mean gap for the 2nd CDN was 6.4mm (range 2.7-9mm), 3rd CDN 6.1mm (range 3.5-9) and 4th CDN 5.3 (range 3-9). The grading of the repair was best in the epineural group. Allograft repair was better in quality than the connector assisted repair. Following repeated cycling of the repairs there was no change in repair quality in the epieneural or connector-assisted repair groups. There was one downgrading from good to fair in the allograft repair group. There were no repair ruptures. Conclusion: Epineural repair was consistently performed with a higher grade than for connector-assisted and allograft interposition repairs. This is likely to represent the past experience of the operators and the relative inexperience of the de-tensioning techniques. The learning curve for these techniques needs to be established for any future studies in order to standardise repair quality. The repeated cycling of the repairs resulted in no dehiscence at any repair site. The effects of tension on neural regeneration and clinical outcome will be examined in the STRAIN trial.

Ahmet Savran 1, Kubilay Erol 2, Levent Kucuk 2, Erhan Coskunol 2

1 Katip Celebi University Ataturk Research and Training Hospital, Izmir, Turkey; 2 Ege University Medical Faculty Hospital, Izmir, Turkey

Scapulothoracic dissociation is a rare and mortal condition of "closed forequarter amputation". And it is usually associated with multiple trauma. In this case report ve present a 22 years old female patient with motor vehicle accident. Unconscious patient with Glaskow Score of E1M1V1 is intubated at emergency department. Humerus shaft fracture and forearm both bone fracture is seen at X-rays. Extravasation from subclavian artery is determined at CT-Angiography and endovascular embolisation is done. Emergent cardiovascular surgery for subclavian artery repair is perform and exploration of brachial plexus showed total avulsion of all roots. After fasciotomy and temporary stabilization of fractures with splinting, patient is followed at intensive care unit for two days. But exits of the patient is confirmed at the postoperative second day. Scapulothoracic dissociation is a rare but mortal condition. Prognosis depends on nerve injury and associated injuries.

Andrzej Zyluk, Zbigniew Szlosser

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland

We report outcomes of treatment for severe pain associated with long-standing, refractory CRPS in 10 female patients by continuous brachial plexus analgesia. Duration of the disease prior to treatment was 3.5 years on average and baseline pain intensity was a mean of 8.3 in NRS. All patients met the Budapest criteria of CRPS diagnosis. Spinal catheter was implanted into the brachial plexus via open axillary approach. Results. Each patient had performed a mean of 4.4 (range 2-8) spinal catheter implantations. Rapid and strong analgesic effect was obtained immediately after beginning of injection of bupivacaine solution: pain decreased from a mean of 8.3 to 1.6. Duration of maintaining the catheter in the brachial plexus and effective analgesia was 5.3 months (range 2-12). After removal of the catheter the pain returned to baseline. No patient obtained permanent or at least partial reduction of her pain after completion of this therapy.

Antje Straatmann 1, Adriana Miclescu 2, Torbjörn Vedung 1

1 Department of Orthopedic and Hand Surgery, Uppsala University Hospital, Sweden; 2 Department of Surgical Sciences, Uppsala University Hospital, Sweden

Objective: The main objectives for nerve repair is to optimize nerve restitution and to minimize neuroma formation. Persistent postsurgical pain is common after surgery and the predisposing factors for developing pain are mainly unknown. The aim of this retrospective study was to determine the prevalence of persistent neuropathic pain after surgical repair of traumatic peripheral nerve injury in the upper extremity. Methods: The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale questionnaire was sent to 755 patients who underwent nerve repair surgery in the upper extremity between 2004 and 2015 at the Department of Orthopedic and Hand Surgery in Uppsala, Sweden. All nerve repairs were done with epineural suture technique. Additional questions regarding cold intolerance, decreased sensitivity, pain approximated using visual analogue scale (VAS) and present medication were included in the survey. Results: 536 out of 755 patients answered the questionnaires (response rate 71%). Postsurgical pain persisted in 311 patients (58%). Pain intensity was on average rated to VAS 5. Most of the patients with VAS >5 had inadequate pain medication. Cold intolerance was present in 497 patients (93%), and 520 of the patients stated that they had decreased sensibility to stimulation distal to the nerve injury (97%). According to LANSS Pain Scale 35% of the patients developed persistent neuropathic pain. Conclusions: The prevalence of persistent pain and the extent which involves neuropathic pain according to LANSS are increased after nerve repair surgery in the upper extremity. Cold intolerance and decreased sensibility are even more common and were present in almost all patients.

Charlotte Hartig-Andreasen 1, Jytte F Møller 2, Claus Möger 1

1 Hand Surgery Unit, Department of Orthopaedic Surgery, Aarhus University Hospital, Denmark; 2 Pain management team, Department of anesthesiology, Aarhus University Hospital, Denmark

Complex regional pain syndrome (CRPS) is a neurological condition requiring early diagnosis and early multidisciplinary treatment to avoid a chronic condition. CRPS after wrist surgery is a well-known risk. To prevent an acute CRPS to become disabling and chronic intensive hand therapy is mandatory. However, the pathophysiology is not completely understood making treatment difficult. Case presentation: A 27-year-old self-employed man underwent wrist fusion surgery with a dorsal plate due to posttraumatic osteoarthritis secondarily to carpal instability. After surgery pain was controlled with supra- and infraclavicular block. Two days postoperatively the patient developed severe pain and a universal rash interpreted as a reaction to morphine and oxycodone. Fentanyl was administered and amitriptyline treatment initiated for neuropathic pain. Day 6 the pain was intractable, and CRPS was suspected. Treatment with prednisolone, calcium, alendronate and pantoprazole was started. The following two days CRPS became fulminant with classic signs: universal oedema, stiffness of fingers, neuropathic pain, color and temperature changes. Infection was excluded. Despite of fentanyl, prednisolone, calcium and gabapentin treatment pain continued to be intractable. On a numerical rating scale from 0-10 pain in rest was 6 and during activity 8 making rehabilitation with the hand therapist impossible. At day 8 postoperatively ketamine infusion in sub anesthetic doses was given with immediate effect and tablet methadone started. Pain intensity reduced, discoloration diminished and hand therapy resumed. Sixteen days postoperatively reduction in ketamine was initiated. Twenty-four days after surgery, ketamine infusion was discontinued; the patient was pain free on methadone (7.5 mg three times pr. day) and discharged. Discussion: This case present a patient suffering from fulminant CRPS after wrist surgery. Correct diagnosis and multidisciplinary treatment including anesthesiologist, hand surgeons and intensive hand therapy was initiated immediately resulting in complete remission 24 days after surgery. The role of ketamine for treating CRPS remains debated in the literature. Only few small studies exist and are inconclusive. Ketamine infusion is not without potential risk, and whether ketamine should be used in acute or chronic CRPS, or in anesthetic or sub anesthetic doses remains unknown. In this case infusion of ketamine in sub anesthetic doses combined with methadone was efficacious in controlling the pain, making intensive hand therapy possible.

Caroline Leclercq 1, Catalina Parot 2,3

1 Institut de la Main, Paris, France; 2 Instituto Teletón, Santiago, Chile; 3 Hospital Luis Calvo Mackenna, Santiago, Chile

Partial wrist arthrodesis in Cerebral Palsy children PURPOSE Severe fixed wrist flexion deformity in spastic children causes hygiene problems, impairment and poor cosmesis, sometimes associated with pain. Soft tissue procedures alone have not been successful and total wrist arthrodesis is reserved for skeletally mature patients. This study evaluates the outcome of a partial arthrodesis for the treatment of spastic wrist deformities. METHODS: Eleven cerebral palsy children (12 wrists) presenting with a severe flexion deformity of the wrist were treated by a mid-carpal fusion. Results were assessed clinically (resting posture, range of motion), radiographically (union rate and delay, growth disturbance), and functionally (House scale, VAS satisfaction) RESULTS There were 9 boys and 2 girls. Mean age at the time of surgery was 12 years (range 8 – 20 years). All hands were non-functional (House 0-1), and only two had some active motion. The goal of surgery was hygiene, comfort and /or appearance. The surgical technique involved a mid-carpal dorsal wedge osteotomy, fixed with two cross Kwires. Associated procedures included: 9 muscle-tendon lengthening, 1 tendon transfers and 2 hyperselective neurectomies. The mean follow up was 20 months. The resting posture improved from 78º to 21º of flexion. The average passive range of motion changed from flexion 88º /extension minus 40º, to flexion 47º/extension 9º, and the total arc of passive motion changed from an average of 54º to 47º. The union rate was 100% at an average of 6.7 weeks. No significant complication was reported. No worsening of the growth disturbance was noted at 20 months post-op, although this proved very difficult to assess due to the initial deformity. The goal of surgery was reached in all cases, and in addition the function of the hand was improved in 3 cases (House 1 to 3). VAS satisfaction was high (average 7.8). CONCLUSIONS Dorsal carpal wedge osteotomy is an effective technique for the treatment of fixed wrist flexion deformity in skeletally immature patients, allowing to improve the resting position and to preserve some wrist motion.

Mathilde Gras 1,2, Caroline Leclercq 1

1 Institut de la Main, Clinique Bizet, Paris, France; 2 Institut Nollet, Paris, France

Objective Spasticity is characterized by hyperexcitability of the muscle. Several surgical procedures have been described in order to decrease the muscle tone. Since the description of neurotomy by Stoffel in 1912 for the upper limb, this technique has been criticized, especially because of early recurrences. Our encouraging clinical results of hyperselective neurectomy have led us to review the relevant literature and confront it to the results of our recent anatomical studies. In light of those results we propose guidelines for Hyperselective Neurectomies (NHS). Methods A Pubmed search using the term