We aimed to compare reoperations following distal radial fractures (DRFs) managed with early fixation versus delayed fixation following initial closed reduction (CR). We used administrative databases in Ontario, Canada, to identify DRF patients aged 18 years or older from 2003 to 2016. We used procedural and fee codes within 30 days to determine which patients underwent early fixation (≤ seven days) or delayed fixation following CR. We grouped patients in the delayed group by their time to definitive fixation (eight to 14 days, 15 to 21 days, and 22 to 30 days). We used intervention and diagnostic codes to identify reoperations within two years. We used multivariable regression to compare the association between early versus delayed fixation and reoperation for all patients and stratified by age (18 to 60 years and > 60 years).Aims
Methods
It is not clear which type of casting provides the best initial treatment in adults with a distal radial fracture. Given that between 32% and 64% of adequately reduced fractures redisplace during immobilization in a cast, preventing redisplacement and a disabling malunion or secondary surgery is an aim of treatment. In this study, we investigated whether circumferential casting leads to fewer fracture redisplacements and better one-year outcomes compared to plaster splinting. In a pragmatic, open-label, multicentre, two-period cluster-randomized superiority trial, we compared these two types of casting. Recruitment took place in ten hospitals. Eligible patients aged ≥ 18 years with a displaced distal radial fracture, which was acceptably aligned after closed reduction, were included. The primary outcome measure was the rate of redisplacement within five weeks of immobilization. Secondary outcomes were the rate of complaints relating to the cast, clinical outcomes at three months, patient-reported outcome measures (PROMs) (using the numerical rating scale (NRS), the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores), and adverse events such as the development of compartment syndrome during one year of follow-up. We used multivariable mixed-effects logistic regression for the analysis of the primary outcome measure.Aims
Methods
The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes. A retrospective analysis was conducted on patients arthroscopically diagnosed with Palmer 1 A lesions who underwent arthroscopic debridement and partial excision from March 2009 to February 2021, with a minimum follow-up of 24 months. Patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Mayo Wrist Score (MWS), and visual analogue scale (VAS) for pain. The poor outcome group was defined as patients whose preoperative and last follow-up clinical score difference was less than the minimal clinically important difference of the DASH score (10.83). Baseline characteristics, arthroscopic findings, and radiological factors (ulnar variance, MRI, or arthrography) were evaluated to predict poor clinical outcomes.Aims
Methods
Patients with midcarpal instability are difficult to manage. It is a rare condition, and few studies have reported the outcomes of surgical treatment. No prospective or retrospective study has reported the results of arthroscopic palmar capsuloligamentous suturing. Our aim was to report the results of a prospective study of arthroscopic suture of this ligament complex in patients with midcarpal instability. This prospective single-centre study was undertaken between March 2012 and May 2022. The primary outcome was to evaluate the functional outcomes of arthroscopic palmar midcarpal suture. The study included 12 patients, eight male and four female, with a mean age of 27.5 years (19 to 42). They were reviewed at three months, six months, and one year postoperatively.Aims
Methods
There is no level I evidence dealing with the optimal period of immobilization for patients with a displaced distal radial fracture following closed reduction. A shorter period might lead to a better functional outcome due to less stiffness and pain. The aim of this study was to investigate whether this period could be safely reduced from six to four weeks. This multicentre randomized controlled trial (RCT) included adult patients with a displaced distal radial fracture, who were randomized to be treated with immobilization in a cast for four or six weeks following closed reduction. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after follow-up at one year. Secondary outcomes were the abbreviated version of the Disability of Arm, Shoulder and Hand (QuickDASH) score after one year, the functional outcome at six weeks, 12 weeks, and six months, range of motion (ROM), the level of pain after removal of the cast, and complications.Aims
Methods
The benefit of MRI in the preoperative assessment of scaphoid proximal fragment vascularity remains controversial. The purpose of this study is to compare preoperative MRI findings to intraoperative bleeding of the proximal scaphoid. A retrospective review of 102 patients who underwent surgery for scaphoid nonunion between January 2000 and December 2020 at a single institution were identified. Inclusion criteria were: isolated scaphoid nonunion; preoperative MRI assessing the proximal fragment vascularity; and operative details of the vascularity of the proximal fragment with the tourniquet deflated. MRI results and intraoperative findings were dichotomized as either ‘yes’ or ‘no’ for the presence of vascularity. A four-fold contingency table was used to analyze the utility of preoperative MRI with 95% confidence intervals. Relative risk was calculated for subgroups to analyze the association between variables and MRI accuracy.Aims
Methods
A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability. This was a prospective single-centre study undertaken between March 2019 and May 2021. The primary outcome was the evaluation of the reduction of the radiological deformity and the functional outcomes after WADCLR. A secondary outcome was the evaluation of the effectiveness of this technique in patients with the most severe instability (European Wrist Arthroscopy Society (EWAS) stage 5). The patients were reviewed postoperatively at three, six, and 12 months.Aims
Methods
This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed. Cite this article:
The aim of this study was to compare the cost-effectiveness of surgical fixation with Kirschner (K-)wire ersus moulded casting after manipulation of a fracture of the distal radius in an operating theatre setting. An economic evaluation was conducted based on data collected from the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) multicentre randomized controlled trial in the UK. Resource use was collected at three, six, and 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from an NHS and personal social services perspective. Sensitivity analyses were conducted to examine the robustness of cost-effectiveness estimates, and decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves.Aims
Methods
The aim of this retrospective study was to evaluate the rate of conversion to surgical release after a steroid injection in patients with a trigger finger, and to analyze which patient- and trigger finger-related factors affect the outcome of an injection. The medical records of 500 patients (754 fingers) treated for one or more trigger fingers with a steroid injection or with surgical release, between 1 January 2016 and 1 April 2020 with a follow-up of 12 months, were analyzed. Conversion to surgical release was recorded as an unsuccessful treatment after an injection. The effect of patient- and trigger finger-related characteristics on the outcome of an injection was assessed using stepwise manual backward multivariate logistic regression analysis.Aims
Methods
To analyze the short-term outcome of two types of total wrist arthroplasty (TWA) in terms of wrist function, migration, and periprosthetic bone behaviour. A total of 40 patients suffering from non-rheumatoid wrist arthritis were enrolled in a randomized controlled trial comparing the ReMotion and Motec TWAs. Patient-rated and functional outcomes, radiological changes, blood metal ion levels, migration measured by model-based radiostereometric analysis (RSA), bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA), complications, loosening, and revision rates at two years were compared.Aims
Methods
This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation. This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements.Aims
Methods
The aim of this study was to describe the introduction of a virtual pathway for the management of patients with a suspected fracture of the scaphoid, and to report patient-reported outcome measures (PROMs) and satisfaction following treatment using this service. All adult patients who presented with a clinically suspected scaphoid fracture that was not visible on radiographs at the time of presentation during a one-year period were eligible for inclusion in the pathway. Demographic details, findings on examination, and routine four-view radiographs at the time of presentation were collected. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year after presentation and included the abbreviated version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the EuroQol five-dimension five-level health questionnaire (EQ-5D-5L), the Net Promoter Score (NPS), and return to work.Aims
Methods
The aim of this study was to assess and compare active rotation of the forearm in normal subjects after the application of a short-arm cast (SAC) in the semisupination position and a long-arm cast (LAC) in the neutral position. A clinical study was also conducted to compare the functional outcomes of using a SAC in the semisupination position with those of using a LAC in the neutral position in patients who underwent arthroscopic triangular fibrocartilage complex (TFCC) foveal repair. A total of 40 healthy right-handed volunteers were recruited. Active pronation and supination of the forearm were measured in each subject using a goniometer. In the retrospective clinical study, 40 patients who underwent arthroscopic foveal repair were included. The wrist was immobilized postoperatively using a SAC in the semisupination position (approximately 45°) in 16 patients and a LAC in 24. Clinical outcomes were assessed using grip strength and patient-reported outcomes. The degree of disability caused by cast immobilization was also evaluated when the cast was removed.Aims
Methods
The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis. This was a retrospective analysis of 89 wrists in 88 patients between January 2015 and January 2019. All patients were managed conservatively initially with either a short-arm or above-elbow custom-moulded thermoplastic splint for six weeks. Outcome measures recorded included a visual analogue scale for pain, Patient-Rated Wrist Evaluation, Disabilities of the Arm, Shoulder and Hand score, and the modified Mayo Wrist Score (MMWS). Patients were considered to have had a poor outcome if their final MMWS was less than 80 points, or if they required eventual surgical intervention. Univariate and logistic regression analyses were used to identify independent predictors for a poor outcome.Aims
Methods
The aim of this study was to assess arthritis of the basal joint of the thumb quantitatively using bone single-photon emission CT/CT (SPECT/CT) and evaluate its relationship with patients’ pain and function. We retrospectively reviewed 30 patients (53 hands) with symptomatic basal joint arthritis of the thumb between April 2019 and March 2020. Visual analogue scale (VAS) scores for pain, grip strength, and pinch power of both hands and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores were recorded for all patients. Basal joint arthritis was classified according to the modified Eaton-Glickel stage using routine radiographs and the CT scans of SPECT/CT, respectively. The maximum standardized uptake value (SUVmax) from SPECT/CT was measured in the four peritrapezial joints and the highest uptake was used for analysis.Aims
Methods
The aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion. A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis.Aims
Methods
The results of surgery for Dupuytren’s disease can be compromised by the potential for disease recurrence and loss of function. Selecting which patients will benefit from repeat surgery, when to operate, and what procedure to undertake requires judgement and an understanding of patient expectations and functional needs. We undertook this study to investigate patient outcomes and satisfaction following repeat limited fasciectomy for recurrent Dupuytren’s disease. We prospectively identified all patients presenting with recurrence of Dupuytren’s disease who were selected for surgical treatment with repeat limited fasciectomy surgery between January 2013 and February 2015. Patients were assessed preoperatively, and again at a minimum of five years postoperatively. We identified 43 patients who were carefully selected for repeat fasciectomy involving 54 fingers. Patients with severe or aggressive disease with extensive skin involvement were not included; in our practice, these patients are instead counselled and preferentially treated with dermofasciectomy. The primary outcome measured was change in the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were change in finger range of motion, flexion contracture, Semmes-Weinstein monofilament (SWM) values, and overall satisfaction.Aims
Methods
The purpose was to evaluate early clinical, patient-reported, and radiological outcomes of the scapholunate ligament 360° tenodesis (SL 360) technique for treatment of scapholunate (SL) instability. We studied the results of nine patients (eight males and one female with a mean age of 44.7 years (26 to 55)) who underwent the SL 360 procedure for reducible SL instability between January 2016 and June 2019, and who were identified from retrospective review of electronic medical records. Final follow-up of any kind was a mean of 33.7 months (12.0 to 51.3). Clinical, radiological, and patient-reported outcome data included visual analogue scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Mayo Wrist Score (MWS), and Patient-Rated Wrist Examination (PRWE). Means were analyzed using paired Aims
Methods
Patients with a triangular fibrocartilage complex (TFCC) injury report ulnar-sided wrist pain and impaired function. The surgical procedure of TFCC reinsertion aims to improve function in patients with this injury in whom conservative treatment has failed. The purpose of this study was to investigate the outcomes of open TFCC reinsertion. The study involved 274 patients who underwent open repair of the TFCC between December 2013 and December 2018. The patients completed the Patient-Rated Wrist Evaluation (PRWE) questionnaire, and scored pain and function using a visual analogue scale (VAS). Range of motion (ROM) was assessed by experienced hand therapists.Aims
Methods
With novel promising therapies potentially limiting progression of Dupuytren’s disease (DD), better patient stratification is needed. We aimed to quantify DD development and progression after seven years in a population-based cohort, and to identify factors predictive of disease development or progression. All surviving participants from our previous prevalence study were invited to participate in the current prospective cohort study. Participants were examined for presence of DD and Iselin’s classification was applied. They were asked to complete comprehensive questionnaires. Disease progression was defined as advancement to a further Iselin stage or surgery. Potential predictive factors were assessed using multivariable regression analyses. Of 763 participants in our original study, 398 were available for further investigation seven years later.Aims
Methods
Fixation of scaphoid nonunion with a volar locking plate and cancellous bone grafting has been shown to be a successful technique in small series. Few mid- or long-term follow-up studies have been reported. The aim of this study was to report the mid-term radiological and functional outcome of plate fixation for scaphoid nonunion. Patients with a scaphoid nonunion were prospectively enrolled and treated with open reduction using a volar approach, debridement of the nonunion, and fixation using a locking plate and cancellous bone grafting, from the ipsilateral iliac crest. Follow-up included examination, functional assessment using the patient-rated wrist/hand evaluation (PRWHE), and multiplanar reformation CT scans at three-month intervals until union was confirmed.Aims
Methods
The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius. We retrospectively identified 122 adult patients from a single centre over an eight-year period who had undergone corrective osteotomy for a symptomatic malunion of the distal radius. The primary long-term outcome was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, the EQ-5D-5L score, complications, and the Net Promoter Score (NPS). Multivariate regression analysis was used to determine factors associated with the PRWE score.Aims
Methods
In the UK, fasciectomy for Dupuytren’s contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks.Aims
Methods
We quantitatively compared the 3D bone density distributions on CT scans performed on scaphoid waist fractures subacutely that went on to union or nonunion, and assessed whether 2D CT evaluations correlate with 3D bone density evaluations. We constructed 3D models from 17 scaphoid waist fracture CTs performed between four to 18 weeks after fracture that did not unite (nonunion group), 17 age-matched scaphoid waist fracture CTs that healed (union group), and 17 age-matched control CTs without injury (control group). We measured the 3D bone density for the distal and proximal fragments relative to the triquetrum bone density and compared findings among the three groups. We then performed bone density measurements using 2D CT and evaluated the correlation with 3D bone densities. We identified the optimal cutoff with diagnostic values of the 2D method to predict nonunion with receiver operating characteristic (ROC) curves.Aims
Methods
The aim of this study was to investigate whether intraoperative 3D fluoroscopic imaging outperforms dorsal tangential views in the detection of dorsal cortex screw penetration after volar plating of an intra-articular distal radial fracture, as identified on postoperative CT imaging. A total of 165 prospectively enrolled patients who underwent volar plating for an intra-articular distal radial fracture were retrospectively evaluated to study three intraoperative imaging protocols: 1) standard 2D fluoroscopic imaging with anteroposterior (AP) and elevated lateral images (n = 55); 2) 2D fluoroscopic imaging with AP, lateral, and dorsal tangential views images (n = 50); and 3) 3D fluoroscopy (n = 60). Multiplanar reconstructions of postoperative CT scans served as the reference standard.Aims
Methods
The aim of this study was to analyze the association between the shape of the distal radius sigmoid notch and triangular fibrocartilage complex (TFCC) foveal tear. Between 2013 and 2018, patients were retrospectively recruited in two different groups. The patient group comprised individuals who underwent arthroscopic transosseous TFCC foveal repair for foveal tear of the wrist. The control group comprised individuals presenting with various diseases around wrist not affecting the TFCC. The study recruited 176 patients (58 patients, 118 controls). The sigmoid notch shape was classified into four types (flat-face, C-, S-, and ski-slope types) and three radiological parameters related to the sigmoid notch (namely, the radius curvature, depth, and version angle) were measured. The association of radiological parameters and sigmoid notch types with the TFCC foveal tear was investigated in univariate and multivariate analyses. Receiver operating characteristic curves were used to estimate a cut-off for any statistically significant variables.Aims
Methods
The aim of this study was to compare patient-reported outcome measures (PROMs) and the Single Assessment Numerical Evaluation (SANE) score in patients treated with a volar locking plate for a distal radial fracture. This study was a retrospective review of a prospective database of 155 patients who underwent internal fixation with a volar locking plate for a distal radial fracture between August 2014 and April 2017. Data which were collected included postoperative PROMs (Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and Patient-Rated Wrist Evaluation (PRWE)), and SANE scores at one month (n = 153), two months (n = 155), three months (n = 144), six months (n = 128), and one year (n = 73) after operation. Patients with incomplete data were excluded from this study. Correlation and agreement between PROMs and SANE scores were evaluated. Subgroup analyses were carried out to identify correlations according to variables such as age, the length of follow-up, and subcategories of the PRWE score.Aims
Methods
Base of thumb osteoarthritis (BTOA) is a common age-related disease which has a significant negative impact upon quality of life. Our aim was to assess current UK practice in secondary care with regard to the nature of non-surgical treatments, the surgical procedures most commonly performed, and factors influencing the surgical decision-making process. Ten consecutive patients undergoing surgery for BTOA between March 2017 and May 2019 were prospectively identified in 15 UK centres. Demographic details, duration of symptoms, radiological grade, non-surgical management strategies, and surgery conducted were recorded. A supplementary consultant questionnaire consisting of four multiple-choice-questions (MCQ) based on hypothetical clinical scenarios was distributed.Aims
Methods
Besides conventional radiographs, the use of MRI, CT, and bone scintigraphy is frequent in the diagnosis of a fracture of the scaphoid. However, which techniques give the best results remain unknown. The investigation of a new imaging technique initially requires an analysis of its precision. The primary aim of this study was to investigate the interobserver agreement of high-resolution peripheral quantitative CT (HR-pQCT) in the diagnosis of a scaphoid fracture. A secondary aim was to investigate the interobserver agreement for the presence of other fractures and for the classification of scaphoid fracture. Two radiologists and two orthopaedic trauma surgeons evaluated HR-pQCT scans of 31 patients with a clinically-suspected scaphoid fracture. The observers were asked to determine the presence of a scaphoid or other fracture and to classify the scaphoid fracture based on the Herbert classification system. Fleiss kappa statistics were used to calculate the interobserver agreement for the diagnosis of a fracture. Intraclass correlation coefficients (ICCs) were used to assess the agreement for the classification of scaphoid fracture.Aims
Methods
Carpal malalignment after a distal radial fracture occurs due to loss of volar tilt. Several studies have shown that this has an adverse influence on function. We aimed to investigate the magnitude of dorsal tilt that leads to carpal malalignment, whether reduction of dorsal tilt will correct carpal malalignment, and which measure of carpal malalignment is the most useful. Radiographs of patients with a distal radial fracture were prospectively collected and reviewed. Measurements of carpal malalignment were recorded on the initial radiograph, the radiograph following reduction of the fracture, and after a further interval. Linear regression modelling was used to assess the relationship between dorsal tilt and carpal malalignment. Receiver operating characteristic (ROC) analysis was used to identify which values of dorsal tilt led to carpal malalignment.Aims
Methods
The aim of this study was to investigate the difference in functional outcome after repair and non-repair of the pronator quadratus muscle in patients undergoing surgical treatment for a distal radial fracture with volar plating. A total of 72 patients with a distal radial fracture were included in this randomized clinical trial. They were allocated to have the pronator quadratus muscle repaired or not, after volar locked plating of a distal radial fracture. The patients, the assessor, the primary investigator, and the statistician were blinded to the allocation. Randomization was irreversibly performed using a web application that guaranteed a secure and tamper-free assignment. The primary outcome measure was the Patient Rated Wrist Evaluation (PRWE) after 12 months. Secondary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) score, pronation strength, grip strength, the range of pronation and supination, complications, and the operating time.Aims
Patients and Methods
The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires. This was a multicentre, parallel group, randomized controlled noninferiority trial conducted at 12 tertiary trauma centres in Germany. A total of 290 patients with acute displaced fractures of the fifth metacarpal neck were randomized to either intramedullary single-wire (n = 146) or dual-wire fixation (n = 144). The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire six months after surgery, with a third of the minimal clinically important difference (MCID) used as the noninferiority threshold. Secondary outcomes were pain, health-related quality of life (EuroQol five-dimensional questionnaire (EQ-5D)), radiological measures, functional deficits, and complications.Aims
Patients and Methods
The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs. Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants’ self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors.Aims
Patients and Methods
The aim of this study was to compare the clinical effectiveness of Kirschner wire (K-wire) fixation with locking-plate fixation for patients with a dorsally displaced fracture of the distal radius in the five years after injury. We report the five-year follow-up of a multicentre, two-arm, parallel-group randomized controlled trial. A total of 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation were recruited from 18 trauma centres in the United Kingdom. Patients were excluded if the surface of the wrist joint was so badly displaced it required open reduction. In all, 448 patients were randomized to receive either K-wire fixation or locking-plate fixation. In the K-wire group, there were 179 female and 38 male patients with a mean age of 59.1 years (19 to 89). In the locking-plate group, there were 194 female and 37 male patients with a mean age of 58.3 years (20 to 89). The primary outcome measure was the patient-rated wrist evaluation (PRWE). Secondary outcomes were health-related quality of life using the EuroQol five-dimension three-level (EQ-5D-3L) assessment, and further surgery related to the index fracture.Aims
Patients and Methods
Plate and screw fixation has been the standard treatment for painful conditions of the wrist in non-rheumatoid patients in recent decades. We investigated the complications, re-operations, and final outcome in a consecutive series of patients who underwent wrist arthrodesis for non-inflammatory arthritis. A total of 76 patients, including 53 men and 23 women, with a mean age of 50 years (21 to 79) underwent wrist arthrodesis. Complications and re-operations were recorded. At a mean follow-up of 11 years (2 to 18), 63 patients completed questionnaires, and 57 attended for clinical and radiological assessment.Aims
Patients and Methods
The aim of this study was to test the null hypothesis that there
is no difference, from the payer perspective, in the cost of treatment
of a distal radial fracture in an elderly patient, aged >
65 years,
between open reduction and internal fixation (ORIF) and closed reduction (CR). Data relating to the treatment of these injuries in the elderly
between January 2007 and December 2015 were extracted using the
Humana and Medicare Advantage Databases. The primary outcome of
interest was the cost associated with treatment. Secondary analysis included
the cost of common complications. Statistical analysis was performed
using a non-parametric Aims
Materials and Methods
The aims of this study were to compare the mid-term outcomes
of patients with late-stage arthritis of the wrist treated with
proximal row carpectomy (PRC) and dorsal capsular interposition
(DCI) arthroplasty with a matched cohort treated with routine PRC
alone. A total of 25 arthritic wrists (24 patients) with pre-existing
degenerative changes of the proximal capitate and/or the lunate
fossa of the radius were treated with PRC + DCI over a ten-year
period. This group of patients were matched 1:2 with a group of
50 wrists (48 patients) without degenerative changes in the capitate
or lunate fossa that were treated with a routine PRC alone during
the same period. The mean age of the patients at the time of surgery
was 56.8 years (25 to 81), and the demographics and baseline range
of movement of the wrist, grip strength, Quick Disabilities of the
Arm, Shoulder, and Hand (QuickDASH) score, and Patient-Rated Wrist
Evaluation (PRWE) score were similar in both groups. Aims
Patients and Methods
The aim of this meta-analysis was to assess the safety and efficacy
of collagenase clostridium histolyticum compared with fasciectomy
and percutaneous needle fasciotomy (PNF) for Dupuytren’s disease. We systematically searched PubMed, EMBASE, LILACS, Web of Science,
Cochrane, Teseo and the ClinicalTrials.gov registry for clinical
trials and cohort or case-control studies which compared the clinical
outcomes and adverse effects of collagenase with those of fasciectomy
or PNF. Of 1345 articles retrieved, ten were selected. They described
the outcomes of 425 patients treated with collagenase and 418 treated
by fasciectomy or PNF. Complications were assessed using inverse-variance
weighted odds ratios (ORs). Clinical efficacy was assessed by differences
between the means for movement of the joint before and after treatment.
Dose adjustment was applied in all cases.Aims
Materials and Methods
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. 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 (control group). 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.Aims
Patients and Methods
Positive ulnar variance is an established risk factor for idiopathic
ulnar impaction syndrome (UIS). However, not all patients with positive
ulnar variance develop symptomatic UIS and other factors, including
the morphology of the lunate, may be involved. The aim of this study
was to clarify the relationship between lunate morphology and idiopathic
UIS. A cohort of 95 patients with idiopathic UIS (UIS group) was compared
with 95 asymptomatic controls with positive ulnar variance. The
shape of the lunate was measured using the capitate-triquetrum distance
(CTD), ulnar coverage ratio (UCR), radiolunate distance and radiolunate
angle. The association of radiographic parameters and lunate types
with the development of UIS was investigated in univariable and
multivariable analyses. Receiver operating characteristic curves
were used to estimate a cutoff for any statistically significant
variables.Aims
Patients and Methods
To determine whether an early return to sport in professional
Australian Rules Football players after fixation of a non-thumb
metacarpal fracture was safe and effective. A total of 16 patients with a mean age of 25 years (19 to 30)
identified as having a non-thumb metacarpal fracture underwent open
reduction and internal plate and screw fixation. We compared the
players’ professional performance statistics before and after the
injury to determine whether there was any deterioration in their
post-operative performance.Aims
Patients and Methods
Few studies have examined the long-term outcome of carpal tunnel
release (CTR). The aim of this study was to evaluate the patient-reported
long-term outcome of CTR for electrophysiologically severe carpal
tunnel syndrome (CTS). We reviewed the long-term outcome of 40 patients with bilateral
severe CTS who underwent 80 CTRs (46 open, 34 endoscopic) between
2002 and 2012. The outcomes studied were patient-reported outcomes
of numbness resolution, the Boston Carpal Tunnel Questionnaire (BCTQ)
score, and patient satisfaction.Aims
Patients and Methods
The aims of this study were: firstly, to investigate the influence
of the thickness of cartilage at the sigmoid notch on the inclination
of the distal radioulnar joint (DRUJ), and secondly, to compare
the sensitivity and specificity of MRI with plain radiographs for
the assessment of the inclination of the articular surface of the
DRUJ in the coronal plane. Contemporaneous MRI images and radiographs of 100 wrists from
98 asymptomatic patients (mean age 43 years, (16 to 67); 52 male,
53%) with no history of a fracture involving the wrist or surgery
to the wrist, were reviewed. The thickness of the cartilage at the
sigmoid notch, inclination of the DRUJ and Tolat Type of each DRUJ
were determined. Aims
Patients and Methods
We conducted a study to determine whether radiological parameters
correlate with patient reported functional outcome, health-related
quality of life and physical measures of function in patients with
a fracture of the distal radius. The post-operative palmar tilt and ulnar variance at six weeks
and 12 months were correlated with the Patient Rated Wrist Evaluation,
Disabilities of the Arm, Shoulder and Hand, and EuroQol scores,
grip strength, pinch strength and range of movement at three, six
and 12 months for 50 patients (mean age 57 years; 26 to 85) having surgical
fixation, with either percutaneous pinning or reconstruction with
a volar plate, for a fracture of the distal radius.Aims
Patients and Methods
The aim of this study was to compare the Push Ortho Thumb Brace
CMC and a custom-made orthosis in the treatment of patients with
primary osteoarthritis of the carpometacarpal joint of the thumb.
Our outcome measures were pain scores, tests of hand function, patient
satisfaction and patient preference. A multicentre crossover randomised controlled trial was conducted
which included 63 patients (44 women) with primary osteoarthritis
of the carpometacarpal joint of the thumb. Of these, 59 patients
with a mean age of 60.1 years (standard deviation 8.2), completed
the study. Patients used both orthoses for two weeks with a two-week washout
period in-between. Pain was measured on a 10-cm visual analogue
scale. Hand function was assessed using the Jebsen Taylor Hand Function
test, Nine Hole Peg Test, key grip, pinch grip and Functional Index
for Hand Osteoarthritis. Patient preference was assessed using the
Dutch version of the Quebec User Evaluation of Satisfaction with
Assistive Technology score.Aims
Patients and Methods
We performed a systematic review of the current literature regarding
the outcomes of unconstrained metacarpophalangeal joint (MCPJ) arthroplasty. We initially identified 1305 studies, and 406 were found to be
duplicates. After exclusion criteria were applied, seven studies
were included. Outcomes extracted included pre- and post-operative
pain visual analogue scores, range of movement (ROM), strength of
pinch and grip, satisfaction and patient reported outcome measures
(PROMs). Clinical and radiological complications were recorded.
The results are presented in three groups based on the design of
the arthroplasty and the aetiology (pyrocarbon-osteoarthritis (pyro-OA),
pyrocarbon-inflammatory arthritis (pyro-IA), metal-on-polyethylene
(MoP)).Aims
Materials and Methods
Our purpose was to determine the quality of current randomised
controlled trials (RCTs) in hand surgery using standardised metrics. Based on five-year mean impact factors, we selected the six journals
that routinely publish studies of upper extremity surgery. Using
a journal-specific search query, 62 RCTs met our inclusion criteria.
Then three blinded reviewers used the Jadad and revised Coleman Methodology
Score (RCMS) to assess the quality of the manuscripts.Aims
Materials and Methods
The aims of this study were to evaluate the clinical and radiological
outcomes of the Universal-2 total wrist arthroplasty (TWA) in patients
with rheumatoid arthritis. This was a retrospective review of all 95 Universal-2 TWAs which
were performed in our institution between 2003 to 2012 in patients
with rheumatoid arthritis. A total of six patients were lost to
follow-up and two died of unrelated causes. A total of ten patients
had bilateral procedures. Accordingly, 75 patients (85 TWAs) were
included in the study. There were 59 women and 16 men with a mean
age of 59 years (26 to 86). The mean follow-up was 53 months (24
to 120). Clinical assessment involved recording pain on a visual
analogue score, range of movement, grip strength, the Quick Disabilities
of the Arm, Shoulder and Hand (DASH) and Wrightington wrist scores.
Any adverse effects were documented with particular emphasis on
residual pain, limitation of movement, infection, dislocation and
the need for revision surgery. Radiographic assessment was performed pre-operatively and at
three, six and 12 months post-operatively, and annually thereafter.
Arthroplasties were assessed for distal row intercarpal fusion and
loosening. Radiolucent zones around the components were documented
according to a system developed at our institution.Aims
Patients and Methods
The degree of displacement of a fracture of the distal radius
is an important factor which can be assessed using simple radiographic
measurements. Our aim was to investigate the reliability and reproducibility
of these measurements and to determine if they should be used clinically. A 10% sample was randomly generated from 3670 consecutive adult
patients who had presented to University Hospitals of Leicester
NHS Trust between 2007 and 2010 with a fracture of the distal radius.
Radiographs of the 367 patients were assessed by two independent
reviewers. Four measurements of displacement of the fracture were recorded
and the inter-observer correlation assessed using the intra-class
correlation coefficient.Aims
Patients and Methods
Chronic conditions of the wrist may be difficult to manage because
pain and psychiatric conditions are correlated with abnormal function
of the hand. Additionally, intra-articular inflammatory cytokines
may cause pain. We aimed to validate the measurement of inflammatory cytokines
in these conditions and identify features associated with symptoms. The study included 38 patients (18 men, 20 women, mean age 43
years) with a chronic condition of the wrist who underwent arthroscopy.
Before surgery, the Self-Rating Depression Scale (SDS), Hand20 questionnaire
and a visual analogue scale (VAS) for pain were used. Cytokine and
chemokine levels in the synovial fluid of the wrist were measured
using enzyme-linked immunosorbent assays and correlations between
the levels with pain were analysed. Gene expression profiles of
the synovial membranes were assessed using quantitative polymerase
chain reaction.Aims
Patients and Methods
Total wrist arthrodesis (TWA) produces a spectrum of outcomes.
We investigated this by reviewing 77 consecutive TWA performed for
inflammatory and post-traumatic arthropathies, wrist instability
and as a salvage procedure. All operations were performed by a single surgeon using a specifically
designed pre-contoured dorsally applied non-locking wrist arthrodesis
plate at a single centre. Aims
Patients and Methods
This study explores the epidemiology of patients with a fracture
of the scaphoid presenting to a regional teaching hospital. All patients with a confirmed fracture of the scaphoid over a
retrospective period between January 2010 and May 2013 were included.
Their demographics, deprivation status and when the fracture occurred
was noted and assessed. There were 415 fractures in 365 males and
50 females.Aims
Patients and Methods
We compared the ceiling effects of two patient-rating
scores, the Disability of the Arm, Shoulder and Hand (DASH) and
Patient-Rated Wrist Evaluation (PRWE), and a physician-rating score,
the Modified Mayo Wrist Score (MMWS) in assessing the outcome of
surgical treatment of an unstable distal radial fracture. A total
of 77 women with a mean age of 64.2 years (50 to 88) who underwent
fixation using a volar locking plate for an unstable distal radial fracture
between 2011 and 2013 were enrolled in this study. All completed
the DASH and PRWE questionnaires one year post-operatively and were
assessed using the MMWS by the senior author. The ceiling effects
in the outcome data assessed for each score were estimated. The data assessed with both patient-rating scores, the DASH and
PRWE, showed substantial ceiling effects, whereas the data assessed
with MMWS showed no ceiling effect. Researchers should be aware of a possible ceiling effect in the
assessment of the outcome of the surgical treatment of distal radial
fractures using patient-rating scores. It could also increase the
likelihood of a type II error. Cite this article:
We report a new surgical technique for the treatment
of traumatic dislocation of the carpometacarpal (CMC) joint of the
thumb. This is a tenodesis which uses part of the flexor carpi radialis. Between January 2010 and August 2013, 13 patients with traumatic
instability of the CMC joint of the thumb were treated using this
technique. The mean time interval between injury and ligament reconstruction
was 13 days (0 to 42). The mean age of the patients at surgery was
38 years: all were male. At a mean final follow-up of 26 months (24 to 29), no patient
experienced any residual instability. The mean total palmar abduction
of the CMC joint of the thumb was 61° and the mean radial abduction
65° The mean measurements for the uninjured hand were 66° (60° to
73°) and 68° (60° to 75°), respectively. The mean Kapandji thumb
opposition score was 8.5° (8° to 9°). The mean pinch and grip strengths
of the hand were 6.7 kg (3.4 to 8.2) and 40 kg (25 to 49), respectively.
The mean Disabilities of the Arm, Shoulder, and Hand questionnaire
score was 3 (1 to 6). Based on the Smith and Cooney score, we obtained
a mean score of 85 (75 to 95), which included four excellent, seven
good, and two fair results. Our technique offers an alternative method of treating traumatic
dislocation of the CMC joint of the thumb: it produces a stable
joint and acceptable hand function. Cite this article:
Arthritis of the wrist is a painful disabling
condition that has various causes and presentations. The traditional treatment
has been a total wrist fusion at a price of the elimination of movement.
However, forms of treatment which allow the preservation of movement
are now preferred. Modern arthroplasties of the wrist are still
not sufficiently robust to meet the demands of many patients, nor
do they restore normal kinematics of the wrist. A preferable compromise
may be selective excision and partial fusion of the wrist using
knowledge of the aetiology and pattern of degenerative change to
identify which joints can be sacrificed and which can be preserved. This article provides an overview of the treatment options available
for patients with arthritis of the wrist and an algorithm for selecting
an appropriate surgical strategy. Cite this article:
This article is a systematic review of the published
literature about the biomechanics, functional outcome and complications
of intramedullary nailing of fractures of the distal radius. We searched the Medline and EMBASE databases and included all
studies which reported the outcome of intramedullary (IM) nailing
of fractures of the distal radius. Data about functional outcome,
range of movement (ROM), strength and complications, were extracted.
The studies included were appraised independently by both authors
using a validated quality assessment scale for non-controlled studies
and the CONSORT statement for randomised controlled trials (RCTs). The search strategy revealed 785 studies, of which 16 were included
for full paper review. These included three biomechanical studies,
eight case series and five randomised controlled trials (RCTs). The biomechanical studies concluded that IM nails were at least
as strong as locking plates. The clinical studies reported that
IM nailing gave a comparable ROM, functional outcome and grip strength
to other fixation techniques. However, the mean complication rate of intramedullary nailing
was 17.6% (0% to 50%). This is higher than the rates reported in
contemporary studies for volar plating. It raises concerns about
the role of intramedullary nailing, particularly when comparative
studies have failed to show that it has any major advantage over
other techniques. Further adequately powered RCTs comparing the
technique to both volar plating and percutaneous wire fixation are needed. Cite this article:
Wrist block has been used to provide pain relief
for many procedures on the hand and wrist but its role in arthroscopy
of the wrist remains unexplored. Chondrotoxicity has been a concern
with the intra-articular infiltration of local anaesthetic. We aimed
to evaluate and compare the analgesic effect of portal and wrist
joint infiltration with a wrist block on the pain experienced by
patients after arthroscopy of the wrist. A prospective, randomised, double-blind trial was designed and
patients undergoing arthroscopy of the wrist under general anaesthesia
as a day case were recruited for the study. Levo-bupivacaine was
used for both techniques. The effects were evaluated using a ten-point
visual analogue scale, and the use of analgesic agents was also
compared. The primary outcomes for statistical analyses were the
mean pain scores and the use of analgesia post-operatively. A total of 34 patients (63% females) were recruited to the portal
and joint infiltration group and 32 patients (59% males) to the
wrist block group. Mean age was 40.8 years in the first group and
39.7 years in the second group (p >
0.05). Both techniques provided
effective pain relief in the first hour and 24 hours post-operatively
but wrist block gave better pain scores at bedtime on the day of
surgery (p = 0.007) and at 24 hours post-operatively (p = 0.006). Wrist block provides better and more reliable analgesia in patients
undergoing arthroscopy of the wrist without exposing patients to
the risk of chondrotoxicity. Cite this article:
We present an economic evaluation using data
from the Distal Radius Acute Fracture Fixation Trial (DRAFFT) to compare
the relative cost effectiveness of percutaneous Kirschner wire (K-wire)
fixation and volar locking-plate fixation for patients with dorsally-displaced
fractures of the distal radius. The cost effectiveness analysis (cost per quality-adjusted life
year; QALY) was derived from a multi-centre, two-arm, parallel group,
assessor-blind, randomised controlled trial which took place in
18 trauma centres in the United Kingdom. Data from 460 patients
were available for analysis, which includes both a National Health
Service cost perspective including costs of surgery, implants and
healthcare resource use over a 12-month period after surgery, and
a societal perspective, which includes the cost of time off work
and the need for additional private care. There was only a small difference in QALYs gained for patients
treated with locking-plate fixation over those treated with K-wires.
At a mean additional cost of £714 (95% confidence interval 588 to
865) per patient, locking-plate fixation presented an incremental
cost effectiveness ratio (ICER) of £89 322 per QALY within the first
12 months of treatment. Sensitivity analyses were undertaken to
assess the ICER of locking-plate fixation compared with K-wires.
These were greater than £30 000. Compared with locking-plate fixation, K-wire fixation is a ‘cost
saving’ intervention, with similar health benefits. Cite this article:
There is no consensus on the benefit of arthroscopically
assisted reduction of the articular surface combined with fixation
using a volar locking plate for the treatment of intra-articular
distal radial fractures. In this study we compared the functional
and radiographic outcomes of fluoroscopically and arthroscopically
guided reduction of these fractures. Between February 2009 and May 2013, 74 patients with unilateral
unstable intra-articular distal radial fractures were randomised
equally into the two groups for treatment. The mean age of these
74 patients was 64 years (24 to 92). We compared functional outcomes
including active range of movement of the wrist, grip strength and Disabilities
of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic
outcomes that included gap, step, radial inclination, volar angulation
and ulnar variance. There were no significant differences between the techniques
with regard to functional outcomes or radiographic parameters. The
mean gap and step in the fluoroscopic and arthroscopic groups were
comparable at 0.9 mm (standard deviation Arthroscopic reduction conferred no advantage over conventional
fluoroscopic guidance in achieving anatomical reduction of intra-articular
distal radial fractures when using a volar locking plate. Cite this article:
We conducted an observational radiographic study
to determine the inter- and intra-observer reliability of the AO classification
of fractures of the distal radius. Plain posteroanterior and lateral
radiographs of 456 patients with an acute fracture of the distal
radius were classified by a consultant orthopaedic hand specialist
and two specialist trainees, and the k coefficient for the inter-
and intra-observer reliability of the type, group and subgroup classification
was calculated. Only the type of fracture (A, B or C) was found to provide substantial
intra-observer reliability (k type 0.65). The inclusion
of ‘group’ and ‘subgroup’ into the classification reduced the inter-observer
reliability to fair (kgroup 0.29, ksubgroup =
0.28) and the intra-observer reliability to moderate (kgroup 0.53,
ksubgroup 0.49). Disagreement was found to arise between
specific subgroups, which may be amenable to clarification. Cite this article:
We report a new surgical technique of open carpal
tunnel release with subneural reconstruction of the transverse carpal
ligament and compare this with isolated open and endoscopic carpal
tunnel release. Between December 2007 and October 2011, 213 patients with carpal
tunnel syndrome (70 male, 143 female; mean age 45.6 years; 29 to
67) were recruited from three different centres and were randomly
allocated to three groups: group A, open carpal tunnel release with
subneural reconstruction of the transverse carpal ligament (n =
68); group B, isolated open carpal tunnel release (n = 92); and
group C, endoscopic carpal tunnel release (n = 53). At a mean final follow-up of 24 months (22 to 26), we found no
significant difference between the groups in terms of severity of
symptoms or lateral grip strength. Compared with groups B and C,
group A had significantly better functional status, cylindrical
grip strength and pinch grip strength. There were significant differences
in Michigan Hand Outcome scores between groups A and B, A and C,
and B and C. Group A had the best functional status, cylindrical
grip strength, pinch grip strength and Michigan Hand Outcome score. Subneural reconstruction of the transverse carpal ligament during
carpal tunnel decompression maximises hand strength by stabilising
the transverse carpal arch. Cite this article:
We performed a retrospective study to determine
the effect of osteoporosis on the functional outcome of osteoporotic
distal radial fractures treated with a volar locking plate. Between
2009 and 2012 a total of 90 postmenopausal women with an unstable
fracture of the distal radius treated with a volar locking plate
were studied. Changes in the radiological parameters of 51 patients
with osteoporosis (group 1, mean age 66.9, mean T-score –3.16 ( We found that osteoporosis does not have a negative effect on
the functional outcome and additional analysis did not show a correlation
between T-score and outcome. Cite this article:
There is conflicting evidence about the functional
outcome and rate of satisfaction of super-elderly patients (≥ 80 years
of age) after carpal tunnel decompression. We compiled outcome data for 756 patients who underwent a carpal
tunnel decompression over an eight-year study period, 97 of whom
were super-elderly, and 659 patients who formed a younger control
group (<
80 years old). There was no significant difference between
the super-elderly patients and the younger control group in terms
of functional outcome according to the mean (0 to 100) QuickDASH
score (adjusted mean difference at one year 1.8; 95% confidence
interval (CI) -3.4 to 7.0) and satisfaction rate (odds ratio (OR)
0.78; 95% CI 0.34 to 1.58). Super-elderly patients were, however,
more likely to have thenar muscle atrophy at presentation (OR 9.2,
95% CI 5.8 to 14.6). When nerve conduction studies were obtained,
super-elderly patients were more likely to have a severe conduction deficit
(OR 12.4, 95% CI 3.0 to 51.3). Super-elderly patients report functional outcome and satisfaction
rates equal to those of their younger counterparts. They are more
likely to have thenar muscle atrophy and a severe nerve conduction
deficit at presentation, and may therefore warrant earlier decompression. Cite this article:
We hypothesised that the use of pulsed electromagnetic
field (PEMF) bone growth stimulation in acute scaphoid fractures
would significantly shorten the time to union and reduce the number
of nonunions in a randomised, double-blind, placebo-controlled multicentre
trial. A total of 102 patients (78 male, 24 female; mean age 35
years (18 to 77)) from five different medical centres with a unilateral
undisplaced acute scaphoid fracture were randomly allocated to PEMF
(n = 51) or placebo (n = 51) and assessed with regard to functional
and radiological outcomes (multiplanar reconstructed CT scans) at
6, 9, 12, 24 and 52 weeks. The overall time to clinical and radiological healing
did not differ significantly between the active PEMF group and the
placebo group. We concluded that the addition of PEMF bone growth
stimulation to the conservative treatment of acute scaphoid fractures
does not accelerate bone healing. Cite this article:
We conducted an anatomical study to determine
the best technique for transfer of the anterior interosseous nerve (AIN)
for the treatment of proximal ulnar nerve injuries. The AIN, ulnar
nerve, and associated branches were dissected in 24 cadaver arms.
The number of branches of the AIN and length available for transfer
were measured. The nerve was divided just proximal to its termination
in pronator quadratus and transferred to the ulnar nerve through
the shortest available route. Separation of the deep and superficial
branches of the ulnar nerve by blunt dissection alone, was also
assessed. The mean number of AIN branches was 4.8 (3 to 8) and the
mean length of the nerve available for transfer was 72 mm (41 to
106). The transferred nerve reached the ulnar nerve most distally
when placed dorsal to flexor digitorum profundus (FDP). We therefore
conclude that the AIN should be passed dorsal to FDP, and that the
deep and superficial branches of the ulnar nerve require approximately
30 mm of blunt dissection and 20 mm of sharp dissection from the
point of bifurcation to the site of the anastomosis. The use of this technique for transfer of the AIN should improve
the outcome for patients with proximal ulnar nerve injuries. Cite this article:
Damage to the cartilage of the distal radioulnar
joint frequently leads to pain and limitation of movement, therefore repair
of this joint cartilage would be highly desirable. The purpose of
this study was to investigate the fixation of scaffold in cartilage
defects of this joint as part of matrix-assisted regenerative autologous
cartilage techniques. Two techniques of fixation of collagen scaffolds,
one involving fibrin glue alone and one with fibrin glue and sutures, were
compared in artificially created cartilage defects of the distal
radioulnar joint in a human cadaver. After being subjected to continuous
passive rotation, the methods of fixation were evaluated for cover
of the defect and pull out force. No statistically significant differences were found between the
two techniques for either cover of the defect or integrity of the
scaffold. However, a significantly increased mean pull out force
was found for the combined procedure, 0.665 N (0.150 to 1.160) This suggests that although successful fixation of a collagen
type I/III scaffold in a distal radioulnar joint cartilage defect
is feasible with both forms of fixation, fixation with glue and
sutures is preferable. Cite this article:
The purpose of this study was to evaluate treatment
results following arthroscopic triangular fibrocartilage complex (TFCC)
debridement for recalcitrant ulnar wrist pain. According to the
treatment algorithm, 66 patients (36 men and 30 women with a mean
age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain
were allocated to undergo ulnar shortening osteotomy (USO; n = 24),
arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement
(n = 14) or prolonged conservative treatment (n = 13). The mean
follow-up was 36.0 months (15 to 54). Significant differences in
Hand20 score at 18 months were evident between the USO group and
TFCC debridement group (p = 0.003), and between the TFCC repair
group and TFCC debridement group (p = 0.029). Within-group comparisons showed
that Hand20 score at five months or later and pain score at two
months or later were significantly decreased in the USO/TFCC repair
groups. In contrast, scores in the TFCC debridement/conservative
groups did not decrease significantly. Grip strength at 18 months
was significantly improved in the USO/TFCC repair groups, but not
in the TFCC debridement/conservative groups. TFCC debridement shows
little benefit on the clinical course of recalcitrant ulnar wrist
pain even after excluding patients with ulnocarpal abutment or TFCC
detachment from the fovea from the indications for arthroscopic
TFCC debridement. Cite this article:
The aim of this study was to determine the effect
of a Galeazzi fracture on the strength of pronation and supination at
a mean of two years after surgical treatment. The strength of pronation
and supination was measured in varying rotational positions of the
forearm of ten male patients (mean age 38.9 years (21 to 64)) who
had undergone plate fixation for a Galeazzi fracture. The stability
of the distal radioulnar joint was assessed, and a clinical assessment using
the quick-Disabilities of the Arm Shoulder and Hand (quickDASH)
questionnaire and patient-related wrist examination (PRWE) scores
was undertaken. In addition, the strength of pronation and supination
was measured in a male control group of 42 healthy volunteers (mean
age 21.8 years (18 to 37)). The mean absolute loss of strength of supination in the injured
compared with the non-injured arm throughout all ranges of forearm
rotation was 16.1 kg ( Loss of strength of pronation (27.2%), and of supination (12.5%)
in particular, after a Galeazzi fracture is associated with worse
clinical scores, highlighting the importance of supination of the
forearm in function of the upper limb. Cite this article:
The osteoinductive properties of demineralised
bone matrix have been demonstrated in animal studies. However, its therapeutic
efficacy has yet to be proven in humans. The clinical properties
of AlloMatrix, an injectable calcium-based demineralised bone matrix
allograft, were studied in a prospective randomised study of 50
patients with an isolated unstable distal radial fracture treated
by reduction and Kirschner (K-) wire fixation. A total of 24 patients
were randomised to the graft group (13 men and 11 women, mean age
42.3 years (20 to 62)) and 26 to the no graft group (8 men and 18
women, mean age 45.0 years (17 to 69)). At one, three, six and nine weeks, and six and 12 months post-operatively,
patients underwent radiological evaluation, assessments for range
of movement, grip and pinch strength, and also completed the Disabilities
of Arm, Shoulder and Hand questionnaire. At one and six weeks and
one year post-operatively, bone mineral density evaluations of both
wrists were performed. No significant difference in wrist function and speed of recovery,
rate of union, complications or bone mineral density was found between
the two groups. The operating time was significantly higher in the
graft group (p = 0.004). Radiologically, the reduction parameters
remained similar in the two groups and all AlloMatrix extraosseous leakages
disappeared after nine weeks. This prospective randomised controlled trial did not demonstrate
a beneficial effect of AlloMatrix demineralised bone matrix in the
treatment of this category of distal radial fractures treated by
K-wire fixation. Cite this article:
The aims of this study were to assess the efficacy
of a newly designed radiological technique (the radial groove view)
for the detection of protrusion of screws in the groove for the
extensor pollicis longus tendon (EPL) during plating of distal radial
fractures. We also aimed to determine the optimum position of the
forearm to obtain this view. We initially analysed the anatomy of
the EPL groove by performing three-dimensional CT on 51 normal forearms.
The mean horizontal angle of the groove was 17.8° (14° to 23°).
We found that the ideal position of the fluoroscopic beam to obtain
this view was 20° in the horizontal plane and 5° in the sagittal
plane. We then intra-operatively assessed the use of the radial groove
view for detecting protrusion of screws in the EPL groove in 93
fractures that were treated by volar plating. A total of 13 protruding
screws were detected. They were changed to shorter screws and these
patients underwent CT scans of the wrist immediately post-operatively.
There remained one screw that was protruding. These findings suggest
that the use of the radial groove view intra-operatively is a good
method of assessing the possible protrusion of screws into the groove
of EPL when plating a fracture of the distal radius. Cite this article:
Penetration of the dorsal screw when treating
distal radius fractures with volar locking plates is an avoidable complication
that causes lesions of the extensor tendon in between 2% and 6%
of patients. We examined axial fluoroscopic views of the distal
end of the radius to observe small amounts of dorsal screw penetration,
and determined the ideal angle of inclination of the x-ray beam
to the forearm when making this radiological view. Six volar locking plates were inserted at the wrists of cadavers.
The actual screw length was measured under direct vision through
a dorsal approach to the distal radius. Axial radiographs were performed
for different angles of inclination of the forearm at the elbow. Comparing axial radiological measurements and real screw length,
a statistically significant correlation could be demonstrated at
an angle of inclination between 5° and 20°. The ideal angle of inclination
required to minimise the risk of implanting over-long screws in
a dorsal horizon radiological view is 15°. Cite this article:
In Canada, Dupuytren's contracture is managed
with partial fasciectomy or percutaneous needle aponeurotomy (PNA).
Injectable collagenase will soon be available. The optimal management
of Dupuytren’s contracture is controversial and trade-offs exist
between the different methods. Using a cost-utility analysis approach,
our aim was to identify the most cost-effective form of treatment
for managing Dupuytren’s contracture it and the threshold at which
collagenase is cost-effective. We developed an expected-value decision
analysis model for Dupuytren’s contracture affecting a single finger,
comparing the cost-effectiveness of fasciectomy, aponeurotomy and collagenase
from a societal perspective. Cost-effectiveness, one-way sensitivity
and variability analyses were performed using standard thresholds
for cost effective treatment ($50 000 to $100 000/QALY gained).
Percutaneous needle aponeurotomy was the preferred strategy for
managing contractures affecting a single finger. The cost-effectiveness
of primary aponeurotomy improved when repeated to treat recurrence.
Fasciectomy was not cost-effective. Collagenase was cost-effective
relative to and preferred over aponeurotomy at $875 and $470 per
course of treatment, respectively. In summary, our model supports the trend towards non-surgical
interventions for managing Dupuytren’s contracture affecting a single
finger. Injectable collagenase will only be feasible in our publicly
funded healthcare system if it costs significantly less than current
United States pricing. Cite this article:
Acute swelling of the hand is a common problem after trauma or surgery and is associated with both pain and loss of function. We describe a prospective study of 47 patients in which we assessed the effects of a pneumatic compression device (A-V impulse hand pump) on the swollen hand. The pump reduced swelling by increasing the velocity of venous return as demonstrated by Duplex scanning of the median cubital vein. Continuous use of the pump for 48 hours gave a reduction of 78.6% in swelling of the injured hand compared with the opposite, uninjured side. Even when used intermittently, with the pump on for 12 hours out of 24, a statistically significant effect was seen. There was a subjective reduction in pain and an objective improvement in function of the hand. Use of the pump resulted in a nearly normal hand by the time of discharge from hospital after, on average, 48 hours.
We reviewed 26 patients with 34 shoulders treated by the inferior capsular shift operation for inferior and multidirectional instability. The mean follow-up was 8.3 years. In total, 12 shoulders showed voluntary subluxation. Eight operations used an anterior and posterior approach, 11 were by the posterior route, and 15 shoulders had an anterior approach. In 30 shoulders (85%) the outcome was satisfactory and 20 (59%) scored good or excellent results on the Rowe system. Instability had recurred in nine shoulders (26%) from three months to three years after the operation. Six of the 12 shoulders with voluntary subluxation (50%) had recurrence, as against three of the other 22 (14%), a statistically significant difference. The operation is therefore not indicated for voluntary subluxation. The 19 shoulders which had been assessed in 1987 at a mean of 3.5 years after surgery, were also reviewed in 1995 and found to have no significant changes in instability or Rowe score. This shows that the capsular shift appeared to have maintained its tension over an eight-year period. After the use of a posterior approach, 64% of the shoulders showed a posterolateral defect on radiographs of the humerus.
We obtained samples of spinal accessory nerve from patients undergoing radical surgery for tumours or nerve grafting in the neck. These were analysed by light and electron microscopy for the type of fibre. All contained fibres consistent with non-proprioceptive sensory function including pain.
We have assessed the final strength of the deltoid in 121 patients who had repair of isolated or combined lesions of the axillary (circumflex) nerve and were available for statistical analysis. Successful or useful results were achieved in 85% after grafting of isolated lesions. The strength was statistically better when patients had grafting of the axillary nerve within 5.3 months from the time of injury. The dramatic decrease in the rate of success seen with longer delays suggests that surgery should be undertaken within three months of injury. A statistically significant downward trend of the rate of success was noted with increasing age. The force and level of injury to the shoulder play an important role in the type, combination and level of nerve damage and the incidence of associated rotator-cuff, vascular and other injuries to the upper limb. Management of isolated and combined lesions of the axillary nerve after injury to the shoulder needs to be thorough and systematic.
