Search

Background: The purpose of this investigation was to explore prospectively the nature and duration of hand and wrist injuries in training and competition in the Great Britain (GB) amateur boxing squad between 2005 and 2012. Methods: Longitudinal prospective injury surveillance of the GB boxing squad was performed from 2005 to 2012. The location, region affected, description, and the duration of each injury were recorded by the team doctor and team physiotherapist. We recorded whether the injury occurred during competition or training and also whether it was a new or a recurrent injury. The injury rate during competition was calculated as the number of injuries per 1000 hours. Results: Finger carpometacarpal instability and finger metacarpophalangeal joint extensor hood and capsule sprain also known as “boxer’s knuckle” injuries were significantly more common than other injury diagnoses. The number of injuries during training or competition was similar, which is remarkable given the far greater number of training hours than competition hours performed. Injury rate for hand and wrist injuries in competition was 347 injuries per 1000 hours, while the estimated injury rate in training was

Purpose To report the outcomes, complications, and survivorship of pyrocarbon metacarpophalangeal joint arthroplasty in noninflammatory arthropathy at a minimum 5-year follow-up. Methods A retrospective review of 51 implants in 36 patients was undertaken. Patient demographics, complications, further surgery, and implant revision were recorded. Objective outcome was assessed by grip strength, range of motion, and radiological assessment of alignment, loosening, and subsidence. Subjective outcome was assessed by Patient Evaluation Measure, Quick Disabilities of the Arm, Shoulder and Hand score, and visual analog scores (0, best; 10, worst) for appearance, satisfaction, and pain. Results There were 35 index and 16 middle fingers. The average follow-up was 103 months (range, 60–172 months). The mean arc of motion was 54° (range, 20° to 80°). There was no difference in grip strength between operated and nonsurgical side. Six implants were revised, and 3 of these required additional surgery. The average Patient Evaluation Measure and Quick Disabilities of the Arm, Shoulder and Hand scores were 27 (range, 10–54) and 29 (range, 0–57), respectively. Mean visual analog scores for pain, satisfaction, and appearance were all 1 with the respective ranges being 0–7, 0–4, and 0–6. Most implants were Herren grade 1 lucency with the remaining 5 proximal and 12 distal implants being grade 2. Mean subsidence in the proximal component was 2 mm (range, 0–4 mm) and 1 mm (range, 0–3 mm) in the distal component. The degree of loosening or subsidence did not correlate with outcome. Implant survival as assessed by Kaplan–Meier was 88% at 10 years. Conclusions Good pain relief, a functional range of motion, and high satisfaction were seen in the majority of patients. All implant revisions were performed within 18 months of the index procedure. This may represent technical issues rather than problems with the implant. Type of study/level of evidence Therapeutic IV.

We reviewed 63 trapeziometacarpal arthrodeses (57 patients) performed in our unit between April 2007 and May 2013 for osteoarthritis. K-wires, plates, headless compression screws and memory staples were used for fixation. The average age of patients was 50 (range 20–78) years and there were 36 men and 21 women with a mean follow-up of 36 (range 6–62) months. K-wires were used in 31 cases, staples in 12, plates in five, and screws in 15 joints. The overall non-union rate was 11%, however, when using K-wires for fixation, it was 20%. Union was achieved in all cases when staples or screws were used for fixation. Disabilities of the Arm, Shoulder and Hand scores were higher in cases where non-union occurred compared with those that united (66.7 vs. 21.9). Trapeziometacarpal arthrodesis for osteoarthritis gives good clinical outcome with lower (DASH) scores when union occurs. K-wire fixation led to a 20% non-union rate, and as a result, the senior author no longer uses this method of fixation.

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

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

Isolated instability of the index and middle finger carpometacarpal joints is uncommon. An unpublished injury pattern in a consecutive series of 13 elite boxers is described, with mid-term radiological and functional results of two novel surgical treatments. All the boxers (from Australia and the UK) were unable to compete owing to pain and weakness. Four boxers were managed initially by open reduction and temporary K-wire fixation. Nine boxers underwent primary carpometacarpal arthrodesis. All were able to return to their previous level of competition. One boxer who had undergone a soft tissue reconstruction competed at international level but required an arthrodesis because of recurrent symptoms. In elite boxers, simple reduction and wiring may be appropriate for an acute injury causing index or middle finger carpometacarpal joint instability, however, arthrodesis is the treatment of choice when instability and degenerative changes are present.

The aim of this study was to measure inter- and intra-observer agreement on the radiographic classification of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist. Radiographs of 41 patients with SLAC wrist and 47 patients with SNAC wrist were graded on two separate occasions by four orthopaedic consultants specializing in hand and wrist surgery. Inter-observer agreement was evaluated using the multi-rater kappa value. Landis and Koch criteria were used to assess the level of agreement. Intra-observer agreement was tested by re-grading the radiographs after an interval of 2 to 4 weeks and calculating the weighted kappa value. For SLAC wrist, the inter-observer agreement was moderate (kappa value = 0.59) and intra-observer agreement substantial (kappa value = 0.65). For SNAC wrist, the inter-observer agreement was slight (kappa value = 0.20) and intra-observer agreement was fair (kappa value = 0.29). Radiographic classification of SLAC wrist has moderate reliability and reproducibility, whereas classification of SNAC wrist has limited reliability.

Purpose To report the outcome and complications from pyrocarbon proximal interphalangeal (PIP) joint arthroplasty at a minimum of 2 years of follow-up. Methods A retrospective case review was performed on 72 patients with an average age of 57 years, and a total of 97 pyrocarbon PIP joint arthroplasties. Patient demographics, diagnosis, implant revisions, and other repeat surgeries were recorded. Subjective outcome was evaluated at latest follow-up with the Disabilities of the Arm, Shoulder, and Hand score; Patient Evaluation Measure; and visual analog scores of pain, satisfaction, and appearance. Objective outcomes included PIP joint range of motion, grip strength, and radiographic assessment of alignment and loosening. Results The principal diagnosis was primary osteoarthritis in 43 patients(60%), posttraumatic arthritis in 14 (19%), rheumatoid arthritis in 9 (13%), and psoriatic arthritis in 6 (8%). The average follow-up was 60 months (range, 24–108 mo). Twenty-two of 97 digits (23%) had repeat surgery without revision, and 13 digits (13%) had revision at an average of 15 months. There were no significant differences in preoperative and postoperative range of motion. The average Disabilities of the Arm, Shoulder, and Hand score was 22, and the average pain score was zero. Implant migration and loosening was observed but was not related to clinical outcome or revision. Conclusions The survival of pyrocarbon PIP joint arthroplasty was 85% (83 of 97) at 5 years of follow-up, with high patient satisfaction. Patients should be advised that the procedure achieves good relief of pain but does not improve range of motion. Type of study/level of evidence Therapeutic IV.

Aims 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. Patients and Methods 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. Results The mean worst pain was 8.1 (3 to 10) pre-operatively and 5.4 (0 to 10) at latest follow-up (p < 0.001). Movements were preserved with mean dorsiflexion of 29o (0 o to 70 o) and palmar flexion of 21o (0o to 50o). The mean grip strength was 4.8 kg (1.7 to 11.5) pre-operatively and 10 kg (0 to 28) at final follow-up (p < 0.001). The mean QuickDASH and Wrightington wrist scores improved from 61 (16 to 91) to 46 (0 to 89) and 7.9 (1.8 to 10) to 5.7 (0 to 7.8) (p < 0.001). A total of six patients (7%) had major complications; three required revision arthroplasty and three an arthrodesis. The Kaplan-Meier probability of survival using removal of the components as the endpoint was 91% at 7.8 years (95% confidence interval 84 to 91). Conclusion The Universal-2 TWA is recommended for use in patients with rheumatoid arthritis. Cite this article: Bone Joint J 2016;98-B:1642–7.

Nine cases of failed biaxial wrist replacement underwent revision surgery and subsequent clinical and radiographic assessment at a mean follow-up of 28 months. Clinical assessment included the hospital for special surgery (HSS) and activities of daily living scoring systems. Five patients had a revision biaxial wrist replacement, three had wrist fusions and two underwent an excision arthroplasty. The mean HSS score was 73 for the revision biaxial replacements, 63 for the wrist fusions and 92 for the excision arthroplasties. The mean activities for daily living score was 16 for the revision biaxial replacements, 14 for the wrist fusion and 20 for the excision arthroplasties. Despite the experience of implant failure, six patients would still choose a primary wrist replacement again. All patients in this small series appear to have had good clinical outcomes. Revision to another wrist replacement appears no worse than a wrist fusion in the short term and patients value the preservation of movement that an implant offers.

Dupuytren’s disease (DD) is a common progressive fibroproliferative disorder causing permanent digital contracture. Proliferative myofibroblasts are thought to be the cells responsible for DD initiation and recurrence, although their source remains unknown. DD tissue has also been shown to harbor mesenchymal and hematopoietic stem cells. Fibrocytes are circulating cells that show characteristics of fibroblasts and they express surface markers for both hematopoietic and mesenchymal stromal cells. Fibrocytes differentiate from peripheral CD14+ mononuclear cells, which can be inhibited by serum amyloid P (SAP). In this study we have demonstrated the presence of fibrocytes in DD blood and tissue, moreover we have evaluated the effects of SAP and Xiapex (Collagenase Clostridium histolyticum) on fibrocytes derived from DD. H&E staining showed typical Spindle shaped morphology of fibrocytes. FACS analysis based on a unique combination of 3 markers, revealed the increased presence of fibrocytes in blood and tissue of DD patients. Additionally, immunohistology of DD nodule and cord tissue showed the presence of collagen 1+/CD34+ cells. No difference in plasma SAP levels was observed between DD and control. Higher concentrations of SAP significantly inhibited fibrocytes differentiated from DD derived monocytes compared to control. DD fascia derived fibrocytes showed resistance to growth inhibition by SAP, particularly nodule derived fibrocytes showed robust growth even at higher SAP concentrations compared to control. DD derived fibrocytes were positive for typical fibrocyte dual markers, i.e. Collagen 1/LSP-1 and collagen 1/CD34. Xiapex was more effective in inhibiting the growth of nodule derived cells compared to commercially available collagenase A. Our results show for the first time the increased presence of fibrocytes in DD patient’s blood and disease tissue compared to control tissue. Additionally, we evaluate the response of these fibrocytes to SAP and Xiapex therapy.

In clinical trials, treating Dupuytren’s contracture with collagenase injection involves manipulation the day after injection, without local anaesthesia. We evaluated the efficacy and tolerability of manipulation 2 days after injection with local anaesthesia. Forty-five patients received 50 injections into cords contracting metacarpophalangeal and proximal interphalangeal joints; follow-up visits were at 3 and 14 weeks. For the metacarpophalangeal joints there were >90% reduction in contracture at both visits. The proximal interphalangeal joints that improved spontaneously after metacarpophalangeal injection or received direct injections showed 51–55% reduction in contracture. Changes in scores on the Patient Evaluation Measure suggest that patients perceived improvements in their hand function was good and they were satisfied with the procedure. Collagenase and local anaesthesia injections were well tolerated; adverse events were localized to the injection site and were mild and transient in nature. These findings provide another viable option for practising surgeons and may help with the logistics of patient care.

Dupuytren's disease (DD) is a fibroproliferative disorder characterized by aberrant proliferation of myofibroblasts, the source of which remains unknown. Recent studies indicate that circulating and tissue-resident mesenchymal stem cells (MSCs) can differentiate into myofibroblasts. Therefore, the aim of this study was to profile MSCs from phenotypically distinct DD sites including cord, nodule, skin overlying nodule (SON), and perinodular fat (PNF) compared with unaffected internal controls, that is, distant palmar fat (DPF) and transverse palmar fascia (Skoog's fibers) as well as external control carpal tunnel (CT) tissue including skin, fat, and fascia. Freshly isolated primary fibroblasts as well as cells grown up to passage 5 (P5) from DD (n=27) and CT (n=14) samples were analyzed for the presence of established MSC markers CD73, CD90, and CD105 and absence of hematopoietic marker CD34 using fluorescence-activated cell sorting, in-cell quantitative western blotting, immunohistochemistry, and immunocytochemistry. Freshly isolated cells from SON, PNF, and cord biopsies had a higher number of CD34(-)73(+)90(+)105(+) cells compared with Skoog's fibers and CT controls. P3 cells obtained from all DD biopsies compared with CT samples differentiated into osteocytes, adipocytes, and chondrocytes. P3 cord and nodule cells expressed intense α-smooth muscle actin staining compared with skin and fat cells. Stem cell markers including stem cell factor, MSC-homing marker CXCR4, and Wnt/β-catenin downregulator Dkk-1 were all upregulated in SON and PNF compared with CT skin and CT fat, respectively, as shown by real-time quantitative polymerase chain reaction. However, osteogenic marker OSF-1 had a significantly higher expression in the PNF (P=0.002) and cord (P=0.01) compared with the nodule. In conclusion, we have shown the presence of MSCs in specific DD tissue phenotypes compared with internal and external control tissue. These findings provide preliminary support for a potential alternative source of disease myofibroblasts originating from sites such as SON and PNF as opposed to palmar fascia alone.

We describe late anatomic repair of complete distal ulnar collateral ligament (UCL) avulsions of the thumb in the absence of metacarpophalangeal joint arthritis using a dissolvable polylactic acid (PLA) bone anchor in two cases, one of which had a Stener lesion.Patients presented for surgery respectively at 5 months and 2 years after injury. Preoperative X-ray films showed subtle volar subluxation of the proximal phalanx. Volar plate release corrected this in both cases and a transarticular k-wire was not used. Satisfactory repair was achieved in both cases using a dissolvable PLA bone anchor. Flexion-extension mobilization was supervised by a hand therapist from day 1 after surgery. A low profile radial-sided thermoplastic splint to prevent reinjury of the UCL repair was used allowing interphalangeal joint and base of thumb movement, and was worn between therapy sessions for 4 weeks.In both patients, satisfactory UCL stability was maintained at 3-year follow-up after surgery.Dissolvable PLA bone anchors may be used to satisfactorily restore stability and function in late presenting complete distal UCL avulsions of the thumb with or without accompanying Stener lesions.

We describe the use of a vascularised periosteal patch onlay graft based on the 1,2 intercompartmental supraretinacular artery in the management of 11 patients (ten men, one woman) with chronic nonunion involving the proximal third of the scaphoid. The mean age of the patients was 31 years (21 to 45) with the dominant hand affected in eight. Six of the patients were smokers and three had undergone previous surgery to the scaphoid. All of the proximal fragments were avascular. The presence of union was assessed using longitudinal axis CT. Only three patients progressed to union of the scaphoid and four required a salvage operation for a symptomatic nonunion. The remaining four patients with a persistent nonunion are asymptomatic with low pain scores, good grip strength and a functional range of wrist movement. Although this technique has potential technical advantages over vascularised pedicled bone grafting, the rate of union has been disappointing and we do not recommend it as a method of treatment.

Purpose The aim of this cadaveric study was to assess and compare the distance of commonly used dorsal wrist portals to the dorsal ulnar and radial superficial nerves and their branches. Methods Twenty embalmed cadaveric upper limbs were dissected, exposing the nerves and tendons, and wrist arthroscopy portal sites were marked with pins. The horizontal distance between the portals and closest nerve branch was measured with a digital caliper. Statistical analysis of the data was performed with SPSS software for Windows (version 11.5; SPSS, Chicago, IL) by use of Friedman tests and Wilcoxon signed rank tests. Results The median distance of the nearest nerve branch to portal 1-2 was 1.82 mm; portal 3-4, 4.85 mm; portal 4-5, 16.13 mm; portal 6U, 2.47 mm; and midcarpal radial portal (MCP), 6.65 mm. The 4-5 portal was safer than the 1-2 portal ( P P = .015), MCP ( P = .001), and 6U portal ( P P = .01), 3-4 portal ( P = .019), and 6U portal ( P = .003). Conclusions The 4-5 portal is further away from a nerve branch than any other portal, followed by the MCP. Clinical Relevance The results of this study may be of use in the planning of wrist arthroscopy.

We reviewed the outcomes of 34 patients who had undergone vascularised bone grafting for a chronic scaphoid non-union. Mean age was 27 years (range 16–46 years). The dominant hand was involved in 17 cases. Eleven patients were smokers. In 18 cases the fracture involved the proximal and in 16 cases the middle third of the scaphoid. In 26 patients the proximal scaphoid fragment was deemed avascular. Sixteen patients had previously undergone scaphoid fixation and non-vascularised bone grafting. At a follow-up of 1 to 3 years (mean 1.6 years), 15 of the 34 scaphoid non-unions had united. Injury to the dominant hand and duration of the non-union significantly increased the risk of failure. Persistent non-union was more common in proximal third fractures and in the presence of an avascular proximal pole but these findings did not reach statistical significance.

One hundred and sixty-two patients with a diagnosis of scapholunate instability underwent a modified Brunelli procedure over a 7-year period. One hundred and seventeen were assessed with the help of a questionnaire and, of these, 55 patients attended for clinical evaluation. The mean follow-up was 4 (1–8) years. There were 72 patients with dynamic scapholunate instability and 45 patients with static instability. The average age was 38 years. There were 50 males and 67 females. A total of 77 (62%) patients had no to mild pain with a mean visual analogue score of 3.67 (SD = 2.5). The loss in the arc of flexion–extension was due to a reduced range of flexion (mean loss 31%), while 80% of extension was maintained, compared with the contralateral side. The grip strength on the operated side was reduced by 20% of the non-operated side. There was no statistically significant difference ( P>0.05). in the range of movement or the grip strength between the static and dynamic group and patients with or without legal claims. Ninety (79%) patients were satisfied with the result of the surgery (good to excellent) and 88% of the patients felt that they would have the same surgery again. We feel that these results compare favourably with the early results published from this unit and recommend this procedure for dynamic and static scapholunate instability.