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Internal fixation of the scaphoid using a plate has been reported in the literature as far back as 1977. Recently, a specific plate designed for scaphoids has been developed, which provides considerably more buttress support than intramedullary headless screws, and offers a reliable method of rigid internal fixation for complex fractures. Indications to use such a plate include complex acute fractures, such as those with significant waist comminution or steep reverse oblique fractures, and complex nonunions with central bone loss resulting from failed previous headless screw fixation. This is now the authors' preferred treatment for these injuries.

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.

Introduction Four-corner arthrodesis with excision of the scaphoid is an accepted salvage procedure for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) and has been performed in our unit for over 20 years. We have undertaken a retrospective review of 116 of these procedures performed in 110 patients between 1992 and 2009. Fifty-eight patients attended for a clinical evaluation, and 29 responded by postal questionnaire. Methods The surgical technique undertaken was standard. That is, through a dorsal approach the scaphoid and tip of the radial styloid were excised. The capitate, lunate, triquetrum, and hamate articular surfaces were then prepared down to bleeding bone. Bone grafts from the scaphoid and radial styloid were then inserted and fixation undertaken. For the latter, various methods were used, including Kirschner (K-)wires, staples, bone screws, but predominantly the Spider plate (Integra Life Sciences, USA). Thereafter the wrist was immobilized for a minimum period of 2 weeks prior to rehabilitation. Results Follow-up was done at a mean of 9 years and 4 months (range 3–19 years). All patients reported a significant improvement in pain relief and ∼50% of flexion extension, although only 40% of radioulnar deviation. Grip strength was again ∼50% of the contralateral side. Most patients reported a significant improvement in function with 87% returning to work. In addition, radiologic evaluation identified 28 patients (31%) who demonstrated ongoing signs of nonunion, particularly around the triquetrum. Fourteen of these (15%) underwent a further procedure, generally with success. Finally, none of the patients demonstrated any arthritic changes in the lunate fossa on follow-up X-ray, and all secondary procedures were undertaken within 2 years of the primary. Discussion This research has demonstrated that four-corner fusion fixed with a circular plate can result in a satisfactory outcome with a reduction in pain, a functional range of motion, and a satisfactory functional outcome. The bulk of the complications appear to occur in the first 2 years after surgery. Thereafter, analysis shows long-term satisfaction with little deterioration. Nonunion, particularly around the triquetrum, continues to be a problem, but it may be that this bone should be excised along with the scaphoid, resulting in a three-part fusion only. Alternatively, a simple capitolunate fusion may be satisfactory.

Purpose This study aims to report the 5-year survivorship of revision wrist arthroplasties and to report midterm clinical and radiological results. Materials and Methods All patients receiving a revision wrist arthroplasty in our unit between January 1, 1997 and October 31, 2010 were identified, and clinical notes retrospectively analyzed for Quick Disabilities of the Arm, Shoulder and Hand (quickDASH), Patient Evaluation Method (PEM), Patient-Rated Wrist Evaluation (PRWE), the range of movement, and visual analog score (VAS). In cases where patient review had not occurred within the past year, they were invited for assessment, and this data was included in the analysis. Plain radiographs were analyzed for loosening of each component. The 5-year survival was plotted using Kaplan–Meier analysis. Results Of the 19 patients identified, 1 was lost to follow-up and therefore excluded from all analyses. Mean age at revision wrist arthroplasty was 55.8 years and the mean time from primary to revision wrist arthroplasty was 6.7 years. At revision arthroplasty, 7 patients received the Biaxial implant (DePuy, Inc., Warsaw, IN) and 11 received the Universal II implant (Integra, Inc., Plainsboro, NJ). The 5-year implant revision survivorship was 83%. Depending on the variable of interest, clinical data were available for either three, four or five patients. At final follow-up (mean: 10.4 years), mean visual analog score was 2.9, mean quickDASH 57, mean PEM 49, mean PRWE 61, and mean arc of flexion/extension was 26 degrees. Radiological data were available for 12 patients, with evidence of gross loosening present in around 60% of the carpal components and 50% of the radial components at mean 6.7 years. Conclusion Revision wrist replacement implant survival is acceptable, but the majority of the surviving implants are radiologically loose. It is not clear at this time whether they are better or worse than a fusion after a failed primary wrist arthroplasty. Clinical Relevance It is reasonable to offer revision wrist arthroplasty in selective cases, but regular clinical and radiological follow-up is recommended.

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 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 approach to patients who suffer from osteoarthritis (OA) and those with rheumatoid arthritis (RA) is very different. Both patients with hand and wrist problems present with pain and commonly loss of function, but the polyarthritis in RA is only one feature of a systemic auto-immune disease. Over the last few years, significant advances in the biologic treatment of RA have modified its natural history. As a result, the amount of rheumatoid surgery being performed has decreased. As an orthopaedic surgeon, it is important to understand the pathogenesis of both of these diseases and the non-operative and operative treatments available. In RA, traditional procedures such as synovectomy have decreased, while the number of arthroplasties has increased in the hope of preservation of movement. In OA, there has also been an increase in small joint and wrist arthroplasty, but with varying short-term results and the long-term outcome of these interventions is awaited.

Athletic hand injuries present a unique challenge for the treating surgeon. Apart from a detailed understanding of the pathoanatomy of each injury, the surgeon also needs to appreciate the specific demands placed on the injured athlete in their sport in order to ensure an optimal outcome with a timely return to competition. In this article, the most commonly encountered acute hand injuries in athletes are reviewed, focussing on the assessment, principles of treatment and consideration of rehabilitation as pertinent to athletes.

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.

The approach to patients who suffer from osteoarthritis (OA) and those with rheumatoid arthritis (RA) is very different. Both patients with hand and wrist problems present with pain and commonly loss of function, but the polyarthritis in RA is only one feature of a systemic auto-immune disease. Over the last few years, significant advances in the biologic treatment of RA have modified its natural history. As a result, the amount of rheumatoid surgery being performed has decreased. As an orthopaedic surgeon, it is important to understand the pathogenesis of both of these diseases and the non-operative and operative treatments available. In RA, traditional procedures such as synovectomy have decreased, while the number of arthroplasties has increased in the hope of preservation of movement. In OA, there has also been an increase in small joint and wrist arthroplasty, but with varying short-term results and the long-term outcome of these interventions is awaited.

Background Osteoarthritis of the elbow is a difficult problem to treat. The results of total joint arthroplasty have historically been poor. Methods Seventy-nine patients who underwent ulnohumeral arthroplasty between 1994 and 2002 were included in the study. Fifty-nine elbows in 58 patients were available for clinical assessment. There were 14 females and 44 males with an average age of 63 years (32 to 80) and a mean follow-up of 7.8 years (5 to 12). There were 39 (67%) patients with primary osteoarthritis, 18 (31%) with post-traumatic and 1 patient with post-septic arthritis of the elbow. Results Using the visual analogue scale (VAS) (0 to 10), the pain score was seen to improve from 8 (6 to 10) to 3.8 (0 to 9). Twenty six patients (44%) were on minimal or no analgesia. The arc regarding flexion/extension was found to increase by 18°. Twenty-four percent of patients suffered an adverse incident. Radiologically 28 (6%) patients had recurrent bone formation in the olecranon fossa. This however did not correspond to the clinical outcome. Patients with loose bodies seemed to do better in the post-operative phase. Conclusion Ulnohumeral arthroplasty has a role in the management of the arthritic elbow as it provides pain relief in the post-operative period. However the improvement in the range of movement is limited particularly with regard to the arc of extension. This improvement in pain appears to diminish with time.

Background This was a retrospective study presenting our results and survivorship of the Acclaim total elbow when used as a revision implant. Methods Between May 2001 and July 2005, 29 revision elbow replacements were carried out on 28 patients in our institution. Five were redo revisions and one received the fourth sequential implant. A variety of implants were removed for aseptic loosening (17), periprosthetic fracture (7), dislocation (3) and infection (2). Two patients had died and one was unavailable for follow-up. Results At a mean follow-up of 50 months (12 to 80 months) pain, functional assessment scores and radiographs were assessed and a Kaplan-Meier survival curve created. Symptoms were reliably relieved with 72% reporting no pain. Mean flexion was 128° with loss of full extension of 34°. Complications were noted in six cases of which three patients underwent further surgery. None of the 29 revisions has been re-revised till date. Conclusion The medium term results for this implant suggest it is an effective revision prosthesis.

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.

Background: A recent report has suggested that local injection of botulinum toxin type A is an effective method of treatment for chronic tennis elbow. The toxin is thought to provide temporary paralysis of the painful common extensor origin, thereby allowing a healing response to occur. To test this theory, we performed a double-blind, randomized, controlled, pilot trial comparing injections of botulinum toxin type A with those of a placebo (normal saline solution) in the treatment of chronic tennis elbow. Methods: Forty patients with a history of chronic tennis elbow for which all conservative treatment measures, including steroid injection, had failed were randomized into two groups. Half the patients received 50 units of botulinum toxin type A, and the remainder received normal saline solution. The intramuscular injections were performed 5 cm distal to the maximum point of tenderness at the lateral epicondyle, in line with the middle of the wrist. The two solutions used for the injections were identical in appearance and temperature. The results of a quality-of-life assessment with the Short Form-12 (SF-12), the pain score on a visual analogue scale, and the grip strength measured with a validated Jamar dynamometer were recorded before and three months after the injection. Results: Three months following the injections, there was no significant difference between the two groups with regard to grip strength, pain, or quality of life. Conclusions: With the numbers studied, we failed to find a significant difference between the two groups; thus, we have no evidence of a benefit from botulinum toxin injection in the treatment of chronic tennis elbow. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Chronic exertional compartment syndrome (CECS) of the forearm may occur in sports requiring prolonged grip strength. CECS is a function of increasing pressure following muscle expansion within an inelastic tissue envelope resulting in compromise of perfusion and tissue function. Typical symptoms are pain, distal paraesthesia and loss of function. The condition is self-limiting and resolves completely between periods of activity. With no effective medical treatment, the gold standard remains four compartment open fasciotomy (Söderberg, J Bone Joint Surg Br 78(5):780–2, 1996; Wasilewski and Asdourian, Am J Sports Med 19(6):665–7, 1991). Minimally invasive techniques have been described (Croutzet et al., Tech Hand Up Extrem Surg 13(3):137–40, 2009) but have a risk of neuro-vascular injury, especially to the ulnar nerve while releasing the deep flexor compartment. We present a safe technique used with six elite rowers for mini-open fasciotomy to minimise scarring and time away from training while reducing the risk of neurovascular injury.

To the Editor: We are writing in response to the article by Mann and Hammert, which once again addresses the important issue of upper limb surgery after axillary lymph node dissection. In our similar article published last year, we also found little in the literature to support the notion that these patients are at greater risk of complications. However, we, in addition, surveyed hand surgeons, breast surgeons, and breast care nurses in the United Kingdom regarding their opinion on whether surgery should be contraindicated in these patients. We found that a significant difference in opinion existed between these health professionals (P .005). Ninety percent of hand surgeons in the United Kingdom felt that there was no contraindication to surgery, compared to 60% of breast surgeons and only 10% of breast care nurses. Because breast surgeons and breast care nurses are the primary healthcare professionals dealing with breast cancer patients, it might be time to re-evaluate the advice they give regarding ipsilateral upper limb procedures.

Exercise-induced chronic compartment syndrome in the first dorsal compartment is an uncommon entity and relatively rare condition which is not very well understood. It is a usually activity-related condition and is associated with decreased function of muscle with intracompartmental swelling. We present a case with proven exercise-induced raised compartment pressure that responded well to surgical fasciotomy.

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.

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.