Session 5: Hand and Wrist

18. November
11:00 - 12:00
Lokale: 102-103
Chairmen: Maiken Stilling & Jerzy Stiasny

38. Volar locking plate fixation of distal radius fractures and associated complications. A retrospective study of 599 patients with a mean follow-up of 2.5 years
Michelle Fog Andersen, Marcus Landgren, Linnea Bøgeskov Schmidt, Galal Hassani
Department of Orthopaedics, Holbæk Hospital; Department of Orthopaedics, Hand Surgery Unit, Copenhagen University Hospital, Herlev/Gentofte; Department of Orthopaedics, Copenhagen University Hospital, Hvidovre Hospital; Department of Orthopaedics, Hand Surgery Unit, Copenhagen University Hospital, Hvidovre Hospital

Background: In displaced and non-reducible distal radius fractures (DRF), open reduction and internal fixation with volar locking plates (VLP) has become the gold standard. Despite good outcome, surgery is not without complications.
Aim: To evaluate the incidence of postoperative complications after surgical treatment of DRFs with the use of VLPs.
Materials and Methods: We retrospectively reviewed the medical records of all consecutive patients treated with VLP (2.4-mm LCP, Synthes) for a DRF between January 2016 and December 2018 at Hvidovre Hospital. The data were extracted and assessed regarding surgeon experience, secondary surgery and complications. The radiographs were evaluated in according to fracture type (AO/OTA classification), volar plate positioning (Soong grade) and dorsal screw prominence.
Results: A total of 603 DRFs treated with VLP fixation in 599 patients (472 females and 127 males) were included and reviewed. Mean follow-up was 2.5 (range 1 to 4) years after primary surgery. The mean age was 61 years (range 19-93). Fractures were classified as AO 23-A (29.4%), 23-B (19.1%) and 23-C (51.6%). The overall complication rate was 11.1% (67 cases), with 8.3% major (n=50) and 2.8% minor (n=17) complications. The most common complications were those related to metal hardware leading to removal (3.6%), mainly due to intraarticular screw (1.5%) and pain/reduced ROM (1.5%). Other complications were mal-reduction/loss of reduction (2.2%), carpal tunnel syndrome (1.8%), transient neurapraxia (1.7%) and tendon complications, i.e. tenosynovitis (0.5%)/ruptures (0.5%). Secondary revision surgery was performed in 9.5% (57 procedures). No statistical significant differences in complication rates were found in regard to the patient’s age (p = 0.136), the fracture according to AO/OTA type (p = 0.360) or surgeon experience (p = 0.171).
Interpretation / Conclusion: The incidence of postoperative complications in DRFs is low after surgical treatment with VLP fixation, suggesting it is a safe and efficient treatment. However, secondary surgery does occur due to complications. Consequently, it is imperative that the surgeon is aware of the risks and difficulties related to the procedure.

39. High early implant removal- and subluxation incidence after Amandys interposition arthroplasty for radio-carpal osteoarthritis
Robert Gvozdenovic, Lars Vadstrup
Herlev/Gentofte University Hospital of Copenhagen Orthopaedic Surgery Department, Hand Surgery Unit Hospitalsvej 1 2900 Hellerup

Background: Recently, Amandys, a novel pyrocarbon interposition arthroplasty has been introduced as alternative for the treatment of wrist osteoarthritis. This method´s spacer concept does not require extensive carpal bone removal, thus not burning any bridges towards possibility of Total Wrist Arthroplasty.
Aim: According to national regulations for new implants for surgical use, the aim of this study was to report the results of this implant with special focus on safety and early survival.
Materials and Methods: From March 2018 until September 2019, thirteen patients were operated with Amandys implant. There were nine women, four men, aged 42 – 85 years (mean, 63.8 year), at the time of the surgery. Six of thirteen patients had prior surgery to the involved wrist. Pre-operatively, and at the follow-ups, pain was assessed on visual analogue scale (VAS), range of motion measures were collected for the wrist, and grip strength was assessed. q-DASH scores and pre- and postoperative radiographic series were obtained.
Results: Mean follow-up was 21 months (range 16 – 29 months). No patients were lost for follow-up, one died. Four out of thirteen patients experienced implant removal, caused by heavy pain, early after surgical treatment (30 %). All patients were revised with Remotion Total Wrist Arthroplasty, one five months postoperatively, two twelve months after implant surgery, one after seventeen months. Furthermore, three more patients were re-operated, two caused by palmar luxation of the implant, one caused by 90° rotation of the implant. These implants were exchanged with another Amandys implant of different size, combined with capsular strengthening and further bone-socket remodeling procedures. Six remaining patients showed uneventful postoperative course and an acceptable clinical and functional result.
Interpretation / Conclusion: Despite potential benefits in providing a spacer function, without extensive bone removal, the question remains to be answered, if Amandys implant represent an alternative to other surgical solutions. Painful Instability caused by capsular issues and bone-socket preparation seems to be major problems at some patients. If the usage of this implant is planned, extreme caution is warranted.

40. Fixation of combined TFCC foveal and capsular injury by modified ulnar tunnel technique – a feasible solution?
Sabine Simonsen, Robert Gvozdenovic
Department of Orthopaedics, Herlev-Gentofte Hospital; Department of Orthopaedics, Herlev-Gentofte Hospital

Background: Methods for fixation of TFCC injuries vary depending on the type of injury. Different suturing techniques (outside-in, inside-out, all-inside) have been introduced for the capsular injuries (Atzei Class 1). Similarly, different techniques (anchors, trans- osseous sutures, ulnar tunnel) are used for the foveal injuries (Atzei class 3). Solutions for fixation of the combined lesions (Atzei Class 2) have been sparsely investigated.
Aim: The aim of the study was to evaluate the feasibility of the modified ulnar tunnel technique in treating combined TFCC lesions through same 3,2 mm bony canal in ulna, as used for foveal injuries.
Materials and Methods: Between June 2018 and May 2020, 20 patients, underwent surgery in which both components of the injury were sutured, using the all-inside technique for the capsular injury and usual technique for the foveal fixation, through the same ulnar tunnel. All patients had ulnar-sided wrist pain and mild to moderate instability of the distal radioulnar joint (DRUJ). Diagnosis was finally established intraoperatively by the positive hook- and trampoline tests and by visualization of the capsular tear. Full weight-bearing activities were allowed at 3 months. Prospective evaluation included assessment of pain (VAS score), grip strength, range of motion and q-DASH score.
Results: No complications related to surgery occurred. 18 out of 20 patients were eligible for the minimum 12 months follow-up, mean follow-up thirteen months [6-33]. All patients achieved stability of the DRUJ. Mean preoperative VAS score (rest/activity) decreased from 32 and 67 to 6 and 32 postoperatively (p<0.05). Grip strength and range of motion did not change, while q- DASH score improved from 52 preoperatively to 25 postoperatively (p<0.05). Two patients sustained new wrist trauma and were both successfully re- operated. One patient experienced tenderness caused by cyst occurrence after Push-lock ankers and was treated surgically with curettage, 18 months after TFCC surgery.
Interpretation / Conclusion: Arthroscopic TFCC fixation of combined, capsular and foveal tear by modified ulnar tunnel technique is feasible, showing promising results on the short follow-up. Longer follow-up study is needed.

41. The Minimal Clinically Important Difference of the Shortened Disability of the Arm, Shoulder, and Hand Questionnaire for Patients with Thumb CMC Arthritis
Rasmus Wejnold Jørgensen, Marc Randall Kristensen Nyring
Hand Clinic, Department of Orthopedic Surgery, Herlev-Gentofte University Hospital of Copenhagen, Denmark; Department of Orthopedic Surgery, Herlev-Gentofte University Hospital of Copenhagen, Denmark.

Background: The Quick Disability of the Arm, Shoulder and Hand questionnaire (Quick-DASH) is a shortened outcome measure focused on the function of the upper extremity. Evaluating the effect of orthopedic treatment through change in patient reported outcomes requires an understanding of the minimal clinically important difference (MCID).
Aim: The aim of this study was to report the MCID for patients receiving surgical treatment for thumb carpometacarpal joint osteoarthritis (CMC OA).
Materials and Methods: We prospectively analyzed 315 patients receiving surgical treatment for thumb CMC OA. Patients were seen before and 6 months following surgery. We used an anchor-based method and calculated the MCID based on the receiver operating characteristic (ROC) curve.
Results: The MCID of Quick-DASH was estimated to be 18 points. The area under the ROC curve was 0.82, indicating a satisfactory accuracy.
Interpretation / Conclusion: In conclusion, we have calculated the MCID of the Quick-DASH in a population of patients with thumb CMC OA receiving surgical treatment using an anchor-based approach.

42. 1 & 2 Column Fusion - a solution for the SLAC or SNAC Wrist; case series of 43 consecutive patients
Lars Solgård, Robert Gvozdenovic
Herlev-Gentofte University Hospital of Copenhagen, Department of Orthopedics, Hand Surgery Unit

Background: One or Two Column Fusion (1CF, 2CF) has been introduced as an alternative to Four Corner Fusion (4CF).
Aim: The rationale behind is needing less bone grafting and consequently improving the union.
Materials and Methods: From August 2014 to January 2020, 43 consecutive patients, 13 women, with a 58.5 year of age (mean) (range 35-76), has been treated for SLAC/SNAC wrist. In 33 cases the surgery was performed as 2CF, in 10 as 1CF. Os triquetrum has been removed in 5 cases. The union was determined by CT-scan or X-ray follow-up studies, and clinically. The assessments of pain (VAS score 0-100), range of motion (ROM), grip strength, and Disabilities of the Arm, Shoulder and Hand (quick-DASH) Score were prospectively included.
Results: All 43 patients were available for the follow-up, at mean 24.2 months (range 12 - 48). All patients but two achieved union at a mean of 10.8 weeks (range 5 –25 weeks). Pain diminished from 62 (mean), preoperatively to 10 (mean), postoperatively (p<0,05). Grip strength decreased, however, from 31 KgF (mean) to 26 KgF (mean). qDASH improved from 45 to 10 (mean), before, and after the surgery (p<0,05), ROM of 69 °/31 ° (mean) was recorded for total dorso-volar/radio-ulnar flexions, respectively. One pt. united after re- operation. Two patients were converted to total wrist fusion(TWF), one to Total Wrist Arthroplasty (TWA).
Interpretation / Conclusion: 1 & 2CF showed significant improvement in pain and function, with minimal impairment of the grip strength on the short-term follow-up. A union rate of 95% and an acceptable complication rate was achieved, without fusing all carpals.

43. Arthroscopic vs. Open Bone Grafting in the treatment of Scaphoid Nonunion; case control study.
Robert Gvozdenovic, Dejan Susic
Herlev/Gentofte Hospital, University of Copenhagen Orthopaedic Surgery Department, Hand Surgery Unit Hospitalsvej 1, 2900 Hellerup

Background: Scaphoid nonunion is a challenging condition with an incidence of approximately 10%, even when the treatment has been given, while the prevalence among nontreated patients remains unknown. This condition, when left untreated causes pain, functional impairment, wrist osteoarthritis and ultimately, the collapse of the entire wrist. Comparative results between operative techniques are sparse.
Aim: The research question of this study is whether the arthroscopic bone grafting can provide faster union compared to traditional, open grafting technique, in the treatment of scaphoid nonunion.
Materials and Methods: Patients operated by either open bone-grafting method (O; n=49) or arthroscopically assisted bone-grafting method (A; n=22) from 2008 – 2020. Demographically, groups were similar concerning risk factors, such was localization at proximal pole, humpback deformity, inclusive larger dislocations and number of cases with > 6 months nonunion presence. Union time and union rate after surgery was assessed. Patients are assessed clinically and radiographically and/or by CT scan at the follow-up on the 6th – 8th postoperative week. Immobilization continues for intervals of 4 - 6 weeks until union become radiologically and clinically evident. The main criteria for union are the presence of bridging bone trabecula on > 50% of scaphoid-axis CT reconstruction scans and clinical examination.
Results: The mean follow-up was 12,6 months (range 6 – 32 months). Patients treated in A group achieved statistically significant faster union after surgery for scaphoid nonunion than patients treated in O group with a difference in mean of 37.15 (37 days), (p- value= 0.0035). Mean and 95% Confidence Interval [CI] for union time were 54.94 [44.20-65.68] and 92.09 [69.73 – 114.46] days for A and O group, respectively. SD was 22.27 / 70.86 for Arthroscopic and Open group, respectively. Seven patients in the Open group did not achieved union (14%), while only one (5%) from Arthroscopic Group failed to present union at the follow-up (p<0.05).
Interpretation / Conclusion: Arthroscopically assisted Bone Grafting, for the treatment of Scaphoid Nonunion showed significantly higher union rate and faster union time, compared to Open Bone Grafting.

44. 2-year results after Maia® thumb total carpometacarpal arthroplasty.
Anders Lorentsen Jens Chr. Werlinrud
Department of Orthopedics, Odense University Hospital, Region of Southern Denmark. OPEN, Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark, Odense.

Background: The classical treatment of advanced thumb basal joint arthritis in patients, who have failed conservative measures, is trapeziectomy or interposition arthroplasty. Particularly in young and high demand patients, results from these procedures can be unpredictable. In search for better results, various implants have been attempted, including interpositional implants with no bony fixation as well as hemiarthroplasties and total joint replacement. Recent prosthetic designs have improved implant survival.
Aim: This prospective study aims to evaluate patient satisfaction, implant failure and rate of revision at 2-year follow-up.
Materials and Methods: From January 2016 to March 2021 we inserted 200 Maïa® Dual Mobillity (DM- TMC) arthroplasties at Odense University Hospital. The indication for surgery is unacceptable pain, radiologic thumb CMC-arthritis, and exhausted conservative measures. All patients are evaluated at follow-up. We have evaluated 80 implants in 70 patients at 2-year follow-up.
Results: Patient satisfaction (n=80) at 2-year follow-up Very satisfied: 86% (n=69) Satisfied: 6% (n=5) Neither satisfied nor dissatisfied: 4% (n=3) A little dissatisfied:1% (n=1) Dissatisfied: 3% (n=2, same patient) DASH-score 35 (SD 16) pre-op, 12 (SD 18) at 2-year follow-up (n=60). Mean procedure duration: 56 min (90th percentile 45-75 min), Mean age 54 year (IQ-range 50- 58year), 73% of patients were female, 62% of procedures performed on the left side. 6 arthroplasties were revised, 4 due to trapezial osteophytes, 1 due to dislocation, 1 due to unexplainable pain.
Interpretation / Conclusion: The Maïa® DM-TMC arthroplasty show promising results after 2 years follow-up. The most common cause of revision was trapezial osteophytes. Removal of osteophytes may alleviate this problem. One patient (n=2) was dissatisfied with the result of the procedures in both left and right hand, due to excessive pain. During the follow-up period, she was diagnosed with fibromyalgia.