Session 14: Hand and wrist

17. November
09:00 - 10:00
Lokale: 102-105
Chair: Lone Kirkeby and Rasmus W Jørgensen

117. Five-year recurrence of Dupuytren’s contracture after needle fasciotomy or collagenase injection: a randomized controlled trial
Rasmus Wejnold Jørgensen1, Claus Hjorth Jensen1, Stig Jørring1
1. Hand Clinic, Department of Orthopedic Surgery, Herlev-Gentofte University Hospital of Copenhagen, Denmark.

Background: In this randomized controlled trial, we compared the recurrence of Dupuytren’s disease at 5-years following needle fasciotomy or collagenase injection treatment for isolated metacarpophalangeal (MCP) joint contractures. We have previously reported three year results in favour of collagenase injections in the same cohort.
Aim: To compare the recurrence of Dupuytren’s disease at 5-years following needle fasciotomy or collagenase injection treatment for isolated MCP joint contractures. Further, to investigate if the effect seen at 3 years was lasting at the 5-year follow up.
Materials and Methods: The study was conducted between 2013 and 2015. The study design was a single centre randomized controlled clinical trial with an independent blinded observer. Patients were randomized between collagenase clostridium histolyticum injections (Xiapex®) and percutaneous needle fasciotomy (CCH vs PNF). A total of 36 patients were followed in the PNF group and 32 in the CCH group. Two patients in the PNF group died before the 5 year follow up.
Results: Patients who were treated with CCH had a significantly lower recurrence rate than patients treated with PNF during the period (p = 0.049). Of the 34 patients who were followed in the PNF group, 59% (n=20) had recurrence of extension deficit or progression of the disease leading to further treatment. Of the 32 patients who were followed in the CCH group, 44% (n=14) had recurrence or progression. No serious adverse event was reported in any of the patients.
Interpretation / Conclusion: In this randomized controlled trial, we find less recurrence and progression of Dupuytren’s disease using collagenase injection as compared to percutaneous needle fasciotomy five years following treatment for isolated metacarpophalangeal joint contractures.

118. Stable cup fixation at mid-term translates into good long-term survival of cemented and uncemented trapeziometacarpal arthroplasty: A prospective randomized radiostereometry study with 10 years follow-up.
Peter Godthaab Zeuner1, Torben Bæk Hansen1,2, Maiken Stilling2,3,4, Janni Kjærgaard Thillemann1,2,3
1. University Clinic for Hand, Hip and Knee Surgery, Gødstrup Hospital, Herning, Denmark 2. Department of Clinical Medicine, Aarhus University, Denmark 3. AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Denmark 4. Department of Orthopedics, Aarhus University Hospital, Denmark

Background: Aseptic loosening leading to revision has been a substantial problem with both cemented and uncemented cups in trapeziometacarpal (TMC) arthroplasties used for treatment of TMC arthritis. Radiostereometry (RSA) can measure cup migration over time as a measure of implant fixation, which predict the risk of aseptic loosening.
Aim: To evaluate if mid-term cup migration predicts long-term implant survival, and further, to present 10-year clinical results, and patient reported outcomes of cemented and uncemented TMC cups.
Materials and Methods: In a patient-blinded prospective randomized study 28 patients (5 men, 32 TMC joints) aged mean 58 years (range 41–77) were randomized to surgery with a cemented all-polyethylene cup (DLC, n=16) or an uncemented HA-coated Elektra screw cup with metal-on-metal articulation (Elektra, n=16).The same cementless HA-coated metacarpal stem was used. Clinical evaluation of grip strength, QDASH score, and pain on NRS scale, were collected at 3 and 6 months, 1, 2, 5 and 10 years. Imaging with RSA was performed until 5-years, with baseline image taken the first postoperative day. Implant survival was estimated at 10 years follow-up.
Results: Migration (total translation) within the first 2 years was small for both groups (<0.26 mm). From 2 to 5 years, total translation was 0.08 mm (CI95% -0.06 – 0.21) in the DLC group and 0.05 mm (CI95% -0.04 – 0.14) in the Elektra group, which was similar between groups (p=0.74). Compared with preoperative, 10-year grip strength, QDASH score, and pain at rest and in activity improved (p<0.05) and with no difference between groups throughout follow-up (p>0.13). The 10-year survival was 80% (CI95% 50 – 93) for the DLC group and 67% (CI95% 38 – 85) for the Elektra group (p=0.40). All patients with retained arthroplasties at the 10-year follow-up reported excellent satisfaction and willingness (100%) to repeat.
Interpretation / Conclusion: This first prospective randomized trial on DLC and Elektra TMC arthroplasties found similar and stable midterm cup-fixation, which translated into good long-term implant survival. Ten-year clinical outcomes and patient satisfaction was excellent for both groups.

119. Distal radioulnar joint kinematics during active forearm rotation: a paired comparison of patients foveal TFCC injured and non-injured side
Janni Kjærgaard Thillemann1,2,3, Sepp De Raed3,4, Emil Toft Petersen1,2,3, Torben Bæk Hansen1,2, Maiken Stilling2,3,5
1. Department of Orthopaedics, University Clinic for Hand, Hip and Knee Surgery, Gødstrup Hospital, Herning 2. Department of Clinical Medicine, Aarhus University 3. AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital 4. NRT X-RAY A/S, Hasselager 5. Department of Orthopaedic Surgery, Aarhus University, Denmark

Background: Foveal triangular fibrocartilage complex (TFCC) injury may cause distal radioulnar joint (DRUJ) instability. Dynamic radiostereometry (dRSA) is a precise imaging method valid for objective measurement of DRUJ kinematics.
Aim: To use dRSA to study kinematics during active forearm rotation in DRUJs with arthroscopic confirmed foveal TFCC lesion in comparison to non-injured DRUJs.
Materials and Methods: In a prospective cohort study 19 patients (10 men) with a mean age of 34 years (range 22-50) were included. All patients presented with trauma based symptomatic unilateral DRUJ instability evaluated clinically by Ballottement test and had a non-injured contralateral DRUJ for paired comparison. A foveal TFCC lesion was confirmed by arthroscopy post hoc. Bilateral image recordings were made with dRSA during forearm rotation, performed by the patient. Kinematic analyses using CT bone models and anatomical coordinate systems were used to describe the position of the ulnar head center in the sigmoid notch (SN) (DRUJ position ratio) and the ulnar head center distance to the SN (DRUJ distance).
Results: In general, the ulnar head moved in a volar direction of the SN during supination and in dorsal direction during pronation. However, in full pronation the DRUJ position ratio was up to 9% points (CI 1-17) more volar on the TFCC injured DRUJs, and in full supination up to 12% points (CI 3-21) more dorsal, compared to the non-injured DRUJs. The DRUJ distance did not differ in maximum supination and pronation, but in the range from 60o pronation to 10o supination, the DRUJ distance was significantly wider in TFCC injured DRUJs, with a increase of 1.3 mm (CI 0.3-2.3) in 0 degrees rotation.
Interpretation / Conclusion: The ulnar head position during active rotation was more volar in pronation and more dorsal in supination in DRUJs with a foveal TFCC injury. Consequently, the ulnar head moved towards the SN center when the full trajectory of forearm rotation was reached. Further, DRUJs with foveal TFCC lesion had wider distance in neutral forearm rotation, compared with non-injured DRUJs. Evaluation of combined kinematics (multidirectional) seems important when evaluating DRUJ instability during active patient performed exercises.

120. The interrater reliability of the diagnostic Hook -test in the arthroscopic definition of the foveal TFCC injury
Signe Juhl Dynesen1,2, Robert Gvozdenovic
1. University of Copenhagen, Faculty of Health and Medical Sciences, Blegdamsvej 3B, 2200 København; 2. Department of Orthopeadic Surgery, Herlev/Gentofte University Hospital of Copenhagen, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark ; 3. Department of Hand Surgery, Herlev/Gentofte University Hospital of Copenhagen, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark; 4. University of Copenhagen, Faculty of Health and Medical Sciences, Institute of Clinical Medicine, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.

Background: The specificity and sensitivity of the Hook-test to assess foveal TFCC injuries is well documented. However, the inter-rater reliability of this test has only been investigated through studies, where surgeons evaluated the result of the hook-test by looking at videos of the test being performed. To our knowledge, a study that takes surgical testing technique into account has not yet been performed on the diagnostic Hook-test.
Aim: To evaluate the inter-rater reliability of the hook test in vivo, using the technique during live surgery.
Materials and Methods: From December 2022 to April 2023, 27 consecutive patients scheduled for diagnostic wrist arthroscopy were included after giving written consent for the study. The patients included 13 women and 14 men, ranging from 20 to 66 years of age. Four different hand surgeons were used as observers, three of surgeons’ expert level III, and one of surgeons’ expert level IV, according to Tang & Giddins. The diagnostic wrist arthroscopy would proceed as normal until the responsible operating surgeon (Observer 1) had performed the hook test. Afterward, one of the other participating surgeons (Observer 2) would be permitted to also perform the hook test during the same surgical procedure. Both surgeons, unaware of each other findings would independently report their assessments and the surgery would again proceed as normal. Afterward, Cohen’s kappa was calculated and evaluated according to the scale proposed by Landis and Koch.
Results: Of the 27 wrists included, the surgeons were in agreement on 21 of the findings and disagreed on 6, (78%). Since some of the agreement could be derived by the chance alone, we calculated a Kappa value of 0,55, which corresponds to a moderate agreement according to the scale proposed by Landis & Koch.
Interpretation / Conclusion: Despite the reports of being highly accurate and with high sensitivity and specificity, the arthroscopic foveal TFCC hook test may not be as reliable as previously thought when evaluated in vivo. More research is needed on the subject.

121. Arthroscopic versus open cancellous bone grafting for scaphoid delayed/nonunion in adults (SCOPE-OUT): study protocol for a randomized clinical trial
Morten Kjær1, Jeppe Vejlgaard Rasmusssen2, Robert Gvozdenoviz1,3
1. Department of Orthopedics, Hand Clinic, Herlev-Gentofte University Hospital of Copenhagen, Denmark; 2. Department of Orthopedics, Shoulder and elbow clinic, Herlev-Gentofte University Hospital of Copenhagen, Denmark;; 3. University of Copenhagen, Faculty of Health and Medical Sciences, Institute of Clinical Medicine, Blegdamsvej 3B, 2200 Copenhagen N, Denmark

Background: Scaphoid non-union results in pain and decreased hand function. Untreated, almost all cases develop degenerative changes. Despite advances in surgical techniques, the treatment is challenging and often results in a long period with a supportive bandage until the union is established. Open, corticocancellous (CC) or cancellous (C) graft reconstruction and internal fixation are often preferred. Arthroscopic assisted reconstruction with C chips and internal fixation provides minimal trauma to the ligament structures, joint capsule, and extrinsic vascularization with similar union rates. Correction of deformity after operative treatment is debated with some studies favouring CC, and others found no difference. No studies have compared time to union and functional outcomes in arthroscopic vs. open C graft reconstruction.
Aim: We hypothesize that arthroscopic assisted C chips graft reconstruction of scaphoid delayed/non-union provides faster time to union, by at least a mean 3 weeks difference.
Materials and Methods: Single site, prospective, observer-blinded randomized controlled trial. Eighty-eight patients aged 18–68 years with scaphoid delayed/non-union will be randomized, 1:1, to either open iliac crest C graft reconstruction or arthroscopic assisted distal radius C chips graft reconstruction. Patients are stratified for smoking habits, proximal pole involvement and displacement of > / < 2 mm. The primary outcome is time to union, measured with repeated CT scans at 2-week intervals from 6 to 16 weeks postoperatively. Secondary outcomes are Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH), visual analogue scale (VAS), donor site morbidity, union rate, restoration of scaphoid deformity, range of motion, key-pinch, grip strength, EQ5D-5L, patient satisfaction, complications and revision surgery.
Results: N/A
Interpretation / Conclusion: The results of this study will contribute to the treatment algorithm of scaphoid delayed/non- union and assist hand surgeons and patients in making treatment decisions. Eventually, improving time to union will benefit patients in earlier return to normal daily activity and reduce society costs by shortening sick leave. Trial registration: NCT05574582.

122. Inter- and intraobserver agreement for the CT scan assessment of union after surgery for scaphoid fractures and nonunion
Morten Kjær1, Robert Gvozdenoviz1,3, Ivanov Dimitar2
1. Department of Orthopedics, Hand Clinic, Herlev-Gentofte University Hospital of Copenhagen, Denmark; 2. Department of Radiology, Bispebjerg and Frederiksberg University Hospital of Copenhagen, Denmark; 3. University of Copenhagen, Faculty of Health and Medical Sciences, Institute of Clinical Medicine, Blegdamsvej 3B, 2200 Copenhagen N, Denmark

Background: Assessment of scaphoid union using X-Ray is often with some disagreement. Union is defined as signs of consolidation in 3/4 views. Inter- and intraobserver agreement are reported to be fair/moderate of conservatively treated scaphoid fractures. Overlining leads to misinterpretation, and bone bridging cannot be detected. CT-scans are increasingly used to evaluate union, allowing a 3-dimensional assessment of the trabecular architecture. Studies for scaphoid fractures and non-union after surgical intervention, where the metal artifact is present are limited.
Aim: We hypothesized that inter- and intraobserver reliability of the CT-scan assessment of union after operative treatment for scaphoid fracture and nonunion between observers are moderate/substantial.
Materials and Methods: An institutional search identified 230 patients with operative intervention. We randomly selected 60 sets of CT scans (30 fractures and 30 nonunions). Inclusion criteria were age >18 years, operative intervention for scaphoid fractures, and non-union with CT scans 6-26 weeks postoperatively. Exclusion criteria were concomitant injury to the hand and earlier treatment for scaphoid non-union. Three observers evaluated the anonymized CT scans on two occasions 6 weeks apart in random order. Observers were asked to classify the scaphoids with >/< 50% bone bridging, and with no healing/partial healing/full healing.
Results: Cohens Kappa found overall moderate interobserver agreement (no healing vs. partial healing vs. full healing) (0.58), substantial (0.66) for non-union cases, and moderate for fractures (0.47). Overall interobserver agreement for >/<50% healing was fair (0.35), fair for fractures (0.23) and moderate for nonunion cases (0.46). Results from intrarater agreement await.
Interpretation / Conclusion: Our results suggest CT scan between observers are reliable in both scaphoid fractures and nonunion (no healing/partial healing/full healing). The agreement was better in nonunion cases compared to fractures. Interater reliability for >/< 50 % healing was fair suggesting attention for this evaluation. Subgroup analysis revealed consistent substantial agreement between 2 of the observers. The third observer varied between slight to a moderate agreement.

123. Outcomes after Flexor Tendon Surgery in the Capital Region of Denmark
Benedicte Heegaard1, Rasmus Wejnold Jørgensen1
1. Hand Clinic, Department of Orthopedic surgery, Herlev-Gentofte University Hospital of Copenhagen, Denmark

Background: The management of flexor tendon injuries in the hand is a well-known challenge worldwide, however, the exact outcomes and postoperative complications in Denmark have not yet been reviewed.
Aim: To report outcomes and incidence of postoperative complications in patients undergoing surgery after traumatic flexor tendon injuries in the hand. Secondly, to investigate if trauma in zone II of the hand is associated with a poor outcome.
Materials and Methods: We retrospectively reviewed patients who had been surgically treated for flexor tendon injuries of the hand in two hospitals in Denmark in the period of 2010-2020. Demographic information, trauma type and postoperative complications were recorded. Major postoperative complications included re- rupture, surgical tenolysis and admission due to infection. Minor complications included infection treated with oral antibiotics and decrease in mobility.
Results: In total, 281 patients (mean age 35 years, 64% male) were reviewed. Ninety-five (34%) patients had trauma in zone I, 137 (49%) had trauma in zone II, and 49 (17%) had trauma in the other zones of the hand. The median time from trauma to surgery was 3 days. The median time from surgery to the last visit at the hospital was 99 days with an average of 16 contacts to the hospital after surgery. In total, 18% experienced a major complication and 35% experienced a minor complication. Twenty-three (8%) patients experienced re-rupture, 15 (5%) underwent surgical tenolysis due to adhesions, and 6 patients (2%) were admitted and revised due to infection. At the final visit, 27% had a flexion deficit of > 1 cm and/or extension deficit of >10 degrees and 19 patients (7%) were treated with oral antibiotics due to infection. Traumas in zone II of the hand were not associated with a higher incidence of complications nor a worse outcome as compared to traumas in zone I.
Interpretation / Conclusion: Following traumatic flexor tendon injuries, 18% of patients experience a major postoperative complication and 35% experience a minor complication, including infection treated with oral antibiotics or decreased mobility. Patients with zone II traumas do not experience a poorer outcome as compared to patients with zone I traumas.