HAND AND WRIST - American Academy of Orthopaedic Surgeons - AAOS

28 Pages·2012·1.62 MB·English

HAND AND WRIST
PAPERS manifestations affecting the long bones of the wrist, identify
risk factors for developing the disease in this location, and
evaluate the success of percutaneous drilling for its treatment.
PAPER NO. 106 METHODS: Ten wrists in six patients who had symptomatic
osteonecrosis were identified. Their mean age at presentation was
Tri-plane Osteotomy Correction of Distal Radius
41 years (range, 21 to 61 years) and all were women. Patients were
Malunion Addresses Shortening, Angular, and treated by percutaneous drilling when they failed non-operative
Rotational Deformity modalities. Clinical evaluation (including pre- and post-operative
MI Hand Questionnaire (MHQ) scores), plain radiographs,
William H. Seitz, Jr, MD, Cleveland, OH
and MRI evaluations were performed to assess and characterize
Soheil Payvandi, DO, Sacramento, CA
the disease, and the incidence of risk factors was recorded.
Jinyoung Jeong, MD, Suwon, Republic of Korea
RESULTS: There was disease occurrence in the radius in all
INTRODUCTION: Rotational malalignment following fracture 10 wrists, and in the ulna in four wrists. The mean age was 41
of the distal radius may be under appreciated and contribute to years (range, 21 to 61 years), and all patients presented initially
subluxation and dysfunction of the distal radioulnar joint. Rotational with symptomatic osteonecrosis of the large joints (knee or hip)
malunion is demonstrated by both plain radiographic and CT imaging. secondary to corticosteroid use. These patients later developed
METHODS: Eleven patients with shortened, angular and symptomatic wrists, which impaired activities of daily living.
rotational malunion underwent correction by performance of Other risk factors included alcohol or tobacco use, blood dyscrasias,
triplane osteotomy. Additional radiographic analysis of both and systemic lupus erythematosus. Treatment consisted of
“sawbones” models and cadaver wrists was performed to define percutaneous drilling and all reported improvements as measured
the degree of rotational offset required to diagnose this deformity. by the MHQ. One patient required additional bilateral drillings
RESULTS: Healing of the osteotomy of the distal radius was followed by further improvements in her scores. At a mean
achieved in all 11 patients. Fixation utilized low profile anatomy- followup of 35 months (range, 32 to 84 months), there was no
specific plates. Preoperative pronation/supination arc was 40° radiographic evidence suggesting disease progression in any wrist.
and postoperative arc was 130°. In eight of the 11, pain was rated DISCUSSION AND CONCLUSION: The distal radius and ulna are
as 0 on a 10 point scale while the other three ranged between 2 rare sites of osteonecrosis, associated with multifocal disease. The
and 5. At two year follow-up grip strength measured 80% of the clinical presentation and risk factors are similar to osteonecrosis
contralateral side while total range of motion measured 76% of in the large joints. Magnetic resonance imaging shows evidence
the contralateral side. All 11 patients were functional at daily of necrotic lesions. The results of the present study suggest that
household activities, five out of seven previously working patients disease in these sites can be safely and effectively treated with
were back to work, and all patients felt that their postoperative percutaneous drilling. Level of Evidence: Level IV Therapeutic
status was a significant improvement over their preoperative status. Study.
Plain x-ray evaluation of “sawbones” radius models demonstrated
observable cortical offset with as little as 15° malrotation. PAPER NO. 108
However visualuation of DRUJ subluxation required 30° of Clinical Outcomes of Total Wrist Arthroplasty for Post-
malrotation, which was readily demonstrated on CT scan images.
traumatic Arthritis
DISCUSSION AND CONCLUSION: Triplane osteotomy is
effective in restoring pronation and supination, diminishing pain Jason Nydick, DO, Pensacola Beach, FL
and increasing function. Radiographic evidence of medial and/or Alfred V. Hess, MD, Temple Terrace, FL
lateral cortical “step-off” should raise the suspicion of a rotational Bailee Williams, Tampa, FL
component to the fracture deformity. CT imaging is helpful Jeffrey D. Stone, MD, Tampa, FL
in making a definitive diagnosis. Recognition of this “third” Scott Greenberg, DO, Bonita Springs, FL
component of distal radius facture displacement is important in
INTRODUCTION: Total wrist arthroplasty (TWA) is an evolving
correcting initial displacement as well as late deformity.
procedure. Current indications include symptomatic patients
PAPER NO. 107 with posttraumatic wrist arthritis, rheumatoid arthritis, and
Kienbock’s disease as an alternative to wrist arthrodesis. Patients
Atraumatic Osteonecrosis of the Distal Radius and
have shown preference of arthroplasty over arthrodesis given the
Ulna: A Case Series and Review retained motion that maximizes function, especially in the case
Michael A. Mont, MD, Baltimore, MD of bilateral disease. The purpose of this study is to evaluate the
clinical outcomes, complications, and implant longevity of TWA.
Aaron J. Johnson, MD, Baltimore, MD
METHODS: A prospective evaluation was performed on 23
David A. Stroh, BS, Baltimore, MD
TWA patients. The average age at the time of surgery was 63.1
Dawn LaPorte, MD, Baltimore, MD
years (range 49- 79). Etiology included post-traumatic arthritis
David R. Marker, Baltimore, MD
(15), rheumatoid (six) and Kienbock’s disease (two). Pain
INTRODUCTION: Atraumatic multifocal osteonecrosis is a score, DASH, Mayo wrist scores were collected during follow
relatively rare disease, defined as the occurrence of this entity up. Wrist motion, complications, radiographs were evaluated.
in three or more discrete anatomic locations. We identified 10 RESULTS: At a mean follow-up period of 28 months (4-55),
wrists with osteonecrotic lesions in six patients who had this the DASH and MAYO wrist scores were 36.5 and 51.5. Mean
disease. The purpose of this study was to describe its clinical pain scores improved from 8.0 to 2.3. The mean wrist motion
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
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PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND & WRIST
was (flexion 41.3 / extension 50.5 / radial 14.1 / ulnar 31.7) pain at final follow up was scored as none in four or eight, mild in
compared to pre-op motion (flexion 45.3 / extension 40.3 three of eight, moderate in one of eight and severe in zero of eight.
radial 8 / ulnar 27). Radiographs revealed no evidence of DISCUSSION AND CONCLUSION: Patients who are treated
loosening at mean follow up. Grip strength averaged 60% for tendon rupture following distal radius fracture functionally
the opposite hand. One patient had failure secondary to deep do very well in regards to active wrist ROM, pain scores, and
infection and was successfully converted to wrist arthrodesis. grip strength. Radiographic evidence demonstrated volar
DISCUSSION AND CONCLUSION: Posttraumatic wrist arthritis is plate prominence in all patients with flexor tendon rupture
becoming the most common indication for total wrist arthroplasty and dorsal screw prominence in all patients with extensor
with improved implant survival and patient outcomes. Previous tendon rupture. Consideration should be given to remove volar
reports on total wrist arthroplasty have shown the benefits for distal radius plates with radiographic evidence of volar plate
bilateral wrist arthrosis with regard to function and for rheumatoid or dorsal screw prominence to reduce risk of tendon rupture.
arthritis with regard to pain. There have been concerns, however,
due to relatively high complication rates. Improvements in implant
design have been encouraging, although long term data has not yet
been presented. Also, with the advances in design over the last 30
years, the indications have been expanded to include intolerable
post-traumatic arthritis. More long-term studies are ultimately
necessary to prove the benefit of total wrist arthroplasty. Total
wrist arthroplasty performed in select patients can yield successful
outcomes with low short-term failure rates.
PAPER NO. 109
The Incidence and Clinical Outcomes of Tendon
Rupture Following Volar Plating Distal Radius Fractures
Jason Nydick, DO, Pensacola Beach, FL
Brian D. White, MD, Tampa, FL
Dawnne Karsky, MS, PA-C, Tampa, FL
Jeffrey D. Stone, MD, Tampa, FL
Alfred V. Hess, MD, Temple Terrace, FL

INTRODUCTION: Our hypothesis is that there will be
identifiable risk factors related to tendon rupture following PAPER NO. 110
distal radius fracture and that patient outcomes will not Complications of Locked Volar Plating for Distal Radius
be adversely affected after undergoing tendon repair.
Fractures
METHODS: A retrospective chart review was performed on patients
treated for tendon rupture following distal radius fracture. Charts Hillary A. Becker, MD, Rochester, MN
were examined to determine age, sex, fracture pattern, initial David M. Brogan, MD, Rochester, MN
treatment, mechanism of injury, time until tendon rupture, tendon David G. Dennison, MD, Rochester, MN
ruptured, and treatment of rupture. Objective and subjective Alexander Yong Shik Shin, MD, Rochester, MN
functional results were evaluated by looking at active range of
INTRODUCTION: The purpose of our study was to evaluate the
motion (ROM), grip strength, and pain score. Radiographic analysis
incidence and characterize the types of complications that occur
was performed on patients with tendon rupture to document volar
with locked volar plating of distal radius fractures at one institution.
plate prominence, dorsal screw prominence, and fracture union.
METHODS: We retrospectively reviewed the records of 153
RESULTS: A total of 2,358 patients between 2002 and 2010 were
randomly selected adult patients with distal radius fractures
treated for distal radius fracture at our institution (1,359=cast,
treated by volar locked plating at one institution from 2001-2009.
999=ORIF). There were 11 tendon ruptures treated in eight
We identified those patients with minor or major complications.
different patients (mean age 64.4 years; seven female) for an
Major complications included hardware-related problems
incidence of eight/2,358 (0.003%) in all patients. There were two
(intra-articular, loosening, pain), tendon rupture or irritation,
extensor tendon ruptures (EPL, ECRB) and nine flexor tendon
carpal tunnel syndrome requiring release, infection requiring
ruptures (FPL=5, FDP=3, FCU). All tendons ruptures occurred
reoperation, major medical complications and non-union.
with volar plate fixation. Patients with tendon rupture were
We identified all other complications as minor complications.
followed for an average of 6.5 months (range 2-16 months) after
RESULTS: There were 16 major and 27 minor complications for a
repair. Injury radiographs demonstrated intra-articular fracture
total of 43 complications (28%). The breakdown of complications is
in five of eight (63%) patients. All eight patients underwent
seen in Figure 1. Of the 43 patients with complications, 14 underwent
primary repair of their tendon ruptures with concomitant volar
further surgery which included six limited or full hardware
plate removal at an average time of 19.9 months (range 4-56
removal, one extensor pollicus longus (EPL) reconstruction, one
months) after initial injury. The mean active wrist ROM was
EPL rerouting, one open carpal tunnel release, one trigger finger
66.5° of flexion, 69.4°of extension, pronation of 85°, and 82.5° of
release, one pin removal. One patient had a Darrach procedure
supination. Mean grip strength was 47.5 kg (range 38-75). Dorsal
and carpal tunnel release followed by plate removal. Two patients
screw prominence of proximal shaft screws or distal locking
had triangular fibrocartilage complex reconstructions in addition
screws was seen in seven of eight (88%) patients with tendon
to plate removal. Two patients had intra-articular hardware
rupture. Volar plate prominence, as described by Soong, et al.,
but declined surgery for removal as they were asymptomatic.
was determined to be Grade 0 in two of eight (25%), Grade 1 in
DISCUSSION AND CONCLUSION: The incidence of complications
two of eight (25%), and Grade 2 in four of eight (50%). Residual
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
776
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PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND & WRIST
in this study was 43/153 or 28%. The most common complication release, trigger finger release, mass excision, first dorsal compartment
seen in our series of patients was sensory disturbances (17/43) release, and tenolysis. The overall infection rate was 0.9%. All
followed by hardware-related problems (nine/43). All but two infections were considered superficial. In patients who received
patients had resolution of their sensory disturbances at the time of antibiotic prophylaxis (n=232), the infection rate was 1.29%.
final follow up. Tendon-related complications accounted for four In those who did not receive prophylaxis (n=403), the infection
of 43 of the total complications. While many of the complications rate was 0.75%. These differences were not statistically significant
we reported were minor, there was still a relatively high rate of (p=0.67). Diabetes and smoking were not associated with an
secondary operations (14/153 or 9%). Interestingly, there were increased risk for infection. When compared to other procedures,
no flexor tendon ruptures/irritation as has been documented by tenolysis was 8.46 times more likely to result in an infection.
others as a complication of volar plating. DISCUSSION AND CONCLUSION: The overall rates of infection
following elective soft tissue hand surgery are very low. Antibiotics
did not appear to confer additional protection from surgical site
infection, and their routine administration is thus is not indicated
in these procedures.
PAPER NO. 111
Is Antibiotic Prophylaxis Necessary in Clean Soft
Tissue Hand Surgery?
Richard J. Tosti, MD, Philadelphia, PA
John R. Fowler, MD, Phoenixville, PA
Joseph Dwyer, MD, Philadelphia, PA
Asif M. Ilyas, MD, Wayne, PA
Joseph J. Thoder, MD, Chalfont, PA
INTRODUCTION: Indications for antibiotic prophylaxis in clean
soft tissue hand surgery are not well defined. Available evidence PAPER NO. 112
for prophylaxis in hand procedures has focused on traumatic
Diagnosis of Displacement and Instability of an Acute
hand surgery or carpal tunnel release; a paucity of data exists
Scaphoid Waist Fracture
regarding the necessity of antibiotics in common, elective hand
procedures. The purposes of this study were to 1) determine if Geert Buijze, MSc, Boston, Netherlands
antibiotic prophylaxis reduced the rate of surgical site infections Peter Jorgsholm, Kerteminde, Denmark
in elective hand surgery and 2) identify associated risk factors. Niels Thomsen, PhD, Malmo, Sweden
METHODS: A multi-center, retrospective review was performed
Anders Björkman, MD, PhD, Malmö, Sweden
on 635 consecutive elective soft tissue hand procedures.
Jack Besjakov, Malmo, Sweden
Procedures with concomitant implant or incomplete records
David C. Ring, MD, Boston, MA
were excluded. Antibiotic delivery was given at the discretion
of the senior surgeon. Patient co-morbidities were recorded. INTRODUCTION: Fracture displacement is the most
Outcomes were measured by the presence of deep or superficial important factor associated with nonunion of a scaphoid
infections within 30 days from the operation. A univariate waist fracture. We evaluated the diagnostic performance
analysis was performed to identify associated risk factors. characteristics of radiographs and computed tomography (CT)
RESULTS: The five most common procedures were carpal tunnel in diagnosing displacement and instability of scaphoid waist
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
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PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND & WRIST
fractures using wrist arthroscopy as the reference standard. PAPER NO. 113
METHODS: During a six-year period (2004-2010) at two Randomized Trial Comparing Two Fixation Methods for
institutions, 44 adult patients with a scaphoid waist fracture
Unstable Fractures of Distal Radius
elected arthroscopy-assisted operative fracture treatment
a mean of nine days after injury (range, two to 22 days). Aditya Soral, MS, New Delhi, India
The prospective cohort of operated patients consisted of all Manish K K. Varshney, MS, Jamshedpur, India
radiographically displaced scaphoid fractures and a selection of
INTRODUCTION: Optimal treatment of unstable distal radius
non-displaced scaphoid fractures (based on preference in order
fractures is debatable. Intrafocal closed pinning (Kapandji
to avoid cast immobilization or randomization as part of another
technique) with or without bridging external fixator and
study). In addition to radiographs, all patients had CT with
locked volar plating are and well studied acceptable methods
reconstructions in planes defined by the long axis of the scaphoid.
of fixation, however head-to-head comparison is sparse.
RESULTS: The reference standard (arthroscopy) revealed 22
We compared the radiological and functional outcome of
displaced fractures (prevalence, 50%) and 29 unstable fractures
intrafocal pinning to volar locked plating. We also did a cost-
of the scaphoid waist (prevalence, 66%). All intra-operatively
effect analysis with functional outcome as the end-point.
displaced fractures were unstable as were seven of the 22
METHODS: Sixty patients with unstable fracture of the distal
non-displaced fractures. Among the 44 patients, radiographs
radius were randomized to two treatment groups and studied over a
demonstrated displacement in 11 patients (25%) and CT in 20
period of two years (2006 to 2008). In first group fracture was fixed
(45%). The sensitivity, specificity, and accuracy for diagnosing intra-
by intrafocal pinning using Kapandji technique but was modified
operative displacement were 46%, 96%, and 71%, respectively, for
by fixing K wires to external fixator not spanning the radio-carpal
radiographs and 77%, 86%, and 82%, respectively, for CT. The
Joint (group1). The other group underwent locked plating through
sensitivity, specificity, and accuracy for diagnosing intra-operative
the volar approach (group2). Functional comparison was done
instability were 35%, 93%, and 55%, respectively, for radiographs
using the DASH score, VAS score was used for pain assessment
and 62%, 87%, and 71%, respectively, for CT. Assuming a 10%
and acceptability of procedure at minimum follow up of one year.
prevalence of fracture displacement and instability among all
Other variables evaluated for comparison were range of motion
scaphoid waist fractures, the positive and negative predictive values
at the wrist joint, radial length, radial tilt and radial inclination
for displacement were 53% and 16% respectively for radiographs,
and grip strength. Time to surgery, duration of surgery, hospital
and 39% and 30% for CT, and for instability were 37% and 14%
stay, implant cost, complications and number of hospital visits,
respectively for radiographs, and 34% and 20% for CT. CT was
readmissions, time to union, absence from work were evaluated for
significantly more accurate than radiographs at determining intra-
cost analysis of the procedure. Levine’s test for equality was used
operative fracture displacement (p<0.05) and instability (p<0.05).
to judge uniform distribution, Students t-test was used to compare
DISCUSSION AND CONCLUSION: Radiographs and CT scans
continuous variables while chi-square for discrete variables.The
are much more specific than they are sensitive. Nonetheless, the
mean follow-up period was 30 months (24 months to 36 months).
positive and negative values of both modalities are poor, primarily
RESULTS: Both the groups were comparable in terms of age, sex
because the prevalence of displaced fractures among all scaphoid
distribution and fracture pattern. Mean DASH score in group1
fractures is low. These low predictive values mean that test results
of 14 (SD 5.2; range 9 to 20) was not significantly different (p=
do not provide certainties in clinical practice, and we need to be
0.93) from group2 of 22 (SD 7.8; range 14 to 31). No significant
comfortable discussing the probability rather than the certainty
difference was found in the movements at wrist, grip strength
of displacement with our patients. Radiographs and CT scans do
and the various radiological parameters between two groups.
not accurately diagnose intra-operative fracture displacement or
The overall cost of procedure was approximately $450 for group1
instability.
while $1,250 for group2 which was highly significant (p<0.001).
DISCUSSION AND CONCLUSION: Modified Kapandji
procedure and locked volar plating were both found to produce
comparable functional and radiological results, however former
was significantly more cost effective as compared to latter. We
concluded that modified Kapandji technique is a viable cheaper
alternative for fixing unstable distal radius fracture compared to
locked volar plating.
Figure 1: Arthroscopic
image of a wrist PAPER NO. 114
showing a non- Hypovitaminosis D in Postmenopausal Women with a
displaced and stable
Distal Radius Fracture
fracture (arrow).
Hyun S. Gong, MD, Seongnam, Republic of Korea
Cheol Ho Song, Seoul, Republic of Korea
Figure 2. Arthroscopic INTRODUCTION: Although hypovitaminosis D is reported
image of a wrist
to be common in the general population, few reports have
showing a non-
examined vitamin D levels in patients with a distal radius
displaced and
fracture (DRF). The authors hypothesized that postmenopausal
unstable fracture.
women with a DRF may have depressed vitamin D levels.
The tip of the probe
METHODS: The data of 104 postmenopausal women treated
is gently pressed
for a distal radius fracture (DRF group) and 107 age-matched
against the distal
control patients with soft tissue disease, such as tenosynovitis
fragment to open up
or lateral epicondylitis (control group) were compared. Serum
the fracture gap.
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
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PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND & WRIST
vitamin D levels (25-hydroxycholecalciferol, 25(OH)D) pronation strength in patients with a DRF treated by volar plating.
3
and the levels of several bone metabolism markers including METHODS: Thirty-four patients of mean age of 55 years
serum parathyroid hormone, osteocalcin, C-telopeptide, underwent bilateral isokinetic testing at one year after open
and urine N-telopeptide were sampled and compared. reduction and internal fixation using volar plating. Isokinetic
RESULTS: The mean 25(OH)D level was significantly lower in the pronation and supination strengths were compared between
3
DRF group than in the control group (p < 0.001). In particular, the operated and normal sides. Clinical outcomes such as grip
patients in their sixth and seventh deciles in the DRF group had strengths, range of motions, and DASH scores were evaluated
significantly lower vitamin D levels than patients in the control and analysed for any associations with isokinetic results.
group. Twenty-seven patients (26%) and 19 patients (18%) in the RESULTS: Differences in pronation strength were not statistically
DRF group were vitamin D insufficient (defined as a serum level of significant (p=0.188 for peak torque and p=0.190 for total
20-32ng/mL) or vitamin D deficient (defined as a serum level of < work), while supination torque and total work were significantly
20ng/mL), respectively, as compared with 12 patients (11%) and lower in the operated sides (p=0.015 and p=0.029 respectively).
two patients (2%) in the control group. The levels of the assessed Decreases in pronation strength were found to correlate
markers of bone metabolism were similar in the two groups. significantly with decreases in supination strength and grip
DISCUSSION AND CONCLUSION: Postmenopausal women with power. Wrist motion and DASH scores were not found to be
a DRF were found to have significantly lower serum vitamin D levels correlated with decreases in pronation or supination strengths.
than the control. Since vitamin D is required for bone metabolism DISCUSSION AND CONCLUSION: In patients with a DRF treated
and musculoskeletal function, further studies are warranted to by volar plating, pronation strength was not significantly different
determine whether hypovitaminosis D is a risk factor for DRF and between the operated and normal sides at one year postoperatively,
whether vitamin D supplementation helps rehabilitation and the and decreases in pronation or supination strengths were not found
prevention of future fractures in patients with a DRF. to affect clinical outcomes as assessed by DASH scores. This study
suggests that dissection of the PQ may have minimal clinical
PAPER NO. 115 impact on forearm pronation function.
Corrective Osteotomy of Post Traumatic Distal Radius
PAPER NO. 117
Deformity Using Volar Locking Plate
Longterm Outcome of Perilunate Fracture Dislocations
Sujith Konan, MRCS, London, United Kingdom
Sanjeev Kakar, MD, Rochester, MN
Sophia Opel, MBBS, Rickmansworth, United Kingdom
Brandon J. Yuan, MD, Rochester, MN
Elliot Sorene, FRCS, London, United Kingdom
Peter C. Rhee, MD, Rochester, MN
INTRODUCTION: Post traumatic distal radius deformity may cause
David B. Jones, Jr, MD, Rochester, MN
severe morbidity with restriction of wrist mobility and function.
Steven L. Moran, MD, Rochester, MN
Corrective osteotomy is often necessary to realign the functional
axis of the wrist to correct symptomatic malunion. The aim of INTRODUCTION: Patients sustaining perilunate dislocations
this study was to review the mid term results of a single surgeons’ and fracture dislocations experience impaired functional
series of distal radius corrective osteotomies following distal outcome with associated radiographic deterioration over time.
radius fracture malunion using a fixed angle volar locking plate. METHODS: A retrospective review was conducted analyzing
METHODS: Seventeen patients underwent corrective osteotomy the outcome of all perilunate dislocations and fracture
using a fixed angle volar locking plate for post-traumatic distal dislocations treated within our institution from 1985 to
radius malunion. The indication for the operation was pain and 2009. Standardized postoperative assessments included
functional limitation. Fourteen were women and three were wrist range of motion, grip strength and Mayo Wrist Score.
men, with an average age of 52 years. Outcome was assessed Preoperative and postoperative radiographs were examined to
using radiological and clinical confirmation of union, patient ascertain the incidence of post traumatic arthritis. Statistical
satisfaction and the DASH questionnaire postoperatively. analyses used included parametric and nonparametric t tests.
RESULTS: At mid term follow up, no complications were noted in RESULTS: Ninety-four patients were treated within our institution
any cases. Radiological union was confirmed in all cases at three over the last 25 years. There were 30 perilunate dislocations
months. Patients noticed an improvement in their wrist function. and 64 fracture dislocations (five open and 89 closed injuries).
This was objectively confirmed by an average post operative Complete radiographic records were present in 57 patients and
DASH score of 13.48. Wrist alignment significantly improved, included 20 perilunate dislocations and 37 fracture dislocations
as demonstrated by measurements on plain radiographs. (four open and 53 closed injuries). Forty-one patients were treated
DISCUSSION AND CONCLUSION: At mid term follow up, with combined volar and dorsal approaches, 11 dorsal only and
corrective osteotomy of the distal radius for symptomatic post five volar only approaches. There were no statistically significant
traumatic malunion has excellent functional outcome. differences between the pure dislocation versus the fracture
dislocation groups with respect to contralateral grip strength
PAPER NO. 116 (64% versus 68% respectively). The fracture dislocation group
Isokinetic Evaluation of Pronation After Volar Plating of tended to have improved flexion to extension arc compared to the
purely ligamentous injury patients (86 degrees versus 74 degrees).
a Distal Radius Fracture
Thirty-three percent of patients underwent additional secondary
Hyun S. Gong, MD, Seongnam, Republic of Korea procedures. The pure dislocation patients went onto a higher
Jung Kyu Huh, MD, In-Cheon, Republic of Korea rate of salvage procedures compared to the fracture dislocation
patients (35% versus 5%). According to the Mayo wrist scores,
INTRODUCTION: Pronator quadratus (PQ) is an important
23% of patients had good to excellent results and at final follow up,
contributor to forearm pronation, and there is concern that
only 59% of patients returned to work indicating the significant
volar plating of a distal radius fracture (DRF) may damage the
morbidity associated with this injury. Normal scapholunate (SL)
PQ function. We hypothesized that pronation strength would
angles were achieved intraoperatively in 18 of 20 dislocations and
decrease after volar plating of a DRF, thus we evaluated isokinetic
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
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34 of 37 fracture dislocations. At follow up, 13 of 20 and 31 out unions.
of 37 patients within the respective groups maintained normal
SL angles. The presence of a type 2 lunate did not guard against
DISI development. Radiographic analysis demonstrated signs
of degenerative changes in both injury groups (35% dislocation
only and 52% fracture dislocation patients). This may have been
attributable to difficulties in maintaining the lunate within its
fossa. At latest follow up, 16 of 20 and 31 of 37 patients within
the dislocation and fracture dislocation groups, respectively, had
evidence of greater than one third of ulnar translocation of the
lunate. Compared to immediate post operative radiographs, there
was a 16% and 8% decrease in carpal height ratio at follow up within
the dislocation and fracture dislocation patients, respectively.
DISCUSSION AND CONCLUSION: Perilunate dislocations and
fracture dislocations result in significant morbidity and impaired
functional outcome in patients over the long term.
PAPER NO. 118
The Modified Russe Procedure for Scaphoid Waist
Fracture Non-union with Deformity
Steve K. Lee, MD, New York, NY
Jorge L. Roman-Deynes, MD, New York, NY
INTRODUCTION: Scaphoid non-unions continue to PAPER NO. 119
be a challenging problem for which the ideal treatment
Predictors of Secondary Displacement in Operatively
remains controversial. We hypothesize that the modified
Russe procedure offers a reliable method to reduce the and Non-Operatively Managed Distal Radius Fractures
deformity and fix the construct for predictable healing. Bryan Lawson, MD, Live Oak, TX
METHODS: This was a retrospective review of a subset taken from Melvin Makhni, Boston, MA
21 patients treated for scaphoid fracture non-union. In the subset,
Phoebe Kuo, BA, Belle Mead, NJ
a modified Russe procedure was performed for scaphoid waist
David Zurakowski, PhD, Boston, MA
fracture non-union with humpback deformity and no evidence of
Tamara Rozental, MD, Boston, MA
avascular necrosis. Bone graft was harvested from the distal radius
Charles Day, MD, MBA, Boston, MA
and a “matchstick “of volar cortex was placed into the nonunion
site as a strut. Cancellous bone graft was packed in the remainder INTRODUCTION: We hypothesize that certain demographic
of the nonunion site followed by fixation with a headless screw parameters inherent to each distal radius fracture, initially
(Figure 1). The cohort was followed for healing rate, range of managed operatively or non-operatively, will reliably predict
motion, grip strength, radiographic parameters of scapholunate the likelihood of secondary fracture displacement at a
(SL) and intra-scaphoid angles, pain, return to work status defined healing period. The objective of our study is to assess
and complications. Statistical analysis was performed by one- the predictive value of these presenting demographics by
way analysis of variance testing with significance set at p<0.05. reviewing radiographs for evidence of secondary displacement.
RESULTS: Eight patients (seven male, one female) met inclusion METHODS: Radiographic records were retrospectively reviewed
criteria from the original cohort of 21. The mean ages of the for all distal radius fractures seen in the orthopaedic hand clinic
patients was 26 years (range 19-32) and mean follow-up period between September 2002 and February 2009. A total of 881 cases
was 18 weeks (range 8-27). All the patients healed at a mean time of were reviewed. All patients included in this study received AP
8.5 weeks (range 7-10). Compared to the contralateral side, mean and lateral radiographs taken at diagnosis, after fixation, and “at
total wrist range of motion (extension + flexion) was 88% and healing” (eight weeks post-presentation). Patients were excluded
mean grip strength was 96%. The mean SL angle postoperatively if younger than 18 years, did not return for follow-up imaging,
was 39 degrees (range 34-45), which was significantly less than or displayed ulnar and radial fractures on presentation. A total of
the preoperative angle of 65 degrees (range 50-90)(p=0.001). The 415 cases were included for review (183 operative fixation, 232
mean intra-scaphoid angle postoperatively was 29 degrees (range non-operative) (Figure 1). The initial reduction was considered
25-35), which was significantly less than the preoperative angle of preserved if the measured dorsal angulation was less than 10
52 degrees (range 35-70)( p=0.001). The mean visual analog pain degrees or the volar angulation was less than 25 degrees on the final
scale post-operatively was 1 (range 0-2). All the patients returned radiograph. Additionally, an articular step-off < 2mm, an articular
to their original work, and there were no reported complications. gap < 2mm, or radial shortening < 5mm was used as a baseline
DISCUSSION AND CONCLUSION: A modification of the Russe for preserved reduction. Each patient was classified according to
technique using the volar cortex of the distal radius as a strut, their age (18-44, 45-64, 65+), gender, A/O classification, presence
followed by cancellous bone and headless screw fixation for of dorsal comminution, and the number of fracture parts. The
the treatment of scaphoid non-unions is a reliable method with relative rate of secondary fracture displacement was determined
predictable healing. This modification restores and maintains the for each variable via univariate statistical analysis (Pearson’s Chi-
scapholunate and intra-scaphoid angles, while avoiding the donor squared or Fishers Exact test). The variables were then evaluated
site morbidities associated with iliac crest bone graft harvesting. via multivariate analysis to elucidate those predictive of secondary
It also provides excellent radiographic and functional results. We displacement without two-way interaction with other variables.
recommend this technique to treat scaphoid fracture waist non- RESULTS: The results of the univariate analysis revealed that
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
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higher rates of displacement are observed in older patients and in were the same for both groups. Patients were evaluated at two,
fractures displaying A/O class C, dorsal comminution, or 3+ parts. six, 12, and 24 weeks (or until fracture union) following surgery.
Furthermore, multivariate analysis of these variables show that RESULTS: Forty-two patients were enrolled (15 male, 27 females;
A/O class C and older patient age are independently predictive of mean age 57), with an average follow up of eight months. Thirty
displacement without significant two-way interaction (Figure 2). patients were randomized to receive ketorolac and 12 to receive no
DISCUSSION AND CONCLUSION: Of the analyzed patient ketorolac. The average time to evidence of healing on orthogonal
demographics an age of 65+, A/O class C, fractures displaying views measured in days was 43.19 days for the group receiving
dorsal comminution, or 3+ parts all displayed a significantly ketoroac and 42.92 days for the group not receiving ketorolac. There
higher rate of secondary fracture displacement when compared were no cases of delayed unions, nonunions, or adverse reactions.
within their own classification demographic. Only a patient DISCUSSION AND CONCLUSION: All fractures of both groups
age of 65+ or A/O class C fractures were independent predictors demonstrated evidence of healing with bridging callus on
of secondary fracture displacement without any two-way orthogonal views by the six week exam with the no statistical
interactions with other variables. These predictive variables are difference in average days to healing. The use of ketorolac did not
useful in assessing risk for the overall population presenting result in any delayed unions or nonunions following volar plate
with distal radius fracture before treatment is chosen. fixation of distal radius fractures.
PAPER NO. 241
Nerve Regeneration Using White Adipose Tissue (WAT)
Flap and Insulin-like Growth Factor-1 (IGF-1) as a
Scaffold
Ayhan Kilic, MD, New York, NY
Bukola Ojo, BS, New York, NY
Rebecca A. Rajfer, New York, NY
Geoffrey Konopka, MD, MPH, Houston, TX
Daniel A. Hagg, PhD, New York, NY
Eugene Jang, MS, New York, NY
Yelena Akelina, New York, NY
Jeremy Mao, DDS, PhD, New York, NY
Melvin P. Rosenwasser, MD, New York, NY
Peter Tang, MD, New York, NY
INTRODUCTION: White adipose tissue (WAT) and insulin-
like growth factor-1 (IGF-1) have shown potential to
enhance peripheral nerve regeneration. We hypothesized
that white adipose tissue flap (WATF) enriched with IGF-1
as an in vivo biologic scaffold would provide functional and
histological benefits in a sciatic nerve crush injury model.
METHODS: Forty male Sprague-Dawley rats were divided into four
arms. All rats underwent a crush injury to one sciatic nerve and
received a pedicled WATF, controlled local release of IGF-1, both,
or no treatment at the lesion area (experimental control) for four
PAPER NO. 120 weeks. The WATF was composed of adipose tissue derived from the
inguinal region. IGF-1 was delivered from polylactic-co-glycolic
Prospective Randomized Trial of Peri-Operative
acid (PLGA) microspheres embedded in fibrin gel adjacent to the
Ketorolac on Distal Radius Fracture Healing
crush injury. Tibialis anterior (TA) muscle weights and maximum
Andrew Brown, MD, Philadelphia, PA isometric tetanic force (ITF) of the TA muscle normalized to
Asif M. Ilyas, MD, Wayne, PA the contralateral side were recorded. Histological sections 1mm
Charles F. Leinberry, MD, Chester Springs, PA distal to the lesion were histomorphometrically analyzed. Data
were analyzed utilizing Student’s t-test and two-way ANOVA.
INTRODUCTION: The analgesic effects of ketorolac have been
RESULTS: At four weeks, the mean normalized ITFs were as follows:
well established, however its effect on bone healing is less clear.
WATF 51.9±12.3%, IGF-1 33.5±5.7%, WATF/IGF-1 46.7±22.8%,
Basic science studies have suggested a deleterious effect by NSAIDs
and experimental control 44.8±12.8%. The presence of the WATF
on bone metabolism and bone healing but a paucity of evidence
as a main effect resulted in a statistically significant 26.1% increase
exists as to whether this translates to clinical relevance. This study
in normalized ITF (p<0.05). There was a statistically significant
aims to prospectively evaluate the effect of ketorolac on healing
11.3% increase in myelin thickness and 13.1% increase in total
time for distal radius fractures undergoing volar plate fixation.
axon count in the WATF-only group versus control (p<0.01). The
METHODS: Patients undergoing distal radius fracture volar plate
TA muscle weights were similar across all groups. Both functional
fixation were prospectively randomized to either a single peri-
and histomorphometric data suggest that the presence of IGF-
operative intravenous 30mg dose of ketorolac or to receive no
1 suppressed the effect of the WATF rather than enhanced it.
ketorolac. Fractures were assessed for time to fracture union as defined
DISCUSSION AND CONCLUSION: Utilizing a pedicled WATF
by the presence of bridging callus on orthogonal radiographic views,
yielded beneficial functional and histomorphometrical results in a
or adverse healing events. The remainder of the post-operative
sciatic nerve axotnomesis experimental model in rats. IGF-1 does
protocol including analgesia, immobilization, and rehabilitation
not appear to enhance the regenerative effect of the WATF.
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
781
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PAPER NO. 242 (amplitude: 1.08 ± 0.30 V conduit vs. 1.00 V ± 0.25 autograft, p
Functional Results of Ulnar Club Hand Management = 0.89). Both groups reMEd significantly worse than normal
controls (conduction latency amplitude: 1.01 ± 0.02 ms, p < 0.01;
Ramin Espandar, MD, Tehran, Iran, Islamic Republic of
amplitude: 2.49 ± 0.68 V, p < 0.01). There was no recovery of nerve
INTRODUCTION: Ulnar deficiency is a rare congenital conduction or muscle function in the unrepaired group. In all
disorder of the upper extremity; there is not any evidence nerve repairs, regenerating axons traversed the entire graft. Cross-
based study in the management of the deformity. sectional nerve histology showed lower mid-graft axon counts for
METHODS: We include all ulnar deficiency patients (five boys conduit vs. autograft (5002 ± 1631 conduit vs. 7479 ± 686 autograft,
and one girl, with seven involved extremities) from 1993 to p = 0.002), but distal sciatic nerve axon counts were similar
2006. After recognizing the type of deformity, management between groups (4487 ± 1521 conduit vs. 5775 ± 1435 autograft, p
was performed according to current recommendations. We = 0.106). Mean axon diameters were also similar between groups
determined the effect of anlage resection, restoration of (4.189 ± 0.257 um conduit vs. 4.112 ± 0.400 um autograft for mid-
opposition and syndactyly release on the function of the limb. graft, p = 0.62; 3.510 ± 0.501 um conduit vs. 3.535 ± 0.318 um
RESULTS: In short term follow up, anlage resection was effective autograft for distal nerve, p = 0.91). See Figure 2 for representative
in correction of ulnar deviation; however, the deformity partially images of distal nerve histology at 20X magnification.
recurred later in all of the cases. Surprisingly, the function of the DISCUSSION AND CONCLUSION: Aligned nanofiber conduits
limb was not significantly affected with the extent of the deformity. are a promising new alternative to nerve autograft in the repair
On the other hand, the operations used for opposition of the of peripheral nerve gap injuries. They produce equivalent motor
thumb like first metacarpal rotational osteotomies and tendon outcomes compared to autograft in a well-accepted animal model
transfers for powerful opposition were more effective in the hand, of nerve gap injury. This experiment demonstrates the importance
as well as limb function, compared with anlage resection alone. of longitudinal structure in promoting nerve regeneration. Future
DISCUSSION AND CONCLUSION: Based on comparision research should investigate the effects of extracellular matrix
between operated and neglected cases, the most important factor components and neurotrophic factors within these conduits to
in the hand and limb function in ulnar club hand patients is further optimize axonal growth.
the function of the thumb. Accordingly, we consider restoring
opposition and syndactyly release more effective than anlage
resection on limb function in this group of patients.
PAPER NO. 243
uPeripheral Nerve Repair with Aligned Nanofiber
Tubular Conduits in a Rat Model
Jenny Jin, BS, San Francisco, CA
Michelle Park, East Palo Alto, CA
Arvind Rengarajan, BS, Cupertino, CA
Qia Zhang, BA, Millbrae, CA

Hubert T. Kim, MD, PhD, San Francisco, CA
Alfred C. Kuo, MD, San Francisco, CA PAPER NO. 244
INTRODUCTION: No therapy, including the gold standard of nerve Tension Free Post-Operative Immobilization for
autograft, reliably restores function after segmental peripheral
Dupuytren’s Disease
nerve injuries. The current alternatives to nerve autograft are
Michael Rivlin, MD, Philadelphia, PA
inferior for the repair of large-diameter nerves or long nerve gaps.
We hypothesized that synthetic, tubular conduits with surfaces Meredith Osterman, MD, Philadelphia, PA
that contain longitudinally aligned nanofibers (aligned nanofiber Sidney M. Jacoby, MD, Philadelphia, PA
conduits) may stimulate the repair of gap injuries to peripheral nerves. Terri Skirven, King of Prussia, PA
METHODS: We tested bilayer poly (L-lactide-co-caprolactone) Uzoma N. Ukomadu, MD, Philadelphia, PA
conduits with internal longitudinal nanofiber alignment A. L. Osterman, MD, Villanova, PA
in the repair of a 10 mm sciatic nerve gap in the rat model.
INTRODUCTION: Open fasciectomy represents a standard
Twenty-six female Lewis rats (200-225 grams) underwent 10
treatment of Dupuytren’s disease. Although patients are
mm resection of the right sciatic nerve. The gap was repaired
commonly immobilized in extension to prevent post-
by reversed nerve autograft (n = 10), conduit (n = 10; Figure
operative contracture formation, immobilizing the extremity
1), or was left unrepaired (n = 6). The primary outcome was
under tension may precipitate a flare reaction and scar related
motor function at 12 weeks. Secondary outcomes included
complications. This study explores the incidence of flare
electrophysiologic measurements and nerve histology.
reaction and other complications with postoperative tension-
RESULTS: At 12 weeks post repair, motor function testing
free splinting after fasciectomy for Dupuytren’s contracture.
showed equivalent recovery of gastrocnemius isometric tetanic
METHODS: The study was designed to retrospectively review
force (63 ± 9% conduit vs. 69 ± 11% autograft, normalized to
patients’ charts that underwent surgery for Dupuytren’s contracture.
contralateral side, p = 0.29) and muscle mass (58 ± 8% conduit
The 228 procedures in 192 patients identified underwent surgery
vs. 62 ± 7% autograft, normalized to contralateral side, p = 0.30)
by the senior author between 2000 and 2010. Postoperative notes
in the autograft and conduit groups. Electrophysiologic tests also
were reviewed for wound healing problems, scar appearance, flare
showed equivalent recovery of nerve conduction (conduction
reaction and complications. The grading system defined by Evans
latency: 1.68 ± 0.34 ms conduit vs. 1.73 ± 0.35 ms autograft, p
was used to standardize flare reaction and scar complications.
= 0.92) and gastrocnemius compound muscle action potential
RESULTS: Using tension free splinting the incidence of flare
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
782
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reaction was 3.5% (8/228). The eight patients that had flare technique (modified Kessler or other), use of epitendinous suture and
reactions had mild involvement, and no severe reaction was date of publication (before or after year 2000) were extracted. Articles
observed. Fifteen patients had hypertrophic scars, eight were excluded if they did not report information on re-operation,
had hypersensitive scars and six had recurrent contractures. re-rupture or adhesions. Unadjusted pooled meta-analysis was used
DISCUSSION AND CONCLUSION: The incidence of flare reaction to report the incidence of complications, while meta-regression
using tension free immobilization postoperatively was low in our was used to describe the potential contributory factors for each
study. According to our findings, tissue complication and wound complication while controlling for age, gender and zone of injury.
healing problems are rare when tensionless splinting is employed. RESULTS: Unadjusted meta-analysis revealed rates of re-operation
of 5.8%, re-rupture of 3.9% and adhesions of 3.9%. Meta-regression
PAPER NO. 245 analysis of 29 studies showed that re-rupture is not influenced by
The Use of Phenol for Refractory Neuromas of the Hand core suture technique or use of an epitendinous suture. However,
the presence of an epitendinous suture decreases re-operation by
and Forearm
84% (OR 0.16; CI 0.06, 0.42). Adhesion development is 134%
Ryan S. Vitali, MD, Seal Beach, CA higher (OR 2.34; CI 1.07, 5.11) if the modified Kessler technique
Matthew M. Malerich, MD, Bakersfield, CA is not used. There is a 3% increase in the likelihood of adhesions
INTRODUCTION: Refractory neuromas in the hand and with each month of follow up (OR=1.03, CI 1.005, 1.05).
forearm can be debilitating. For 4.5 years we have been using Publication date did not influence the incidence of complications.
aqueous phenol for treatment of these refractory neuromas. The DISCUSSION AND CONCLUSION: The published literature
objective of our presentation is to describe the technique and supports use of the modified Kessler repair technique with
review our series of patients who have undergone this treatment. an epitendinous suture to minimize complications. While
METHODS: Sixteen patients with refractory neuromas for two to complication rates are low, our data suggests that there has been
25 years underwent aqueous phenol injection into a segment of no definitive improvement in reported complications pre and post
the involved nerve and its neuroma. Patients were followed for an 2000.
average of 3.4 years and a minimum of two years. Indications for
PAPER NO. 247
the injection were failed prior neuroma surgery which included
multiple resections, rerouting neuromas, multiple failed neurolysis, Is There a Need for Routine Postoperative Follow
burying the neuroma into bone and implanted nerve stimulators. Up Post Trapeziectomy or Single Digit Dupuytren’s
The technique requires the nerve to be surgically exposed and
Fasciectomy?
isolated from surrounding tissue as the phenol is quite caustic. The
phenol is injected into a 0.75-3 cm segment of the involved nerve Sherif Elnikety, MRCS, London, United Kingdom
as well as the resultant neuroma. Eye protection is mandatory. Moataz El-Husseiny, Stanmore, United Kingdom
RESULTS: All patients experienced immediate relief of symptoms. Tamer Kamal, Kent, United Kingdom
There was consistently a flare up seven to 10 days after the injection Andrew Smith, MD, Canterbury, United Kingdom
which resolved in three to seven days. The pain was found to completely
INTRODUCTION: “No routine post-operative follow
subside for three to eight months. Recurrence of pain was to 20-
up appointments” policy has been implemented in NHS
40% of pre-injection pain level. Repeat injections were performed
hospitals in different specialties for uncomplicated surgical
in several of the patients and were found to have increased efficacy.
procedures. In trauma and orthopaedics, few studies to date
DISCUSSION AND CONCLUSION: Phenol injection demonstrates
reviewed this practice and reflected on the patients’ opinions.
significant pain relief for refractory neuromas, warranting further
METHODS: In this study we prospectively surveyed 50 patients
investigation of this technique. We realize that follow up is short,
post simple trapeziectomy and 71 patients post single digit
but pain relief in this patient population for two or more years is
Dupuytren’s fasciectomy for their opinion of post operative
substantial and gratifying. Many of these patients were in pain
care and whether they would have liked to be reviewed by the
management and we were able to eliminate their need for heavy
surgeon in a routine post operative follow up appointment
narcotic use. Open phenol injection for refractory neuromas
or not. The total of 121 patients were recruited over two years
is a treatment option for this unsolved and, in many instances,
for this study; each patient had post operative follow up by the
debilitating condition.
hand therapist for three months. All patients included in this
study had their operations done by one surgeon in one hospital.
PAPER NO. 246
All patients were reviewed by a hand therapist within two
Complications after Flexor Tendon Repair: A
weeks post operatively and treatment protocols were followed
Systematic Review and Meta-regression Analysis with all the patients. During their final appointment with the
Christopher J. Dy, MD, New York, NY hand therapist, all patients completed a questionnaire survey.
RESULTS: A total of 116 patients completed the study, five post
Alexia Hernandez-Soria, MD, New York, NY
Dupuytren’s fasciectomy patients were lost for follow up. A total
Yan Ma, PhD, New York, NY
of 106 patients (91%) were satisfied with their post operative
Timothy Roberts, New York, NY
management and 99 patients (85%) did not want to be reviewed by
Aaron Daluiski, MD, New York, NY
the surgeon in a post operative outpatient follow up appointment.
INTRODUCTION: Although outcomes after flexor tendon repair DISCUSSION AND CONCLUSION: This study reflects the
have reportedly improved with modern treatment, complications successful application of “hand therapy led follow up and
are not uncommon. However, the incidence of these complications discharge” policy with no routine post operative review by the
and the potential contributory factors are not well described. surgeon in our organization. We succeeded in reducing the waste
METHODS: We performed a systematic review to identify in the NHS by avoiding at least 215 unnecessary routine follow-up
publications in which patients with flexor tendon ruptures were appointments over a two-year period. By applying this policy we
surgically treated. Demographics, zone of injury, core suture also succeeded in avoiding the inconvenience to patients having
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
783
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multiple trips to the hospital. We advise implementing this practice
for other common uncomplicated surgical procedures with the
possibility of giving the patient the option to request appointment
with the surgeon if needed.
PAPER NO. 248
Flexor Tendon Excursion and Load During Passive and
Active Motion: A Cadaver Study
Anthony Sapienza, MD, New York, NY
Hong Kee Yoon, Seoul, Republic of Korea
Raj Karia, MPH, New York, NY
Steve K. Lee, MD, New York, NY
INTRODUCTION: Early motion protocols after flexor
tendon repair of the hand are designed to promote tendon
excursion to minimize adhesion formation without placing
excessive load on the repair. We hypothesize that there
will be differing amounts of tendinous excursion and
load with passive and active motion that are quantifiable.
METHODS: Six cadaveric above elbow specimens were mounted
to allow for active motion by tendon loading and passive motion.
Lateral fluoroscopic images were used to measure FDP and FDS
tendon excursions via intra-tendinuous metal markers placed
at the junction between the A1 and A2 pulleys in the index,
middle and ring fingers. Measurements were performed during
the following exercises: 1) passive extension to 0°, 2) passive
extension to 60°, 3) digital extension with wrist tenodesis, 4)
digital flexion with wrist tenodesis, 5) passive flexion, 6) straight
fist, 7) block PIP, 8) block DIP, 9) hook, 10) place & hold. The
tension on FDP and FDS tendons was recorded for respectively
appropriate motions. Data was analyzed by ANOVA and Tukey
HSD for pair-wise comparison between the different exercises
and Student’s t-test was used to compare the tension forces in
the active and passive exercises. Significance was set at p<0.05.
RESULTS: Mean tendon forces were higher in all active versus
passive movements (p<0.01). The highest forces were during the
block PIP for the FDS (6.01N, range 5.75-9.00) and block DIP for
the FDP (8.78N, range 8.98-12.05) (Figure 1). Mean FDS tendon
excursions during all active movements, except block DIP, were
larger than excursions during the passive movements (p<0.01).
Mean FDP tendon excursions for the active movements of block
PIP, block DIP, hook, and place & hold were larger than excursions
during the passive movements of extension to 0°, extension to
60°, digital extension with wrist tenodesis, digital flexion with
wrist tenodesis and passive flexion. The hook position had the PAPER NO. 249
highest mean excursion (12.8mm, 18.4mm) while the block Percutaneous Needle Fasciotomy vs. Collagenase in
DIP had the lowest mean excursion (3.4mm, 2.6mm) for the
the Treatment of Dupuytren’s Disease of the Hand
FDS and FDP tendons, respectively. The highest inter-tendinous
excursion (between FDS and FDP) was the hook position Jason Nydick, DO, Pensacola Beach, FL
(5.6mm) and the lowest was the block PIP (0.8mm) (Figure 2). Alfred V. Hess, MD, Temple Terrace, FL
DISCUSSION AND CONCLUSION: Active motion results in Jeffrey D. Stone, MD, Tampa, FL
higher tendinous excursion than does passive motion. Hook Bailee Williams, Tampa, FL
position exercise results in the highest total tendinous excursion Michael J. Garcia, MD, Tampa, FL
and the highest inter-tendinous excursion (between FDS and
INTRODUCTION: Dupuytren’s disease is a progressive genetic
FDP tendons). Blocking exercises place the highest loads on
disorder of pathologic collagen production and deposition. It
the flexor tendons. This knowledge may help optimize the
begins with palpable nodules in the palm with later development
management of the post-operative exercise therapy regimen.
of pathologic collagen cords, which extend longitudinally,
thicken and shorten causing flexion contractures of the joints. The
purpose of this study is to compare the results of percutaneous
needle fasciotomy (PNF) to collagenase injection in the treatment
of Dupuytren’s contracture of the hand. Our hypothesis is that
both percutaneous fasciotomy and collagenase treatment may
yield similar clinical outcomes. We hope to further identify risks,
u The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use).
784
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