Aims. Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK. Methods. We carried out a multicentre, survey-based cross-sectional study in 37 UK centres over a 16-month period from June 2022 to September 2023. The survey results were analyzed descriptively. Results. A total of 37 centres participated, of which nine were tertiary referral hand centres and 28 were district general hospitals. There was a total of 112 respondents (69 surgeons and 43 hand therapists). The strongest influence on the decision to offer surgery was the lack of a firm ‘endpoint’ to stressing the metacarpophalangeal joint (MCPJ) in either full extension or with the MCPJ in 30° of flexion. There was variability in whether additional imaging was used in managing acute UCL injuries, with 46% routinely using additional imaging while 54% did not. The use of a bone anchor was by far the most common surgical option for reconstructing an acute ligament avulsion (97%, n = 67) with a transosseous suture used by 3% (n = 2). The most common duration of immobilization for those managed conservatively was six weeks (58%, n = 65) and four weeks (30%, n = 34). Most surgeons (87%, n = 60) and hand therapists (95%, n = 41) would consider randomizing patients with complete UCL ruptures in a future clinical trial. Conclusion. The management of complete UCL ruptures in the UK is highly variable in certain areas, and there is a willingness for clinical trials on this subject. Cite this article: Bone Jt Open 2024;5(8):708–714

Two case reports illustrate a relatively simple procedure to preserve thumb function in trauma and locally invasive tumours. The first case report is of a man who presented with a slowly growing chondrosarcoma involving his left thumb metacarpal. Radiological investigations and incision biopsy confirmed the diagnosis of a low-grade chondrosarcoma. Thumb function sparing wide local excision of the metacarpal, including the thenar muscles was carried out. The floating thumb was stabilised with a temporary silicone block interposed between trapezium and the proximal phalanx. After four weeks the silicone block was replaced with a tri cortical bone graft from the opposite iliac crest and fixed distally to the proximal phalanx and proximally to the trapezium. The second case report is of a soldier who sustained multiple injuries including open fracture of left thumb metacarpal with associated soft tissue and bone loss. This was from a mortar shell explosion in a commando operation in the jungle. After immediate debridement locally he was transferred to the UK. On arrival ARDS and sepsis requiring ITU treatment further compromised his clinical status. One week later he underwent debridement and stabilisation of his thumb injury with an external fixature. This got infected and went on to develop a non-union. Some seven months post trauma he went on to have the metacarpal reconstructed using iliac crest bone graft. These two very different cases underwent a similar reconstructive procedure to try and preserve the thumb and regain some function. After rehabilitation both patients are pleased to have their thumb preserved

Aim of the study: The evaluation of denervation efficiency in the treatment of the arthritis of the base of the thumb. Material and method. Between 2001– 2004, 15 patients were surgically treated for arthritis of the basis of the thumb. There were all females of an average age of 53 years. In all patients the procedure was done ambulatory under local anesthesia. After completing a protocol form, regarding pain motion and power of the thumb, an incision was made at the level of the wrist crease extended from the level of FCR to the level of the 2nd extensor compartment. Through this incision the articular branches which conform the studies of Wilhem and Fusche supply the 1st CMC joint were divided. A supplementary incision for the first intermetacarpal space was made. The patients were free to return to their activities the third postoperative day and they were reviewed after 3, 6, 12, 24 months by an independent doctor. Their data were also recorded conform the protocol. Results: Twelve patients out of 15 had excellent improvement of their strength. Pinch and grip power was doubled. Mobility of the thumb according to Kapanji scale was improved in all cases. Pain was reduced in 65% average. The patients were satisfied from the operation. There was one patient with poor improvement and two patients who never shown up at the follow-up. As the last were at the beginning of our learning curve we think that could have a less satisfactory result. Discussion: The method is simple with minimal impact to the patient activity or life. It gives good results in 65% –75% and leaves further operative procedures possible. Although there not enough data yet for this procedure and our number of cases is small with short follow-up we believe that it is a nice procedure, it satisfies both the patient and the surgeon regarding the overall improvement of mobility and pain

Aims. Osteoarthritis (OA) affecting the thumb carpometacarpal joint (CMCJ) is a common painful condition. In this study, we aimed to explore clinicians’ approach to management with a particular focus on the role of specific interventions that will inform the design of future clinical trials. Methods. We interviewed a purposive sample of 24 clinicians, consisting of 12 surgeons and 12 therapists (four occupational therapists and eight physiotherapists) who managed patients with CMCJ OA. This is a qualitative study using semi-structured, online interviews. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Results. A total of 14 themes were developed, six of which were developed relating to the clinical management of CMCJ OA: 1) A flexible ‘ladder’ approach starting with conservative treatment first; 2) The malleable role of steroid injection; 3) Surgery as an invasive and risky last resort; 4) A shared and collaborative approach; 5) Treating the whole person; and 6) Severity of life impact influences treatment. The remaining eight themes were developed relating to clinical trial barriers and facilitators: 1) We need to embrace uncertainty; 2) You are not losing out by taking part; 3) It is difficult to be neutral about certain treatments; 4) Difficult to recruit to ‘no treatment’ ; 5) Difficult to recruit to a trial comparing no surgery to surgery; 6) Patients are keen to participate in research; 7) Burden on staff and participants; and 8) A enthusiasm for a variety of potential trial arms. Conclusion. Our findings contribute to a better understanding of how clinicians manage thumb CMCJ OA in their practice settings. Our study also provides useful insights informing the design of randomized clinical trials involving steroid injections and surgery in people with thumb CMCJ OA. Cite this article: Bone Jt Open 2022;3(4):321–331

Aims: Department of Hand Surgery in the National Institute of Traumatology and Oxyology – before 2001: National Institute of Traumatology – was established in 1959 as the first independent hand surgery department in Hungary. Our Institute was the centre of operations for thumb reconstruction nearly in 2 decades in Hungary. Methods: The techniques for thumb reconstruction, selected after considering many factors, will be presented in my lecture. All the treatment options we applied in our practice for thumb reconstruction will be summarized in the form of a table. In the first period we performed 3 stage thumb reconstructions (31 cases). This period was followed by the method of elongation acquired from professor Ivan Matev, mainly in young growing patients, but also performed in adults by extending the indications (36 cases). Phalangization proved to be an excellent technique in many patients when the major part of the first phalanx was preserved after the injury (47 cases). Results: Indications, surgical technique and results achieved with all these three methods will be highlighted in my presentation

Abstract. Aim. This study aims to Inter and intra observer reliability compare, use of a standard goniometer (SG) to measure intermetacarpal angle (degrees) vs use of a new technique of using a digital vernier calliper (DVC) (mm) to measure the distance between the first and second metacarpal head. Method. Maximal active abduction and extension of both thumbs was measured in 20 healthy volunteers on two occasions at least one week apart by two assessors. Results. The inter and intra-observer agreement was higher & the variance of the data was lower using the DVC with the new technique than the SG for both thumb abduction and extension. Additionally, the correlation between measurement of extension and abduction was higher using the DVC than the SG. Conclusion. Whilst both tools provide acceptable intra and inter-observer agreement, the new technique using a DVC is consistently better and more reliable than a SG in measuring thumb abduction and extension. The study also supports our hypothesis that the thumb rotates around the second metacarpal head with a consistent radius

Introduction. Despite the rising popularity of 1st carpometacarpal joint (CMCJ) arthrodesis as one of the surgical options for basilar thumb arthritis, the available literature on this is poor. This study aims to investigate post-operative pinch and grip strength following 1st CMCJ arthrodesis, at a minimum of 1 year follow-up. Complication rates, range of motion and patient reported scores were also evaluated. Methods. A retrospective cohort (2012–2020) was used, which included patients who had arthrodesis performed by the Hands surgeons at Counties Manukau DHB. In a 15 minute visit, we took the measurements using our standard dynamometer and pinch gauge, and collected three questionnaires [QuickDASH, PRWHE, PEM]. For analysis, we compared our results to the preoperative measures, contralateral hand, and to a previous study on a similar cohort looking at thumb strength following trapeziectomy. Results. 42 arthrodesis were performed, and 24 were available for follow-up. The average follow-up time was 77 months and the average age was 51 years old. Overall, we found a statistically significant improvement in thumb strength following surgery. Mean preoperative grip strength was 21.4kg and 32.5kg postoperatively (= +11kg). Preoperative pinch strength was 5.5kg and 7kg postoperatively (= +1.5kg). These results were significantly higher compared to the trapeziectomy cohort. We also found an improvement in 1st CMCJ ROM post-operatively. 7 complications were reported (29.1%). 4 were metalware-related and 3 were non-union. QuickDASH score significantly improved from a median of 42.95 to 12.5 while PRWHE from 67.5 to 14.5. Overall patient satisfaction was 87.4%. Conclusion. 1st CMCJ arthrodesis leads to an improvement in thumb function, pain and range of movement and results in high patient satisfaction, and therefore should be recommended for younger patients who need a pain-free and strong thumb

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with the flexor carpi radialis (FCR) tendon is one of the most common procedures for the treatment of thumb carpometacarpal (CMC) arthritis. An alternative method involves trapeziectomy alone (TA). The trapeziectomy with LRTI procedure was developed to theoretically improve biomechanical strength and hand function when compared to TA, which leaves an anatomical void proximal to the first metacarpal. The LRTI procedure takes longer to perform and includes an autologous tendon graft. The goal of this retrospective cohort study was to evaluate the clinical outcomes of trapeziectomy with or without LRTI at a minimum follow-up of 1 year. A total of 43 adult patients who had underwent a total of 58 (TA=36, LRTI=22) surgical procedures for CMC arthritis participated in the study. This single surgeon retrospective cohort study sampled patients who underwent CMC arthroplasty with either TA or LRTI techniques between 2008 and 2020 with a minimum time of 1 year post-operatively. The patients were evaluated subjectively (The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire) and objectively (hand/thumb strength, pre/post-operative hand radiographs). Both the TA and LRTI procedures provided good pain relief, motion, strength, and stability without any severe complications. There was no statistically significant difference in hand or thumb strength between the two groups. Radiography showed that compared to the preoperative status, the trapezial space decreased similarly between the two groups. There was no difference in size of collapse between TA and LRTI post-operatively. The TA procedure had similar outcomes to LRTI and has the advantages of shorter surgical time, less incision length, and lower surgical complexity. TA provided equivalent trapezial space to LRTI after the operation. Future study should investigate these two procedures in a head-to-head comparison rather than longitudinally where both surgeon experience and time since procedure at follow-up may have impacted results

Introduction. An understanding of anatomic variability can help guide the surgeon on intervention strategies. Well-functioning thumb metacarpophalangeal joints (MCPJ) are essential for carrying out typical daily activities. However, current options for arthroplasty are limited. This is further hindered by the lack of a precise understanding of the geometric variation present in the population. In this paper, we offer new insight into the major modes of geometric variation in the thumb MCP using Statistical Shape Modelling. Methods. Ten participants free from hand or wrist disease or injury were recruited for CT imaging (Ethics Ref:14/LO/1059). 1. Participants were sex matched with mean age 31yrs (range 27–37yrs). Metacarpal (MC1) and proximal phalanx (PP1) bone surfaces were identified in the CT volumes using a greyscale threshold, and meshed. The ten MC1 and ten PP1 segmented bones were aligned by estimating their principal axes using Principal Component Analysis (PCA), and registration was performed to enable statistical comparison of the position of each mesh vertex. PCA was then used again, to reduce the dimensionality of the data by identifying the main ‘modes’ of independent size and shape variation (principal components, PCs) present in the population. Once the PCs were identified, the variation described by each PC was explored by inspecting the shape change at two standard deviations either side of the mean bone shape. Results. For the ten MC1s, over 80% of the variation was described by the first two PCs (Table 1). Figure 1 shows the effect of the variation in PC1. The majority of geometric variation of the ten PP1s was also described by the first two PCs, with PC1 describing 78.9%. Figure 2 shows the effect of this component on the mean bone geometry. Both the distal articulating surface (head) of the MC1 and the proximal articulating surface (base) of the PP1 vary in overall size. However, the MC1 head also varies in shape (curvature), whereas the PP1 base does not appear to undergo noticeable variation in shape. In this study population, smaller MC1 was observed to correlate with a flatter head, whereas the PP1 head shape did not vary with size. Discussion. The flatter MC1 head (smaller height-radius ratio) may have implications for MCPJ instability, and possibly for osteoarthritic degeneration. A recent study predicted similar trends for the first CMC joint. 2. Previous investigation also observed correlation between MC1 head curvature and MCPJ RoM. 3. , which may explain clinical observations of differing thumb movement strategies. This study used a convenience sample and cannot describe a full population's variability, though the high variance captured by only two PCs suggests adequate external validity amongst similar populations. Further confidence would be gained from studying the joint (i.e. single PCA containing both bones), and wider populations. Significance. These data: provide more precise description of anatomic variation; may offer insights into thumb movement strategies and MCPJ osteoarthritic degeneration. 4. ; and support implant design for individuals whose anatomy can bear an anatomic reconstruction. For any figures or tables, please contact the authors directly

There is no agreement as to the superiority or specific indications for cast treatment, percutaneous pinning or open fracture fixation for Bennett's fractures of the thumb metacarpal. We undertook this study to compare the outcomes of treatment for patients treated for Bennett's fracture in the medium term. We reviewed 33 patients treated in our unit for a bennett's fracture to the thumb metacarpal with closed reduction and casting. Each patient was matched with a patient treated surgically. Patients were matched for sex, age, Gedda grade of injury and hand dominance. Patients were reviewed at a minimum of 5-years and 66-patients were reviewed in total. Patients were examined clinically and also asked to complete a DASH questionnaire score and the brief Michigan hand questionnaire. Follow up plain radiographs were taken of the thumb and these were reviewed and graded for degenerative change using the Eaton-Littler score. Sixty-six patients were included in the study, with 33 in the surgical and non-surgical cohorts respectively. The average age was 39 years old. In each cohort, 12/33 were female, 19/33 were right-handed with 25% of individuals injuring their dominant hand. In each coort there were 16 Grade 1 fractures, 4 Grade 2 and 13 Grade 3 fractures. There was no difference between the surgically treated and cast-treatment cohorts of patients when radiographic arthritis, pinch grip, the brief Michigan Hand Questionnaire and pain were assessed at final review. The surgical cohort had significantly lower DASH scores at final follow-up. There was no significant difference in the normalised bMHQ scores. Our study was unable to demonstrate superiority of either operative or non-operative fracture stabilization. Patients in the surgical cohort reported superior satisfaction and DASH scores but did not demonstrate any superiority in any other objectively measured domain

Objectives. Little is known about tissue changes underlying bone marrow lesions (BMLs) in non-weight-bearing joints with osteoarthritis (OA). Our aim was to characterize BMLs in OA of the hand using dynamic histomorphometry. We therefore quantified bone turnover and angiogenesis in subchondral bone at the base of the thumb, and compared the findings with control bone from hip OA. Methods. Patients with OA at the base of the thumb, or the hip, underwent preoperative MRI to assess BMLs, and tetracycline labelling to determine bone turnover. Three groups were compared: trapezium bones removed by trapeziectomy from patients with thumb base OA (n = 20); femoral heads with (n = 24); and those without (n = 9) BMLs obtained from patients with hip OA who underwent total hip arthroplasty. Results. All trapezium bones demonstrated MRI-defined BMLs. Compared with femoral heads without BMLs, the trapezia demonstrated significantly higher bone turnover (mean . sd. 0.2 (0.1) versus 0.01 (0.01) µm. 3. /µm. 2. /day), mineralizing surface (18.5% (13.1) versus 1.4% (1.3)) and vascularity (5.2% (1.1) versus 1.2% (0.6)). Femoral heads with BMLs exhibited higher bone turnover (0.3 (0.2) versus 0.2 (0.1) µm. 3. /µm. 2. /day), a higher mineralization rate (26.6% (10.6) versus 18.6% (11.9)) and greater trabecular thickness (301.3 µm (108) versus 163.6 µm (24.8)) than the trapezia. Conclusion. Bone turnover and angiogenesis were enhanced in BMLs of both the thumb base and hip OA, of which the latter exhibited the highest bone turnover. Thus, the increase in bone turnover in weight-bearing joints like the hip may be more pronounced than less mechanically loaded osteoarthritic joints demonstrating BMLs. The histological changes observed may explain the water signal from BMLs on MRI. Cite this article: M. Shabestari, N. J. Kise, M. A. Landin, S. Sesseng, J. C. Hellund, J. E. Reseland, E. F. Eriksen, I. K. Haugen. Enhanced angiogenesis and increased bone turnover characterize bone marrow lesions in osteoarthritis at the base of the thumb. Bone Joint Res 2018;7:406–413. DOI: 10.1302/2046-3758.76.BJR-2017-0083.R3

Thumb Carpometacarpal (CMC) arthritis is a common pathology of the hand. Surgical treatment with thumb reconstruction is well described. Retrospective outcomes have been described for multiple techniques, suggesting patient satisfaction with multiple different techniques. The Thompson technique uses a slip of Abductor Pollicis Longus for suspension and interposition as well as excision of the trapezium. Retrospective outcomes suggest good patient satisfaction. We describe the improvement in Patient rated outcomes scores (PROS) and changes in pinch and grip strength in a prospectively collected cohort of patients treated with a modification of the Thompson technique. To assess changes in Patient-Rated Wrist Evaluation (PRWE) and Disabilities of the Arm, Shoulder, and Hand (QDASH) scores, as well as to determine the percentage of patients that surpassed the Minimal Clinically Important Difference (MCID) figure that has been described in the literature for these tests. In addition, measurements for evaluation of pinch and grip strength prior to surgery, at six, and at twelve months follow-up were done. Between June 2016 and February 2019, a consecutive prospective series of Thirty-seven LRTI procedures with APL suspension arthroplasty (Thompson technique) were performed on 34 patients with osteoarthritis of the thumb CMC joint (24 women / 13 men; age 63±8.553). All surgeries were performed by the senior surgeon. Data was collected as part of a wrist pain database. Patients failing conservative treatment and electing surgical management of thumb arthritis were enrolled into the database. Patients were evaluated pre-operatively with the PRWE and QDASH questionnaires and grip and pinch strength measurements, and postoperatively at 6 and 12 months. The MCID for QDASH and PRWE is 14 and will be evaluated at the same time points for each patient. Paired student T-test was used to determine differences in the means. Data are presented as mean ± SD unless stated otherwise. Differences with p<.05 were considered significant. Compared to the pre-operative assessment, at six months, the means of PRWE pain score and PRWE functional score decreased significantly (32.824 SD±10.721 vs. 19.265 SD±12.268 and 30.262 SD±10.050 vs. 16.431 SD± 9.697 respectively, n=34,, p<0.05). 69% of the patients surpassed the MCID of 14 six months after the surgery. In addition, QDASH mean score also dropped from 56.108 to 32.219 (SD± 21.375 n=32. p<0.05) at six months. At one year, 76% of the patients were above the MCID of 14. The mean scores of these three questionnaires did not show significant change between six and twelve months. Compared to the initial pre-operative assessment, we found no statistically significant difference in the means of grip strength, point pinch, and lateral key pinch at six and twelve months. Thumb reconstruction with APL suspension arthroplasty demonstrates significant improvement in pain and functionality. No significant improvement in grip and pinch strength is observed, even at one year postoperatively

There is no consensus for the appropriate surgical management of chronic ulnar collateral ligament (UCL) injuries of the thumb. A systematic review of Pubmed, MEDLINE, EMBASE and ePub Ahead of Print was performed in accordance with Preferred Reporting of Items in Systematic Review and Meta-analysis (PRISMA) guidelines and formal protocol registered with PROSPERO. Two authors collated data from 10 studies that met strict inclusion criteria, using various surgical techniques in 131 thumbs. Results were heterogenous and metanalysis of results not possible. These data were, therefore, qualitatively assessed and synthesised. Bias was assessed using the ROBINS-I tool. Direct repair, reconstruction with free tendon or bone-tissue-bone grafts and arthrodesis all demonstrated favourable outcomes with Patient Reported Outcome Measures. Direct repair can be safely performed more than two months following injury, with a positive mean Disabilities of the Arm, Shoulder and Hand (DASH) score of 13.5 despite evidence of radiographic osteoarthritis. Arthrodesis should be considered in heavy manual laborers or those at risk of osteoarthritis as it provides significant reduction in pain (Mean Visual Analogue Score of 1.2) when compared to other methods. Free tendon grafting has been criticised for failure rates and poor functional grip strength, however collated analysis of 97 patients found a single graft rupture and mean grip strength of 97% (of the contralateral thumb). Bone-tissue-bone grafting was the least effective method across all outcome measures. Studies included were at high risk of bias, however, it can be concluded that delayed direct repair can be performed safely, while arthrodesis may benefit certain patient subgroups. New findings suggest poor efficacy of bone-tissue-bone grafts, but that free tendon grafting with palmaris longus are in fact safe with good restoration of grip strength. The optimal graft and configuration are yet to be determined for reconstructive methods

The opposable thumb is one of the defining characteristics of human anatomy and is involved in most activities of daily life. Lack of optimal thumb motion results in pain, weakness, and decrease in quality of life. First carpometacarpal (CMC1) osteoarthritis (OA) is one of the most common sites of OA. Current clinical diagnosis and monitoring of CMC1 OA disease are primarily aided by X-ray radiography; however, many studies have reported discrepancies between radiographic evidence of CMC1 OA and patient-related outcomes of pain and disability. Radiographs lack soft-tissue contrast and are insufficient for the detection of early characteristics of OA such as synovitis, which play a key role in CMC OA disease progression. Magnetic resonance imaging (MRI) and two-dimensional ultrasound (2D-US) are alternative options that are excellent for imaging soft tissue pathology. However, MRI has high operating costs and long wait-times, while 2D-US is highly operator dependent and provides 2D images of 3D anatomical structures. Three-dimensional ultrasound imaging may be an option to address the clinical need for a rapid and safe point of care imaging device. The purpose of this research project is to validate the use of mechanically translated 3D-US in CMC OA patients to assess the measurement capabilities of the device in a clinically diverse population in comparison to MRI. Four CMC1-OA patients were scanned using the 3D-US device, which was attached to a Canon Aplio i700 US machine with a 14L5 linear transducer with a 10MHz operating frequency and 58mm. Complimentary MR images were acquired using a 3.0 T MRI system and LT 3D coronal photon dense cube fat suppression sequence was used. The volume of the synovium was segmented from both 3D-US and MR images by two raters and the measured volumes were compared to find volume percent differences. Paired sample t-test were used to determine any statistically significant differences between the volumetric measurements observed by the raters and in the measurements found using MRI vs. 3D-US. Interclass Correlation Coefficients were used to determine inter- and intra-rater reliability. The mean volume percent difference observed between the two raters for the 3D-US and MRI acquired synovial volumes was 1.77% and 4.76%, respectively. The smallest percent difference in volume found between raters was 0.91% and was from an MR image. A paired sample t-test demonstrated that there was no significant difference between the volumetric values observed between MRI and 3D-US. ICC values of 0.99 and 0.98 for 3D-US and MRI respectively, indicate that there was excellent inter-rater reliability between the two raters. A novel application of a 3D-US acquisition device was evaluated using a CMC OA patient population to determine its clinical feasibility and measurement capabilities in comparison to MRI. As this device is compatible with any commercially available ultrasound machine, it increases its accessibility and ease of use, while proving a method for overcoming some of the limitations associated with radiography, MRI, and 2DUS. 3DUS has the potential to provide clinicians with a tool to quantitatively measure and monitor OA progression at the patient's bedside

In radial polydactyly, the Wassel’s classification is most commonly employed. This classification depends upon the bifurcation site of the thumb. In this paper the author discusses his experience in the treatment of duplicated thumb at various levels. In duplicated thumbs, the supernumery digit (thumb) is excised in patients in whom one of the two thumbs is extremely hypoplastic. When both of the digits have an equal amount of tissue, some reconstructive surgical procedure is employed to centralize the thumb to improve the cosmesis and/or function. If thumb excision is done in such a case, the thumb may develop instability, axial deviation and may require secondary procedures for stabilization. The thumb may develop vascular compromise, though rarely, due to anomalous vascular supply. The author has employed the Bilhautcloquet procedure or its modification in the treatment of 12 cases of duplicated thumb. This paper discusses the entity, the surgical technique and the results in 12 cases of duplicated thumb. The mean follow up is 3 years

Two case reports illustrate a relatively simple procedure to preserve thumb function in trauma and locally invasive tumours. The first case report is of a man who presented with a slowly growing chondrosarcoma involving his left thumb metacarpal. Radiological investigations and incision biopsy confirmed the diagnosis of a low-grade chondrosarcoma. Thumb function sparing wide local excision of the metacarpal, including the thenar muscles was carried out. The floating thumb was stabilised with a temporary silicone block interposed between trapezium and the proximal phalanx. After four weeks the silicone block was replaced with a tri cortical bone graft from the opposite iliac crest and fixed distally to the proximal phalanx and proximally to the trapezium. The second case report is of a soldier who sustained multiple injuries including open fractures of left thumb metacarpal with associated soft tissue and bone loss. This was from a mortar shell explosion in the jungle. After immediate debridement locally he was transferred to the UK. On arrival he was found to be septic and with ARDS, requiring ITU treatment. One week later he underwent debridement and stabilisation of his thumb injury with an external fixator. This got infected and he went on to develop a non-union. He needed multiple visits to the Operating theatre to sort out his other injuries. Some seven months post trauma he went on to have the metacarpal successfully reconstructed using iliac crest bone graft. These two very different cases underwent a similar reconstructive procedure to try and preserve the thumb and regain some function. After rehabilitation both patients are pleased to have had their thumb preserved

Background. We would like to analyze the risk factors of no thumb test among knee alignment tests during total knee arthroplasty surgery. Methods. The 156 cases of total knee arthroplasty by an operator from October 2009 to April 2010 were analyzed according to preoperative indicators including body weight, height, degree of varus deformity, and patella subluxation and surgical indicators such as pre-osteotomy patella thickness, degree of patella degeneration, no thumb test which was evaluated after medial prepatella incision and before bone resection (1st test), no thumb test which was evaluated with corrective valgus stress (2nd test, J test), and the kind of prosthesis. We comparatively analyzed indicators affecting no thumb test (3rd test). Results. There was no relation between age, sex, and body weight and no thumb test (3rd test). Patellar sulcus angle (p = 0.795), patellar congruence angle (p = 0.276) and preoperative mechanical axis showed no relationship. The 1st no thumb test (p = 0.007) and 2nd test (p = 0.002) showed signifi cant relation with the 3rd no thumb test. Among surgical indicators, pre-osteotomy patella thickness (p = 0.275) and degeneration of patella (p = 0.320) were not relevant but post-osteotomy patellar thickness (p = 0.002) was relevant to no thumb test (3rd test). According to prosthesis, there was no signifi cance with Nexgen (p = 0.575). However, there was signifi cant correlation between Scorpio (p = 0.011), Vanguard (p = 0.049) and no thumb test (3rd test). Especially, Scorpio had a tendency to dislocate the patella, but Vanguard to stabilize the patella. Conclusions. No thumb test (3rd test) is correlated positively with 1st test, 2nd test, and post-osteotomy patella thickness. Therefore, the more patella osteotomy and the prosthesis with high affi nity to patellofemoral alignment would be required for correct patella alignment

From January 2000 to March 2004 16 thumbs after total avulsion-amputation were replanted in our hospitals. In 15 cases this was successful. In one case the thumb was lost 28 hours after replantation. Mostly the amputation was in the region of the first phalanx or the IP-joint of the thumb. In all cases our operative procedure for this form of amputation was the reconstruction of the vessels with vein grafts after the osteosynthesis and the reconstruction of the tendons. The donorsite region for the grafts was in 12 cases the dorsal forefoot and in 4 cases the distal forearm. In none of these cases there was the possibility of reconstructing both arteries. Mostly only an anastomosis for one artery and one vein could be done. For none of these patients it was possible to reconstruct the nerves primarily. Until now transphers of neurovascular skinislands of longfingers, free nerve transplantations with coaptations to the proximal stump of the injured nerve, free nerve transplantations with coaptations to the trunk of the median nerve or in one case an end-to-side coaptation have been performed to achieve a resensibility of the thumbs. In one case a patient rejected an operative nervereconstruction, because a sprouting of the proximal stump of the injured nerve lead to a (reduced) sensibility of the thumb. In 4 cases a therapy to achieve a resensibility has so far not been carried out. After replantations of injured thumbs necroses of the skin in different kinds were noticed. In 4 cases secondary skinreconstructions were necessary. All 15 successful replanted thumbs achieved very good results concerning function, strength and patient’s satisfaction. Our results don’t agree with the mostly bad results after total avulsionamputations mentioned in literature. We think that the replantation after total avulsionamputation of the thumb has a high chance of being successful and can achieve very good longtime results

Introduction: The thumb metacarpophalangeal (MCP) joint dislocations in children are relatively uncommon and scarcely described in the English literature. The aim of this study was to report the clinical course and outcome of traumatic dislocations of the thumb metacarpophalangeal joints in children. Materials and methods: We retrospectively reviewed a cohort of 37 traumatic dislocations of the thumb metacarpophalangeal joints in 37 children between 1990 and 2005. All patients were treated by five orthopaedic surgeons at a tertiary referral children’s hospital. The outcome measures included patient demographics, method of reduction and short-term outcome. The mean follow-up was 6 weeks. Results: The mean age at injury was 7.3 years. These occurred predominantly in boys (78.3%) and were dorsal dislocations in 97.2%. Thirty-three presented acutely on the day of injury, while 3 within 1–2 weeks. Four patients needed open reduction with or without temporary stabilisation. Thirty-three had a closed reduction (under general anaesthesia-12, under ring block-5, under sedation-9 and without anaesthesia-7). All patients undergoing closed or open reduction under anaesthesia had 1–4 unsuccessful relocation attempts. Two of four open reductions revealed soft tissue interposition of volar plate and flexor pollicis longus. Post-reduction, the thumb was immobilised in a thumb spica or plaster for 2 to 3 weeks period. All gained good result. There were no infections, recurrent dislocation or gross stiffness. Conclusion: Thumb metacarpophalangeal (MCP) joint dislocations in children are mostly dorsal and managed non-operatively in majority with satisfactory outcome. Irreducible dislocations may need open reduction due to volar plate and flexor pollicis longus tendon interposition

Introduction and Aims: Many surgical techniques are available for thumb reconstruction. These include deepening of the first web, flaps, osteoplastic reconstructions, toe to thumb transfer, pollicisation and metacarpal lengthening. The aim of this study is to assess the outcome following use of distraction methods for thumb lengthening. Method: Nineteen patients who underwent thumb metacarpal lengthening over a six-year period have been reviewed retrospectively. Lengthening was performed for terminal deficiency in 12 cases and for segmental bone loss in seven cases. The callotasis method was used in 11 patients and the Matev method in eight. The Orthofix mini-external fixator was used as the distracting device in all cases. Results: Final gains in length achieved measured from 22mm to 41mm, with an average fixator application time of 86 days (range 58 to 125). Complications included two malunions, one overlengthening, four pin migrations through bone and six cases of pin track sepsis. There were no skin or neurovascular complications. Narrowing of the first web space has been found to be a significant problem associated with thumb metacarpal lengthening in this study. This necessitated subsequent deepening of the web space in 14 patients with adductor release in seven patients. Conclusion: Distraction methods for thumb reconstruction are relatively easy, safe and do not require special facilities or prolonged theatre time. Where indicated, these techniques provide a useful alternative to other methods of thumb reconstruction