Introduction. Orthopaedic and trauma surgeons not infrequently encounter the hallucal interphalangeal joint sesamoid (HIPJS) in irreducible traumatic dislocations. However, patients with the classic triad of plantar keratoma beneath a hyperextended interphalangeal (IP) joint associated with stiffness of the first metatarsophalangeal joint tend to present to podiatrists rather than orthopaedic surgeons. Methods. We present our experience with the HIPJS following first metatarsophalangeal joint (MTP1) arthrodesis in 18 feet of 16 women, aged 42 to 70 years old. Where CT scan was available, volume of the HIPJS was determined using Vitrea Software. Results. Two groups of patients were identified. Group 1 consisted of 12 feet in 11 women, who developed a painful keratoma beneath a gradually hyperextending IP joint of the great toe, at varying intervals (range 6 to 75 months) following MTP1 arthrodesis. Group 2 comprised 6 feet in 5 women who had undergone MTP1 arthrodesis but reported no symptoms in relation to an undetected and/or recognized, but unexcised HIPJS (range 15 to 97 months). We found no difference in average size of the HIPJS between Groups 1 and 2 (190.42 mm. 3. and 196.47 mm. 3. , respectively). Clinically, all toes had been fused in good position and no difference existed in the post-operative angle subtended by the proximal phalanx of the arthrodesed big toe with the first metatarsal between the 2 groups. A good outcome followed removal of metalwork and excision of the HIPJS in the symptomatic patients. Conclusion. Think of a HIPJS in the patient who presents with a painful plantar keratoma beneath a hyperextended interphalangeal joint following MTP1 arthrodesis. Do not rush into a Moberg osteotomy as this will only push the big toe higher against the toe-box. Consider prophylactic excision of a HIPJS prior to MTP1 arthrodesis

Distal interphalangeal joint (DIPJ) fusion using a k-wire has been the gold standard treatment for DIPJ arthritis. Recent studies have shown similar patient outcomes with the headless compression screws (HCS), however there has been no cost analysis to compare the two. Therefore, this study aims to 1) review the cost of DIPJ fusion between k-wire and HCS 2) compare functional outcome and patient satisfaction between the two groups. A retrospective review was performed over a nine-year period from 2012-2021 in Counties Manukau. Cost analysis was performed between patients who underwent DIPJ fusion with either HCS or k-wire. Costs included were surgical cost, repeat operations and follow-up clinic costs. The difference in pre-operative and post-operative functional and pain scores were also compared using the patient rate wrist/hand evaluation (PRWHE). Of the 85 eligible patients, 49 underwent fusion with k-wires and 36 had HCS. The overall cost was significantly lower in the HCS group which was 6554 New Zealand Dollars (NZD), whereas this was 10408 NZD in the k-wire group (p<0.0001). The adjusted relative risk of 1.3 indicate that the cost of k-wires is 1.3 times more than HCS (P=0.0053). The patients’ post-operative PRWHE pain (−22 vs −18, p<0.0001) and functional scores (−38 vs −36, p<0.0001) improved significantly in HCS group compared to the k-wire group. Literatures have shown similar DIPJ fusion outcomes between k-wire and HCS. K-wires often need to be removed post-operatively due to the metalware irritation. This leads to more surgical procedures and clinic follow-ups, which overall increases the cost of DIPJ fusion with k-wires. DIPJ fusion with HCS is a more cost-effective with a lower surgical and follow-up costs compared to the k-wiring technique. Patients with HCS also tend to have a significant improvement in post-operative pain and functional scores

Background Bony or cartilaginous ossicles appear at the plantar aspect of the interphalangeal joint of the great toe. The variation in pattern, prevalence and anatomic relationships of these structures is not clearly established in the literature, especially in a Caucasian population. Without this knowledge, pathology at this joint may be underestimated and surgical approaches may be poorly planned particularly as radiographs underestimate the incidence of ossicles at this joint. The aims of this study were to determine the incidence and pattern of ossicles at this joint and to establish their anatomical relationships in order to aid planning the approach for their excision. Method The left great toe interphalangeal joint was dissected in forty British Caucasian cadavers and the pattern of ossicles and their anatomic relationships were established. Results In 27.5% of specimens, there was no identifiable ossicle and in these cases, the tendon of flexor hallucis longus was adherent to the joint capsule. In the remaining specimens (72.5%), a bursa separated the tendon of flexor hallucis longus from the plantar joint capsule and ossicles were found embedded within the joint capsule. Over a half (52.5%) of the specimens had a single ossicle located centrally within the plantar capsule and the remaining 20% had two ossicles lying within the capsule. Conclusion This study shows that a large proportion of the population have either one or two bony or cartilaginous ossicles at this joint. In addition, the study has clarified the anatomy of this joint and shown that, when present, ossicles do not lie within the tendon of flexor hallucis longus and could be most safely approached from either a medial or lateral approach

Aims. The paediatric trigger thumb is a distinct clinical entity with unique anatomical abnormalities. The aim of this study was to present the long-term outcomes of A1 pulley release in idiopathic paediatric trigger thumbs based on established patient-reported outcome measures. Methods. This study was a cross-sectional, questionnaire-based study conducted at a tertiary care orthopaedic centre. All cases of idiopathic paediatric trigger thumbs which underwent A1 pulley release between 2004 and 2011 and had a minimum follow-up period of ten years were included in the study. The abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH) was administered as an online survey, and ipsi- and contralateral thumb motion was assessed. Results. A total of 67 patients completed the survey, of whom 63 (94%) had full interphalangeal joint extension or hyperextension. Severe metacarpophalangeal joint hyperextension (> 40°) was documented in 15 cases (22%). The median QuickDASH score was 0 (0 to 61), indicating excellent function at a median follow-up of 15 years (10 to 19). Overall satisfaction was high, with 56 patients (84%) reporting the maximal satisfaction score of 5. Among 37 patients who underwent surgery at age ≤ two years, 34 (92%) reported the largest satisfaction, whereas this was the case for 22 of 30 patients (73%) with surgery at aged > two years (p = 0.053). Notta’s nodule resolved in 49 patients (73%) at final follow-up. No residual triggering or revision surgery was observed. Conclusion. Surgical release of A1 pulley in paediatric trigger thumb is an acceptable procedure with excellent functional long-term outcomes. There was a trend towards higher satisfaction with earlier surgery among the patients. Cite this article: Bone Jt Open 2024;5(9):736–741

Introduction

Patients suffering from finger joint pain or dysfunction due to arthritis and traumatic injury may require arthroplasty and joint replacement. Single-part silicone-based implants remain the material of choice and most widely used option, although reports on their long-term clinical performance are variable. For trauma indications, patients have a high expectation of functionality necessitating the use of materials with high wear resistance and mechanical performance. A new proximal inter phalangeal (PIP) joint designed by Zrinski AG (Wurmlingen, Germany), comprising a self-mating carbon fibre reinforced polyetheretherketone (CFR-PEEK) coupling, may provide a suitable alternative. Here we describe the wear performance of the CFR-PEEK components in a PIP joint wear simulator and subsequent characterisation of the wear particles.

Osteoarthritis (OA) of the equine distal interphalangeal joint (DIPJ) is a common cause of lameness. MicroRNAs (miRNAs) from biofluids such as plasma and synovial fluid make promising biomarker and therapeutic candidates. The objectives of this study are (1) Identify differentially expressed (DE) miRNAs in mild and severe equine DIPJ OA synovial fluid samples and (2) Determine the effects of DE miRNAs on equine chondrocytes in monolayer culture. Synovial fluid samples from five horses with mild and twelve horses with severe DIPJ OA were submitted for RNA-sequencing; OA diagnosis was made from MRI T2 mapping, macroscopic and histological evaluation. Transfection of equine chondrocytes (n=3) was performed using the Lipofectamine® RNAiMAX system with a negative control and a miR-92a mimic and inhibitor. qPCR was used to quantify target mRNA genes. RNA-seq showed two miRNAs (miR-16 and miR-92a) were significantly DE (p<0.05). Ingenuity Pathway Analysis (IPA) identified important downstream targets of miR-92a involved in the pathogenesis of osteoarthritis and so this miRNA was used to transfect equine chondrocytes from three donor horses diagnosed with OA. Transfection was successfully demonstrated by a 1000-20000 fold increase in miR-92a expression in the equine chondrocytes. There was a significant (p<0.05) increase in COMP, COL3A1 and Sox9 in the miR-92a mimic treatment and there was no difference in ADAMTS-5 expression between the miR-92 mimic and inhibitor treatment. RNA-seq demonstrated miR-92a was downregulated in severe OA synovial fluid samples which has not previously been reported in horses, however miR-92a is known to play a role in the pathogenesis of OA in other species. Over expression of miR-92a in equine chondrocytes led to significantly increased COMP and Sox9 expression, consistent with a chondrogenic phenotype which has been identified in human and murine chondrocytes

1 . The extensor assembly of the fingers consists of the central tendon joined by three pairs of components: a) the retinacular ligaments, which link the movements of the interphalangeal joints; b) the "wing" tendons, a lumbrical on the radial side, and usually a palmar interosseous on the ulnar side; c) the phalangeal tendons, usually dorsal interossei. 2. The retinacular ligaments are relaxed in full extension of the proximal interphalangeal joints and are, in this position, unable to extend the distal joints fully. This is because the interphalangeal joint surfaces are eccentric. 3. The pull of the wing tendons alters the shape of the extensor expansion and transfers the pull of the long extensor tendon from the base of the middle phalanx to the base of the distal phalanx, thus enabling full extension of the distal joint to be powerfully achieved. 4. The action of the lumbrical muscle, as an extensor of the interphalangeal joint, is demonstrated by a diagram showing its site and length in the various positions of the finger, calculated from the known excursions of the tendons. This is consistent with the observations on action potentials. 5. The phalangeal tendons of the dorsal interossei have a bifid insertion, a) into the phalangeal tubercle at the base of the proximal phalanx, and b) into the transverse band, and hence to the central tendon. The muscle acts at one or both of these attachments, according to the positions of the metacarpo-phalangeal and interphalangeal joints, in its varying functions of flexion, abduction and hyperextension. Finally an explanation of the deformity of clawing in ulnar palsy is given

We reviewed 13 patients with a complex fracture-dislocation of the proximal interphalangeal joint of a finger and one patient with a complex fracture-dislocation of the interphalangeal joint of thumb. We had treated these injuries using a pins and rubbers traction system which had been modified to avoid friction of the pins against the bone during mobilisation of the joint in order to minimise the risk of osteolysis. A Michigan hand outcome questionnaire was used for subjective assessment. The active range of movement (AROM) of the proximal and distal interphalangeal joints and the grip strength were used for objective assessment. The mean follow-up was 34 months (12 to 49). The mean normalised Michigan hand outcome score was 84. The mean AROM of the proximal interphalangeal joint was 85° and that of the distal interphalangeal joint 48°. The mean grip strength was 92% of the uninvolved hand. Twelve patients have returned to their original occupations. There has been no radiological osteolysis or clinical osteomyelitis. This modified traction system has given acceptable results with a low rate of complications. It is light, cheap, effective and easy to apply

Ten patients, who underwent treatment for complex fracture-dislocation of the proximal interphalangeal joint of finger and one patient for that of the interphalangeal joint of thumb with a modified pins and rubbers traction system, were reviewed to evaluate the clinical and functional results. Two patients had open fracture-dislocation, 5 had pilon fractures and 4 had fracture-dislocations. The system was modified to avoid rotation of the pins in the bone during joint mobilization, thus minimizing the risk of osteolysis due to friction of pins over the bone. Michigan hand scoring system was used for subjective assessment and range of motion at proximal and distal interphalangeal joints and grip strength for objective assessment. Average follow-up was 18 months (range 3 months to 28 months). The average normalised Michigan hand score was 86. Based on Michigan scores, overall hand function was rated excellent in 8 patients, good in 2 and poor in 1. Eight patients have returned to their original jobs. The average arc of flexion in the proximal interphalangeal joint was 85 degrees and in the distal interphalangeal joint it was 47 degrees. The average grip strength was 95 percent of the uninvolved side. Two patients developed minor pin site infection, which did not necessitate pin removal or any alteration in the treatment regime. There have been no cases of osteolysis, osteitis or osteomyelitis. This modification of pins and rubbers traction system has given very acceptable results with a low complication rate. It is light, cheap, effective and easy to apply

Normal digital flexion relies on flexor tendon pulleys to transmit linear muscular force to angular digital motion. Despite the critical role these pulleys play, there is a growing trend among surgeons to partially sacrifice or “vent” them during flexor tendon repair to improve surgical exposure. Although this new practice is reported to improve outcomes after flexor tendon repair, there is concern for the long-term effects of bowstringing, reduced finger range of motion (ROM) and altered tendon biomechanics. The objective of this study was to examine the effects of the application of a thermoplastic ring, acting as an “external” pulley, on flexor tendon biomechanics and finger ROM. We hypothesized that the application of an external thermoplastic ring would produce a centripetal force over the tendon to reduce bowstringing, improve finger ROM, and restore tendon loads following pulley venting. Twelve digits comprised of the index, long, and ring fingers from four cadaveric specimens were tested using a novel in-vitro active finger motion simulator. Servo-motors were used to generate motion. Loads induced by flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP), and joint range of motion were measured with each sequential sectioning of the A2, A3, and A4 flexor pulley, in comparison to a native healthy finger condition. At each finger condition, A2 and A4 external thermoplastic pulley rings were applied over the proximal phalanx and middle phalanx, respectively, to recreate A2 and A4 function. Results were recorded and analyzed using a one way repeated-measures ANOVA. Following venting of the A2, A3 and A4 pulley, proximal interphalangeal joint (PIPJ) ROM significantly decreased by 17.02 ± 8.42 degrees and distal interphalangeal joint (DIPJ) range of motion decreased by 17.25 ± 8.68 degrees compared to intact pulleys. Application of the external rings restored range of motion to within 8.14 ± 8.17 degrees at the PIPJ and to within 7.72 ± 8.95 degrees at the DIPJ. Similarly, pulley venting resulted in a 36% reduction in FDS load and 50% in FDP load compared to intact pulleys. Following application of the external rings, loads were almost restored to normal at 7% reduction for FDS load and 13% reduction for FDP load. Venting of flexor tendon pulleys significantly alters flexor tendon biomechanics and digit range of motion. The application of thermoplastic rings acting as external pulleys over the proximal and middle phalanges is an effective, inexpensive, non-invasive and reproducible therapeutic method to restore flexor tendon biomechanics and digit range of motion

1. The intrinsic paralysis that occurs in leprosy has been treated by the sublimis transfer of Stiles and Bunnell for the past nine years. Since 1951 300 hands have been operated upon, and 150 patients selected geographically have been followed up in this study. 2. The patients have been assessed by a standard method involving: 1) Measurement of range of movement of the interphalangeal joint (unassisted movement, assisted active movement and passive movement); 2) grasp index; and 3) photographs of each hand in six standard positions. 3. Assessment of the open hand—The Stiles-Bunnell procedure is effective in achieving a fully open hand: 73 per cent of the fingers scored good or excellent results. A defect in the operation is that it sometimes hyperextends the interphalangeal joint, producing an "intrinsic plus" hand. 4. Assessment of sequence of joint flexion—The Stiles-Bunnell operation restores satisfactory mechanism of closure of the hand in 93 per cent of cases—that is, the metacarpo-phalangeal joints flex before the interphalangeal joints. 5. The closedfist assessment—About 30 per cent of patients had some defect in the complete closure of the fist after operation. In 5 per cent of cases the fingers did not reach the palm after operation. 6. Complications—The "intrinsic plus" defect is commonest in the best and most mobile hands. This is a late complication which gets worse in succeeding years. It can be corrected by Littler's operation together with a profundus tenodesis in the middle segment of the finger. Lateral deviation of fingers due to radial-side attachment of the transferred tendon can be avoided by ulnar-side attachment of the tendon used for the index finger. Bowstringing of the sublimis stump in the flexor sheath may be avoided by division of the sublimis at it insertion. Weakness of grasp and pinch from loss of sublimis may be avoided by using only one or two sublimis tendons split into several strands. The index finger sublimis should be left in position. 7. It is concluded that the sublimis transfer of Stiles and Bunnell is a very powerful corrective of intrinsic paralysis of the fingers. Its chief defect is that it is too powerful and produces the opposite deformity. For this reason the use of this operation should be restricted to fingers in which there is some limitation of passive extension. For fully mobile fingers an operation should be selected which does not remove the sublimis from its normal position

We treated 32 displaced mallet finger fractures by a two extension block Kirschner-wire technique. The clinical and radiological outcomes were evaluated at a mean follow-up of 49 months (25 to 84). The mean joint surface involvement was 38.4% (33% to 50%) and 18 patients (56%) had accompanying joint subluxation. All 32 fractures united with a mean time to union of 6.2 weeks (5.1 to 8.2). Congruent joint surfaces and anatomical reduction were seen in all cases. The mean flexion of the distal interphalangeal joints was 83.1° (75° to 90°) and the mean extension loss was 0.9° (0° to 7°). No digit had a prominent dorsal bump or a recurrent mallet deformity. We believe that this technique, when properly applied, produces satisfactory results both clinically and radiologically

Aim. Distal interphalangeal joint (DIPJ) arthrodesis is a well-accepted treatment of disease in the DIPJ of the hand. The ideal technique should be technically simple, quick, cheap, have minimal complications and yield a rapid return to function. Recent large published series report major complications of 11.1% and minor complications of 26% for this procedure. The study objective is to determine patient satisfaction and complication rates of DIPJ fusion using the Autofix screw (Small Bone Innovations, France), a smaller diameter headless compression screw. Methods. A standard questionnaire was devised to assess patients' overall satisfaction and complications related to the procedure. This data is compared to equivalent procedures published internationally. The patient's radiological records were reviewed to determine bone union at 7 weeks post-operation. Results. 39 fingers were fused in 29 participants. Mean follow up was 36 months (range 2–48 months). Patient satisfaction was above 90%. We had a major complication rate of 2.56%, a minor complication rate of 20.5%. There was a higher rate of complications in patients younger than 60 years of age. Discussion. Our technique for the insertion of the Autofix, headless compression screw is shown. It is a simple, quick and effective technique for the fusion of distal interphalangeal joints of all fingers; there is no ‘down-time’, and complication rates are superior to the largest series published in international literature. Furthermore, we demonstrated 100% union by 7 weeks in our patient sample. We attribute these results to 3 aspects of the procedure. 1) The Autofix screw is a smaller diameter screw than previously used for this procedure. 2) The screw generates significant compression across the fusion site. 3) We utilise bone graft as part of our routine management. NO DISCLOSURES

The authors report their results of “extension-block Kirschner wire fixation” for the treatment of mallet finger fracture. This technique should be considered in presence of a large bone fragment involving more than the 30% of the articular surface, with or without palmar subluxation of the distal phalanx. A modification of the extension-block technique is described reducing the fragment to 0° extension of the distal interphalangeal joint. The results confirmed the better outcomes of this modification, minimizing the postoperative extension lag at the distal interphalangeal joint. The Wehbe and Schneider method was used to classify the mallet finger fractures and the results were graded according to Crawford’s criteria (66,6% excellent and 33,4% good). The extension-block K wire technique, when properly applied, is a very helpful procedure avoiding the risks and complications of the open surgery and achieving a good indirect anatomical reduction of the fracture

A retrospective analysis was done on 20 cases of interphalangeal joint fusion of the great toe utilizing longitudinal cortical screw fixation. The purpose of this study was to present a series of interphalangeal joint fusion great toe done in both paediatric and adult patients using 3.5mm cortical screws. Most of the patients had interphalangeal joint fusion along with Jones transfer and other associated procedures with a mean follow up period of 19 months. Arthrodesis was successfully achieved in all the patients. No one had pain at the interphalangeal joint of the great toe. A literature review on interphalangeal joint arthrodesis was done and advantages of cortical screw fixation over other techniques have also been presented

Purpose of the study: Duplication of the thumb is the most common congenital anomaly of the first ray. The characteristic feature of type IV is the diversity of the clinical forms and the presence of certain complex forms particularly difficult to treat (Hung IVD). We propose a new procedure for reconstruction of IVD type thumb duplication. Material and method: This new procedure was used for thumb reconstruction in two boys with type IVD thumb duplication. Mean age at surgery was 10 months. Surgical technique. The future incisions were traced with a central skin resection removing the most hypoplastic nail entirely (generally the radial nail). At the bone level, a longitudinal osteotomy of the proximal phalanges was made over the entire length to remove the central part and obtain a width for the first phalanx comparable to that of the contralateral thumb. An oblique osteotomy was cut in the base of the distal phalanx of the ulnar hemithumb with resection of a radial corner. The same type of osteotomy was performed at the base of the distal phalanx of the radial hemithumb, but with preservation of the radial corner and resection of the rest of the radial thumb. The proximal hemiphalanges were sutured as were the bases of the distal phalanges. This produced automatic realignment and stabilisation of the interphalangeal joint without an ungueal intervention. Results: The three children were reviewed at 24, 18 and 12 months. The Horii score was good in all cases. Discussion: Type IVD duplications of the thumb are difficult to treat and may leave serious sequelae. Our technique is based on the principle of a central resection of the proximal phalanges associated with partial resection of the base of the distal phalanges. This enables realignment and stabilisation of the interphalangeal joint while avoiding the problem of ungueal dystrophy since only one nail is preserved. Our preliminary results are encouraging but must be confirmed with a longer term study

1. The range of variation in the movements at the metatarso-phalangeal and interphalangeal joints of the big toe in fifty males has been investigated by means of lateral radiographs. 2. In the "neutral" position the proximal phalanx is dorsiflexed on the metatarsal and the distal phalanx dorsiflexed on the proximal. Sometimes the distal phalanx is plantar flexed on the proximal but this is not associated with any obvious abnormality of function. 3. There is a wide variation between individuals in the amount of movement found at these joints. 4. At the metatarso-phalangeal joint dorsiflexion is much more free than plantar flexion. The opposite is the case at the interphalangeal joint. 5. There is no significant difference between the right and left sides. Only in plantar flexion at both joints are there significant reductions in the range of movement in older age groups. These reductions are not functionally important. 6. There is an inverse relationship between active and passive dorsiflexion: the greater the range of active dorsiflexion, the less is the range of additional passive dorsiflexion. 7. In lateral radiographs the head of the metatarsal is always rounded

Introduction. Mallet toe is a flexion deformity of the distal interphalangeal joint of the lesser toe. It causes pain and callosity in the toe tip and the dorsum of the distal interphalangeal joint. Campbell refers to the “terminal Syme’s amputation” for this condition but the results of this have not previously been reported. Material and Methods. This is a retrospective review of 35 toes in 22 patients that underwent distal phalangectomy. Sixteen patients were aged over 70. Patients were interviewed by an independent observer regarding the pain relief, cosmetic acceptability and satisfaction with the procedure and were examined for callosity, stump tenderness, sensitivity and neuroma. Results. All patients were satisfied including pain relief and cosmetic acceptability at an average follow up of 4.6 years. One patient had mild wound infection. One patient had asymptomatic nail growth. No stump tenderness, sensitivity or neuroma was noted. Discussion and Conclusion. Coughlin reported a satisfaction rate of 89% and 86% following successful fusion and excision arthroplasty respectively. In this series all patients were satisfied. We feel that distal phalangectomy is an option in a selected group of elderly patients where pain relief and functional outcome is the priority

We reviewed the results of reconstruction of 97 upper limbs in a consecutive series of 57 tetraplegic patients, treated from 1982 to 1990. Of these, 49 had functional and eight had cosmetic reconstructions. The principal functional objectives were to provide active elbow extension, hook grip, and key pinch. Elbow extension was provided in 34 limbs, using deltoid-to-triceps transfer. Hook grip was provided in 58 limbs, mostly using extensor carpi radialis longus to flexor pollicis longus transfer, and key pinch in 68, mostly using brachioradialis to flexor pollicis longus transfer. Many other procedures were employed. At an average follow-up of 37 months, 70% had good or excellent subjective results, and objective measurements of function compared favourably with other series. Revisions were required for 11 active transfers and three tenodeses, while complications included rupture of anastomoses and problems with thumb interphalangeal joint stabilisation and wound healing. We report a reliable clinical method for differentiating between the activity of extensor carpi radialis longus and brevis and describe a successful new split flexor pollicis longus tenodesis for stabilising the thumb interphalangeal joint. Bilateral simultaneous surgery gave generally better results than did unilateral surgery

1. The claw position of a finger with intrinsic paralysis is caused by the blocking effect of the transverse lamina on the long extensor. This starts as soon as the metacarpo-phalangeal joint is hyperextended, and increases with further hyperextension. Thus the long extensor loses its pull on the interphalangeal joints and allows them to flex. Therefore, in intrinsic paralysis the claw position can be prevented or cured by keeping the metacarpo-phalangeal joint in flexion, however slight, which can be done by splinting, by tenodesis or by capsulorrhaphy. 2. Replacement of the intrinsics by some active element, although it may improve the action of the fingers, is not necessary for the correction of claw finger. The function of the intrinsics in the prevention of claw finger is not to be found in their extending effect on the interphalangeal joints, but in the flexion effect on the metacarpo-phalangeal joint, or at least in preventing its hyperextension. This is in accordance with the fact that loss of intrinsic function is disastrous only in supple fingers, in which the metacarpo-phalangeal joints tend to assume extreme degrees of hyperextension (Riordan 1953, Brand 1958). In such fingers, the wide range of hyperextension available at the metacarpo-phalangeal joints is, of course, part of a generalised laxity of the soft parts of the fingers. These soft parts generally tend to counteract the tendency to clawing; the less their resistance, the more the human finger as a whole will tend to behave like a musculo-articular model, and such a model without intrinsics will always immediately assume the claw position

The rheological properties of synovial fluid (SF) are largely attributed to the presence of high molecular weight hyaluronic acid (HA). In normal SF, HA has been shown to be an anti-inflammatory molecule able to increase the viscosity and promote endogenous production of HA. The aim of the present report was to investigate the possible effect of HA concentration in rheological properties (elastic modulus, G´ and viscous modulus, G´´) of osteoarthritic equine SF. For this purpose, SF from intercarpal, metacarpophalangeal and distal interphalangeal joint was aspirated by aseptic arthrocentesis from 60 Warmblood horses. For determining HA concentrations in equine SF samples, a commercially available ELISA kit was used. Additionally, full rheological sample characterization was carried out with an AR-G2 rheometer (TA Instruments Ltd., UK) in order to measure the elastic G´ and viscous G´´ moduli, at horse's body (37.5 ºC) temperature. The ANOVA findings revealed statistically significant main effects of the factors Joint Type (p = 0.001), and main effects of covariates Age (p = 0.019) and HA (p < 0.001) on the mean values of logG” and logG' measurements. Interpreting the coefficients of the covariate HA, a positive correlation of HA was detected on the response logG” and logG' measurements. Collectively, these data illustrate the role of HA in equine pathological SF

Purpose: Two questions arise after metatarsophalangeal hallux arthrodesis: what are the 3D changes observed when walking on flat ground ? and is the arthrodesis compensation essentially at the talocrural or interphalangeal level ?. Material and methods: Our series included twelve patients (ten women and two men) mean age 60.7 years. Nine patients had unilateral arthrodesis and three bilateral arthrodesis. The optoelectronic exploration was conducted barefoot. The patients wore underclothes and 27 reflectors. A miniaturised reflector was placed on the distal end of each hallux. Three valid recordings were made. Results: General gait parameters and kinematic and kinetic values were unchanged (excepting nonsignificant maximal ankle dorsiflexion). On the arthrodesis side we observed: significant decline in propulsion force in the anteroposterior and vertical planes; significantly later heel lift-off; systematic anterior displacement of the ground reaction force of the metatarsophalangeal joint (not seen on the healthy side). Discussion: We propose a coherent explanation of these observations. The kinetics of balance movement under the head of the first metatarsal head is changed. When the foot is flat on the ground, as the ankle balance movement occurs, the weight of the body is transferred earlier and massively to the forefoot. While in the healthy foot this occurs under the metatarsophalangeal joint of the great toe, in arthrodesis patients body weight is transferred under the interphalangeal joint of the great toe. The balance movement of the interphalangeal joint of the great toe occurs when the ankle balance movement is terminated. The centre of the balance movement is more distal and heel lift-off tends to occur later. During the propulsion phase, the greater lever arm limits the propulsion force, explaining the lesser peak force observed on the arthrodesis side. Use of reflectors on the distal end of the hallux demonstrated that the arthrodesis compensation occurs essentially at the interphalangeal level, exposing this joint to greater risk of degeneration

Purpose of the study: Distal amputation of the long fingers with loss of dorsal or volar tissue may leave bone exposed requiring fingertip reconstruction to restore sensorial and tactile function. Several methods have been proposed for fingertip reconstruction. Among the methods the most widely used, thenar flaps predominate because of they are reliable and easy to perform but especially because of the very high-quality tissue function achieved. Material and methods: We report a series of 86 patients who presented an amputation of a long finger during a 4-year period (January 1998 to December 2002). A tenar flap was constructed within 24 of the operation. Mean patient age was 26 years; 80% of the accidents were occupational accidents; tissue loss was caused by sharp instruments in 72% of the cases; three-quarters of the cases involved the left non-dominant hand; the greatest damage was to the middle finger in 58% of cases. Loss of dorsal tissue was noted for 80% of the amputations. Trunk anesthesia was used for all patients to achieve cover with a thenar flap with a proximal pedicle in 80%. The flap was weaned from its blood supply at 18 days on average. Results: Outcome was assessed with three criteria at mean follow-up of one year. Subjectively, 80% of patients were satisfied with the operation. Permanent flexion of the distal interphalangeal joint was totally absent in 70% of patients. Using the British Medical Research Council, sensibility was scored S3 in 60% and S2 in 40%. Discussion: Described as early as 1926, the thenar flap is a novel method for achieving a cutaneous cover very close to the anatomic fingertip. Several drawbacks have nevertheless been formulated, namely permanent flexion of the distal interphalangeal joint, cutaneous sequelae at the donor site, and the «blind» nature of the flap which can be devoid of sensitivity. Analyzing the results obtained in our series showed that harvesting a flap in the middle of the thenar zone avoiding the medial region which raises the risk of a cheloid scar, the risk of distal interphalangeal flexion can be avoided by starting active-passive rehabilitation exercises as early as possible. At two months, the fingertip starts gaining sensitivity via the periphery. Conclusion: Thenar flaps are reliable, easy to perform flaps which provide an attractive solution to the reconstruction of long fingers

1. The range of variation in full extension at the interphalangeal and metacarpo-phalangeal joints of the thumbs of 133 male and 100 female Europeans, and of 31 male Indians and 30 male Africans, has been investigated. 2. There is considerable variation between individuals in the maximum extension of both joints of the right and left thumbs in all groups studied. 3. The distribution for each joint in both thumbs in all groups is fairly symmetrical. 4. There is a high correlation between the right and left thumbs for both joints in all groups. 5. The mean angle of extension at the right and left metacarpo-phalangeal joints in all groups is similar. Female Europeans, however, show a significantly greater mean angle than male Europeans. 6. The mean interphalangeal angle of extension in male Europeans is significantly greater than that in female Europeans and the mean in the Indian and African groups is significantly greater than in the male European group. 7. There is slight negative correlation between the metacarpo-phalangeal angle and interphalangeal angle in each thumb in the European groups. 8. Many subjects in all groups can increase extension at the metacarpo-phalangeal joint after flexing the carpo-metacarpal joint. Marked hyperextension (over 40°) is more frequent in the left than in the right thumb, in females than in males, and in male Indians than in male Europeans and Africans. 9. Maximum extension at the interphalangeal joints is not related to the presence of a sesamoid bone in the anterior part of the capsule of the joint. 10. The surfaces of the metacarpo-phalangeal joints vary considerably in shape. Those which are flat form about 10 per cent. of the sample and do not show hyperextension. 11. The factors influencing the amount of extension at the interphalangeal joint is the degree of laxity of the anterior capsule. The problem at the metacarpo-phalangeal joint is more complex; both the capsule and the shape of the joint surfaces play important roles

Rheumatoid arthritis is a whole body, lifetime incurable disease. The problems engendered by the disease process itself are highly individual, given that each set of problems that a patient has, the assessment and planning of surgery is a crucial aspect of the appropriate management of patients with polyarthritis. The presence of deformity does not necessarily indicate a problem of function, but one has to accept that certain deformities cause more problems than others and I draw your attention to swan neck deformity being relatively function-impairing and Boutonnière deformities less so. There is always a balance between the risk of surgery and the benefits to be obtained. The assessment is functional, anatomical, radiological, psychological, medical, financial and, finally, surgical. The functional assessment is intended to identify the problems a patient has in the activities of daily living, the anatomical assessment identifies the structures damaged which need to be prepared or replaced, the x-rays define the bone loss and, therefore, determine the limits of bony surgery, the psychological aspect identifies the patient’s capacity and willingness to be involved in often quite complex therapy programmes over a significant period of time. The medical problems of vasculitis and active disease are less frequent now but are contra-indications to surgery in the acute phases. The financial aspects are often under-rated. The costs of maintaining someone with significant disabilities is really quite great and, therefore, although surgery may only give some small improvement in function, it often has quite a significant impact on the degree of care and help an individual needs. Finally, the surgical assessment is to identify which structures and in which order. In terms of planning, the surgical priorities, described by Nalebuff, are:. 1 Nerves 2 Flexor tendons 3 Wrist 4 Thumb 5 MCP joints 6 Extensors 7 PIP joints 8 Distal Interphalangeal joints. Prolonged nerve compressions do not recover well; ruptures of flexor tendons are very difficult to treat; if the wrist is painful and unstable it inhibits any function that the hand might have; the thumb is 50% of hand function; metacarpophalangeal joints need to be stable and to flex approximately to 60° in order to be functional; extensor tendons need to glide and to be able to lift fingers away from the palm; the interphalangeal joints contribute greatly to the closing of grasp. The role of the therapist is pre-operatively to assess the patient appropriately for surgery, assessing all the aspects defined above and to ensure that the patient is compliant with the treatment post-operatively. The aphorism that 20% of the effort comes from the surgeon, 50% from the therapist and 20% from the patient is probably a fairly accurate representation of the importance of therapy post-operatively. Therapy must be planned, purposeful and progressive

Introduction and Objective. Zone 2 flexor tendon injuries are still one of the challenges for hand surgeons. It is not always possible to achieve perfect results in hand functions after these injuries. There is no consensus in the literature regarding the treatment of zone 2 flexor tendon injuries, tendon repair and surgical technique to be applied to the A2 pulley. The narrow fibro-osseous canal structure in zone 2 can cause adhesions and loss of motion due to the increase in tendon volume due to surgical repair. Different surgical techniques have been defined to prevent this situation. In our study, in the treatment of zone 2 flexor tendon injuries; Among the surgical techniques to be performed in addition to FDP tendon repair; We aimed to compare the biomechanical results of single FDS slip repair, A2 pulley release and two different pulley plasty methods (Kapandji and V-Y pulley plasty). Materials and Methods. In our study, 12 human upper extremity cadavers preserved with modified Larssen solution (MLS) and amputated at the mid ½ level of the arm were used. A total of 36 fingers (second, third and the fourth fingers were used for each cadaver) were divided into four groups and 9 fingers were used for each group. With the finger fully flexed, the FDS and FDP tendons were cut right in the middle of the A2 pulley and repaired with the cruciate four-strand technique. The surgical techniques described above were applied to the groups. Photographs of fingers with different loads (50 – 700 gr) were taken before and after the application. Proximal interphalangeal (PIP) joint angle, PIP joint maximum flexion angle and bowstring distance were measured. The gliding coefficient was calculated by applying the PIP joint angle to the single-phase exponential association equation. Results. Gliding coefficient after repair increased by %21.46 ± 44.41, %62.71 ± 116.9, %26.8 ± 35.35 and %20.39 ± 28.78 in single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. The gliding coefficient increased significantly in all groups after surgical applications (p<0.05). PIP joint maximum flexion angle decreased by %3.17 ± 7.92, %12.82 ± 10.94, %8.33 ± 3.29 and %7.35 ± 5.02 in single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. PIP joint maximum flexion angle decreased significantly after surgery in all groups (p<0.05). However, there was no statistically significant difference between surgical techniques for gliding coefficient and PIP joint maximum flexion angle. Bowstring distance between single FDS slip repair, kapandji pulley plasty and V-Y pulley plasty showed no significant difference in most loads (p>0.05). Bowstring distance was significantly increased in the A2 pulley release group compared to the other three groups (p<0.05). Conclusion. Digital motion was negatively affected after flexor tendon repair. Similar results were found in terms of gliding coefficient and maximum flexion angle among different surgical methods. As single FDS slipe repair preserves the anatomical structure of the A2 pulley therefore we prefer it as an ideal method for zone 2 flexor tendon repair. However, resection of FDS slip may jeopardizes nutrition to the flexor digitorum profundus tendon which weakens the repair site. Therefore the results must be confirmed by an in vivo study before a clinical recommendation can be made. Keywords: Flexor tendon; injury; pulley plasty; cadaver;

We randomised 79 patients (84 hands, 90 fingers) with Dupuytren’s contracture of the proximal interphalangeal joint to have either a ‘firebreak’ skin graft (39 patients, 41 hands, 44 fingers) or a fasciectomy (40 patients, 43 hands, 46 fingers) if, after full correction, the skin over the proximal phalanx could be easily closed by a Z-plasty. Patients were reviewed after three, six, 12, 24 and 36 months to note any complications, the range of movement and recurrence. Both groups were similar in regard to age, gender and factors considered to influence the outcome such as bilateral disease, family history, the presence of diabetes, smoking and alcohol intake. The degree of contracture of the metacarpophalangeal and interphalangeal joints of the operated fingers was similar in the two groups and both were comparable in terms of grip strength, range of movement and disability at each follow-up. The recurrence rate was 12.2%. We did not identify any improvement in correction or recurrence of contracture after firebreak dermofasciectomy up to three years after surgery

Aim. To examine the mid-term survival, clinical and patient reported outcomes of the silastic 1. st. metatarsophalangeal joint replacement for the treatment of end stage hallux rigidus. Methods. We reviewed 83 consecutive silastic arthroplasties performed in 79 patients for end stage hallux rigidus. There were 3 men and 76 women; mean age 63 years (range 45–78 years). No patient was lost to follow up. Average follow-up was 5.3 years (1.1–11.3 years). The EQ 5D–5L Health index, Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS) of pain and overall satisfaction rate (Likert scale) were collected for patient reported outcomes. Results. 2 patients required revision; 1 for early infection (2 months) and 1 for stem breakage (10 years 1 month). 5 patients reported lateral metatarsalgia, 2 patients reported neuropathic pain, 6 patients developed superficial infection which fully responded to oral antibiotics, and 1 patient developed interphalangeal joint pain. 2 patients died in the cohort. Pre-operative mean MOXFQ was 44, mean EQ5D Index was 0.564 and VAS was 6.97. At mean follow-up of 5.3 years, the mean MOXFQ was 12.7 (0–57), the mean EQ5D Index was 0.851 (−0.02–1) and the mean VAS was 1.67 (0–8). The mean range of motion was 35° (30° dorsiflexion and 5° plantarflexion). The overall satisfaction rate was 90.2%. The implant survival rate was 97.6%. Conclusions. The silastic big toe arthroplasty offers excellent clinical mid term survival and functional outcomes and could be considered as an attractive alternative to traditional fusion for end stage hallux rigidus

Aetiology and pathogenesis: The pathogenesis of boutonnière deformity, in the rheumatoid patient is usually quite clear, and is due to either a central slip failure or volar subluxation of the middle phalanx. This subluxation is seen more commonly in the patients with psoriatic arthropathy. The most common cause is a chronic synovitis of the proximal interphalangeal joint leading to attenuation of the sagital fibres between the central slip and the lateral bands and at a later stage disruption or attenuation of the central slip itself. Synovitis of the pip joint with separation of the lateral bands from the central slip allows the lateral bands to sublux forwards to lie anterior to the axis of rotation thus the intrinsics which extend the proximal and distal joints of the finger come to act as flexors of the proximal joint and continue to act as extensors to the distal joint. The patient will use the intrinsic muscles and they now have a flexion force upon the PIP joint and hyperextension force on the DIP joint, causing a boutonnière deformity. Volar subluxation of the middle phalanx draws forwards the lateral bands and defunctions the central slip creating the same imbalance. Scarring of the volar plate as is seen in volar plate injuries with the production of a pseudo-boutonnière deformity is sometimes seen in psoriatic arthropathy. In a boutonnière deformity the PIP joint is flexed and the DIP joint is extended. With the joints in this position, the origin and insertion of the intrinsic muscles are closer together, and as a consequence, with the passing of time, the muscles fibres will remodel in a shortened position, creating a lateral band tightness. Classification: Boutonnière deformity can be classified into four stages. Type I. The deformity is totally correctable passively, and there is full flexion of the DIP joint when the PIP joint is fully extended. The patient has a passively correctable flexion deformity of the PIP joint, and can actively flex the distal interphalangeal joint. The anatomical alterations are the following: elongation of the sagital fibres and volar displacement of the lateral bands but no secondary shortening of musculo-tendinous system. Type II. Flexion of the DIP joint is limited when the PIP joint is passively corrected. The patient cannot actively or passively flex the distal interphalangeal joint, when the PIP joint is passively corrected. Secondary shortening of the intrinsic/lateral band system because the intrinsics have remodelled in a shortened position. Type III. Stiffness of the PIP joint without joint destruction. There is no passive correction of the deformity but the joint surfaces are sound. The patient can not passively extend the PIP joint nor flex the DIP joint. Type IV. Stiffness of the PIP joint with joint destruction. In these cases, stiffness of the PIP joint is not only due to soft tissue remodelling but mainly to joint destruction. In this type, destruction of the joint cartilage should be added to the previously described anatomical deformities. X-ray examination is needed to confirm the diagnosis. Treatment: Boutonnière deformities, are both aesthetically and functionally less disabling than swan neck deformities because there is usually little loss of active PIP joint flexion. Some therapeutic options exist, and choosing the most appropriate surgical procedure will depend on the severity of the anatomical deformities which need to be corrected. Correction of PIP joint flexion. Mobilisation of the lateral bands and transposition of the lateral bands posterior to the axis of rotation of the PIP joint. Release of the volar plate of the PIP joint is often necessary because of secondary contracture. Improving active DIP joint flexion. The only way to restore loss of active DIP joint flexion is by performing a Dolphin tenotomy or formal lengthening of the conjoined lateral bands over the middle phalanx. Improving passive PIP joint extension. Passive extension of the PIP joint can usually be obtained by gentle manipulation and serial application of plaster of paris casts, as well as the use of a Capner (or armchair splint)the dorsal structures are usually quite thin and lax. If the joint can not be passively extended, a surgical release of the lateral bands is indicated,. Y-V plasty shortening of the central slip and extensor mechanism is usually necessary. A longitudinal incision at both sides of the central slip, allowing the lateral bands to displace dorsally during PIP joint extension with reefing of the lateral bands to the remnants of the central slip is needed in most cases. PIP joint arthroplasty. A PIP joint arthroplasty should be considered when the joint is destroyed. A radiological examination is essential in making the diagnosis, as many stiff PIP joints in flexion do not have their joint surfaces preserved because boutonnière deformities are often secondary to PIP joint synovitis. A full soft tissue procedure must be performed at the same time. DIP joint arthrodesis. Arthrodesis is only indicated for the treatment of uncorrectable deformity of the DIP joint with or without joint destruction, confirmed by radiological examination. The functional results of an arthroplasty are far superior for the treatment of a swan neck than a boutonnière deformity, because of the integrity of the extensor apparatus in the former, allowing for immediate postoperative motion. 7. PIP joint arthrodesis will be the treatment of choice if the finger presents a gross deformity with deteriorating function or failed surgery

The surgical correction of hammer digits offers a variety of surgical treatments ranging from arthroplasty to arthrodesis, with many options for fixation. In the present study, we compared 2 buried implants for arthrodesis of lesser digit deformities: a Smart Toe® implant and a buried Kirschner wire. Both implants were placed in a prepared interphalangeal joint, did not violate other digital or metatarsal joints, and were not exposed percutaneously. A retrospective comparative study was performed of 117 digits with either a Smart Toe® implant or a buried Kirschner wire, performed from January 1, 2007 to December 31, 2010. Of the 117 digits, 31 were excluded because of a lack of 90-day radiographic follow-up. The average follow-up was 94 to 1130 days. The average patient age was 61.47 (range 43 to 84) years. Of the 86 included digits, 48 were left digits and 38 were right. Of the digits corrected, 54 were second digits, 24 were third digits and 8 were fourth digits. Fifty-eight Smart Toe® implants were found (15 with 19-mm straight; 2 with 19-mm angulated; 34 with 16-mm straight; and 7 with 16-mm angulated). Twenty-eight buried Kirschner wires were evaluated. No statistically significant difference was found between the Smart Toe® implants and the buried Kirschner wires, including the rate of malunion, nonunion, fracture of internal fixation, and the need for revision surgery. Of the 86 implants, 87.9% of the Smart Toe® implants and 85.7% of the buried Kirschner wires were in good position (0° to 10° of transverse angulation on radiographs). Osseous union was achieved in 68.9% of Smart Toe® implants and 82.1% of buried Kirschner wires. Fracture of internal fixation occurred in 12 of the Smart Toe® implants (20.7%) and 2 of the buried Kirschner wires (7.1%). Most of the fractured internal fixation and malunions or nonunions were asymptomatic, leading to revision surgery in only 8.6% of the Smart Toe® implants and 10.7% of the buried Kirschner wires. Both the Smart Toe® implant and the buried Kirschner wire offer a viable choice for internal fixation of an arthrodesis of the digit compared with other studies using other techniques

A case is reported of a young girl who presented with macrodactyly of the right middle finger and tumour masses on the palmar side of both interphalangeal joints. The lesions were fibrocartilaginous and appeared to be hyperplastic palmar plates. The macrodactyly and the hyperplasia of the palmar plates were attributed to trauma

1. An investigation of interdigital clavus or corn does not support the opinion that it is found most often in the web of the fourth interspace. 2. Most occur in that interval, but less than a third involve the web. 3. The commonest site is the area of impingement of the distal interphalangeal joint of the fifth toe on the proximal interphalangeal joint of the fourth

1. From India a family is reported in which fifteen of fifty-seven were affected by the nail-patella syndrome. 2. Additional coincidental features not described previously were fiexion deformities of both hips and hyperextension of the interphalangeal joints of the fingers. 3. Patients affected by the condition do not always show the same blood group

Giant cell tumor of the tendon sheath (nodular synovitis) is a benign soft tissue tumor, usually affecting older women, that most often occurs in the interphalangeal joints of the fingers, wrist or knee. Malign giant cell tumor of the tendon sheath is rare. We present a case of a 56-year-old woman presented with a slow-growing, painless mass on the anteromedial aspect of the ankle 5 year duration. Apparent rapid enlargement of the mass was observed and went under surgery. The resected tumor, measuring 50x21x28 mm.cm, was encapsulated and located on the tibialis anterior tendon sheath of the ankle. The tumor was intracapsular and its margins was clear. We performed radioterapy. The patient was quite well at the last follow-up 12 months after wide excision. It seems likely that may expect the good outcome, superficial location and the minority of the tumor composed of malignant component. However, long-term follow-up is mandatory, due to the poor prognosis

There are many operations for hallux valgus and hallux rigidus, but Keller's operation remains one of the most popular, particularly for the older patient. A prospective trial was carried out to compare the results of Keller's operation modified by Kirschner-wire distraction with those of the standard operation. The results suggest that there is no advantage in using temporary Kirschner-wire distraction; indeed, degenerative changes in the interphalangeal joint and a subjectively worse result may result from its use

Immobilisation of the thumb is widely believed to be important in the management of fractures of the carpal scaphoid. To assess the need for this, we randomly allocated 392 fresh fractures for treatment by either a forearm gauntlet (Colles') cast, leaving the thumb free, or by a conventional 'scaphoid' plaster incorporating the thumb as far as its interphalangeal joint. In the 292 fractures which were followed for six months, the incidence of nonunion was independent of the type of cast used

1. A review of intra-articular and peri-articular fractures of the phalanges has been carried out, and the late results of such injuries have been examined. 2. These fractures usually unite by bone. 3. The results of conservative treatment by immobilisation are satisfactory in the case of mallet fractures, hyperextension sprain fractures and collateral avulsion fractures of the proximal phalanges. 4. The less satisfactory results after collateral avulsion fractures of the interphalangeal joints and avulsion fractures complicating dislocations are discussed

This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed.

Cite this article: Bone Joint J 2022;104-B(12):1329–1333.

We reviewed 31 patients at a mean of five years after mallet deformity of the finger had been treated with a thermoplastic splint. Intra-articular fractures were present in 35% of patients. Osteoarthritic changes had developed in 48%, most in association with fracture, and 29% had a swan-neck deformity. There was a loss of extension greater than 10° in 35%; the average deficit at the interphalangeal joint was 8.3° and the average flexion arc was 48.5°. Despite these findings, patient satisfaction was generally high, with little evidence of functional impairment

The February 2024 Wrist & Hand Roundup³⁶⁰ looks at: Occupational therapy for thumb carpometacarpal osteoarthritis?; Age and patient-reported benefits from operative management of intra-articular distal radius fractures: a meta-regression analysis; Long-term outcomes of nonsurgical treatment of thumb carpometacarpal osteoarthritis: a cohort study; Semi-occlusive dressing versus surgery in fingertip injuries: a randomized controlled trial; Re-fracture in partial union of the scaphoid waist?; The WALANT distal radius fracture: a systematic review; Endoscopic carpal tunnel release with or without hand therapy?; Ten-year trends in the level of evidence in hand surgery.

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.

1. Trigger thumbs present at birth can be safely watched for twelve months because there is an expected spontaneous recovery rate of at least 30 per cent. 2. Trigger thumbs in children first noticed between the age of six to thirty months can be safely watched for six months because there is an expected spontaneous recovery rate of about 12 per cent. 3. Delayed operation left no residual contracture of the interphalangeal joint provided the release was done before the age of four years. 4. Operation is recommended if the child is over the age of three years when first seen

The June 2024 Foot & Ankle Roundup³⁶⁰ looks at: First MTPJ fusion in young versus old patients; Minimally invasive calcaneum Zadek osteotomy and the effect of sequential burr passes; Comparison between Achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional Achilles tendinopathy; Revision ankle arthroplasty – is it worthwhile?; Tibiotalocalcaneal arthrodesis or below-knee amputation – salvage or sacrifice?; Fusion or replacement for hallux rigidus?.

External fixation is useful for the treatment of selected injuries to the hand. Some authors have suggested that external fixation of a phalanx may tether the extensor hood, thereby hindering active movements and predisposing to permanent adhesions. There is no consensus as to the best site for placement of the pin to minimise these problems. This study was performed on cadaver specimens to investigate the influence of the pin site on the range of simulated active movement of the interphalangeal joint. The dorsal midline position produces least interference with the extensor mechanism; radial and ulnar to this, interdigitating oblique fibres prevent a clean longitudinal split in the direction of gliding thus limiting movement of the extensor hood. At the proximal phalanx, positioning of the pin just off the midline avoids the thickening of the proximal median hood, whereas at the middle phalanx, a true midline position utilises the bare area at its base

The aim of this study was to explore whether adverse reactions would occur during the material’s degradation period even at a later time point after surgery and whether these phenomena were clinically significant and would influence the final outcome. 12 unstable, displaced metacarpal fractures in 10 patients (7 males, 3 females; mean age 36.4 y, range 18–75 y) were treated with the Inion. ®. OTPSTM Biodegradable Mini Plating System. 9 patients (10 fractures) were available for follow-up (mean 25.6 months, range 14 to 44 m). For patients without appearance of foreign body reaction the minimum follow-up time was 24 months. Patients were examined both radiologically to evaluate fracture healing, and clinically by completing the DASH-score and a visual analogue scale for pain assessment. Grip strength, finger strength and range of motion of metacarpo-phalangeal and interphalangeal joints were measured. Fracture healing occurred uneventfully in all patients within six weeks. The most important complication was a foreign body reaction observed in 4 of our patients more than a year postoperatively. All were re-operated and had the materials removed. Histological examination confirmed the diagnosis of aseptic inflammation and foreign body reaction. Although internal fixation of metacarpal fractures by using bioabsorbable implants is a satisfactory alternative fixation method, patients should be advised of this possible late complication and should be followed postoperatively for at least one and a half year, possibly longer

We examined prospectively 4719 newborn infants to determine the congenital incidence of trigger thumb. No cases were found. Fifteen other children aged from 15 to 51 months had surgery for this condition. The anomaly had not been seen at birth and all thumbs presented with a flexion contracture without triggering. The condition is usually seen after birth as a flexion contracture of the interphalangeal joint. The term ‘congenital’ is a misnomer because patients acquire the deformity after birth. The term ‘trigger’ is inaccurate as most thumbs show a fixed-flexion contracture without triggering. We suggest that rather than ‘congenital trigger thumb’ a more appropriate description of this disorder is ‘acquired thumb flexion contracture in children’. If the contracture persists after one year of age, treatment by dividing the A-1 pulley is simple and effective

PURPOSE: The success of treatment for mucous cysts of the distal interphalangeal joints of the fingers has been widely variable. The aim of this study was to evaluate the results of surgical treatment of these cysts at our hand unit. METHODS: Eighty one cysts were treated, with a mean follow up of 18 months(6–24 months). Thirty-one patients (25%) had nail ridging or deformity at presentation. All patients had surgical excision and joint debridement through a dorsal approach. RESULTS: All patients who underwent surgery had evidence of osteoarthritis with osteophytosis at the time of surgery. No recurrences were noted. Nail ridging resolved after surgery in 55 (67%) digits; the remaining digits had partial improvement or persistent ridging. Five (6%) infections occurred and were treated successfully with antibiotics(4 cases) or debridement,(1 case).6 patients had increased stiffness of the joint and occasional pain or swelling noted in 8 (9.8%) cases. CONCLUSIONS: Contrary to the published literature, the recurrence rate following excision and joint debridement is very low. Although some patients have decreased range of motion, pain is usually relieved. Some residual sypmtoms might be related to the underlying arthritic process rather than a complication of treatment

Introduction and Objectives: Hallux valgus is one of the most frequent causes of consultation seen by the Trauma and Orthopedic Specialist in feet. Many techniques have been described for its treatment, amongst them Keller-Brandes resection arthroplasty, although there are still doubts about its efficacy in young patients. Materials and Methods: We reviewed a total of 29 patients, 40 feet, in patients under 63 years of age operated using the Keller-Brandes technique. Anteroposterior and lateral X-rays were taken of both feet when weight-bearing and the intermetatarsal, metatarsalphalangeal, interphalangeal angles and proximal articular set angle (PASA) were measured and compared with their preoperative values. The metatarsophalangeal and interphalangeal joint balances were assessed clinically, pain was assessed using a visual analog scale and using the specific OAFAS questionnaire for the metatarsophalangeal joint. Results: Mean age at surgery was 56 years of age. The follow-up was 6.88 years. Pre and postoperative X-ray measurements were analyzed statistically and no significant differences were found. The mean value obtained using the AOFAS questionnaire was 72.18, whereas pain was quantified at a mean value of 2.7 using the visual analog scale. Discussion and Conclusions: We have obtained good results using the Keller-Brandes technique as far as residual pain, both of the hallux and of the other lesser toes, and moderate results in relation to mobility of the articulation of the first toe. In spite of these results, we must consider the repercussion and biomechanical results of this technique

Aims

This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation.

Introduction. The operative management for Distal Tibialis Anterior Tendinopathy (DTAT) without rupture has not previously been described. We present 15 cases. Method. of 39 patients diagnosed clinically and radiographically with DTAT, we reviewed the 13 patients who underwent surgery for failure of non-operative management. Assessment included pre and post-operative AOFAS midfoot scoring, clinical examination and post-operative VAS pain scoring. Results. Twelve women (13 feet) and one man (two feet) underwent surgery. Mean age at surgery was 59 years (42 to 76 years). The mean duration of symptoms prior to surgery was one year (5 to 25 months). The mean pre-operative AOFAS score was 50 (23 to 75). Pre-operative MRI showed tendinosis in six tendons and tendinosis with longitudinal split tears in nine tendons. Five of the 14 cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Nine tendons were augmented with an Extensor Hallucis Longus (EHL) transfer into the medial cuneiform. The mean improvement in AOFAS score was 35 (4 to 57), with mean post-operative pain VAS of 1 (0 to 6.7) at a mean follow-up of 24 months (three to 65). Two patients underwent concomitant procedures on the same foot. Four of the nine treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In seven cases the patient was completely satisfied. Five were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain-free, was troubled by her toe catching when walking barefoot. No patients regret having had the surgery. Conclusion. Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provides a high level of patient satisfaction if non-operative management fails

Introduction: We present 34 patients diagnosed with hallux rigidus treated by percutaneous surgery. We analyzed the surgical techniques used and the functional results achieved. Materials and methods: We retrospectively collected 34 patients (24 women). Patients were stratified by means of parametric x-rays (Hanft classification from 1 to 4). Treatment consisted in a double osteotomy, also known as Keller’s technique, using percutaneous procedures. The postoperative protocol consisted of walking, use of orthopedic footware, and early mobilization. Results: Mean age was 68.78 years and mean follow-up was 31.45 months. Mean time from first clinical visit to surgery was 4.38 years; most patients had received conservative treatment. The mean degree of hallux rigidus according to the standard classification was 2.5. The mean value of the metacarpophalangeal joint arc and interphalangeal joint arc was 40.35°and 52.14° respectively. Return to work activities was achieved in 90.9%. The mean value according on the VAS (visual analogue scale) (0–10) was 3.14. The mean value on the AOFAS scale was 62.57 (0–100). Conclusions: Percutaneous surgery is a satisfactory method for the treatment of hallux rigidus, enabling the patient to quickly return to work. This procedure avoids the use of osteosynthesis materials and minimizes the complications seen in open surgery

Introduction: Dorsally angulated metaphyseal fractures of the proximal phalanges usually occur in the middle aged or elderly and are common. Reduction is difficult to maintain with non-operative treatment, due the action of the intrinsic muscles. Most techniques advocated in the literature suggest a transmetacarpal K-wire fixation. We present the results of a simple method of stabilisation using intramedullary K-wires without violating the articular surface. Methods: Over a three-year period, sixty patients with these fractures were treated in this way. A single wire is inserted through the rim of the proximal phalangeal base with MCPJ fully flexed, avoiding transfixion of the collateral ligament. The wire is passed up the medullary canal, across the fracture and up either to subchondral bone or to engage the opposite cortex. The metacar-pophalangeal joints were immobilised with a thermoplastic splint in full flexion and interphalangeal joints mobilised under supervision by the hand therapists. The wire was removed at three weeks. Results: Most patients achieved a full range of movement at 6 weeks follow-up. There were no pin site infections. Conclusion: Dorsally angulated metaphyseal fractures of the proximal phalanges fractures are difficult to treat by non-operative means. If the fracture heals in an angulated position the altered line of pull of the intrinsics will result in loss of flexion at the MCPJ and of power grip. This method is straightforward and gives satisfactory results. It avoids damage to the articular surface of the MCPJ, allows mobilisation of the entire digit and reliably controls the fracture

Introduction: The metacarpophalangeal joint of the thumb is prone to frequent injury in the capsule and collateral ligaments, especially the ulnar collateral ligament. Delayed diagnosis, inappropriate treatment or progressive laxity of the ligament complex can lead to chronic instability of the MCP joint of the thumb. Various surgical repair procedures have been described. We present the surgical procedure consisting of a bone-retinaculum-bone autograft taken from the second tunnel of the flexor retinaculum of the carpus. Purpose: Our purpose is to present the experience of seven cases in which chronic instability of the thumb was treated using a bone-retinaculum-bone autograft. Materials and methods:. Type of study: Descriptive. Period: 2003–2004. Number of cases: 7 (4 women and 3 men) aged 23 to 65. Injury-to-surgery time more than one year. Results:. - We achieved stability of the MCP joint in all cases. - The metacarpophalangeal and interphalangeal joint balance was not diminished. - The grasp force was sustained at over 80% of that of the healthy side. - Two elderly women were not employed; the other five returned to their previous jobs. Conclusions: Given the results obtained, we think this is an excellent method for deferred reconstruction of thumb instability and, although it involves considerable technical difficulty, we feel it is an option to bear in mind for this type of injury

We present a system for treatment by controlled motion after repair of flexor tendons in the hand. This Washington regimen incorporates both controlled active extension against passive flexion by rubber band and the use of controlled passive extension and flexion. We utilise the Brooke Army Hospital modification of the rubber band passive flexion splint; this provides for maximal excursion of the tendon with full passive flexion of the finger. The 66 patients (78 fingers) who form the basis of this study all sustained complete laceration of the flexor profundus and superficialis tendons in "no man's land". Results were evaluated by the Strickland formula of total active motion (TAM) of the proximal and distal interphalangeal joints. Sixty-two fingers (80%) were rated "excellent", 14 fingers (18%) were "good", two fingers (2%) were "fair", none was rated "poor". Our regimen of controlled motion rehabilitation has also been applied with equal success to cases of flexor tendon grafting

Background: The results of operative management for distal tibialis anterior tendinopathy (DTAT) without rupture have not previously been described in the orthopaedic literature. We present the results of 15 operative procedures. Method: Of 40 patients diagnosed clinically and radiographically with DTAT, we reviewed the 13 patients who underwent surgery for failure of non-operative management. Assessment included pre and postoperative AOFAS midfoot scores, clinical examination and postoperative VAS pain scoring. Results: Twelve women (13 feet) and one man (2 feet) underwent surgery. The mean age at surgery was 59 years. The mean duration of symptoms prior to surgery was 1 year. The mean pre-operative AOFAS score was 53. Preoperative MRI showed tendinosis with longitudinal split tears in 10 tendons and tendinosis alone in two tendons. Seven of the 15 cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Nine tendons were augmented with an Extensor Hallucis Longus (EHL) transfer into the medial cuneiform. All patients improved postoperatively, with a mean improvement in AOFAS score of 32 and the mean postoperative pain VAS of 1.0 out of 10, at a mean follow-up of 24 months. Three patients underwent concomitant procedures on the same foot. Four of the nine treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In seven cases the patient was completely satisfied. Five were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain free, was troubled by her toe-catching when walking barefoot. No patient regretted having had the surgery. Conclusion: Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provides a high level of patient satisfaction if non-operative management fails

Aim: The purpose of this prospective study was an evaluation of results in primary treatment of flexor tendon laceration in zone II. Special emphasis has been given to the postoperative rehabilitation program. Material and Methods: Nineteen patients, (23 fingers), with laceration of the flexor tendons in zone II were treated operatively. Twelve males and seven females were included in the study. Their mean age was 28 (range, 16 to 50) years. In twelve cases a concomitant laceration of the digital nerve was present, hi all cases primary repair of all injured tendons and nerves was performed and a dorsal splint was applied. On third to fifth postoperative day an exercise program commenced involving passive flexion-active extension of the injured fingers. Eighteen (22 fingers) of 19 patients completed the follow-up. Results: The results were estimated according to Strickland’s original classification system. In fifteen cases the result was excellent, in five good, and in two fair. Conclusions: After primary repair of injured flexor tendons, close follow-up, early protected motion and unrestricted motion of the interphalangeal joints affers the best chance of restoring optimal function to the hand

Giant cell tumour of tendon sheath is usually benign in nature but their tendency to recur is well known, this cause problems for surgeons and there is always a puzzle in determining the appropriate therapy. This study was done to highlight characteristics, differential diagnosis and current options of treatment for giant cell tumour of tendon sheath. We report two cases treated at our hospital. Both are females, one of 24 years while other was 65 years at the time of diagnosis. First patient had incidental associated benign teratoma of ovary as well. One tumour was of thumb in non dominant hand while in older patient it was at distal interphalangeal joint of ring finger in dominant hand. Both presented with history of slowly growing painful swelling, they were treated with local excision but in both patients there was an aggressive local recurrence. Revision surgery was performed with wider local excision. There was no recurrence this time. Giant cell tumour of tendon sheath is mostly benign condition but need to be differentiated from serious conditions like clear cell sarcoma. Therapy of choice is local excision. Wider excision after surgery should be reconsidered where microscopic examination reveals a lesion with characteristics suggestive of potential aggressive behaviour. A literature review and discussion of salient diagnostic and treatment issues is included

1. The method of treatment of a mallet finger deformity by immobilisation in a plaster in the position of hyperextension of the distal interphalangeal joint and flexion of the proximal interphalangeal joint is, on the whole, unsatisfactory because the splint is difficult to apply, it may need to be changed frequently, and it is sometimes complicated by pressure sores. 2. In many cases the deformity is still present after six weeks of adequate immobilisation, but gradual improvement from the contraction of fibrous tissue occurs for up to six months. Therefore an assessment of the results of any method of treatment should be made only after an interval of at least six months. 3. The subjective end results at the end of six months are satisfactory whether or not there has been efficient immobilisation in hyperextension. Few patients have any disability and only rarely is this sufficient to cause interference with normal activities. A high proportion of patients show slight persistent deformity and limitation of movement, and this is seemingly uninfluenced appreciably by the type or duration of treatment. 4. The only treatment necessary for most cases of mallet finger is the application of elastic adhesive strapping or a straight spatula splint in order to relieve the initial discomfort from the injury

Purpose of the study: Amputation of the thumb is a serious hand injury producing a major functional and aesthetic handicap. In 1980, Foucher proposed a twisted two toes transfer associating elements harvested from the first and second toes on the same pedicle for the reconstruction of an ‘articulated’ thumb with preserved potential for growth. Material and method: Since 2002, two children aged 10 and 14 years underwent this procedure. The thumb amputation was trans MP for one and at the base of P1 for the second. The transfer associated a sheath of skin from the hallux to wrap around the skeleton of the second toe which was harvested as need to the IP or the MP. The aesthetic, functional (400 point scale), and radiological outcomes were assessed. Results: Follow-up was 5 years and 2.5 years. The aesthetic result was comparable to wrap-around transfers. Regarding the functional outcome, the overall hand function was scored 86% and 72% of normal, mobility 77% and 72%, and force 75% and 79%. One patient had persistent deficient active flexion of the interphalangeal joint because of flexor adherences. Despite the reconstruction of the “two-joint” thumb, fine movements were difficult. Sensitivity was noted normal: Weber 5 and 8 mm. Healing of the donor site was rapid and the sequelae discrete. The first ray was preserved. Gait was not hindered. In one patient, radiographs showed skeleton growth. Discussion: Transfer of the second toe provides a potential for growth, but the aspect is less than satisfactory and the functional results often disappointing. There are no indications except for very proximal amputations. Total transfer of the great toe would also provide potential for growth, but the voluminous aspect and the very important sequelae for the foot rule out this option. Conclusion: For growing children, the twisted two toe transfer for amputations of the metacarpophalangeal region is the only available technique allowing nearly normal reconstruction of the thumb in terms of mobility, force, sensitivity, appearance, and growth. The foot reconstruction is simple, aesthetic and functional. The complexity of the procedure may nevertheless limit is use

We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically. The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001). The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux

Introduction and Aims: Severe Dupuytren’s contracture of the proximal interphalangeal (PIP) joint is a difficult condition to treat; a two-stage technique has been advocated by some surgeons for such cases. The present study set out to determine the early results of this technique. Method: Thirteen patients (11 with primary and two with recurrent disease) with a severe Dupuytren’s contracture of the proximal interphalangeal (PIP) joint were treated by geometric correction (in line distraction followed by angular correction) using the OrthofixTM mini external fixator followed by its removal and partial fasciectomy (without collateral ligament or volar plate release). The mean duration of distraction was 14 days. Results: In the PIP joint the mean true fixed flexion deformity pre-operatively was 75 degrees (range 45–90). At a mean follow-up of 21 months, the mean residual flexion deformity was 35 degrees (range 10–90). The mean arc of motion increased from 26 (range 10–55) to 51 degrees (range 0–90). At follow-up, the mean arc of motion was 33 degrees (range 0–70) and 73 degrees (range 45–110) at the distal interphalangeal and meta-carpophalangeal joints respectively. There were no cases of reflex sympathetic dystrophy or neurovascular damage. One patient had a fracture of the proximal phalanx and a second patient had an early recurrence, which led to a poor clinical outcome. The rest had an excellent clinical outcome according to the Michigan Hand Questionnaire. Conclusion: Although the technique is challenging, the early results are promising and we recommend it for the management of this difficult problem

1. Léri's pleonosteosis is characterised by broadening and deformity of the thumbs and great toes, flexion contracture of the interphalangeal joints, limited movement of other joints, and often a Mongoloid facies. Four such cases are described. 2. A review of the twenty reports in the literature, and the cases now described, shows that the deformities are due to capsular contracture rather than deformity of bone. 3. In one patient there was striking evidence of fibro-cartilaginous thickening of the anterior carpal ligaments. It is suggested that the primary pathological change in pleonosteosis may be in the joint capsules rather than in the epiphyses. 4. The patient with thickening of the anterior carpal ligaments had bilateral median palsy from carpal tunnel compression. 5. The causes of carpal tunnel compression of the median nerve are reviewed. Acute compression may be due not only to dislocation of the semilunar bone but to haemorrhage in the palm. Late compression by bone may occur twenty to fifty years after injury. Late compression without bone abnormality has been attributed to occupational stress, but it is suggested that pathological thickening of the anterior carpal ligament may be the cause. 6. The patient with pleonosteosis and bilateral median palsy had also bilateral Morton's metatarsalgia with large digital neuromata. 7. Plantar digital neuritis has already been shown to be an ischaemic nerve lesion preceded by degenerative changes in the digital artery. The significance of the fibrous tunnel through which the artery passes to reach the digital cleft is considered

The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review.

Extensor tendon attachment to the dorsum of the proximal phalanx may fully extend the finger metacarpal phalangeal joint (MPJ). 15 fresh-frozen cadaveric hands were axially loaded in the line of pull to the extensor digitorum comunis of the index, middle, ring and small finger at the level just proximal to the MPJ. We measured force of extension at the MP joint in 3 groups: 1) native specimen, 2) extensor tendon release at the proximal interphalangeal (PIP) joint with release of lumbricals/lateral bands, 3) extensor tendon release at the PIP joint and dorsal proximal phalanx and lumbrical/lateral band release. Degree change of extension was calculated using arctan function with height change of the distal aspect of the proximal phalanx, and the length of the proximal phalanx. We used Student T-test to determine significant decrease in the extension of the phalanges. Extension of all fingers decreased slightly when the extensor tendon were severed at the PIP joint with release of the lateral bands/lumbricals (8deg+/−2deg). After this release, the finger no longer extended. Slight loss of extension was not statistically significant (p >.05) between group 1 and group 2. Groups 1 and 2 were significantly different compared to group 3. In summary, distal extensor tendon transection and release of lateral bands/lumbricals resulted in little change in force and degree of finger extension. The distal insertion of the extensor, released when exposing the PIP joint dorsally, may not need to be repaired to the base of the middle phalanx

OBJECTIVE: The purpose of this study were to present a new surgical classification, based on types of injuries, and to evaluate significance of our post-operative protocol for fingertip replantation, especially crush-avulsion cases. METHODS:Twenty fingertip amputations in 20 consecutive patients were replanted at our institute for recent 5 years. There were 17 male patients and 3 female patients, ranging in age from 19 to 62 years(mean,45.3years). All cases were classified as crush and avulsion according to Yamano. There were 13 amputations in Zone I and 7 in Zone II according to Tamai’s classification for the level of amputation. Also, we classified our cases based on the type of injury. [New Classification] Type IA: Distal transverse palm arterial arch (DTPA) is remained in the proximal part Type IB: DTPA is remained in the amputated part Type II : Loss of DTPA There were 4 cases in Type IA, 4 in Type IB, and 12 in Type II. Postoperatively, 12000–24000U of urokinase and 500 ml of low molecular-weight dextran were given intravenously for 7 consecutive days. In very severe crush/avulsion cases, 10000–15000 U of heparin were given intravenously for 5 days additionally. RESULTS: The overall survival rate of the 20 replantations was 90.0% (zone I:83.3%, Zone II:100%). The survival rate was 100% in type IA, 100% in type IB, and 83.3% in type II. For arterial repair, vein grafts were necessary in 1 of 4 type IA(25%), 1 of 4 type IB(25%), and 11 of 12 type II(91.7%). In 3 of 4 type IA, end to end anastomosis were possible by the technique of transpositioning DTPA. In 3 of 4 type IB, proper digital artery was anastomosed to central artery of the pulp. Regarding functional outcomes with a follow-up period greater than 6mons, excellent cases were 87.0% (according to Tamai’s functional classification). The mean range of motion of the distal interphalangeal joint was 40 degrees. All patients achieved protective sensation of replanted fingertips. Other complications were cold intolerance(22.2%), nail deformity(66.6%), and pulp atrophy (33.3%). Blood transfusions were not necessary in all cases. CONCLUSIONS: Our new classification of fingertip amputation based on DTPA was available for strategy of arterial repair, because if DTPA is lost, most cases (91.7%) need vein grafts. Also, in crush/avulsion fingertip amputation, our clinical protocol was very useful and raised success rate of fingertip replantation (90.0%) for crush-avulsion cases

Used routinely in maxillofacial reconstructive surgery, the chondrocostal graft is also applied to hand surgery in traumatic or pathologic indications. The purpose of this overview was to analyze at long-term follow-up the radiological and histological evolution of this autograft, in hand and wrist surgery. We extrapolated this autograft technique to the elbow by using perichondrium. Since 1992, 148 patients have undergone chondrocostal autograft: 116 osteoarthritis of the thumb carpometacarpal joint, 18 radioscaphoid arthritis, 6 articular malunions of the distal radius, 4 kienbock's disease, and 4 traumatic loss of cartilage of the proximal interphalangeal (PIP) joint. Perichondrium autografts were used in 3 patients with elbow osteoarthritis. Magnetic Resonance Imaging (MRI) was performed in 19 patients with a mean follow-up of 68 months (4–159). Histological studies were performed on: i) perioperative chondrocostal grafts (n=3), ii) chondrocostal grafts explanted between 2 and 48 months after surgery (n=10), and iii) perioperative perichondrium grafts (n=2). Whatever the indication, the reconstruction by a chondrocostal/ostochondrocostal or perichondrium graft yielded satisfactory clinical results at long-term follow-up. The main question was the viability of the graft. -. For rib cartilage grafting: The radiological study indicated the non-wear of the graft and a certain degree of ossification. The MRI and histology confirmed a very small degree of osseous metaplasia and graft viability. The biopsies showed neo-vascularization of the cartilage that had undergone morphological, constitutional and architectural changes. Comparison of these structural modifications with perioperative chondrocostal graft histology is in progress. -. For perichondrium grafting: The first cases gave satisfactory clinical results but must be confirmed on a larger number of patients. Histological results highlighted a tissue composed of one fibrous layer and one cartilage-like layer, a common composition of supporting tissue. Despite the strong mechanical strain in the hand and wrist, chondrocostal graft is a biological arthroplasty that is trustworthy and secure over the long term, although it can cause infrequent complications inherent to this type of surgery. Despite the inevitable histological modification, the cartilage remains alive and is of satisfactory quality at long term follow-up and fulfills the requirements for interposition and reconstruction of an articular surface. The perichondrium graft constitutes a new arsenal to cure cartilage resurfacing. The importance of perichondrium for the survival of the grafted cartilage, as previously reported, as well as its role in resurfacing, is being investigated

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees.

Cite this article: Bone Joint J 2021;103-B(3):430–439.

Dupuytren's disease is often disabling and traditionally has been managed with various surgical methods, with recurrence rates up to 50 %. Recently clostridial collagenase injection has been licensed for use in the NHS. We prospectively analysed the results of clostridial collagenase injection in 62 patients with varying degrees of Metacarpo phalangeal (MCP) and Proximal interphalangeal (PIP) joint contractures. There were 48 males and 14 females with an average age of 66 years. The average MCPJ and PIPJ deformities were 33 and 17 degrees respectively. Following the infiltration and subsequent manipulation under local anaesthetic and night splinting for 3 months, patients were followed up at 4 weeks and 6 months. Deformities persisted in 5 patients and later required surgical correction. MCPJ deformities were more amenable for correction than PIPJ and in those with recurrence. The average residual deformity was 7 degrees. Common complications include bruising, swelling, pain not responding to routine analgesia, lymphangitis and skin break in some but none required any additional interventions. 14 patients had completed 6 month follow up and there was no recurrence. Subjective assessment through questionnaires revealed high patient satisfaction rate with early return to work within 1 week in most patients. Patients with previous operations preferred injections over operative correction. Collagenase injections are effective in deformity correction with higher satisfaction rate and low morbidity. Early results are encouraging but long term follow up is required to assess recurrence rates

Treatment for the comminuted intra-articular fractures of base of phalanxes remains a challenging problem in hand surgery. The outcomes are commonly associated with pain, stiffness, chronic instability and degenerative arthritis of proximal interphalangeal (PIP) joints. We present our short term results in 12 consecutive patients suffering from these complex fractures treated by closed reduction and application of a dynamic external fixator (Giddins’s frame). The average range of movement achieved was 11–86 degrees and there were no serious complications. We used the construct with slight modification and in our experience this may be helpful to reduce the pin site infection. It is relatively simple, uses widely available equipment (K-wire), and compact thus allows more than one finger to be treated. Early return to work, good pain relief and high level of patient’s satisfaction was achieved. Our short term results were comparable to best previously published results. Based on our experience we recommend this easy technique to treat these complex fractures of IP joints

Aims

The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.

The purpose of this study was to retrospectively review the outcomes of percutaneous flexor tenotomies of diabetic claw toes with ulcers or pending ulcers. A retrospective chart review between January 1999 and June 2005 was performed to identify those patients that had undergone a percutaneous flexor tenotomy for diabetic claw toe deformities. Thirty-four toes in fourteen patients were identified. Twenty-four toes had ulcerations at the terminal aspect and three of these had radiographic evidence of osteomyelitis of the terminal phalange. All patients had palpable pulses and good capillary refill. A percutaneous flexor tenotomy was performed in an outpatient clinic on all toes, patients with a rigid flexor contracture at the proximal interphalangeal (PIP) joint underwent an osteoclaysis to correct a portion of the deformity. The average follow-up was thrirteen months, all patients with ulcers healed and there were no significant complications. Those without osteomyelitis healed within an average of three weeks and those with osteomyelitis healed within an average of eight weeks. A Percutaneous flexor tenotomy with osteoclasis of the PIP joint performed in an outpatient clinic is a safe and effective method to off-load the tip of the toe such that ulcer healing can occur. The presence of osteomyelitis is not a contraindication for this technique; however, an increased healing time can be expected

Pain, stiffness, instability and degenerative arthritis are common sequelae of complex fracture-dislocations of the proximal interphalangeal (PIP) joint. Operations were carried out to obtain stability, followed by application of a dynamic external fixator in 20 patients with a mean age of 29 years. This provided stability and distraction, and allowed controlled passive movement. Most (70%) of the patients had a chronic lesion and the mean time from injury to surgery was 215 days (3 to 1953). The final mean range of movement was 12 to 86°. Complications included redislocation and septic arthritis, which affected the outcome. Four pin-track infections and two breakages of the hinge did not influence the result. The PIP Compass hinge is a useful adjunct to surgical reconstruction of the injured PIP joint

Finger arthroplasty lacks the success seen with hip and knee joint replacements. The Van Straten Leuwen Poeschmann Metal (LPM) prosthesis was intended for the proximal interphalangeal (PIP) joints. However revision rates of 30% after 19 months were reported alongside massive osteolysis. Three failed LPM titanium niobium (TiNb) coated cobalt chrome (CoCr) components were obtained- two distal and one proximal. All three components were analysed using an environmental scanning electron microscope (ESEM). This gave the chemical composition of the surface to determine if the TiNb surface coating was still intact. The distal components were analysed using a ZYGO non-contact profilometer (1nm resolution) with the proximal component unable to be analysed due to its shape. ZYGO analysis gave the roughness average (Ra) of the surface and determined the presence of scratches, pitting and other damage. Images obtained from both the ZYGO and the ESEM indicated that the surfaces of all components were heavily worn. On the articulating surfaces of both distal components unidirectional scratching was dominant, while the non-articulating surface showed multidirectional scratching. The presence of unidirectional scratching suggested two-body wear, whilst the multidirectional scratching on the non-articulating surface of the distal component suggested that trapped debris may have caused three-body wear. The ESEM chemical analysis showed that in some regions on the distal component the TiNb coating had been removed completely and in other areas it had been scratched or penetrated. On the proximal component the TiNb coating had been almost completely removed from the articulating surfaces and was only present in small amounts on the non-articulating surfaces. There was little evidence of bone attachment to the titanium coating which was intended to help provide fixation. ESEM images showed the coating had been removed in some sections where there was minimal scratching, suggesting this scratching did not impact significantly in the coating removal. Therefore here the main cause of coating removal may have been corrosion, although scratching may have also have played a part. The osteolysis reported clinically may have been linked to the wear debris from the failed coating

Aims

In the UK, fasciectomy for Dupuytren’s contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients.

Abstract

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

The distal interphalangeal (DIP) joints of the fingers are prone to functional impotence in some degenerative diseases. In this case, different surgical techniques can be used, from DIP arthrodesis to joint denervation, much more confidential, which aims to preserve an already reduced mobility. The four fingers (except the thumb) of 6 fresh hands from different cadavers were dissected under optic magnification. Two DIP joints were harvested from fresh dissected hands, in order to follow with the microscope the course of the nerve branchlets up to their articular entry. These two specimens were decalcified, and then embedded in paraffin. The blocks were serially cut in 5μm slices (1 slice each 250μm), which were observed at 25 and x100 magnification, after Masson’s trichrom staining. A constant proximal articular branch, arising from the proper digital palmar nerve, was exclusively devoted to joint supply. This branch was located medially and arose in average at 7 mm from its entry point in the joint, where it was accompanied by small arterial branches. Before its entry into the inferomedial part of the DIP joint, it ran under the flexor digitorum profun-dus tendon. It then could divide into 2 or 3 branchlets. The proper digital palmar nerve abandoned, along its course, some nerve fibers to the tendinous synovium and neighboring structures. Then, ending its course, it gave off a distal articular branch, hidden among numerous cutaneous branches for the fingertip. The DIP joint nerve supply seems so under the exclusive dependence of the proper digital palmar nerve without any input from the dorsal side. On the histological slices, the nerves were mainly observed in peri- and intracapsular situation. Could cutting these two articular nerves be sufficient to relieve pain from the DIP? This is what we are investigating through a clinical series; the first results are presented here

Objective: To challenge the validity of using biomarker concentrations in synovial fluid for the assessment of joint pathology. Hypothesis: Synovial fluid biomarker concentrations are influenced by both cartilage and synovial fluid volumes. Methods: Synovial fluid volumes were determined from the equine metacarpophalangeal (MCP), proximal inter-phalangeal (PIP) and distal interphalangeal (DIP) joints, which have different disease prevalences. Chondrocyte density was calculated from a defined site in each joint. Cartilage volume was measured by novel application of Peripheral Quantitative Computed Tomography (pQCT). Cartilage oligomeric matrix protein (COMP), glycos-aminoglycans (GAG) and total protein (TP) concentrations were measured and then adjusted for cartilage and synovial fluid volume and compared between joints. Results: Mean synovial fluid volume was significantly greater in the MCP than the distal joints (p< 0.0001) (3.2 ±0.5ml, 0.5 ±0.1ml and 0.6 ±0.1ml respectively). In contrast, the DIP had the greatest cartilage volume compared to the proximal joints (5360 ±667mm3 2640mm3, 1940 ±331mm3 respectively). There was no significant difference in the cartilage cellularity between all joints. The DIP had higher TP, COMP and GAG concentrations, however, when values were expressed per unit cartilage volume the opposite was found, with the MCP then exhibiting significantly higher concentrations. Conclusions: These data show the joint with the highest prevalence to osteoarthritis has the lowest biomarker synovial fluid concentrations but the highest biomarker levels per unit cartilage, suggesting a higher release. These results indicate that meaningful interpretation of biomarkers in synovial fluid require consideration of both fluid and cartilage volume

Apoptosis of articular chondrocytes may play an important role in the pathogenesis of osteoarthritis (OA). The aim of this study was to investigate the incidence of chondrocyte apoptosis in equine articular cartilage (AC) specimens and examine the relationship between the process of cell death and the degree of cartilage degradation. The study comprised 2 populations of equine cartilage taken from the left forelimb. Population 1 (n=10) consisted of full depth cartilage from weight-bearing regions of equine metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. Population 2 (n=9) comprised cartilage from 6 different regions of the MCP joint: dorsomedial, dorsolateral, centromedial, centrolateral, palmarome-dial and palmarolateral areas. Cartilage from each horse for each of the joints and joint regions was not always available. Seven micrometre cryostat sections were obtained. Haematoxylin and Eosin with Safranin-O stained sections were used to score structural differences between samples for features of cartilage pathology using a ‘modified’ Mankin scoring system. Two methods were used to quantify apoptotic chondrocytes: a direct method in which chondrocytes were assessed for morphological features of apoptosis using a light microscope and an immunohistochemical staining technique to detect the expression of active caspase-3 using a commercially available monoclonal antibody. Apoptosis assessed by the direct method did not show any association with increasing severity of OA (r=0.11, p=0.7205). Overall there was a positive correlation between caspase-3 expression and cartilage damage (r= 0.44, p=0.0043). Caspase-3 expression was found to increase linearly with increasing severity of OA in the superficial, middle and deep zones of AC (r=0.36, p=0.0198; r=0.49, p=0.0011 and r=0.37, p=0.0237 respectively). Moreover, caspase-3 expression was higher in the superficial and middle zones than in the deep zone (p< 0.001). In the superficial, middle and deep zones the expression of caspase-3 was higher in the MCP joint than the PIP joint (p< 0.05, p< 0.01 and p< 0.05 respectively). The significant positive correlation between disease severity and chondrocyte apoptosis, suggests that this process plays an important role in the pathogenesis of OA. The differences in the extent of apoptosis observed in different joints could be explained by the biomechanical environment of the joints

Introduction: Mitchell’s operation is a double step-cut osteotomy through the neck of first metatarsal (MT) which displaces laterally and plantar flexes the metatarsal head and minimally shortens the first MT. In coexisted further forefoot abnormalities this osteotomy can be combined by additional corrective osteotomies of the rest metatarsals and straightening of toes. Material and Methods: A prospective study was carried out in our Department, on 42 patients (51feet) operated with this osteotomy alone or combined. The mean follow-up time was 10 years (range, 3–15 years). The average age of patients was 58 years. The average angle of HV deformity was 38 degrees (in nine feet this angle was more than 40 degrees). Mean inter-metatarsal (IM) angulation was 15 degrees. The procedure was always followed by Y or V capsuloplasty of first metatarsophallangeal (MTP) joint. Moderate arthritis of first MTP joint was not considered by us as a contraindication for this operation. The osteotomy was secured by two crossed K-wires. In 20 feet (15 patients) with coexisted forefoot abnormalities oblique osteotomies of the rest metatarsals, arthrodeses of proximal interphalangeal (PIP) joints and elongation of extensor tendons were carried out. Results: In examination, we checked the correction of the deformities; we assessed pain and comfortability in wearing shoes and the joints motion, hi early postoperative examination the mean correction in HV angle was 18 degrees and in IM angle was 5 degrees, but in last examination there was a loss of 5 degrees in the HV angle correction. One hallux was overcorrected. 90% of the results were satisfactory including all feet with osteoarmritis of first MTP joint. 10% of the results considered as poor including all feet with preoperative HV deformity of more than 40 degrees. Ten feet (eight patients) suffered from metatarsalgia established because of fall of MT arch. We feel that Mitchell’s osteotomy is not suitable for HV deformity exceeding the 40 degrees

Allogeneic bone is one of the most commonly used tissue grafts, with a variety of applications in orthopaedic surgery. The aim of this work is to analyze the initial results obtained using allografts in reconstructive surgery of the hand. In the period between January 2000 and August 2003, eight patients between 16 and 52 years of age (average age: 36 years) were treated using an allograft to replace the metacarpal bone and/or phalangeal bone of the hand. In three cases the initial cause was a recurring neoplasm (aneurysm, cyst, osteoma, osteoid, and TGC); in the other patients the aetiology was traumatic. The site of reconstruction was a metacarpal bone in three patients; in two of these it was associated with reconstruction of MPj (in one patient there was double bone loss at the third and fourth metacarpal bone); in one patient the lesion affected only the MPj. In the other five patients the reconstruction was performed at the phalanx, transferring the proximal interphalangeal (PIP) joint as well (except in one case). Different synthesis procedures were performed to obtain a good stability: miniplates, micro-screw, K-wires, and staples. A bone allograft (two cases) was used with platelet gel and a compound of stem cells to promote better recovery of the bone. The patients were followed for a period of between 6 and 40 months after surgery. The time needed to obtain a good healing was on average 6 months (in one case without the proximal recovery of the bone). The total range of movement in fingers that were reconstructed was between 0° and 270°, with an average of 121°. No patient reported any persisting pain. In reconstructive surgery of the hand allografts have only been used occasionally up to now. We believe that this preliminary study provides some useful findings. The waiting time for perfect recovery of a bone before the start of rehabilitation treatment can cause severe stiffness to joints: the osteosynthesis must be as stable as possible to allow for early mobilisation of the joint, especially in post-traumatic cases. Some questions about the future of joint capsules, articular cartilage, and extensor tendons of allograft still remain unanswered. In conclusion, we believe that the results obtained in this preliminary report are encouraging and point towards obtaining a reconstruction of bone loss that is as “biological” as possible

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.

Objectives

To determine the pattern of mutations of the WISP3 gene in clinically identified progressive pseudorheumatoid dysplasia (PPD) in an Indian population.