Locking of the MCP joint of the finger, except with stenosing tenosynovitis, is relatively rare. The middle finger is most frequently involved. We treated 7 patients who had locking of the MCP joint of the middle finger because of osteophyte of the metacarpal head. The locking of the MCP joint usually occurred in the older patient as a result of significant osteophyte around the metacarpal head. Unlocking of the MCP joint was done by closed manipulation under local anaesthesia. Locking of the MCP joint of the finger because of other causes than tenosynovitis has been reported infrequently. Locking of the MCP joint caused by osteophyte of the head of the metacarpal is characterised by painful loss of extension of the MCP joint without loss of flexion. We have treated 7 patients who had locking of the MCP joint occurring in the middle finger with an obvious osteophyte of the metacarpal head. Seven patients, 4 women and 3 men, were treated in our Department. None of the patients had a history of trauma to their hands, and in all of them it was the dominant hand which was affected and usually due to powerful full flexion movement of the fingers. The average age was 73.8 years (65 – 81). The duration of locking was from 3 hours to 14 days. All the patients were treated within 30–60 minutes after reporting to our Clinic. The presentation of the patients was extremely similar. In all cases active and passive extension was blocked and they had pain around the finger. Full flexion was possible. The MCP joint was tender around the palmar aspect with slight diffuse swelling around the dorsal aspect. Radiographs of the MCP showed degenerative changes in all the patients and oblique views demonstrated an osteophyte either on the ulnar or the radial side of the head. Local anaesthetic Lignocaine 1% 5ml was injected in the MCP and around the joint and after 5–10 minutes manipulation was performed, unlocking achieved and the patients straightaway extended and flexed the finger fully. No-one underwent surgical release. Follow-up from 3 to 8 months, average 6 months. No recurrence of the locking. Akio Minami reported 4 cases of MCP joint locking of the middle finger, treated surgically. Williams classified the locking of the MCP joint in 3 groups. Langenskiold reported 2 cases of intrinsic locking of the MCP due to catching of the collateral ligament on the lateral bony projection of the metacarpal head. It is very difficult to explain why the middle finger is most likely affected. Kessler noted that the MCP joint seldom participates in a generalised degenerative OA

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

Aims. We performed a systematic review of the current literature regarding the outcomes of unconstrained metacarpophalangeal joint (MCPJ) arthroplasty. Materials and Methods. We initially identified 1305 studies, and 406 were found to be duplicates. After exclusion criteria were applied, seven studies were included. Outcomes extracted included pre- and post-operative pain visual analogue scores, range of movement (ROM), strength of pinch and grip, satisfaction and patient reported outcome measures (PROMs). Clinical and radiological complications were recorded. The results are presented in three groups based on the design of the arthroplasty and the aetiology (pyrocarbon-osteoarthritis (pyro-OA), pyrocarbon-inflammatory arthritis (pyro-IA), metal-on-polyethylene (MoP)). Results. Results show that pyrocarbon implants provide an 85% reduction in pain, 144% increase of pinch grip and 13° improvements in ROM for both OA and IA combined. Patients receiving MoP arthroplasties had a reduction in pinch strength. Satisfaction rates were 91% and 92% for pyrocarbon-OA and pyrocarbon-IA groups, respectively. There were nine failures in 87 joints (10.3%) over a mean follow-up of 5.5 years (1.0 to 14.3) for pyro-OA. There were 18 failures in 149 joints (12.1%) over a mean period of 6.6 years (1.0 to 16.0) for pyro-IA. Meta-analysis was not possible due to the heterogeneity of the studies and the limited presentation of data. Conclusion. We would recommend prospective data collection for small joint arthroplasties of the hand consisting of PROMs that would allow clinicians to come to stronger conclusions about the impact on function of replacing the MCPJs. A national joint registry may be the best way to achieve this. Cite this article: Bone Joint J 2017;99-B:100–6

Intra-operative fluoroscopy in thumb metacarpophalangeal joint arthrodesis has been recommended as a means of achieving optimal alignment more consistently. This is not our current practice. A patient attending dissatisfied with an arthrodesis in excessive flexion performed outwith our unit highlighted the potential for problems, and we therefore elected to review our own outcomes. An evaluation of the alignment achieved in thumb metacarpophalangeal joint arthrodeses, to determine if current outcomes satisfactory or if fluoroscopic assistance should be considered. Radiological review of alignment of thumb metacarpophalangeal joint arthodeses carried out by two Consultant Surgeons with specialist interests in upper limb surgery in a District General hospital. Cases were predominantly identified retrospectively from sequential review of operating lists. The radiological images were, or had been taken, as part of routine follow-up and were not standardised. The alignment was also assessed independently by a junior doctor with no involvement in the patient's surgical treatment and no knowledge of the intended alignment. Recommended positions for arthrodesis have covered a range from 0 to 30 degrees, so for the purposes of analysis that range was considered acceptable. 14 cases had an average fusion position of 18 degrees flexion (range 6 to 30 degrees). 6 underwent concurrent ipsilaterel trapeziectomy. The series achieved satisfactory alignment radiologically without the routine use of intra-operative fluoroscopy

There are few reports describing dislocation of the metacarpophalangeal joint of the thumb in children. This study describes the clinical features and outcome of 37 such dislocations and correlates the radiological pattern with the type of dislocation. The mean age at injury was 7.3 years (3 to 13). A total of 33 children underwent closed reduction (11 under general anaesthesia). Four needed open reduction in two of which there was soft-tissue interposition. All cases obtained a good result. There was no infection, recurrent dislocation or significant stiffness. So-called ‘simple complete’ dislocations that present with the classic radiological finding of the joint at 90° dorsal angulation may be ‘complex complete’ injuries and require open reduction

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

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

We reviewed the records and radiographs of 381 patients with rheumatoid arthritis who had undergone silastic metacarpophalangeal joint replacement during the past 17 years. The number of implants was 1336 in the course of 404 operations. Implant failure was defined as either revision or fracture of the implant as seen on radiography. At 17 years, the survivorship was 63%, although on radiographs two-thirds of the implants were seen to be broken. Factors which improved survival included soft-tissue balancing, crossed intrinsic transfer and realignment of the wrist. Surgery to the thumb and proximal interphalangeal joint had a deleterious effect and the use of grommets did not protect the implant from fracture

Since November 2003 there have been 62 Metacarpophalangeal Joint (MCPJ) replacements carried out on 16 patients at Macclesfield District general hospital. 11 of the patients were female and 5 were male. The mean patient age at procedure was 64.9 years, with an age range of 28 to 80. Of the 62 MCPJ replacements carried out, 58 (93.5%) were as a result of rheumatoid arthritis, with only 4 (6.5%) as a result of osteo-arthritis. The primary objective of this study is to assess their outcomes to date. Data was collected retrospectively by means of case note review. Outcomes measured were patient rating of pain and function at post operative review and post operative complications. All operations were carried out by a single surgeon, using his standard operative technique, and all replacements used the Neuflex Finger Joint Implant System. All 16 patients attended for post operative review. At the time of discharge 13 patients rated their outcome as excellent to good, 1 patient was deceased and 2 patients are currently under follow up with no reported complications. Mean time to discharge was 19 months (2–68). Of the total 62 joints replaced, 10 revisions were carried out. Of these, 3 were as a result of dislocation, 6 were for subluxation and 1 as a result of failure of the prosthesis. There were 3 other post operative complications; 1 was for superficial wound infection, 1 resulting from a prominent prosthesis and 1 hypertrophic scar. Results showed that 81.3% of patients rated their range of movement as good to excellent and 87.5% reported an improvement in pain. Overall, 81% of patients rated their outcome at discharge as good to excellent. From the data available we conclude that the Neuflex system is an effective treatment method with a low complication rate

We report the use of a free tendon graft in 70 patients to repair lesions of the capsuloligamentous complex of the metacarpophalangeal joint of the thumb. Of these 37 had a lesion of the ulnar collateral ligament, 18 of the radial collateral and 11 of the volar plate. Four patients had combined lesions. We outline our techniques and review 51 of the patients. Of those 47 (92%) were satisfied, and all but one had regained full stability. Pinch grip strength was normal in 48. About one-third of the patients had some loss of flexion/extension; this was seldom noticed by the patients and caused no significant disability. Free tendon graft reconstruction is indicated for severe fresh lesions, for old lesions with chronic disability and for lesions which have not responded to conservative management

The aim was to compare the medium term results of metacarpophalangeal joint (MCPJ) arthroplasty using three different types of silicone hinged implants. All rheumatoid arthritis patients undergoing four finger MCPJ arthroplasty at Burwood Hospital have had standardised pre and post operative assessments for up to four years consisting of: measurement of MCPJ active arc of motion (AOM); finger ulnar drift (UD) and the Baltimore upper extremity function test (UEFT). All surgery was undertaken or directly supervised by one surgeon using a standardised technique followed by a dynamic and static splintage programme supervised by the same hand therapists. Implants – Swanson; 25 hands, 100 joints, 1989 to 1995 – Avanta; 27 hands, 108 joints, 1995 to 2000 – Neuflex; 11 hands, 44 joints, 1999 to 2003. Swanson – at two years the AOM changed from 46 – 80° to 15 – 51°; UD reduced from 33 to 4°and 66% had improved from partial and poor to functional UE categories. Avanta – the AOM changed from 51 – 79 to 15– 60; UD from 31 to 7° and 67% had improved to functional. Neuflex – the AOM changed from 42 – 68 to 17 – 63°; UD from 32 to 11 and 45% had improved to functional classification. From two to four years the UEFT for the Swanson and Avanta had significantly deteriorated. The medium term outcomes for the three implants were very similar. Neuflex use was discontinued in 2003 because of early recurrence of ulnar drift. The significant deterioration of hand function from two to four years is likely to be the effect of progressive rheumatoid disease as the AOM and UD remained unchanged

Objective

We explanted NeuFlex metacarpophalangeal (MP) joint prostheses to identify common features, such as position of fracture, and thus better understand the reasons for implant failure.

Purpose: Trauma to the radial collateral ligaments requires the same attention as trauma to the ulnar ligaments. Damage is uncommon due to the particular anatomic position, but nevertheless a distinct clinical entity.

Material and methods: We report a retrospective analysis of 14 patients, eight who underwent emergency surgery and six with trauma sequelae. Mean follow-up was 22 months and mean age 37 years. Among the recent lesions, the pain score (scale from 1 to 5) was 4.5) and the instability score (scale from 1 to 3) was 3. Palmar subdislocation was 4.8 mm and laxity was 16.7°. Among the old lesions (> 1 month) the corresponding data were pain 3.3, instability 2.5, palmar sub-dislocation 4.2 mm, laxity 19.1°. Two patients had signs of osteoarthritis. At surgery, the phalanx and metacarpus were equally injured. Associated lesions (capsule, short abductor) were present in 78% of the patient. The radial collateral ligaments and the soft tissue were reinserted or retightened in all cases. One patients required arthrodesis due to cartilage damage.

Results: Among the recent injuries, 71% reached a good subjective result: amplitude loss (flexion/extension) was 17°, force was 75% and laxity was 5°. Two patients had palmar subdisloction. Among the older lesions, a good subjective result was achieved in 66%: loss of amplitude case 32°, force was 69% and laxity was 8°. Palmar subdislocation was 2 mm on the average. We had two cases of persistent dysaesthesia.

Discussion: Radial injury appears to be falsely benign because the Stener lesion is not found on this side of the metacarpophalange. The importance of the injury in these traumas is related to the vulnerability of the dorsal region of the medial collateral ligament and is probably the cause of poor outcome after surgery for older lesions with palmar dislocation which is difficult to correct. We advocate emergency surgery for a wide range of indications. We always operate major radial laxity (> 35°) or laxity associated with palmar subdislocation. For other cases, we use the anterior forced drawer view to disclose potential associated dorsal injury.

Ten cases of complete rupture of the collateral ligaments of the metacarpophalangeal finger joints are reported. The nature of this injury, the pre-operative morbidity and the intra-operative pathology are analysed. In all cases surgery was performed with satisfactory results. Operation is indicated for joint stability, grip and pinch strength, pain control and early functional recovery.

Aims. The objective of this systematic review was to describe trapeziectomy outcomes and complications in the context of osteoarthritis of the base of the thumb after a five-year minimum follow-up. Methods. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to guide study design, and 267 full-text articles were assessed for eligibility. After exclusion criteria application, 22 studies were included, involving 728 patients and 823 trapeziectomies. Outcomes included pre- and postoperative clinical and radiological characteristics. Complications and revisions were recorded. Results. All the studies reported good results regarding pain and range of motion at the last follow-up of 8.3 years (5 to 22); the mean satisfaction rate was 91% (84% to 100%). It was difficult to assess the impact on metacarpophalangeal joint motion in extension with contrary results. The key pinch returned to its preoperative values, whereas tip pinch showed a modest improvement (+14%), with a mild improvement found in grip strength (+25%) at the last follow-up. The mean progressive trapezial collapse was 48% (0% to 85%) and was not correlated with pain, grip strength, or satisfaction. The most represented complications were linked to tendons or nerves affected during additional procedures to stabilize the joint (11.6%; n = 56). Mechanical complications included symptomatic scapho-M1 impingement (3.1%; n = 15/580), leading to nine surgical revisions out of 581 trapeziectomies. Meta-analysis was not possible due to study heterogeneity and limited data. Conclusion. After a minimum five-year follow-up, trapeziectomy achieved high patient satisfaction and pain relief. However, strength seemed to be deteriorating with detrimental consequences, but this did not correlate with trapezial collapse. The issues related to underestimating mechanical complications and varying degrees of success should be highlighted in the information given to patients. Evidence-based analyses should help the surgeon in their decision-making. Cite this article: Bone Jt Open 2021;2(3):141–149

Aims. The results of surgery for Dupuytren’s disease can be compromised by the potential for disease recurrence and loss of function. Selecting which patients will benefit from repeat surgery, when to operate, and what procedure to undertake requires judgement and an understanding of patient expectations and functional needs. We undertook this study to investigate patient outcomes and satisfaction following repeat limited fasciectomy for recurrent Dupuytren’s disease. Methods. We prospectively identified all patients presenting with recurrence of Dupuytren’s disease who were selected for surgical treatment with repeat limited fasciectomy surgery between January 2013 and February 2015. Patients were assessed preoperatively, and again at a minimum of five years postoperatively. We identified 43 patients who were carefully selected for repeat fasciectomy involving 54 fingers. Patients with severe or aggressive disease with extensive skin involvement were not included; in our practice, these patients are instead counselled and preferentially treated with dermofasciectomy. The primary outcome measured was change in the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were change in finger range of motion, flexion contracture, Semmes-Weinstein monofilament (SWM) values, and overall satisfaction. Results. There was a significant improvement in MHQ scores, across all domains, with a mean overall score increase of 24 points (p < 0.001). The summed flexion contracture across the metacarpophalangeal joint (MCPJ) and the proximal interphalangeal joint (PIPJ) reduced from means of 72.0° (SD 15.9°) to 5.6° (SD 6.8°) (p < 0.001). A significant increase in maximal flexion was seen at the MCPJ (p < 0.001) but not the PIPJ (p = 0.550). The mean overall satisfaction score from the visual analogue scale was 8.9 (7.9 to 10.0). Complications were uncommon although five fingers showed reduced sensibility at final follow-up. Conclusion. Our study shows that repeat limited fasciectomy for selected patients presenting with recurrence of Dupuytren’s disease can be an effective and safe treatment resulting in excellent patient-reported outcomes and levels of satisfaction. Cite this article: Bone Joint J 2021;103-B(5):946–950

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. Methods. Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. Results. The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. Conclusion. This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354–1358

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

Introduction. An educated public are becoming increasingly aware of percutaneous needle fasciotomy (PNF) for the treatment of Dupuytren's contracture. We believe that it has an important place in the management of this condition and have set up a dedicated one-stop clinic to perform this procedure. Methods. A prospective study of 61 patients with Dupuytren's, who have undergone PNF have been recruited so far. The study population includes 50 men and 11 women. The average age is 65. The senior author has operated on 81 fingers including 69 MCP joints, 62 PIP joints and 6 DIP joints. We recorded contractures prior to PNF and immediately following the procedure, as well as any complications. At follow up we recorded the Patient global impression of change (PGIC), DASH scores, degree of straightness of the operated finger and whether they would have the procedure again or recommend it. Results. For MCP joints the average pre treatment contracture was 43. o. and immediately post operatively it was 3. o. For PIP joints the average pre treatment contracture was 48. o. and immediately post operatively it was 17. o. For DIP joints the average pre treatment contracture was 41. o. and immediately post operatively it was 20. o. 8 patients had small skin tears and 2 found it too uncomfortable to continue. No nerve or tendon injuries. Mean follow up was 9 months (6–24). At follow up the average PGIC was 6 (very good) and the average DASH score was 30.9 (excellent). Subjectively the vast majority of fingers remained straight. All but 4 patients would have the procedure again and would recommend it to others. Discussion. This specialist clinic offers a very effective, safe procedure and our patients are highly satisfied withthe results. It is also cost effective for our Department

Purpose. To analyse the early results of unconstrained pyrocarbon joint replacements in patients with osteo-arthritis of the metacarpo-phalangeal joints. Background. Silicone arthroplasty, as introduced by Swanson in 1962 has remained the most popular procedure to treat arthritis of the metacarpo-phalangeal (MCP) joints. However, despite providing good pain relief, they have shown to demonstrate breakage rates up to 82% at 5 years. This is of great concern in the osteoarthritis (OA) patient group, who tend to be younger and have higher functional demands compared to their rheumatoid counterparts. The newer unconstrained pyrolytic carbon MCP joint prostheses may therefore be more suitable in OA patients whose soft tissue constraints are intact and whose hand function is strong. This study is the first to analyse the results of this implant in a cohort of OA patients only, with prospective data. Methods. 19 primary pyrocarbon metacarpo-phalangeal joint replacements, in 11 patients (5 men and 6 women) were reviewed, with prospective data collection. The diagnosis was primary osteoarthritis in all patients. The mean age at operation was 66.4 years (range 55–82 years). 2 patients underwent concomitant trapiezectomy and one underwent DIPJ fusion. All patients were right hand dominant −75% underwent surgery in their dominant hand. Eleven of the nineteen joints were performed in the index finger, with the remainder in the middle finger. Mean follow up is 22.1 months (range 11–37). Results. At the 3 month post-operative hand therapy assessment, the arc of motion had improved from a mean of 32 degrees to 45 degrees and flexion had improved from a mean of 51 degrees to 66 degrees. Grip strength improved from a mean 20 to 27Kg. DASH scores significantly improved from a mean of 40 to 10 (p=0.01). All patients were satisfied with their outcomes and would have the surgery again. Pre-operative radiographs demonstrated joint narrowing in all patients but no evidence of heterotopic ossification, cystic change or erosions. Post-operatively, there has been no radiographic evidence of joint dislocation, resorption stress-shielding, loosening, migration or heterotopic ossification. There were three intra-operative complications of phalangeal fractures that were immediately treated with a cerclage wire. In one patient there has been a fracture of the proximal phalangeal implant at 14 months which was asymptomatic. One patient has required revision for mal-rotation of the implant leading to loss of index finger supination. Conclusion. Our results demonstrate excellent early results of pyrocarbon MCP joint arthroplasty in OA patients

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

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

The April 2023 Wrist & Hand Roundup³⁶⁰ looks at: MRI-based classification for acute scaphoid injuries: the OxSMART; Deep learning for detection of scaphoid fractures?; Ulnar shortening osteotomy in adolescents; Cost-utility analysis of thumb carpometacarpal resection arthroplasty; Arthritis of the wrist following scaphoid fracture nonunion; Extensor hood injuries in elite boxers; Risk factors for reoperation after flexor tendon repair; Nonoperative versus operative treatment for displaced finger metacarpal shaft fractures.

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.

Aims

The aim of this study was to assess and compare active rotation of the forearm in normal subjects after the application of a short-arm cast (SAC) in the semisupination position and a long-arm cast (LAC) in the neutral position. A clinical study was also conducted to compare the functional outcomes of using a SAC in the semisupination position with those of using a LAC in the neutral position in patients who underwent arthroscopic triangular fibrocartilage complex (TFCC) foveal repair.

Aim. We aimed to assess the efficacy of conservative management of proximal phalanx fractures in a plaster slab. Methods. 23 consecutive patients with proximal phalanx fractures were included in this prospective study. The fractures were reduced and the position was held with a dorsal slab for three weeks. They were followed up an average of 7 weeks (range 2 to 45) after the injury. Radiographic confirmation of adequate reduction was carried out each week until union. After removal of the plaster, range of motion of the finger and radiological evidence of union, non-union or malunion was documented. Results. In united fractures, an average angulation of 4° (apex volar) was measured (range 0 to 45°). In one case (45°) this was not acceptable. All other cases measured less than 15° of angulation. On the AP radiograph the angulation was on average 2° (range 0 to 8°). On average 1.3 mm of shortening (range 0 to 5mm) were measured. In one case delayed union with rotational deformity of 20° was evident. After removal of the slab mild stiffness was noted in one case at the metacarpophalangeal joint and in two cases at the proximal interphalangeal joint. Conclusion. Most proximal phalanx fractures can be managed conservatively with acceptable results. NO DISCLOSURES

In some centres, serial bedside aspirations, in association with intravenous antibiotics, are still an accepted treatment for septic arthritis (Mathews, Postgraduate Medical Journal, 2008). However, there is a risk that bacterial products remain in the joint, even when the bacteria have been destroyed. We have conducted a study to ascertain whether bacterial products alone have an effect on in situ chondrocyte viability. A hip aspirate (25μl), containing Staphylococcus aureus, from a patient with septic arthritis was added to 5ml culture medium and incubated (37°C) for 48hrs. The solution was then centrifuged (3400g for 10mins) and the supernatant removed. Cartilage explants were harvested from a bovine metacarpophalangeal joint, placed into the bacterial supernatant and incubated at 37°C. Explants were removed at hourly intervals over a 6-hour period and stained with the fluorescent probes chloromethylfluorescein di-acetate (10μM) and propidium iodide (10μM) to label living chondrocytes green and dead cells red respectively. Following imaging of cartilage by confocal microscopy, the percentage cell death at each time point was obtained using Volocity 4 software. Chondrocyte death increased markedly with time: 0.04% at 2hrs, 28% at 4hrs and 39% at 6hrs. This study shows that bacterial products rapidly penetrate the cartilage matrix and have a damaging effect on in situ chondrocyte viability. Further work will clarify the contributions made by the various toxic components in the culture supernatant, but these data support the need to remove the bacteria and their products aggressively as part of the treatment of septic arthritis

Staphylococcus aureus is a highly virulent pathogen and implicated in approximately 50% of cases of septic arthritis. Studies investigating other S. aureus-related infections suggest that alpha-(Hla), beta-(Hlb) and gamma-(Hlg) toxins are key virulence factors, with the ‘pore-forming’ alpha-toxin considered the most potent. Here, we have assessed the influence of alpha-toxin alone on in situ chondrocyte viability. Osteochondral explants were harvested from the metacarpophalangeal joints of 3-year-old cows and cultured in Dulbecco's Modified Eagle's Medium. The flasks were then inoculated with isogenic ‘knockout’ strains of S. aureus: DU5946 (Hla+Hlb-Hlg-: alpha-toxin only strain) or DU1090 (Hla-Hlb+Hlg+: beta- and gamma-toxin only strain). Explants were incubated (37°C) and stained after 18, 24 and 40hrs with chloromethylfluorescein-di-acetate and propidium iodide, labelling living chondrocytes green and dead cells red, respectively. Axial sections were imaged by confocal microscopy and the percentage cell death determined. Alpha-toxin-producing S. aureus caused 24.8+/−3.7% chondrocyte death at 18hrs and 44.6+/−7.2% death at 24hrs. At 40hrs, there was significantly more chondrocyte death (87.4+/−3.6%;p<0.001) compared to the alpha-toxin knockout strain, which was negligible (4.1+/−1.7%; means+/−SEM; N=4 independent experiments). In this in vitro bovine cartilage explant model, whereby the effects of defined toxins were determined in isolation of a complex host immune response, in situ chondrocyte viability was dramatically and exclusively reduced by alpha-toxin. This work forms the basis for developing a rational treatment to reduce the extent of cartilage destruction during an episode of septic arthritis. IDMS was supported by Orthopaedic Research UK and The Royal College of Surgeons of Edinburgh

We have demonstrated that toxins produced by Staphylococcus aureus, a common infective agent in septic arthritis (SA), cause rapid in situ chondrocyte death. Here, we have compared the sensitivity of chondrocytes within the superficial and deep zones (SZ, DZ) of cartilage to the same toxins. Culture medium containing the toxins produced by S. aureus strain 8325-4, which include alpha-, beta-, and gamma-toxin, was prepared. Cartilage explants free of subchondral bone were taken from the metacarpophalangeal joints of 3-year-old cows, and incubated (37°C) with the toxins. Explants were stained after 6hrs with chloromethylfluorescein-di-acetate and propidium iodide, labelling living chondrocytes green and dead cells red, respectively. Full-thickness coronal sections were imaged by confocal microscopy and the percentage cell death within the SZ (100μm from articular surface) and DZ (100μm from subchondral bone interface) determined. Both zones were incubated with the same toxin culture medium for the same time period. At 0hrs, chondrocytes within all zones were >98% viable. However, after incubation with toxin-containing culture medium for 6hrs, 71.9+/−11.2% of the SZ cells were dead compared to only 47.4+/−6.7% in the DZ (p=0.03;data are means+/−SEM;N=4). These results suggest that SZ chondrocytes are considerably more sensitive to S. aureus toxins than those within deeper zones. As SZ chondrocytes are close to the synovial fluid harbouring bacterial toxins, these data emphasise the need to remove bacteria and their products aggressively as part of the treatment of SA. IDMS was supported by Orthopaedic Research UK and The Royal College of Surgeons of Edinburgh

The internal fixation of osteochondral fragments in fractures normally utilizes intra-articular screws inserted through a pilot hole drilled into cartilage/bone. This trauma causes cartilage injury leading to chondrocyte death. We have quantified the cell death following cartilage drilling and identified irrigation conditions that can protect chondrocytes. Articular cartilage of bovine metacarpophalangeal joints of 3yr-old cows was irrigated in the presence/absence of saline of various compositions. Holes were then made using a standard 1.5mm drill (Ortho Solutions Ltd.) at 18,000 rpm through the articular cartilage into bone. Osteochondral explants were then harvested and cultured in Dulbecco's Modified Eagle's Medium containing chloromethylfluorescein-di-acetate and propidium iodide (10uM each), to label living chondrocytes green and dead cells red, respectively. Axial images were taken by confocal microscopy and the width of the zone of cell death (ZCD) around the hole determined. With no irrigation, new drills caused a ZCD of 171±25um, which was increased when drills used 50+ times were tested (279±31um;p=0.03). With saline irrigation, the ZCD was reduced for old drills (150±6um;p=0.016) but not for new drills (124±8um) suggesting the heating effect of the old drills caused additional chondrocyte death. However for new drills, the ZCD was further reduced significantly to 82±7um when the osmolarity of the saline irrigation solution was raised to 480mOsm using sucrose. Data are mean±s.e.m., from at least 5 separate experiments each with a minimum of 3 replicates. The results demonstrate a chondroprotective effect of raising the osmolarity of saline used during drilling of cartilage which could be clinically beneficial

Staphylococcus aureus is a highly virulent pathogen and is implicated in approximately 50% of cases of septic arthritis. Studies investigating other S. aureus-related infections have suggested that alpha (Hla), beta (Hlb) and gamma (Hlg) toxins are key virulence factors. In particular, the ‘pore-forming’ alpha toxin is believed to be most potent. In this study, we have assessed the influence of alpha toxin on in situ chondrocyte viability. Osteochondral explants were harvested from the metacarpophalangeal joints of 3-year-old cows and placed into flasks containing Dulbecco's Modified Eagle's Medium. The flasks were then inoculated with the following isogenic ‘knockout’ strains of S. aureus: DU5946 (Hla+Hlb-Hlg-) or DU1090 (Hla-Hlb+Hlg+). The explants were incubated (37°C) and stained after 18, 24 and 40hrs with chloromethylfluorescein di-acetate and propidium iodide, labelling living chondrocytes green and dead cells red, respectively. Axial sections were imaged by confocal microscopy and the percentage cell death obtained using Volocity 4 software. The alpha toxin-producing S. aureus caused rapid cell death, with 24.8+/−3.7% at 18hrs and 44.6+/−7.2% at 24hrs. At 40hrs, there was significantly more chondrocyte death (87.4+/−3.6%; p<0.001) compared to the alpha toxin knockout strain (4.1+/−1.7%; means +/− SEM; n=4). In situ chondrocyte viability was significantly compromised by alpha toxin, with beta and gamma toxins having minimal effect. Further work will clarify the exact mechanism through which this important toxin induces chondrocyte death. Thereafter, it is hoped that targeted treatments can be developed to reduce the extent of cartilage destruction during, and after, an episode of septic arthritis

Hand fasciotomy is a rarely performed procedure which should be considered by military surgeons, and performed where necessary. Maximising hand function is vital in all military patients, but is even more significant in those who have lost multiple limbs and require maximal function from remaining hands, which are commonly injured too. It is vital that compartments are decompressed expediently to minimize muscle ischaemia. Cases were identified from the JTTR from March 2003. Data were collected prospectively from Aug 2009 to Feb 2010. Patient notes were analysed and the following recorded –demographics, mechanism of injury (MOI), associated injuries, echelon of care at which fasciotomy was performed, indication recorded by operating surgeon, and specialty of operating surgeon. 9 patients were identified, median age was 23, MOI was IED in 8/9 and mine in 1/9/. All were multiply injured. 4/9 (44%) were performed at R3 and 5/9 (56%) at R4. All fasciotomies at R4 were performed at the first debridement, intrinsic muscles were found to be necrotic in 1 case. At R3 3/4 were performed by orthopaedic surgeons and 1/4 by a plastic surgeon, at R4 all were performed by hand surgeons, either orthopaedic or plastic. All fasciotomies performed at R4 were at the first debridement, and 1 revealed necrotic intrinsic muscles. This implies that some of these patients may have benefited from earlier procedures. In upper limb injury where it is not possible to passively flex the metacarpophalangeal joints to 90 degrees, decompressing the hand should be considered

We used high-resolution ultrasonography to image the ulnar collateral ligament in 39 patients who had sustained recent injuries of the metacarpophalangeal joint of the thumb. All the patients were subsequently operated on and the lesions of the ligament were recorded. In 36 patients the preoperative ultrasonographic diagnosis was correct. Five of these showed no rupture of the ligament. In the other 31, ultrasonography correctly distinguished between rupture in situ (15) and rupture with dislocation of the ligament (16). Misdiagnosis by ultrasonography in three cases was due to delay of the investigation (three weeks after injury) in one, to technical error in one and to misinterpretation of the image in one

Few studies have investigated the direct effect of bacteria and their products on articular cartilage chondrocytes ex vivo. An ex vivo model that allows the analysis of chondrocytes in situ would therefore be an important and exciting area of future research. It was hypothesised that a bovine cartilage explant model of septic arthritis would be an ideal model for providing fundamental information on the basic cellular mechanisms of cartilage destruction and chondrocyte death induced by bacterial infection uncomplicated by the immune response. A fresh metacarpophalangeal joint from an abattoir slaughtered 3-year-old cow was skinned, rinsed in water and opened under sterile conditions. The cartilage explants were harvested using surgical scalpels and placed into a total of three tissue culture bottles (2 explants per bottle) containing 10ml Dulbecco's Modified Eagle Medium (DMEM). 50ml of a knee aspirate from a patient with septic arthritis, containing Group B streptococci (GBS), was added to bottle 1, 50ml of a negative knee aspirate was added to bottle 2 and 50ml DMEM to bottle 3. The explants were incubated at 37°C for 24 hours. They were then stained with the fluorescent probes Chloromethylfluorescein Di-acetate (CMFDA) and Propidium Iodide and analysed using a Confocal Scanning Laser Microscope. Cell counts to assess percentage cell death were performed using Velocity 4 software. There was strikingly more cell death observed at 24 hours in the cartilage explant exposed to bacteria in comparison to the non-infected controls. The percentage chondrocyte death was 43% in the presence of GBS, 0.8% in the presence of the negative aspirate and 0.2% in the presence of the DMEM control. Although this is a very preliminary pilot study, it demonstrates an extremely rapid effect on the cartilage. Future bovine explant studies of septic arthritis will therefore be feasible and achievable

We randomly selected 39 patients undergoing excision of the trapezium for osteoarthritis of the first carpometacarpal joint into two groups, with mobilisation either at one or at four weeks after operation. The patients were reviewed at a median of six months (6 to 8). The clinical details, the severity of the disease and the preoperative clinical measurements of both groups were similar. Excision of the trapezium resulted in significant improvement in objective and subjective function. Comparison of the outcomes of the two groups showed no differences except that patients found early mobilisation significantly more convenient. Although there was no significant difference in the range of movement between the groups, there was a small loss of movement at the metacarpophalangeal joint in the late mobilisation group. Our findings show that simple excision of the trapezium is an effective procedure for patients with carpometacarpal osteoarthritis of the thumb and that prolonged splintage is neither necessary nor desirable

Aim: To assess the functional and radiological outcome of AO wrist Arthrodesis using the AO wrist fusion plate. Method: An 8 year, independent, retrospective, radiological and functional review was performed using The DASH (Disabilities of the Arm, Shoulder and Hand questionnaire) and the Buck-Gramcko/Lohmann outcome scores. Results: Twenty-eight patients were reviewed. The two scoring systems correlated consistently in regards to the functional outcome. However, patients with systemic disease experienced problems completing the DASH questionnaire. Mono-articular arthritis was associated with an excellent/good outcome in 95% of cases. Results for patients with systemic disease were markedly worse. There was one case of plate breakage associated with a delayed union of the second MCP joint. There was a 100% union rate, no significant post-operative infections and no tendon ruptures. Conclusion: The short to mid term clinical outcomes for the AO wrist fusion plate are encouraging and its use can be recommended in a variety of wrist pathologies

The Mathys. ¯. finger joint replacement system offers a novel fixation method into the proximal and distal medullary canals and a semi-constrained articulation. This comprises a separable, form-fit joint with a distal/proximal play of 0.7 mm, a lateral excursion of 10°, and rotation of up to 6°. This has theoretical advantages of increased radio-ulnar stability, preventing ulnar drift in patients with rheumatoid disease, and enhanced osseointegration offering implant longevity. In our unit, however, high failure rates were noted, prompting a review of cases to quantify our suspicions. Case notes of all patients who underwent finger joint replacement using the Mathys. ¯. implant between 1999 and 2005 were retrieved. Twenty-two devices were implanted by a single surgeon during this period. Four were in finger proximal interphalangeal joints, 17 in finger metacarpophalangeal joints and one in a thumb carpometacarpal joint (CMCJ). Indications for joint replacement included sixteen for rheumatoid arthritis (RA) and five for post-traumatic joint problems. The only thumb CMCJ was replaced for primary osteoarthritis. Patients were reviewed regularly and implant performance assessed critically along with survival of the implant to revision, infection or death of the patient. Mean follow up was 30 months. Sixteen implants failed including the only thumb CMCJ. Modes of failure were rotation (11), poor range of motion (two), infection (two) and dislocation (the CMCJ). Similar ball and socket designs for uncemented thumb CMCJ replacement, such as the Ledoux prosthesis, have previously shown poor survival and have been withdrawn from the market. Of the finger implants in RA patients (n=16), 12 implants failed of which ten were due to rotation. Time to failure ranged from two to 48 months (mean 15 months). The authors do not recommend the use of this implant, especially in cases of rheumatoid arthritis

Various prostheses for total replacement of the first metatarsophalangeal joint for painful hallux valgus and hallux rigidus are briefly discussed. Altogether, the results of eighty-six replacements in sixty-nine patients have been recorded after an average interval of two years. In seventy-eight operations a Silastic* prosthesis as designed by Swanson for the replacement of metacarpophalangeal joints was used, with no case of fracture or deep infection up to date. Overall, the assessment of pain showed that 98 per cent of operations gave either complete or considerable relief. For hallux valgus, the objective assessment showed excellent or good results in 79 per cent, fair in 16 per cent and poor in 5 per cent. For hallux rigidus the corresponding figures were 86, 14 and 0. The technique of replacement described promises to be most satisfactory, especially for hallux rigidus. In selected cases of hallux valgus, a basal osteotomy of the first metatarsal should be added

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

1. A new procedure, called "the extensor diversion graft operation", has been devised for correcting the deformity and reducing the disability of the intrinsic minus fingers so commonly seen in leprosy. 2. The procedure consists of the insertion of a free tendon graft which spans the metacarpophalangeal joint along its volar aspect and is attached at both ends to the extensor mechanism, to the extensor tendon proximally and to the lateral band distally. 3. The procedure reduces extensor dominance at the metacarpo-phalangeal joint and improves the balance of forces, allowing the assumption of a straight posture by use of the extrinsic muscles. 4. The assessment of function of ninety-seven fingers on average eight months after operation has shown that in addition to correction of deformity, this procedure in the majority of cases also restores partial independence of movement at the metacarpo-phalangeal and proximal interphalangeal joints, to such an extent that the finger can reach and hold a functionally useful position. 5. One advantage of the procedure is that it obviates the need for re-education of muscles

Intra-articular screw fixation is indicated for internal fixation of large osteochondral fragments secondary to trauma or osteochondritis dissecans. During surgery, orthopaedic drills are used to prepare a hole through which the screw can pass. Previous work has shown that mechanical injury to articular cartilage results in a zone of cell death adjacent to the traumatised articular cartilage (1). Here, we characterise and quantify the margin of in situ chondrocyte death surrounding drill holes and screws (standard cortical and headless compression designs) placed in mature bovine articular cartilage to model the orthopaedic procedure. Drill holes (1mm) were made through the articular cartilage and bone of intact bovine metacarpophalangeal joints obtained from 3-yr old cows within 12hrs of slaughter. Osteochondral explants (∼1cm square and 2-3mm thick) encompassing the drilled holes in articular cartilage and subchondral bone were harvested using a chisel. Explants were then incubated in Dulbecco's modified Eagle's medium for 45mins with CMFDA (5-chloromethylfluorescein diacetate) and PI (propidium iodide; both at 10micromolar) to identify/quantify living and dead in situ chondrocytes respectively in a consecutive series of axial optical sections using confocal scanning laser microscopy (CLSM). The drill holes through cartilage appeared to have clearly defined edges with no macroscopic evidence of cartilage splitting. However visualisation of fluorescently-labelled in situ chondrocytes by CLSM demonstrated clear cell death around the periphery of the drilled hole which was 166±19 micrometers in width. This increased with a larger diameter (1.5mm) drill to 450±151 micrometers (all data are means±s.e.m.; n=3). Preliminary experiments indicated that the margin of chondrocyte death around a 1.5mm hole was dramatically increased further by the insertion of screws into pre-drilled holes. These results suggest that the mechanical trauma associated with cartilage drilling and the insertion of intra-articular screws occurs with marked death of in situ chondrocytes extending into normal cartilage beyond the area occupied by the screw. As chondrocytes are not replaced in mature cartilage, their loss around the hole/screw will mean that the extracellular matrix is not maintained, inevitably leading to cartilage failure

Aim: To describe a new radiological sign after rupture of the thumb ulnar collateral ligament. Introduction: Rupture of the thumb ulnar collateral ligament is a commonly missed injury, with delayed diagnosis leading to considerable morbidity. Stress radiographs and MRI scans have been used to diagnose chronic (gamekeepers thumb) or acute (skiers thumb) injuries to this ligament. The former often causes discomfort and the latter are often not readily available. We describe a new radiological sign seen on the lateral radiographs of the thumb, which has previously not been described in the literature. The ‘sag sign’ is volar subluxation of the proximal phalanx in relation to the metacarpal at the metacarpal phalangeal joint. Method: Between 2001–2006, radiographs of nineteen patients who had undergone repair of thumb ulnar collateral ligaments were retrospectively reviewed. There were 12 male and 7 female patients with an average age of 44. These were compared to a control group of normal thumb radiographs. The ‘sag sign’ was present on all the lateral radiographs of thumbs with ulnar collateral ligament tears. Once the ligament was repaired, the metacarpophalangeal joint alignment returned to normal. The sign was validated by senior house officers and registrars in orthopaedics training. Conclusion: The sag sign is a reliable indicator of an underlying injury to the thumb ulnar collateral ligament. Many studies have looked at the radiological diagnosis of this commonly missed injury. Stress radiography and ultrasound require straining an injured thumb which can extend the lesion and cause discomfort. MRI and MR arthrography are both sensitive and specific, but are costly and time consuming. Our sign is evident on plain film, is easily available, and does not require additional apparatus

Introduction. Evaluating the success of a treatment has changed. Currently, the emphasis is on patient-rated outcome scores rather than surgeon recording of outcome measures. Functional outcome and patient satisfaction following Dupuytren's disease surgery is poorly quantified in the literature. This study aimed to assess subjective patient hand function, disability and satisfaction using a PEM score and its correlation with residual contracture. Methods. Percutaneous Needle Fasciotomy (PNF) is performed in our outpatient clinic to treat Dupuytren's contracture at MCP joints. A validated patient completed questionnaire (PEM) was used to record patient demographics, side of surgery, finger involved, time since surgery, residual symptoms, disability, subjective hand function and satisfaction. The questionnaire was posted to all patients who had PNF over the study period (n=68) along with a stamped addressed envelope and participant information sheet. Results. 68 patients had PNF surgery on 73 hands. Completed questionnaires were returned from 46 patients (51 hands), a response rate of 70%. Mean follow-up was 15 months (SD +/− 10), range 5-36 months. Wilcoxon Signed Ranks Test showed that change in ‘function of hand’ over time was statistically significant (z = 5.82, n-ties = 50, p < 0.001). Spearman's test showed a significant correlation between any residual contracture and total score on the PEM (r. s. = 0.540, N=51, p <0 .001, two tailed). Multiple linear regression revealed that the correction achieved at time of surgery was a significant predictor of subjective hand function (p= 0.001). Most of the patients were satisfied with their surgery and its outcome, a cumulative mean score of 4.80 with SD +- 2.58. Conclusion. Significant improvement in contracture and deformity and good patient satisfaction can be achieved by percutaneous needle fasciotomy. Hand function measured using this tool (PEM Score) was strongly correlated with final deformity at follow-up

Staphylococcus aureus is the most common bacterial isolate in septic arthritis. From studies on isolated cartilage cells, the ‘pore-forming’ alpha and gamma toxins are considered the most virulent factors. However, understanding the response of in situ chondrocytes is important in order to identify new treatments to reduce the extent of cartilage damage during, and following, episodes of septic arthritis. Animal models can give useful information; however the interpretation of data can be complex because of the strong immune response. Thus, to clarify the role of S. aureus toxins on in situ chondrocytes we have developed a bovine cartilage explant model. Metacarpophalangeal joints, from 3-year-old cows, were opened under sterile conditions within 6hrs of slaughter and cartilage explants harvested. Explants were placed into flasks containing Dulbecco's Modified Eagle Medium (DMEM). Aspirates from a patient with septic arthritis of the hip, containing S. aureus, were compared to negative aspirates (no bacterial growth) from a patient with an inflamed knee joint (controls). The explants were incubated at 37 degrees Celsius and stained after 18, 24 and 40hrs with the fluorescent probes chloromethylfluorescein di-acetate and propidium iodide (10 micromolar each) to label living chondrocytes green and dead cells red respectively. Following imaging of cartilage by confocal laser scanning microscopy, the percentage cell death at each time point was obtained using Volocity 4 software. There was no detectable change in chondrocyte viability (<1% cell death) over 40hrs incubation with the negative aspirate. However, for the aspirate from a patient positive for S. aureus, there was a rapid increase in cell death between 18 and 24hrs (0.2 +/− 0.3% to 23 +/− 5% cell death respectively) and almost complete cell death at 40hrs (80 +/− 12%; data are means +/− s.d; n=4). These results show that a strain of S. aureus capable of manifesting clinical disease exerts a potent effect on in situ chondrocytes. In the absence of an immune response, chondrocyte death was purely the result of the bacteria and their products. This bovine cartilage explant model could therefore be useful for studying the effects of S. aureus on chondrocyte behaviour and, ultimately, cartilage integrity

Saline (0.9%) is typically used to rinse joints during osteo-articular surgery. It is not unusual for cartilage to then be exposed to the air of the operating theatre for 1-2hrs, which can lead to chondrocyte death. We have compared the survival of in situ chondrocytes within bovine cartilage which has been rinsed in various solutions or simply drained of synovial fluid (SF) and then allowed to dry, to identify approaches that could reduce chondrocyte death arising from cartilage drying. Metacarpophalangeal joints from 3yr-old cows were opened under aseptic conditions. The joints were then (a) rinsed with saline (Baxter's Healthcare, Newbury), (b) rinsed with saline+glucose (20mM; both 300mOsm) or (c) drained of SF, and allowed to dry at room temperature. Full depth cartilage explants were taken after 2hrs, placed into Dulbecco's modified Eagle's medium and incubated with CMFDA (5-chloromethyl-fluorescein diacetate; 10microM) and propidium iodide (10microM) for the identification/quantification of living and dead cells respectively by confocal scanning laser microscopy and image analysis. After 2hrs, the appearance and properties of the cartilage of the drying joints were clearly different. Saline-rinsed cartilage was dark purple and appeared dull with the cartilage difficult to sample. However when the rinsing solution was saline+glucose, or when joints were drained of SF, the cartilage was almost identical to the freshly-opened joint with a pearly-blue, shiny appearance, and cartilage sampling was easy. Chondrocyte death was markedly increased in saline rinsed/dried joints after 2hrs (21±9% cell death). In contrast, there was no significant (P>0.05) death in saline+glucose rinsed/dried (2±1%) or SF-drained joints (3±2%;means±s.e.m.;n=5). The loss of cartilage wet weight over 2hrs (time=0 taken as 100%) was almost identical between cartilage rinsed in saline (73.6±1.6%), saline + glucose (78.6±1.1%) or SF (75.0±0.2%; data means±s.d.;n=2). These results suggest that it was not the loss of water per se during cartilage drying that was the key determinant of chondrocyte viability. As chondrocytes are normally anaerobic, the rise in cartilage pO2 which occurs during exposure to air could have a deleterious effect on cell viability however the presence of glucose or SF protects through an anti-oxidant effect