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

Suture anchors have gained popularity in recent years, particularly owing to their ease of use for attaching soft tissues to bone and improved biomechanical properties. Three methods to reattach avulsed finger flexor tendons to the distal phalanx were biomechanically compared: a 1.8mm metal Mitek barbed suture anchor, twin 1.3mm PLA suture anchors (Microfix), or a pull-out suture over a button. The suture-anchor interface was tested by pulling the suture at 0, 45, 90° to the anchor's axis. The anchors were tested similarly in plastic foam bone substitute. Repairs of transected tendons in cadaveric fingers were loaded cyclically, then to failure. The results were subject to statistical analysis using Student t test (p< 0.001) and 1-way ANOVA (p<0.0001). The suture failed prematurely if pulled across the axis of the anchor. Conversely, fixation in bone substitute was stronger when pulling at an angle from the axis. Cyclic loads caused significantly more gap formation in-vitro with twin 1.3mm anchors than the other methods; this method was significantly weaker. The 1.8mm anchor gave similar performance to the pull-out suture and button, while the twin 1.3mm anchors were weaker and vulnerable to gap formation even with passive motion alone. A suture anchor embedded at between 45 and 90o to the direction of pull gave greater strength than if the pull was in-line. The absorbable 1.3 mm Microfix PLA anchors appeared to be a weak construct, even when twin 1.3 mm anchors were compared to a single metallic 1.8 mm Mitek anchor or the pull-out suture over button technique. All three methods are likely to be satisfactory for reattachment of finger flexor tendons if a low load or non-loading rehabilitation of the hand is planned; however the gap formation on cyclic loading with the Microfix is a concern even if patients are restricted to passive motion

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

Aim. There are no definitive criteria for the definition of osteomyelitis in the hand and wrist and published case series are small. It remains a relatively uncommon, but difficult to treat problem. We present a series of 30 cases from 2016 to 2021 from a tertiary referral centre. We propose that the principles of thorough surgical debridement, dead space management, skeletal stabilisation and culture driven antibiotic therapy are the key to management of osteomyelitis in the hand and wrist. In addition, we show how these basic principles can be used for both functional and aesthetic impact for the wrist and digits with illustrated cases. Methods. We conducted a retrospective chart review over a 6 year period and recorded the site of the infection, the soft tissue and bony management, whether antibiotic eluting bone filler was used, the isolated bacterial species, the number of surgical procedures undertaken to treat the infection and the success rate for clearing the infection. Results. 17/30 cases had pre-existing metalwork in-situ. There were 19 phalangeal/metacarpal infections and 11 carpal infections. 24 patients had native joint involvement. A drug eluting bone void filler was used in 23/30 cases in order to manage the dead space. In 7/30 cases had polymicrobial organisms isolated, 15/30 had only one organism cultured. The most common organism cultured was Staphylococcus aureus. Complete resolution of osteomyelitis or joint infection was achieved in 29/30 cases with follow up ranging from six months to six years. 2/30 cases required thorough debridement of the distal phalanx; bone void filler provided an aesthetically optimal result to improve fingertip contour whilst managing the dead space. Conclusion. Osteomyelitis of the hand and wrist is optimally managed with thorough surgical debridement, dead space management with a drug eluting bone void filler, skeletal stabilisation and culture directed antibiotic therapy. In addition, the bone void filler provides pulp support and improves the aesthetic contour of fingertips in which distal phalangeal osteomyelitis was successfully treated

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

Background. As hallux valgus (HV) worsens clinical and radiological signs of arthritis develop in metatarsophalangeal joint due to incongruity of joint surfaces. The purpose of this prospective study was to determine if intraoperative mapping of articular erosion of the first metatarsal head, base of the proximal phalanx, and tibial and fibular sesamoids can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity. Materials and methods. We analysed 50 patients prospectively who underwent surgery between Jan 2009-Jan 2010. Patients with a known history of previous first metatarsophalangeal joint surgical intervention, trauma, or systemic arthritis were excluded from analysis. Preoperative demographics and AOFAS score were recorded. Intraoperative evaluation and quantification of the first metatarsal head, base of the proximal phalanx, and sesamoid articular cartilage erosion was performed. Cartilage wear was documented using International Cartilage Research Society grading. Results and Discussion. P. Bock et al have showed that the extent of cartilage lesions were clearly correlated with the degree of hallux valgus angle proving that a malaligned joint is more prone to cartilage degeneration. Kristen et al have described a correlation between a higher pre-operative hallux valgus angle and the post-operative Kitaoka et al score. The higher the preoperative hallux valgus angle, the lower the post-operative score. Our series showed the mean IMA is 15 degrees. The mean AOFAS score was 62. There was a significant positive correlation between hallux valgus angle and AOFAS score. We also found correlation between sesamoid wear and AOFAS score and HV angle. Conclusion. We conclude that preoperative clinical parameters (ie, age) and radiographic measurements (ie, HV, IMA) directly define the incidence and location of articular erosion and are helpful in the preoperative assessment of the HV deformity

Aim. Open fractures with bone loss and skin lesions carry a high risk of infection and complication. Treatment options are usually a two-stage approach (debridement, temporary stabilization with external fixation followed by open reduction and stabilization with plate). We describe an experience for a single stage procedure with an antibiotic eluting bone graft substitute (BGS) for prophylaxis of implant-related infection. Method. Between December 2014 and January 2016 were analysed the data of twenty-six patients with open fractures (Gustilo and Anderson grade I and II) or with skin lesion and high risk of contamination and bone loss. They where treated with debridement of soft tissue, closed reduction of fracture, placement of a plate augmented with BGS eluting antibiotic (gentamicin (1) and/or Vancomicin (2)). Ampicillin and sulbactam 3g three times daily was used as systemic antibiotic prophylaxis minimum for one week. Clinical outcome and radiographic bone defect filling were assessed by blinded observers. Results. From 2014 to 2015 twelve male and fourteen female with mean age 53yrs (24–77) were treated with plate and BGS. Fracture locations were four distal femur (m:4; f: 1), four tibial plateau (m:3; f:1), one proximal humerus (f:1), seven calcaneus (m:4; f: 3), one talus (m:1), four forearm (m:3), one elbow (f:1) and two phalanx (m: 2). Follow up was fourteen month (range: 3 – 26 months). During follow-up no implant-related infection was observed. One patient developed sterile seroma, which was treated conservatively. The calcium sulphate phase of BS dissolved in all cases within 4–6 weeks. Bone ingrowth was assessed at 1, 2, 3, 6 and 12 months. On six patients large bone was treated with a revision surgery (autologous cancellous bone graft combined with BGS and antibiotic. No complications were reported. Conclusions. We suggest the application of poly therapy for the treatment of bone defects. BGS eluting antibiotic is easy to use and offers the opportunity for a one-stage procedure and might reduce the risk of implanted-related infection and allow early joint mobilization. Good early clinical outcomes were observed in almost all cases. More studies and larger series are necessary to confirm the potential for the prophylaxis of infection in the treatment of open fractures. (1): CERAMENT™|G. (2): CERAMENT™|V”

Aim:. To review the short to medium term radiological, clinical and functional outcomes of reconstructive surgery for severe forefoot deformities in patients with Rheumatoid arthritis. Methods:. We conducted a review of prospectively collected data of patients with Rheumatoid arthritis who received reconstructive surgery for forefoot deformities. Patients requiring metatarso-phalangeal joint arthrodesis and excision of the lesser metatarsals for hallux valgus, dislocation of the lesser metatarso-phalangeal joints and intractable plantar keratosis were included. The patients were followed up at 2 weeks, 6 weeks, 3 months and 6 months. X-Rays were performed preoperatively, postoperatively, at 6 weeks, 3 months and 6 months follow-up. Patients completed a SF36, and AOFAS (American Orthopaedic Foot and ankle Score) forefoot score preoperatively and at 6 months postoperatively. Results:. Ten feet in eight patients were included in the study. Follow-up was for a minimum of 6 months. All patients were female, with an average age of 58 years (34–69 years). Radiologically there was an average correction in the hallux valgus angle from 48 degrees to 15 degrees. The inter-metatarsal angle improved from 14 to 9 degrees. Objective scores were significantly improved. The mean SF36 score pre-operatively was 36 (24–54) and 67 (54–82) post operatively (P < 0.05). The AOFAS score improved from a mean of 32 (28–50) pre operatively to 74 (64–78) post-operatively (p < 0.05). One patient required re-operation for further metatarsal shortening due to ongoing pain and two patients required oral antibiotics for minor superficial wound infections. All hallux metatarsophalangeal joint arthrodesis procedures united in a mean time of 3.5 months. Conclusion:. Forefoot reconstruction in these very symptomatic, disabled patients resulted in significant deformity correction and improvement in function and pain. The complication rate was low. Adequate resection of the lesser metatarsals is necessary to avoid ongoing pain from the phalanx articulating with the metatarsal

Introduction:. 20 cases of bone defect have been treated by the induced membrane technique avoiding allograft, microsurgery and amputation. Material and Methods:. 9 cases of long bone defect (humerus and forearm) and 11 cases of bone defect at the hand have been included in this multicentre prospective study (3 centers). The aetiology in 11 cases was trauma, 7 cases were septic nonunions and 2 cases followed tumors. In the hand the bone loss was at least one phalanx, and for long bones the mean defect was 5 cm (3–11). All cases were treated by the induced membrane technique which consists in stable fixation, flap if necessary and in filling the void created by the bone defect by a cement spacer (PMMA). This technique needs a second stage procedure at the 2. nd. month where the cement is removed and the void is filled by cancellous bone. The key point of this induced membrane technique is to respect the foreign body membrane which appeared around the cement spacer and which creates a biologic chamber for the second procedure. Bone union was evaluated prospectively in each case by a surgeon not involved in the treatment, by X-ray and CT scan. Failure was defined as a nonunion at 1 year, or an uncontrolled sepsis at 1 month. Results:. 3 cases failed to achieve bone union, 2 in the hand and 1 in a long bone. No septic complications occurred and all septic cases healed. In 14 cases bone union was achieved with a delay of 5 months (1, 5–12). 2 biopsies allowed us to prove that osteoid tissue was created by the technique. At hand level all fingers have included. At shoulder and elbow level, function reached 75% of motion of the contralateral side. Discussion:. Masquelet first reported 35 cases of large bone defect of tibia nonunion treated by the induced membrane technique which allow filling a bone defect with cancellous bone alone. The cement spacer induces a foreign body membrane (neo periosteum) which constitute a biological chamber. Animal models showed the properties of the membrane: secretion of growths factors (VEGF, TGFbéta1, BMP2) and osteoinductive activitie of the cells. Conclusion:. This technique is useful in emergency or in septic condition where a bone defect cannot be solved by shortening. The technique avoids the use of microsurgery and the limit is the quantity of available cancellous bone

Background. There are reports of good early results in small numbers of patients implanted with the ‘Moje’ ceramic prosthesis. Published evidence thus far involves only small groups of patients with short-term follow-up. The purpose of this prospective study was to evaluate the emerging mid-term clinical and radiological results from our centre. Methods. We describe our single-surgeon experience of 63 components in 48 patients at a mean follow-up of 44 months. Patient satisfaction was assessed by questionnaire and radiographic assessment was performed immediately post-operatively and at the maximum follow-up. Results. Mean American Orthopaedic Foot and Ankle Society (AOFAS) Hallux score increased from 56 to 72 (p< 0.01) and mean satisfaction score was 7.6 (scale 1-10). 67% reported minimal or no pain. Five implants have been removed (8%), four because of pain associated with implant loosening and subsidence, and one because of deep infection. 57% of metatarsal and 56% of phalangeal components had subsided and we found radiographic evidence of loosening in 58% of x-rays analysed at the maximum follow-up. Presence of prosthesis subsidence was associated with greater margin of uncovered bone under the prosthesis (P=0.05 for metatarsal, P=0.03 for proximal phalanx component) and longer time to follow-up (P< 0.001). Conclusion. In spite of the good clinical outcome at the mid-term stage with 91% implant survival, given the widespread loosening and subsidence encountered in our study, the long-term outcome following this procedure is uncertain

Diagnosing musculoskeletal pathology from radiographs is an important skill in orthopaedics and emergency medicine. Knowing which fractures are more likely to be missed allows a high index of suspicion when looking at certain radiographs. Likewise, knowing which fractures will be rigorously followed up if they are missed helps to increase index of suspicion for those fractures. Therefore we used a prospectively gathered database of missed radiographic diagnoses to determine which injuries are missed most commonly and how these injuries are followed up. Four hundred and thirty two missed radiographic diagnoses were recorded from a total of thirty seven thousand, two hundred and seventy nine radiographs (37,279) in an emergency medicine department over three years. The most common area in which fractures were missed was the foot (22%), followed by hand (19%) and wrist (15%). The most common diagnosis to be missed was fracture of a proximal phalanx, followed by fracture of a distal radius and fracture of a metatarsal. The hip, knee, cervical spine and wrist were the areas most likely to be followed up, each with 32–35% of missed diagnoses being followed up in this way. The areas most likely to be further imaged with CT or MRI were the knee and hip. Two of the missed fractured femurs were managed operatively. Our results show that missed radiographic diagnosis are most commonly of the foot and hand, and that missed diagnosis of knee and femur fractures are followed up most rigorously. By showing which radiographs are most likely to contain missed fractures, and what these fractures are, we allow orthopaedic trainees to increase their level of diagnostic suspicion when reviewing these radiographs

Introduction. Despite the multiple patho-aetiological basis of Hallux valgus (HV), corrective osteotomy is a common and globally performed orthopaedic procedure. Over-correction of the inter-metatarsal angle (IMA), however, is not without consequence. Through increased joint pressures, over-correction may predispose to joint degeneration. Hypothesizing that over-correction leads to an increase in intra-articular joint pressures, we constructed a mechanical simulation of the 1. st. metatarsal-phalangeal joint. Methods. The vector forces of Flexor Hallucis Longus, Extensor Hallucis Longus, Extensor Hallucis Brevis and Adductor Hallucis, acting upon the 1. st. proximal phalanx were simulated with tensioned weighted rope. A Foley catheter balloon inflated to 1.5ml, simulated intra-articular distractive vector forces. The joint was freely mobile. At 5° IMA intervals from 10° valgus to 15° varus, intrarticular pressures were recorded using a contact pressure (Graseby™, Hertfordshire, UK) transducer attached to a calibrated manometer (Digitech Instruments™, Ulhasnagar, India). At each angle, measurements were repeated five times with removal and recalibration of the pressure monitor after each measurement. Results. A decline and subsequent increase in mean pressure was observed at each 5° interval from 10°valgus to neutral and then to 15° varus (mean±s.d.; 48.02±5.67, 24.72±1.01, 12.34±0.84, 18.96±2.46, 32.88±5.06, 42.92±4.99 milibar for 10°, 5° valgus, neutral, 5°, 10°and 15° varus IMA). One-way analysis of variance with post-hoc Tukey multiple comparison test revealed a significant increase in pressure from neutral and 5° valgus to 10° and 15° varus (p< 0.05). [First Metatarsal Phalangreal joint pressures]. Conclusion. This is the first description demonstrating increases in intrarticular pressures as the IMA tended from 5° to 15° varus, replicating inatrogenic Hallux Varus iatrogenically produced through osteotomy and over-correction of the IMA. Over-correction and increased intrarticular joint pressure may have an aetiological basis to post-operative 1. st. MTPJ degeneration. Over-correction is not a benign entity requiring consideration in Hallux Valgus corrective osteotomy

Introduction

Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics.