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Bone & Joint Open
Vol. 5, Issue 8 | Pages 652 - 661
8 Aug 2024
Taha R Davis T Montgomery A Karantana A

Aims

The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality.

Methods

A multicentre, cross-sectional retrospective study of MSFs at six centres in the UK. We collected and analyzed healthcare records, operative notes, and radiographs of adults presenting within ten days of a MSF affecting the second to fifth metacarpal between 1 August 2016 and 31 July 2017. Total emergency department (ED) attendances were used to estimate prevalence.


Bone & Joint Open
Vol. 3, Issue 11 | Pages 898 - 906
15 Nov 2022
Dakin H Rombach I Dritsaki M Gray A Ball C Lamb SE Nanchahal J

Aims

To estimate the potential cost-effectiveness of adalimumab compared with standard care alone for the treatment of early-stage Dupuytren’s disease (DD) and the value of further research from an NHS perspective.

Methods

We used data from the Repurposing anti-TNF for Dupuytren’s disease (RIDD) randomized controlled trial of intranodular adalimumab injections in patients with early-stage progressive DD. RIDD found that intranodular adalimumab injections reduced nodule hardness and size in patients with early-stage DD, indicating the potential to control disease progression. A within-trial cost-utility analysis compared four adalimumab injections with no further treatment against standard care alone, taking a 12-month time horizon and using prospective data on EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and resource use from the RIDD trial. We also developed a patient-level simulation model similar to a Markov model to extrapolate trial outcomes over a lifetime using data from the RIDD trial and a literature review. This also evaluated repeated courses of adalimumab each time the nodule reactivated (every three years) in patients who initially responded.


The Bone & Joint Journal
Vol. 104-B, Issue 8 | Pages 946 - 952
1 Aug 2022
Wu F Zhang Y Liu B

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. Methods. This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements. Results. Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients’ subjective pain score. No peri- or postoperative complications were encountered. Conclusion. Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946–952


The Bone & Joint Journal
Vol. 103-B, Issue 7 | Pages 1277 - 1283
1 Jul 2021
Hinde S Richardson G Fairhurst C Brealey SD Cook L Rangan A Costa ML Dias JJ

Aims

The aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion.

Methods

A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis.


Bone & Joint Open
Vol. 2, Issue 6 | Pages 447 - 453
1 Jun 2021
Dean BJF Little C Riley ND Sellon E Sheehan W Burford J Hormbrey P Costa ML

Aims

To determine the role of early MRI in the management of suspected scaphoid fractures.

Methods

A total of 337 consecutive patients presenting to an emergency department (ED) following wrist trauma over a 12-month period were prospectively included in this service evaluation project. MRI was not required in 62 patients with clear diagnoses, and 17 patients were not managed as per pathway, leaving a total of 258 patients with normal scaphoid series radiographs who were then referred directly from ED for an acute wrist MRI scan. Patient demographics, clinical details, outcomes, and complications were recorded at a minimum of a year following injury.


The Bone & Joint Journal
Vol. 102-B, Issue 11 | Pages 1542 - 1548
2 Nov 2020
Stirling PHC Oliver WM Ling Tan H Brown IDM Oliver CW McQueen MM Molyneux SG Duckworth AD

Aims

The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius.

Methods

We retrospectively identified 122 adult patients from a single centre over an eight-year period who had undergone corrective osteotomy for a symptomatic malunion of the distal radius. The primary long-term outcome was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, the EQ-5D-5L score, complications, and the Net Promoter Score (NPS). Multivariate regression analysis was used to determine factors associated with the PRWE score.


The Bone & Joint Journal
Vol. 102-B, Issue 10 | Pages 1354 - 1358
3 Oct 2020
Noureddine H Vejsbjerg K Harrop JE White MJ Chakravarthy J Harrison JWK

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.


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1263 - 1271
1 Oct 2019
Eisenschenk A Spitzmüller R Güthoff C Obladen A Kim S Henning E Dornberger JE Stengel D

Aims

The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires.

Patients and Methods

This was a multicentre, parallel group, randomized controlled noninferiority trial conducted at 12 tertiary trauma centres in Germany. A total of 290 patients with acute displaced fractures of the fifth metacarpal neck were randomized to either intramedullary single-wire (n = 146) or dual-wire fixation (n = 144). The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire six months after surgery, with a third of the minimal clinically important difference (MCID) used as the noninferiority threshold. Secondary outcomes were pain, health-related quality of life (EuroQol five-dimensional questionnaire (EQ-5D)), radiological measures, functional deficits, and complications.


Aims

The aim of this study was to compare the clinical effectiveness of Kirschner wire (K-wire) fixation with locking-plate fixation for patients with a dorsally displaced fracture of the distal radius in the five years after injury.

Patients and Methods

We report the five-year follow-up of a multicentre, two-arm, parallel-group randomized controlled trial. A total of 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation were recruited from 18 trauma centres in the United Kingdom. Patients were excluded if the surface of the wrist joint was so badly displaced it required open reduction. In all, 448 patients were randomized to receive either K-wire fixation or locking-plate fixation. In the K-wire group, there were 179 female and 38 male patients with a mean age of 59.1 years (19 to 89). In the locking-plate group, there were 194 female and 37 male patients with a mean age of 58.3 years (20 to 89). The primary outcome measure was the patient-rated wrist evaluation (PRWE). Secondary outcomes were health-related quality of life using the EuroQol five-dimension three-level (EQ-5D-3L) assessment, and further surgery related to the index fracture.


The Bone & Joint Journal
Vol. 100-B, Issue 1 | Pages 73 - 80
1 Jan 2018
Sanjuan-Cerveró R Carrera-Hueso FJ Vazquez-Ferreiro P Ramon-Barrios MA

Aims. The aim of this meta-analysis was to assess the safety and efficacy of collagenase clostridium histolyticum compared with fasciectomy and percutaneous needle fasciotomy (PNF) for Dupuytren’s disease. Materials and Methods. We systematically searched PubMed, EMBASE, LILACS, Web of Science, Cochrane, Teseo and the ClinicalTrials.gov registry for clinical trials and cohort or case-control studies which compared the clinical outcomes and adverse effects of collagenase with those of fasciectomy or PNF. Of 1345 articles retrieved, ten were selected. They described the outcomes of 425 patients treated with collagenase and 418 treated by fasciectomy or PNF. Complications were assessed using inverse-variance weighted odds ratios (ORs). Clinical efficacy was assessed by differences between the means for movement of the joint before and after treatment. Dose adjustment was applied in all cases. Results. Random-effects modelling showed that patients treated with collagenase had 3.24 increased odds of adverse effects compared with those treated by fasciectomy (OR 4.39) or PNF (OR 1.72,). The effect was lost when only major complications were assessed. Joint movement analysis revealed a difference between means of less than 10%, indicating equivalent clinical efficacy in the short and medium term for collagenase and fasciectomy. We were unable to analyse this for PNF due to a shortage of data. Conclusion. There were no significant differences in effect size between collagenase and fasciectomy. The use of collagenase was associated with a higher overall risk of adverse effects than both fasciectomy and PNF. Cite this article: Bone Joint J 2018;100-B:73–80


The Bone & Joint Journal
Vol. 99-B, Issue 3 | Pages 376 - 382
1 Mar 2017
Plant CE Parsons NR Costa ML

Aims. We conducted a study to determine whether radiological parameters correlate with patient reported functional outcome, health-related quality of life and physical measures of function in patients with a fracture of the distal radius. Patients and Methods. The post-operative palmar tilt and ulnar variance at six weeks and 12 months were correlated with the Patient Rated Wrist Evaluation, Disabilities of the Arm, Shoulder and Hand, and EuroQol scores, grip strength, pinch strength and range of movement at three, six and 12 months for 50 patients (mean age 57 years; 26 to 85) having surgical fixation, with either percutaneous pinning or reconstruction with a volar plate, for a fracture of the distal radius. Results. Radiological parameters were found to correlate poorly with the patient reported outcomes (r = 0.00 to 0.47) and physical measures of function (r = 0.01 to 0.51) at all intervals. Conclusion. This study raises concerns about the use of radiological parameters to determine management, and to act as a surrogates for successful treatment, in patients with a fracture of the distal radius. Restoration of ‘normal’ radiographic parameters may not be necessary to achieve a satisfactory functional outcome for the patient. Cite this article: Bone Joint J 2017;99-B:376–82


The Bone & Joint Journal
Vol. 97-B, Issue 10 | Pages 1370 - 1376
1 Oct 2015
Jordan RW Saithna A

This article is a systematic review of the published literature about the biomechanics, functional outcome and complications of intramedullary nailing of fractures of the distal radius. We searched the Medline and EMBASE databases and included all studies which reported the outcome of intramedullary (IM) nailing of fractures of the distal radius. Data about functional outcome, range of movement (ROM), strength and complications, were extracted. The studies included were appraised independently by both authors using a validated quality assessment scale for non-controlled studies and the CONSORT statement for randomised controlled trials (RCTs). The search strategy revealed 785 studies, of which 16 were included for full paper review. These included three biomechanical studies, eight case series and five randomised controlled trials (RCTs). . The biomechanical studies concluded that IM nails were at least as strong as locking plates. The clinical studies reported that IM nailing gave a comparable ROM, functional outcome and grip strength to other fixation techniques. . However, the mean complication rate of intramedullary nailing was 17.6% (0% to 50%). This is higher than the rates reported in contemporary studies for volar plating. It raises concerns about the role of intramedullary nailing, particularly when comparative studies have failed to show that it has any major advantage over other techniques. Further adequately powered RCTs comparing the technique to both volar plating and percutaneous wire fixation are needed. Cite this article: Bone Joint J 2015;97-B:1370–6


The Bone & Joint Journal
Vol. 97-B, Issue 8 | Pages 1082 - 1089
1 Aug 2015
Tubeuf S Yu G Achten J Parsons NR Rangan A Lamb SE Costa ML

We present an economic evaluation using data from the Distal Radius Acute Fracture Fixation Trial (DRAFFT) to compare the relative cost effectiveness of percutaneous Kirschner wire (K-wire) fixation and volar locking-plate fixation for patients with dorsally-displaced fractures of the distal radius. . The cost effectiveness analysis (cost per quality-adjusted life year; QALY) was derived from a multi-centre, two-arm, parallel group, assessor-blind, randomised controlled trial which took place in 18 trauma centres in the United Kingdom. Data from 460 patients were available for analysis, which includes both a National Health Service cost perspective including costs of surgery, implants and healthcare resource use over a 12-month period after surgery, and a societal perspective, which includes the cost of time off work and the need for additional private care. . There was only a small difference in QALYs gained for patients treated with locking-plate fixation over those treated with K-wires. At a mean additional cost of £714 (95% confidence interval 588 to 865) per patient, locking-plate fixation presented an incremental cost effectiveness ratio (ICER) of £89 322 per QALY within the first 12 months of treatment. Sensitivity analyses were undertaken to assess the ICER of locking-plate fixation compared with K-wires. These were greater than £30 000. . Compared with locking-plate fixation, K-wire fixation is a ‘cost saving’ intervention, with similar health benefits. Cite this article: Bone Joint J 2015;97-B:1082–9


The Bone & Joint Journal
Vol. 97-B, Issue 7 | Pages 957 - 962
1 Jul 2015
Yamazaki H Uchiyama S Komatsu M Hashimoto S Kobayashi Y Sakurai T Kato H

There is no consensus on the benefit of arthroscopically assisted reduction of the articular surface combined with fixation using a volar locking plate for the treatment of intra-articular distal radial fractures. In this study we compared the functional and radiographic outcomes of fluoroscopically and arthroscopically guided reduction of these fractures.

Between February 2009 and May 2013, 74 patients with unilateral unstable intra-articular distal radial fractures were randomised equally into the two groups for treatment. The mean age of these 74 patients was 64 years (24 to 92). We compared functional outcomes including active range of movement of the wrist, grip strength and Disabilities of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic outcomes that included gap, step, radial inclination, volar angulation and ulnar variance.

There were no significant differences between the techniques with regard to functional outcomes or radiographic parameters. The mean gap and step in the fluoroscopic and arthroscopic groups were comparable at 0.9 mm (standard deviation (sd) 0.7) and 0.7 mm (sd 0.7) and 0.6 mm (sd 0.6) and 0.4 mm (sd 0.5), respectively; p = 0.18 and p = 0.35).

Arthroscopic reduction conferred no advantage over conventional fluoroscopic guidance in achieving anatomical reduction of intra-articular distal radial fractures when using a volar locking plate.

Cite this article: Bone Joint J 2015; 97-B:957–62.


The Bone & Joint Journal
Vol. 97-B, Issue 2 | Pages 229 - 234
1 Feb 2015
Choi W Lee HJ Kim D Lee C Lee BG Kim J Lee K

We performed a retrospective study to determine the effect of osteoporosis on the functional outcome of osteoporotic distal radial fractures treated with a volar locking plate. Between 2009 and 2012 a total of 90 postmenopausal women with an unstable fracture of the distal radius treated with a volar locking plate were studied. Changes in the radiological parameters of 51 patients with osteoporosis (group 1, mean age 66.9, mean T-score –3.16 (sd 0.56)) were not significantly different from those in 39 patients without osteoporosis (group 2, mean age 61.1, mean T-score –1.72 (sd 0.57)). The mean Disabilities of the Arm, Shoulder and Hand (DASH) score at final follow-up was 11.5 (sd 12.2) in group 1 and 10.5 (sd 13.25) in group 2. The mean modified Mayo wrist score at final follow-up was 79.0 (sd 14.04) in group 1 and 82.6 (sd 13.1) in group 2. However, this difference was not statistically significant (p = 0.35 for DASH score, p = 0.2 for modified Mayo wrist score). Univariable and multivariable logistic regression analysis showed that only the step-off of the radiocarpal joint was related to both a poor DASH and modified Mayo wrist score. Pearson’s correlation coefficient showed a weak negative relationship only between the T-score and the change in volar tilt (intraclass coefficient –0.26, p = 0.02).

We found that osteoporosis does not have a negative effect on the functional outcome and additional analysis did not show a correlation between T-score and outcome.

Cite this article: Bone Joint J 2015;97-B:229–34.


The Bone & Joint Journal
Vol. 95-B, Issue 12 | Pages 1687 - 1696
1 Dec 2013
Nishizuka T Tatebe M Hirata H Shinohara T Yamamoto M Iwatsuki K

The purpose of this study was to evaluate treatment results following arthroscopic triangular fibrocartilage complex (TFCC) debridement for recalcitrant ulnar wrist pain. According to the treatment algorithm, 66 patients (36 men and 30 women with a mean age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain were allocated to undergo ulnar shortening osteotomy (USO; n = 24), arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement (n = 14) or prolonged conservative treatment (n = 13). The mean follow-up was 36.0 months (15 to 54). Significant differences in Hand20 score at 18 months were evident between the USO group and TFCC debridement group (p = 0.003), and between the TFCC repair group and TFCC debridement group (p = 0.029). Within-group comparisons showed that Hand20 score at five months or later and pain score at two months or later were significantly decreased in the USO/TFCC repair groups. In contrast, scores in the TFCC debridement/conservative groups did not decrease significantly. Grip strength at 18 months was significantly improved in the USO/TFCC repair groups, but not in the TFCC debridement/conservative groups. TFCC debridement shows little benefit on the clinical course of recalcitrant ulnar wrist pain even after excluding patients with ulnocarpal abutment or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement.

Cite this article: Bone Joint J 2013;95-B:1687–96.


The Bone & Joint Journal
Vol. 95-B, Issue 11 | Pages 1514 - 1520
1 Nov 2013
D’Agostino P Barbier O

The osteoinductive properties of demineralised bone matrix have been demonstrated in animal studies. However, its therapeutic efficacy has yet to be proven in humans. The clinical properties of AlloMatrix, an injectable calcium-based demineralised bone matrix allograft, were studied in a prospective randomised study of 50 patients with an isolated unstable distal radial fracture treated by reduction and Kirschner (K-) wire fixation. A total of 24 patients were randomised to the graft group (13 men and 11 women, mean age 42.3 years (20 to 62)) and 26 to the no graft group (8 men and 18 women, mean age 45.0 years (17 to 69)).

At one, three, six and nine weeks, and six and 12 months post-operatively, patients underwent radiological evaluation, assessments for range of movement, grip and pinch strength, and also completed the Disabilities of Arm, Shoulder and Hand questionnaire. At one and six weeks and one year post-operatively, bone mineral density evaluations of both wrists were performed.

No significant difference in wrist function and speed of recovery, rate of union, complications or bone mineral density was found between the two groups. The operating time was significantly higher in the graft group (p = 0.004). Radiologically, the reduction parameters remained similar in the two groups and all AlloMatrix extraosseous leakages disappeared after nine weeks.

This prospective randomised controlled trial did not demonstrate a beneficial effect of AlloMatrix demineralised bone matrix in the treatment of this category of distal radial fractures treated by K-wire fixation.

Cite this article: Bone Joint J 2013;95-B:1514–20.


The Bone & Joint Journal
Vol. 95-B, Issue 8 | Pages 1094 - 1100
1 Aug 2013
Baltzer H Binhammer PA

In Canada, Dupuytren's contracture is managed with partial fasciectomy or percutaneous needle aponeurotomy (PNA). Injectable collagenase will soon be available. The optimal management of Dupuytren’s contracture is controversial and trade-offs exist between the different methods. Using a cost-utility analysis approach, our aim was to identify the most cost-effective form of treatment for managing Dupuytren’s contracture it and the threshold at which collagenase is cost-effective. We developed an expected-value decision analysis model for Dupuytren’s contracture affecting a single finger, comparing the cost-effectiveness of fasciectomy, aponeurotomy and collagenase from a societal perspective. Cost-effectiveness, one-way sensitivity and variability analyses were performed using standard thresholds for cost effective treatment ($50 000 to $100 000/QALY gained). Percutaneous needle aponeurotomy was the preferred strategy for managing contractures affecting a single finger. The cost-effectiveness of primary aponeurotomy improved when repeated to treat recurrence. Fasciectomy was not cost-effective. Collagenase was cost-effective relative to and preferred over aponeurotomy at $875 and $470 per course of treatment, respectively. . In summary, our model supports the trend towards non-surgical interventions for managing Dupuytren’s contracture affecting a single finger. Injectable collagenase will only be feasible in our publicly funded healthcare system if it costs significantly less than current United States pricing. Cite this article: Bone Joint J 2013;95-B:1094–1100