Session 16: Hand/Wrist and Trauma III

Maiken Stilling, Martin Bille Henriksen , Karsten Krøner, Bo Munk, Janni Kjærgaard Thilleman
Department of Orthopaedics, University Clinic of Hand, Hip and Knee Surgery, Hospital Unit West; Department of Orthopaedics, Aalborg University Hospital; Department of Orthopaedics, Aarhus University Hospital; Department of Orthopaedics, Aarhus University Hospital; Department of Orthopaedics, University Clinic of Hand, Hip and Knee Surgery, Hospital Unit West


Background: Long-term follow-up studies with surface-replacement (SR) proximal interphalangeal (PIP) finger arthroplasty are sparse.
Purpose / Aim of Study: To compare long-term fixation and function of cementless (CL) versus cemented (C) Avanta PIP arthroplasty.
Materials and Methods: In a prospective, randomized, patient- blinded clinical trial, we included 30 osteoarthritic PIP joints in 30 patients (7 males) at a mean age of 56 years (34-69). Dorsal Chamay approach, and CL (n=15) or C (n=15) fixation of SR PIP joint Avanta arthroplasty, was used in 1 of the 4 ulnar fingers. We present the long-term (7-10 years) follow-up of 23 patients evaluated with implant migration (RSA), radiographic and functional outcome, and patient reported pain and satisfaction.
Findings / Results: The proximal and distal components had similar mean subsidence and mean rotation around the long axis in the two groups (p>0.24). 3 CL and 2 C proximal components, and 1 CL and 2 C components, subsided more than 1mm. 8 CL and 7 C PIP joints had pronounced periarticular calcifications but no functional limitation (mean active ROM of 60°). Functional outcome was similar between groups (p>0.20) with mean active PIP ROM of 46° (range -9° to 55°), grip strength of 22 kg (sd 10), pinch strength of 1.9 kg (sd 0.9), Quick-DASH of mean 24 (sd 26), VAS pain at rest of mean 0.6 (sd 1.4), and VAS pain in loaded activity of 1.7 (sd 2.5). 4 fingers were stiff and 3 were amputated. 1 implant broke and was revised with arthrodesis. VAS satisfaction was 7 (sd 3.6). 70% were willing to repeat SR PIP surgery.
Conclusions: At long-term follow-up functional results, pain relief, and patient satisfaction with Avanta SR PIP arthroplasty was good. Fixation of CL and C components were similar, but 35% of components subsided. 65% of patients had pronounced periarticular calcifications but no functional limitation.

Lone Kirkeby, Lene Dremstrup, Torben Bæk Hansen
University Clinic of Hand, Hip and Knee Surgery, Regional Hospital Holstebro, Aarhus University; University Clinic of Hand, Hip and Knee Surgery, Regional Hospital Holstebro, Aarhus University; University Clinic of Hand, Hip and Knee Surgery, Regional Hospital Holstebro, Aarhus University


Background: Dual mobility cup design in total joint arthroplasty may result in increased mobility and fewer dislocations. In 2013 a dual mobility cup design was introduced to be used with the Elektra stem for total joint arthroplasty of the trapeziometacarpal (TM) joint.
Purpose / Aim of Study: To determine the functional outcome after TM total joint arthroplasty comparing the use of a dual mobility cup to the use of a standard (single mobility) cup.
Materials and Methods: The patients were prospectively included. All patients had Eaton grade 2 or 3 osteoarthritis in the TM joint. Patients operated June 2010 to October 2014 using the Elektra bimetal cementless screw cup (standard cup) were compared to patients operated June 2013 to September 2014 using the Moovis Elektra dual mobility press-fit cementless cup. In bilateral cases only the first operated hand was included. The Disability of the Hand, Shoulder and Arm (DASH) score, pain using a continuous 100-mm visual analog scale (VAS), grip strength, Karpandji score and extension of thumb were registered preoperatively and at 3 and 12 months after surgery.
Findings / Results: 58 patients (12 males/46 females), mean age 56 years (SD 7.0), in the Elektra bimetal group and 46 patients (6 males/40 females), mean age 58 years (SD 6.4), in the Moovis dual mobility group completed the study. Improvement in VAS at activity from preoperative to 12 months was significantly better in the Elektra bimetal group (P=0,024). We found no significant difference in the improvement regarding DASH, VAS at rest, grip strength, Karpandji score or extension of the thumb in the two groups. No dislocations were recorded in the observation period.
Conclusions: Dual mobility cup in total TM joint arthroplasty does not result in better mobility or functional outcome than a standard cup. No difference in dislocation rate was recorded.

Lene Dremstrup, Maiken Stilling, Lone Kirkeby, Torben Bæk Hansen
University Clinic for Hand, Hip and Knee Surgery,, Hospital Unit West, Holstebro; University Clinic for Hand, Hip and Knee Surgery, Department of Clinical Medicine, Aarhus University, Hospital Unit West, Holstebro, Aarhus University, Aarhus; University Clinic for Hand, Hip and Knee Surgery, Department of Clinical Medicine, Hospital Unit West, Holstebro, Aarhus University, Aarhus; University Clinic for Hand, Hip and Knee Surgery,Department of Clinical Medicine, Hospital Unit West, Holstebro, Aarhus University, Aarhus


Background: Cup failure is a recognized problem in total trapeziometacarpal (TM) joint prosthesis, which may be related to cup design and bone quality.
Purpose / Aim of Study: To evaluate cup migration and clinical outcome with the Elektra bi-metal TM screw cup.
Materials and Methods: Case-study of the first 50 patients (50 hands, 42 females) with Eaton stage 2-4 osteoarthritis of the TM joint scheduled for surgery with the Elektra bi-material (CoCr/TA6V) metal-on-metal gridblasted hydroxyapatite-coated TM screw cup (Nov 2011 thru June 2014). Bone Mineral Density (BMD) was measured pre-operative in the trapezium. Cup migration (model-based RSA), DASH score and function were measured at baseline, 3 months, 1 and 2 years. Total Translation (TT) of the cup was calculated as square root (x^2+y^2+z^2).
Findings / Results: Patients were mean 57 years (range 43-71). All patients received the planned surgery and there were no intraoperative complications. TT cup migration at 2 years follow-up was mean 0.47 (sd 0.9) mm, and there was no increase in migration from 3 months to 2 years (p>0.19). At 2 years followup 3 cups (8%) had progressive migration above 1mm and might be loose. 4 cups were revised within the follow-up period, 3 due to aseptic loosening of which 2 also had pseudotumour, and 1 due to pain. 1 cup dislocated and had closed reduction. DASH score improved a mean 30 (sd 25) to 1 year (p=0.000). Pre-operative BMD measurements are ongoing.
Conclusions: Elektra bi-metal screw cup fixation was acceptable for most implants (92%) up to 2 years as measured by RSA, and the functional results improved significantly. The cup could be inserted in all patients and there were no intraoperative complications. However 8% were revised within 2 years and of these 2 had pseudotumour.

Maiken Stilling, Lone Kirkeby, Lene Dremstrup, Torben Bæk-Hansen
Department of Orthopaedics, University Clinic of Hand, Hip and Knee Surgery, Hospital Unit West; Department of Orthopaedics, University Clinic of Hand, Hip and Knee Surgery, Hospital Unit West; Department of Orthopaedics, University Clinic of Hand, Hip and Knee Surgery, Hospital Unit West; Department of Orthopaedics, University Clinic of Hand, Hip and Knee Surgery, Hospital Unit West


Background: Cup failure is a recognized problem in total trapeziometacarpal (TM) joint prosthesis, which may be related to cup design and bone quality.
Purpose / Aim of Study: To evaluate cup migration and clinical outcome with a new large conical press-fit TM cup design with dual- mobility articulation.
Materials and Methods: Case-study of the first 50 patients (50 hands, 43 females) with Eaton stage 2-4 osteoarthritis of the TM joint scheduled for surgery with the Moovis Elektra press-fit dual-mobility TM cup (June 2013 thru June 2014). Bone Mineral Density (BMD) was measured pre-operative in the trapezium. Cup migration (model-based RSA), DASH score and function were measured at baseline, 3 months, 1 and 2 years. Total Translation (TT) of the cup was calculated as square root (x^2+y^2+z^2).
Findings / Results: Patients were mean 56 years (range 43-69). Only 44 out of planned 50 Moovis cups were inserted because 3 trapeziums were too small, 2 trapeziums fractured and 1 was too soft. Pre-operative BMD was mean 0.67 (range 0.42 – 1.04) g/cm2. TT cup migration at 2 years followup was mean 0.39 (sd 0.6) mm, and there was no increase in migration from 3 months to 2 years (p>0.20). At 2 years followup 2 Moovis cups (6%) had progressive migration above 1mm and might be loose, but no cups dislocated or were revised by 2 years followup. There was no correlation between pre- operative BMD and cup migration (p>0.43). DASH score improved a mean 22 (sd 24) to 1 year (p=0.000).
Conclusions: Moovis Elektra cup fixation was acceptable for most implants (94%) up to 2 years, no implants dislocated or were revised, and the functional results improved up to 1 year. The cup was too large to fit the trapezium in 3 patients, but instead a smaller cup design (Electra Bimetal) could be utilized. 3 patients had intraoperative trapezium fracture, which may be related to the large cup size.

Andrey Kovalev, Lone Kirkeby, Torben Bæk Hansen
University Clinic for Hand, Hip and Knee Surgery , Regional Hospital Holstebro, Aarhus University ; University Clinic for Hand, Hip and Knee Surgery , Regional Hospital Holstebro, Aarhus University ; University Clinic for Hand, Hip and Knee Surgery, Regional Hospital Holstebro, Aarhus University


Background: Heterotopic ossification (HO) is a frequent complication after surgery of the hip and the pelvis, however the pathophysiological entities responsible for the formation of HO remain largely unclear.
Purpose / Aim of Study: The incidence of heterotopic ossification (HO) following total joint replacement of the trapeziometacarpal (TMC) joint is unknown, and the purpose of this study was to study the incidence of HO 12 months after TMC total joint replacement, and the impact of HO on self reported functional outcome.
Materials and Methods: All patients who had TMC total joint replacement during the period 2004-2014 were prospectively included in the study with radiographs 12 months after the operation, and classified using the Brooker classification adapted to the TMC joint. Self reported functional outcome was measured with the Disabilities of the Arm, Shoulder and Hand score (DASH score), and pain at rest and activity using a continous 100- mm visual analog scale (VAS).
Findings / Results: A total of 329 TMC joints with implants were egelible for the study, but 19 joints were excluded because of missing radiographs or due to loss of follow-up leaving 310 joints for evaluation. The incidence of Brooker grade 3+4 calcifications was 27% (85/310) at 12 months. Implant fixation type (cemented vs cementless) did not influence the incidence of HO, but a significant higher incidence of HO in metal on metal compared to metal on polyethylene articulation was found. We did not find any association between HO and DASH or VAS at 12 months.
Conclusions: HO is observed with the same frequency after TMC joint total replacement as in hip replacement, and articulation with metal on metal seems to increase the risk of HO. However HO seems not to influence patient reported outcome or pain at 12 months after the operation.

Jan Duedal Rölfing, Mette Normann Lund, Lars Borris, Daniel Wæver, Rikke Thorninger
Dept. of Orthopaedics, Aarhus University Hospital, Aalborg University Hospital; Dept. of Orthopaedics, Aarhus University Hospital; Dept. of Orthopaedics, Aarhus University Hospital; Dept. of Orthopaedics, Aarhus University Hospital; Dept. of Orthopaedics, Aarhus University Hospital, Randers Regional Hospital


Background: The Danish guidelines regarding distal radius fractures (DRF) (AO type 23-A2-3, 23-C1-3) warrant operation, if one of the following 5 criteria is met after closed reduction: dorsal tilt >10 degrees; ulnar variance >2 mm; articular step-off >2 mm; incongruence of the distal radioulnar joint (DRUJ); substantial comminution of the dorsal cortex. Many DRF classification systems exist and their inter-rater agreement varies widely, however the inter- rater agreement of the Danish DRF guidelines has not yet been determined.
Purpose / Aim of Study: To estimate the inter-rater agreement of the Danish DRF guidelines.
Materials and Methods: A trauma consultant and a medical officer independently rated 176 radiographs of Colles’ fractures after closed reduction according to the 5 criteria. All 176 cases were operated at our institution between 2009 and 2013. Kappa statistics were applied.
Findings / Results: The inter-rater agreement regarding acceptable reduction (yes/no) was “poor”, because in only 49/176 cases the raters agreed on all five criteria. The agreement was “good” for dorsal tilt (kappa=0.67) and 120 patients were operated based on this indication. The observers agreed in 149/176 cases regarding articular step-off >2mm; 144/176 incongruence of DRUJ; 127/176 ulnar variance >2mm; and 90/176 substantial dorsal bone loss.
Conclusions: Careful consideration is necessary when one decides, which Colles’ fracture requires operation. For patients with high functional demands, the Danish DRF guidelines stipulate indications for ORIF. In the present study, unacceptable dorsal tilt was the primary indication for ORIF. However, in cases with less than 10 degrees dorsal tilt or if the observers did not agree about the dorsal tilt, the poor inter-rater agreement of the remaining 4 indications, highlights the subjective decision-making.

Lise Kronborg, Thomas Bandholm, Henrik Palm, Henrik Kehlet, Morten Tange Kristensen
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy, Copenhagen University Hospital at Hvidovre; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy, Clinical Research Centre, Department of Orthopedic Surgery, Copenhagen University Hospital at Hvidovre; Hip Fracture Unit, Department of Orthopedic Surgery, Copenhagen University Hospital at Hvidovre; Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy, Department of Orthopedic Surgery, Copenhagen University Hospital at Hvidovre


Background: Patients with a hip fracture (HF) experience knee- extension strength deficit in the fractured limb of more than 50% and impaired physical function immediately after HF surgery. This is likely to contribute to the long term loss of physical function, change of residence and high mortality after HF.
Purpose / Aim of Study: To determine whether daily acute in-hospital physiotherapy (PT) with progressive knee-extension strength training (10RM) of the fractured limb using ankle weight cuffs in 3 sets of 10 repetitions, is more efficacious in reducing knee-extension strength deficit at follow-up compared to PT without strength training in patients with a HF.
Materials and Methods: A randomized, assessor-blinded study of 90 patients (mean age 79.6 (7.5) years, 69 women, 52 with a trochanteric fracture) admitted to the Hip Fracture Unit at Hvidovre Hospital. The primary outcome was the change in maximal isometric knee-extension strength in the fractured limb in % of the non- fractured limb from 1-3 days after surgery (baseline) to postoperative day 10 or discharge (follow-up).
Findings / Results: In the intention-to-treat analysis of between-group differences, the primary outcome improved 8.1%, CI (-2.3; 18.4) by additional strength training from baseline to follow-up versus a significant improvement by 10.5%, CI (0.3; 20.7) in the per- protocol analysis of non-missing data.
Conclusions: In-hospital PT with strength training was not more efficacious, although in favor, compared to PT without strength training in reducing the knee- extension strength deficit at follow-up in patients with HF, and the participants had a substantial strength deficit at follow-up despite targeted PT. It is debatable whether larger improvements than the observed can be expected given that only five exercise sessions, on average, were completed. Trial identifier: NCT00848913

Pernille Bovbjerg, Morten Schultz Larsen , Carsten Fladmose, Jesper Schønnemann
Orthopedic, Odense University Hospital; Orthopedic, Odense University Hospital; Orthopedic, Odense University Hospital; Orthopedic, SHS Aabenraa


Background: 50 % of elderly patients admitted with a hip fracture have a pertrochanteric fracture and are often treated with an intramedullary nail. In Denmark we have no consensus among orthopaedics in the choice of intramedullary nails.
Purpose / Aim of Study: To examine the incidence of reoperation and difference in failures for short gamma nail (SGN) and long gamma nail (LGN)
Materials and Methods: Patients with a pertrochanteric fracture treated with a Gamma 3 nail in 5 different hospitals in Southern Denmark in 2012 were included. Data was received from Dansk Tværfagligt register for hoftenære Lårbensbrud. All patients included were treated with either SGN or LGN. For all patients we received CPR, operation date, diagnose and if relevant reoperation date and treatment. All radiographs were examined to divide the patients into the two groups SGN and LGN and to classify the fracture. TAD and diathesis were measured on post operative x-rays. If the patient were reoperated the failure and the choice of treatment were found in the medical journal with 2 years follow up.
Findings / Results: 216 out of 250 fractures were included. Patients excluded did not have a pertrochanteric fracture, another treatment then Gamma 3 nail, another treatment or x-ray was not available. We found 12 reoperations, 5 and 7 in the SGN and LGN group. 3 cut out in each group. 1 patient with LGN sustained ipsilateral fracture after a second fall, but no patients with SGN had a secondary fracture. 1 patient with SGN had a hairline fracture seen on the post operative x-ray. 1 patient in each group had a total hip arthroplasty because of arthrosis. 1 with LGN had a non union and 1 with LGN had the nail removed because of pain.
Conclusions: There is no difference between SGN and LGN in the type of failures or the incidence of reoperations.

Jette Nielsen, Dorthe Sørensen, Lars Hyldstrup, Jens -Erik Beck Jensen, Henrik Palm
The Osteoporosis Clinic,Department 545, Copenhagen University Hvidovre Hospital; The Osteoporosis Clinic,Department 545, Copenhagen University Hvidovre Hospital; The Osteoporosis Clinic,Department 545, Copenhagen University Hvidovre Hospital; The Osteoporosis Clinic, Department 545, Copenhagen University Hvidovre Hospital; Hip Fracture Unit,Department of Orthopaedics, Copenhagen University Hvidovre Hospital


Background: Hip fracture (HF) patients have a high risk of sustaining other fractures already within the first postop. year, but early initiation of osteoporosis treatment might reduce the risk. Literature often describes sub-optimal osteoporosis evaluation and treatment initiation following HFs, with only around 10-15% of HF-patients starting anti-osteoporotic treatment.
Purpose / Aim of Study: We hypothesized that our Fracture Liaison Service (FLS) resulted in a higher rate of osteoporosis treatment.
Materials and Methods: Our FLS consists of two nurses from The Osteoporosis Clinic visiting the HF- Unit, located as a separate ward within the Dep. of Orthopaedics. All patient records are evaluated by the two FLS- nurses biweekly with use of a developed FLS-algorithm evaluating mental status, age and co-morbidities. Relevant patients are then bedside by the two FLS-nurses offered an outpatient clinic visit in the Dep. of Osteoporosis scheduled within 3-6 months postop. Here DXA-scans and blood samples are taken before the osteoporosis specialists examine and treat the patients.
Findings / Results: All 524 consecutive HF-patients admitted during 2014 were evaluated by the two FLS-nurses, who found 75% (393/524) to be candidates for an invitation to a follow-up visit in the osteoporosis outpatient clinic, 59% (312/524) accepted the invitation and were scheduled for a follow-up visit. 34% (178/524) met for examination in the outpatient clinic, where 22% (113/524) were given anti-osteoporotic treatment. This latter increased from 16% in 2013.
Conclusions: With this FLS-model, we reached a slightly higher rate of anti-osteoporotic treatment than most often described among HF-patients. The large group of invited patients not showing up in the outpatient clinic is a challenge and new actions are required to further increase the osteoporosis treatment subsequent to HFs.

Rasmus Wejnold Jørgensen, Stig Brorson, Claus Hjorth Jensen
Ortopædkirurgisk afdeling, Gentofte Hospital; Ortopædkirurgisk afdeling, Herlev Hospital; Ortopædkirurgisk afdeling, Gentofte Hospital


Background: Disorders of the thumb metacarpophalangeal (MCP) joint can lead to significant loss of function, and pain. Thumb MCP arthrodesis following traumatic injuries is inadequately described and recent studies have questioned the results follow this treatment.
Purpose / Aim of Study: The purpose of this study was to report outcome and disability following thumb metacarpophalangeal (MCP) joint arthrodesis due to traumatic injuries with chronic instability and pain.
Materials and Methods: A retrospective review of 26 patients operated with MCP joint arthrodesis, median follow-up 42 months (8- 104months). Subjective outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand- questionnaire (DASH). In addition, patient satisfaction, pain, stiffness, and impairment of activities of daily living were assessed on a Visual Analogue Scale (VAS) followed by a question on whether they would have undergone the same procedure again.
Findings / Results: Two patients (7.7%) needed re- operation due to continuous instability and pain. Four patients (15.4%) needed hardware removal. Median DASH-score was 18 (25-75% range 6- 47), with lower DASH scores being better. Scores were significantly worse than in gender and age matched individuals (p<0.05). Median VAS for pain was 3.7 (range 0-8). More than 50% of patients reported mild, moderate or severe pain but all patients reported that they were willing to undergo the same procedure again.
Conclusions: Our data suggests that patients with post-traumatic thumb injuries managed with thumb MCP joint arthrodesis perform worse than gender and age matched individuals. Many lived with pain, but all reported that they were willing to undergo the same procedure again. We suggest that the disability scale by the National Board of Industrial Injuries should be reconsidered for patients operated with thumb MCP artrhodesis.

Komal Tariq, Lisa Forkman, Julie Erichsen, Søren Overgaard, Bjarke Viberg
Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, University of Southern Denmark/Odense University Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, University of Southern Denmark/Odense University Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, University of Southern Denmark/Odense University Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, University of Southern Denmark/Odense University Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, University of Southern Denmark/Odense University Hospital


Background: Register studies have advocated for the use of the lateral approach (LA) to the hip instead of the posterior approach (PA) when performing hemiarthroplasty surgery in order to reduce subsequent hip dislocation.
Purpose / Aim of Study: The aim was to conduct a systematic review with meta-analysis to compare LA with PA in terms of major and minor complications (register studies not included).
Materials and Methods: On October 16th 2015 an electronic search of PubMed, Embase and Cochrane databases was performed. Two authors independently screened 4802 articles by title, abstract, and finally full text of 28 eligible articles was read. Data on demographics and complications was extracted by two authors and re-checked by further two authors. Complications were grouped into minor (no surgery) or major (open surgery) complications. The quality of studies was assessed according to Risk of Bias Assessment Tool for Nonrandomized Studies. Meta-analysis was only performed for dislocation due to lack of reporting for other complications.
Findings / Results: Six studies compromising 3348 patients, LA 1969 and PA 1379, was included thereof one RCT. The median follow-up ranged from 6-28 months. The quality of the cohort studies was in general low with high risk of bias. The risk ratio (95 % CI) for LA was 0.27 (0.17;0.41) for dislocation compared to PA. Only 2 studies had information on the major complications. One study was a cohort study showing difference in total revisions due to periprostethic fractures but included old cemented and uncemented stem designs. The other was the RCT which showed no differences in any parameter between LA and PA, and was the only study using a piriformis preserving approach.
Conclusions: LA demonstrates a 27 % reduced risk of dislocation, but in a RCT no difference was seen, which may be due to a piriformis preserving technique.