Session 2: Hand and Wrist

Rasmus Wejnold Jørgensen , Kiran Anderson, Claus Hjorth Jensen
Håndkirurgisk Klinik, Ortopædkirurgisk afd. , Gentofte Hospital; Håndkirurgisk klinik, Ortopædkirurgisk afd., Gentofte University Hospital, Copenhagen, Denmark; Håndkirurgisk klinik, Gentofte Hospital


Background: Recovery time after surgery for thumb CMC-1 J osteoarthritis usually approximates three to six months regardless of operative technique.
Purpose / Aim of Study: The purpose of this study was to examine if adding a suspension arthroplasty (Mini Tight Rope, Arthrex) to Ligament Reconstruction Tendon Interposition of the CMC-1 joint would add stability to the thumb and thereby give a faster recovery and less pain at 6 months postoperatively.
Materials and Methods: 12 consecutive patients underwent thumb CMC-1 J LRTI arthroplasty a.m. Burton Pellegrini. In addition, they underwent a suspension arthroplasty using two strands of #2 FiberWire suture which are fixed with two oblong stainless-steel buttons for cortical fixation between first and second metacarpal bone (Mini Tight Rope, Arthrex). Patients were then given a soft cast and mobilization was begun at 3-5 days after surgery. The patients are followed using Quick- DASH questionnaire, VAS pain, satisfaction, range of motion and pinch strength preoperatively and at 3, 6, 12 and 24 months postoperatively. Each patient was matched with three controls from our own database of 250 patients receiving only LRTI arthroplasty matched on gender, age and preoperative Q-DASH.
Findings / Results: Preoperative Q-DASH for cases has a median of 44 (range 13-70) and for controls a median of 45 (range 13-75). 6-month postoperative Q-DASH for cases has a median of 6.8 (range 0-27) and controls a median of 20,5 (range 0-70). Preliminary results show a significant difference in Q-DASH for cases and controls at 6 months postoperatively. Regarding question 9 of the Q-DASH (1=no pain and 5=extreme pain) cases has a preoperative median of 4 (range 2-4) and for controls a median of 3 (range 3-5). 6-month postoperative results show a median of 1 (range 1-3) for cases and a median of 2 (range 1-5) for controls. This is not statistically significant.
Conclusions: Treating thumb CMC-1 osteoarthritis with a combination of LRTI and suture suspension arthroplasty between first and second metacarpal bone show significantly lower Q-DASH at 6-months follow up compared to LRTI alone. However, the pain level at 6-months follow up is not significantly different for case and controls.

Sebastian Breddam Mosegaard, Maiken Stilling, Torben Bæk Hansen
University Clinic for Hand, Hip and Knee Surgery, Department of Orthopaedics, Regional Hospital West Jutland; University Clinic for Hand, Hip and Knee Surgery, Department of Orthopaedics, Regional Hospital West Jutland; University Clinic for Hand, Hip and Knee Surgery, Department of Orthopaedics, Regional Hospital West Jutland


Background: Carpal tunnel syndrome is a common upper limb nerve compression disease where operative treatment is used when conservative treatment fails. However, several factors may influence the results of the operation including preoperative pain catastrophizing.
Purpose / Aim of Study: Based on demographic characteristics, PROMs and with special reference to pain catastrophizing the purpose of this study was to identify risk factors for low patient- reported satisfaction following surgical treatment of idiopathic CTS with CTR. The main hypothesis of this study was that: Higher preoperative pain catastrophizing increases the risk of low postoperative patient reported satisfaction.
Materials and Methods: A total of 417 hands from 417 patients (64.5% females) with a mean age of 58.0 years was included in this 1-year prospective follow-up study. Data on DASH score, EQ-5D, distal motor latency and pain catastrophizing was collected preoperatively and data on DASH score, EQ-5D and patient satisfaction was collected 12 months postoperatively. Wilcoxon matched-pairs signed-rank test was used to test for improvement in DASH and EQ-5D. Risk factors for low postoperative patient reported satisfaction was examined using stepwise multiple logistic regression analysis.
Findings / Results: We found a general improvement in patients DASH score (12.29 [95% CI: 10.65 – 13.90], p<0.001) and EQ-5D (0.14 [95% CI: 0.13 – 0.16], p<0.001) from preoperative to 12 months postoperative. In the fully adjusted multiple regression analysis there was only statistically significant effect of preoperative pain catastrophizing. A 1-unit increase on the preoperative pain catastrophizing scale lead to an increased risk of OR=1.05 (p=0.022) for low 12-month postoperative patient satisfaction. There was no statistically significant predictive effect of preoperative EQ-5D (p=0.869), DASH (p=0.076), distal motor latency (p=0.067), age (p=0.505), or gender (p=0.222) on 12-month postoperative patient satisfaction.
Conclusions: Patients improved both DASH and EQ-5D scores from preoperative to 12 months postoperative. Higher preoperative score on the Pain Catastrophizing Scale seems to have a negative effect on postoperative patient reported satisfaction 12 months after carpal tunnel release.

Sabine Simonsen, Søren Ohrt-Nissen, Robert Gvozdenovic
Orthopaedic Surgery, Herlev-Gentofte Hospital; Orthopaedic Surgery, Hvidovre Hospital; Orthopaedic Surgery, Gentofte Hospital


Background: Traumatic disruption of the Triangular fibrocartilage complex (TFCC) is a common cause of ulnar sided wrist pain and is often associated with decreased grip strength and impaired function .TFCC injuries are present in up to 80% of displaced distal radius fractures, but can also occur after a minor wrist trauma. TFCC injuries that do not respond to conservative treatment should be offered diagnostic arthroscopic surgery and re- attachment if indicated.
Purpose / Aim of Study: The aim of this study was to evaluate the clinical and patient-reported outcome one year after TFCC re- attachment by modified ulnar tunnel technique.
Materials and Methods: Between April 2013 and June 2018, 32 patients underwent surgery with the modified Iwasaki ulnar tunnel technique for foveal re-attachment of TFCC injury. All patients had ulnar- sided wrist pain and mild instability of the distal radioulnar joint (DRUJ). Diagnosis was finally established intraoperatively by the hook-test. All patients were immobilized for 2 weeks in a sugar tong splint and then with a removable orthosis with limited rotation for further 4 weeks. Full weight-bearing activities were allowed at 3 months. Prospective evaluation included assessment of pain (VAS score), grip strength, range of motion and q-DASH score.
Findings / Results: The study included 32 patients with 31 available for one-year follow-up. 21 patients had preoperative MRI of which 13 (62 %) showed no signs of TFCC injury. Median preoperative activity VAS score was 60 [50-70], which decreased to 14 [6-20] (p=0.001). Median q-DASH score was 41 [36-43], which improved to 11 [4-25] (p ¡Ü 0.001). Grip strength also improved significantly (p ¡Ü 0.001), while improvement in rotation of the forearm was observed without significance. All patients achieved full stability, except one who needed re-fixation due to early discontinuation of the splint. One patient underwent synovectomy without improvement of symptoms. One patient was referred to SL ligament reconstruction.
Conclusions: Modified ulnar tunnel method improves stability and symptoms in patients with TFCC injury. Preoperative MRI is not sensitive for TFCC injury and should primarily be considered for differential diagnostic purposes.

Lotte Priess Larsen, Torben Bæk Hansen
Orthopedic , Regional Hospital West Jutland; Orthopedic, Regional Hospital West Jutland


Background: In recent years the concept of WALANT (Wide Awake Local Anaesthetic No Tourniquet) surgery has gained in popularity and is increasingly reported internationally as useful in hand surgery. WALANT provides benefits for both the patient and the surgeon, but concerns are present regarding the use in more complex surgical procedures. Numerous case reports of WALANT in hand surgery are available but studies describing total joint arthroplasty (TJA) of the trapeziometacarpal joint are yet to be published.
Purpose / Aim of Study: With this study we wanted to do a descriptive study of possible adverse effects and patient acceptance of WALANT in TJA of the trapeziometacarpal joint and to compare the duration of the operation in WALANT with TJA performed in a bloodless field under general or regional anaesthesia.
Materials and Methods: In a matched cohort study we compared duration of the operation in 27 patients at mean age 58 (range 48-69) receiving TJA in WALANT with 27 patients at mean age 59 (range 43-72) receiving TJA in general or regional anaesthesia with the use of tourniquet. All patients were operated by the same surgeon in the same institution and with the same operative team. In the WALANT group we also registered conversion to general anaesthesia, intraoperative supplemental local anaesthesia, use of tourniquet, adverse effects to the anaesthesia and willingness to repeat (WTR).
Findings / Results: There were no conversions to general anaesthesia, 2 patients required additional local anaesthesia intraopertively, 1 patient required the use of tourniquet for 2 minutes, 1 case of adrenalin rush was registered. WTR in the WALANT group was 100%. There was no significant difference in operating time in the two groups.
Conclusions: The use of WALANT in thumb TJA surgery is well tolerated by patients and provides a safe and reliable method of anaesthesia. WALANT provides similar working conditions as experienced with the use of tourniquet during general/regional anaesthesia and is not associated with prolonged operating time.

Stig Jørring, Claus Hjorth Jensen
Department of orthopaedic surgery, Herlev Gentofte Hospital; Department of orthopaedic surgery, Herlev Gentofte Hospital


Background: Few studies report on recurrence rates following treatment with collagenase histolyticum injections (CI) of Dupuytrens contracture in comparison to other treatment modalities.
Purpose / Aim of Study: To evaluate CI against another minimally invasive treatment modality a RCT comparing CI and percutaneous needle fasciotomy (PNF) of the MCP joints in Dupuytrens Contracture (DC) was undertaken.
Materials and Methods: 77 patients suffering from DC with isolated extension deficit > 30 degrees in the MP joint were randomized in a RCT. The patients were allocated to either CI injection in accordance with manufacturers guidelines or PNF. Only one finger was treated in each patient, and only one injection was given to the patients in the CI group. A correction of 20 degrees in extension deficit at 1 month was considered an acceptable result. Patients were followed 1-3 years. Recurrence of > 30 degrees or new treatment of the finger were considered failure.
Findings / Results: 5 patients withdrew from the study prior to treatment leaving 34 patients in the CI group and 36 in the PNF group. At 1 month 32 patients in the CI group (94%) and 35 patients in the PNF group (97 %) were considered having an acceptable result and were consequently planned for subsequent follow up at 1, 2, 3 and 5 years. Analysis of durability in accordance with Kaplan Meyers Statistics showed a significantly lower recurrence rate of DD in favour of CI treatment 1 to 3 years after treatment. Log Rank P 0.005.
Conclusions: Considering recurrence CI yields superior results compared to PNF at follow up at 1-3 years in the treatment of isolated DC in the metacarpophalangeal joints.

Jamila Eriksen, Niels Henrik Søe, Dimitar Ivanov Radev, Xiong Xie, Eva Balslev, Merete Juhl Kønig, Lisbeth Vesterløkke, Helle Raagaard Larsen, Nana Vermehren, Guðlaug Rósa Sigurðardóttir, Britt Ebstrup,
Department of Handsurgery, Nordsjællands Hospital; Department of Handsurgery, Herlev and Gentofte University Hospital; Department of Radiology, Bispebjerg Hospital; Department of MRI, Herlev and Gentofte University Hospital; Department of Pathology, Herlev and Gentofte University Hospital; Department of ultrasound, Herlev and Gentofte University Hospital; Department of Handsurgery, Herlev and Gentofte University Hospital; Department of Handsurgery, Herlev and Gentofte University Hospital; , Aleris-Hamlet Hospital; Department of Anæestesiology, Rigshospitalet; Anæstesiology and Day Care Surgery, Herlev and Gentofte University Hospital; ,


Background: The clinical dorsal wrist ganglion accounts for 60- 70% of the hand and wrist ganglia. Little is known of the ætiology or pathogenesis of this unsightly and often painful soft tissue mass and recurrence after lege artis surgical incision is seen in up to 30% of cases.
Purpose / Aim of Study: The purpose of the study is to gather as much knowledge about the dorsal wrist ganglion as possible through patient history, imaging and pathological examination to see whether this can improve diagnosis and treatment and hinder recurrence.
Materials and Methods: 42 patients with clinical dorsal ganglion have over two years been included into the study at two Danish handsurgery departments. The affected wrists, which have not formerly been treated, have been examined by X-ray, MRI imaging and ultrasound imaging. After excision of the dorsal wrist ganglion by the same surgeon, the tissue has been stained with CD68, vimentin and D2-40 and examined microscopically. Patients are followed at 3 months, 6 months, 1 year and 2 years and in case of recurrence. The study is ongoing.
Findings / Results: We discovered that approximately 50% of the clinical dorsal ganglia were ganglion cysts and 50% synovial cysts. Preliminary results show greater recurrence rates in patients with synovial cysts. X- ray, MRI and ultrasound imaging cannot precisely give the exact origin nor predict the type of tissue the mass is composed of. Neither is there a clear connection to gender, former trauma or occupation.
Conclusions: This study shows that although the clinical dorsal ganglion has the same appearance, location and similar characteristics on X-ray, MRI and ultrasound imaging, the tissue excised is clearly one of two distinct tissue types, namely ganglion and synovial cysts. The aforementioned imaging techniques are therefore not clinically diagnostic and may not be justified in the diagnosis and treatment of dorsal wrist ganglia. The discovery of differences in recurrence rate in the two tissue types is also new information, which can lead to improved patient information and begin to question the choice of treatment method whether it be open or arthroscopic excision.

Lars Soelberg Vadstrup
Ortopædkirurgisk afdeling, Herlev Gentofte Hospital


Background: The objective of this study is to evaluate scapholunate ligament reconstruction using a modified ScaphoLunate Axis Method (SLAM) in patients with a dynamic or reducible static scapholunate ligament tear. Many different methods have been suggested in the past, some with promising results and some with less promising results. The minimal invasive SLAM procedure is reliable in treating SL ruptures and the results are promising.
Purpose / Aim of Study: To evaluate scapholunate ligament reconstruction using a modified ScaphoLunate Axis Method (SLAM) in patients with a dynamic or reducible static scapholunate ligament tear.
Materials and Methods: Between June 2014 and June 2019, 43 consecutive patients have been operated using the ScaphoLunate Axis Method (Arthrex) for reconstruction of a scapholunate ligament tear. The SL lesion was identified by wrist arthroscopy, and the scaphoid reducibility was identified prior to minimal open ligament reconstruction in a single session. Follow-up was 12 months. Evaluation pre-operatively and at 3, 6 and 12 month after surgery included assessment of range of motion (ROM), grip strength and Disabilities of the Arm, Shoulder and Hand (quick-DASH) Score.
Findings / Results: There were three complications during surgery the operative procedures or the recovery / hand therapy. All but one patient improved in the patient reported outcome measure at 12 months as q-DASH values improved significantly (p<0.05). Mean q-DASH value pre-operatively was 39 (range 9-80), and 21 (range 0-72) post-operatively. ROM and grip strength was unchanged at 12 month compared to pre-operative measures. Mean grip strength was 39 Kilogram- Forces (KgF) pre-operatively, and 43 KgF post- operatively (86 % strength of the contralateral side).
Conclusions: Short-term results of the SLAM procedure for patients with a dynamic or reducible static scapholunate ligament tear provided satisfactory results with a few observed complications. The presented technique using a tendon autograft (PL or part of the FCR) placed along the axis of rotation of the SL joint, fixated in both the scaphoid and the lunate, minimize loss of the obtained SL reduction and reconstructs the scapho-lunate ligament complex.

Cæcilie West, Robert Gvozdenovic, Dimitar Radev
Handsection, Department of Orthopeadic Surgery, Herlev Gentofte Hospital; Handsection, Department of Orthopeadic Surgery, Herlev Gentofte Hospital; Department of Radiology, Bispebjerg Frederiksberg Hospital


Background: Scaphoid waist fractures are often undisplaced but can be complicated by a humpback deformity with or without union. It is believed that not only nonunion, but also malunion can cause impaired outcome. However, there are no consensus on reliable measurements of scaphoid malunion to predict functional and subjective outcome. The lateral intrascaphoid angle (LISA) has previously shown to be a good predictor of outcome but is suspected to have poor inter- and intra-rater reliability. Height-length ratio (HLR) seems to have a high intra- and interrater reliability but a poor predictor of outcome and the dorsal cortical angle (DCA) seems to be less prone to observer bias than LISA but a poorer predictor of outcome. To our knowledge, the normal values of HLR, LISA and DCA, have never been investigated on a larger population of normal scaphoids.
Purpose / Aim of Study: To determine the normal values of the most commonly used measurements (HLR, LISA, DCA) on a sagittal CT scans of the scaphoid.
Materials and Methods: We included CT scans of normal wrists and scans with pathology not related to the scaphoid. Exclusion criteria were age younger than 18, any type of scaphoid pathology, signs of carpal instability, osteoarthritis and wrist-near fractures among others. All CT scans were reformatted along the long axis of the scaphoid and images of 0,5-2mm thickness were obtained. 3 observers (1 musculoskeletal radiologist, 1 hand surgeon and 1 orthopedic resident) applied the measurements. Descriptive values were calculated using measurement from all three observers. Interrater reliability was estimated using intraclass correlation coefficient.
Findings / Results: We investigated CT scans from 62 patients (53 % men), mean age 39 years. The mean HL-ratio was 0,58 (range 0,49-0,70), mean LISA 27 degrees (4- 58) and mean DCA was 128 degrees (106-151). Interrater reliability was good (0,83) for HL-ratio, moderate (0,74) for DCA and poor (0,03) for LISA.
Conclusions: This study provides an impression of the normal values of the scaphoid and may aid in decision making when defining malunion. We suggest that LISA cannot be utilized as a measure of deformity. Further studies on the correlation between HL-ratio, DCA and clinical outcome are needed.

Frederik Flensted Andersen, Rasmus Wejnold Jørgensen, Claus Hjorth Jensen, Jens-Christian Vedel, Henrik Daugaard
Hand Clinic, Department of Orthopedics, Herlev-Gentofte University Hospital ; Department of Orthopedics, Herlev-Gentofte University Hospital ; Hand Clinic, Department of Orthopedics, Herlev-Gentofte University Hospital ; Department of Orthopedics, Herlev-Gentofte University Hospital ; Hand Clinic, Department of Orthopedics, Herlev-Gentofte University Hospital


Background: Treatment options for trigger digits are typically either surgery or corticosteroid injections. Though previous studies have shown big differences in success- and recurrence rates when comparing the treatments, follow-ups have been short and cohorts small
Purpose / Aim of Study: The purpose of the study was to compare corticosteroid injection with surgical treatment of first time and reoccurring trigger finger
Materials and Methods: In a retrospective chart review, records of 815 patients referred with trigger finger during the period 2014-2015 were identified. Inclusion criteria was primary treatment of the finger with corticosteroid injection or surgery as first line treatment. 210 cases were excluded, due to previous treatment of the same finger or wrong diagnosis, as patients were initially identified by the ICD- 10 code for trigger finger. Primary treatment type, recurrence, secondary treatment type and comorbidities were recorded. Minimum follow-ups were 2 years.
Findings / Results: Of 605 primary trigger digits, 539 were treated with corticosteroid-injection and 66 with surgery as first line treatment. 330 recurrences in the corticosteroid group as compared to 8 in the surgery group were observed, Chi square, (p<0,001). Increased risk of recurrence was seen after treatment of the third finger regardless the treatment as compared to the other digits. Among others, carpal tunnel syndrome was associated with an increased risk of recurrence among those treated with injection. As second-line treatment, 207 patients had corticosteroid-injection, 106 were operated and 25 had other treatment. After second line treatment 106 trigger fingers recurred again in the injection group as compared to 8 in the surgery group, Chi square, (p<0,001). Time to recurrence was significantly shorter in the corticosteroid group, survival analysis (p<0,001) with a Hazard ratio of 6,839 (CI95%: 3,39-13,79, p<0,05).
Conclusions: Significantly higher recurrence rate of trigger finger was observed when comparing corticosteroid-injection to surgical treatment both primary and secondary. Recurrence happened faster upon surgery, but at any timepoint, the risk of recurrence are higher among those treated with corticosteroid-injection as primary treatment.

Benjamin Presman, Morten Bo Larsen , Dimitar Ivanov Radev, Stig Jørring, Claus Hjorth Jensen, Robert Gvozdenovic
Orthopaedic Surgery, Section of Hand Surgery, Gentofte Hospital, Copenhagen University, Hellerup, Denmark.; Orthopaedic Surgery, Section of Hand Surgery, Gentofte Hospital, Copenhagen University, Hellerup, Denmark.; Radiology , Gentofte Hospital, Copenhagen University, Hellerup, Denmark.; Orthopaedic Surgery, Section of Hand Surgery, Gentofte Hospital, Copenhagen University, Hellerup, Denmark.; Orthopaedic Surgery, Section of Hand Surgery, Gentofte Hospital, Copenhagen University, Hellerup, Denmark.; Orthopaedic Surgery, Section of Hand Surgery, Gentofte Hospital, Copenhagen University, Hellerup, Denmark.


Background: Non-union is reported to occur in approximately 10% of all scaphoid fractures. It is known, that the occurrence of nonunion is affected by factors such as fracture location, displacement and the time from injury to treatment. However, the impact of humpback deformity and bony cysts on union rate and time to healing after surgery has not been studied.
Purpose / Aim of Study: The purpose of this study was to examine, if the degree of humpback deformity or the size of cysts along the fracture line besides different treatment methods are associated with the union rate and healing time following surgery of scaphoid nonunion.
Materials and Methods: 63 patients with scaphoid delayed or nonunion and preoperative CT scans were retrospectively analyzed. Four orthopedic surgeons and one intra- scaphoid angle, the height/length ratio, the size of the cysts and displacement of the fracture were radiologist independently analyzed the CT scans. The dorsal cortical angle, measured. Healing was assessed by CT scan or by conventional x-ray and clinical examination.
Findings / Results: Open surgery was the treatment of choice in 49 patients, 8 patients were treated arthroscopically and 6 patients with delayed union were operated with percutaneous method. Overall union rate was 86% (54/63) and was achieved after 84 days (mean). The failure rate and time to healing was not associated with the degree of the humpback deformity, size of the cysts or displacement of the fracture. Patients treated arthroscopically achieved significantly faster healing (42 days) as compared to patients treated by open techniques (92 days) (p¡Ü0.05). Time from injury to surgery was significantly correlated with time to union but not associated with the union rate (p¡Ü0.05, p¡Ü0.4, respectively).
Conclusions: The degree of humpback deformity and the size of cysts along the fracture line have no predictive value for the surgical result. Time to healing following surgery is influenced by the surgical technique and the time from injury to the surgical treatment of scaphoid nonunion.