[Reconstruction of the middle phalangeal base of the finger using an osteocartilaginous autograft from the hamate]

Long-term preservation of metacarpophalangeal joint function in traumatic defects by metatarsophalangeal osteochondral transplantation

INTRODUCTION

The integrity of the metacarpophalangeal (MCP) joints is essential for finger and hand function. Preservation of range-of-motion is one of the aims in reconstruction of complex injuries to these joints. Osteochondral transplants have shown to be reliable in reconstruction of various joint defects. This series presents three patients with traumatic injuries to four MCP joints, which were reconstructed by seven avascular osteochondral transplants of metatarsophalangeal (MTP) joints. The joints were examined for radiographic signs of resorption or joint space narrowing, and if this would affect the joints' function in the long term.

METHODS

In three patients (40, 45 and 48 years) with complex injuries to their MCP joints (one milling, two saw injuries), four joints were reconstructed by three metatarsal head and four osteochondral transplants of the base of the proximal toe phalanges. Beside the joint itself, various soft tissue defects were reconstructed in each patient. The patients were clinically and radiographically examined after 9, 6, respectively, 7 years.

RESULTS

All patients were satisfied with the result without any pain in the MCP joints. Range-of-motion in the four affected joints rated 25, 60, 75, and 80°, DASH scores rated 13, 29, and 17, respectively. None of the patients complained of problems at their feet. Radiographic examination revealed moderate joint space narrowing in one of the four joints. In another patient, localized osteolysis was found around the screws' heads, so that the screws were removed 7 years post-op.

CONCLUSIONS

Osteochondral transplants for reconstruction of MCP defects are able to preserve function in severely injured joints even in the long term. Joint space narrowing may occur, which is not accompanied by pain, however. Since localized osteolysis can cause screw head prominence, mid-term radiographic follow-up is necessary to prevent damage to the joint. In the long term, remaining bone stock may be adequate for total joint replacement.

[Differented Aproaches for Fracture Treatment in the Hand - when doing what?]

Treatment of finger fractures is demanding twice. Malunion and incongruence of the joints frequently result in severe functional restriction and should not be tolerated. On the other hand surgical access to the fracture site is frequently limited by the proximity of vulnerable structures like nerves, vessels, ligaments, and tendons.This article presents a selection of treatment options, that in the opinion of the authors have been proven beyond the background of a large institution with reference to alternative procedures and the management of special situations.

Ligamentoplasty with interposition of the proximal interphalangeal joint in the treatment of unicondylar osteochondral defects: a cadaveric feasibility study

BACKGROUND

Injuries to the proximal interphalangeal (PIP) joint are common and complex. However, the treatment of osteochondral defects of the head of the proximal phalanx has rarely been described. Herein, we propose a new technique for the management of unicondylar defects of the proximal phalanx that can restore joint amplitudes and provide PIP stability.

METHODS

In this cadaveric feasibility study, unicondylar defects were generated using striking wedges and chisels. First, a transverse tunnel measuring 2 mm in diameter passing through the head of the proximal phalanx was made. A second tunnel at the base of the middle phalanx with the same diameter was then created. The hemitendon of the flexor carpi radialis graft was passed through each of these tunnels. The proximal end of the graft was interposed in the area with a loss of bone substance. The ligamentoplasty was then tensed and fixed by two anchors on the proximal phalanx. Joint amplitudes and frontal stability were measured preoperatively and postoperatively.

RESULTS

There was no significant change in the joint's range of motion: preoperatively, the mean mobility arcs were -2° to 113.80°, and they were -2° to 110° after the procedure (P=0.999). There was no significant difference in joint stability (P>0.05).

CONCLUSIONS

Ligamentoplasty with PIP interposition appears to be a possible solution for the management of unicondylar defects of the proximal phalanx. An evaluation of clinical results is planned in order to definitively confirm the validity of this procedure.

Viscoelastic properties of the human A2 finger pulley

INTRODUCTION

Biomechanical evaluation of the viscoelastic properties tissue deformation, stiffness, and maximum breaking load of the human A2 pulley. We hypothesized that the A2 pulleys of index, middle, and ring fingers exhibit no difference regarding the aforementioned biomechanical parameters.

METHODS

Forty-one A2 pulleys of 14 upper extremities (8 body donors) were assessed. Cyclic and load-to-failure testing were performed. The biomechanical parameters tissue deformation during cyclic and load-to-failure testing, stiffness, and maximum breaking load were determined.

RESULTS

No significant differences between the fingers could be detected regarding the biomechanical parameters. A significant negative correlation could be detected between stiffness and deformation of the pulley. Significant positive correlations could be identified between stiffness and maximum breaking load and between maximum breaking load and deformation of the pulleys.

CONCLUSIONS

Assessment of the viscoelastic properties of the A2 finger pulley promotes precise diagnosis of pulley lesions and will help to optimize treatment.

[Percutaneous treatment of unstable fractures of the base of the middle phalanx : Technique according to Hintringer and Ender]

OBJECTIVE

Reconstruction of intra-articular impression fractures of the middle phalanx by percutaneous reduction over a small dorsal cortical window. Stabilization by lattice-like arranged K‑wires.

INDICATIONS

Impression fractures of the base of the middle phalanx with or without dislocation in the proximal interphalangeal joint.

CONTRAINDICATIONS

Fractures extending to the shaft of the middle phalanx.

SURGICAL TECHNIQUE

By a cortical window at the dorsum of the middle phalanx (through the tendon free triangle) the impression fracture is reduced from the medullary cavity. Reduction is secured and the articular surface is supported by lattice-like arranged K‑wires.

POSTOPERATIVE MANAGEMENT

Thermoplastic splint for the finger for 6 weeks, subsequently K‑wire removal, active range of motion exercises and hand occupational therapy.

RESULTS

In two case series already published, good clinical and radiological results were reported. No complications were detected in either series.

Dorsal transosseous reduction and locking plate fixation for articular depressed middle phalangeal base fracture

PURPOSE

An articular depressed fragment at the base of the middle phalanx can be an obstacle to congruent reduction and stable fixation. This study assessed the outcomes of a transosseous reduction technique combined with locking plate fixation for the treatment of articular depressed middle phalangeal base fracture.

METHODS

Between 2015 and 2017, seven patients (eight fingers) with intraarticular comminuted middle phalangeal base fracture were included in this study. Mean follow-up was 19 months (range 12-30 months). All patients showed depression of the articular fragment on sagittal computed tomography (CT) scan and were treated with a transosseous reduction technique and dorsal locking plate fixation. Radiographic evaluation was performed to ensure restoration of a concentric articular surface postoperatively. Total active range of motion (TAM) of the finger, grip strength, and the quick Disabilities of the Arm, Shoulder and Hand (quick DASH) score were evaluated at the last follow-up. Complications were also assessed.

RESULTS

All fractures obtained bony union with a concentric joint. There was no significant loss of reduction during the follow-up period. The mean active proximal interphalangeal (PIP) joint and distal interphalangeal joint motion arcs at follow-up were 89° and 61°, respectively. Mean TAM of the affected finger and mean grip strength were 94% (range 80-100%) and 94% (range 86-100%) of the contralateral side, respectively. Mean quick DASH score was 2.3 (range 0-9.1). All patients returned to work. No surgery-related complications occurred.

CONCLUSIONS

This technique provides satisfactory restoration of articular congruence and enables the early joint mobilization of articular depression-type fractures of the base of the middle phalanx.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, level IV.