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Legerstee IWF, Derksen BM, van der Oest MJW, Hundepool CA, Duraku LS, Selles RW, Michiel Zuidam J. Clinical outcomes after primary repair for thumb ulnar collateral ligament ruptures: a systematic review and meta-analysis. J Hand Surg Eur Vol 2024; 49:534-545. [PMID: 38488512 DOI: 10.1177/17531934241235556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
There is no consensus on the best surgical technique for treating thumb ulnar collateral ligament (UCL) ruptures. This systematic review and meta-analysis investigates which primary repair technique and postoperative immobilization protocol result in the best clinical outcomes. A literature search was conducted in Embase, Medline ALL Ovid, Web of Science Core Selection and Cochrane Central Register of Controlled Trials. Pain, stability, tip pinch strength, key pinch strength, grip strength, return to work and metacarpophalangeal joint range of motion were collected as postoperative outcomes. In total, 29 studies were included. All surgical techniques resulted in satisfactory clinical outcomes, with no significant differences between bone anchor reinsertion, suture fixation, K-wire fixation and a combination of techniques. K-wire immobilization resulted in worse postoperative pain, but similar stability compared to immobilization without a K-wire. Clinical outcomes after thumb UCL repair are excellent, with no differences in clinical outcomes noted among surgical techniques.
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Affiliation(s)
- Ingmar W F Legerstee
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, the Netherlands
- Hand and Arm Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bas M Derksen
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Mark J W van der Oest
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Caroline A Hundepool
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Liron S Duraku
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, the Netherlands
- Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - J Michiel Zuidam
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, the Netherlands
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2
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Barrera-Ochoa S, Cavaca R, Sapage R, Martínez-Garza J, Prieto-Mere J, Mendez-Sanchez G. Biological Versus Nonbiological Reconstruction of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint: A Retrospective Study. J Hand Surg Am 2024; 49:432-442. [PMID: 38506782 DOI: 10.1016/j.jhsa.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/28/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE The purpose of this study was to compare clinical and radiologic outcomes of biological ligament reconstruction (BLR) versus nonbiological ligament reconstruction (NBLR) for chronic injuries involving the ulnar collateral ligament of the thumb's metacarpophalangeal joint. METHODS Forty-two patients who underwent static BLR (n = 24) or NBLR (n = 18) were included in this retrospective analysis. Preoperative, postoperative, and contralateral thumb measurements (clinical evaluation, radiographs, and subjective outcome questionnaires) were compared over a mean of 38 months of follow-up. RESULTS Average postoperative thumb metacarpophalangeal and interphalangeal joint ranges of motion were 2° to 54° and 0 to 71°, respectively, for BLR and 0° to 58° and 0° to 71°, respectively, for NBLR. Average grip and pinch strengths, relative to the unaffected hand, were 102% and 84% versus 103% and 89%, respectively. All patients demonstrated stability with a firm end point, compared with the unaffected thumb. The average Quick Disabilities of the Arm, Shoulder, and Hand score among all patients was 12 for the disability/symptom module, 0 for the sports module, and 17 for the work module. Stiffness was reported among four patients, and no patient sustained wound-related issues or other complications. CONCLUSIONS Nonbiological ligament reconstruction of the thumb ulnar collateral ligament generates short-term outcomes comparable with those of BLR, potentially allowing for expedited recovery and rehabilitation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Sergi Barrera-Ochoa
- Institut de la Mà, Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Rita Cavaca
- Institut de la Mà, Hospital Universitari General de Catalunya, Barcelona, Spain; Orthopedic and Traumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Rita Sapage
- Institut de la Mà, Hospital Universitari General de Catalunya, Barcelona, Spain; Orthopedic and Traumatology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | | | - Jose Prieto-Mere
- Institut de la Mà, Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Gerardo Mendez-Sanchez
- Institut de la Mà, Hospital Universitari General de Catalunya, Barcelona, Spain; Orthopedic and Traumatology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
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3
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Knisely B, Noland SS, Melville DM. Ultrasound versus MRI in the evaluation of the thumb metacarpophalangeal joint. J Ultrason 2023; 23:e214-e222. [PMID: 38020517 PMCID: PMC10668926 DOI: 10.15557/jou.2023.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 12/01/2023] Open
Abstract
An intricate and unique combination of ligamentous, fibrocartilaginous, and osseous structures stabilize the thumb metacarpophalangeal joint. Both ultrasound and high-resolution magnetic resonance imaging are extremely useful in evaluating these critical structures. This article reviews common injuries of the thumb metacarpophalangeal joint, while highlighting the merits, limitations, and pitfalls of the two imaging modalities. A clear appreciation of each method, paired with anatomic knowledge, will lend greater confidence and accuracy to diagnosing impactful injuries and guiding intervention.
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Robinson DM, Kakar S, Jelsing E. Acute Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injury: Diagnosis, Management, and Return to Sports Considerations. Curr Sports Med Rep 2023; 22:238-244. [PMID: 37294200 DOI: 10.1249/jsr.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
ABSTRACT Thumb metacarpophalangeal joint ulnar collateral ligament injuries are common in athletes and range from mild sprains to complete retracted tears. The typical injury mechanism of a valgus force directed onto an abducted or extended thumb is frequently seen in certain sporting activities, such as skiing, football, and baseball. Ultrasound and magnetic resonance imaging are excellent imaging supplements to the clinical evaluation for diagnosis confirmation. Positive treatment outcomes have been demonstrated when these injuries are appropriately managed both nonoperatively and surgically. When deciding on a treatment plan, it is paramount to take the athlete's injury severity and sport-specific factors into account. The aim of this review is to summarize the sport epidemiology, diagnosis, treatment options, and return to play considerations for athletes who sustain an acute thumb metacarpophalangeal joint ulnar collateral ligament injury.
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Affiliation(s)
- David M Robinson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Dar QA, Avoricani A, Hayes WT, Levy KH, Wang H, Koehler SM. Biomechanical Comparison of 3 Thumb Ulnar Collateral Ligament Repair Methods. J Hand Surg Am 2023; 48:89.e1-89.e9. [PMID: 34823921 DOI: 10.1016/j.jhsa.2021.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 07/21/2021] [Accepted: 09/22/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Differences in range of motion, pinch strength, biomechanical strength, or joint angulation have previously been investigated for various means of treatment of ulnar collateral ligament (UCL) tears. We sought to address a gap in the literature by comparing thumb metacarpophalangeal (MCP) joint angle measurements and biomechanical strength before complete, acute UCL tear and after repair with suture anchors (SA), suture tape (ST) anchor augmentation, or reconstruction with palmaris longus graft (PL). METHODS Thumbs and, if present, the PL tendon were harvested from 15 fresh-frozen cadavers. Each thumb specimen was secured into a servohydraulic biomechanical testing frame to evaluate native radiographic MCP joint angles at 0° flexion when loaded with 0, 5, and 13 N of radial force. Subsequently, a single hand surgeon (S.M.K.) performed complete transection and UCL repair via 1 of 3 methods: SA (n = 5), ST (n = 5), or reconstruction with PL (n = 5). Following repair, MCP joint angles were radiographically evaluated. Specimens that did not fail during joint angle testing were transferred to a separate testing frame for load-to-failure testing. Angle measurements and mean load-to-failure were compared between the groups, and angulation was also compared with each group's native control. RESULTS Both ST and SA groups demonstrated comparable stiffness to their native controls, whereas the PL group was significantly more lax. The ST repair was significantly stiffer than the other constructs. ST also required higher forces to reach failure compared to both SA and PL. No difference was found between SA and PL groups. CONCLUSIONS Although both ST and SA constructs recapitulate native joint stiffness, repair with ST demonstrated the greatest biomechanical strength in stiffness and load-to-failure. CLINICAL RELEVANCE For complete, acute tears of the thumb UCL, ST may be superior for maintaining MCP joint stability and strength over SA and PL.
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Affiliation(s)
- Qurratul-Ain Dar
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY
| | - Alba Avoricani
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY
| | - Westley T Hayes
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY
| | - Kenneth H Levy
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY
| | - Hanbin Wang
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY.
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Crum RP, Cervantes L, Berger AJ. Pediatric hand ultrasound: common indications, injury, inflammation and masses. Pediatr Radiol 2022; 52:1671-1686. [PMID: 35368212 DOI: 10.1007/s00247-022-05286-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/01/2021] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
Abstract
Ultrasound is a uniquely valuable tool for evaluating musculoskeletal problems in the pediatric hand. Acute and chronic injuries involving tendons and ligaments of the hand can be quickly assessed and can guide surgical decision-making. Using ultrasound, palpable lesions and masses can be evaluated for cystic and solid components aiding in differential diagnosis. Additionally, ultrasound provides evaluation of acute versus chronic changes of inflammatory arthritis, assessing disease severity and subclinical synovitis and serving as an adjunct to medical management. This review will cover common indications and ultrasound findings of the pediatric hand, focusing on common injuries, inflammatory arthritis and masses. Important anatomical features of the hand will be discussed as well as imaging technique and evaluation in the pediatric patient.
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Affiliation(s)
- Rachel Pevsner Crum
- Department of Pediatric Radiology, Nicklaus Children's Hospital, 3100 SW 62 Ave., Miami, FL, 33155, USA.
| | - Luisa Cervantes
- Department of Pediatric Radiology, Nicklaus Children's Hospital, 3100 SW 62 Ave., Miami, FL, 33155, USA
| | - Aaron J Berger
- Division of Pediatric Plastic Surgery, Nicklaus Children's Hospital, Miami, FL, USA
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Forli A, Bentejac A, Lateur G, Corcella D. Recent and chronic sprains of the First Metacarpo-Phalangeal Joint. Orthop Traumatol Surg Res 2022; 108:103156. [PMID: 34848387 DOI: 10.1016/j.otsr.2021.103156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 06/11/2021] [Indexed: 02/03/2023]
Abstract
Sprains of the first metacarpo-phalangeal joint (MCPJ) are a common form of hand injury that mainly affects the ulnar collateral ligament. Although the diagnosis is made on the physical findings, radiographs must be obtained and ultrasonography or magnetic resonance imaging (MRI) is necessary in some cases. If the joint is unstable or a bony fragment is displaced, surgery must be performed within 4 weeks after the injury. Beyond this interval, ligament reconstruction is the preferred treatment. The objective of this article is to provide evidence, from both older and recent studies, that guides the choice of the best treatment in clinical practice. To this end, we will address the following questions: (1) What is a Stener lesion? (history and pathophysiology); (2) In addition to the physical examination, what other investigations are appropriate in doubtful cases? (with special attention to the indications of ultrasonography and MRI); (3) What are the clinical and radiological criteria for performing surgery in patients with acute first MCPJ sprains? (4) What reconstruction procedures are appropriate in patients with acute or chronic MCPJ sprains?
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Affiliation(s)
- Alexandra Forli
- Clinique universitaire de chirurgie réparatrice, de la main et des brûlés, Hôpital Michalon, CHU Grenoble, 38043 Grenoble cedex 09, France.
| | - Antonin Bentejac
- Clinique universitaire de chirurgie réparatrice, de la main et des brûlés, Hôpital Michalon, CHU Grenoble, 38043 Grenoble cedex 09, France
| | - Gabriel Lateur
- Clinique universitaire de chirurgie orthopédique et traumatologie du sport, Hôpital Sud, CHU Grenoble, 38043 Grenoble cedex 09, France
| | - Denis Corcella
- Clinique universitaire de chirurgie réparatrice, de la main et des brûlés, Hôpital Michalon, CHU Grenoble, 38043 Grenoble cedex 09, France
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8
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Boucke PC, Cordier T, Häfeli M, Schibli S. [Simplified active motion protocol following Extensor indicis to Extensor pollicis longus tendon transfer using a side-to-side suture]. HANDCHIR MIKROCHIR P 2021; 53:67-71. [PMID: 33588492 DOI: 10.1055/a-1326-1950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Ruptures of the Extensor pollicis longus tendon are commonly treated by Extensor indicis transfer using Pulvertaft suture technique. Current literature does not yet give evidence for a preferable post-operative therapy protocol. A side-to-side suture technique is significantly stronger than the Pulvertaft repair technique and therefore allows an immediate active postoperative treatment. We present a new postoperative protocol, which is simple, fast and safe, and should make treatment easier for patients and therapists. PATIENTS AND METHODS We treated 10 patients with a transfer of the extensor indicis tendon between 07/2016 and 08/2017 according to the new active protocol. Patients were seen for follow-up at 2, 4 and 8 weeks. Thumb range of motion, pinch and grip strength as well as subjective parameters like pain and general satisfaction were measured. RESULTS All patients regained full function of their thumbs with retropulsion over the level of the palm at 4 weeks. Median pinch strength was 89 % and grip strength 74 % of the contralateral side at week 4. There was no secondary rupture of the reconstructed tendon over a one-year period. All patients were satisfied with the result of the operation and the protocol. CONCLUSION Our new active postoperative protocol for extensor indicis transfer using a side-to-side suture has proven to be safe and less strenuous for patients and therapists and has been established as standard treatment in our clinic.
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Poggi DS, Massarella M, Piccirilli E. The Treatment of Chronic Ulnar Collateral Ligament of the Thumb Injury Using Extensor Pollicis Brevis: Surgical Technique. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2021; 3:56-60. [PMID: 35415531 PMCID: PMC8991867 DOI: 10.1016/j.jhsg.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/01/2020] [Indexed: 11/16/2022] Open
Abstract
Chronic rupture of the ulnar collateral ligament of the thumb is a complex lesion that typically results in chronic joint instability, functional limitation in pinch, and persistent pain at the metacarpophalangeal (MCP) joint of the thumb. Different surgical techniques have been proposed, including tendon graft and transpositions. In this article, we report our experience in treating chronic ulnar collateral ligament injuries using extensor pollicis brevis tendon in a Sakellarides modified technique. During the surgical procedure, we detach the extensor pollicis brevis proximally and drive the tendon through the neck of the first metacarpal and the base of the proximal phalanx to reconstruct the ligament at the ulnar side. In our experience, the surgical technique provides good MCP joint strength and stability and allows a good functional recovery with few postoperative complications. This technique provides good stability of the MCP joint using an absorbable suture and allows early mobilization of the joint with minimal stiffness.
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Herrera JM, Herrera L, Rotella P, Cantero Téllez R, Castellanos J, Vázquez F. Percutaneous Reconstruction of the Ulnar Collateral Ligament of the Metacarpophalangeal Joint of the Thumb: Technique and Results. REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2020. [DOI: 10.1055/s-0040-1719014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Objectives The present study aims to describe a new percutaneous technique for the reconstruction of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb with a tendon graft, and to evaluate the functional outcomes and stability six months postoperatively.
Material and methods The percutaneous ligamentoplasty technique was performed with a palmaris longus tendon graft and tenodesis screws in 6 patients with ulnar instability of the thumb (> 30° degrees of radial deviation) for more than 6 weeks. Range of motion, grip strength, and pinch strength (lateral/key pinch, tip pinch, and palmar pinch) were assessed in comparison to the contralateral limb, as well as the Quick Disabilities of the Arm, Shoulder and Hand (DASH) score.
Results At 6 months, the joint movement was of 100%, the grip strength was of 94.8%, the key pinch was of 95%, the palmar pinch was of 85.7%, and the tip pinch was of 93.5% compared to the contralateral limb. The internal tilt was of 14° compared to 9° at the contralateral limb. The Quick DASH score decreased from 24.2 to 2.6 points.
Conclusion We devised this versatile surgical procedure to obtain early mobility with the advantages related to the percutaneous techniques.
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Affiliation(s)
- Juan Manuel Herrera
- Hand Surgery Unit, Centro Privado de Cirugía del Pie y la Mano (CEPYM), Tucumán, Argentina
- Hand Surgery Unit, Centro Integral de Ortopedia y Traumatología (CIOT), Tucumán, Argentina
| | - Lucas Herrera
- Hand Surgery Unit, Centro Integral de Ortopedia y Traumatología (CIOT), Tucumán, Argentina
| | - Pablo Rotella
- Hand Surgery Unit, Instituto Rotella, Tucumán, Argentina
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Huynh MNQ, Tang K, Cheung K. A Comparison of Conservative and Operative Management of Thumb Ulnar Collateral Ligament Avulsion Fractures in Children. Hand (N Y) 2020; 15:812-817. [PMID: 30857433 PMCID: PMC7850252 DOI: 10.1177/1558944719831237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The optimal management of pediatric thumb ulnar collateral ligament (UCL) avulsion fractures remains poorly defined. The purpose of this study was to elucidate patient outcomes based on initial management and fracture characteristics. Methods: A retrospective study of all patients younger than 18 years of age presenting with a thumb UCL avulsion fracture was performed. Patients were grouped by their initial management. The primary outcome of the study was time to return to full activity. Fractures were characterized by articular surface involvement, displacement, and rotation. Results: Forty-seven patients with thumb UCL avulsion fractures were identified. Ten patients underwent surgery as initial treatment; all healed without complication, with a mean recovery time of 6.2 ± 1.8 weeks. Thirty-seven patients were treated conservatively; although most healed, the recovery time was longer (9.2 ± 8.3 weeks, adjusted hazard ratio = 2.3, 95% confidence interval = 1.0-5.5). Four cases (11%) required conversion to surgery that all healed without complications. Fractures treated with immobilization alone were significantly smaller, less displaced, and less rotated than those initially treated with surgery; however, 19 fractures that would have met criteria for surgery were treated with immobilization and successfully healed within 7.1 ± 2.9 weeks. Fracture characteristics did not predict which patients would fail conservative treatment or have prolonged recovery times. Conclusions: While surgery provided definitive treatment without delay in recovery, immobilization may not be an unreasonable treatment choice even for patients with large or displaced fractures. In cases where patients failed immobilization, surgery as a second-line treatment had good results.
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Affiliation(s)
| | - Ken Tang
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Kevin Cheung
- Children’s Hospital of Eastern Ontario, Ottawa, Canada,Kevin Cheung, Division of Plastic Surgery, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada K1H 8L1.
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Lee SJ, Rabinovich RV, Kim A. Thumb Ulnar Collateral Ligament Repair with Suture Tape Augmentation. J Hand Surg Asian Pac Vol 2020; 25:32-38. [PMID: 32000599 DOI: 10.1142/s2424835520500046] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The purpose of this study is to describe our technique of thumb ulnar collateral ligament (UCL) repair with suture tape augmentation and to evaluate the short-term outcomes in our initial series of patients treated with this method of repair. Methods: Patients with minimum one-year follow up after isolated UCL repair with suture tape augmentation were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and study-specific questions. Thirteen of 15 (87%) consecutive patients who were treated using this method of repair were available for follow-up, 9 with acute tears and 4 with chronic tears. Results: Average post-operative thumb metacarpophalangeal (MCP) and interphalangeal (IP) joint range-of-motion (ROM) was 0-57.5° and 0-71°, respectively, for chronic tears and 2.2-53.9° and 0-71°, respectively, for acute tears. Average grip and pinch strength relative to the unaffected hand was 102% and 84%, respectively, among patients with chronic tears and 103.3% and 88.7%, respectively, among those with acute tears. All patients demonstrated stability with a firm endpoint, relative to the unaffected thumb. The average QuickDASH score among all patients was 11.9 for the disability/symptom module, 0 for the sport module and 16.5 for the work module. Stiffness was reported among 4 patients and no patient suffered wound-related issues or other complications. Conclusions: Thumb UCL repair with suture tape augmentation demonstrates short-term outcomes comparable to what has been reported for other methods of repair. It may potentially allow for an expedited recovery and rehabilitation process.
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Affiliation(s)
- Steven J Lee
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Remy V Rabinovich
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Andrew Kim
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
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13
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Daley D, Geary M, Gaston RG. Thumb Metacarpophalangeal Ulnar and Radial Collateral Ligament Injuries. Clin Sports Med 2020; 39:443-455. [DOI: 10.1016/j.csm.2019.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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14
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Jakubietz RG, Erguen S, Bernuth S, Meffert RH, Gilbert F, Jakubietz M. An anatomical study on the Stener-type lesion of the radial collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg Eur Vol 2020; 45:131-135. [PMID: 31739733 DOI: 10.1177/1753193419887344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The Stener-type lesion of the radial collateral ligament is rare. The insertion of the abductor pollicis brevis is believed to preclude its occurrence. The aim of this study was to determine whether this lesion can be induced mechanically. Four specimens were tested in neutral rotation and 20° of supination, in 45° and 30° of flexion, and in the neutral position. The angle of ulnar adduction to form a Stener-type lesion was measured. The lesion occurred only in 45° flexion in all specimens. A lesser angle of flexion decreased the rate of ligament displacement. In the neutral position no ligament displacement was found. A Stener-type lesion of the radial collateral ligament can occur in ulnar adduction and flexion of the metacarpophalangeal joint. Supination of the joint increases the likelihood of ligament displacement. As distal ruptures of the radial collateral ligament are uncommon, a high index of suspicion is required for diagnosis.
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Affiliation(s)
- Rafael G Jakubietz
- Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Sueleyman Erguen
- Institute for Anatomy and Cellbiology, University Wuerzburg, Wuerzburg, Germany
| | - Silvia Bernuth
- Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Rainer H Meffert
- Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Fabian Gilbert
- Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Michael Jakubietz
- Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
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Bernstein DT, McCulloch PC, Winston LA, Liberman SR. Early Return to Play With Thumb Spica Gauntlet Casting for Ulnar Collateral Ligament Injuries Complicated by Adjacent Joint Dislocations in Collegiate Football Linemen. Hand (N Y) 2020; 15:92-96. [PMID: 30015508 PMCID: PMC6966282 DOI: 10.1177/1558944718788644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Treatment of thumb ulnar collateral ligament (UCL) ruptures in elite athletes aims to restore thumb stability while minimizing lost playing time. Thus, surgical repair with early protected return to play in a thumb spica cast has been advocated. The purpose of this study was to document adjacent joint dislocations after primary surgical repair sustained during protected return to play with thumb spica casting in elite-level football players. Methods: Three Division I collegiate starting linemen sustaining adjacent joint dislocations in thumb spica casts following acute surgical repair of ipsilateral thumb UCL ruptures were retrospectively reviewed. Demographic data were recorded as well as the timeline for injury, treatment, and subsequent return to sport. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were obtained at final follow-up. Results: The mean time from thumb UCL injury to surgical repair was 8.7 days, and the mean return to sport was 13.3 days from surgery. There were 4 simple dislocations including 3 proximal interphalangeal (PIP) joints and 1 elbow. Each PIP dislocation was close reduced and treated with buddy straps with immediate return to play. The elbow dislocation was close reduced and splinted with return to play 22 days after injury. The mean QuickDASH score was 2.3 at 12 month follow-up. Conclusions: This report highlights that while thumb spica casting protects the surgically repaired thumb UCL and allows for earlier return to play, it risks placing additional stress upon adjacent joints and therefore adjacent injury. Appropriate counseling of the risks and benefits of this treatment strategy is essential.
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Affiliation(s)
| | | | - Leland A. Winston
- Houston Methodist Hospital, TX,
USA,Rice University, Houston, TX, USA
| | - Shari R. Liberman
- Houston Methodist Hospital, TX,
USA,Rice University, Houston, TX, USA,Shari R. Liberman, Department of Orthopedics
& Sports Medicine, Houston Methodist Hospital, 6445 Fannin Street,
Outpatient Center, Suite 2500, Houston, TX 77030, USA.
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16
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Kumar A, Trikha V, Mittal S, Passey J, Chouhan D, Jain A. Fracture of first metacarpal head: A rare case presentation and review of literature. J Clin Orthop Trauma 2020; 11:672-677. [PMID: 32684710 PMCID: PMC7355070 DOI: 10.1016/j.jcot.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/28/2022] Open
Abstract
Fractures around the head and neck region of first metacarpal are unusual and have not been reported in literature. We report a case of fracture of head of first metacarpal with intact articular surface, treated with open reduction and internal fixation, with a follow up period of six months. Surgical procedure, intraoperative difficulties in obtaining reduction and steps to overcome them have been described. Satisfactory functional outcomes can be achieved using stable internal fixation with minimal hardware and early mobilization in first metacarpal head fractures.
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Affiliation(s)
- Arvind Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Vivek Trikha
- JPN Apex Trauma Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Samarth Mittal
- JPN Apex Trauma Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India,Corresponding author. JPN Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Jigyasa Passey
- Department of Anatomy, Maulana Azad Medical College, New Delhi, India
| | - Dushyant Chouhan
- Department of Orthopedics, Lady Hardinge Medical College, New Delhi, India
| | - Aditya Jain
- Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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17
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Wang KK, Boyce G, Peters T, Anderson H, Hoy G. Efficacy of Primary Repair in Professional Athletes with Chronic Radial Collateral Ligament Injuries of Thumb Metacarpophalangeal Joint. J Hand Surg Asian Pac Vol 2019; 24:138-143. [PMID: 31035879 DOI: 10.1142/s2424835519500176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Management of grade III injuries of the radial collateral ligament (RCL) of the thumb is controversial. These injuries are often treated with early surgery. However, early surgery may not be practical for the professional athlete. We report on the outcome of delayed primary repair of chronic RCL injuries without the use of tendon grafts or tendon transfers. Methods: Twelve elite professional athletes with 15 soft tissue RCL injuries who underwent delayed surgery (greater than 6 weeks) were included in this study. Athletes were managed with splinting and ongoing play during the sporting season, and underwent surgery at the conclusion of the season. Mean duration from injury to surgery was 5 months. Mean follow-up was 4.2 years after surgery. Patient-report outcome measures including pain, satisfaction rating, and disability of the arm, shoulder and hand (DASH) scores were collected. Examination findings including range of motion, laxity, and grip and pinch strength were also measured. Return-to-play data were collected for all athletes. Results: The RCL was able to be primarily repaired with suture anchors in all cases. All twelve patients were able to return to competitive play at the same pre-injury professional level. Post-operative joint function such as range of motion and laxity were comparable to the unaffected contralateral side, as were grip and lateral pinch strengths. Tip-pinch strength is lower compared to the unaffected side, but is comparable to age and sex-matched reference group. Conclusions: Delayed primary repair of the RCL is a viable option and results in satisfactory long-term outcomes. This option may be more preferable to the professional athlete who wishes to avoid surgery during the sporting season.
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Affiliation(s)
- Kemble K Wang
- * Upper Limb Surgery Division, Melbourne Orthopaedic Group, Melbourne, Australia
| | - Glenn Boyce
- * Upper Limb Surgery Division, Melbourne Orthopaedic Group, Melbourne, Australia
| | - Tracy Peters
- * Upper Limb Surgery Division, Melbourne Orthopaedic Group, Melbourne, Australia
| | - Hamish Anderson
- * Upper Limb Surgery Division, Melbourne Orthopaedic Group, Melbourne, Australia
| | - Greg Hoy
- * Upper Limb Surgery Division, Melbourne Orthopaedic Group, Melbourne, Australia.,† Department of Orthopaedic Surgery, Austin Hospital, Melbourne, Australia.,‡ Department of Surgery, Monash University, Melbourne, Australia
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18
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Sochacki KR, Jack RA, Nauert R, Liberman SR, McCulloch PC, Lintner DM, Harris JD. Performance and Return to Sport After Thumb Ulnar Collateral Ligament Surgery in National Football League Players. Hand (N Y) 2019; 14:487-493. [PMID: 29480741 PMCID: PMC6760080 DOI: 10.1177/1558944718760001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Acute ruptures of the ulnar collateral ligament (UCL) of the thumb are common injuries in sports. Surgical repair of complete tears has yielded excellent results in elite athletes. Methods: National Football League (NFL) players who underwent thumb UCL surgery and matched controls were identified. Demographic and performance data were collected. Performance scores were calculated using a standardized scoring system. Return to sport (RTS) in the NFL was defined as playing in at least 1 NFL game after thumb UCL surgery. Comparisons between case and control groups and preoperative and postoperative time points were made using paired-samples Student t tests. Results: Twenty-three players were identified (mean age: 28.8 ± 3.4 years and mean experience in the NFL: 5.9 ± 3.4 years). Twenty-two players (95.7%) were able to return to sport in the NFL at an average of 132.2 ± 126.1 days. The overall 1-year NFL career survival rate of players undergoing thumb UCL surgery was 87.0%. There was not a statistically significant decrease in games per season and career length for any position following surgery. No positions had a significant difference in postoperative performance when compared with preoperative performance, and there was no significant performance difference postoperatively when compared with matched controls. Conclusions: There is a high rate of RTS in the NFL following thumb UCL surgery. Players who underwent thumb UCL surgery played in a similar number of games per season and had similar career lengths in the NFL as controls. No position group had any significant postoperative performance score differences when compared with postindex matched controls.
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Affiliation(s)
| | - Robert A. Jack
- Houston Methodist Orthopedics & Sports Medicine, TX, USA
| | - Richard Nauert
- Houston Methodist Orthopedics & Sports Medicine, TX, USA
| | | | | | | | - Joshua D. Harris
- Houston Methodist Orthopedics & Sports Medicine, TX, USA,Joshua D. Harris, Houston Methodist Orthopedics & Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX 77030, USA.
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19
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Kim BS, Doermann A, McGarry M, Akeda M, Ihn H, Lee TQ. Additional Dorsal Fibrocartilage Repair in a Combined Radial Collateral Ligament and Dorsal Fibrocartilage Injury of the Thumb Metacarpophalangeal Joint. Orthopedics 2019; 42:e268-e272. [PMID: 30763448 DOI: 10.3928/01477447-20190211-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/11/2018] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to evaluate the necessity of an additional dorsal fibrocartilage (DFC) repair in combined radial collateral ligament (RCL) and DFC injuries of the thumb metacarpophalangeal joint (MPJ). Eight cadaveric thumbs were used. Ulnar/radial deviation, prosupination, and volar/dorsal laxity were measured. Serial sectioning was performed of the RCL and the DFC. The RCL followed by the DFC were then reattached sequentially. Measurements were performed for intact, RCL cut, RCL+DFC cut, RCL repair alone, and RCL+DFC repair. The neutral position shifted ulnarly, pronated, and subluxed volarly after RCL+DFC cut. Volar subluxation was reduced with RCL+DFC repair compared with RCL repair alone. With external loading, ulnar deviation, pronation, and volar laxity increased significantly after RCL+DFC cut. Ulnar deviation reduced significantly with RCL+DFC repair (12.4°, 10.8°, and 10.9°) compared with RCL repair alone (14.4°, 14.3°, and 18.9°) at 0°, 30°, and 60°, respectively. Pronation reduced significantly with RCL+DFC repair (7.1° and 9.4°) compared with RCL repair alone (10.2° and 12.6°) at 0° and 30°, respectively. Volar subluxation reduced significantly with RCL+DFC repair (0.9 mm and 1.2 mm) compared with RCL repair alone (2.1 mm and 1.8 mm) at 30°and 60°, respectively. Radial collateral ligament repair alone does not restore anatomic dorsoradial stability of the thumb MPJ in a combined RCL and DFC injury. Combined repair of the RCL and the DFC is recommended to reduce the MPJ to its native position and minimize postoperative laxity. [Orthopedics. 2019; 42(2):e268-e272.].
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20
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Pulos N, Shin AY. Treatment of Ulnar Collateral Ligament Injuries of the Thumb: A Critical Analysis Review. JBJS Rev 2019; 5:01874474-201702000-00003. [PMID: 28248741 DOI: 10.2106/jbjs.rvw.16.00051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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21
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Gil JA, Ebert K, Blanchard K, Goodman AD, Crisco JJ, Katarincic JA. Efficacy of a radial-based thumb metacarpophalangeal-stabilizing orthosis for protecting the thumb metacarpophalangeal joint ulnar collateral ligament. J Hand Ther 2019; 32:80-85. [PMID: 28711411 PMCID: PMC6107430 DOI: 10.1016/j.jht.2017.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 05/31/2017] [Accepted: 06/11/2017] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Basic research (biomechanics). INTRODUCTION The high degree of motion that occurs at the thumb metacarpophalangeal (MCP) joint must be taken into account when immobilizing a partially torn or repaired thumb ulnar collateral ligament. PURPOSE OF THE STUDY To determine the efficacy of a radial-based thumb MCP-stabilizing orthosis in resisting abduction across the thumb ulnar collateral ligament. METHODS Ten fresh cadaveric hands were mounted to a custom board. An anteroposterior radiograph of the thumb was obtained with a 2 N preload valgus force applied to the thumb, and the angle between the Kirschner wires was measured as a baseline. Subsequently, 20, 40, 60, 80, and 100 N valgus forces were applied 15 mm distal to the MCP joint. Anteroposterior radiographs of the thumb were obtained after each force was applied. The angle of displacement between the wires was measured and compared with the baseline angle. The angles were measured with an imaging processing tool. A custom radial-based thumb MCP-stabilizing orthosis was fashioned for each cadaveric thumb by a certified hand therapist. The aforementioned loading protocol was then repeated. RESULTS The radial-based thumb MCP-stabilizing orthosis significantly reduced mean abduction angles at each applied load. DISCUSSION We found that our orthosis, despite being hand-based and leaving the thumb IP and CMC joints free, significantly reduced mean abduction angles at each applied load. CONCLUSIONS This investigation provides objective evidence that our radial-based thumb MCP-stabilizing orthosis effectively reduces the degree of abduction that occurs at the thumb MCP joint up to at least 100 N. LEVEL OF EVIDENCE n/a (cadaveric).
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Affiliation(s)
- Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA.
| | - Kerry Ebert
- University Orthopedics, Hand Therapy, Providence, RI, USA
| | - Keri Blanchard
- University Orthopedics, Hand Therapy, Providence, RI, USA
| | - Avi D Goodman
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Joseph J Crisco
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Julia A Katarincic
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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22
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Gil JA, Chambers A, Shah KN, Crisco JJ, Got C, Akelman E. A Biomechanical Evaluation of a 2-Suture Anchor Repair Technique for Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries. Hand (N Y) 2018; 13:581-585. [PMID: 28836462 PMCID: PMC6109898 DOI: 10.1177/1558944717725380] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A complete thumb ulnar collateral ligament (UCL) repaired with 1-suture anchor has been demonstrated to be significantly weaker compared with the intact UCL. The objective of this study is to test the biomechanical strength of a 2-anchor thumb UCL repair. METHODS Nine paired fresh-frozen hands were used for this biomechanical analysis. One thumb from each pair was randomized to the control group and one to the repair group. In the control group, the UCL was loaded to failure in tension. In the repair group, the UCL was dissected off of the proximal phalanx, subsequently repaired with a 2-anchor technique, and then tested to failure. RESULTS The mean yield load was 342 N (95% confidence interval [CI], 215-470 N) in the control group and 68 N (95% CI, 45-91 N) in the repair group. The mean maximum load at failure was 379 N (95% CI, 246-513 N) in the control group and 84 N (95% CI, 62-105 N) in the repair group. The mean stiffness was 72 N/m (95% CI, 48-96 N/m) in the control group and 17 N/m (95% CI, 13-21 N) in the repair group. The mean displacement at failure was 7.8 mm (95% CI, 7-9 mm) in the control group and 7.8 mm (95% CI, 7-9 mm) in the repair group. CONCLUSIONS The 2-anchor repair technique we tested does not acutely reestablish the strength of the insertion of the native insertion of the UCL with this technique.
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Affiliation(s)
- Joseph A. Gil
- Brown University, Providence, RI, USA,Joseph A. Gil, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, 593 Eddy Street, Providence, RI 02903, USA.
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Jack RA, Sochacki KR, Gagliano B, Lintner DM, Harris JD, McCulloch PC. Performance and Return to Sport After Thumb Ulnar Collateral Ligament Repair in Major League Baseball Players. Orthop J Sports Med 2018; 6:2325967117747268. [PMID: 29326958 PMCID: PMC5757434 DOI: 10.1177/2325967117747268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Acute ruptures of the ulnar collateral ligament (UCL) of the thumb are common injuries in sports. Surgical repair has yielded excellent results and high return-to-sport (RTS) rates in elite athletes. Purpose To determine (1) the RTS rate in Major League Baseball (MLB) players following thumb UCL repair, (2) postoperative career length and games played per season, (3) pre- and postoperative performance, (4) postoperative performance compared with matched control players, and (5) whether dominant and nondominant hand injuries respond differently. Study Design Cohort study; Level of evidence, 3. Methods MLB players who underwent thumb UCL surgery from August 3, 1987, to September 6, 2016, were identified. Demographic and performance data were collected for each player, and matched controls were identified. RTS in the MLB was defined as playing in at least 1 MLB game after surgery. Comparisons were made by use of paired-samples Student t tests. Results Twenty-one players were identified, with a mean ± SD age of 31.7 ± 3.9 years and mean experience in the MLB of 8.6 ± 3.3 years at time of surgery. Twenty-one players (100%) achieved RTS in the MLB at a mean 120.0 ± 75.9 days. No significant decrease was found in games per season or career length for any position following surgery. Infielders had a significantly lower rate of postoperative wins above replacement (WAR) compared with preoperatively (P = .006), but no significant differences in postoperative performance score were found compared with controls after the index date. No significant difference was found for performance between players undergoing surgery on their dominant hand and those who had surgery on their nondominant (glove) hand compared with controls. Conclusion In this study, 100% of MLB players achieved RTS after thumb UCL repair, with in-season players returning at a mean of 8 weeks. Players who underwent thumb UCL repair played in a similar number of games per season and had similar career lengths in the MLB as controls. Infielders had a significantly lower postoperative WAR compared with preoperatively, but no significant postoperative performance score differences were noted when infielders were compared with post-index date matched controls. No significant performance differences were noted with regard to surgery on dominant and nondominant hands.
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Affiliation(s)
- Robert A Jack
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, USA
| | - Kyle R Sochacki
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, USA
| | - Bryce Gagliano
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, USA
| | - David M Lintner
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, USA
| | - Joshua D Harris
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, USA
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24
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Kim BS, Doermann A, McGarry M, Akeda M, Ihn H, Lee TQ. Dorsoradial Instability of the Thumb Metacarpophalangeal Joint: A Biomechanical Investigation. J Hand Surg Am 2017; 42:1029.e1-1029.e8. [PMID: 28807347 DOI: 10.1016/j.jhsa.2017.06.102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/30/2017] [Accepted: 06/28/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To define the role of the dorsal capsule and associated dorsal fibrocartilage (DFC) and their interactions with the radial collateral ligament (RCL) as a thumb metacarpophalangeal (MCP) joint stabilizer. METHODS Eight cadaveric thumbs were mounted onto a custom jig with 20 N of muscle load applied. The thumb position in space was digitized to measure ulnar-radial, pronation-supination, and volar-dorsal laxity at 0°, 30°, and 60° MCP joint flexion. Serial sectioning was performed and measurements were repeated for the intact state, proper RCL insufficiency, proper and accessory (complete) RCL insufficiency, complete RCL with 50% DFC (radial) insufficiency, and complete RCL with complete DFC insufficiency. RESULTS Ulnar-radial deviation, pronation-supination, and volar-dorsal translation significantly changed at 30° and 60° MCP joint flexion when comparing complete RCL insufficiency with complete RCL with 50% DFC insufficiency. At 30° flexion, significant increases were found in ulnar deviation, pronation, and volar translation, and there was a decrease in supination. At 60° flexion, ulnar deviation, pronation, and volar translation increased and radial deviation decreased significantly. At 30° flexion, the resting position significantly pronated and translated volarly. At 60° flexion, the resting position significantly shifted ulnarly, pronated, and translated volarly. CONCLUSIONS The DFC acts as a secondary stabilizer of the thumb MCP joint, working in tandem with the RCL. It acts by stabilizing the MCP joint dorsoradially when external forces are applied across the joint. This cadaveric study shows that RCL insufficiency with a concomitant DFC injury is less likely to be stable than RCL injuries alone, and that this effect is more pronounced with MCP joint flexion. CLINICAL RELEVANCE Increasing incompetence of the secondary stabilizers of the RCL, such as the DFC, will likely result in increased clinical instability upon physical examination. The results of this study also suggest the need to consider repair of the DFC at the time of RCL repair.
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Affiliation(s)
- Byung-Sung Kim
- Department of Orthopedic Surgery, College of Medicine, Soonchunhyang University, Bucheon, Republic of Korea; Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, University of California, Irvine, CA.
| | - Alex Doermann
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, University of California, Irvine, CA
| | - Michelle McGarry
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, University of California, Irvine, CA
| | - Masaki Akeda
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, University of California, Irvine, CA
| | - Hansel Ihn
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, University of California, Irvine, CA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, University of California, Irvine, CA
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Abstract
Finger injuries are common in athletes playing in professional ball sports. Understanding the intricate anatomy of the digit is necessary to properly diagnose and manage finger injuries. Unrecognized or poorly managed finger injuries can lead to chronic deformities that can affect an athlete's performance. Multiple factors and treatment options should be considered to provide the best functional outcome and rapid return to play for an athlete. This article discusses the mechanism of injury, diagnosis, treatment, and return-to-play recommendations for common finger injuries in ball sports.
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Affiliation(s)
- David T Netscher
- Division of Plastic Surgery, Department of Orthopedic Surgery, Baylor College of Medicine, 6624 Fannin Street, Suite 2730, Houston, TX 77030, USA.
| | - Dang T Pham
- Department of Surgery, Houston Methodist Hospital, Weill Medical College of Cornell University, 6550 Fannin Street, Smith Tower 1661, Houston, TX 77030, USA
| | - Kimberly Goldie Staines
- Department of Physical Medicine and Rehabilitation, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, RCL117, Houston, TX 77030, USA
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Abstract
Return-to-play (RTP) decisions often represent a challenge to physicians caring for athletes. The multifaceted and unique nature of each RTP decision makes standardization of the decision-making process impossible and demands of the physician thoughtful consideration of all competing interests and variables. Such difficult medical decisions are further complicated by unique ethical and legal considerations. Although no concrete RTP recommendations are available, the consensus of experienced team physicians and knowledge of the rules and regulations that apply to RTP are helpful guides to treating the various upper extremity injuries that occur in elite athletes.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to identify current principles in the diagnosis and treatment of collateral ligament injuries of the thumb in the athlete. RECENT FINDINGS Cadaver studies have clearly identified the ulnar and radial collateral ligaments origin and insertion footprints for repair or reconstruction. Ulnar and radial collateral ligament injuries are common in athletics. History and physical examination are paramount in determining partial versus complete tear. When surgical treatment is indicated, placing the repair/reconstruction in the anatomic footprint restores stability while maintaining motion. The senior author's preferred techniques are reported.
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Affiliation(s)
- Daniel M Avery
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 East 72nd Street, 4th Floor, New York, NY, 10021, USA
| | - Elizabeth R Inkellis
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 East 72nd Street, 4th Floor, New York, NY, 10021, USA
| | - Michelle G Carlson
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 East 72nd Street, 4th Floor, New York, NY, 10021, USA.
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Werner BC, Belkin NS, Kennelly S, Weiss L, Barnes RP, Rodeo SA, Warren RF, Hotchkiss RN. Injuries to the Collateral Ligaments of the Metacarpophalangeal Joint of the Thumb, Including Simultaneous Combined Thumb Ulnar and Radial Collateral Ligament Injuries, in National Football League Athletes. Am J Sports Med 2017; 45:195-200. [PMID: 27566241 DOI: 10.1177/0363546516660979] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Thumb collateral ligament injuries occur frequently in the National Football League (NFL). In the general population or in recreational athletes, pure metacarpophalangeal (MCP) abduction or adduction mechanisms yield isolated ulnar collateral ligament (UCL) and radial collateral ligament (RCL) tears, respectively, while NFL athletes may sustain combined mechanism injury patterns. PURPOSE To evaluate the incidence of simultaneous combined thumb UCL and RCL tears among all thumb MCP collateral ligament injuries in NFL athletes on a single team. STUDY DESIGN Case series; Level of evidence, 4. METHODS A retrospective review of all thumb injuries on a single NFL team from 1991 to 2014 was performed. All players with a thumb MCP collateral ligament injury were included. Collateral ligament injuries were confirmed by review of both physical examination findings and magnetic resonance imaging. Player demographics, surgical details, and return-to-play data were obtained from the team electronic medical record and surgeons' records. RESULTS A total of 36 thumbs in 32 NFL players were included in the study, yielding an incidence of 1.6 thumb MCP collateral ligament injuries per year on a single NFL team. Of these, 9 thumbs (25%) had a simultaneous combined UCL and RCL tear injury pattern confirmed on both physical examination and MRI. The remaining 27 thumbs (75%) were isolated UCL injuries. All combined UCL/RCL injuries required surgery due to dysfunction from instability; 63.0% of isolated UCL injuries required surgical repair ( P = .032) due to continued pain and dysfunction from instability. Repair, when required, was delayed until the end of the season. All players with combined UCL/RCL injuries and isolated UCL injuries returned to play professional football the following season. CONCLUSION Simultaneous combined thumb UCL and RCL tear is a previously undescribed injury pattern that occurred in 25% of thumb MCP collateral ligament injuries on a single NFL team over a 23-year period. All players with combined thumb UCL/RCL injuries required surgical repair, which was significantly higher compared with players with isolated UCL injuries. Team physicians and hand surgeons treating elite football players with suspected thumb collateral ligament injuries should examine for RCL and UCL instability and consider MRI if any concern exists for a combined ligament injury pattern, as this injury is likely frequently missed.
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Affiliation(s)
| | | | - Steve Kennelly
- New York Football Giants, East Rutherford, New Jersey, USA
| | - Leigh Weiss
- New York Football Giants, East Rutherford, New Jersey, USA
| | | | - Scott A Rodeo
- Hospital for Special Surgery, New York, New York, USA
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Diagnosis, Treatment, and Return to Play for Four Common Sports Injuries of the Hand and Wrist. J Am Acad Orthop Surg 2016; 24:853-862. [PMID: 27792055 DOI: 10.5435/jaaos-d-15-00388] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hand and wrist injuries in the high-level athlete are challenging because they may be underestimated by the patient, family, and team, and return to play may be longer than desired. The needs of the player and the team must be balanced with the long-term functional ramifications of the injury. Four common soft-tissue sports injuries are flexor digitorum profundus avulsion, flexor pulley rupture, extensor carpi ulnaris dislocation, and thumb metacarpophalangeal joint ulnar collateral ligament injury. For each of these injuries, the assessment, treatment, and considerations for return to play should be individualized on the basis of the patient, the sport, and the timing of the injury.
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Christensen T, Sarfani S, Shin AY, Kakar S. Long-Term Outcomes of Primary Repair of Chronic Thumb Ulnar Collateral Ligament Injuries. Hand (N Y) 2016; 11:303-309. [PMID: 27698632 PMCID: PMC5030867 DOI: 10.1177/1558944716628482] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The purpose of this study is to evaluate long-term outcomes of ligamentous repair rather than reconstruction for chronic thumb ulnar collateral ligament (UCL) injuries. Methods: Patients at least 15-years status-post repair of a chronic (greater than 6 weeks) UCL tear were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS) pain scale, and study-specific questions. Twelve of 21 (57%) living patients were available for long-term, greater than 15-year follow-up (average 24.5 years, range 16.9-35.6). Results: Eighty-eight percent of patients had some degree of osteoarthritis. Increased age at the time of injury and higher DASH scores were correlated with increased grades of the thumb metacarpophalangeal osteoarthritis. Delay to treatment and VAS pain scores had no correlation with radiographic findings. Conclusions: Repair of a chronic UCL injury with available local tissue appears to be a reasonable alternative to ligament reconstruction, resulting in durable long-term outcomes despite the majority of patients progressing to osteoarthritis.
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Affiliation(s)
| | | | - Alexander Y. Shin
- Mayo Clinic, Rochester, MN, USA,Alexander Y. Shin, Department of Orthopedics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Wieschhoff GG, Sheehan SE, Wortman JR, Dyer GSM, Sodickson AD, Patel KI, Khurana B. Traumatic Finger Injuries: What the Orthopedic Surgeon Wants to Know. Radiographics 2016; 36:1106-28. [DOI: 10.1148/rg.2016150216] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ulnare Kollateralbandplastik des Daumengrundgelenks bei chronischer Instabilität. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2015; 27:380-93. [DOI: 10.1007/s00064-015-0413-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/10/2015] [Accepted: 07/10/2015] [Indexed: 10/23/2022]
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Avery DM, Caggiano NM, Matullo KS. Ulnar collateral ligament injuries of the thumb: a comprehensive review. Orthop Clin North Am 2015; 46:281-92. [PMID: 25771322 DOI: 10.1016/j.ocl.2014.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Injuries to the thumb ulnar collateral ligament (UCL) are common. Failure to address the ensuing laxity of the metacarpophalangeal joint can lead to compromised grip and pinch, pain, and ultimately osteoarthritis. Instability to valgus stress with the lack of a firm end point is a strong indicator of complete rupture of the UCL. Nonoperative treatment is reserved for incomplete ruptures of the thumb UCL. Operative intervention is typically performed for complete ruptures. Repair of acute ruptures and reconstruction for chronic injuries yield excellent results. Complications are rare and most patients show preservation of motion, key pinch, and grip strength.
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Affiliation(s)
- Daniel M Avery
- Department of Orthopaedic Surgery, St. Luke's University Hospital, 801 Ostrum Street, PPH-2, Bethlehem, PA 18015, USA
| | - Nicholas M Caggiano
- Department of Orthopaedic Surgery, St. Luke's University Hospital, 801 Ostrum Street, PPH-2, Bethlehem, PA 18015, USA
| | - Kristofer S Matullo
- Division of Hand Surgery, Department of Orthopaedic Surgery, St. Luke's University Health Network, Bethlehem, PA 18015, USA.
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Potini VC, Sood A, Sood A, Mastromonaco E. Volar dislocation of the thumb metacarpophalangeal joint with acute repair of the ulnar collateral ligament. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2014; 1:5-7. [PMID: 27252947 PMCID: PMC4627101 DOI: 10.3109/23320885.2014.965254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/07/2014] [Accepted: 09/10/2014] [Indexed: 11/13/2022]
Abstract
Volar dislocations of the thumb metacarpophalangeal joint are uncommon and can be associated with rupture of the ulnar collateral ligament (UCL). We report a case where a volar thumb dislocation was successfully closed reduced, but instability required open repair of the UCL. Early motion protocol helped achieve favorable results.
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Affiliation(s)
- Vishnu C Potini
- Department of Orthopaedic Surgery, Rutgers University- New Jersey Medical School , Newark, NJ 07101, USA
| | - Amit Sood
- Department of Orthopaedic Surgery, Rutgers University- New Jersey Medical School , Newark, NJ 07101, USA
| | - Aditya Sood
- Department of Plastic Surgery, Rutgers University- New Jersey Medical School , 90 Bergen St, DOC 7100, Newark, NJ 07101, USA
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Werner BC, Hadeed MM, Lyons ML, Gluck JS, Diduch DR, Chhabra AB. Return to football and long-term clinical outcomes after thumb ulnar collateral ligament suture anchor repair in collegiate athletes. J Hand Surg Am 2014; 39:1992-8. [PMID: 25139463 DOI: 10.1016/j.jhsa.2014.06.132] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate return to play after complete thumb ulnar collateral ligament (UCL) injury treated with suture anchor repair for both skill position and non-skill position collegiate football athletes and report minimum 2-year clinical outcomes in this population. METHODS For this retrospective study, inclusion criteria were complete rupture of the thumb UCL and suture anchor repair in a collegiate football athlete performed by a single surgeon who used an identical technique for all patients. Data collection included chart review, determination of return to play, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcomes. RESULTS A total of 18 collegiate football athletes were identified, all of whom were evaluated for follow-up by telephone, e-mail, or regular mail at an average 6-year follow-up. Nine were skill position players; the remaining 9 played in nonskill positions. All players returned to at least the same level of play. The average QuickDASH score for the entire cohort was 1 out of 100; QuickDASH work score, 0 out of 100; and sport score, 1 out of 100. Average time to surgery for skill position players was 12 days compared with 43 for non-skill position players. Average return to play for skill position players was 7 weeks postoperatively compared with 4 weeks for non-skill position players. There was no difference in average QuickDASH overall scores or subgroup scores between cohorts. CONCLUSIONS Collegiate football athletes treated for thumb UCL injuries with suture anchor repair had quick return to play, reliable return to the same level of activity, and excellent long-term clinical outcomes. Skill position players had surgery sooner after injury and returned to play later than non-skill position players, with no differences in final level of play or clinical outcomes. Management of thumb UCL injuries in collegiate football athletes can be safely and effectively tailored according to the demands of the player's football position. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA
| | - Michael M Hadeed
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA
| | - Matthew L Lyons
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA
| | - Joshua S Gluck
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA
| | - A Bobby Chhabra
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA.
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Superimposed electrical stimulation improves mobility of pre-stiff thumbs after ulnar collateral ligament injury of the metacarpophalangeal joint: a randomized study. Ann Phys Rehabil Med 2014; 57:373-80. [PMID: 24894392 DOI: 10.1016/j.rehab.2014.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 04/16/2014] [Accepted: 04/19/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed at testing the ability of the superimposed electrical stimulation technique to restore the mobility of pre-stiff thumbs after operative repair for rupture of the ulnar collateral ligament. MATERIAL AND METHODS Eight patients demonstrating a pre-stiff metacarpophalangeal joint were involved in two rehabilitation sessions of a counterbalanced design. In the voluntary contraction session, they performed 20min of repeated active flexions of the impaired metacarpophalangeal joint. In the superimposed electrical stimulation session, they performed 20min of percutaneous neuromuscular electrical stimulations which were superimposed to voluntary flexion. RESULTS Mean active range of motion improvement from pre- to post-session was significantly greater in the superimposed electrical stimulation condition compared to the voluntary contraction condition (11±5 deg versus 3±4 deg; P<0.01). CONCLUSION Superimposing electrical stimulation to voluntary contractions is an efficient technique to improve active range of motion of the pre-stiff metacarpophalangeal joint of the thumb.
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Abstract
Ulnar collateral ligament (UCL) injuries of the thumb are common. Surgical repair is accepted as the treatment of choice for complete rupture of the ligament. Biomechanical studies have suggested that Mitek bone anchor repairs are potentially safe and strong enough to allow early controlled active mobilization. To date, there have been no studies to compare early active mobilization following Mitek bone anchor repair to standard postoperative rehabilitation involving thumb spica immobilization for the first 4 to 6 weeks. We performed a small pilot randomized control trial to assess the outcome of this new rehabilitation technique to that of standard immobilization following UCL repair with Mitek bone anchor. Our results show that on average early active mobilization leads to an earlier return to full hand function (6 vs. 8 wk) and an earlier return to work (7 vs. 11 wk). There is no difference in the final range of motion achieved. We suggest that Mitek bone anchor repairs for UCL ruptures are robust enough to allow early active mobilization and that a larger trial is warranted to assess whether early active mobilization is superior to standard rehabilitation.
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Iba K, Wada T, Hiraiwa T, Kanaya K, Oki G, Yamashita T. Reconstruction of chronic thumb metacarpophalangeal joint radial collateral ligament injuries with a half-slip of the abductor pollicis brevis tendon. J Hand Surg Am 2013; 38:1945-50. [PMID: 23928013 DOI: 10.1016/j.jhsa.2013.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 06/14/2013] [Accepted: 06/14/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate a reconstructive method for chronic radial collateral ligament (RCL) injuries of the thumb metacarpophalangeal (MCP) joint using a combination of RCL advancement and the transfer of a half-slip of the abductor pollicis brevis tendon. METHODS Eight patients (4 male and 4 female; mean age, 25 y) with chronic RCL injury of the thumb MCP joint were enrolled. All patients were referred to our institution because of continuing pain and instability on the radial side of the MCP joint when grasping or pinching objects. The mechanism of the injury was adduction stress to the thumb during sporting activities in 5 patients, a heavy object falling on the thumb in 1, and a fall in 2. The mean duration from RCL injury to surgery was 20 weeks. The average postoperative follow-up was 51 months. We evaluated postoperative outcomes including pain, range of motion of the thumb MCP joint, grip strength, key pinch strength, Disabilities of the Arm, Shoulder, and Hand score, and ability to return to preinjury work or sporting activities. RESULTS No patients demonstrated continuing symptoms, and the MCP joint was stable after surgery. Postoperative grip and pinch strength (37 and 6.3 kg, respectively) were increased compared with preoperative values (34 and 3.9 kg, respectively). All patients returned fully to their preinjury work or sporting activities within 6 months after surgery. Although postoperative flexion was decreased by an average of 6°, no patients noted functional deficiency. CONCLUSIONS We recommend the reconstructive method of RCL advancement and transfer of a half-slip of the abductor pollicis brevis tendon to alleviate pain and improve grip and pinch strength in chronic RCL injuries of the thumb MCP joint.
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Affiliation(s)
- Kousuke Iba
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
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