FESSH Abstracts

A-0001 Iatrogenic elbow flexion contractures inchildren with amyoplasia

Olga Agranovich and Alexey BaindurashviliThe Turner Scientific and Research Institute for Children’sOrthopaedics, St. Petersburg, Russia

Iatrogenic elbow flexion contracture is not a very rareelbow deformity after posterior elbow capsulotomywith triceps lengthening or after tendon transfer sur-gery in children with elbow extension contracturedue to amyoplasia. This may cause the patient diffi-culty in reaching the perineum or using crutches andwheelchair. Fourteen elbows with iatrogenic flexioncontractures in 10 patients with an average age of 7years (4–16 years) were treated in our clinic. At birth,all children had elbow extension contractures withsevere limitation of active and passive flexion. Allchildren were treated with posterior elbow capsulot-omy with triceps lengthening and tendon transfer tobiceps. At an average 3 years after surgery (range 2–5 years), all patients had flexion contractures with anaverage of 110� (range 70–120�) and severe limitationof self-service.

To solve this problem, the following methods wereused:

1. Stretching (cast with Ilizarov device).2. Stretching with tendon transfer to biceps.3. Extension osteotomy of the humerus.

After treatment, eight children were able to reachthe perineum or using crutches and wheelchair, andtwo patients became more independent in dailyliving.

We analyzed the outcomes and found the maincourses of iatrogenic elbow flexion contractures inpatients with arthrogryposis.

1. Too long fixation elbow in flexion after posteriorelbow capsulotomy with triceps lengthening.

2. Too triceps lengthening.

3. A triceps to biceps transfer for restoration ofactive flexion.

4. One-stage restoration of passive and activeelbow flexion (posterior elbow capsulotomywith triceps lengthening and tendon transfer).

Adequate treatment for elbow extension contrac-tures in patients with amyoplasia, saving balancebetween biceps and triceps, helps to prevent iatro-genic elbow flexion contractures.

A-0003 Is cortical contact necessary to preventmetacarpal stem subsidence in trapeziometacarpalarthroplasty?

J. Duerinckx1, S. Perelli2 and P. Caekebeke1

1Ziekenhuis Oost-Limburg, Genk, Belgium2University of Pavia, Pavia, Italy

Cortical contact has been recommended to preventpostoperative subsidence of cementless metacarpalstems in trapeziometacarpal joint replacement. Dueto relatively large size increments, this is not alwayspossible. We hypothesized that cortical contact is notessential. In this study, 87 consecutive Maıa pros-theses (Groupe Lepine, France) were radiographi-cally evaluated immediately after surgery and at1 year postoperatively. Stem fit inside the intrame-dullary canal of the first metacarpal and subsidencewere measured. In 67 cases, the stem did not haveany cortical contact. No subsidence was noted. Ourresults show that a cementless stem can be safelyplaced in the first metacarpal without cortical contactif the following conditions are met: the stem is ana-tomically shaped, the cancellous bone of the intra-medullary canal has been properly impacted, stemplacement is press fit and rotational stable, and keypinch loading is avoided during the first 6 weeks aftersurgery.

Journal of Hand Surgery

(European Volume)

2018, Vol. 43(Supplement 2) S17–S210

! The Author(s) 2018

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DOI: 10.1177/1753193418769834

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A-0012 Universal 2 total wrist arthroplasty as asalvage procedure for failed BIAX total wristarthroplasty

H. J. A. Zijlker1,2, M. J. Berkhout1,2, M. J. P. F. Ritt1,2,C. N. van Leeuwen1,2 and C. B. IJsselstein1,2

1VU University Medical Center, Amsterdam, TheNetherlands2Albert Schweitzer Hospital, Dordrecht, The Netherlands

Introduction: The widely used treatment for failedtotal wrist arthroplasty (TWA) is conversion to atotal wrist arthrodesis. However, salvage of failedTWA by replacing the failed wrist implant may haveobvious advantages. In this study, we evaluate a largecase series in which failed BIAX implants are con-verted to Universal 2 implants.Methods: A retrospective study of patients with failedBIAX implants that had been converted to Universal 2implants was conducted. All cases were evaluatedfor clinical outcome and complications, includingthe need for revision of the Universal 2 implants.The Patient Rated Wrist Hand Evaluation (PRWHE)and the Quick Disabilities of Arm, Shoulder andHand (QuickDASH) questionnaires measured thefunction of the affected wrist. Additionally, allpatients were asked study-specific questions.Results: Thirty-seven patients (40 wrists) with failedBIAX implants that were converted to Universal 2implants were included in this study. Twenty-fiveUniversal 2 implants were still in situ after themean period of 99 months and demonstrated moder-ate PRWHE (49/100) and QuickDASH (51/100) scores.The remaining 15 Universal 2 implants were con-verted to a total wrist arthrodesis or a tertiary TWA.Thirty patients were satisfied with the Universal 2implant.Conclusion: Conversion to a Universal 2 implant is aviable salvage option for failed BIAX implants, whichmaintains the function of the wrist and postpones apossible conversion to a total wrist arthrodesis.Type of study/Level of Evidence: Therapeutic/IV.

A-0018 Surgical fixation of metacarpophalangealcollateral ligament rupture of the fingers

Charlotte Waxweiler, Nicolas Cuylits, Anne Lejeune,Konstantin Drossos and Nader ChahidiCentre de Chirurgie de la Main, Clinique du Parc Leopold,Brussels, Belgium

Introduction: Collateral ligament injury of the meta-carpophalangeal (MCP) joint of the fingers is under-reported in the literature and widely underestimated

by medical community. Herein, we present theresults from a large series of patients and reviewfactors influencing success of surgery.Methods: We performed a retrospective study of 46patients who underwent surgical fixation of the MCPcollateral ligament using bone anchor in an acute orchronic setting. The diagnosis was predominantlyclinical based on laxity testing of the joint. We col-lected demographic data as well as intraoperativefindings and postoperative results.Results: Postsurgery, with a median follow-up of 17months, all patients presented with a stable joint anda complete resolution of pain. The mean flexion ofthe MCP joint was 77.91�, and extension was amean of 0.84�. We measured the injured gripstrength at a mean of 88.52% of the opposite hand,and the mean Quick-DASH score used to evaluatedisability was 9.56 on a scale of 100 (with 100 com-plete disability). Importantly, time from injury to sur-gery did not influence postoperative results.Conclusion: Surgical treatment of MCP collateralligament rupture with bone anchors is a safe techni-que that gives reproducible positive results that arenot influenced by demographic data or time to treat-ment. This pathology is not rare, and a better diag-nosis would increase the incidence in future reports.

A-0019 Mallet fracture: DIPJ volar subluxation isnot predicted by fragment size but direction of forceand anatomy of DIPJ

Samuel Isaacs1, Michael Solomons2 and Nick Riley3

1Department of Plastic and Reconstructive Surgery, OxfordUniversity Hospital NHS Foundation Trust, West Wing JohnRadcliffe, Headley Way, Oxford, UK2Martin Singer Hand Unit, Department of OrthopaedicSurgery, Groote Schuur Hospital, Cape Town, South Africa3Department of Hand Surgery, Nuffield Orthopaedic Centre,Oxford University Hospital NHS Foundation Trust, Oxford,UK

Aims: The aims of the study were to (1) review themechanism of injury in mallet fractures (MF) in 30adult patients, (2) identify the direction of force(hyperextension/hyperflexion injury) in the abovegroup, (3) determine whether the direction of forcepredicts distal interphalangeal joint (DIPJ) volar sub-luxation; and (4) determine whether the fragmentsize (% joint involvement) predicts DIPJ volarsubluxation.Method: A retrospective review of 30 patients treatedfor mallet fracture had X-rays reviewed, interviewedfor mechanism of injury, digit affected, and directionof force. A standardized questionnaire was used and

SS18 Journal of Hand Surgery (Eur) 43(Supplement 2)

completed by the patient. X-Ray views of the affectedfinger were reviewed independently by two consul-tant hand surgeons, the percentage of joint surfacearea involvement was recorded, and whether DIPJvolar subluxation was present was noted.Results: Of the 30 patients, 9 patients had hyperex-tension MF with DIPJ volar subluxation; of these ninepatients, seven patients had joint involvement of25–50% and two patients had 0–25%. Twelve of the30 patients had hyperflexion MF with no DIPJ volarsubluxation: 4 had joint involvement of 0–25%; 4 had25–50%, and 4 had 50–75%. Nine of the 30 patientswere unable to recall direction of force: four patientshad DIPJ volar subluxation with joint involvement of25–50% and five had no DIPJ volar subluxation; two ofnine patients had 0–25% joint involvement, one of thenine patients had 50–75%; none of the patients had75–100%.Conclusion: MF with DIPJ volar subluxation is animportant subgroup and must be identified and man-aged surgically. Direction of force possibly predictsDIPJ volar subluxation, but there is no correlationbetween fragment size and DIPJ volar displacementin this group of 30 patients. This is possibly explainedby the anatomy of the DIPJ, which is a complex inter-play of flexor and extensor tendon balance as well asthe strong collateral ligaments.

A-0022 Treatment of advanced Kienbock disease(Lichtman IIIB) with a shortening osteotomy of theradius in 17 cases

Jose Botelheiro1 and Silvia Silverio2

1Hospital dos Lusiadas, Lisbon, Portugal2Hospital de Sant’Ana, Parede, Portugal

Objectives: For most surgeons, shortening osteo-tomies of the radius are not indicated in Kienbockdisease patients with carpal colapse (Lichtman IIIB).We reviewed and present our cases.Materials and Methods: Since 1985, all 53 cases ofKienbock disease were treated with a shorteningosteotomy of the radius. Patient data and X-rayswere reviewed, but only the 17 cases with carpalcolapse are presented here. The age of the patientswas between 15 years and 66 years (median 32years), with only 6 left wrists and 5 male patients.There were 11 cases of ‘‘cubitus minus’’ and 9 withlunate fragmentation in standard X-rays of the wrist.Last revision of the patients was between 9 monthsand 23 years after surgery, with a median period of 4years.Results: All patients felt better after surgery.Medium flexion–extension of the wrist improved

from 68� to 94�, grip strength from 21% to 73% ofthe other hand, and Mayo Wrist Score from 24 to68. On a 0–3 scale, pain decreased from 2.19 to 0.66.Conclusions: Carpal colapse in stage IIIB Kienbockdisease is adaptative and its correction is not man-datory. Our results and those of other surgeons, verysimilar to those obtained in patients without carpalcolapse, should enlarge the current indications forshortening osteotomies of the radius in the treatmentof Kienbock disease.

A-0023 Addition of liposome bupivacaine tobupivacaine 0.5% in wrist nerve blocks improvesanalgesia compared to bupivacaine 0.5% alone forDupuytren’s contracture release

Catherine Vandepitte, Joris Duerinckx, Ine Leunen,Sam Van Boxstael, Hassanin Jalil, Sofie Louage,Ingrid Meex, Sigrid Christiaens, Gulhan Ozyurek,Marijke Cipers and Max KurodaZiekenhuis Oost-Limburg, Genk, Belgium

Dupuytren’s finger flexion contracture can be treatedby injections of collagenase Clostridium histolyticum(CCH) into the affected cords. This is often a painfulprocedure, as pain occurs during CCH injection, theinflammatory response that lasts for several daysafter injection, and the manipulation to break up thecords. Local nerve blocks can be used to make theseprocedures less painful. We tested the hypothesisthat addition of liposome bupivacaine (LB,EXPAREL�) 1.3% to bupivacaine in ulnar andmedian nerve blocks results in improved analgesiaand longer duration of sensory–motor block com-pared to blocks performed with bupivacaine alone.Thirty-two patients were randomized to one of bothtreatment groups and prospectively followed up.Addition of LB to bupivacaine in ulnar and medianblocks in subjects having Dupuytren’s contracturerelease resulted in similar block onset but longerblock duration, improved pain scores, and improvedsatisfaction. The addition of LB provided anesthesiaand analgesia for both phases of treatment (injectionand manipulation) with a single injection.

A-0024 Clinical evaluation of surgical managementof hand pathologies under local anesthesia

Juanos Cabanas Jordi1,2, Schuind Frederic1,2,Jennart Harold1,2 and Zorman David1,2

1CHU Tivoli, La Louviere, Belgium2Erasme Hospital, Brussels, Belgium

FESSH Abstracts SS19

Hand surgery can actually be managed under localanesthesia, as described in recent North Americanstudies. It is actually admitted that xylocaine withepinephrine infiltrations are perfectly safe andallow to realize the intervention without using a tour-niquet (wide awake local anesthesia no tourniquet(WALANT) technique). Our objective was not to con-firm the safety of these procedures (that is alreadydone) but to establish the possibility to realize themin Belgium, where this strategy is less usual, andcould be more difficult to accept for the patientsand also the surgeons. We realized a multicenterobservational prospective study between October2016 and April 2017, including 44 patients and 47operations. We wrote two questionnaires: the firstone for the patients, asking essentially for pain con-trol, mobility, and satisfaction, and the second onewas given to the surgeons, asking for the difficultyof the infiltration and the surgery. We obtained verygood results for seven different indications in termsof pain control (71% of response for postoperativepain with step one analgesics), anxiety (1.6 on ascale between 0 and 10 during surgery), and rapidrecovery and patient satisfaction (95% of the patientswould ask for the same procedure if another surgerywas necessary). We observed high levels of comfortfor surgeon during the different times of the proce-dure (100% of surgeons will keep applying this tech-nique). We also confirmed the necessity to wait atleast 25 min between infiltration and surgery time(two cases of lengthening of surgical time between2 min and 3 min because of a premature incision). Incontrast, we observed excellent levels of visualiza-tion, even with a lower quantity of product than thatdescribed in the literature (10 cc instead of 20 cc incarpal tunnel surgery). In conclusion, WALANT was asafe and efficient technique, giving high levels ofsatisfaction for the patients and the surgeons, witha fast learning curve for the infiltration technique, anexcellent visualization of the surgical site, and thepossibility to obtain the patient collaboration formany indications (trigger finger and tendon repair).

A-0027 Double nerve transfer for the reanimationof axillary nerve palsies

Thibault Lafosse, Amaury Grandjean, Thibault Gerosa,Malo Lehanneur, Thomas Bihel andEmmanuel MasmejeanAlps Surgery Institute, Clinique Generale Annecy, France

Background: Axillary nerve palsies result in a deltoidand teres minor impairment, severely compromisingthe function of the shoulder. It can occur after a

lesion of the axillary nerve or a partial tear of theupper brachial plexus such as C5–C6 brachialplexus injuries (BPIs). It usually recovers in lessthan 6 months but sometimes incompletely. Wedescribe our surgical management of axillary nervepalsies with double nerve transfers to the anteriorbranch of the axillary nerve and to the branch ofthe teres minor.Methods: We manage axillary nerve palsies with adouble nerve transfer, which reinforces the probabil-ity of recovery through an axillary or posteriorapproach with transfer of a branch of the long headof triceps to the anterior branch of the axillary nerve(Lht to AA) and to the branch of the teres minor (Lhtto Tm) or an Lht to AA and a fascicle of the ulnarnerve to the branch of the teres minor (U to Tm).We performed an anatomical study to describe thetechnique and assess the feasibility. We measuredthe length and diameter of these branches and per-formed the transfer with tensionless sutures. Weoperated on 10 patients following this procedureand evaluated the motor deficits in the territory ofharvested nerves and the recovery of the deltoidand teres minor.Results: Ten cadavers were dissected. The meanlength for the anterior branch of the axillary nerve,the teres minor, the triceps, and the ulnar nervebranches was 34, 25, 54, and 28 mm, respectively.Their respective diameters were 3, 3, 2, and 2 mm.The transfer was always feasible. We operated on 10patients. There were four isolated axillary nerve pal-sies and six C5–C6 BPIs. We performed four Lht to AAwith Lht to tm and six Lht to AA with U to Tm. Therewere no deficits in the ulnar nerve territory, particu-larly after transfer to both biceps branch for elbowflexion and teres minor branch in C5–C6 BPI cases.Patients with more than 18 months of follow-uprecovered a full range of motion, an M4 deltoid andteres minor and an M4 elbow flexion in case of C5–C6BPIs.Conclusion: Axillary nerve palsies can cause long-term impairment of the shoulder. Either in isolatedor in C5–C6 BPI palsies, the challenge is to recover agood function particularly in external rotation, target-ing motor branches of the axillary nerve. We describeour technique to manage such palsies in earlystages, the double nerve transfer enhances thechances of recovery without compromising anyother function and should be attempted wheneverpossible.

SS20 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0028 Transfer of a fascicle from C7 root to thesuprascapular nerve in C5C6 brachial plexuspalsies

Thibault Lafosse, Malo Lehanneur, Amaury Grandjean,Thibault Gerosa, Thomas Bihel andEmmanuel MasmejeanAlps Surgery Institute, Clinique Generale, Annecy, France

Background: In C5–C6 brachial plexus paralysis,neurotization of the suprascapular nerve (SSN) bythe spinal accessory nerve (SAN) is the mostcommon procedure to reanimate the rotator cuffmuscles and to stabilize the shoulder. Because ofthe continuing shortcomings in this transfer, suchas trapezius palsy and nerve diameter inadequacy,we propose to systematically preserve the SAN andthe function of the trapezius muscle using the pec-toral fascicle of the C7 root to reinnervate the SSNafter hyperselective intraneurodissection andselection.Methods: We first performed an anatomical feasibil-ity study including eight brachial plexus dissectionson fresh cadavers. A supraclavicular approach wastaken, allowing isolation of the SSN, microdissectionof the C7 root, and harvesting of an anteromedialfascicle of C7. Once the nerves were freed, severalcriteria were evaluated such as the length of the fas-cicle from C7, the excess length between the twonerves, and their diameters. We then planned andperformed a systematic C7 to SSN nerve transfer inall our C5–C6 BPI cases whenever the stimulation ofC7 fired a response in the pectoralis major muscle.When a distal branch from C7 was also used to rea-nimate a paralyzed function (e.g. long head of tricepsto axillary nerve), the most distal branch was cutfirst, and we ensured the most distal function (e.g.elbow extension) was still preserved when stimulat-ing C7, before cutting the selected branch.Results: A tensionless suture was possible in eachand every cadaver case, with an averaged excesslength of 4.7 mm (range 2.2–7.1). The diameters ofthe two nerve stumps macroscopically fitted prop-erly, with an average diameter of 2.2 mm for thesuprascapular nerve (range 1.9–2.7 mm) and2.1 mm for the pectoral fascicle (range 1.8–2.6 mm).We operated on seven patients using this techniqueover the past 18 months. Patients with sufficientfollow-up recovered a mean forward elevation of100�, external rotation with adducted arm at 45�,and external rotation with abducted arm at 60�.There were no deficits in the C7 territory. In onecase of C5–C6 obstetrical brachial plexus palsy,there was no response after stimulation of the C7root, and the remaining function of the upper limb

was striked after the stimulation of C8–D1 roots. Insuch case, the SAN was used to transfer to the SSN.Conclusions: Both our anatomical study and clinicalexperience show that a neurotization of the supras-capular nerve by a pectoral fascicle from C7 is pos-sible. When the function of the shoulder was severelyimpaired by a trapezius palsy resulting from the har-vest of the SAN, we believe that a systematic C7 toSSN transfer should be performed in C5–C6 BPIswhenever possible. All of the criteria for clinical suc-cess seems present. A clinical study is currently runto assess definitive outcomes in our series.

A-0030 Surgical treatment for polydigit amputation:A retrospective analysis of the clinical results

Yasunori Kaneshiro1, Koichi Yano1,Kiyohito Takamatsu2 and Noriaki Hidaka3

1Seikeikai Hospital, Sakai, Japan2Yodogawa Christian Hospital, Osaka, Japan3Osaka City General Hospital, Osaka, Japan

Hypothesis: Polydigit amputation is a more severeinjury than single-digit amputation. It requires alonger operation time for replantation with a longerwarm ischemia time and often a secondary or recon-struction surgery. Therefore, our hypothesis is thatthe clinical results of replantation for polydigit ampu-tation are not as good as expected. The purpose ofthis study was to report clinical results of replanta-tion and reconstruction surgery for polydigitamputation.Methods: A retrospective study of 61 fingers of 21patients with polydigit amputation who had morethan one digit in Tamai’s zone III or IV was performed.Nineteen patients were men and 2 were women, witha mean follow-up period of 14 months. The numberof amputation fingers, zone of injury, survival rate,and clinical results of replantation and reconstruc-tion surgery at the final follow-up were reviewed andanalyzed.Results: The mean number of amputated fingers was2.8 (2–5) per patient. Crush injuries were the mainmechanism of injury in 15 patients. Five were clean-cut, and one was an avulsion. Regarding the injuredarea of the fingers, 24 fingers were injured in zone IV,21 in zone III, 10 in zone I, and 3 in zone III. Thesurvival rate of replantation was 87% (45 of 52digits). The mean final %TAM of the injured digitswas 58%, and the mean %TAM of zone IV was signif-icantly lower than those of other zones (mean 28%;p< 0.01). The grip strength at the final follow-up inthree-finger amputation was lower than that in two-finger amputation (45% vs 75%; p< 0.05). Aging was

FESSH Abstracts SS21

negatively correlated with the sensory recovery(r¼�0.36; p< 0.05). In the second toe transfer forfinger reconstruction in five patients, the %TAM andgrip strength at the final follow-up were significantlyhigher in patients with the PIP joint than in thosewithout the PIP joint (%TAM, 72% vs 28%, p< 0.05;grip strength, 70% vs 21% of the normal side;p< 0.05).Summary� The success rate of polydigit replantation was

similar to single finger replantation.� Clinical outcomes were poor, particularly in zone

IV injuries and in more involved fingers.� In the second toe transfer for finger reconstruc-

tion, better clinical results were achieved inpatients with the PIP joint than in those withoutthe PIP joint.

A-0033 Results of the surgical treatment of deQuervain’s tenosynovitis: 80 cases with a meanfollow-up of 9.5 years

Johanne Garcon1, Bertille Charruau2, Emilie Marteau2,Guillaume Bacle2 and Jacky Laulan2

1CHU Poitiers2CHU Tours

Introduction: Surgical treatment for de Quervaintenosynovitis is only indicated after failure of medicaltreatment, promoted by anatomical variations. Weused Le Viet’s technique to avoid tendon instability.The aim of our study was to evaluate long-termresults with the hypothesis that this surgical techni-que is reliable with lasting results over time.Patients and Methods: Patients operated on between1995 and 2015 were included, and the results wereassessed with a phone questionnaire with a mini-mum of 1-year follow-up (FU). Surgical techniquedescribed by Le Viet was followed, with a subcuta-neous fixation of the retinaculum flap. Presence ofany anatomical variant was always specified. In 26cases, another pathology was treated at the sametime. In addition to demographic data, the studylooked for the presence of pain quantified by VAS,functional impairment, possible dislocation of ten-dons, and satisfaction.Results: There were no preoperative or immediatepostoperative complications. Among the 89 operatedpatients, 74 (80 cases) patients were assessed, with68 women and 6 men, with a mean age of 48.5 years(19–71 years). The 15 patients who lost to FU had aninitial evolution comparable to the rest of the popula-tion. A supernumerary septum was noticed in 50cases and a long abductor pollicis multifascicled

tendon in 35 cases. There were no recurrences.Functional impairment was absent in 68 cases, mod-erate in 8 cases, and significant for 4, including 3 withassociated diseases. The mean VAS was 0.76 (0–10).None of the cases reported tendinous dislocation orneuroma. Patients were very satisfied in 72 cases,satisfied in 6 cases, and unsatisfied in 2 cases withassociated diseases.Discussion: The results of this series with a mean FUof 9.5 years are favorable with a total regression ofany functional impairment in 85% of cases and asatisfaction rate of 97.5%. None of the casesshowed tendon dislocation, neuroma, or recurrence.The residual problems were all related to associateddiseases, initially present or developed since.Conclusion: The Le Viet’s technique gives reliable,lasting results without complication or recurrence.

A-0034 Three-dimensional fasciectomy – A newtechnique for fasciectomy: A study of 585 patients

Ben Miranda, Charlotte Elliott, Chris Kearsey,David Haughton, Mark Webb, Ian Harvey andFahmy FahmyCountess of Chester Hospital NHS Foundation Trust,Chester, UK

Background: Numerous Dupuytren’s fasciectomytechniques have been described, each associatedwith unique surgical challenges, complications, andrecurrence rates. We describe a common groundsurgical approach to Dupuytren’s disease whichaims to address the potential contributors to thehigh recurrence rate and unite current limited fas-ciectomy practice that varies considerably betweensurgeons: three-dimensional fasciectomy (3-DF).Methods: We describe the 3-DF principles: raisingthin skin flaps (addressing dermal involvement),excising diseased palmar fascia with a 3- to 5-mmclearance margin (treating highly locally recurrentconditions), and excising the vertical septae ofLegueu and Juvara (providing deep clearance, henceaddressing all potentially involved pathological tis-sues). We compared the surgical outcomes betweentraditional limited fasciectomy (LF) and 3-DF.Results: From the 786 operations (n¼ 585), post-operative recurrence rates were significantly lowerfor the 3-DF (2/145, 1.4%) group than the LF group(72/641, 11.2%) (p¼ 0.001), and the time to recur-rence was significantly longer (5.0� 0 years vs4.0� 0.2 years; p< 0.0001). With recurrenceexcluded, there were no differences between thepostoperative complication rates for 3-DF (5/145,3.45%) and LF (41/641, 6.4%) (p¼ 0.4).

SS22 Journal of Hand Surgery (Eur) 43(Supplement 2)

Conclusions: Our results suggest that 3-DF leads tolower recurrence rates and a longer disease-freeperiod for patients, without increasing complications.3-DF provides a safe, efficacious, common groundsurgical approach in the treatment of Dupuytren’sflexion deformity.

A-0036 Predictive factors for flexor pollicis longuscrepitus after volar locking plate fixation forintra-articular fractures of the distal radius: Aretrospective comparative study

Wakasugi Takuma1,2, Saito Kenta1,2, Takeda Hideyuki2,Suzuki Hidetsugu3 and Saito Asami2

1Department of Hand Surgery, Konan Hospital, Ibaraki,Japan2Department of Orthopedic Surgery, Konan Hospital,Ibaraki, Japan3Department of Orthopedic Surgery, Tsuchiura KyodoGeneral Hospital, Ibaraki, Japan

Background: Intra-articular fractures of the distalradius are now widely treated using volar lockingplates, but there are many reports about tendinouscomplications associated with plates and screws.Flexor pollicis longus (FPL) subdermal crepitus(local crepitus on palpation with the thumb flexedand extended and the wrist kept dorsiflexed) wasreported as a clinical sign of FPL attrition by volarlocking plate. This sign could be followed by FPLtenosynovitis and tendon rupture, so patients withthis sign could be recommended to undergo surgeryfor hardware removal. However, there are no litera-ture analyzing the predictive factors for FPL subder-mal crepitus.Objective: To analyze the predictive factors for FPLsubdermal crepitus.Study design: Retrospective comparative study.Patients and Methods: Among patients with intra-articular fractures of the distal radius, we retrospec-tively analyzed 53 patients who were treated withvolar locking plates and who also had undergonesurgery for hardware removal as prophylaxis for ten-dinous complications or for patients’ preference.Regarding the predictive factors for FPL subdermalcrepitus, we investigated the direction of fracture dis-placement (dorsal or volar) and the presence of full-thickness lacerations of the pronator quadratusmuscle identified during surgical dissection as pre-operative factors. Regarding postoperative factors,we investigated radiographic parameters of radialinclination, volar tilt, ulnar variance after bony heal-ing, and the plate position using Soong grading. Wealso investigated the range of wrist dorsiflexion and

soft tissue coverage of the plate using Yamazaki’scriteria during hardware removal.Results: The average age of the patients was 55(range 17–84) years. According to the AO classifica-tion system, there were 5 types of B3 fractures, 10types of C1 fractures, 20 types of C2 fractures, and 18types of C3 fractures. FPL subdermal crepitus wasobserved in 20 (38%) patients. In the comparativeanalysis between patients with and without FPL sub-dermal crepitus, patients with dorsally displacedfractures had significantly higher incidence rates ofFPL subdermal crepitus than those with volar dis-placed fractures (47% vs 13%; p< 0.05). Patientswith full-thickness pronator quadratus muscle andthose with higher Soong grades had a tendencytoward higher incidence rates of FPL subdermal cre-pitus than those without these factors (55% vs 26%;p¼ 0.07, 45% vs 9%, p¼ 0.06, respectively). Softtissue coverage of the plate, range of wrist dorsiflex-ion, and other radiographic parameters were notassociated with the incidence of FPL subdermalcrepitus.Conclusions: Patients with dorsally displaced intra-articular fractures of the distal radius should be clo-sely monitored, and if FPL subdermal crepitus isidentified, then the patient should be advised toundergo surgery for hardware removal.

A-0037 Findings of an early limited-sequence MRIprotocol in suspected scaphoid fractures

Jefin Jose Edakalathur, Kevin Syam and Adam WattsWrightington Hospital, Wigan, UK

Objectives: The aim of the study was to evaluate thebenefits of early limited-sequence (15 min) MRI pro-tocol in suspected scaphoid fractures.Methods: The patients suspected to have scaphoidfractures by the accident and emergency departmentwere referred to an orthopedic clinic to be assessedby a consultant or a registrar. The main tests usedfor the clinical assessment were anatomical snuffbox tenderness, pain on axial loading of the scaphoid,and tenderness on scaphoid tubercle. If a scaphoidfracture is suspected based on the assessment in theclinic and the review of X-rays taken in the A&Edepartment fail to demonstrate a definitive fractureline, then patients are placed in a splint and an earlylimited-sequence magnetic resonance imaging (MRI)was done on the same day to rule out an occult sca-phoid fracture. This limited-sequence MRI involvedmainly only T1 coronal images of the wrist as com-pared to a whole wrist MRI. This in effect requiredonly 15-min slots for each patient and reduced the

FESSH Abstracts SS23

actual scan times to as little as 6 min. The scan willbe the reviewed by a musculoskeletal radiologist andreported within 1 week. The patients were reviewedthe following week with the MRI results. Once a sca-phoid fracture is ruled out, the patients are given asplint for comfort and sent to physiotherapy for thestart of mobilization as soon as possible. An auditwas undertaken of the management of patients withpossible occult scaphoid fractures after institution ofthis protocol over a 12-month period. The details ofthe initial clinical evaluation and diagnosis wereobtained from the clinic letters. Patients were eval-uated based on the clinical test done, whether theprotocol was followed or not, the number of furtherclinic and physiotherapy visits needed, and the MRIfindings.Results: A total of 366 patients referred from A&E aspossible scaphoid fractures were included in thestudy. In 117 patients, radiologically occult scaphoidfracture could not be excluded after initial clinicianevaluation. Eighty-one patients had limited-sequenceMRI scans according to the protocol. This resulted inthe detection of 43 traumatic injuries including 6 sca-phoid fractures, 19 carpal bone bruises, 6 occultdistal radius fractures, 12 soft tissue injuries, and25 non-trauma lesions. Fourteen patients hadnormal scans. Thus, pathology was identified in83% of cases utilizing this protocol. No injuries areknown to have been missed.Conclusion: This study showed that early MRI is areliable and quick method for evaluation of patientswith suspected occult scaphoid fractures. It resultedin the detection of occult scaphoid fractures as wellas other occult wrist injuries, the long-term clinicaloutcome of which has to be studied further. The uti-lization of this protocol helped in lowering the periodof plaster immobilization and number of clinic visitsneeded, thereby streamlining the patient care in asafe and reliable manner.

A-0041 Treatment for Dupuytren’s disease with awhole vial of Clostridium histiolyticum collagenasedissolved in 0.6 ml of solvent

Yannick Goubau1,2, Bart Berghs1, Bert Vanmierlo1,Francis Bonte1, Chul Ki Goorens3 and Jean Goubau1,3

1AZ Sint-Jan, Brugge, Belgium2ASZ Aalst, Aalst, Belgium3UZ Brussel, Jette, Belgium

Over the past few years, treatment for Dupuytren’sdisease has changed tremendously. Classic treat-ments include total fasciectomy, serial fasciectomy,and needle aponeurotomy. These treatments are

beginning to be replaced by treatment with collage-nase. In Belgium, the product is reimbursed for con-tractures of at least 20�, in at most two joints. Theproducer advises to use 0.58 mg of active enzyme in avolume of 25 ml for metacarpophalangeal (MP) jointsand 0.58 mg in a volume of 0.20 ml for a PIP joint. Wetried to minimize the need for two doses using a doseof 0.9 mg in a volume of 0.6 ml. We treated 43 handsin 39 patients. They were followed up for a meanperiod of 27 months (19–38 months). We recordedgain in extension, recurrence rate, and patient satis-faction. We treated a mean of 2.5 joints per patient(range 1–4). For the radial two fingers, we did nottreat enough patients to draw any conclusion. Wetreated 12 MP joints of the middle finger and gaineda mean of 32� at the final follow-up. We treated fourPIP joints of the middle finger and lost a mean of 6� ofextension at the final follow-up. We treated 20 MPjoints of the ring finger and gained a mean of 40� atthe final follow-up. We treated 11 PIP joints of thering finger and gained a mean of 20� at the finalfollow-up. We treated 19 MP joints of the littlefinger and gained a mean of 53� at the final follow-up. We treated 21 PIP joints of the little finger andgained a mean of 15� at the final follow-up. Eventhough large corrections were sometimes obtained,a significant part of the treated joints still had a con-tracture of more than 20� at the final follow-up (4/51MP joints and 28/36 PIP joints). Of the 39 patients, 25were satisfied and 24 of them would have the sameprocedure again. Seven patients wanted a new treat-ment (of which two of them would have collagenasetreatment again. Dilution of the enzyme in 0.6 ml ofsolvent seems to increase extension in both MP andPIP joints, even though full correction was not alwaysobtained (mainly for PIP joints)

A-0042 Botulinum toxin in treatment of patientswith obstetrical brachial plexus palsy sequelae

Nikita Khusainov, Margarita Savina andEvgeniya KochenovaTurner Scientific Research Institute for PediatricOrthopedics, Saint Petersburg, Russia

Objective: To asses the efficacy and identify primaryindications for botulinum toxin treatment as anoption in the management of patients with obstetricalbrachial plexus palsy (OBPP).Material and Methods: Botulinum toxin was used inthe treatment of 11 patients with OBPP divided intotwo groups. In group 1, five patients (mean age 6.2years) with co-contractions of triceps muscle thatsignificantly limited active elbow flexion were treated

SS24 Journal of Hand Surgery (Eur) 43(Supplement 2)

with injection into the medial head of triceps. Ingroup 2, five patients (mean age 3 years) withshoulder internal rotational contracture wereinjected into subscapularis, latissimus dorsi, andteres major muscles to decrease the strength ofshoulder internal rotators and improve both passiveand active abduction and exorotation of the humerus.Clinical examination, magnetic resonance imaging,and two-channel surface electromyography wereused as examination tools.Results: All five patients from the group 1 had sig-nificant improvement of active elbow flexion: bothamplitude and velocity of elbow flexion increased.In all cases, improvement was noticed on the thirdday after injection with a slight increase during thefirst week reaching the plato. Normalization ofbiceps–triceps reciprocal activity was confirmed bytwo-channel surface electromyography. In group 2,only one patient (1 year girl with no signs of shoulderjoint instability) had an improvement of activehumerus abduction and exorotation. During examina-tion, it was shown by MRI that in two patients whohad no effect after injection, a subluxation of thehumeral head took place, two more patientsobviously were too old (4 and 7 years) and had rigidcontracture of the injected muscles. No side effectsor complications in both groups were noticed.Conclusion: Botulinum toxin treatment is an effectiveoption in the management of patients with OBPPsequelae. Co-contraction of triceps muscle thatlimits active elbow flexion is the strongest indication.Internal rotational contracture does not respond tothis method of treatment so well, as it is described inthe literature, especially in older children. Thoughtfulexamination must be performed before the treatmentto exclude humeral head dislocation at first.Botulinum toxin treatment in OBPP patients withfunction-limiting muscle co-contractions is an effec-tive and safe method. This procedure allows toimprove hand function significantly in quite elegantmanner almost at any age with long-lasting effect.

A-0043 Scope in hand surgery using surgeon-administered local/regional anaesthesia

Sim Wei Ping, Tan Shoun and Vaikunthan RajaratnamKhoo Teck Puat Hospital, Singapore

Introduction: Hand and wrist surgeries are often car-ried out under local/regional anaesthesia. Wedescribe our experience using surgeon-administeredlocal/regional anesthesia (SALoRA) without sedationto deliver acute and elective hand surgery anaesthe-sia in a tertiary public hospital in Singapore. This is in

comparison with wide awake local anaesthesia withno tourniquet (WALANT), which has been increasingin popularity.Methods: A retrospective analysis was conducted onall surgeries performed under SALoRA betweenJanuary 2013 and December 2016 at our institution.Surgeries on areas other than the hand, wrist, fore-arms and elbows were excluded. The records werereviewed to analyze the demographics of the patientsand case profile of cases performed and theiroutcomes.Results: Of the total 3016 cases performed, 1994patients (1275 men, age 45.78� 16) were availablefor analysis for the study period. The case distribu-tion was similar to most other published day handsurgery. Tourniquet was utilized in 1357 (68%) ofcases with an average operation time of 26� 19 min.Mean tourniquet use was 24� 15 min. Detailed ana-lysis will be presented.Conclusion: A wide spectrum of surgeries in thehand, wrist and elbow can be performed usingSALoRA safely. This has increased productivity, effi-ciency and utilization of resources. All these can beperformed without the negative points of WALANT,providing a truly bloodless field, quick turnaroundtime without the need for extra manpower to monitorpatients post-LA infiltration and prior to operationand no risk of systemic adrenaline effects.

A-0044 Accuracy of the assessment of the stage ofosteoarthritis CMC I joint – X-Ray versusarthroscopy

Holger Erne, Michael Cerny, Denis Ehrl, Anna Bauer,Steffen Low, Hans-Gunther Machens andDaniel SchmaussDepartment of Plastic and Hand Surgery, TechnicalUniversity Munich, Munich, Germany

Background: Arthroscopy of the basal thumb jointhas become a valuable tool in the diagnostic andtherapeutic workup of trapeziometacarpal jointosteoarthritis. The aim of this study was to evaluatethe diagnostic accuracy of conventional X-ray com-pared to arthroscopy for the assessment of trapezio-metacarpal joint osteoarthritis. We further present anew classification system for arthroscopic assess-ment of trapeziometacarpal osteoarthritis, becausecurrent classification systems do not seemappropriate.Materials and Methods: In 23 patients experiencingsymptomatic trapeziometacarpal joint osteoarthritis,arthroscopic diagnostic workup was performed. Thegrade of osteoarthritis was evaluated according to

FESSH Abstracts SS25

the Outerbridge classification. The preoperative con-ventional X-rays were presented to 10 experiencedhand surgeons who were not involved in the treat-ment and blinded to arthroscopy results. The pro-bands were asked to determine which grade ofosteoarthritis according to the Outerbridge classifi-cation they would expect to find in arthroscopy. Theseratings were compared with the arthroscopic results.Results: Of the 23 basal thumb joints evaluated usingarthroscopy, 11 were found to have cartilage lesionsgrade 4 according to the Outerbridge classification, 8lesions grade 3, 4 lesions grade 2, and no lesiongrade 1. Overall, 43% of the cartilage lesions werecorrectly diagnosed using conventional X-ray. In caseof grade 4 lesions, 73% of the probands made thecorrect diagnosis, in case of grade 3 lesions 38%and in grade 2 lesions 13%. In every case of inaccu-racy, the grade of osteoarthritis was underestimated.Conclusion: The assessment of trapeziometacarpaljoint osteoarthritis using conventional X-ray seemsto be very inaccurate. Arthroscopy of the thumbsaddle joint should be the diagnostic gold standardfor trapeziometacarpal joint osteoarthritis. The newclassification system presented in this study mightfacilitate grading of trapeziometacarpal joint osteoar-thritis found in arthroscopy.

A-0045 Can open injuries in the hand wait? Ourexperience with treating open hand injuries aselective day surgery

Sim Wei Ping, Liang Zhiren Benjamin andVaikunthan RajaratnamKhoo Teck Puat Hospital, Singapore

Introduction: Open hand injuries presenting throughthe emergency department are routinely admittedand arranged for surgery acutely. Current practicein most of our local institutions is treating these inju-ries as emergencies, competing with other surgicalemergencies. In this study, we report our results oftreating open hand injuries as elective day surgeryprocedures and the prevalence of deep-seated handinfection postoperatively.Methods: A retrospective analysis of all patients sus-taining open hand injuries who underwent electiveday surgery from January 2015 to December 2016was performed. Polytrauma, bite injuries, activeinfection, and severe injuries requiring immediateattention for possible replantation or critical revas-cularization were excluded. Patients who developeddeep-seated infection post primary surgery requiringsurgical debridement were highlighted and evalu-ated. Demographic data, injury details, timing to

surgical management, and antibiotic therapy werealso looked at.Results: A total of 232 cases (211 men, age36.87� 14 years) were included in this study; 91%were conducted with surgeon-administered local/regional anesthesia. Time to surgery was49.9� 32.2 h. Our results revealed that deep infec-tions were not associated with time of surgery.Conclusion: Timing to surgery of open hand injuriesdid not affect the outcomes of deep-seated infectionin this retrospective single-center study. Treatmentof open injuries in the hand as elective day surgery isa safe and effective means of managing such cases ina busy tertiary hospital. It affords effective utilizationof health-care resources and at the same time allow-ing for a consultant delivered service.

A-0047 How reliable is the radiographic diagnosisof mild Madelung deformity?

Sebastian Farr1, Thierry G. Guitton2, David Ring3 andScience of Variation Group1Orthopedic Hospital Speising, Vienna, Austria2University Medical Center, Groningen, The Netherlands3Dell Medical School, The University of Texas, Austin, TX,USA

Background: Patients with Madelung deformity exhi-bit a spectrum of mild-to-severe deformity and dis-tortion of wrist geometry. It may, however, be difficultto reliably distinguish mild Madelung deformity fromnormal. Given the high prevalence of nonspecificwrist pain, it is important that mild Madelung defor-mity may not be subjected to overtreatment. Thisstudy thus tested the reliability of the diagnosis ofmild Madelung deformity on a single posteroanterior(PA) radiograph.Methods: An online survey was sent to hand andwrist surgeons of the Science of Variation StudyGroup for evaluation of 25 PA wrist radiographs com-prising 5 cases with suspected mild Madelung defor-mity and 20 radiographs without any evident wristpathology. Interobserver agreement was evaluatedboth via average percent agreement and Fleiss’kappa. To evaluate the relationship of rater charac-teristics and accuracy, a linear regression model wascomputed.Results: The interobserver agreement among the 69participating surgeons was low (¼0.12). The overallsensitivity, specificity, and accuracy were 0.30, 0.86,and 0.75, respectively. The mean confidence was7.4� 0.4 for mild Madelung and 7.8� 0.5 for normal(p¼ 0.112). The observers’ confidence level was the

SS26 Journal of Hand Surgery (Eur) 43(Supplement 2)

only factor that had a mild but significant effect onthe accuracy of the ratings.Conclusions: The diagnosis of mild Madelung defor-mity is unreliable. Until there is good evidence thatmild Madelung can be reliably and accurately diag-nosed and that we have an intervention that relievessymptoms better than sham surgery, it seems wiseto err on the side of caution and treat mild Madelungdeformity supportively.

A-0049 Principles of surgical treatment of wristcontractures in children with arthrogryposis

Olga Agranovich and Evgeniia KochenovaThe Turner Scientific Research Institute for Children’sOrthopedics, Saint Petersburg, Russia

The prevalence of wrist contractures in children witharthrogryposis multiplex congenita (AMC) is reportedfrom 40% to 88%. For the majority of children withAMC, the wrist contractures are rigid and do notrespond to nonoperative care. Multiple surgical pro-cedures have been proposed to correct wrist con-tractures, but results were controversial because offurther limit of motion and recurrence of deformity.The objects of the study were 90 patients (162 upperextremities) with the wrist contractures in AMC,which were examined and treated at the age from 6months to 17 years in 2009–2016. There are differentclinical variants of the wrist contractures includingflexion contracture, flexion contracture associatedwith ulnar deviation, which are the most commonlyseen, and isolated ulnar deviation that occurs veryrare. Patients were divided into three groups: withC6–C7, C5–C7, and C5–Th1 levels of spinal cordlesion. Clinical, X-ray study, and neurophysiologicalexamination were performed. One hundred and sixty-two operations were performed using the followingsurgical techniques: tendon transfers, carpal wedgeosteotomy, and shortening osteotomy of the forearmbones.

Passive correction of wrist deformities, range ofpassive and active motions, muscle strength, andfunctional capacity for grasps decreased in patientswith increased amount of damaged segments. Carpalcoalition were observed in 29% of cases, most ofthem, especially total carpal fusion, were revealedin patients with C5–Th1 level of spinal cord lesion(43%). In choosing variant of surgical treatment, thefollowing parameters were taken into account: var-iant of deformity and possibility of passive correctionof wrist contracture. In patients with C6–C7 andC5–C7 levels, tendon transfers were predominated(76% and 82%). In group with C5–Th1 level, tendon

transfers and carpal wedge osteotomy in differentcombinations were performed in equal percentage(51% and 49%). For objective results assessment ofsurgical treatment, we took into consideration thefollowing criteria: wrist resting position, active exten-sion, cosmetic appearance, and functional capacityfor grasps. All results were divided into threegroups: good, satisfactory, and unsatisfactory.Children with C6–C7 and C5–C7 levels of spinal cordlesion had 88% and 84% of good results and 12% and16% of satisfactory. In both groups, restoration ofactive wrist extension up to the neutral position andmore and significant improvement of cosmeticappearance and functional capacity for grasps wereachieved. In the C5–Th1 group, patients had 11% ofgood, 79% of satisfactory, and 10% of unsatisfactoryresults of treatment. Improvement of wrist positionand appearance and minimal increasing functionalcapacity for grasps were observed. Recurrence ofwrist deformity was revealed in 13% (21 wrists), inmost of cases in patients with C5–Th1 level of spinalcord lesion (13 wrists).

Varied surgical approach to wrist contracturestreatment in cooperation of determination the levelof spinal cord lesion can provide predictable resultsand improve wrist function, appearance, and qualityof life of children with AMC as much as possible.

A-0060 Outcomes of the Ivory arthroplasty fortrapeziometacarpal joint osteoarthritis with aminimum of 10-year follow-up: A prospectivesingle-centre cohort study

Gino Vissers1, Bart Berghs1, Bert Vanmierlo1,Francis Bonte1, Chul Ki Goorens2 and Jean Goubau1,2

1AZ Sint-Jan Hospital, Bruges, Belgium2Vrije Universiteit Brussel, Brussels, Belgium

Introduction: This study investigated the long-termfunctional outcome after total replacement of thetrapeziometacarpal joint with the Ivory prosthesis(Stryker Corporate, Kalamazoo, Michigan, USA) foradvanced trapeziometacarpal joint osteoarthritis.Materials and Methods: In this prospective single-centre study, clinical outcome (mobility andstrength), overall function, pain, and radiological out-come were analyzed after a minimum of 10 years offollow-up. Opening of the first web space and meta-carpophalangeal flexion and extension were graded.Opposition and retropulsion were graded by Kapandjiscores. Key pinch, precision pinch, and grip strengthwere measured using a calibrated hydraulic pinchgauge and a calibrated hydraulic hand dynamometer.To assess the overall function, the Quick Disabilities

FESSH Abstracts SS27

of the Arm, Shoulder and Hand score was used. Painscore was assessed with the visual analog scale.Radiological outcome was evaluated using frontaland profile views as described by Kapandji andEaton with and without stress.Results and Discussion: A total of 26 Ivory arthro-plasties were evaluated. Of the 32 eligible patients,24 patients were included in the study. Two patientshad bilateral arthroplasties. The female to male ratiowas 22:2, and the mean age was 71 (range 57–83)years. The mean follow-up period was 130 (range120–142) months. Patient satisfaction was high,with 85% of the patients willingly to repeat surgery.Retropulsion of the thumb was significantly improvedwith 25% compared to preoperatively. Flexion of themetacarpophalangeal joint was improved with 5.5%compared to the contralateral thumb. Overall func-tion improved by 54%. Pain decreased by 81% with amean visual analog scale score of 1.3/10 at a mini-mum of 10 years of follow-up. Radiological evaluationrevealed polythene wear with secondary jointinstability that needed revision in two patients and abroken implant that needed revision in another malepatient. Three patients had asymptomatic polythenewear that required no revision but remain in follow-up. One patient had a failure of the prosthesis andwas converted to a trapeziectomy. The 10-year over-all survival of the prosthesis was 85%.Conclusion: These long-term results suggest thatthe Ivory arthroplasty is a reliable option for treatingadvanced trapeziometacarpal osteoarthritis, becauseit gives an important improvement in overall functionand pain reduction. However, revision of the implantwithin 10 years after surgery is needed in 15%.

A-0070 Thumb basal joint osteoarthritis –Reconstruction and tendon interposition versushematoma distraction arthroplasty: A prospectiverandomized controlled trial

A. Toro-Aguilera1, P. Martınez-Galarza1 andC. Heras-Palou2

1Hand and Wrist Unit, Fundacio Sanitaria Mollet,Barcelona, Spain2Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK

Purpose: Numerous techniques have been describedfor the surgical treatment of thumb basal joint arthri-tis. To date, there is no gold standard surgicaltreatment.Methods: The study was designed as a blindedsingle-centre prospective randomized trial. Patientswere treated by trapeziectomy and ligament recon-struction (LRTI) suspension arthroplasty versus

hematoma distraction arthroplasty (HDA). Twoexperienced consultant hand surgeons (first twoauthors) performed all surgeries in a 2-yeardesigned study with a total of 50 patients in eachgroup. No loses were reported at postoperative 6-month follow-up. Clinical evaluation was evaluatedwith tip and key pinch and patient perception with aQuickDASH questionnaire. All data were comparedwith preoperative values at 6 months and publishednormal values. Surgical time and complications wereregistered. This project has the approval of theresearch ethics committee. We present 40% of thestudy’s completion.Results: These are preliminary results until finaldata collection. Both groups were statisticallyequivalent in age, sex, and work status. Tip and keypinch kilograms–force values at 6 months were 4.14(SD 2.19) and 5.57 (SD 2.57) for the LRTI group and3.38 (SD 1.41) and 4.75 (SD 1.58) for the HDA group.The LRTI and HDA groups improved 18 points (SD29.4) and 39 points (SD 34.19), respectively, inQuickDASH score (p¼ 0.23). Surgical time dedicatedfor LRTI was 39 and 41 min for HDA. We had no com-plications in LRTI group and one complex regionalpain syndrome with good resolution in the HDAgroup.Conclusions: To date, at 6-month follow-up, the LRTIand HDA were comparable on all measurements.However, there seems to be a trend in a better func-tional outcome in the HDA group. This is a statisti-cally nonsignificant difference due to the highdispersion of the QuickDASH data. We expect toincrease the level of accuracy as the studyprogresses.

A-0072 Digital shortening with auricular secondphalanx resection into Dupuytren’s digital hooks

Guy Raimbeau, Nicolas Bigorre, Walid Balti,Fabrice Rabarin, Jerome Jeudy, Pierre Alain Fouque,Alexandre Petit, Bruno Cesari and Yan Saint CastCentre de la Main, Trelaze, France

Introduction: The fifth finger strong digital hookduring the Dupuytren’s disease continues to be atherapeutic problem. The fifth finger amputation,which is sometimes the right and imperative solution,has a harsh functional and aesthetical result andexposes the patient to an adjacent digital hooksaggravation. The second phalanx removal with digitalarthrodesis is a surgical solution, which may well besuggested. The aim of this study was to report a con-tinuous series of 36 cases.

SS28 Journal of Hand Surgery (Eur) 43(Supplement 2)

Materials and Methods: This was a retrospectiveseries of 33 patients; 26 men and 7 women, operatedfrom 1994 to 2015. The patients showed a severe fifthfinger digital hook and had a previous surgery in30 cases. The combined extension deficit was 143�

(75–270), and functional and aesthetical discomfortwas important. The surgical technique consisted ofa dorsal approach, a more or less extensive excisionof the second phalanx and an arthrodesis with analignment of the remaining digital segment, keepingthe pulpoungueal complex. During patients’ review,the following were observed: functional discomfortand utilization, aesthetical aspect, residual pain,pulpar sensitivity, digital retraction recurrence, andoverall satisfaction.Results: Six patients were dead and two were lostto follow-up. Twenty-five patients (27 cases) werereviewed at the mean follow-up of 64 months(12–280). We did not deplore any postoperativecomplications. Twenty-two patients (24 cases)were satisfied or very satisfied. The aestheticresult was noted at 7.13/10 (1–10), and painaccording to the visual analog scale was 0.46(0–5). Cold pain was found in nine (33.3%) casesand decreased pulpal sensitivity in three (11.1%)cases. The hand flat could be possible in 21cases, while in the other cases it was not becauseof the little finger. Wearing of glove was again pos-sible in 26 cases. The bone consolidation wasacquired in 18 (66.6%) cases, while in all othercases, there was a pseudarthrodesis without clin-ical repercussions. We deplored five local recur-rences at the level of the little finger.Discussion: Digital shortening without a palmarapproach seems to bring a satisfying solution withfifth finger severe digital hooks with Dupuytren’s dis-ease. This technique allows us to keep a functionaldigital segment, sensitive and aesthetic, with noimportant morbidity amounting.

A-0075 Correlation between extension-blockK-wire insertion angle and postoperative extensionloss in mallet finger fracture

Sang Ki Lee1 and Youn Moo Heo2

1Eulji University College of Medicine, Daejeon, Korea2Konyang University College of Medicine, Daejeon, Korea

Introduction: Extension-block pinning represents asimple and reliable surgical technique. Althoughthis procedure is commonly performed successfully,some patients develop postoperative extension loss.To date, the relationship between extension-blockKirschner wire (K-wire) insertion angle and

postoperative extension loss in mallet finger fractureremains unclear.Hypothesis: We aimed to clarify this relationship andfurther evaluate how various operative and nono-perative factors affect postoperative extension lossafter extension-block pinning for mallet fingerfracture.Materials and Methods: A retrospective study wasconducted to investigate the relationship betweenextension block K-wire insertion angle and post-operative extension loss. The inclusion criteria were(1) a dorsal intra-articular fracture fragment invol-ving 30% of the base of the distal phalanx with orwithout volar subluxation of the distal phalanx and(2) <3 weeks delay from the injury without treatment.Extension-block K-wire insertion angle and fixationangle of the distal interphalangeal (DIP) joint wereassessed using lateral radiograph at immediate post-operative time. Postoperative extension loss wasassessed by using lateral radiograph at the lastfollow-up. Extension-block K-wire insertion anglewas defined as the acute angle between extensionblock K-wire and longitudinal axis of middle phalan-geal head. DIP joint fixation angle was defined as theacute angle between the distal phalanx and middlephalanx longitudinal axes.Results: Seventy-five patients were included. Thecorrelation analysis revealed that extension-blockK-wire insertion angle had a negative correlationwith postoperative extension loss, whereas fracturesize and time to operation had a positive correlation(correlation coefficient for extension block K-wireangle: �0.66, facture size: þ0.67, time to operation:þ0.60). When stratifying patients in terms of negativeand positive fixation angles of the DIP joint, the inde-pendent t-test showed that mean postoperativeextension loss is �3.67� and þ4.54� (DIP joint fixationangles of <0� and �0�, respectively, p¼ 0.024). Whenstratifying patients in terms of extension-block K-wire insertion angle (30�, 30�–40�, >40�), analysis ofvariance showed significantly less postoperativeextension loss for higher insertion angles (>40�)than for medium insertion angles (30�–40�). Meanpostoperative extension loss difference betweenhigher insertion angle (>40�) and medium insertionangle (30�–40�) was 11� (p¼ 0.002).

Discussion: Both operative factors (extension-block K-wire insertion angle and DIP joint fixationangle) and nonoperative factors (fracture size andtime to operation) are important, as they may affectpostoperative extension loss when treating acutebony mallet finger via the extension-block K-wiremethod. Insertion angles within 25�–45� wereachieved, and postoperative extension loss decreasedinversely within this range. When stratifying

FESSH Abstracts SS29

according to insertion angles, significantly lowerpostoperative extension loss was found in for anglesof 40�–45�. Furthermore, lower postoperative exten-sion loss occurs when the DIP joint is extended tomore than 0� during the fixation of the transarticularK-wire. Finally, there is higher likelihood for post-operative extension loss in cases with bigger fracturefragment or longer time to operation.

A-0080 Establishment of normal ranges of upperextremity length, circumference, and rate ofgrowth in the pediatric population

Tyler Edmond, Alexandra Laps and Joshua M. AbzugUniversity of Maryland School of Medicine, Baltimore, MD,USA

Objective: Upper extremity length and circumferenceabnormalities are present in a number of conditionsin the pediatric population such as Marfan syndrome,brachial plexus birth palsy, mesomelia, and hypo-chondroplasia. In most cases, upper limb hypoplasiaand hypertrophy are diagnosed when one limbappears substantially different from the otherduring the physical examination. However, occasion-ally when this discrepancy exists, it can be difficult todetermine which limb is the abnormal one.Furthermore, when both limbs are involved in a con-dition, the diagnosis of upper limb hypoplasia orhypertrophy becomes much more difficult due tothe lack of normative values. The purpose of thisstudy was to establish normal values for upper extre-mity length, circumference, and rate of growth inchildren aged 0–17 years.Methods: A total of 377 participants (212 female; 0–17 years) were recruited from a population of pedia-tric orthopaedic patients and their siblings. Fourmeasurements were taken for each upper extremityof each participant: upper arm length measured fromthe tip of the acromion to the elbow flexion crease,upper arm circumference measured at 5 or 10 cmproximal to the elbow flexion crease depending onthe size of the patient, forearm length measuredfrom the elbow flexion crease to the wrist flexioncrease, and forearm circumference, measured at 5or 10 cm distal to the elbow flexion crease dependingon the size of the patient.Results: Mean values for arm and forearm lengthand circumference for each age, 0 to 17 years, wereestablished. The determination of a child’s expectedarm length is dependent on their height, age, andsex, while the calculation of a child’s expected fore-arm length depends on their weight, age, and sex.Expected arm circumference in pediatric patients

can be determined by their height, weight, and age.In contrast, expected forearm circumference wasindependent of age, height, and sex, linked solely topatient weight. Male and female arms and forearmshave similar growth rates of lengths and circumfer-ences. No significant differences were found betweenright and left extremities for each of the four mea-surements taken.Conclusions: Contralateral limbs can be used com-paratively for length and circumference of the armand forearm in cases of unilateral upper extremityabnormality. The establishment of normal valuesfor upper extremity length, circumference, andgrowth rate will be a useful diagnostic tool forupper extremity hypoplasia and hypertrophy, allow-ing future studies to determine the impact of thesevariables.

A-0082 Transphyseal humeral separations areassociated with high fates of misdiagnosis byradiologists and emergency department physicians

Arun Hariharan1, Christine Ho2, Andrea Bauer3,Charles Mehlman4, Nathan O’Hara1, Paul Sponseller5

and Joshua M. Abzug6

1University of Maryland Orthopaedic Associates, Baltimore,MD, USA2Texas Scottish Rite Hospital for Children, Dallas, TX, USA3Boston Children’s Hospital, Boston, MA, USA4Cincinnati Children’s Hospital Medical Center, Cincinnati,OH, USA5John’s Hopkins Hospital, Baltimore, MD, USA6University of Maryland School of Medicine, Baltimore, MD,USA

Objective: Transphyseal humeral separations (TPHS)are rare injuries that lack substantial data regardinginjury patterns, diagnostic accuracy, treatment meth-odology, and overall outcomes. Given the rarity ofthese injuries, they are often misdiagnosed, whichmay lead to a delay in care. This study aims toassess the accuracy of diagnosis of TPHS by radiol-ogists and emergency department (ED) physicians aswell as their effects on the time to surgery andpatient outcomes.Methods: A retrospective review was conducted atfive pediatric institutions to identify all transphysealhumeral separations (n¼ 64) in patients 0–3 years ofage from January 1991 to December 2016. Patientdemographics, time to surgery, and diagnosis byradiologists and ED physicians were recorded.Frequencies and means were recorded for demo-graphic and epidemiological analyses, the rate ofmisdiagnosis, and the reported misdiagnoses.

SS30 Journal of Hand Surgery (Eur) 43(Supplement 2)

Results: Sixty-four patients with a mean age of 17.4months were identified. The most common mechan-ism of injury was accidental trauma (n¼ 40), followedby nonaccidental trauma (n¼ 17), cesarean section(n¼ 4), and vaginal delivery (n¼ 3). Time to surgerywas greater than 24 h in 40 patients. Accurate diag-nosis by the radiologist occurred in 8 instances(12.5%) and by the ED physician in 24 cases(37.5%). In the radiology group, the misdiagnoses(87.5%) recorded were lateral condyle fracture(n¼ 18), nonspecific distal humerus fracture(n¼ 17), elbow dislocation (n¼ 4), supracondylarhumerus fracture (n¼ 9), and medial condyle frac-ture (n¼ 3). In the ED group, the misdiagnoses(62.5%) recorded were lateral condyle fracture(n¼ 12), supracondylar humerus fracture (n¼ 10),nonspecific distal humerus fracture (n¼ 9), medialcondyle fracture (n¼ 7), and elbow dislocation(n¼ 7). The mechanism of injury did not have a sig-nificant correlation with diagnostic accuracy by eithergroup. Moreover, the diagnostic accuracy did nothave a significant correlation with time to surgery.Conclusion: Transphyseal humeral separations arerare injuries that are associated with high rates ofinitial misdiagnosis, ranging from 62.5% in ED physi-cians to 87.5% among radiologists. Despite the mis-diagnoses, there does not appear to be a relationshipto time to surgery. This multicenter analysis providesthe largest series assessing the rates of misdiagno-sis of transphyseal humeral separations. It is impor-tant to consider providing increased education toradiologists and ED physicians to accurately diagno-sis TPHS, as these injuries are associated with highrates of non-accidental trauma.

A-0085 Operative management for pediatric andadolescent scaphoid nonunions: A meta-analysis

Julio Jauregui1, Edward Seger2, Mark Shasti1 andJoshua M. Abzug1

1University of Maryland School of Medicine, Baltimore, MD,USA2SUNY Downstate Medical Center, Brooklyn, NY, USA

Objective: Scaphoid fractures in the pediatric popula-tion represent approximately 3% of all hand andcarpal fractures; however, their incidence is rising.Cast immobilization has been shown to yield excel-lent results in the acute phase; however, as many as10% of patients develop nonunions. Multiple fixationtechniques exist but there is no consensus regardingthe best surgical treatment following the develop-ment of a pediatric/adolescent scaphoid nonunion.The purpose of this study was to evaluate the current

body of literature regarding pediatric/adolescent sca-phoid nonunions and determine success and func-tional outcomes following surgical fixation.Methods: A comprehensive literature review wasperformed utilizing Medline, Ovid, and Embase data-bases to compare surgical techniques for adolescentscaphoid nonunions on the basis of union rates, func-tional outcomes, and operative complications. Theinitial search returned 2110 publications. Inclusioncriteria consisted of a scaphoid fracture with morethan 3 months of no clinical or radiographic improve-ment following cast immobilization and age less than18 years. Ultimately, 11 studies met inclusion criteriaand were included in the final analysis.Results: A total of 176 surgically treated pediatric/adolescent scaphoid nonunions were identified fromthe 11 studies, including 157 non-vascularized bonegraft procedures and 19 non-grafted rigid fixationprocedures. Patients treated with a non-graftedmethod achieved union with a total random effectsmodel revealing a union rate of 94.6%, while thegrafted cohort had a union rate of 94.7%. Functionaloutcomes including range of motion and grip strengthwere significantly improved in both cohorts. Patientsmanaged operatively with bone graft had four compli-cations, in contrast patients without bone grafting didnot report complications (p¼ 0.9).Conclusions: Surgical treatment of pediatric/adoles-cent scaphoid fracture nonunions produces excellentunion rates and functional outcomes following surgi-cal intervention, using both grafted and non-graftedtechniques. Given the current evidence, there is noadvantage to the use of bone graft in skeletallyimmature patients; however, this should always beevaluated in a case-to-case scenario. Future pro-spective studies are needed to assess whether theoutcomes of a specific technique are more favorableand to determine whether differences exist based onfracture location.

A-0086 Cyanoacrylate-assisted four-corner fish-mouth technique for microvascular anastomosis

Sze-Ryn Chung1, Muntasir Mannan Choudhury1,Sarah Jiayu Too2, Duncan Angus McGrouther1 andAndrew Yuan Hui Chin1

1Department of Hand Surgery, Singapore General Hospital2Yong Loo Lin School of Medicine, National UniversitySingapore, Singapore

Objective: The conventional end-to-end technique ofmicrovascular anastomosis with interrupted suturescan be time consuming especially in the hands of aless experienced microsurgeon. It has been shown to

FESSH Abstracts SS31

cause media wall necrosis with intimal hyperplasia,leading to intraluminal thrombosis. Studies havebeen done on the use of tissue adhesives to achievesutureless microvascular anastomosis. The ‘fish-mouth’ technique that was described by Egemen in2011 combines two sutures that were placed 180�

apart with cyanoacrylate tissue adhesive. Wedescribe a modification of the ‘fish-mouth’ technique,whereby four corner stitches were used instead oftwo, for microvascular anastomosis.Methodology: Twelve anastomoses were carried outon bilateral common iliac arteries in six rabbits. Twogroups were compared; conventional anastomosisversus four corner ‘fish-mouth’ (FCFM) technique.Conventional anastomosis involved seven to nineinterrupted sutures. For the described technique,four parallel incisions were made at 90� apart ofboth ends of transacted vessel. Four sutures wereplaced passing from the proximal end to exit fromthe distal part of the longitudinal incisions. Eachcorner was held in place to allow intimal contactbetween the two lids. The tissue adhesive was thenapplied onto the ‘fish-mouth’ flap. Outcomes weremeasured.Results: In both groups, 100% patency rates wereachieved. The mean anastomosis time for the con-ventional and FCFM group was 30 and 28.7 min,respectively, and the mean bleeding time was 1.8and 0.5 min, respectively. Histopathological evalua-tion for both anastomoses showed distinct findingsthat were significant. There was no intraluminaladhesive leakage in the FCFM.Conclusion: Our preliminary results for both conven-tional and the described technique are comparable interms of anastomosis and bleeding time. A largersample size would be needed to produce more sig-nificant results.

A-0087 Management of severe radial club hand bysoft tissue distraction prior to centralization usingJESS fixator

Shringari Mahadevaiah Venugopal andBhaskaranand KumarB.I.R.R.D. (T) Hospital, T.T.D., Tirupati, Andhra Pradesh,India

Objective: In cases of severe radial club hand, that is,Bayne’s type III and type IV centralization as a pri-mary definitive procedure is difficult due to tight softtissue contractures. Precentralization soft tissue dis-traction is advised in order to avoid extensive dissec-tion, bony resection, and acute stretching of theneurovascular structures. This study aimed to

evaluate the quality of the result of stiff radial clubhand by soft tissue distraction prior to definitive pro-cedure, to find out the difficulties associated with thistechnique prior to definitive procedure.Materials and Methods: In a prospective study, 31cases with 31 radial club hands of Bayne’s types IIIand IV were treated by gradual soft tissue stretchingusing differential distraction followed by centraliza-tion. There were 4 type III and 27 type IV radial clubhands. All hands were fixed with Joshi’s externalstabilizing system (JESS). Two transfixing ‘K’ wireswere passed in the ulna as well as in the metacarpalswherever feasible and two ‘K’ wires in ulna and onein the metacarpal were passed in severe contrac-tures. Differential distraction of two turns on radialside and one turn on the ulnar side per day was car-ried. Mean distraction time was 12.7 weeks (10–20weeks). Among these, 23 patients eventually under-went centralization and 2 underwent radialization. Sixcases were missed for follow-up.Results: Average age of the patients was 4.9 years(range 1–15 years), with male (M) to female (F) ratioof 1.8:1(M: 20; F: 11). The average radial deviationwith HFA (hand forearm angle) improved from87.45� � 23.96� preoperatively to 32.00� � 32.04�

postoperatively. HFP (hand forearm position/translation) at preoperative and postoperativefollow-ups was 18.40� 4.45 mm and 14.78�3.73 mm, respectively. The ulna length at preopera-tive and postoperative follow-ups was 6.16� 0.72 cmand 6.41� 0.81 cm, respectively. According toKanojia’s assessment criteria, 19 cases (61.2%) hadgood outcomes, 6 cases (19.4%) had satisfactory out-come, and 6 cases (19.4%) unsatisfactory.Discussion: Soft-tissue distraction in severe radialclub hands (types III and IV) prior to definitive proce-dure like centralization is a powerful technique forrepositioning the wrist. The differential distractionby JESS achieves improvement in the HFA, HF, with-out overstretching of soft tissues, nerves, and ves-sels. JESS external fixator is easy to apply, stable,and of low expenditure and could be readjustedeasily.Conclusion: The present study confirms differentialsoft-tissue distraction prior to definitive procedure insevere radial club hands helps to achieve betterresults.

SS32 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0088 Review of errors in distal radius fractures

Maria Angeles De la Red Gallego1,Manuel Ruben Sanchez Crespo1,Higinio Ayala Gutierrez1, Jose Couceiro Otero1,Olga Velez Garcia1, Ana Alfonso Fernandez2,Ciro Santos Ledo2 and Fernando Del Canto Alvarez1

1Hospital Universitario Marques de Valdecilla, Santander,Spain2Hospital Sierrallana, Santander, Spain

Distal radius fractures (DRFs) represent the mostcommon fracture treated by physicians. The bimodaldistribution shows two peaks, one of the high energyinjuries in young patients and other due to low energyinjuries in the elderly. An appropriate treatment ofeach fracture is important in order to avoid mistakes.Even if it’s the most common injury that hand sur-geons deal with, we must be aware that each fracturemight have its own ‘‘personality’’ and we must treatthem according to this. We present some cases offailure in the treatment of DRF (a collapse in a non-surgical DRF, an intraarticular screw in a surgicallytreated fracture, a case of collapse in a surgicallymanaged one, a case of broken screws and plate,etc.) and we ought to analyze the committed errorsin order to prevent them.

A-0089 A systematic review of volar locking plateremoval after distal radius fracture

Michiro Yamamoto, Yuki Fujihara, Nasa Fujihara andHitoshi HirataNagoya University, Nagoya, Japan

Background: Indication of volar locking plate (VLP)removal after bony healing of distal radius fracture(DRF) is controversial. Studies with various range ofremoval rate were reported. The purpose of this sys-tematic review was to investigate the frequency andthe reasons of hardware removal over the world. Wehypothesized that more frequent VLP removal con-tributes to better clinical outcomes.Methods: The authors searched all available litera-ture in the PubMed and EMBASE databases for arti-cles reporting on outcomes of treatment using VLPfor DRF. Data collection included hardware removalrate, complication rate, clinical, and radiological out-comes. We analyzed correlation between hardwareremoval rate with clinical and radiological outcomes.Results: A total of 3472 articles were screened, yield-ing 52 studies for final review. The mean hardwareremoval rate was 9%, ranging from 0% to 100%. Themean removal rate in studies from France, Norway,Japan, and Belgium was as high as 19%. The mean

removal rate in studies from the United States waslow (3%). The most frequent reasons for extractionwere routine removal (22%), tendon irritation ortenosynovitis (14%), hardware problem (14%), andpatient’ request (13%). Although routine removaland patient’ request were not counted as complica-tion, correlation between removal rate withcomplication rate was strong (�¼ 0.64, p< 0.001).Correlations between clinical and radiological out-comes were week except for volar tilt (�¼�0.42,p¼ 0.009).Conclusions: There was a diversity of removal rateand reasons in the studies over the world. High fre-quent VLP removal does not contribute to clinicaloutcomes including complication rate. Anatomicalreduction and appropriate plate selection and place-ment at the initial surgery are important to reducefurther intervention.

A-0092 Bilhaut procedure: Expanding theindications

Igor Shvedovchenko1,2 and Andrej Koltsov1

1Federal State Institution St. Petersburg Scientific andPractical Centre of Medical and Social Expertise,Prosthetics and Rehabilitation named after G. A. Albrechtof the Ministry of Labour and Social Protection of theRussian Federation2Department of Medical Physics, St. Petersburg StatePolytechnical University, St. Petersburg, Russia

Objective: The goal is to consider the possibilities ofBilhaut procedure in congenital polydactylytreatment.Materials and Methods: Twenty-four Bilhaut opera-tions were performed in children aged from 8 monthsto 6 years during the last 10 years. Eight patients hadthumb polyphalangy, 14 had thumb polydactyly (in 5cases, polydactyly was combined with duplicatedfinger triphalangism), and 2 had triphalanged fingerspolyphalangism. The indications for Bilhaut proce-dure were equal developing of the main finger andthe additional one, the main finger underdevelop-ment 30% and less, good-sized clinodactyly at thelevel of metacarpophalangeal and interphalangealjoint. A classic Bilhaut technique was used in 13 chil-dren, while in the rest it was modified according tothe specific anatomical features. Only soft tissues ofan additional finger were used in two operations, softtissues and additional proximal phalanx segmentwere used in two cases and the connection of onlyproximal or only nail fingers also in two cases. In fivepatients, the Bilhaut was combined with triphalan-gism elimination.

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Discussion: There is no agreement about Bilhautprocedure in fingers polydactyly. In some articles,the efficacy of this technique versus standard recon-structions is considered not proven. But this techni-que is constantly being upgraded to diminish itsdisadvantages. Our opinion is that Bilhaut procedureis excellent when you use only this idea and modify itaccording to the present anatomical peculiarities.Long-term outcomes show that nail deformity forma-tion is possible. This deformation is easily correctedin older age. Neither growth impairment nor previousmobility impairment was obtained.Conclusion: Bilhaut procedure in hand polydactylytreatment is expedient to use, and indications for itcan be extended.

A-0094 Volar lunate facet – secondary dislocationafter distal radius plate fixation: Correction optionsand salvage procedures

Christoph Pezzei, Stefan Quadelbauer andMartin LeixneringAUVA, Lorenz Bohler Trauma Center, Vienna

Objective: The secondary dislocation of the volarlunate facet fragment after operative fixation is a ser-ious problem. Significant predictors of loss of reduc-tion are number of fragments, subsidence lunatedistance, fragment size for fixation. Standard fixedangle plates may not provide adequate control ofthis fragment even when placed sufficiently distal.Carpal translation with volar subluxation more than4 mm leads to severe wrist dysfunction.Methods: In revision surgery, anatomical reductionand restoration of the articular congruity is the firstkey in treatment. The principles are mobilization ofthe displaced fragments, anatomical reduction andrefixation, and neutralization of the tension forcesof the short radiolunate ligaments. Sometimes it isnecessary to perform an additional volar open wedgeosteotomy on the distal radius to correct the radio-carpal joint inclination. For fixation, hook plates orsmall fixed-angle plates are used. But the plate cov-erage and the number of screws in the lunate facetdoes not address all aspects of stability. It is essen-tial to prevent the carpal translation. To reduce theload to the volar ulnar fragment, a temporary radio-carpal arthrodesis for 6–8 weeks is necessary.Therefore, a K-wire fixation between the radius andthe lunate is used. Depending on the time factor andanatomical conditions, a reconstruction with reas-sessment of the fragments is needed and it is notalways possible. If the cartilage of the radiocarpaljoint is destroyed and severe painful osteoarthritis

results, a salvage procedure is necessary. Our stan-dard method is a volar RSL fusion with a fixed-angleframe plate.Results: Between 2006 and 2014, 11 patients weretreated with an RSL fusion from a volar approach.The mean age was 55 years. Average follow-up was5.2 years. The CT scans at follow-up showed nopseudarthrosis, and no case of midcarpal arthrosiswas related to surgical procedures. The clinicalresults showed good pain relief in all the cases(VAS 2.2). Residual function covers 95� flexion–exten-sion arc, 35� radial–ulnar deviation arc, and 75% ofgrip strength compared to the contralateral side.DASH score 27 and PRWE score 31 points.Conclusions: The correction of secondary dislocatedvolar lunate facet fragments should be performed asearly as possible, and the important factor is ade-quate refixation of the fragments. As a salvage pro-cedure, we perform a volar RSL fusion with goodlong-term results.

A-0099 The creation of a wide awake hand surgeryservice in an NHS Trust in the United Kingdom:Challenges, cost savings and effectiveness

Constantinos Kritiotis1,2, Zaf Naqui1, Anuj Mishra1 andIshan Radotra1

1Manchester Hand Centre, Salford Royal NHS FoundationTrust, Manchester, UK2Iasis Private Hospital, Paphos, Cyprus

Background: The wide awake local anaesthesia notourniquet (WALANT) concept has been proved tobe an efficient, safe and cheap method to operateon various hand pathologies and trauma. We describeour experience with this method in a major handsurgery unit in the United Kingdom and compareour outcomes with those of a regional private handsurgery centre in Paphos, Cyprus.Objectives: To show our results with the utilization ofthe WALANT method in aspects of patient satisfac-tion, safety as well as cost reduction and improvedtheatre utilization.Study design and Methods: In this retrospectivestudy, we present our results from over 100 casestreated with this method in aspect of patient satisfac-tion, outcomes/complications as well as cost-effec-tiveness. Cases treated range from carpal tunneldecompressions to open reduction and internal fixa-tion (ORIF) of metacarpals or phalanges using platesand screws, cubital tunnel releases, ulnar collateralligament repairs as well as trapeziectomies. Themethod followed was administration of local anaes-thesia (LA; lidocaine with 1:100,000 adrenaline) in the

SS34 Journal of Hand Surgery (Eur) 43(Supplement 2)

area of the procedure, as advocated by Lalonde et al.No tourniquet was used during the procedure. All thepatients were operated on an ambulatory surgerysetting and were discharged immediately after theprocedure. The mean time from the injection of theLA until surgery commenced was 11.5 min and allthe patients were either injected in theatre or in theanaesthetic room.Results: There was a high satisfaction rate amongpatients as the procedure was comfortable even forlengthy procedures. Compared to Cyprus, we had twopatients who required sedation during the proceduredue to panic attacks as well as vasovagal attacks.There was also increased bleeding during the proce-dures compared to procedures done under a tourni-quet; however, this did not prevent us fromcompleting the procedures. Also the fact that theUK patients were operated in a public hospital settingmade them more reluctant to have their procedureswide awake and preferred to have their procedureunder general anesthesia (GA) as there was no addi-tional cost to them. No persistent ischaemia of digitsor any other WALANT-related complications wasnoted. There were also no operating list cancella-tions due to lack of anaesthetist and there was asignificant reduction in turnover time and as well assignificant cost saving based on the NHS NationalTariff Prices. Also, there were less cancellationsdue to patient comorbidities.Conclusions: Wide awake hand surgery in an NHShospital can result in less cancellations, improvedtheatre utilization, significant cost savings as wellas improved patient outcomes. However, betterimplementation measures should be put in place,like permission to inject patients in the ward atleast 30 min prior to their surgery in order to allowadrenaline to work better (and therefore have lessintraoperative bleeding), staff education regardingwide-awake hand surgery as well as patient educa-tion so as more patients opt for it.

A-0104 The double thenar flap for two adjacentfingertip amputations

Ji Sup Kim1, Hyun Sik Park, Jong-Ick Whang andHo Jung Kang2

1Department of Orthopedic Surgery, International St.Mary’s Hospital, Catholic-Kwandong University, Incheon,South Korea2Department of Orthopedic Surgery, Yonsei UniversityCollege of Medicine, Seoul, South Korea

Objective: Thenar flap is a well-described technique,but there is a scarcity of reports about its use in

patients with multiple fingertip injury. The aim ofthis study was to introduce surgical technique ofdouble thenar flap and to evaluate clinical outcomeand related complications.Methods: Multiple fingertip amputations treated bythenar flap reconstruction were retrospectively iden-tified and evaluated from October 2013 to October2016. At the last follow-up, the patients wereassessed for cold intolerance in the reconstructedfingers, two-point discrimination, range of motion(ROM), functional outcomes by quick disabilities ofthe arm, shoulder and hand (DASH) score, functionaland appearance outcomes by Michigan HandOutcome Questionnaire (MHQ), and return to worktime.Results: Twelve patients (24 fingers) underwentdouble thenar flap procedures medially (n¼ 5) or lat-erally (n¼ 5) based on pedicled thenar flap used. Thedonor site was covered with a partial or full thicknessskin graft from the medial foot. The combination ofinjured digits requiring reconstruction included bothmiddle and ring fingers (n¼ 9), both index and middlefingers (n¼ 3). The mean age was 42 years (18–60years). The mean time for division and inset was 15days (13–16 days). The mean follow-up time was 13.5months (12–16 months). All flaps have survived. Themean total active range of motion (TAM) in flexionmeasured at the last follow-up was 249� (238–260�). Objective sensibility in the flaps was ascer-tained as an average static two-point discriminationof 6.9 mm (3–7 mm). The mean quick DASH score was3.3 (range 0–9.1). The mean MHQ score was 93.8(range 88–100). All patients returned to work within6.2 weeks on average. No complication was reported.Conclusion: Double thenar flap technique is a goodoption for simultaneous coverage of small to largedefects in adjacent two fingertips.

A-0105 Comparison of two bone grafting techniquesfor the treatment of scaphoid waist nonunions: Iliacbone graft versus anterolateral corner of distal endof radius

Ji Sup Kim1 and Ho Jung Kang2

1Department of Orthopedic Surgery, International St.Mary’s Hospital, Catholic-Kwandong University, Incheon,South Korea2Department of Orthopedic Surgery, Yonsei UniversityCollege of Medicine, Seoul, South Korea

Objective: As a source of corticocancellous grafts fortreating scaphoid nonunions, the anterolateralcorner of the distal radial metaphysis has severaladvantages over iliac bone. However, comprehensive

FESSH Abstracts SS35

comparison on its surgical outcomes compared tothe traditional AIBG has not been fully explored.The aim of this study was to compare the twogroups depending on the source of corticocancellousautograft (iliac crest vs anterolateral corner of distalend of radius) for the treatment of scaphoid waistnon-unions.Methods: A total of 50 waist nonunions were includedin this retrospective follow-up study. Ten patientswere not accessible, and two patients refused toattend follow-up checks. Therefore, a total of 38patients were included in this study with a meanfollow-up interval of 16 (12–36) months; 23 patientswere treated using iliac bone graft (Group A) and 15patients with anterolateral corner of distal radius(Group B). Clinical assessment included range ofmotion (ROM), pain according to the visual analoguescale (VAS), grip strength, Disability of the Arm,Shoulder and Hand Score, Patient-Rated WristEvaluation Score, and modified Mayo Wrist Score.The follow-up study on each patient included a CTscan of the wrist which was analyzed for union,osteoarthritis, dorsiflexed intercalated segmentinstability, and humpback deformity.Results: Thirty-seven of the 38 (97%) of the scaphoidwaist nonunions showed union, 22/23 (95.7%) in theGroup A and 15/15 (100%) in the Group B. Union rateand time to union showed no significant differencesbetween the two groups. Radiologically, restorationof scaphoid deformity was corrected, and degree ofrestoring normal scaphoid alignment evaluated withscapholunate angles showed superior deformity cor-rection capability in Group B than in Group A(p< 0.05). Radiologically, the average lateral intras-caphoid angle, the radiolunate angle, and the sca-pholunate angle are improved postoperatively inboth groups (p< 0.05). Percentage of significant resi-dual deformity postoperatively was not significantbetween the two groups. Functional outcomes eval-uated with restriction of ROM, modified MAYO score,the PRWE score, the DASH score, and the rate ofcomplications showed no difference between thetwo groups.Conclusions: Corticocancellous bone graft fromanterolateral corner of distal end of radius has com-parable results with the one from traditional iliaccrest with regard to bony union, restoring normalscaphoid alignment, wrist function, and it showsbetter results than the traditional AIBG with regardto restoring normal scaphoid alignment evaluatedwith the scapholunate angle.

A-0107 Prognostic factors for resumption of work,ADL and hobbies after traumatic hand or wristinjury

N. Neutel1, P. Houpt2 and A. H. Schuurman1

1University Medical Centre Utrecht, The Netherlands2Isala Hospital, Zwolle, The Netherlands

Introduction: Traumatic hand and wrist injuries havea substantial impact, both economically as onpatients’ lives. For predicting patients’ time offwork, several biomedical, sociodemographic, psycho-logical and work-related prognostic factors havebeen suggested in previous studies. No prognosticfactors have been previously identified for the timepatients need to resume their ADL, resume theirhobbies and for the duration of their complaints.The aim of this study was to measure the impact oftraumatic hand and wrist injuries more broadly, byinvestigating prognostic factors for all the abovemen-tioned outcomes.Methods: In this prospective cohort study, 383patients with a traumatic hand or wrist injury wereincluded. In 354 patients, there was a completefollow-up. Data were collected through personalinterviews. Potential prognostic factors for all out-come measures were identified by univariate analy-sis. For the time off work, hazard ratios forprognostic factors were calculated using Cox regres-sion. A hazard ratio of 2, for example, means twice asmany patients have had an event (returned to work)at any point in time after the trauma.Results: The type of work, diagnosis, complication,occurrence of the trauma and gender were prognos-tic factors for the time off work in the Cox regressionanalysis. Having a blue collar job gives patients ahazard ratio of 2.52 (condidence interval (CI) 1.89–3.37), a diagnosis other than a distortion givespatients a hazard ratio of 2.48 (CI 1.63–3.76) and acomplication gives patients a hazard ratio of 1.88(1.04–3.42). Furthermore, blaming someone else forthe trauma gives patients a hazard ratio of 1.70 (CI1.11–2.59) and female gender resulted in a hazardratio of 1.61 (CI 1.22–2.12).

In univariate analysis, prognostic factors for ADLresumption, hobby resumption and the duration ofcomplaints are gender, diagnosis, operative treat-ment and complication. Furthermore, age is posi-tively correlated with the time to ADL resumptionand the duration of complaints.

Due to the trauma, 13 patients did not return towork at all, another 17 patients returned to work ina different job, 29 patients did not (completely)resume their ADL, 40 patients did not resume theirhobby and 101 patients were not free of complaints

SS36 Journal of Hand Surgery (Eur) 43(Supplement 2)

after 6 months. Patients resumed their work partiallyin a median time of 1 week (interquartile range (IQR)0–5), fully in 2 weeks (IQR 0–6), their ADL in 4.5weeks (IQR 1–9) and their hobbies in 5 weeks (IQR1–12). Patients were free of complaints in a mediantime of 9 weeks (IQR 5–24).Conclusion: Prognostic factors for return to work arethe type of work, diagnosis, complication, occurrenceof the trauma and gender. Prognostic factors for ADLresumption, hobby resumption and the duration ofcomplaints are gender, diagnosis, operative treat-ment and complication. Age is a prognostic factorfor the time to ADL resumption and for the durationof complaints.

Considering these factors can be helpful inexplaining patients what to expect in terms ofresumption of their daily activities.

A-0108 Correlation of subject self-measured wristrange of motion with direct provider measurement

Kevin J. Renfree, Kelly Scott, Cece Skotak andHamy TemkitMayo Clinic, Phoenix, AZ, USA

Introduction: Range of motion (ROM) is an importantoutcome measure for wrist injuries. Remote assess-ment may be useful, but data are limited regardingvalidity and reliability. We sought to establishintra-and inter-rater agreement between visual esti-mation, direct goniometric measurement, and mea-surements of self-taken digital photographs and linetracings of wrist ROM.Methods: Thirty-seven consecutive patients who hadundergone wrist surgery or sustained a wrist injurywere enrolled. Active wrist ROM (extension (E), flex-ion (F), radial deviation (RD), ulnar deviation (UD))was assessed by three different providers and finalROM measurements included (1) patient estimation,(2) provider estimation, (3) provider goniometricdirect measurements, (4) provider goniometricphotograph measurements, and (5) provider gonio-metric tracing measurements. Intra- and inter-rateragreement was described using intra-class/inter-class correlation (ICC) measurement.Results: Compared to each provider’s own gonio-metric measurements (intra-rater agreement), allthree providers had excellent correlation on visualestimation of extension and flexion (ICC range 0.82–0.87), measurements of self-photographs of exten-sion and flexion (ICC range 0.84–0.85), and measure-ments of self-drawn tracings of extension and UD(ICC range 0.76–0.85). When comparing providers(inter-rater agreement), excellent correlation was

seen with visual estimation of E/F/RD/UD (ICCrange 0.79–0.95) and on goniometric measurementsof E/F/RD/UD (ICC range 0.84–0.94). Agreement wasexcellent on goniometric measurement of self-photographs of E/F/RD (ICC range 0.83–0.97) andon goniometric measurement of self-drawn tracingsof E/F/RD/UD (ICC range 0.86–0.95).Discussion: Both visual estimation of wrist E/F andgoniometric measurements of self-taken digitalphotographs of wrist E/F had excellent intra- andinter-rater agreement regardless of experiencelevel. Goniometric measurements of self-drawn tra-cings of E/UD had excellent intra- and inter-rateragreement. These results study support remotemonitoring of wrist ROM, especially flexion andextension with visual estimation and digital photo-graphs. We hope that future research will furtherevaluate the applicability of these methods with theultimate goal of increasing patient access and opti-mizing outcomes.

A-0109 Correlation between patient-rated outcomequestionnaire and Single Assessment NumericalEvaluation score in the fracture of distal radius

Chang-Hun Lee1, Wan-Sun Choi2, Sung-Jae Kim3,Joo-Hak Kim4 and Kwang-Hyun Lee5

1Eulji Medical Center, Eulji University College of Medicine,Seoul, Korea2Ajou University College of Medicine, Suwon, Korea3Hallym University College of Medicine, Hwasung, Korea4Seonam University College of Medicine, Goyang, Korea5Hanyang University College of Medicine, Seoul, Korea

Objective: To compare the patient-rated outcomequestionnaire (PRO) and the Single AssessmentNumerical Evaluation (SANE) scores in the fractureof distal radius.Methods: This study was a retrospective review of aprospectively filled database of 212 patients who under-went internal fixation with volar locking plate for thefracture of distal radius between August 2014 and April2017. All patients were operated on by the same sur-geon. The patient database included postoperative PRO(The Disabilities of the Arm, Shoulder, and Hand(DASH), patient-rated wrist evaluation (PRWE)) andSANE scores at 1 month, 2 months, 3 months, 6months and 1 year after the operation. Any patientwith incomplete data was removed from the study.Results: The Pearson correlation coefficient (r)between DASH, PRWE and SANE scores was �0.76(p< 0.01) and �0.72 (p< 0.01), respectively. In sub-group analysis, the correlation between the PRWE

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pain, function score and SANE score was �0.66(p< 0.01) and �0.69 (p< 0.01).Conclusions: This study shows that there is a signif-icant correlation between postoperative SANE andPRO in the fracture of distal radius. We recommendthe SANE score as a reliable outcome indicator forthe follow-up in the fracture of distal radius.

A-0110 Pollicization in adults: What kind of surgeryto use?

Igor Shvedovchenko1,2, Andrej Koltsov1 andBoris Kasparov1

1Federal State Institution St. Petersburg Scientific andPractical Centre of Medical and Social Expertise,Prosthetics and Rehabilitation named after G. A. Albrechtof the Ministry of Labour and Social Protection of theRussian Federation2Department of Medical Physics, St. Petersburg StatePolytechnical University, St Petersburg, Russia

Pollicization is one of the most effective techniques ofbilateral grip restoration in trauma sequelae inadults. We need an algorithm of pollicization variantchoosing, which depends on the definite anatomicalfeatures of misshaped hand.Materials and Methods: We have an experience of472 pollicizations in congenital and acquired defor-mities, and only in 14 cases this method was used intrauma sequelae in adults. Three main variants ofthis surgery were used. The criteria for selectionwere thumb amputation level, the rest fingers condi-tion, the scar intensity of hand soft tissues, and theprognosed condition of neurovascular bundles.Results: Thumb amputation level: in seven cases, thefirst metacarpal bone and thenar muscles remainedunchanged; in six hands, the proximal third of thefirst metacarpal bone and carpo-metacarpal jointwere preserved; in three hands, the first metacarpalbone was absent but trapezoid bone remained.

The rest fingers condition: in three cases, two tofive fingers were intact; in six cases, there werestumps of two to five or three to five fingers at theproximal phalanges level; one patient had two to fivefingers contractures and metacarpal bones deforma-tion; two patients had two to three metacarpal bonesdefects; and two patients had proximal phalangesdefects with carpo-metacarpal joints destruction.

Scar intensity of hand soft tissues: cicatricialmasses at the hand dorsum were found in twopatients, at the palmar surface in two patients, andat both dorsal and palmar surfaces in one patient.

Prognosed condition of arteries and nerves: weexpected problems with bundles in two patients

who had two to three metacarpal bones defects andapparent scars in this region. In five cases, difficul-ties with dorsal veins were expected.

In four hands, the fourth finger was moved in thethumb position, in the rest cases index wastransferred.

Pollicization by Hilgenfeldt technique was per-formed in five hands, it let us to ignore the dorsalveins condition. In two patients, index was trans-ferred to the thumb position using backflow throughthe bifurcation of the common palmar digital artery.Pollicization at separated dorsal veins and palmarbundles was made in seven hands.

In 11 hands, transferred finger was connected withfirst metacarpal bone remnant, and in 3 hands, thereconstruction of the first carpo-metacarpal jointwas performed.

Finger transfer together with contracture elimina-tion was performed in one patient. Pollicization incombination with radial flap transfer was used intwo patients: in one case simultaneously and in theother 6 months after the thumb reconstruction.

No problems in postoperative period were noticed.Conclusion: When choosing pollicization variant intrauma sequelae in adults, the following data are tobe considered:� the condition of the dorsal veins, arteries and

nerves;� the thumb amputation level, carpo-metocarpal

joint and thenar muscles condition;� deformation of the finger planning to be

transferred,� prognosed cover tissue deficit by the surgery

termination.

A-0111 Core excision and tendon ball implantationfor the treatment of advanced-stage Kienbock’sdisease

Toru Sunagawa and Rikuo ShinomiyaGraduate School of Biomedical and Health Sciences,Hiroshima University, Hiroshima, Japan

Objective: The treatment strategy for the advanced-stage Kienbock’s disease is still controversial, andmany kinds of operative method have been reported.We positively rebuilt the lunate by the combination ofvascularized bone graft and decompression in thesecases for more than 10 years. However, the recon-struction was not promising when fragmentation andcollapse of the lunate were extensive. In late years,for these progressive cases, particularly long-termcourse and/or elderly cases, we performed the com-bination of the core excision of lunate and the tendon

SS38 Journal of Hand Surgery (Eur) 43(Supplement 2)

ball implantation that keep interosseous ligamentsfor the purpose of pain relief and carpal height pre-servation. The purpose of this study was to report ouroperative technique and postoperative results.Operative Method: From the dorsal approach, fenes-tration was conducted at the dorsal center of thelunate and excision of internal necrotic bone wasperformed through this window. During these steps,the interosseous ligaments around lunate and articu-lar cartilage of the lunate should be kept intact aspossible. Then, tendon ball which made with the pal-maris longus tendon was inserted into the lunatecavity. Postoperatively, the wrist was fixed for 3weeks with a splint.Materials: Six cases of five men and one woman withan average age of 46.2 years old were included in thisstudy. The preoperative period ranged from 6 monthsto 15 years with an average of 5.9 years. TheLichtman X-ray stage was IIIA in one, IIIB in four,and IV in one. The follow-up period ranged from 10months to 5.9 years with an average of 1.5 years.Results: The pain relieved in all cases and allreturned to a former job. The range of motion was56% of intact side preoperatively and 68% postopera-tively. The grip strength increased from 48% preo-peratively to 70% postoperatively. Mayo Wrist Scorewas good in one and fair in five because of the limitedrange of motion and the grip strength. The carpalheight ration was kept from 0.47 preoperatively to0.46 postoperatively.Conclusion: The combination of the core excision oflunate and the tendon ball implantation was effectivefor pain relief and carpal height preservation. Thistechnique is relatively less invasive and may be oneof the options for the treatment of Kienbock’s diseasein the advanced stage, particularly long-term courseand/or elderly cases.

A-0114 Reconstruction of ulnar dislocation of theextensor tendon at the metacarpophalangeal joint

Masayoshi Ikeda1,2, Yuka Kobayashi2,Takehiko Takagi2, Ikuo Saito2,3, Takayuki Ishii2,Daisuke Nakajima2 and Masahiko Watanabe2

1Shonan Central Hospital, Fujisawa, Japan2Tokai University School of Medicine, Isehara, Japan3Isehara Kyodo Hospital, Isehara, Japan

Objective: Ulnar dislocation of the extensor tendon atthe metacarpophalangeal (MCP) joint is a relativelyrare condition, which compromises the hand func-tion. We describe a reconstruction technique forthis condition and report the results of five casestreated using this technique.

Materials and Methods: Five patients (two womenand three men; age 25–82 years) with spontaneousulnar dislocation of the long finger extensor tendon(extensor digitorum communis (EDC)) were treated.One patient had an additional extensor dislocation ofthe index finger (EDC and extensor indicis proprius).One patient had additional dislocations of the EDC ofthe ring finger and the extensor digitorum minimi(EDM) of the small finger. The main symptomswere pain or snapping of the MCP joint. There wasno history of trauma and all patients were referred toour hospital several months after symptom onset.

The operation was performed under local anesthe-sia using lidocaine hydrochloride and epinephrine.Through a longitudinal incision, the extensor tendonwas proximally exposed from the MCP joint. A distallybased slip of the middle third of the EDC was devel-oped and looped around the radial collateral liga-ment in a distal to proximal direction under theattenuated sagittal band. During active motion ofthe MCP joint, the tendon slip was sutured back toitself under proper tension, which centralizes EDCover the MCP joint. The defect of the middle one-third of EDC was closed primarily. After 4 weeks ofthe MCP joint immobilization in extension, activemotion exercise was initiated.Results: All EDC dislocations were reconstructedusing the abovementioned technique. In the patientwith EDM dislocation, a half-slip of EDM was used forreconstruction. The radial sagittal band was thin andattenuated in all cases.

There was no recurrence of EDC dislocation of thelong finger in any patient. In the patient with preo-perative extensor dislocation of both index and longfingers, dislocation of the extensor tendon of theindex finger disappeared after EDC reconstructionof the long finger. Another patient, who had preo-perative non-symptomatic ulnar subluxation of theextensor of the ring and small fingers, complainedof a symptomatic dislocation resulting from repeatedprolonged guitar practice after EDC reconstruction ofthe long finger. This patient required additionalreconstruction of the ring and small fingers at alater date. Follow-up ranged from 6 to 18 months.There were no postoperative complications. In allpatients, preoperative symptoms disappeared andfull function was restored.Conclusions: This technique is simple, and propertension can be determined by the surgeon while thepatient actively flexes and extends the MCP jointunder local anesthesia. Different from previouslyreported techniques, the central part of the extensortendon is used as a slip to reconstruct the radialstability, thereby preserving the connection between

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the extensors via the membranous juncturaetendinum.

A-0115 The outcomes of extension block pinningand nonsurgical management for mallet fracture

Shin Woo Choi1, Jae Kwang Kim1, Young Ho Shin1 andJoo-Yul Bae2

1Asan Medical Center, Seoul, South Korea2Gangneung Asan Hospital, Gangneung-si, South Korea

Purpose: We aimed to compare the clinical andradiographic results of patients with a mallet frac-ture involving more than one-third of the articularsurface, but without a high degree of distal interpha-langeal (DIP) joint subluxation, treated with extensionblock pinning or nonsurgical management.Methods: Forty-nine patients with a mallet fractureinvolving more than one-third of the articular surfacewere reviewed. Twenty-six cases were treated usingextension block pinning (surgery group) and 23 weretreated nonsurgically (nonsurgical group). At thefinal follow-up, extension lag and flexion of the DIPjoint of the affected digit were measured. Distal inter-phalangeal joint pain was rated using a visual analogscale and the overall clinical outcomes were gradedusing Crawford’s criteria. Complications, includingnail deformity and dorsal prominence, were alsoassessed. The rate of DIP joint subluxation and frac-ture fragment size were radiographically evaluated.Results: Mean extension lag and flexion of the DIPjoint and mean visual analog pain scores were notsignificantly different in the two groups. Outcomes,as assessed using Crawford’s criteria, were excellentin 5, good in 12, fair in 6, and poor in 3 in the surgerygroup, and excellent in 2, good in 11, fair in 8, andpoor in 2 in the nonsurgical group. Moreover, thefrequency of nail deformity or dorsal prominencewas similar in the two groups. The rate of DIP sub-luxation and mean fracture fragment size were simi-lar between the two groups. All the fractures hadunited by 3 months after injury in both groups.Conclusions: The clinical outcomes do not signifi-cantly differ between extension block pinning andnonsurgical management for mallet fractures invol-ving more than one-third of the articular surface, butwithout high degree subluxation of the DIP joint.

A-0119 The clinical research of contralateral C7nerve transfer

Gao Kaiming, Lao Jie, Zhao Xin and Gu YudongDepartment of Hand Surgery, Huashan Hospital

Objective: To evaluate the outcome of patients trea-ted with contralateral C7 (cC7) transfer and to deter-mine the factors that affect the outcome of thisprocedure.Materials and Methods: A retrospective review of 73patients with total brachial plexus root avulsion injury(BPAI) who underwent cC7 transfer was conducted.All of the surgeries were performed by two stagesand the pedicled ulnar nerve was the bridged nerve.The 73 patients were divided into two groups accord-ing to different number of the recipient nerves. Ingroup 1 (51 patients), the cC7 nerve was used totransfer to median nerve only. The entire cC7 wasused in 11 patients; the posterior division togetherwith the lateral part of the anterior division transferto median nerve in 15 patients; the anterior or theposterior division alone transfer to median nerve in25 patients. In group 2, the cC7 nerve was used totransfer to two nerves simultaneously. The entirecC7 transfer to median nerve and biceps branch in12 patients and transfer to median nerve and tricepsbranch in 10 patients. The mean follow-up period was7.3 years.Results: The efficient of these 73 patients was 54.8%in wrist and finger flexor, 57.5% in median nerve areasensation, 66.7% in the elbow flexor, and 20% in theelbow extensor. The patients with entire cC7 roottransfer achieved significantly better recovery thanthe patients with partial cC7 root transfer. The bestfunction recovery could be induced if the intervalbetween two stages was 4–8 months. Functionalrecovery of biceps branch was significantly betterthan that of triceps branch.Conclusion: cC7 transfer is an effective procedure intreating total BPAI patients. If transferred to singlenerve, the entire C7 root transfer can obtain signifi-cantly better recovery and we emphasize using theentire root as the donor. The optimal intervalbetween two surgery stages is 4–8 months. If trans-ferred to two nerves, the two recipient nerves shouldbe collaborative in motor function.

SS40 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0122 Volar plate fixation versus plaster indisplaced extra-articular distal radius fractures: Amulticentre randomized controlled trial

Marjolein Mulders1, Monique Walenkamp1,Susan van Dieren1, Peter Leenhouts1,Jasper Winkelhagen2, Bas Twigt3,Egbert Jan Verleisdonk4, Percy van Eerten5,Jan Bernard Sintenie6, Carel Goslings1 andNiels Schep7

1Academic Medical Center, Amsterdam, The Netherlands2Westfriesgasthuis, Hoorn, The Netherlands3BovenIJ Hospital, Amsterdam, The Netherlands4Diakonessenhuis, Utrecht, The Netherlands5Maxima Medical Center, Veldhoven, The Netherlands6Elkerliek Hospital, Helmond, The Netherlands7Maasstad Hospital, Rotterdam, The Netherlands

Introduction: Despite the high incidence of displacedextra-articular distal radius fractures and the sub-stantial implications of suboptimal management, itis still undecided how patients with these fracturesshould be treated. In recent years, there is a trendtowards open reduction and internal fixation (ORIF).However, adequate randomized controlled trialsaddressing this topic in adults are lacking. The pur-pose of this randomized controlled trial was to com-pare the functional outcome of open reduction andvolar plate fixation versus plaster immobilization indisplaced extra-articular distal radius fractures.Methods: A multicentre randomized controlled trialin patients from 18 years to 75 years with an ade-quately reduced extra-articular distal radius fracture(AO type A2/3) was performed. The primary outcomewas the functional outcome measured with theDisability of the Arm, Shoulder and Hand (DASH)questionnaire after 12 months. Secondary outcomesincluded functional outcome measured with thePatient-Rated Wrist Evaluation (PRWE) question-naire, quality of life measured with the Short Form-36 (SF-36) health questionnaire, range of motion, gripstrength, pain as measured on a Visual AnalogueScale (VAS), radiographic measurements, and com-plications. Clinical and radiological follow-up tookplace at the outpatient clinic at 1, 2/3 and 6 weeks,and at 3, 6 and 12 months.Results: A total of 90 patients were randomized toORIF with a volar plate (47 patients) or plaster immo-bilization (43 patients). The median age was 59 years(IQR 46–65), and 74% of the patients were women.Median DASH scores were significantly better in theoperative group at 6 weeks (p< 0.001), and 3(p< 0.001), 6 (p¼ 0.004) and 12 months (p¼ 0.018).The same applied for the PRWE scores and for phy-sical score on the SF-36. The mental score on theSF-36 was significantly better in the operative

group at 6 weeks. At 12 months, supination(p¼ 0.003), extension (p¼ 0.012), flexion (p¼ 0.007)and grip strength (p¼ 0.011) were significantlyworse in the non-operative group than the operativegroup. Moreover, VAS pain scores were significantlylower in the operative group up to 3 months offollow-up (p< 0.001). During the entire follow-up,operatively treated patients had significant betterradiological parameters than non-operatively treatedpatients. Twelve fractures (28%) in the non-operatively treated group redisplaced within 6weeks and underwent ORIF, and six patients (14%)had a symptomatic malunion for which a correctiveosteotomy was performed.Conclusion: Patients with displaced extra-articulardistal radius fractures treated operatively havebetter functional outcomes after 12 months as mea-sured by the DASH and PRWE questionnaires thannon-operative treated patients. In addition, 42% ofnon-operatively treated patients are secondarilytreated operatively due to a redislocation or a symp-tomatic malunion.

A-0126 Should collagenase Clostridium histiolyti-cum be used in all joints in the treatment ofDupuytren’s disease?

Charlotte Hartig-Andreasen1,2, Lena Schroll1 andJeppe Lange1

1Department of orthopedic surgery, Regional HospitalHorsens, Denmark2Hand Surgery Unit, Department of Orthopaedic Surgery,Aarhus University Hospital

Introduction/Objectives: The optimal minimal inva-sive treatment for Dupuytren contractures remainsdebated. XIAPEX� is a treatment introduced into thecommercial market since its approval in 2009. Whenintroducing new efficacious procedures into everydayclinical practice, the effectiveness of these must beevaluated. The aim of this study was to evaluate theeffect of XIAPEX treatment at RegionshospitaletHorsens after a minimum 1-year follow-up (FU).

Outcomes of this study were (1) overall improve-ments in degrees from baseline to FU in metacarpo-phalangeal joints (MCP) and proximalinterphalangeal joints (PIP); (2) contraction recur-rence defined as extension deficit (ED) above 20�;(3) Hurst end point defined as ED below 5�

Materials and Methods: Hundred and thirty-one MCPjoints and 67 PIP joints treated from January 2013 toMay 2016 were available for FU. Mean FU was 2.5years (95% CI 2.4–2.6). Mean age at treatment was68 years (95% CI 67–69); 82% were men. Thirty-nine

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had received treatment in the affected joint prior toour XIAPEX (22 percutaneous needle fasciotomy, 13open surgery and 4 XIAPEX).Results: Baseline mean ED was 49� (95% CI 46–51)for MCP and 56� (95% CI 52–60) for PIP. Mean EDsafter correction were, respectively, 0� (95% CI 0–0.4)and 7� (95% CI 4–10) for MCP and PIP. At FU, meanEDs were 7� (95% CI 5–10) for MCP and 42� (95% CI36–47) for PIP. Overall improvements in MCP and PIPrange of motion were, respectively, 42� (38–46) and14� (8–19). Recurrence rate was 11% for MCP and79% for PIP joints; 73% of MCP joints achieved theHurst endpoint and 6% of PIP joints; 90% of thepatients were willing to repeat treatment. Uni- andmultivariate regression analysis did not identify anycorrelations between selected predictor variables inany of the reported outcomes.Conclusions: XIAPEX is a viable first-line treatmentof MCP Dupuytren’s contractures. However, theresults in PIP joint contracture are not optimal andwe advice that use in PIP joints should be performedcautiously.

A-0129 Functional outcome after ulna shorteningosteotomy in regard to DRUJ configuration

Rafael G. Jakubietz, Fabian Gilbert,Michael G. Jakubietz, Karsten Schmidt andRainer H. MeffertDepartment of Trauma, Hand, Plastic and ReconstructiveSurgery, Julius-Maximilians-University Wurzburg,Wurzburg, Germany

Objective: Ulna shortening osteotomy is a standardprocedure for ulnar impaction syndrome and hasshown good clinical results in midterm follow-upstudies. The reverse oblique distal radioulnar joint(DRUJ) configuration is associated with inferior post-operative results as osteoarthritis might result fromincreased pressure in the DRUJ. The aim of this ret-rospective study was to evaluate whether differentconfigurations of the DRUJ led to different functionaland radiographic results.Methods: Sixty-two patients with a minimum follow-upof 5 years after ulna shortening osteotomy wereincluded in this retrospective study. PreoperativeX-rays were assessed for the DRUJ configurationaccording to the Tolat classification, while postopera-tive radiographs were evaluated in regard to signs ofosteoarthritis using the Kellgren–Lawrence score.Functional outcome was assessed using the Disabilityof the Arm, Shoulder and Hand score (DASH) score andmeasuring the range of motion and the grip strength.

Results: Statistical analysis revealed significantlybetter results in patients with parallel configurationof the DRUJ (Tolat type 1 configuration) for DASHscore, grip strength and supination compared tonon-parallel configurations (Tolat type 2 and 3). Inpatients displaying the Tolat type 1 configuration,the mean DASH score was 9 compared to 18 in theTolat type 2 and 3 groups. Apart from supination, nostatistically significant differences were observed inrange of motion among all groups. No progressivedegenerative changes at the DRUJ requiring surgicalintervention were encountered.Conclusion: While long-term postoperative range ofmotion failed to display statistically significant differ-ences between different types of DRUJ configura-tions except for supination, better results regardinggrip strength and DASH scores were seen in a par-allel-aligned DRUJ configuration. While onset ofosteoarthritis seems to be later than the observationperiod, a non-parallel configuration predisposespatients for inferior functional outcomes regardingDASH score and grip strength.

A-0131 Cat and dog bites are different and requiredifferent principles of surgical management

Abby Choke and Duncan Angus McGroutherDepartment of Hand Surgery, Singapore General Hospital

Objective: We have compared bite injuries caused bycats and dogs and analyzed the distinct tissuedamage in relation to the animal’s dental morphol-ogy. The history of the incident is important in distin-guishing puncture wounds caused by a ‘snap andrelease’, from avulsion-type injuries associated witha ‘grip and hold’ bite. We aim to define the principlesof surgical management depending on the factorsabove.Methodology: We have recorded the demographics,presence of infection, related complications, andbacteriology of all animal bites admitted to our insti-tution from 2013 to 2017.Results: A total of 71 animal bites were included ofwhich 26 were cats and 45 were dogs. The mean agewas 41.2 and 52.1 years, respectively, mean timefrom presentation-to-surgery was 59 and 25 h, andboth have a female predominance. The commonestcomplication associated with cat bites were infec-tions (61.5%). Dog bites were associated with greaterdegree of soft tissue damage, which included tendonrupture (6.7%), nerve injury (11%), fractures (4.4%),amputations (4.4%), and skin defects requiring res-urfacing (5.7%). The commonest organism for bothwere Pasteurella species.

SS42 Journal of Hand Surgery (Eur) 43(Supplement 2)

Conclusion: Cats have two pairs of long and sharpcanines that mimic hypodermic needles. We shouldalways assume that deep structures are penetratedand therefore joints, tendon sheaths, and bone sur-faces should be debrided in depth and irrigated. Dogshave wider and shorter teeth, and they tend to gripand hold causing an avulsion-type injury with moreextensive tissue damage. We believe that a thoroughunderstanding of the animal’s dental morphology andpattern of injury is important in defining the surgicalmanagement.

A-0135 Arthroscopic wafer procedure versus ulnarshortening osteotomy as a surgical treatment foridiopathic ulnar impaction syndrome

Won-Taek Oh1, Yun-Rak Choi1, Ho-Jung Kang1,Il-Hyun Koh1, Ji-Sub Kim2, Sang-Yun Lee1 andJung-Jun Hong1

1Yonsei University College of Medicine, Seoul, South Korea2Catholic Kwandong University College of Medicine, SouthKorea

Purpose: To compare clinical and radiological out-comes and complication rates of the arthroscopicwafer procedure (AWP) and ulnar shortening osteot-omy (USO) for idiopathic ulnar impaction syndrome(UIS).Methods: From May 2009 to June 2014, 42 patientswho were older than 45 years with idiopathic UISunderwent either AWP or USO under the followingidentical surgical indications: (1) ulnar positive<4 mm; (2) Palmer type IID or IID lesion of the trian-gular fibrocartilage complex; (3) stable distal radio-ulnar joint (DRUJ)/lunotriquetral joint; and (4) noevidence of osteoarthritis of DRUJ/ulnocarpal joint.The patient assignment was not randomized. Visualanalog scale (VAS) for ulnar wrist pain, grip strength,range of motion, Mayo Wrist score (MWS), and thedisabilities of arm, shoulder, and hand (DASH)score at 3, 6, 12, 24 months after surgery wereused to compare the clinical outcomes. Ulnar var-iance, cystic change of lunate and triquetrum, andDRUJ arthritis on radiographs were comparedwithin or between groups. Any operation-relatedcomplications were also compared.Results: This study evaluated 19 patients after AWPand 23 patients after USO. At 3 months, AWP pro-duced significantly better outcomes than USO ingrip strength (79.6%� 14.3% vs 62.7%� 12.6%;p< 0.001), MWS (81.8� 7.9 vs 71.3� 14.2; p¼ 0.005),and DASH scores (19.4� 8.4 vs 31.5� 14.0;p¼ 0.001); clinical outcomes were similar at 6, 12,and 24 months. Complication rates were 34.8% for

USO and 10.5% for AWP, including DRUJ arthritis(n¼ 4), implant irritation (n¼ 6), and refractureafter implant removal (n¼ 2) with USO, and second-ary surgery (n¼ 1) and tendinopathy (n¼ 1) with AWP.Conclusions: AWP and USO for idiopathic UIS withsubtle positive ulnar variance achieved similar clin-ical radiological outcomes at 2 years after surgery.However, compared to USO, AWP showed lower com-plication rates and better grip strength, MWS, andDASH scores at 3 months after surgery.

A-0137 Comparative mechanical properties ofconventional and locking Kirschner wire fixation:An experimental study in chicken humerus

Veeranon Chunyawongsak, Suriya Luenam andArkaphat KosiyatrakulDepartment of Orthopaedic Surgery, PhramongkutklaoHospital and College of Medicine, Bangkok, Thailand

Background: Kirschner wires or K-wire fixation isone of the most frequently used operative proceduresfor the treatment of phalangeal fracture. However,the insufficient stability to allow early motion andthe need of postoperative immobilization are itsmajor disadvantages. Increase the stability of con-struction by connecting the end of each K-wirestogether or locking K-wires fixation was designedto solve these problems. Nowadays, there are noevidences supporting this hypothesis.Purpose: We designed a biomechanical study tocompare rigidities of conventional crossed K-wirestechnique and locking crossed K-wires technique inosteotomized chicken humerus.Methods: Forty chicken humeri were randomizedinto two groups. Group 1, each bone was transverselyosteotomized and fixed with conventional crossed K-wires method. The locking crossed K-wires fixationwas applied in group 2. Ten bones from each groupwere tested under tension load, and the other 10were tested under four-point bending load.Results: Comparing the locking and conventionalcrossed K-wires groups in tension test, they obtainedmaximum force of 129.80� 13.48 N and 46.68�7.97 N, maximum displacement of 15.43� 2.04 mmand 6.57� 1.01 mm, maximum stress 129.80�13.48 MPa and 46.68� 7.97 MPa, and maximumstrain of 30.86� 4.08% and 13.14� 2.02%, respec-tively. For four-point bending test, locking and con-ventional crossed K-wires groups obtained maximumforce of 84.23� 7.06 N and 46.80� 10.54 N, maximumdisplacement 8.46� 1.15 mm and 4.91� 1.71 mm,maximum stress 4.60� 0.63 MPa and 2.61�0.70 MPa, maximum strain 12.14� 1.82% and

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6.41� 1.19%, and elasticity 59.20� 11.46 N/mm2 and35.97� 5.67 N/mm2, respectively. Both tension andfour-point bending test were all statistically signifi-cantly higher in locking crossed K-wires group(p< 0.001).Conclusions: The locking crossed K-wires group hassignificantly better biomechanical stabilization overconventional crossed K-wires fixation method.

A-0140 Benefits of the implantation of a ‘‘wideawake surgery’’ circuit in hand surgery

Ana M. Far-Riera, Carlos Perez-Uribarri,Marcos Sanchez Jimenez, Tomas Pujol Oliver andJose Marıa Rapariz GonzalezHospital Son Llatzer, Palma De Mallorca, Islas Baleares,Spain

Introduction: Surgery without sedation or cuff ische-mia (wide awake surgery, WAS) has become popularin recent years in North America. In Canada, morethan 80% of the carpal tunnels are operated outsidethe operating room using this technique.Aims: To evaluate the benefits of the implantation ofan ambulatory WAS circuit in hand surgery.Materials and Methods: We present a prospectivecohort study comparing 150 cases of ambulatoryhand surgery, where only the combination of lido-caine and epinephrine was used, out from the opera-tion room at the office area, without preoperativeanalysis; and another 150 cases performed underregional anesthesia in the operating theater andambulatory major surgery circuit with preanesthesia.The resources used, the time spent in the hospital,and surgical wound were evaluated. Patient satisfac-tion and intra and postoperative pain were collectedin a specific survey.Results: No increase in problems with the surgicalwound has been found with respect to surgery withregional anesthesia. The stay in the hospital was sig-nificantly lower in the WAS group. The preoperativepain was greater in cases with plexus anesthesiathan in those of WAS. The consumption of personneland hospital resources was much lower for the inter-ventions at the office area. The yield per day was alsohigher. Time on the waiting list was shortened bymore than 3 months. Satisfaction was high in bothgroups, although always in favor of surgery withoutsedation, especially during the postoperative period.Conclusion: Procedures such as Tunnel carpal syn-drome and trigger finger can be performed safely bywide awake surgery. Patient satisfaction is similar inboth groups. We recommend its use because it sup-poses a benefit for the patient for convenience, speed

and no need to perform the preoperative blood ana-lysis. It also represents a significant saving in hospi-tal resources and an opportunity to free the operatingroom for other complex surgeries.

A-0143 WALANT for tendon transfers afterneglected peripheral nerve and shoulder plexusinjuries

Sergii Strafun, Andrii Lysak, Artur Bezuhlyi,Sergii Tymoshenko and Mykola OberemokState institution ‘‘Institute of Traumatology andOrthopedics of NAMS of Ukraine,’’ Kyiv, Ukraine

Objective: Study the possibility of WALANT for tendontransfers on forearm and hand.Methods: During 2016–2017, WALANT was per-formed in 32 patients with traumatic injuries of per-ipheral nerves of the upper limb. The average agewas 38.7� 14.7 (range 16–68). For anesthesia,20–30 ml of 1% lidocaine with 0.2–0.3 ml of 0.18%solution of epinephrine was used. Thirteen patientsunderwent thumb opposition restoration (ninepatients – medial nerve lesions and four patients –shoulder plexus injury). Ten patients underwentMerle d’Aubigne tendon transfer (seven – isolatedradial nerve injury and three – shoulder plexuslesions). Five patients with neurogenic IV–V fingersdeformity, due to ulnar nerve damage, underwenttransfer of FDS to the tendons of intrinsic hand mus-cles. Three patients with shoulder plexus lesions andone patient with shoulder medial vascular–nervetrunk injury underwent transfer of ECRL to FDP.Results: Goal of all surgical interventions, with a suf-ficient and comfortable level of analgesia, has beenachieved. WALANT tendon transfers allowed to solveimportant issues of intraoperative determination oftension and strength of donor muscle, as well asselection of the method of its insertion, to optimallyrestore function and avoid pathological settings,hyper-corrections and contractions. The possibilityof visual demonstration of restored function, duringsurgical intervention – to convince the effectivenessof transposition and awareness of the degree of cor-rection, already motivates patients to work closelywith the physician during rehab.Conclusions: WALANT is a modern and self-con-tained option for intraoperative anesthesia. Its roleand place are function-creating interventions invol-ving complex of sliding and active structures, therestoration of which requires close intraoperativeinteraction with the patient.

SS44 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0144 More alternatives for zones 1 and 2 flexorpollicis longus tendon reconstruction

Irina Miguleva and Aleksei FainSklifosovsky Clinical and Research Institute for EmergencyMedicine, Moscow, Russia

Objective: Due to its anatomical features and biome-chanical characteristics, reconstruction of flexor pol-licis longus tendon (FPL) is difficult and complicationrate is high. The purpose of this study was to evaluatethe final outcome of a rather large series of FPLreconstructions and to compare these results withthose of fingers profundus tendon reconstruction.Methods: Hundred and seventy-two patients under-went reconstruction of FPL tendon lacerated in zones1 and 2. Sixty four patients were treated in the acutesetting within the first 24 h after injury and in 108cases surgery was performed after several weeksor even months delay. FPL advancement was carriedout in 19 acute cases with distal stump length nomore than 12–14 mm. In the acute zone 2 lacerationcases, FPL primary grafting procedure from secondtoe extensor tendon was performed in 25 patients. In18 patients, primary index flexor digitorum superfi-cialis (FDS)-to-FPL transfer was performed withproximal FPL stump suturing to transferred indexFDS tendon in the distal forearm. In two patientswith severe FPL gliding channel destruction, siliconespacer from tip to distal forearm was implanted inthe acute setting. In 21 late reconstruction cases,FPL advancement was successfully performed, in65 cases with good flexor tendon bed condition con-ventional single-stage FPL grafting from second toeextensor was performed, and in one patient indexFDS-to-FPL transfer with own proximal end suturingwas performed. Twenty-two patients were treated bytwo-stage reconstruction: at the second stage, freegraft procedure using second toe extensor tendonwas carried out in 11 patients and in 7 patientsindex FDS-to-FPL transfer with own proximal endsuturing at the low forearm level was performed.One patient had a postoperative course complicatedby silicone rod removal because of infection, andthree patients declined second-stage surgery.Results: The functional outcomes were clinicallyevaluated at follow-up examination 6 months aftersurgery in 134 thumbs (78% of cases). The overalloutcome was excellent in 71 thumbs (53%), good in36 (26.9%), and fair in 17 (12.7%). The rupture ratewas 7.4% (10 thumbs). In the late conventional graft-ing group, 53 of 65 results were evaluated: 27 (51%)were graded as excellent, 14 (26.5%) as good, 8 (15%)revealed fair function, and in 4 thumbs (7.5%) graftsruptured. Our reported single-stage grafting results

in 132 fingers using also toe extensor tendonsincluded 59.1% excellent, 22% good, 7.5% fair, 2.6%contractures, and 9.7% ruptures. There is no signifi-cant difference (p> 0.05) in the rate of the excellentoutcomes and the rupture rate between the thumband the fingers conventional grafting groups.Conclusions: Our practical experience suggests theFPL advancement to be highly effective in the acutesetting for its zone 1 lacerations and that this proce-dure is also often successful for zone 1 FPL latesurgery cases. As for zone 2 FPL injuries, primarygrafting in the acute setting, conventional single-stage grafting, two-stage reconstruction, and indexFDS-to-FPL transfer with own proximal end suturingprovide reasonably good outcomes with low compli-cation rates.

A-0147 Revision surgery of failed trapeziometa-carpal arthroplasty: Secondary trapeziectomy

Charlotte Waxweiler, Nicolas Cuylits,Petrus Van Hoonacker, Konstantin Drossos,Anne Lejeune, Nader Chahidi and David LumensCentre de Chirurgie de la Main, Parc Leopold Clinic,Brussels, Belgium

Introduction: Basal thumb arthroplasty is a com-monly performed procedure to treat trapeziometa-carpal (TMC) arthritis. The risk of failure is highlyfluctuating in the literature, and only few report thefunctional results of secondary trapeziectomy result-ing from failed joint replacement. We aim to describeour large series of patients with secondarytrapeziectomy.Materials and Methods: This is a retrospective studyof 32 patients undergoing secondary trapeziectomyafter failed TMC arthroplasty with a mean follow-upof 48.8 months (�26.8). We realized an objective eva-luation of the mobility of the thumb and the strengthof the hand, a subjective evaluation with visual ana-logue scales and DASH questionnaire, and a radiolo-gic evaluation to assess the thumb shortening.Results: The mean age at revision surgery is 62 yearsand is composed of 28 women for 4 men. The survivalof the prosthesis is 19.5 months, and not reaching 1year in 66% of the cases. The major indications forrevision were loosening of the trapezial implant in56% of the cases, and luxation of the prosthesis in22%. The handgrip strengths of the two hands arecomparable, as well as the key pinch strength. TheKapandji score reached 9.4� 1/10 and was asso-ciated with an adequate measured mobility of thethumb. The vast majority of the patients were satis-fied or very satisfied by the revision surgery

FESSH Abstracts SS45

(respectively, 32% and 53% of the patients). Themean DASH score attains 22.6� 17.6/100. Themean Barron Eaton’s height ratio reached0.61� 0.04 on the injured side and 0.55� 0.07 onthe opposite hand, and the length difference wasnot significantly different and did not impact signifi-cantly clinical function of the thumb (pain, mobility,strength).Conclusion: Secondary trapeziectomy is a very effi-cient rescue procedure that gives good functionalresults with high satisfaction rates. These data leadus to accept the risk of failure of TMC joint arthro-plasty that can be salvaged with a reliable procedurethat gives replicable postoperative results.

A-0152 Long-term outcome after distal radialfractures in octogenarians

E. A. K. van Delft1, F. A. van Brussel2,C. J. L. Molenaar3, K. J. van Stralen3, N. W. L. Schep4

and J. Vermeulen3

1VU Medical Center, Amsterdam, The Netherlands2AMC, Amsterdam, The Netherlands3Spaarne Gasthuis, Haarlem, The Netherlands4Maasstad Ziekenhuis, Rotterdam, The Netherlands

Objective: Distal radial fractures in patients over 80years old are traditionally treated non-operatively inthe Netherlands. Little is known of the long-termfunctional outcome. The aim of this study was toevaluate the treatment and long-term patient-reported outcome of distal radial fractures inoctogenarians.Methods: All consecutive patients over 80 years oldwith a distal radial fracture presented at the emer-gency department of a large teaching hospital in theNetherlands in 2015 were registered retrospectively.Radiographic characteristics, AO classification, andreduction technique were scored. Functional out-come after 1 year was evaluated by the PRWE andQuickDASH questionnaires. Correlation betweenfracture type, treatment, radiological outcome andpatient-reported outcome were analysed.Results: A total of 128 patients (male:female; 4:124),with a median age of 85 years, were included; 97%(120/128) of the patients were treated non-surgically.In 51% (63/128) of the patients, closed reduction wasperformed. Fracture types were predominantly 23-A2.1 (n¼ 37), 23-A2.2 (n¼ 33) and 23-C1 (n¼ 33). Inthe 70 patients that completed follow-up, medianPRWE score was 3.25 after 1 year and medianQuickDASH score was 6.82. Fifty patients did notcomplete follow-up because of death (n¼ 18), cogni-tive impairment (n¼ 34) or loss to follow-up (n¼ 6).

Dorsal angulation (28.5%) resulted in significantlypoorer PRWE scores as compared to the patientswithout dorsal angulation. No other radiologicalcharacteristics could be identified on top of dorsalangulation, even if the factors had resulted in morefrequent malunions after cast removal.Conclusion: The overall long-term patient-reportedoutcome of octogenarians with non-surgically trea-ted distal radial fractures is good. However, dorsalangulation seems to influence the outcome after 1year and in this group surgical treatment may beconsidered.

A-0153 Soft tissue tumours of the hand and wrist

Pamela Chong Qin Yi, Ou Yang Youheng,Chung Sze Ryn, Suraya Zainul Bin Abidin,Muntasir Mannan Choudhury, Chin Yuan Hui Andrew,Tay Shian Chao Vincent and Duncan Angus McGroutherSingapore General Hospital, Singapore

Introduction and Objectives: Large-scale epidemio-logical data of soft tissue tumours in the hand areinfrequently published. The existing literature is nothomogeneous with differing accounts of the com-monest tumours. Epidemiological data can providediagnostic cues to guide the workup and manage-ment of hand tumours. Epidemiology is also impor-tant in the planning and delivery of healthcareservices.Materials and Methods: A retrospective review of allpatients between 2004 and 2015, who underwentexcision of hand tumours in a tertiary hospital inSingapore, was conducted. The following data werecollected: age, gender, ethnicity, histological diagno-sis, laterality, malignancy and location of tumour.Results: A total of 5000 patients were identified witha mean age of 52 (8–101 years), male to female ratioof 1:1.15. Majority of the patients were Chinese (75%),followed by Malays (9%), Indians (8%) and others(8%). The most common hand tumours excisedwere ganglions (44%), with the majority located inthe wrist. The next most common were giant celltumours (8%), which were most commonly found inthe digits. The majority of soft tissue tumours werebenign (99.8%), with only 0.2% malignant cases.Conclusion: The overwhelming majority of soft tissuetumours of the hand and wrist are benign and thiscan guide workup as well as counselling of patientsprior to operation. Malignant tumours, while the min-ority, have the potential for significant morbidity andmortality if not appropriately evaluated or treated.

SS46 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0155 High incidence of re-dislocation ofpaediatric distal both-bone forearm fractures

E. A. K. van Delft1, J. Vermeulen2 and G. van der Bij31VU Medical Center, Amsterdam, The Netherlands2Spaarne Gasthuis, Haarlem, The Netherlands3OLVG West, Amsterdam, The Netherlands

Introduction: Metaphyseal fractures of the distalforearm are common in paediatric patients.Displaced fractures need to be reduced and stabi-lized. In literature, a range of methods of stabilizationhave been described: above-elbow cast, percuta-neous pinning with Kirschner wires and internal fixa-tion. Treating these fractures only by reduction andcast immobilization has been debated in the past.Various rates of dislocation have been described,ranging from 7% to 91%. We conducted this studyto invest the incidence of secondary dislocation inAO type 23-M/3.1 paediatric both-bone forearm frac-tures and to invest weather primary use of Kirschnerwires could prevent the rate of secondary dislocationand therefore reoperations in paediatric patients.Material and Methods: To assess the clinical contro-versy of the treatment of both-bone metaphysealpaediatric forearm fractures, we conducted a retro-spective cohort study of all consecutive paediatricpatients who presented at the emergency depart-ment of a large teaching hospital in theNetherlands, throughout a 2-year period (2015–2016). We retrospectively analysed the patient files.Radiographic characteristics and OTC/AO-classifica-tion were assessed. Type of treatment, reductiontechnique, surgical interventions, removal of hard-ware and complications were recorded.Results: Fifty-one patients (boy/girl 32/19; mean age9 years) were included in this study. In 14/51 patients,reduction of the fracture in the emergency depart-ment was performed. In 12/14 patients, the reductionwas insufficient and there was need for reduction inthe operating room. One of them needed open reduc-tion and K-wiring. Of the 51 patients, 21 suffered asecondary displacement. Reoperation was performedin all 21 patients: 20 of them were treated with K-wires.Conclusion: Paediatric distal both-bone forearmfractures have a high rate of secondary dislocation.The primary use of Kirschner wires might preventthis high rate of secondary dislocation and thereforereduce the amount of reoperations in paediatricpatients.

A-0160 The association of scapular kinematics andcarpal tunnel syndrome

Nicolas Bigorre, Alexandre Petit, Jerome Jeudy,Yann Saint Cast, Fabrice Rabarin, Bruno Cesari andFrederic DegezCentre de la Main, Trelaze, France

Shoulder and cervical pain and associated gleno-humeral joint movement dysfunctions have beencommonly described but have not been reported inupper limb nerve compression. Yet Novak in 1997reported that repetitive use and static postures is asource of nerve compression and may directly affectnerve tension or pressure, producing chronic com-pression. The purpose of this study was to demon-strate the relationship between the scapulardyskinesia and the carpal tunnel syndrome and toevaluate the correction of these dyskinesias aftercarpal tunnel release.

This was a retrospective study of 133 patients (106women and 27 men) of mean age 45.8 years (22–64).We included patients with carpal tunnel syndromewho were treated between January 2016 and May2017. Patients who had a history of surgery on theshoulder or who presented signs of thoracic outletsyndrome or subacromial impingement wereexcluded from this revision. We analyzed descrip-tively the kinematics of the shoulder on the affectedside and noted the presence of kyphotic posture. Weperformed the same pre- and postoperative ana-lyses: we measured the internal rotation of eachshoulder, looked for pain in the upper trapezius, oron the insertion of the pectoralis minor on the cor-acoid process.

Scapular dyskinesia was present in 83 (62.4%)patients. A thoracic kyphotic posture was noted in67% of patients. The internal rotation of the affectedside was 36� (0–90�) and significantly lower com-pared to the opposite side which was 50� (0–90�)p¼ 2.85� 10�11. Pain in the upper trapezius wasfound in 44.4% of cases and pain in the insertion ofthe pectoralis minor in 54.9% of cases.Postoperatively, the rotation was significantlyincreased at 50.4� (0–90�) p¼ 2.54� 10�8. Scapularpain had also improved, with upper trapezial painfound in 27.8% (p¼ 5.19� 10�8) and pectoralisminor pain in 44.4% (p¼ 5.61� 10�11).

There is a relationship between scapular dyskine-sia and carpal tunnel syndrome. These are partiallycorrected with the release of the carpal tunnel and itcan’t therefore be concluded whether dyskinesia isone of the causes or a consequence of painful adap-tation. So, successful management of the carpaltunnel syndrome should begin with initial

FESSH Abstracts SS47

identification of all sites contributing to the present-ing symptoms. Treatment must then be directedtoward the sources of nerve compression and mus-culoskeletal dysfunction and not only on carpaltunnel release.

A-0165 The use of dermal substitute Matriderm�

and autologous skin grafting in the treatment ofsoft tissue defects with exposed tendon and bone

Jikang Park, Sangwoo Kang and Jungkwon ChaChungbuk National University Hospital, Cheongju, SouthKorea

Background: For patients with exposed tendon andbone can be reconstructed with a flap. Because thetendon or bone exposed area has poor vascularity, flapsurgery may be impossible or very difficult. In some ofthese cases, skin grafts are another option. However,skin grafts have some limitations, not availableexposed tendon and bone, poor elasticity, scar con-tracture and limitations of joint motion due to contrac-tures. The purpose of this study was to evaluate theusefulness of dermal substitute Matriderm with auto-logous skin grafts in the treatment of soft tissuedefects with exposed tendon and bone.Methods: Between 2011 and 2016, 12 soft tissuedefect patients with exposed tendon and bone werecovered by the Matriderm with an autologous skingraft. We assessed graft survival to evaluate theeffectiveness of Matriderm. The Vancouver BurnSkin Score (VBSS) was used to evaluate skin qualityafter a minimum of 3 months or later.Results: The take rate of the matrix-and-skin graftwas 92%. The mean age of patients was 32.6 years(range 2–76 years). The mean defect size was 63(range 4.4–420) cm2. The average follow-up was 9.6months (range 6–14 months). Median of scar elasti-city in VBSS is 2.5.Conclusions: Matriderm with autologous skin graftsis used to cover the soft tissue defect with exposedtendon and bone, resulting in an excellent functionaland cosmetic outcome. In selected cases, it seems tobe an alternative option for the management of softtissue defect that cannot be covered by primary clo-sure or a flap.

A-0167 Wide-awake minimal selective fasciectomyfor Dupuytren’s contracture

Jikang Park, Sangwoo Kang and Jungkwon ChaChungbuk National University Hospital, Cheongju, SouthKorea

Background: Most Dupuytren’s contracture opera-tions can be performed with tourniquet controlunder general or brachial plexus block anesthesia.The wide-awake technique is increasingly used inhand surgery.Objective: The purpose of this study is to show theeffectiveness of the wide-awake minimal selectivefasciectomy for Dupuytren’s contracture.Materials and Methods: We reviewed 16 patients (36digits) with Dupuytren’s contracture who were treatedsurgically. Eleven digits (six patients) were in thewide-awake group, who received minimal selectivefasciectomy and epinephrine-contained lidocaine asa local anesthetic agent, with a tourniquet wrappingbut with no pressure applied (group A). The other 25digits (10 patients) were in the conventional selectivefasciectomy group that received brachial plexus(group B: 10 digits, 5 patients) block or generalanesthesia (group C: 15 digits, 5 patients) and a 250-mmHg tourniquet application. The pain was assessedusing visual analog score (VAS) during injection,operation (tourniquet’s, incision site), and post-opera-tive. Operation time was recorded for each patient.Postoperative total active motion (TAM) and any com-plications within 4 weeks were recorded.Results: The mean age of the group A, group B andgroup C was 68, 62, and 60 years, respectively. Intra-operation (Tourniquet’s, incision site) and post-operative pain in the conventional group (groups Band C) were significantly higher than the wide-awake group (group A). Mean operation time was32 min/digit in group A, 64 min/digit at group B, and62 min/digit at group C. There were no significantdifferences between any of these individual groupsin TAM.Conclusion: Wide-awake minimal selective fasciect-omy technique offers better comfort for patients andless operative time and as with the conventionaltechnique.

A-0171 Functional and radiographical results of theISIS CMC prosthesis: A prospective study

Francisco Cuadrado Abajo,Manuel Ruben Sanchez Crespo,Fernando Javier del Canto Alvarez,Marıa de los Angeles de la Red Gallego,Higinio Ayala Gutierrez, Olga Marıa Velez Garcıa,Jose Couceiro Otero and Vanesa Martınez CortavitarteMarques de Valdecilla Universitary Hospital, Santander,Spain

Objectives: Degenerative thumb carpometacarpal(CMC) osteoarthritis is currently one of the most

SS48 Journal of Hand Surgery (Eur) 43(Supplement 2)

prevalent joint conditions in the hand, and it canseverely hinder hand function. Treatment with carpo-metacarpal implants, namely carpometacarpal pros-theses, is rising as an attractive alternative due to itsreported favorable short-term outcomes. Results forprosthetic models featuring threaded cups have beeninfrequently reported in the past, owing to the highfailure rate of previous designs. The objective of thisprospective study involving the Isis prosthesis is toassess its functional and radiographical results andits complications.Materials and Methods: Between April 2014 andJune 2017, 28 ISIS CMC prosthesis were implantedin 27 patients. All of the implants were semicon-strained with a threaded, uncemented cup compo-nent and an uncemented metacarpal stem. Astandard dorsal approach was performed in all ofthe cases.

We prospectively followed up our patients on ayear-to-year basis after the first postoperative year.Pain measured on the visual analog scale (VAS),range of motion, strength, and overall hand functionassessed with the Henck and Van Capelle test wereobtained for each patient, pre and postoperatively.

The radiographical parameters studied includedthe pre and postsurgical Eaton stage of the scapho-trapeziotrapezoidal joint, the presence or absence ofperiprosthetic radiolucent areas, and the distancebetween the trapezium base and the apex of thefirst metacarpal head, both before and after surgery.All complications were recorded.

The statistical analysis was carried out with thelatest SPSS statistical software version (SPSS Inc.,Chicago, IL, USA).Results: Of the 27 patients, 21 were women. Themean age was 59 years. The non-dominant handwas affected in 21 cases. The mean follow-up was 2years (1–4). The mean preoperative Van Capelle testscore was 19, and it was 36 postoperatively (excellent36–40 points). The VAS pain scale improved a mean of6.5 points. Grip strength values improved a mean of5 kg from the preoperative scores. Pinch strengthvalues improved a mean of 2 kg.

Radiographically, there was a mean increase in thetrapezium base to apex of the first metacarpal headdistance of 3 mm. None of the cases exhibited radi-olucencies or loosening signs.

The Eaton stage did not progress during thefollow-up.

The mean satisfaction was 9.5 of 10. All of thepatients went back to their previous activities within3–6 months after the surgery except for one.

No dislocations or infections were recorded in ourseries. We did register three cases of de Quervain’s

Tenosynovitis and one case of epicondylitis, all ofthem resolved favorably with medical treatment.Conclusions: The ISIS CMC prosthesis has shown tohave very satisfactory short-term postoperativeresults, with a 100% survival rate at 2 years in ourseries. If technical errors are avoided, complicationsappear to be minimal. These results compare favor-ably to those reported in the indexed literature formodels with cemented cups, other models withthreaded cups, and even models with impactedpress-fit cups. Nonetheless, long-term survival stu-dies are recommendable.

A-0173 Fingertip reconstruction with an innervateddigital artery perforator flap

Yoshitaka Tanaka, Hiroyuki Gotani, Kosuke Sasaki andHirohisa YagiOsaka Ekisaikai Hospital, Osaka, Japan

Purpose: To evaluate the results of fingertip recon-struction with an innervated digital artery perforator(IDAP) flap.Methods: Ten patients (10 fingers) underwent finger-tip reconstruction with an IDAP flap between April2015 and January 2017. The mean age was 46.6years (range 21–65 years). The defect size was from1.2� 1.5 to 3.0� 1.5 cm. The mean follow-up periodwas 5.9 months (range 4–7 months). Surgically,the distal part of the flap was set at the edge of thewound and the proximal part was extended to thedorsum of the middle phalanx. The incision wasbegun dorsally or vollary, and subcutaneous tissuewas dissected from the periosteum of the phalanxwithout injury to the extensor tendon paratenon,until the neurovascular bundle was identified at theproximal side of the flap. Following neurovascularbundle identification, the flap was dissected fromthe volar side to the periosteum and was then mobi-lized as a digital island flap. The flap was also sepa-rated from the neurovascular bundle, except at thepedicle, located distally at the flap, which includedthe perforator arteries and the subcutaneous veins,to enable the flap to rotate 180�.Results: All flaps survived without complications,such as congestion, partial necrosis, or any contrac-tures of the proximal interphalangeal joint. A static2-point discrimination test in the flaps measured6 mm in two patients and 5 mm in the other patients,compared to 5 mm on the contralateral hand. Allpatients registered sensitivity to the 0.5 g (number4, green) Semmes-Weinstein monofilament test, aresult comparable to the contralateral hand.

FESSH Abstracts SS49

Conclusion: The IDAP flap is a useful method becauseof its low PIP joint contracture complication rate.

A-0185 Do surgeons agree on what constitutestension at nerve repair sites?

Joshua M. Abzug1, Fraser J. Leversedge2,John S. Taras3, Peter Tang4, Harry A. Hoyen5,Peter J. Evans5 and Scott H. Kozin6

1University of Maryland School of Medicine, Baltimore, MD,USA2Duke Health, Durham, NC, USA3Drexel University, Philadelphia, PA, USA4Allegheny Orthopedic Associates, Pittsburgh, PA, USA5Case Western Reserve University, Cleveland, OH, USA6Shriner’s Hospital for Children, Philadelphia, PA, USA

Objective: Tension at nerve repair sites is known toyield poor clinical outcomes as a result of impairedvascularity and nerve regeneration. However, no defi-nition of ‘‘tension’’ truly exists in clinical medicine.The purpose of this study was to assess whether ornot surgeons performing nerve repair agree on howmuch tension is present when repairing a nerve.Methods: Fifteen surgeons who commonly performperipheral nerve surgeries participated in this cada-veric study. The common digital nerves to the second,third, and fourth webspaces were exposed and trans-ected. In a randomized fashion, one nerve in eachhand had 2 mm transected from it and one nervehad 5 mm transected. The surgeons were thenasked to assess the nerve gaps and tension by visua-lization alone as well as with tactile perception byreapproximating the nerve ends. A five-point Likertscale was used for each response (i.e. for tension:low, low-to-moderate, moderate, moderate-to-high,very high).Results: Visual inspection of the gaps following 0 and2 mm resections demonstrated no significant con-sensus regarding the gap as small, small-to-moderate, moderate, moderate-to-large or largeamong the 15 surgeons, with nearly equal numbersof responses being small-to-moderate/moderate andmoderate-to-large/large. The gap following 5 mm ofresection was felt to be moderate-to-large or largeby the vast majority of surgeons. No significant dif-ferences were present among the 15 surgeons whenperforming tactile sensation of the nerve repair toassess tension for the 0 and 2 mm transectednerves (i.e. no difference between low, low-to-mod-erate, moderate, moderate-to-high, and very high).When trying to re-approximate nerves with 5 mmloss of substance, 87% of respondents believed theamount of tension present represented very high

tension and only one surgeon felt it would be suitablefor a repair.Conclusions: The amount of ‘‘tension’’ present in anerve repair varies among surgeons when no nerveor 2 mm of nerve is transected. If 5 mm of nerve isremoved when trimming a nerve, the vast majority ofsurgeons feel that the tension required to reapprox-imate the nerve ends is very high or moderate-high,therefore consideration for nerve conduits or graftingshould occur. ‘‘Tension’’ continues to be a term thathas no clear definition in clinical medicine, eventhough the adverse effects of ‘‘tension’’ in nerverepair have been well characterized.

A-0186 Assessment of differences regarding themanagement of pediatric supracondylar humerusfractures between hand and pediatric orthopedicsurgeons

Thao Nguyen, Alexandria L. Case, Xiaomao Zhu,Raymond A. Pensy, W. Andrew Eglseder andJoshua M. AbzugUniversity of Maryland School of Medicine, Baltimore, MD,USA

Objective: Supracondylar fractures of the humerusare a common injury in the pediatric population andare managed by a variety of surgeons. As not allhospital centers have a pediatric orthopedics sur-geon, adult hand surgeons also handle the treatmentof these fractures. The purpose of this study was todetermine whether any difference exist in the man-agement of pediatric supracondylar humerus frac-tures between pediatric orthopedic surgeons andhand surgeons.Methods: A retrospective review was performed toidentify patients treated surgically for Gartland typeII or III supracondylar humerus fractures over a6-year period. Data collected included patient demo-graphics, Gartland classification, time to definitivetreatment, preoperative nerve deficit and/or vascularinjury, closed versus open reduction, pin configura-tion, operative time, complications (compartmentsyndrome, infection, loss of fixation), time and loca-tion (inpatient vs outpatient) of removal of hardware,postoperative nerve injury, and physical therapyreferral. Two groups of patients were establishedbased on the treating physician: pediatric orthopedicattending surgeons (PO) and hand attending sur-geons (HS). Statistical analysis between continuousdata was performed with Student’s t-test, whileFisher’s exact test was used to calculate differencesbetween discrete data. For all analyses, statisticalsignificance was set at p< 0.05.

SS50 Journal of Hand Surgery (Eur) 43(Supplement 2)

Results: A total of 65 patients were included in thereview: 23 patients were treated by HS and 42patients by PO. Significant differences exist in therate of open reduction (HS: 17%; PO: 0%), operativetimes (HS: 40.1 min; PO: 25.4 min), use of cross pins(HS: 26%; PO: 2%), return to the operating room forremoval of hardware (HS: 26%; PO: 0%), and refer-rals to physical therapy (HS: 43%; PO: 7%). Therewere no differences in the timing of surgery, compli-cation rate, or postoperative nerve palsy between thetwo groups.Conclusions: Adult hand and pediatric orthopedicsurgeons treating pediatric supracondylar humerusfractures have similar patient outcomes and lowcomplication rates. Differences exist regarding themanagement of these patients including the potentialfor substantially higher health-care costs when thesefractures are treated by hand surgeons due to theincreased use of open reduction techniques, thelonger operative times, higher use of cross pins,return to the operating room for removal of hard-ware, and more referrals to physical therapy.

A-0189 Upper extremity injuries related to pediatricand adolescent sports participation

Xuyang Song, Alexandria L. Case and Joshua M. AbzugUniversity of Maryland School of Medicine, Baltimore, MD,USA

Objective: Orthopedic injuries are extremely commonin the pediatric and adolescent population. Themajority of these involve the upper extremity, withsports participation being one of the most commonmechanisms of injury. The purpose of this study wasto assess the epidemiology surrounding pediatric andadolescent upper extremity sports injuries.Methods: A questionnaire was administered to allpediatric and adolescent patients (or their parents)who presented for evaluation of an upper extremitysports-related injury. Data collected included patientdemographics, the sport they were playing when theinjury occurred, the injury location, the years ofexperience playing that sport, the amount of formaltraining in that sport, the competitive setting at thetime of injury, and whether the appropriate protectiveequipment was utilized. The diagnoses were recordedand simple statistical analysis was performed.Results: One hundred seventy-five patients presentingwith upper extremity injuries from sports participationwere analyzed (153 men and 22 women). The handwas the most common location of injury accountingfor 23% of injuries, followed by the shoulder (15%)and the elbow (9%). The vast majority of injuries

were fractures accounting for 59% of cases, followedby acromioclavicular joint separations (3%) and dislo-cations (3%). Football was the most common sportduring which an injury occurred (46%, 80/175), fol-lowed by basketball (19%, 33/175). The mostcommon sport during which males sustained aninjury was football (52%), whereas basketball wasthe most common sport that females sustained aninjury (27%). The type of play most frequently asso-ciated with an injury was unorganized play (40%), fol-lowed by organized recreational play (32%). No form ofprotective equipment was utilized in 61% of patients.Furthermore, appropriate protective equipment wasonly utilized by 7% (5/69) of patients participating insports activity in an unorganized manner and by 46%(5/105) of whom played in an organized league.Thirty-two percent of patients had experienced aprior injury while playing the same sport.Conclusions: Pediatric and adolescent patients fre-quently injure their upper extremity during sportsparticipation. The vast majority of these injuriesoccur during unorganized play without the use of pro-tective equipment. Many patients have little to noformal training in their respective sport. Theincreased use of proper protective equipment aswell as improved education of fundamental techni-ques may decrease the occurrence of pediatric andadolescent upper extremity sports injuries.

A-0191 Ossification of the proximal and middlephalangeal condyles: A radiographic aid forphalangeal neck fracture reduction

Karan Dua1, Nathan O’Hara2, Igor Shusterman2 andJoshua M. Abzug2

1SUNY Downstate Medical Center, Brooklyn, NY, USA2University of Maryland School of Medicine, Baltimore, MD,USA

Objective: Phalangeal neck fractures are most oftendorsally displaced and angulated. Surgical treatmentis often necessary to restore the retrocondylarrecess. The purpose of this study was to determinewhether radiographic landmarks could serve as areference tool for assessing phalangeal neck frac-ture alignment based on age and sex.Methods: One thousand sixty-one lateral fingerradiographs that were interpreted as ‘‘normal’’ bypediatric radiologists in children aged 1–18 yearswere retrospectively reviewed. The proximal andmiddle phalanges of each digit had a line drawnalong the volar cortex (termed the volar phalangealline (VPL)) and a second perpendicular line wasdrawn at the level of the phalangeal condyle. A

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ratio of the anterior to posterior aspects of the pha-langeal condyle was determined at the intersection ofthese lines. Patient sex was recorded to determine ifthis influenced the temporal course of ossification. Alinear regression model was utilized to determinethe average annual coefficient of growth for the pha-langeal condyles.Results: The average coefficient of growth for theproximal and middle phalangeal condyles in thesecond through fifth digits increased significantly aspatient age increased (p< 0.001). As children increasein age, the VPL will intersect the phalangeal condylemore dorsally due to the eccentric ossification. The8- to 9-year-old group had the largest change insize. In most children over 9 years of age, the VPLwill intersect the middle third of the condyle. No sig-nificant difference exists between the ratios of theproximal and middle phalanges. Gender did not sig-nificantly affect the linear regression model.Conclusions: The phalangeal condyles ossify in aneccentric manner with a rapid growth phase between8 and 9 years of age. The VPL will intersect the pha-langeal condyle more dorsally with increasing age.There is no difference in the time course of develop-ment between the proximal and middle phalangesand gender does not influence growth patterns. Thevolar phalangeal line (VPL) and knowledge of where itshould intersect the phalangeal condyle can be usedas a reference guide for evaluating the reduction ofproximal and middle phalangeal neck fractures inchildren.

A-0192 Outcomes of radial head fractures inpatients under 50 years old: What is better – openreduction internal fixation or arthroplasty?

Sanmeet Singh, Xuyang Song, Alexandria L. Case,W. Andrew Eglseder, Raymond A. Pensy andJoshua M. AbzugUniversity of Maryland School of Medicine, Baltimore, MD,USA

Objective: Arthroplasty has been recommended forradial head fractures with more than three articularfragments due to increased complications with openreduction internal fixation (ORIF), including nonunionand loss of forearm rotation. However, the active life-styles of patients under 50 years of age may not be inline with radial head replacement. The purpose ofthis study is to evaluate the outcomes of radialhead fractures with more than three articular frac-tures in patients under 50 years of age to determinewhich treatment may be more appropriate: replace-ment or ORIF.

Methods: A retrospective review of all patients pre-senting to a high-volume Level 1 trauma center overa 6-year period to identify patients aged 18–50 withradial head fractures. Factors assessed includedpatient demographics, age of patient at the time ofsurgery, the number of fragments, Mason classifica-tion, associated soft tissue injuries (if any), disloca-tions, or other fractures, the need for bone grafting,implant type if replacement was performed, and out-comes data including range of motion (ROM), compli-cations, and conversion to replacement.Results: Thirty-five patients were identified, with anaverage follow-up of 8.5 months. Thirty-five percenthad greater than three articular fragments. Eighty-five percent of this subset underwent open reductionand internal fixation, with only 15% undergoing pros-thetic replacement. The average postoperative ROMin the ORIF group was 67.8� of pronation and 61.6� ofsupination. None of the patients in the ORIF groupexperienced nonunion, malunion, or failure of thehardware. Thirty-six percent had removal of theirhardware, capsulectomy, and excision of hetero-trophic ossification to improve post-operative rangeof motion. No patients in the group with greater thanthree fragments corrected by ORIF required conver-sion to a radial head replacement.Conclusion: The notion that ‘‘smashed’’ radial headfractures (those with more than three articular frag-ments) need to have a replacement performed maynot be optimal for patients under 50 years of age.Treatment of young patients with ORIF of a‘‘smashed’’ radial head can lead to excellent out-comes with low complication rates. Better under-standing of the specific fracture patterns of theseinjuries may help guide surgeons in choosing whichtreatment to perform for ‘‘smashed’’ radial headfractures to optimize postoperative mobility inyoung patients.

A-0193 Functional assessment and clinicaloutcomes after combined flexor and extensortenolysis: A retrospective chart review

Emma Avery, Robert Strazar and Avinash IslurSt. Boniface Hospital, Winnipeg, CA, USA

Objective: The majority of hand literature suggeststhat digital flexor and extensor tenolysis be per-formed in a staged fashion rather simultaneously.Complications of a one-stage procedure is thoughtto be related to a compromise in digital bloodsupply resulting in delayed wound healing, partialskin flap necrosis, or digital ischemia. The aims ofthis study were to review all combined dorsopalmar

SS52 Journal of Hand Surgery (Eur) 43(Supplement 2)

tenolysis cases in a single-centre study and (1)assess the incidence of wound healing complications,(2) compare the difference in pre- and post-activerange of motion (ROM), and (3) demonstrate a sys-tematic approach for combing flexor and extensortenolysis in the same operation.Methods: A retrospective chart review of all patientsundergoing simultaneous digital flexor and extensortenolysis between 2008 and 2016 was performed.Data were collected on pre- and post-tenolysis pas-sive flexion and extension, and active flexion andextension of each interphalangeal joint (metacarpal,proximal interphalangeal, and distal interphalangealjoint) pre- and post-tenolysis. Wound healing compli-cations were noted and compared to previously pub-lished literature on complications following singleflexor or extensor tenolysis. A Wilcoxon signed-rank test was used to compare preoperative andpostoperative ROM measures. General linearmodels were used to identify independent character-istics associated with ROM improvement. Variables inthe models included age, sex, handedness, andfollow-up time. Complication rates were comparedbetween this study and previously published litera-ture via a �2 or Fisher’s exact test where appropriate.ROM improvement was compared between this studyand previously published literature using a two-sample t-test. All statistical analyses were per-formed using SAS version 9.3.Results: Twenty-six patients (14 men and 12 women)underwent simultaneous digital extensor and flexortenolysis between 2008 and 2016. All patients hadpreviously suffered closed or open phalangeal frac-tures treated conservatively with closed reductionand splinting alone or closed/open reduction withKirschner wire fixation. The median age at time ofsurgery was 54 years (IQR 45–64). Preoperative inju-ries included fracture of the proximal phalanx (n¼ 9),fracture of the middle phalanx (n¼ 2), metacarpalfracture (n¼ 2), crush injury at the PIPJ (n¼ 6), dis-location (n¼ 2), bite injury/infection (n¼ 2), saw injury(n¼ 4), and de-gloving (n¼ 3). The median total activeROM (TAR) preoperatively of the MCP, PIP, and DIPjoints was 73, and the median postoperative TAR was151, resulting in an overall median improvement inTAR of 40 (5–100; p< 0.001). Median duration offollow-up was 5.3 months (IQR 3.7–11.4 months)and would healing complications included prolongedswelling (3%), paresthesia (7%), swan neck contrac-ture (3%), hematoma (3%), tendon rupture (3%), andpoor result (7%). No cases of partial or complete skinflap necrosis occurred, as well there were no casesof digital ischemia or compromise.Conclusions: Simultaneous digital flexor and exten-sor tenolysis is a systematic and progressive

approach to combined injuries. The procedure canbe safely performed and should be considered inpatients with severe stiffness post phalangeal frac-ture. When performed appropriately, there is littlethreat to the skin flaps or digital vascular supply.

A-0195 High precision and accuracy with model-based RSA in two different wrist arthroplasties

Trygve Holm-Glad, Stephan Rohrl, Masako Tsukanaka,Magne Røkkum and Ole ReigstadOslo University Hospital, Oslo, Norway

Objective: Radiostereometric analysis (RSA) is amethod for measuring micromotion in joint arthro-plasties, thereby predicting future loosening. RSAhas never been used in total wrist arthroplasties(TWA). We investigated (1) the precision of model-based RSA using both phantom and clinical doubleexaminations, (2) the precision of different bonemarker distributions in a phantom model, and (3) theaccuracy of model-based RSA in two different TWA.Methods: Reverse engineered models of theRemotion� and Motec� TWA were obtained by laserscanning. Precision and accuracy of the radial andcarpal/metacarpal component of each arthroplastywere analyzed with regards to translation and rotationalong the three coordinate axes. Precision is the sameas repeatability and was analyzed from 10 phantomand 30 clinical double examinations in each arthro-plasty. Precision was expressed by a repeatabilitycoefficient as 2 SD of the differences betweendouble examinations. Measured movements abovethe precision value are certainly caused by truemotion and not by measurement error. Levene’s testfor equality of variances was used to examine the dif-ference in precision between different bone markerdistributions. The sample size for future RSA studieswas calculated based on the least precise standarddeviations from the double examinations. Accuracyis the ‘‘trueness’’ of the measurements and wastested in a phantom model with the implants attachedto a movable micrometer. A ‘‘zero migration’’ stereo-radiograph was first obtained, followed by 10 prede-fined translations from 0.05 mm to 5.0 mm along allthree axes, and nine predefined rotations from 0.08�

to 6.0� along all three axes, resulting in 72 stereora-diographs. Accuracy was defined as the mean differ-ence between measured and true migrations.When doing migration measurements, one shouldcorrect for this error.Results: In the phantom model, the precision fortranslations ranged from 0.03 to 0.14 mm and forrotations from 0.18� to 1.56�. In patients the precision

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for translations ranged from 0.06 to 0.18 mm, and forrotations from 0.33 to 2.22�. Fourteen patients ineach group would be sufficient to detect a differencein translation of 0.1 mm in any direction, whereas 20patients in each group would be needed to detect adifference of 1.0�, considering an alpha level of 0.05and a beta level of 0.2 (80% power). Less than fourbone markers resulted in inferior precision com-pared to six markers (p< 0.05). Accuracy rangedfrom �0.06 to 0.04 mm and from �0.38 to �0.01�.Conclusions: Model-based RSA in TWA is precise andaccurate. The method can, therefore, be used tomeasure micromotion in TWA. Since the implantsfill up much of the space within the small wristbones, the bone markers have to be placed close tothe implants where they easily disappear on stereo-radiographs. To increase the likelihood of visualizingat least four bone markers, we recommend placingat least six bone markers around each component.

A-0198 The adequacy of emergency room andurgent care center radiographs for pediatric upperextremity injuries

Eric Marguiles1, Alexandria L. Case1, Karan Dua2,Nathan O’Hara1 and Joshua M. Abzug1

1University of Maryland School of Medicine, Baltimore, MD,USA2SUNY Downstate Medical Center, Brooklyn, NY, USA

Objective: Emergency room (ER) and urgent carecenter (UCC) providers are often the first evaluatorsof acute pediatric upper extremity injuries, includingobtaining radiographs. After evaluation of thesepatients in the ER/UCC, they are commonly referredto hand surgeons for further evaluation, who some-times need to obtain additional radiographs.Additional radiographs may increase the length ofthe visit, the health-care costs associated with theinjury, and the radiation exposure to the patient.The purpose of this study was to determine the ade-quacy of the initial radiographs obtained by ER andUCC providers for pediatric upper extremity injuries.Methods: A prospective study was performed ofpatients who presented to the pediatric upper extre-mity office for injury evaluation after being seen at anoutside ER/UCC, during which radiographs wereobtained. The adequacy of the initial radiographswas determined in a binary fashion with imagesdeemed ‘‘adequate’’ if no additional radiographswere obtained and considered ‘‘inadequate’’ if thesenior resident or attending physician ordered newradiographs. Patients who required additional radio-graphs to assess a potential loss of reduction were

excluded from the study. The duration of the officevisit was recorded for all patients.Results: Fifty-one patients were enrolled in thestudy. The average number of radiographs obtainedby an outside ER/UCC was 2.9 (SD¼ 0.87). Fifty-threepercent of ER/UCC radiographs were deemed ade-quate and 47% were considered inadequate.Patients with inadequate radiographs required anaverage of 3.4 (95% CI: 2.7–4.0) additional images.The most common reasons for repeat radiographswere missing views (33%), an inadequate lateralview (29%), and poor image quality (17%). Patientswith adequate images had a significantly shorterclinic visit time (p< 0.0001) compared to patientswith inadequate radiographs, with a mean differenceof 32.0 min (95% CI: 22.4–41.6). Preliminary analysisshowed physician assistants took a lower proportionof inadequate images compared to physicians andnurse practitioners. Furthermore, it was noted thatthe original hand and finger radiographs were typi-cally more adequate.Conclusions: ER/UCC pediatric upper extremity diag-nostic imaging is often insufficient to permit the ade-quate diagnosis and treatment by hand surgeons.The need for repeat injury radiographs increasesradiation exposure to the patient, requires longerclinic visits for the patient and family, and increasesthe financial cost to the overall healthcare system.ER/UCC providers would benefit from better educa-tion regarding how to optimize the radiographsobtained during acute pediatric upper extremityinjury evaluations, which would lower patient mor-bidity and healthcare costs.

A-0202 The EuroQol EQ-5D to measure quality oflife in patients with hand and upper extremityconditions: A systematic literature review about itsapplication and measurement properties

Miriam Marks, Cecile Grobet and Laurent AudigeSchulthess Klinik, Zurich, Switzerland

Objective: The most widely used instrument to mea-sure quality of life (QoL) is the EuroQol EQ-5D.However, its use in assessing hand and upper extre-mity condition-related QoL as well as its measure-ment properties remain largely undefined. Therefore,the objective of this systematic literature review wasto provide an overview of the application of EQ-5D inpatients with hand and upper extremity disorders andto analyse its measurement properties.Methods: We searched in Medline, EMBASE,Cochrane and Scopus for clinical studies investigat-ing patients with orthopaedic disorders of the hand

SS54 Journal of Hand Surgery (Eur) 43(Supplement 2)

and upper extremity, where the EQ-5D was used asan outcome measure. Furthermore, we searched forvalidation studies. Data describing the use of the EQ-5D were extracted. The measurement properties ofthe EQ-5D and the quality of the validation studieswere graded according to the COSMIN guidelines.Results: Twenty-three studies were included in thereview. In 18% of the studies, patients with hand con-ditions such as carpal tunnel syndrome (CTS),Dupuytren contracture and rheumatoid arthritiswere assessed. The remaining studies investigatedpatients with shoulder conditions. In 65% of the stu-dies, QoL was the primary outcome and in 22%, theEQ-5D was used for cost–utility analyses. The EQ-5Dmeasurement properties were reported in one articleinvestigating patients with CTS, and two articlesincluding patients after proximal humeral fracture.Positive ratings were seen for construct validitywith correlations �0.7 with the Short Form (SF)-12or SF-6D health surveys. Test–retest reliability wasalso high with intraclass correlation coefficients�0.77. Responsiveness was moderate for patientswith CTS (standardized response mean (SRM)¼ 0.5)and high for patients after proximal humeral frac-tures (SRM¼ 0.9). However, ceiling effects wereidentified with 16–48% of the patients achieving thehighest score. The methodological quality of thethree validation studies ranged from fair to good.Conclusions: The EQ-5D is increasingly used inpatients with hand and upper extremity conditions.Investigations about the measurement propertiesare few, but the available studies indicate good relia-bility and validity. Further research should especiallyfocus on the responsiveness in patients with handconditions.

A-0203 Oligodactyly with thumb

Yo Han Lee, Jihyeung Kim, Hyun Sik Seok,Hyun Sik Gong, Kee Jeong Bae and Goo Hyun BaekSeoul National University, Seoul, South Korea

Background: Oligodactyly of the hand is one of therarest congenital anomalies of upper extremities anddefined as the presence of fewer than five fingers ona hand. Although it usually occurs in association withhypoplasia or absence of ulna, it can occur withoutabnormality of the forearm bones. The purpose ofthis study is to present clinical features and radio-graphic characteristics of hand oligodactyly withthumb.Methods: Five patients of oligodactyly with thumbwho showed normal forearm bones were evaluated.Two patients had three-fingered hand with thumb

and three had two-fingered hand with thumb. Weanalyzed associated abnormalities of carpal andmetacarpal bones and measured the lengths ofradius and ulna and width of the wrist on thesimple radiographs. We also devised new classifica-tion system of oligodactyly based on the thumb defor-mities and locations of missing digits.Results: Syndactyly among fingers was associated infour patients, clinodactyly caused by delta bone inone, hypoplasia of the thumb in one, camptodactylyin one, symphalangism in one, and radial head dis-location in one. Considering the abnormalities of thecarpal bones, the missing digits were presumed to beulnar-sided digits in two patients, central digits inone patient, and both ulnar-sided and central digitsin two patients. In patients with missing of centraldigits, an adjacent metacarpal was hypertrophied.Although the ulnar variances were within normalrange, the average lengths of radius and ulna were6% and 5% shorter than those of contralateralnormal side. The average width of the wrist was 9%narrower than that of contralateral normal side.Conclusions: Syndactyly and hypertrophied metacar-pal were most commonly observed findings in theoligodactyly with thumb. Although oligodactyly withthumb may be a type of ulnar longitudinal deficiency,it can also be a type of central deficiency or combinedtype of ulnar longitudinal deficiency with central defi-ciency or radial longitudinal deficiency. We suggest aclassification system of oligodactyly with thumbbased on locations of missing digits and associatedthumb deformities.

A-0204 Extensor pollicis brevis insertion pattern asa possible cause of boutonniere deformity in therheumatoid thumb

Shunji Okita1, Keiichiro Nishida1, Taichi Saito1,Yasunori Shimamura1, Aiji Ohtsuka2 andToshifumi Ozaki11Department of Orthopedic Surgery, Okayama UniversityGraduate School of Medicine, Dentistry and PharmaceuticalSciences, Okayama, Japan2Department of Human Morphology, Okayama UniversityGraduate School of Medicine, Dentistry and PharmaceuticalSciences, Okayama, Japan

Objective: Recent studies on the anatomy of theextensor pollicis brevis (EPB) suggest that thereare several variations of the EPB insertion.However, no study has focused on the relationshipbetween the insertion pattern of EPB and the devel-opment of boutonniere deformity. The aim of the cur-rent study was to evaluate EPB insertion pattern

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macroscopically and histologically using cadavericthumbs and to compare its incidence with that ofrheumatoid arthritis (RA) patients.Methods: We investigated 103 fingers (50 right and 53left) of 58 adult cadavers (25 males and 33 females).Next, we reviewed the surgical records of 24 fingersof 19 RA patients with thumb boutonniere deformity.The incidence of insertion patterns of the cadavericthumbs and the RA thumbs were compared using the�2 test and Fisher’s exact test. A p value less than0.05 was considered statistically significant.Results: Macroscopically, the EPB insertion patternwas classified into two types: the EPB ending at thelevel of the MCP joint (Type P) and the EPB ending atthe level of the IP joint (Type D). In the cadavericfingers, 71% (n¼ 73) of the fingers were Type P fin-gers and 29% (n¼ 30) were Type D. In the RA patientswith thumb boutonniere deformity, 33% (n¼ 8) of thefingers were Type P, while 67% (n¼ 16) of the fingerswere Type D. The incidence of Type D was signifi-cantly higher (p< 0.05) in the thumbs of patientswith RA and boutonniere deformity than in the cada-veric thumbs. Histological examination revealed thatthe Type P fingers consisted of 52% (n¼ 54) of TypeP1 with the EPB firmly attached to the periosteum atthe dorsal base of the proximal phalanx of thethumbs and 18% (n¼ 19) of Type P2 with the EPBinserts to the dorsal capsule fibrocartilage complexin the thumbs.Conclusions: The incidence of Type D was signifi-cantly higher in the thumbs of patients with RA andboutonniere deformity than in the cadaveric thumbs.Our results suggested EPB insertion into the distalphalanx might be a potential risk of thumb bouton-niere deformity in RA.

A-0206 Comparison of contact and non-contactultrasound examination of the hand

Rebecca Lim1, Chin Shu Ting2, Chan Kai Li2,Abby Choke1, Tay Shian Chao1,2 andDuncan Angus McGrouther1,2

1Department of Hand Surgery, Singapore General Hospital,Singapore2Biomechanics Laboratory, Singapore General Hospital,Singapore

The use of diagnostic ultrasound imaging (US) in theoutpatient setting of hand surgery practices is low, asevidenced by the paucity of literature surroundingthis low cost yet effective modality. The small fieldof view and poor contact of transducers with curvedcontours of the hands and feet are some of the rea-sons that restrict US evaluation. A water bath

technique overcomes these limitations. In a prospec-tive study, we imaged healthy volunteers using twotechniques; the traditional contact probe with gel andin a water bath at four sites: the first dorsal interros-eous muscle, thenar eminence, flexor tendon, andthe median nerve. A group of doctors (n¼ 25) fromour department were asked to identify named struc-tures by outlining them on the US images. The relia-bility of the two methods was compared using theinter-rater intraclass correlation coefficient (ICC),which demonstrated that the water bath methodwas more reliable (ICC 0.97, p< 0.001), whereas thetraditional probe with gel method had only moderatereliability (ICC 0.71, p< 0.01). Data show that softstructures in the hand are more identifiable by clin-icians in a water bath and this methodology should beused more often in clinical practice.

A-0210 Surgical treatment of mucous cysts bysubcutaneous excision and osteophyte resection:Results in 68 cases at a mean 6.63-year follow-up

Steven Roulet, Bertille Charruau, Charles Agout,Guillaume Bacle, Emilie Marteau and Jacky LaulanHand Surgery Unit, Department of Orthopedic Surgery 1,Trousseau University Hospital, Medical University FrancoisRabelais of Tours, Tours, France

Objective: Mucous cysts originate from osteoarthriticdegeneration. Our hypothesis is that the treatment isbased primarily on the removal of osteophytes. Thegoal of this study is to demonstrate that joint debri-dement, in addition to excision of the cystic pouchwithout an associated skin flap or graft, is sufficientin effectively treating mucous cysts with a recurrencerate that does not exceed other techniques.Methods: Eighty-one mucous cysts were operated.All interventions consisted of an excision associatedwith a joint irregularity debridement. The mean ageat surgery was 62.4 years. In one-third of cases, anail deformity was present. Gross evidence ofosteoarthritis was present in 84% documentedcases. Sixty-seven patients (68 cysts) were contactedby an independent evaluator and answered a phonequestionnaire on average 6.6 years after surgery(range 1.04–20.8 years).Results: In the postoperative period, three patientsdeveloped infection and one a delayed cutaneoushealing (four complications occurred in cysts asso-ciated with a fistula). All pre-existing nail deformitieshad resolved. Four patients preferred to return forconsultation but none had developed a recurrenceof the mucous cyst. In one case (1.5%), there was arecurrence. It was observed 4 months after excision

SS56 Journal of Hand Surgery (Eur) 43(Supplement 2)

of a subungual cyst. The patient was treated byarthrodesis of the DIP joint. In 53 cases (78%),patients felt no discomfort using their operatedfinger. Patients considered themselves cured in 50cases (73.5%) and 65 (96%) were very satisfied orsatisfied with the procedure and would undergo sur-gery again.Conclusions: The recurrence rate in this series is1.5%. This result is consistent with that of other stu-dies with same technique reporting a recurrence rateof between 0% and 2%. Our only failure may be due toinadequate excision of the cystic pouch because of itssubungual location and proximity of the germinalmatrix. Results are better than studies with skingraft or advancement flap without joint debridementreporting a recurrence rate of 3.3% and 8.3%. Theauthors who performed a graft or a flap without sys-tematic joint debridement also have a higher recur-rence rate, up to 28%. In our opinion, the positiveresults of surgeries where skin procedure is per-formed are due to the associated joint debridement.Our procedure is sufficient to effectively treatmucous cysts with less morbidity. Complicationsare rare and occur only in cysts associated with afistula, justifying their early surgical treatment.

A-0226 Risk factors and results of operative treat-ment of persistent brachial plexus injury caused byshoulder dislocation

Olga Gutkowska, Jacek Martynkiewicz and Jerzy GoskClinical Department of Traumatology and Hand Surgery,Wrociaw University Hospital, Wrociaw, Poland

Objective: Brachial plexus injury (BPI) is observed in5–65% of patients after shoulder dislocation. In themajority of the cases, it can be managed conserva-tively with satisfactory outcome. However, in somepatients, symptoms tend to persist and requireoperative intervention. The aim of this work is todetermine the risk factors for persistent BPI result-ing from shoulder dislocation and to find out whetherany certain group of dislocators requires enhancedsurveillance for unrelenting neurologic deficit of theupper extremity. It also aims to determine the effec-tiveness of operative treatment in patients with thistype of injury.Methods: The study comprised 73 patients operatedon at our Institution for BPI resulting from shoulderdislocation between the years 2000 and 2016, after amean period of 9.2 months after dislocation. Suchpotential risk factors for persistent BPI as patientage, gender, energy of initial trauma, presence and

type of accompanying injuries and time interval fromdislocation to its reduction were analysed.

External neurolysis of BP from axillary approachwas the procedure of choice. The results of operativetreatment were analysed on a subgroup of 33patients who completed 2-year follow-up (mean 5.1years). Motor function of affected limbs was assessedwith BMRC scale. Sensory function wasevaluated with BMRC scale modified by Omer andDellon and with Highet’s classification. The influenceof the above-listed factors as well as time from dis-location to operation and the number of nervesinvolved on the outcomes of surgery were analysed.

Statistical analysis was conducted with the use ofSTATISTICA v. 13. Categorical data were analysedusing the �2 test with Yate’s correction. The distribu-tion of two and more than two independent sampleswas compared through Mann–Whitney U test andKruskal–Wallis test, respectively.Results: Shoulder dislocation caused injury to infra-clavicular BP. Fibrous scar tissue caused compres-sion of neural elements. Persistent BPI was morecommon in older patients. Elderly patients moreoften sustained multiple nerve injuries resultingfrom low-energy trauma, while single nerve injurieswere more often observed in younger patients afterhigh-energy trauma. Single nerve injury was diag-nosed in 30% of the patients. Axillary nerve wasmost commonly affected. Fracture of the greatertuberosity of humerus coincided with total BPI in50% of the cases. Longer unreduced period causedinjury to multiple nerves.

Good postoperative recovery of nerve function wasobserved in 100% of musculocutaneous, 93.3% ofradial, 66.7% of median, 64% of axillary and 50% ofulnar nerve injuries. No recovery was observed in5.6% of median, 6.7% of radial, 10% of ulnar and20% of axillary nerve injuries. Injury to a singlenerve coincided with unsatisfactory treatment out-comes. Ulnar and median nerve injuries more oftenrequired operative intervention due to their lowpotential for spontaneous recovery.Conclusions: Since no typical characteristics of a‘patient at risk can be listed, vigilance and systematiccontrol are recommended in all patients manifestingsymptoms of neurologic deficit after shoulder dislo-cation. Obtaining improvement in peripheral nervefunction in some patients requires operative inter-vention. The results of surgery are usually good,with low complication risk.

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A-0231 Retrieval analysis of thirty explantedNeuFlex metacarpophalangeal joint prostheses

Thomas Joyce1 and Grey Giddins2

1Newcastle University, Newcastle upon Tyne, UK2Royal United Hospital, Bath, UK

Objective: We explanted NeuFlex metacarpophalan-geal (MP) joint prostheses to identify common fea-tures, such as position of fracture, and thus betterunderstand the reasons for implant failure.Methods: Explanted NeuFlex MP joint prostheseswere retrieved as part of an-ongoing implant retrie-val programme. Following revision MP joint surgery,the implants were cleaned and sent for assessment.Ethical advice was sought but not required. Theexplants were photographed. The position of frac-ture, if any, was noted. Patient demographics wererecorded.Results: Thirty NeuFlex MP explants were available.Seven (23%) were not fractured. Eleven explants(37%) had fractured at the hinge; nine (30%) had frac-tured at the junction of the distal stem and hinge; andthree (10%) had fractured at both the hinge and distalstem. NeuFlex MP joint explants ranged in size from0 to 40. Smaller sizes were retrieved from smallerfingers; larger implants came from the middle andindex fingers. The age at revision ranged from 43 to81 (median 58) years. Time in vivo ranged from 6 to120 (median 58.5) months. All but two implants wereobtained from rheumatoid joints, the remainder hadosteoarthritis. Discolouration of some explants hadoccurred; other explants appeared to show nocolour change.Conclusions: This appears to be the first report of theposition of fracture of NeuFlex explants. It is alsothe largest report of silicone arthroplasty explants.The majority (77%) had fractured. Nine (30%)NeuFlex explants had fractured at the junction ofthe distal stem and hinge; the typical position seenwith Swanson and Sutter/Avanta MP joint explants.Eleven (37%) fractured across the hinge; this hasnot previously been reported although has beenseen in in vitro testing. The hinge is thinner thanthe hinge-stem junction so may be at risk of morerapid failure; however, the median time in vivo forhinge fractures was 63 months as opposed to 54months for fractures at the distal stem. Intriguingly,3 (10%) NeuFlex explants suffered fractures both atthe hinge and at the junction of the distal stem andhinge which has also never been reported previously.Fracture at the junction of the distal stem and hingeshows the importance of subluxing forces in rheuma-toid MP joints and therefore suggests these need tobe mitigated as much as possible. Fracture across

the hinge could indicate this as a position whichcould be increased in thickness, to increase thetime taken to fracture, although there may be a con-comitant increase in stiffness of the implant. Withimproved designs, patients might suffer fewer orlater failures. The latest Norwegian ArthroplastyRegistry report shows that revision MP joint arthro-plasties accounted for 42% of all MP joint replace-ment operations in 2015. Therefore, this is animportant area where opportunities exist to reducerevision rates.

A-0237 Neuropathic pain after repair of brachialplexus injury: A 30-year follow-up of the Narakas’series

Swenn Maxence Krahenbuhl, Chantal Bonnard andLaurent WehrliLausanne University Hospital, Lausanne, Switzerland

Objective: Assessment of long-term neuropathicpain evolution, quality of life and satisfaction levelafter brachial plexus repair.Methods: We identified 523 patients victim of trau-matic brachial plexus injuries who underwent surgi-cal repair by A. Narakas from 1969 to 1992. Twohundred and fifteen patients coming from abroadwere excluded from the study. Two hundred andthirty patients could not be located, 13 medical fileshad been lost and 14 patients had died. Fifty-onepatients could be reached by telephone and 46 ofthem accepted to answer the following question-naires: Short Form Health Survey (SF12),Neuropathic Pain Symptom inventory (NPSI),ABILHAND and Disability of Arm, Shoulder andHand (DASH), and satisfaction with the surgery.Data were recorded and statistically analyzed usingstatistical software (SPSS version 23.0; SPSS, Inc.,Chicago, IL, USA). We than reviewed their clinical,operative and follow-up data. Forty-five patientsaccepted to come back for a physical examination.Results: Forty-five patients with a mean age of 21.9years at the time of injury participated in the study.There were a vast majority of men (41 M, 91%). Themean time to surgery was 3.8 months, and the meanfollow-up period was 31 years. NPSI score was sig-nificantly (p¼ 0.05) higher for complete (C5 to D1)compared to partial injuries (36 vs 22.5). NPSI scoreof injuries involving C8 and D1 was significantly(p¼ 0.05) higher (37 vs 17) than for other roots. Nosignificant differences were reported in long-termneuropathic pain between avulsion and rupture, aswell as supra- or infraclavicular injuries. Completelesion has a significantly higher NPSI score of

SS58 Journal of Hand Surgery (Eur) 43(Supplement 2)

background (7, p¼ 0.5) and breakthrough (7.5,p¼ 0.2) pain compared to partial injuries. SF12 wasdirectly correlated with NPSI according a linearregression analysis (p¼ 0.01). More surprisingly,quality of life was not different between completeand partial lesions. Regarding satisfaction, 36patients (74%) answered ‘‘definitely yes’’ or‘‘probably yes’’ whether they would undergo surgeryagain. Three patients answered ‘‘probably not,’’ oneanswered ‘‘definitely not,’’ and six were ‘‘uncertain.’’Conclusion: Our data suggest that complete brachialplexus injuries generate more pain than partial inju-ries. This can be explained by the fact that thesecomplete lesions contain C8-D1 roots. Apparently,the lower the lesion is, the greater is the pain. Itseems that the long-term evolution of pain is thesame between all groups. The quality of life isdirectly correlated with pain and not function of thelimb. Obviously, it is easier for the patients to copewith a non or dysfunctional limb than with omnipre-sent pain.

A-0239 Wrist and finger motion: A comparison ofgoniometric and 3D motion capture technique

Lisa Reissner, Gabriella Fischer, Pietro Giovanoli andMaurizio CalcagniDivision of Hand and Plastic Surgery, University HospitalZurich, Switzerland

Objective: The objective measurement of finger andwrist range of motion (ROM) is of great importance toclinicians when assessing the outcomes of therapeu-tic interventions and surgical procedures. The aim ofthe study was to test the reproducibility of activerange of motion (ROM) of all fingers and wrist jointangles measured with a 3D motion capture systemand to compare it with manual goniometry.Methods: Active finger and wrist joints motion of 20healthy volunteers without any previous hand andwrist pathologies were assessed with the 3Dmotion capture system and measured with amanual goniometer by a trained hand surgeon.Active maximum joint angles of all fingers and wristwere registered twice on two different days to eval-uate the test–retest reliability. The mean absolutedifference (MAD), standard deviation of the difference(SD) and standard error of measurement (SEM)between measurements were calculated for bothmeasurement systems and compared within thesame task.Results: SEM values for the motion capture methodlie between 1.9� and 4.5� except for the MCP5, IP andMCP1 (5.1�–8.5�). For the goniometric

measurements, SEM was between 5� and 11� in alljoints except for PIP2-5 and DIP5 (4.2�–4.9�). Overall,all agreement parameters reveal smaller individualinter-session differences with the motion capturesystem. Mean MAD and SD of differences for max-imal finger and wrist joint angle measurements were4.5� and 5.8� for the motion capture system, com-pared to the goniometry with 7.4� and 9.0�,respectively.Conclusion: Joint angles derived from 3D motionanalysis showed smaller mean of absolute differ-ence, suggesting overall a better reliability for thistechnique. Furthermore, the advantage of 3Dmotion analysis is the dynamic evaluation of thewrist and all finger joints simultaneously. Mainadvantages of the goniometric method are that it ischeap, fast and does not require data post-proces-sing or any knowledge about joint angle calculations.

A-0240 Development of a new measurementmethod for kinematic analysis of the hand

Gabriella Fischer, Lisa Reissner, Diana Jermann,Pietro Giovanoli and Maurizio CalcagniDivision of Hand and Plastic Surgery, University HospitalZurich, Switzerland

Objective: The aim of the study was the developmentof a method for the simultaneous kinematic mea-surement of all finger joints, the wrist and the radio-ulnar joint. It included the choice of the marker set,the definition and standardization of the measuredmotion tasks, the selection of the kinematic modeland the development of the joint angle calculationroutine. The main interest was in demonstrating therepeatability of the chosen method.Methods: Twenty healthy volunteers participated inthe study. To investigate the repeatability of the test-ing protocol, they performed a set of basic motiontasks. Each task was repeated five times and eachsubject was measured twice on two different days.

The repeatability of the finger joint angles was ana-lysed for two different concepts of the marker set on10 volunteers and compared. In the first approach,one marker was placed on every finger joint, for thesecond approach two markers were placed on everybony segment proximal and distal to the joint.Furthermore, two different methods to calculatethe joint centres and axis of rotation were examined.The joint centre and axis calculation with a geometricapproach was based on the marker positions andanthropometric data. In the functional approach, theindividual joint centres and axis of rotation were cal-culated during a calibration movement by means of

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mathematical optimization. The maximum distanceof the calculated joint centres and the maximumangle between the calculated joint axes were com-puted and compared.Results: The joint angles derived from the two-marker per segment method showed a better test–retest repeatability. The maximal distance betweenthe functional joint centres computed from differenttrials was 2.4 mm (SD 1.1 mm) and 2.7 mm (SD1.2 mm) for the TMC and wrist joint, respectively.The mean maximal difference in the orientation ofthe joint axes ranged between 4 and 7�, when calcu-lated from different calibration trials within the samemeasurement reflecting a good reliability of themethod. A simulation on the effect of a randomlydistributed marker placement error of 2 mmshowed a higher variability of the geometric approachfor the thumb joints and similar results for the wrist.Conclusion: Based on these results, the marker setwith two markers per segment on the fingers avoid-ing the joint region was chosen for further examina-tion. This is in accordance with the literature, wherethe skin movement artefacts close to the joint aredescribed to be higher. Furthermore, the functionalmethod was chosen for further examinations ofall joints because it revealed a good repeatability ofthe calculated joint coordinate system. Furthermore,it better represents one’s individual anatomicalproperties.

A-0241 Kinematic analysis of the hand duringopening a jar and yoghurt

Lisa Reissner, Gabriella Fischer, Pietro Giovanoli andMaurizio CalcagniDivision of Hand and Plastic Surgery, University HospitalZurich, Switzerland

Objective: The great relevance of the upper extremi-ties in activities of daily living has made researchersand clinicians gaining increased interest in theassessment of human hand movements. However,the measurement of the small hand joints remainschallenging. The aim of the study was to prove fea-sibility to measure complex manual tasks with a 3Dmotion capture system, to quantify the repeatabilityand to analyse the angular motion patterns of twofunctional tasks in healthy volunteers.Method: Twenty healthy volunteers were recordedduring the performance of a set of basic motiontasks as well as during two functional activities:opening a jar and yoghurt. To analyse the test–retest repeatability, each subject was assessedtwice on two different measurement days.

The kinematic data were collected with a motion ana-lysis system consisting of 11 infrared cameras. Amarker set with 46 skin markers was used torecord the kinematics of the hand, thumb and fingerssimultaneously.Results: The kinematics of the functional tasks con-firmed to be measurable with the chosen marker setand specific angular motion pattern of the two ADLwere reported. Overall, the markers were visibleduring 97% of the time. The mean active range ofmotion (AROM) for the individual joints ranges from17� to 77� and between 19% and 68.5% of the max-imum range of motion was exploited during the dailyactivities.

The repeatability of the mean AROM during thefunctional tasks, expressed as the standard error ofmeasurement (SEM), was within a range of 2�–13� forthe individual joints. The mean SEM over all jointsduring the yoghurt- and jar-opening task was 5.7�

and 6.8�, respectively. The coefficients of multiplecorrelations tended to show a better repeatability ofthe angular motion pattern within (0.66–0.92) theindividuals than between (0.16 and 0.85) the subjectsfor both ADL and for all joints.Conclusion: Thus, the simultaneous motion analysisof the entire hand and fingers during functional tasksis feasible and the joint kinematics could be partiallyshown to be reproducible during the two analysedactivities of daily living. The implementation of thekinematic analysis of the hand within daily activitieshas provided a first impression of angular motionpatterns of two activities of daily living and thereforeimplies a first step towards the goal to quantitativelymeasure hand function.

A-0245 Adaptive proximal scaphoid implant:Indications and results

Nicolas Dreant and Marie-Anne PoumellecPole Urgence Main, Nice, France

Introduction: Adaptive proximal scaphoid implantwas created for radioscaphoid arthritis treatment incase of scaphoid nonunion advanced collapse of thewrist (SNAC wrist) and scapholunate advanced col-lapse of the wrist (SLAC wrist). The conceptors firstpublication in 2000 showed promising results of 25cases with a 6-month mean follow-up. They con-cluded that proximal scaphoid arthroplasty is effi-cient in the treatment of radioscaphoid arthritis andin preventing the carpal collapse.Materials and Methods: We designed a prospective38 patients study with a mean age of 55 years, treatedbetween May 2003 and February 2013 by the same

SS60 Journal of Hand Surgery (Eur) 43(Supplement 2)

surgeon. Twelve had a large open approach, 7 anarthroscopic approach and 19 a transverse miniopen approach. The mean follow-up of this serieswas 8 years (range 4–14). Indications were painfulscaphoid pseudarthrosis 8 times, SNAC wrist stage1: 7 times, SNAC wrist stage 2: 14 times, SLAC wriststage 1: 7 times and SLAC wrist stage 2: 2 times.Patients were reviewed clinically and radiographi-cally at 1 month, 6 months, 1 year and at the lastfollow-up. Three early implant luxations (twopalmar and one dorsal) have been reoperated.Results: Results of this series showed a wrist func-tion increasing in term of pain, range of motion andgrip strength. Return to work was achieved in 75% ofthe cases. The mean modified Mayo score calculatedat the maximum follow-up for each patient was 80%(range 70–90).Discussion: These results are comparable to thosepublished in the literature (Pequignot, Mathoulin,Gilham). Best indications for the use of the APSIare SNAC wrists stages 1 and 2 and SLAC wristsstages 1. This was suggested by the precited authorsand confirmed by the results of our series.Conclusion: APSI is a ‘simple’ solution for a difficultproblem: It diminishes the scaphoid pseudarthrosispain when conservative treatment has failed, theperiscaphoid arthritis pain when associated withradial styloidectomy, and prevents carpal collapseby maintaining the initial scaphoid height.

A-0246 Treatment and survival differences acrosstumor sites in malignant peripheral nerve sheathtumors: An SEER database analysis

Enrico Martin1,2, Ivo S. Muskens1,2, Timothy R. Smith2

and Marike L. D. Broekman1,2

1University Medical Center Utrecht, Utrecht, TheNetherlands2Brigham and Women’s Hospital, Boston, MA, USA

Objective: Currently, literature is lacking data on dif-ferences across all tumor sites in survival and treat-ment in malignant peripheral nerve sheath tumors(MPNSTs). The Surveillance, Epidemiology, and EndResults (SEER) program is a cancer registry that col-lects data from 18 geographic areas across theUnited States, encompassing approximately 28% ofits population. The SEER database provides ameans of assessing possible predictive factors ofsurvival and treatment modalities in rare tumors.Methods: MPNST cases were obtained from theSEER program from 1973 to 2013. Tumor siteswere recoded into intracranial, spinal, head andneck (H&N), limbs, core, and unknown. Patient and

tumor characteristics, treatment modalities, and sur-vival were extracted. Survival analyses were con-ducted using primary tumors only. Overall survivalwas assessed using univariate and multivariateCox-regression hazard models per site of origin andof all tumors combined. In the latter, site of originwas an additional variable. Kaplan–Meier survivalcurves were constructed per tumor site for overallsurvival (OS) and disease-specific survival (DSS).Results: A total of 3267 MPNST patients were regis-tered in SEER; 167 intracranial (5.1%), 119 spinal(3.6%), 449 H&N (13.7%), 1022 limb (31.3%), 1307core (40.0%), and 203 with unknown location (6.2%).The largest tumors were found in core (size, median:80.0 mm, IQR: 60.0–115.0 mm) and limb sites (size:70.0 mm, IQR: 40.0–100.0 mm), and the smallestwere intracranial (size: 37.4 mm, IQR: 17.3–43.5 mm). Intracranial tumors were resected leastfrequently (58.1%), whereas spinal tumors weremost often resected (83.0%). Gross total resectionwas most in spinal tumors (42.6%) and least in coretumors (24.9%). Radiation was administered in 35.5%of intracranial and 41.8% of limb MPNSTs.Radiotherapy was given in a neoadjuvant setting in4.2% and adjuvant in 28.0% of all cases.Preoperative radiation was most often used in limbsites (6.8%). Independent factors associated withdecreased survival were older age, male gender,Black race, no surgery, partial resection, largetumor size, high tumor grade, H&N site, and coresite (all p< 0.05). Intracranial and pediatric tumorsshowed superior survival (both p< 0.05). Similar find-ings are found in multivariate analyses per tumorsite. Overall, patients with intracranial tumorsshowed superior OS and DSS curves, whereas coretumors had the worst OS and DSS (p< 0.001).Conclusion: Site of origin is an independent prognos-tic factor for survival in MPNSTs. Intracranial tumorstend to have an even better survival than those aris-ing in extremities. Tumors arising from core sites areassociated with the poorest prognosis; head and necktumors were also associated with poorer prognosiscompared to limb sites. Also, pediatric cases weresignificantly associated with better prognosis com-pared to adult cases independent from tumor site,size, and treatment modality. Treatment modalitiesand extent of resection also vary slightly amongtumor sites. Physicians should, therefore, be awareof these differences when planning treatment forpatients as well as in counselling them. Apart fromtumor origin, older age, male gender, black race,higher tumor grade and large tumors may be asso-ciated with decreased survival.

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A-0252 A review of animal models in hand surgerysimulation

Charles Yuen Yung Loh1, Aline Yen Ling Wang1,Vincent Tze Yang Tiong2, Thanassi Athanassopoulos3,Meiling Loh4, Philip Lim5 and Huang-kai Kao1

1Department of Plastic Surgery, Center for VascularizedComposite Allotransplantation, Chang Gung MemorialHospital, Taoyuan, Taiwan2Department of Radiology, Tan Tock Seng Hospital,Singapore3Department of Plastic Surgery, Aberdeen Royal Infirmary,Aberdeen, UK4Department of Plastic Surgery, Tan Tock Seng Hospital,Singapore5Department of Plastic Surgery, Hull York Medical School(HYMS), York Teaching Hospital, York, UK

Background: The use of live and cadaveric animalmodels in surgical training is well established as ameans of teaching and improving surgical skill in acontrolled setting. We aim to review, evaluate, andsummarize the models published in the literaturethat are applicable to Hand Surgery training.Materials and Methods: A PubMed search for key-words relating to animal models in hand surgery andthe associated procedures was conducted. Animalmodels that had cross over between specialtiessuch as microsurgery with neurosurgery wereincluded as they were deemed to be relevant to ourtraining curriculum. A level of evidence and recom-mendation assessment was then given to each sur-gical model.Results: Our review found animal models applicableto hand surgery training in four major categoriesnamely microsurgery training, flap raising and handtrauma surgery. Twenty-four separate articlesdescribed various methods of practicing microsurgi-cal techniques on different types of animals.Fourteen different articles each described variousmethods of conducting flap-based procedureswhich consisted of either local or perforator flap dis-section. Eight articles described different models forpracticing hand surgery techniques. Finally, eightarticles described animal models that were usedfor head and neck procedures that were alsoapplicable.Conclusions: A comprehensive summary of animalmodels related to hand surgery training has beencompiled. Cadaveric animal models provide a readilyavailable introduction to many procedures and oughtto be used instead of live models when feasible.

A-0257 Comparison of functional outcome followingtwo rehabilitation protocols after flexor tendonrepair

Christian Wirtz, Elisabeth Oberfeld, Rahel Meier andEsther VogelinDepartment of Plastic and Hand Surgery, Inselspital,University of Bern, Switzerland

Introduction: Operative techniques and postoperativerehabilitation protocols after flexor tendon repair inzones 1 and 2 have improved over the last decadesand are still topic of debate. After the introduction ofthe Lim/Tsai suture technique with early activemotion regime and place and hold (EAM) demon-strating good results, an increased rate of secondarytendon rupture was noted in due course. A modifiedpostoperative controlled active motion (CAM) proto-col was established and results of functional clinicaloutcome are presented. The results are compared toprevious published data of EAM regime.Methods: This is a retrospective analysis of patients,who underwent primary flexor tendon repair in zones1 and 2 using the Lim/Tsai suture technique followedby CAM rehabilitation protocol from 2014 to 2017.Fifty-six patients with 63 FDP tendon lacerationswere included with or without concomitant FDSlaceration. Exclusion criteria were replantation,revascularization, age <16 years. Endpoints weretotal active motion (TAM), extension deficit, gripstrength and rupture rate Ø12 weeks after surgery.The results are compared to 46 patients with 51 FDPtendon lacerations and same excluding criteria andsuture technique followed EAM protocols with place-and-hold exercises.Results: The CAM regime compared to EAM protocolwas associated with statistically significant(p< 0.001) lower TAM values Ø 208�(96–295�) vs232� (190–290�). Grip strength of the injured sidewas lower in the CAM group Ø 26 kg (8–52 kg) vs34.6 kg (14–60 kg) in the EAM group with comparablegrip strength of the uninjured side in both groups43 kg (16–73 kg) vs 45 kg (22–70 kg). There was anequal gender ratio towards male in the EAM groupf/m: 1/4.75 compared to the CAM group f/m: 1/4.73.

Active extension deficits were nearly identical inboth groups: CAM 14.1� (0–50�) and EAM 12� (5–30�). There were 3 tendon ruptures in the CAMgroup (4.7%) compared to 14 (9.4%) tendon rupturesafter EAM treatment.Conclusion: Our results demonstrate a favorableeffect of CAM protocol on rupture rate and equalextensions deficits compared to previously usedEAM rehabilitation regime after tendon repair inzones 1 and 2 using the Lim/Tsai suture technique.

SS62 Journal of Hand Surgery (Eur) 43(Supplement 2)

Restrained controlled active motion might be thereason for lower TAM and grip strength values after3 months. On the other hand, increased tensile forcewith place and hold exercises could be an explana-tion for a higher rupture rate.

A-0258 Comparison of clinical results betweenlow-profile plating and external fixation forfracture-dislocations of the proximalinterphalangeal joint

Atsuhiko Murayama, Kentaro Watanabe, Hideyuki Otaand Yuki FujiharaDepartment of Orthopaedic Surgery Rheumatology, NagoyaEkisaikai Hospital, Nagoya, Japan

Aim: Fracture dislocations of the proximal interpha-langeal (PIP) joint are often difficult to treat despitemany treatment options available. We conducted aretrospective study to compare clinical resultsbetween two groups of cases, as follows: cases trea-ted by a low-profile plate for internal fixation andcases treated using an external fixator in additionto Kirschner-wire fixation.Methods: Thirty-seven patients (37 fingers) with frac-ture-dislocation of the PIP joint, including 34 malesand 3 females, followed up for more than 3 monthswere evaluated. Twenty-five fingers were injuredfrom sports; 9 fingers, from falls; and 3 fingers,from other accidents. Details of the injured fingersare as follows: 9 index fingers, 4 middle fingers, 15ring fingers, and 9 little fingers. Thirteen fingerswere treated by the plate fixation (group P) and 24fingers using external fixator with Kirschner-wirefixation (group E). In group P, the plates were usedfor 10 fingers by palmar approach and for 3 fingers bydorsal approach. The period up to bony union, therange of motion of the distal interphalangeal (DIP)and PIP joints at the last hospital visit, and the ther-apy duration were compared between the groups.Results: The mean periods up to bony union ingroups P and E were 33 and 26 days, respectively.The mean angles of active flexion/extension of theDIP�PIP joints in groups P and E were 63�/�2��95�/�7� and 53�/�3��86�/�12�, respectively. Both flexionand extension showed better improvement in group Pthan in group E. The therapy duration in group P(mean: 77 days) was shorter than that in group E(mean: 96 days).Discussion: Although this study showed that bothmethods yield good clinical results, low-profile plat-ing is considered more preferable. Fractured site canbe more rigidly fixed on using a plate than on usingan external fixator in addition to pinning. The former

allows patients to start active motion exercise justafter surgery. In addition, the patients treated usinga plate had little problem in daily living because of nometal parts exposure. However, the plate fixationmethod is relatively invasive and technicallydemanding.Conclusion: In the treatment of fracture dislocationsof the PIP joint, anatomical restoration of the articu-lar surface and an early motion exercise are critical.The treatment method should be chosen according tosurgeon’s skill and fracture severity.

A-0261 Tension failure greenstick fractures andslightly Z-folded concave side cortex are riskfactors for fracture displacement in conservativetreatment of pediatric distal radius incompletefracture without manipulation

Souichi Ohta, Ryosuke Ikeguchi, Hiroki Oda,Hirofumi Yurie, Hisataka Takeuchi, Sadaki Mitsuzawaand Shuichi MatsudaKyoto University, Kyoto, Japan

Objective: In the conservative treatment of pediatricdistal radius incomplete fractures, although the frac-ture angulation at the initial consultation is consid-ered to be within the limit of spontaneous correction,the progression of angular deformity within the castis observed infrequently during the first 2 weeks ofcast fixation. In this study, risk factors for the pro-gression of angular deformity in the conservativetreatment of pediatric distal radius fractures withoutmanipulation were retrospectively investigated.Methods: From 2005 to 2013, 70 children (4–14 years)were conservatively treated without manipulationbecause the fracture angulation during the initialconsultation was within 20�. On-call orthopedic resi-dents in the emergency department treated all casesexcept torus fractures using a long-arm cast with theelbow at 90� and neutral forearm position. WristX-rays were performed at 1 and 2 weeks after theinjury. The angle between the distal radial fragmentand the radial shaft was measured in the lateral viewof plain radiograph. Because the angle in the ante-roposterior view did not show significant change, thiswas not assessed in the anteroposterior view. Twoexaminers blinded to the clinical data performedassessment. Compression greenstick fracture is anincomplete fracture with a slight plastic deformationof the convex side cortex, and significant angulationor overlapping of the concave side cortex. Tensionfailure greenstick fracture is another type of green-stick fracture with angulation of the concave sidecortex and complete disruption of the convex side

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cortex. The association between individual factors(age, gender, lesioned side, presence of associatedulna fracture, fracture pattern, direction of angula-tion, and presence of the slightly Z-folded concaveside cortex) and fracture displacement was assessedusing Mann–Whitney U-test and Fisher’s exact test. Ap-value of <0.05 was considered significant.Results: In total, 28 children had compression green-stick fracture, 10 had tension failure greenstick frac-ture, 22 had torus fracture, 9 had epiphysiolysis, and1 had complete fracture. In total, 6 children (4 males,2 females; mean age, 7.8 years) had an increasedangulation of >10� within 2 weeks after the initialconsultation; 5 children had tension failure green-stick fractures; and 1 child had a complete fracture.Among the 10 tension failure greenstick fractures, 5children with fracture displacement had slightlyZ-folded concave side cortex, whereas the other 5children without displacement did not. Tension fail-ure greenstick fracture (p< 0.0001) and slightlyZ-folded concave side cortex (p¼ 0.0009) showed sig-nificant association with fracture displacement. Age,gender, lesioned side, presence of associated ulnafracture, and direction of angulation showed no sig-nificant association with fracture displacement.Conclusion: Tension failure greenstick fractures andslightly Z-folded concave side cortex are risk factorsfor fracture displacement in the conservative treat-ment of pediatric distal radius incomplete fracturewithout manipulation.

A-0262 Partial excision of volar plate and dorsalcapsulotomy in patients with post-traumaticankylosis of finger joint in the hand

Yo Han Lee, Jihyeung Kim, Young Ho Lee,Hyun Sik Gong, Kee Jeong Bae and Goo Hyun BaekSeoul National University, Seoul, South Korea

Background: Post-traumatic ankylosis of the fingerjoint is one of the complications after traumatic handinjury. If there is no improvement through conserva-tive treatments, surgical treatments can be consid-ered. Although several surgical techniques such asdorsal capsulotomy and release of the accessory col-lateral ligament have been suggested, the result wasnot satisfactory. The purposes of this study are tosuggest new surgical technique to restore fingerjoint motion and to present the surgical outcome ofthis technique.Methods: We retrospectively reviewed 16 patients, 8males and 8 females, who were diagnosed as post-traumatic ankylosis of finger joint, underwent partialexcision of volar plate and dorsal capsulotomy

between January 2014 and June 2016 and followedup for more than 1 year. There were 12 metacarpo-phalangeal (MCP) joints and 4 proximal interphalan-geal (PIP) joints. The average interval between theinitial injury and the surgery was 64 (range 10 to120) months.Results: Of the 12 MCP joints, the average range ofmotion was improved from 38� to 92� 1 year aftersurgery. Of the four PIP joints, the average range ofmotion was improved from 44� to 85� 1 year aftersurgery. There were no acute complications suchas instability, infection, and wound dehiscence. Allthe patients were satisfied with the surgicaloutcomes.Conclusions: Because this technique does notrelease both collateral ligaments, the joint stabilitycan be maintained. We can also safely release volarplate and dorsal capsule through anterior and pos-terior dual approaches. Partial excision of volar plateand dorsal capsulotomy can be one of the goodoptions in patients with post-traumatic ankylosis offinger joint.

A-0263 Parenting stress in mothers of children withcongenital hand or foot differences and its effect onthe surgical decision-making for their children

Jihyeung Kim, Young Ho Lee, Kee Jeong Bae,Hyun Sik Gong and Goo Hyun BaekDepartment of Orthopedic Surgery, Seoul NationalUniversity, College of Medicine, Seoul, South Korea

Purpose: The main purposes of this study were toassess the levels of parenting stress in the mothersof children with congenital hand or foot differencesand to evaluate the effects of this stress on the pre-ferred roles of mothers in surgical decision-makingfor their children.Methods: This study included 89 mothers of childrenwith polydactyly of the hand, polydactyly of the foot, ahypoplastic thumb, or macrodactyly. The parentingstress level was assessed using the ParentingStress Index-Short Form (PSI-SF). Additionally, themothers were requested to indicate their preferredand retrospectively perceived levels of involvement insurgical decision-making for their children using theControl Preferences Scale, which is comprised of fivelevels ranging from fully active to fully passive.Results: The average PSI-SF scores of the mothersof children with polydactyly of the hand, polydactyly ofthe foot, a hypoplastic thumb, and macrodactyly were73.2, 75.9, 74.1, and 72, respectively, and 15 mothers(16.9%) had a clinically significant level of stress(PSI-SF� 90). In the mothers of children with

SS64 Journal of Hand Surgery (Eur) 43(Supplement 2)

polydactyly of the foot, the PSI score was associatedwith the preferred role in surgical decision-making.Additionally, as the PSI score increased, the motherspreferred to be actively involved in the decision-making process.Conclusions: The assessment of parenting stresslevels in the mothers of children with congenitalhand or foot differences can play an important rolein the screening of candidates who require psychia-tric treatment or support. The mothers of childrenwith polydactyly of the foot who had higher levels ofparenting stress preferred to have a more active rolein surgical decision-making for their children. Thus,an evaluation of the PSI in mothers of children withcongenital hand or foot differences can aid physiciansto modify their style of decision-making based on thepreferred role of the mother.

A-0266 The effectiveness of intraoperative 3Dfluoroscopy in the treatment of intra-articulardistal radius fractures: A randomized controlledtrial

C. A. Selles1, R. J. O. de Muinck Keizer1,M. S. H. Beerekamp1, P. A. Leenhouts1, M. Maas2,J. C. Goslings1 and N. W. L. Schep3

1Trauma Unit, Department of Surgery, Academic MedicalCenter, University of Amsterdam, the Netherlands2Department of Radiology, Academic Medical Center,University of Amsterdam, the Netherlands3Department of Trauma and Hand Surgery, MaasstadHospital, Rotterdam, the Netherlands

Objective: Three-dimensional (3D) fluoroscopy isthought to be beneficial in the operative reductionand fixation of intra-articular distal radius fractures.The goal of this multicenter randomized controlledtrial was to investigate the effectiveness of the addi-tional use of intraoperative 3D fluoroscopy comparedto conventional 2D fluoroscopy in patients requiringoperative treatment for intra-articular distal radiusfractures.Methods: We performed a multicenter prospectiverandomized controlled trial where patients were ran-domized between 3D or conventional fluoroscopyduring operative treatment of their distal radius frac-ture. The primary outcome measure was quality offracture reduction and fixation. Secondary outcomemeasures were the number of revision operationsand the number of complications after 1 year offollow-up and functional outcome measured with thePatient-Rated Wrist Evaluation (PRWE) questionnaire.Results: A total of 207 distal radius fractures wereincluded in the study. The postoperative CT scan

showed an indication for additional revision of reduc-tion or implant position in 25% of the 3D group versus31% in the 2D group (p¼ 0.34). There was no signifi-cant difference in the number of complications andrevision surgeries performed within 1 year. Themedian PRWE score was 7 for the 3D group and 8for the 2D group (p¼ 0.8).Conclusions: The use of intraoperative 3D fluoro-scopy does not improve the quality of reduction andfixation in the management of intra-articular distalradius fractures. There was no benefit of intraopera-tive 3D fluoroscopy with regard to postoperative com-plications, quality of life, or functional outcome.

A-0267 Carpal alignment: A new method forassessment

C. A. Selles1, L. Ras1, M. M. J. Walenkamp1, M. Maas2,J. C. Goslings1 and N. W. L. Schep3

1Trauma Unit, Department of Surgery, Academic MedicalCenter, Amsterdam, the Netherlands2Department of Radiology, Academic Medical Center,Amsterdam, the Netherlands3Department of Trauma and Hand Surgery, MaasstadHospital, Rotterdam, the Netherlands

Objective: The aim of this study was to compare theinter- and intra-observer variability of a new perpen-dicular method with the existing method in fracturedand unfractured wrists. Additionally, the agreementbetween the two methods was analyzed, and normaldistribution of carpal alignment in unfractured wristswas investigated.Methods: Carpal alignment was assessed on lateralplain radiographs using two different methods: onedescribed by Ng and McQueen, and another newlyproposed method, the perpendicular method. Usingthe perpendicular method, the observer draws oneline along the inner rim of the volar cortex of theradius and one perpendicular line to the center ofthe capitate. The carpus is aligned when the linealong the inner rim transects the center of the capi-tate, and consequently the length of the perpendicu-lar line was 0 mm. Three examiners measured thecarpal alignment in 100 patients; 50 with nonfrac-tured and 50 with fractured distal radius.Intraobserver and interobserver variability for bothmethods were determined and expressed as intra-class correlation coefficients. The normal distributionof carpal alignment in a population with unfracturedwrists using both methods was also determined.Results: The interobserver coefficient for the per-pendicular method was 0.98 and that for the Ngmethod was 0.86. The intraobserver coefficient for

FESSH Abstracts SS65

three examiners was 0.89, 0.62, and 0.63 for the Ngmethod. For the perpendicular method, the intraob-server variability was 0.96, 0.89, and 0.72, respec-tively. In patients with unfractured wrists, the meanperpendicular to the center of the capitate was0.25 mm dorsally.Conclusions: The new proposed method is a repro-ducible method for measuring carpal alignment witha high inter- and intra-class coefficient.

A-0275 Clinical and biological results of autologousfat transplantation for treatment ofcarpometacarpal-1 osteoarthritis: Differencesbetween the anti-inflammatory effects of fat andADSPCs on osteoarthritic chondrocytes

Elisabeth M. Haas1,2, Sara Taha1, Paolo Alberton1,Attila Aszodi1, Riccardo E. Giunta2, Elias Volkmer1,2

and Maximilian M. Saller1

1Experimental Surgery and Regenerative Medicine(ExperiMed), Department of General, Trauma andReconstructive Surgery, Ludwig-Maximilians-University(LMU), Germany2Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Germany

Background: Carpometacarpal osteoarthritis(CMC-OA) is a common clinical condition whichaffects 11–33% of the elderly population. It leads topain, weakness and laxity of the thumb. Until now,there is no satisfactory approach to stop the progres-sion of this disease. The most common final treat-ment option is the excision of the trapezium. In a pilotstudy, we treated 100 patients with intraarticularautologous fat transplantation. This new therapy isa promising intermediate solution for the treatmentof thumb CMC OA. Interestingly, our results showedthat just approximately half of the 100 CMC-OApatients who received autologous fat showed areduction of pain after 1 year.Objective: Our area of interest in this study is to showhow fat and isolated adipose derived stem/progenitorcells (ADSPCs) can influence the cartilage micro-environment by the secretion of bioactive factors.Materials and Methods: Human fat tissue was col-lected from five patients undergoing abdominal lipo-suction. Fat- and ADSPC-conditioned medium wasprepared by incubating fat and ADSPCs for 48 hwith TNF-a to stimulate the secretion of immunomo-dulatory factors. Stimulated and non-stimulated fatand ADSPCs were analyzed by RNA-Seq to determinewhich factors might be involved in the anti inflamma-tory effect of fat and ADSPCs. In addition, chondro-cytes from osteoarthritic cartilage from five patients

undergoing trapeziectomy were isolated and subse-quently incubated with conditioned medium for 72 h.Before and after cultivation of osteoarthritic chon-drocytes with conditioned medium, chondrocyteswere analyzed by RNA-Seq to evaluate the effect offat- and ADSPC-conditioned medium onto the trans-ciptome of osteoarthritic chondrocytes.Results: The most promising genes are IL6, TIMP2,HGF, TGFb1, and IDO. In order to see the effect ofconditioned medium from fat and ADSPCs on chon-drocytes before and after cultivation with conditionedmedium, gene sequencing has been performed. Thegene expression of MMP1, MMP13, IL1, SOCS1,SOCS3, COL2A1, ACAN, and SOX9 is of specialinterest.Conclusion: By the utilization of transcriptome ana-lysis, we have identified important bioactive factorsthat are involved in the anti-inflammatory effect of fatand ADSPCs onto CMC-OA. Additionally, we haveseen that ADSPCs show a different inflammatoryresponse when compared to white fat tissue.

A-0277 Intra-individual comparison of surgicalresults between open and Paine retinaculotomerelease in patients with bilateral carpal tunnelsyndrome

Carlos Henrique Fernandes, Lia Miyamoto Meirelles,Marcela Fernandes, Luis Renato Nakachima,Joao Baptista Gomes dos Santos and Flavio FallopaHospital Sao Paulo/Universidade federal de Sao Paulo/Hand Surgery Unit, Brazil

An intra-individual comparison of surgical resultsbetween open and Paine’s retinaculotome releasewas performed in patients with bilateral carpaltunnel syndrome, each hand was operated by oneof the techniques.

Eighteen patients, in the total of 36 hands, wereevaluated at the preoperative period and secondweek, first month, third month and sixth month post-operative period. Patients were evaluated for gripstrength, visual analog pain scale (VAS), and for theBoston Carpal Tunnel Questionnaire.

The values of all force types were not statisticallydifferent among patients submitted to different sur-gical techniques. The pain measures did not presentdifferences between the groups of patients submittedto the different techniques. The Boston CarpalTunnel Questionnaire score showed the group sub-mitted to the open technique presenting significantlyhigher values in 2 weeks (t¼ 2.297, p¼ 0.036) and 3months (t¼ 2.449; p¼ 0.026) after surgery for symp-tom severity. Again, the open technique presented

SS66 Journal of Hand Surgery (Eur) 43(Supplement 2)

values significantly higher at 2 weeks (t¼ 2.342,p¼ 0.036), 3 months (t¼ 2.413, p¼ 0.028), and 6months (t¼ 2.553, p¼ 0.023) after surgery for func-tional status.

The surgical treatment of carpal tunnel syndromewith Paine’s retinaculotome presented better resultsthan the open technique when evaluated by theBoston Carpal Tunnel Questionnaire, and no differ-ences were found regarding measures of strengthor pain.

A-0283 Arthroscopic management of distal radiusfractures

Yukio Abe and Kenzo FujiiSaiseikai Shimonoseki General Hospital, Shimonoseki,Japan

Background: We developed a surgical procedure thatcan facilitate arthroscopic intervention for palmarlocking plate fixation for distal radius fracture (DRF)with a less invasive technique. This study is to inves-tigate the effectiveness of our original procedure forthe treatment of DRF.Methods: Four hundred and six wrists of 400 conse-cutive patients underwent our original procedure: theplate presetting arthroscopic reduction technique(PART) for DRF. The fractures were reduced, anato-mical alignment was regained with the aid of a fluoro-scopy, and the palmar locking plate was preset. Wristarthroscopy was then performed and the intra-articular condition assessed. If there were any resi-dual dislocations of the intra-articular fragments,these were reduced arthroscopically, and soft tissueinjuries were subsequently treated. The traction wasthen removed, and the plate was securely fixed.Results: On arthroscopic inspection, intra-articulardislocations were found to be residual in about22%, even if reduction seemed to have been achievedwhen viewed with fluoroscopy. Scapholunate inter-osseous ligament injury was recognized in about30%, and traumatic triangular fibrocartilage complexinjury was observed in about 45%. The outcome was76% of excellent, 22% of good, 1.5% of fair, and 0.5%of poor.Conclusions: Wrist arthroscopy is a feasible adjunctin the treatment of DRF, especially as it enables us toevaluate the reduction of intraarticular fragmentsand soft tissue injuries. Palmar locking plate fixationrecently has become popular, and simultaneousarthroscopic procedures for reduction have becomedifficult because vertical traction must be applied andreleased during surgery. PART can overcome thesedifficulties, and this technique can be performed with

a small skin incision, preserving the pronator quad-ratus muscle, simplifying the combination of platingand arthroscopy, and achieving good final results.

A-0292 Total wrist arthrodesis with a locked, lowprofile fusion plate without carpometacarpal jointfixation: A bicenter trial

S.V. Koehler1, K. Koch2, F. Neubrech1,A. Arsalan-Werner1, H. Krimmer2 and M. Sauerbier1

1Berufsgenossenschaftliche Unfallklinik Frankfurt amMain, Germany2Zentrum fur Handchirurgie Ravensburg im Arztehaus amKrankenhaus St. Elisabeth, Germany

Objective: Total arthrodesis is the last line of defensein the treatment of painful degenerative or posttrau-matic destruction of the wrist. One option for theprocedure is the use of a wrist fusion plate with amultidirectional locking system (APTUS 2.5-TriLockWrist Fusion Plate, Medartis AG, Basel, Switzerland).Compared to conventional implants, the new genera-tion has a low profile height and spares the thirdcarpometacarpal joint (CMC), preserving residualmobility and therefore preventing potential implantremoval. The aim of this study was to evaluate handfunction, patient comfort, pain and bony consolidationin patients with the APTUS wrist fusion plate.Additionally, the practicability and reliability of theplate were evaluated.Methods: A retrospective consecutive follow-up ofthe cases of two independent German hospitals wasconducted. Between 2011 and 2016, the APTUSsystem was used in 28 patients. Of 28 patients, 19were previously treated with a scapholunate liga-ment reconstruction, four-corner fusion, scaphotra-peziotrapezoid arthrodesis, or proximal rowcarpectomy. Total wrist arthrodesis was performedas a result of posttraumatic arthrosis in 22 patients,Kienbock disease in 4 patients, chronic polyarthritisin 1 patient, and infection in another patient. Bonyconsolidation was assessed by CT scan in allpatients. The DASH score, pain measured by visualanalogue scales ranging from 0 to 10 (VAS), patientsatisfaction, grip strength as well as active pronationand supination were examined. Furthermore post-operative complications were recorded.Results: Mean follow-up was 21 months (3–39).Using the CT scan as a determining factor, 26 of 28patients achieved primary bony consolidation. Themean postoperative DASH score was 40 (6–72)points. Pain improved from 7 (3–10) preoperativelyto 2 (0–6) postoperatively. Grip strength improvedfrom 14 (0–38) kg to 22 (12–40) kg. Patients achieved

FESSH Abstracts SS67

a mean pronation and supination of 140� postopera-tively. Of 28 patients, 14 maintained complete activepronation and supination range of motion. Of the 14patients, 13 were satisfied with the treatment.Problems with the extensor tendon apparatus didnot occur. Postoperative complications were foundin 6 of 28 patients and included non-union (n¼ 2),screw breakage (n¼ 2), postoperative hematoma(n¼ 1), and infection (n¼ 1). Plate removal was onlyperformed in 1 of 28 cases as a result of screwbreakage.Conclusions: Total wrist arthrodesis, using a lockedfusion plate that spares the CMC joint, has proved tobe a viable treatment option for the end stage ofosteoarthritic wrist disease. It leads to acceptablepain relief and grip strength and most ADLs can bemaintained. Although there are process-specificcomplications, patient satisfaction rates are high.Usually hardware removal with this new generationof wrist fusion plate is not necessary.

A-0301 Humeral suspension improves flailshoulder conditions in traumatic brachialplexus palsy

Rudolf Rosenauer1,2,3, Hanno Millesi1 andRobert Schmidhammer1,3

1Millesi Center, Vienna, Austria2Trauma Hospital Lorenz Bohler of the Austrian Workers’Compensation Board (AUVA), Vienna, Austria3Austrian Cluster of Tissue Regeneration and LudwigBoltzmann Institute for Experimental and ClinicalTraumatology at the Research Centre for Traumatology ofthe Austrian Workers’ Compensation Board (AUVA), Vienna,Austria; Vienna Private Clinic, Vienna, Austria

Introduction: Upper or complete brachial plexuslesions can lead to a severe weakness of theshoulder muscles. Following the denervation andatrophy of these muscles, the maximum range ofmotion, especially abduction, is impaired. Inferiorsubluxation of the humerus head in the resting posi-tion of the shoulder develops consequently, leadingto a flail shoulder. Unfortunately, there are limitedtherapeutic options to improve this condition.Muscular support can be improved by a trapeziusmuscle transfer. Glenohumeral arthrodesis is avail-able as a salvage procedure with a high rate of fail-ure. We have developed a surgical procedure for there-suspension of the humerus head to the acromion,and this study aims to evaluate the efficacy of thismethod retrospectively.Materials and Methods: Between 2008 and 2014, 13patients suffering from a paralysed upper limb and,

consequently, flail shoulder were treated with thisprocedure. The humerus head was re-suspendedfrom the acromion using an artificial ligament. In 6patients, an additional supraspinatus to trapeziusmuscle-tendon transfer was performed due to com-plete supraspinatus wasting. The mean age was 30years (�11) and the mean follow-up was 36 months(�14). All patients were male, and the right side wasaffected in 85%. The grade of subluxation was deter-mined by measurement of the distance between thelower border of the acromion and the upper border ofthe humerus head clinically. Abduction was mea-sured as the maximum possible thoraco-humeralangle using a goniometer, with the patient standingupright in front of the investigator. Pain was mea-sured using a visual analogue scale. Furthermore,the ASES, the UCLA, and the Simple ShoulderScores were obtained postoperatively.Results: Abduction was improved from 11� (�18)preoperatively to 54� (�17) postoperatively, p< 0.05.Pain was reduced from 3.3 (�3.8) preoperatively to1.7 (�2.8) postoperatively, p< 0.05. The grade of sub-luxation was improved from 3.9 cm (�0.6) preopera-tively to 0.5 cm (�1.2) postoperatively, p< 0.05. Themean postoperative ASES, Simple Shoulder andUCLA Shoulder Score were 60.8 (�13.7), 2.6 (�0.9),and 18.2 (�3.6), respectively. All patients reported ahighly satisfying stability of their shoulder. No for-eign-body reactions or wound healing disordersoccurred.Conclusion: In this article, we present a novel proce-dure to suspend the humerus head from the acro-mion in the case of inferior subluxation of thehumerus head. Subluxation can be reduced withthis procedure, and existing muscle strength can beused exclusively for movement. Restoring dynamicshoulder stability can treat the pain arising from aflail shoulder as well.

A-0302 Clinical improvement in patients older than80 years after carpal tunnel release

Antonio Dudley Porras, Julian Del Rio Hortelano,Andres Leon Gutierrez, Juan Francisco JimenezSanchez and Jens Cardenas SalasHospital Universitario de la Princesa, Madrid, Spain

Objectives: There is still some controversy about thebenefits of the carpal tunnel release (CTR) in olderpatients, even more when the impairment of themedian nerve is high. Some previous studiesshowed partial improvement in patients older than70 years. The objective of the present study is toasses the clinical improvement in patients older

SS68 Journal of Hand Surgery (Eur) 43(Supplement 2)

than 80 years who underwent surgery for carpaltunnel syndrome (CTS) in our service.Methods: A review of the patients older than 80 yearswith CTS that underwent surgery in Hospital de laPrincesas Hand Unit between 2013 and 2016 wasperformed by means of a retrospective study.Twenty-eight patients (31 hands) were evaluated.Mean age was 84 years and 23 patients werefemales. Mean time of evolution before surgery was27 months.

Pain, paresthesias, loss of strength and sensitivitywere registered. Physical exam included Tinel andPhalen tests. In every case, an electrodiagnosticstudy was performed and sensitive conduction velo-city was used to assess the degree of impairment ofthe median nerve in mild (one case), moderate (10cases) or severe (20 cases). Surgical technique wasopen carpal tunnel release. Postoperative improve-ment of pain and paresthesias, and recovery of thestrength and sensibility were registered, so the com-plications after surgery. Electrodiagnostic post-operative control studies were performed in 16cases. Data were analyzed with the SPSS statisticsprogram 22.0 and McNemar test.Results: After CTR, there was an improvement inpain release in all symptomatic cases (p< 0.05),and paresthesias in 85% of previous cases(p< 0.05). In all of patients with previous loss ofstrength, there was a subjective improvement, andin 76% of patients with loss of sensibility (p< 0.05).The patients from the group of severe impairment ofmedian nerve were reviewed separately and the rateof improvement in paresthesias and recovery of sen-sibility was similar (82 and 75%, respectively).Electrodiagnostic studies showed improvement inmore than 80% of patients.

There were 10 hands with mild or moderate pillarpain at the scar that improve spontaneously in a fewmonths. No disesthesic scars were found, and therewas a patient with trigger finger that needed surgeryto correct.Conclusions: Patients older than 80 years old thatunderwent CTR in our study showed a significantimprovement in clinical symptoms and the recoveryof strength and sensibility.

There was a significant improvement in the elec-trodiagnostic studies after surgery.

The clinical improvement of the patients of thestudy was independent from the preoperativedegree of impairment of the median nerve.

A-0307 Evaluation of sarcopenia in patients withdistal radius fractures

Young Hak Roh1, Seok Woo Hong1, Hyun Sik Gong2 andGoo Hyun Baek2

1Department of Orthopaedic Surgery, Ewha WomansUniversity Medical Center, Ewha Womans UniversityCollege of Medicine, Seoul, South Korea2Department of Orthopaedic Surgery, Seoul NationalUniversity College of Medicine, Seoul, South Korea

Objective: Sarcopenia is a core component of physi-cal frailty that predisposes older people to fall andnegatively impact the activities of daily living. Theobjectives of this study were to compare the preva-lence of sarcopenia in patients with distal radiusfractures (DRF) with that in age- and sex-matchedcontrols without DRF and evaluate the associationbetween sarcopenia and the occurrence of DRF.Methods: We prospectively recruited 132 patientsover 50 years of age who sustained DRF due to falland 132 age- and sex-matched controls without DRF.A definition of sarcopenia was based on the consen-sus of the Asian Working Group for Sarcopenia.Sarcopenic components including appendicular leanbody mass, grip strength, and gait speed were com-pared between the two groups. Other factorsassessed for the occurrence of DRF were age,gender, body mass index (BMI), lumbar, and hipbone mineral density (BMD) values. A conditionallogistic regression analysis was conducted to evalu-ate the associations between sarcopenia and theoccurrence of DRF.Results: A total of 39 (30%) of 132 DRF patients weresarcopenic, whereas 23 (17%) of the 132 controls werewithin the sarcopenic criteria (p¼ 0.048). The patientgroup had significantly lower lean body mass andweaker grip strength than those of the controlgroup. However, there was no significant differencein gait speed between the two groups. According toregression analysis, lower appendicular mass indexin men was associated with an increased incidenceof DRF (odds ratio (OR)¼ 0.84, 95% confidence interval(CI)¼ 0.72, 0.95), while weaker grip strength and lowertotal hip BMD values were associated with the occur-rence of DRF in both men (OR¼ 0.77, 95% CI¼ 0.63,0.92; and OR¼ 0.79, 95% CI¼ 0.64, 0.94, respectively)and women (OR¼ 0.78, 95% CI¼ 0.64, 0.93, andOR¼ 0.73, 95% CI¼ 0.52, 0.92, respectively).Conclusions: Sarcopenia is more prevalent inpatients with DRF than in age- and sex-matched con-trols. Lower appendicular mass in men, weaker gripstrength, and lower hip BMD in both men and womenincrease the likelihood of DRF.

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A-0310 Intermediate-term results followingarthroplasty of the basal joint of the thumb

Rasmus Wejnold Jørgensen, Anders Odgaard andClaus Hjorth Jensen.Hand Clinic, Department of Orthopedics, Herlev-GentofteUniversity Hospital of Copenhagen, Denmark

Objective: Indication for thumb carpometacarpal joint(CMC-1) arthroplasty is clinical and radiographicosteoarthritis of the joint resistant to conservativetreatment. The purpose of this study was to evaluatepatient-reported outcome measures after CMC-1arthroplasty.Methods: A prospective database was initiatedSeptember 2013. Patients prospectively answeredQuick-DASH questionnaire preoperatively and at 6months postoperatively following interpositionarthroplasty of the basal joint of the thumb. From2016, the database further collected 12 and 24months postoperative values. Two hundred and thir-teen consecutive patients were available with 6months post-operative results. Thirty-five were avail-able after 12 and 24 months each.

SPSS v 24.0 was used. Student t-test and Mann–Whitney U test were used comparing pre- and post-operative values. Pain was evaluated from the Quick-DASH questionnaire quantified on a scale of one tofive, five being most pain. The validated Quick-DASHquestionnaire was used. p< 0.05 was considered sta-tistically significant.Results: The mean preoperative Quick-DASH was47.98 (SD 16.30) for the group that had follow-up at 6months. The mean 6-month postoperative Quick-DASHwas 23.94 (SD 20.67), showing an average improve-ment of 24.04, p< 0.0001. The mean 12-monthsposto-perative Quick-DASH was 25.52 (SD 22.38). The mean24-month postoperative Quick-DASH was 19.74 (SD18.88). There was no significant improvement from 6to 12 months (p¼ 0.85) or 6 to 24 months (p¼ 0.28).

Preoperative pain was 3.65 (SD 0.71). Six-monthpostoperative pain was 2.18 (SD 0.98), p< 0.0001.Postoperative pain at 12 months was 2.31 (SD 0.99)and at 24 months 1.71 (SD 0.83). There was no sig-nificant improvement in pain from 6 to 12 months(p¼ 0.91) or 6 to 24 months (P¼ 0.09).

At 6-month follow-up, 159 of 213 (74.6%) weresatisfied with the result, at 12 months 25 of 35(71.4%) and at 24 months 26 of 35 (74.3%) were satis-fied. Patients who were satisfied had lower painscores and lower Quick-DASH scores at 6, 12, and24 months (p< 0.001 on all parameters) as comparedto preoperatively.Conclusions: CMC-1 arthroplasty is an effective treat-ment of thumb CMC osteoarthritis. Quick-DASH

scores and pain scores improved at 6-month follow-up. There was no improvement in Quick-DASH or painscores from 6 to 12 months or from 6 to 24 months.Patients who were satisfied had lower pain scores andlower Quick-DASH scores at follow-up compared topatients who were not satisfied.

A-0311 Reconstruction of hypoplastic thumb usinghemi-metatarsal composite tissue transfer

Bin Wang, Shengbo Zhou and Wenhai SunDepartment of Plastic and Reconstructive Surgery,Shanghai 9th People’s Hospital, Shanghai JiaotongUniversity School of Medicine, China

Purpose: This study was conducted to report thefunctional outcomes of hemi-metatarsal compositetissue transfer in reconstruction of type IIIB hypo-plastic thumbs.Methods: Eighteen patients with type IIIB hypoplasticthumbs who had undergone hemi-metatarsal com-posite tissue transfer were included in this studywith at least 4 years of follow-up. Preoperative DSAwas performed to investigate vessel variance.Outcome measures included range of motion andpinch strength. Pediatric Outcomes Data CollectionInstrument (PODCI) scores were also collected.Results: Radial arteries were hypoplastic in 83.3% ofthe cases, which we chose common palmar digitalarteries as the recipient vessel. There was no neuro-vascular complication. The only donor site complica-tion was a metatarsal fracture, which healed withcasting. Range of motion was significantly less thannormal for both the interphalangeal and the meta-carpophalangeal joints. For the returning cohort, keyand tripod pinch were 21% and 45% of normal. Themedian Kapandji score was 6 (range 3 to 8). ThePODCI scores were high for global, upper extremityfunction, happiness, and pain.Conclusions: At a minimum 4-year follow-up, hemi-metatarsal composite tissue transfer for types IIIBthumbs was shown to provide good subjective out-comes, despite limited range of motion and strength,and is a feasible method in the attainment of a 5-digithand.

A-0312 A novel opening wedge osteotomy to correctdelta phalanx deformity in clinodactyly

Bin Wang, Hailei Mao, Wenhai Sun and Gang HanDepartment of Plastic and Reconstructive Surgery,Shanghai 9th People’s Hospital, Shanghai JiaotongUniversity School of Medicine, China

SS70 Journal of Hand Surgery (Eur) 43(Supplement 2)

Purpose: To evaluate the outcomes and complica-tions in a series of children with clinodactyly treatedwith our novel opening wedge osteotomy of theabnormal Delta phalanx.Methods: We performed a retrospective review ofeight children with clinodactyly treated at our institu-tion with a novel opening wedge osteotomy of theabnormal delta phalanx between 2007 and 2017.This k-shaped osteotomy included resection of theabnormal longitudinal physis and double openingwedge osteotomy. Preoperative and postoperativeclinical angle, radiographic angle, digital range ofmotion, and pain were compared and complicationswere recorded.Results: Ten digits in eight patients were included inthe study. All had greater than 28 of preoperativeclinical angulation (mean, 40). Mean age at time ofsurgery was 6 years; mean duration of follow-up was24 months (range 12–48 months). All digits had sig-nificant improvement (mean, 34) in clinical and radio-graphic angles after surgery. This improvement wasmaintained at the final follow-up in all digits. Fivepatients had pain preoperatively and no patient hadpain postoperatively. One digit had a recurrent defor-mity at the final follow-up and three digits developedstiffness at the interphalangeal joint.Conclusions: Our novel opening wedge osteotomy isan effective treatment for angulation in children withsevere clinodactyly although the risk of interphalan-geal joint stiffness still exists.

A-0319 Neuroma prevention with NEUROCAP� in arat sciatic nerve model

Steven L. Peterson1, Harm de Vries2, Hilde Geraedts2

and Michael J. Wheatley3

1Porland Veterans Affairs Medical Center, Portland, OR,USA2Polyganics B.V., Groningen, The Netherlands3Kaiser Permanente, Portland, OR, USA

Objective: Symptomatic neuroma may develop after anerve dissection or bruising of a nerve following anyblunt or sharp trauma to a peripheral nerve, whetheraccidental or planned (i.e. surgery). Neuroma-induced neuropathic pain and morbidity seriouslyaffect the patient’s daily life and functional status.By developing a conduit with a closed end (cap), theformation of neuromas will be better controlled bypreventing axonal sprouting and escape at the siteof nerve transection, and lowering local neurotrophiceffects by preventing attraction and activation ofnerve growth factors which induce axonal sprouting.The objective of the study was to assess the

implantation effects of the NEUROCAP� device in arat sciatic nerve model.Methods: In this Good Laboratory Practice (GLP) ran-domized controlled trial, the right sciatic nerves of 34male Sprague Dawley rats were dissected and trans-ected per study protocol. The rats were divided into atest group, which received the NEUROCAP deviceafter transection of the nerve, and a control groupin which the nerve end was left in situ after transec-tion. Ten animals were sacrificed at 3 months aftertransection (5 test, 5 control), 16 animals at 6-monthfollow-up (8 test, 8 control), and 5 animals at 12months follow-up (3 test, 2 control). Animals wereassessed with regards to autotomy behavior duringtheir survival period. Gross macroscopy informationwas collected regarding neuroma formation, tether-ing to the surrounding tissue and outgrowth of nerveaxons. Histological information was collectedregarding neuroma formation, outgrowth of nerveaxons, axon alignment and myelination, inflammationand degradation of the study device. Histological datawere collected using H&E, Neurofilament 200 andLFB stains.Results: Seven animals showed severe autotomy inthe first 3 days after surgery (three tests and fourcontrols) and were euthanized and replaced, autot-omy in all animals resolved 4 months after transec-tion. Three additional animals (one test and twocontrols) were prematurely euthanized due to non-device related complications, making a final samplessize of 31 animals. Histopathology analysis on theraw data at the location of the transected nervewas performed to determine if a significant effectexists between test samples and control samples.At 3 months after transection, the test group hadless neuroma formation, less nerve outgrowth,more myelinated nerve fibers, more chaotic fasci-cles, and more inflammation when compared to acontrol treatment. Six months after transection, thetest group continued to have less neuroma forma-tion, less nerve outgrowth, and less tethering to thesurrounding tissue when compared to controls; andfewer chaotic fascicles and less inflammation com-pared to 12 weeks. These results were maintained inthe small group of animals at 12-month follow-up.Conclusions: The results indicate that the testeddevice performed better or equivalent to the controltreatment at 3-, 6-, and 12-month duration withregards to neuroma formation, outgrowth of axons,axonal alignment, tethering to the surroundingtissue, and myelination.

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A-0326 Single palmar approach for proximal rowcarpectomy and total wrist fusion in the spastichand

Christoph Erling, Michael Hiller, Thomas Giesen,Olga Politikou and Maurizio CalcagniUniversity Hospital Zurich, Switzerland

Introduction: A total wrist fusion (TWF) with proximalrow carpectomy (PRC) may help address the severelyflexed wrist deformity in patients with cerebral palsy(CP). With proper diagnosis and a well-executed sur-gical plan, successful surgical outcomes can beachieved. Surgeons described different techniquesof TWF in patients with CP. This study aims to showour experience with a volar PRC and TWF, whichGong HS (Tech Hand Up Extrem Surg 2010) initiallydescribed. Our technique uses the same surgicalapproach from the volar side and distinguishesitself through the use of a different osteosynthesismaterial for bone consolidation.Materials and Methods: In three patients and fourwrists, a PRC and TWF were done using a palmarapproach. In all patients, the carpal tunnel wasreleased and the superficial flexor tendons weretransferred to the deep flexor tendons of the fingers.We used a Medartis 2.5 triLock distal radius plate toobtain wrist fusion.Results/scores: The bony site fused in an average of3 months. There was no case of nonunion. The bonefused in an average of 10� of flexion and we obtainedan average of 80� of correction. One case presented apostoperative blister that was managed expectantlywith a favorable outcome. One case presented ascrew loosening, however without the need forfurther therapy. In all cases, patients and their care-givers were satisfied with the postoperative result.Discussion: Different techniques of TWF have beendescribed in the literature. With a palmar dissection,flexor tendon surgery and carpal tunnel release canbe accomplished through the same surgical incision.The PRC provides sufficient bone stock for a suc-cessful arthrodesis without the risk of further comor-bidity associated with an iliac crest graft. The palmararthrodesis is technically feasible and a 2.5 triLocklocking plate seems to give enough stability for suc-cessful bone healing, even if the construct of palmarapplication of the plate is biomechanically lessstable. No secondary procedure for plate removalwas necessary in our patients. The palmar incisionmight be an advantage in a patient group where theforearm is fixed in a prone position due to musclespasticity, as well as in a group that chooses theoperation for aesthetic reasons, too. While ourstudy group consists of only four wrists, to our

knowledge, it is the largest study group where volarPRC and TWF have been described.

A-0328 Prevalence of the Linburg–Comstockanomaly in women with carpal tunnel syndrome

Saulo Rodrigues Moreira, Carlos Henrique Fernandes,Lia Myamoto Meirelles, Luis Renato Nakachima,Joao Baptista Gomes dos Santos and Flavio FallopaHospital Sao Paulo/Universidade Federal de Sao Paulo/Department of Orthopedic Surgery/Hand Surgery Unit,Brazil

Purpose: This study clinically evaluated the preva-lence of anomalous tendon slips from the flexor pol-licis longus to the flexor digitorum profundus of thefingers in a group of patients diagnosed with carpaltunnel syndrome (CTS).Methods: The prevalence of the Linburg–Comstockanomaly was evaluated in 400 hands from 200female patients aged >40 years and clinically diag-nosed with CTS. The control group consisted of 400hands from 200 female volunteers aged >40 years.The patients and controls were asked to perform theflexion and pain clinical tests described by Linburgand Comstock.Results: The flexion test was positive in 305 (76.3%)CTS patient and 242 (60.5%) volunteer hands. Thepain test was positive in 261 (65.3%) CTS patientand 108 (27.0%) control group hands. Of the 305CTS patient hands with positive flexion testing, 244(80.0%) were also positive for the pain test. Only 98(40.5%) of the 242 control group hands with positivefor flexion testing also had a positive pain test. Allthese differences were statistically significant(p< 0.001).Conclusions: In this study, the prevalence of theLinburg–Comstock anomaly was evaluated by theflexion and pain tests, which showed significantlymore positive results in patients diagnosed withCTS than in the non-CTS controls. The concomitantprevalence of positive flexion and pain tests was alsohigher in the CTS patients than in the controls. Theseresults suggest that the Linburg–Comstock anomalymay be related to the etiology of CTS.Type of study/level of evidence: Diagnostic III.

SS72 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0338 Nerve transfer of motor branches from thesupinator muscle to the posterior interosseusnerve in tetraplegia: A 1-year follow-up of 17operated forearms

Joakim Stromberg1, Johanna Wangdell1,Carina Reinholdt1 and Jan Friden1,2

1Centre for Advanced Reconstruction of Extremities(C.A.R.E.), Sahlgrenska University Hospital, Molndal,Sweden2Swiss Paraplegic Centre (SPZ), Nottwil, Switzerland

Objective: A complete spinal lesion at the C6 levelleads to loss of motor function in muscles innervatedby the radial nerve, that is, muscles mediating wrist,thumb and finger extension (EPL, EPB, APL, EDC,EIP, EDM and ECU). However, the upper motor neu-rons that innervate the supinator muscle originatefrom C5 to C6 level and are intact in most tetraplegicpatients with a C6 lesion. Transferring branches con-taining these neurons to the posterior interosseousnerve can attain reinnervation of extensor muscles.The purpose of this study was to investigate the out-come 1-year post surgery in the first nine patientstreated in our unit.Methods: Between October 2014 and August 2016, 17nerve transfers were performed in nine tetraplegicpatients (8 bilateral and 1 unilateral). The mediantime after the spinal trauma was 10 months (range7–15). Preoperative assessment ensured function ofthe radial wrist extensors (ECRB and ECRL), andintraoperative nerve stimulation of the motorbranches to the supinator muscle was performedbefore section and transfer to the posterior inteross-eous nerve.Results: All 17 forearms were assessed 1 year aftersurgery. Eleven of these forearms were found to havedetectable results from the nerve transfer: Six armswere found to have reinnervation with voluntaryextension of thumb and fingers, and five arms hadsome effect including flickers of the extensor mus-cles and stabilization of the wrist (ECU-reinnerva-tion). Six arms showed no signs of reinnervation.Two of the patients in the first group have had furthersurgery with grip reconstruction after 12 and 14months, at which some of the procedures had to bealtered due to the regained extension.Conclusion: Nerve transfer of motor branches fromthe supinator muscle to the posterior interosseousnerve is a novel option that should be considered inpatients with tetraplegia. Contrary to other recon-structive procedures, timing after the spinal injuryas well as the age of the patient is of importancesince neurodegeneration of the posterior inteross-eous nerve might decrease the functional outcome.

Reinnervation cannot be exactly predicted in eachpatient, but restored and useful extension of thumb;fingers and wrist in more than one third of the armsshould justify the operation in informed patients inour opinion. Later grip reconstruction procedureshave to be altered according to the regainedfunctions.

A-0340 Arthroscopic resection of the distal ulna(wafer procedure): An adequate treatment option?

Vanja Celigoj, Bernhard Lukas and Claus J. DeglmannCenter of Hand and Elbow Surgery, Microsurgery andPlastic Surgery, Schoen Klinik Muenchen Harlaching,Munich, Germany

Objective: The arthroscopic intra-articular resectionof the distal ulna (wafer procedure) is one of thetreatment options in symptomatic ulnar impactionsyndrome. In our Hand Surgical Department, 29arthroscopic resections of the ulnar head were per-formed from 2012 to 2016. Range of motion, pain,grip strength and patient satisfaction should beexamined.Methods: Exclusion criteria for our retrospectivestudy of arthroscopic resections of the distal ulnawere simultaneous osseous interventions of thecarpus, which left 25 patients (average age 53years, male to female ratio 9:16) for evaluation.

The active range of motion (aROM) and the gripstrength (Jamar) were examined. Furthermore,Quick-DASH score was recorded preoperatively andon follow-up exam (mean 26� 19 months postop).We evaluated the pain score (VAS 1-10) in rest andon exertion as well as the patient satisfaction.Results: Pain could be reduced to 1.72 VAS in restfrom 3.86 preoperatively and 3.56 on exertion from7.32, respectively.

The Quick-DASH score improved from 48.7 preo-peratively to 32.2 in the follow-up.

Active ROM (extension/flexion) was 109.2� preo-peratively and 114.2� in the follow-up. For pro-/supi-nation active ROM was 163.8� preoperatively and 165�

in the follow-up exam.Grip strength (Jamar) was 96.7% compared to the

non-treated side.Almost 93% of the patients were satisfied with the

result of surgery.Conclusions: Subjective parameters (Quick-DASHand VAS) and patient satisfaction showed a markedimprovement after surgery, and active ROM reachedthe initial levels.

The arthroscopic resection of the distal ulna seemsto be well suited to alleviate the symptoms of ulnar

FESSH Abstracts SS73

impaction syndrome without a long period of conva-lescence. Even if we prefer the open ulna shorteningosteotomy for patients as a standard procedure, thearthroscopic wafer procedure seems to be a goodalternative treatment option, if the shortening osteot-omy is not possible due to DRUJ configuration or notapproved by the patient.

A-0341 Comparative, retrospective study of elbowflexion gain in patients with brachial plexus injurywho underwent neurotization with part of the ulnarnerve to the biceps muscle or to the free gracilismuscle

Marcelo Rosa de Rezende, Renata Gregorio Paulos,Alvaro Baik Cho, Rames Mattar Junior andTeng Hsiang WeiHand and Microsurgery of Orthopaedic and Traumatology,Institute of University of Sao Paulo, Sao Paulo, Brazil

Objective: In an upper brachial plexus injury, the gainof elbow flexion is an important condition for thefunctional improvement of the affected limb. As atherapeutic option, we have the neurotization surgeryof the ulnar nerve in the musculocutaneous nerve,the success of which is related to how soon the pro-cedure can be performed. As an alternative, we havethe free transfer of the gracilis muscle with neuroti-zation in the ulnar nerve, which would be recom-mended for cases in which the procedure isperformed later and in which changes resultingfrom chronic denervation of the flexor muscles ofthe elbow are irreversible. Therefore, the time limitwithin which we recommend each of these proce-dures to be performed is not well defined. The pri-mary objective of our study was to compare theresults of these treatment methods in terms ofelbow flexion strength improvement and, seconda-rily, to evaluate the influence of the time variationbetween injury and surgery in these results.Methods: We performed a comparative, retrospectivestudy that evaluated 69 patients with upper brachialplexus injury. The patients underwent surgical treat-ment with neurotization of part of the ulnar nerve inthe motor branch of the musculocutaneous nerve (48patients, the Oberlin group), or free transfer of thegracilis muscle (21 patients, the Free group) forelbow flexors with neurotization in part of the ulnarnerve. The primary outcome was evaluated using thescale defined by The British Medical ResearchCouncil (BMRC) and a minimum follow-up of 12months was defined. The secondary outcomereferred to the effect of time between trauma andthe plexus surgery, and the results obtained for

gain in elbow flexion with the Oberlin surgery.These results were compared with those obtainedby means of free muscle transfer surgery. We usedthe criteria of M4 or more to classify the elbow flex-ion as a good result.Results: No statistically significant difference wasobserved, regarding the ability to obtain a M4 scoreor higher between the Oberlin (61.3%) and the Freegroups (61.9%). In assessing Oberlin subgroups,operated on within 6, 9 and 12 months, we obtainedgood results in 65%, 60.5% and 58%, respectively,with no statistically significant differences betweensubgroups. The same was observed when eachOberlin subgroup was compared individually withthe Free group. The integrity of the triceps did notinterfere with the final gain of elbow flexion.Considering the possibility of a M2 score or higher,which would allow for complementary surgery, suchas the Steindler procedure, we had similar results,with 87% for the Oberlin group and 95.2% for theFree group.Conclusions: The neurotization surgery of the ulnarnerve on the motor branch of the musculocutaneousnerve, when the operation takes place within 12months of the injury, and the free transfer of thegracilis muscle and neurotization in the ulnar nervein patients with upper brachial plexus injury, showedsimilar gains in elbow flexion strength.

A-0344 Bipolar transfer of the pectoralis majormuscle for restoration of elbow flexion in 29 cases

Adeline Cambon-Binder1, Arnaud Walch2,Pierre-Sylvain Marcheix3 and Zoubir Belkheyar4

1Saint-Antoine Hospital, Paris, France2Edouard Herriot Hospital, Lyon, France3Dupuytren Hospital, Limoges, France4Clinique du Mont Louis, Paris, France

Objective: The aim of this study was to evaluate thefunctional outcomes of bipolar pedicled pectoralismajor (PM) transfer to restore elbow flexion. A tech-nical refinement was developed, allowing directdistal fixation on the biceps muscle and avoidanceof a tendon graft.Methods: We retrospectively reviewed 29 transfers in28 patients who ranged from 5 to 65 years of age(mean age of 31.2 years.). The loss of elbow flexionwas due to brachial plexus palsy for 24 patients,elbow flexors necrosis in four and poliomyelitis inone patient. The whole PM muscle was mobilizedand fixed proximally to the coracoid process.Intraoperative positioning and post-operative immo-bilization of the shoulder and the elbow flexed at 60�

SS74 Journal of Hand Surgery (Eur) 43(Supplement 2)

and 120�, respectively, allowed direct distal fixation ofthe muscle to the biceps brachii tendon. Outcomeevaluation included measurement of active elbowflexion range of motion, and elbow flexion strengthaccording to the MRC grading system and to themaximum weight sustained at the level of the wrist.Results: At the last follow-up (mean of 13 months,ranging from 4 to 37 months), 41% of the transfers(n¼ 12) recovered grade-4 elbow flexion strengthand were able to lift 2.2 kg on average (rangingfrom 0.5 to 5 kg). Fifty-two per cent of the patients(n¼ 15) recovered grade-3 strength, and 7% (n¼ 2)had a poor result (i.e. grade-2 elbow flexion). Themean active elbow flexion was 100� (ranging from30 to 150�) and the patients had 0 to 10� elbow flexioncontracture.Conclusions: Our results indicate that bipolar PMtransfer is a reliable and effective procedure torestore elbow flexion. Flexion of the shoulder andelbow allowed the transfer to reach the elbow foldand avoided the use of an interposition graft betweenthe distal PM and the biceps brachii tendon.

A-0348 Clinical and MRI evaluation of Kienbock’sdisease treated by ‘‘Camembert’’ radial osteotomy:Follow-up of minimum 5 years

Emmanuel J. Camus1,3 and Luc Van Overstraeten2,3

1SELARL Chirurgie de la main, Lesquin, France2HFSU, Tournai, Belgium3ULB, Bruxelles, Belgium

Objectives: In Kienbock’s disease, to avoid collapseof the lunate, radius shortening osteotomy is themost common treatment. Different osteotomieshave been proposed. Neutral shortening and radialclosing wedge are the most popular. The‘‘Camembert’’ osteotomy is a wedge osteotomy thatshortens the radius in front of the lunate, not in frontof the scaphoid. The aim is to unload the lunate byredirecting the compression stress of the grip forcestowards the scaphoid, in the hope that protectslunate from collapse. The authors reviewed a serieswith a minimum follow-up of 5 years.Methods: Fourteen wrists of thirteen patients havebeen operated between 2002 and 2012 by one opera-tor. Three patients were lost, and the series exposesthe results of 11 wrists on 10 patients: 6 men and 4women. The mean age is 40.6 years and the follow-up is 7 years.

In five cases of positive ulnar variance, an ulnarshortening osteotomy according to Sennwald wasused in addition to Camembert.

There were two patients Lichtman’s stage 1, fivestage 2, 4 stage 3A. MRI showed 1 case of oedema ofthe lunate and 10 cases of heterogenous lunates(oedemaþ necrosis).

Preoperatively, the flexion/extension arc was 95�,radial/ulnar tilt 38�, pronosupination 172�. Meangrasp was 13.8 kgF, pain on VAS 8.2, PRWE score82.3, and SANE score 26.6%.Results: All osteotomies healed within 3 months.Extension (þ9�), ulnar deviation (þ10�), grasp (þ15kgF), PRWE (�57), and SANE (þ53) improved signifi-cantly. Pronosupination decrease was not significant.

MRI aspect of the lunate improved 10 times on 11,and 4 lunates healed with normal homogenoussignal. Global results were excellent in 3 cases,good in 5, fair in 2, and bad in 1. The bad resultwas due to luno-capitate arthritis, not to lunate frac-ture or collapse.Discussion and Conclusions: Popular radial shorten-ing osteotomies give in 1/3 to 2/3 cases good clinicalresults. But in half cases, they don’t avoid lunatedegenerative changes. The goal of the camembertosteotomy is not to heal the lunate, but to protect itfrom fracture and collapse, and to maintain the bestshape as possible until it heals. This series showsfrequently good result with no worsening of thelunate shape. This osteotomy, by unloading thelunate and not scaphoid, seems efficient to protectthe lunate. Radiological and MRI aspect of the lunateimprove most of the cases. It can be used combinedwith ulnar shortening according to Sennwald whenulnar variance is neutral or positive. Our results onour 11 oldest cases are hopeful. We propose thisprocedure for Lichtman stages 1-2-3A if there is nocartilage nor ligaments lesions.

A-0358 New open and arthroscopic-assistedapproaches of the axillary nerve

Andres A. Maldonado, Bassem T. Elhassan, AllenT. Bishop, Alex Y. Shin and Robert J. Spinner1Department of Plastic, Hand and Reconstructive Surgery,BG Unfallklinik Frankfurt, Frankfurt, Germany2Department of Neurosurgery, Mayo Clinic, Rochester, MN,USA

Introduction: Previous studies have described a seg-ment of the axillary nerve (AN) that cannot be surgi-cally explored through standard open surgicalapproaches (blind zone). The aim of this study is toevaluate the feasibility of combining the standardposterior approach to the AN with the use of thearthroscope to visualize all segments of the AN anddetermine the AN length that can be seen through

FESSH Abstracts SS75

standard and extended anterior, axillary and poster-ior approaches.Materials and Methods: Ten fresh frozen shouldersin five adult human torsos were included in the study.A standard posterior approach was performed onfour shoulders and dry arthroscopy was performedthrough the surgical opening in an attempt to visua-lize all segments of the AN. A surgical clip wasapplied to the most proximal and anterior segmentsof the AN that could be visualized with the arthro-scope. A standard open deltopectoral approach wasthen performed to determine the exact location of thesurgical clip and its relation to the origin of the AN.Then, we attempted to explore the AN through threedifferent surgical approaches (each approach wasperformed in two shoulders): a standard andextended anterior, axillary and posterior approaches.Surgical clips were used to mark the AN length thatwas visualized through each approach.Results: Using the arthroscopic-assisted approach,all segments of the AN (including the blind zone)were visualized from the quadrilateral space totheir origin from the posterior cord in all four speci-mens. The surgical clip was found at an average 1 cm(range from 0.5 cm to 1.5 cm) from the origin of theAN from the posterior cord. Compared to the stan-dard approaches, the extended anterior, axillary andposterior approaches improved the visualization ofthe AN by 3.6, 1.5 and 2.8 cm, respectively.Conclusions: This cadaveric study shows that it isfeasible to visualize all segments of the AN (includingthe blind zone) using this novel arthroscopic-assistedapproach that combines the use of the standard pos-terior approach to the AN with dry arthroscopicexploration. Clinical studies are necessary to evalu-ate the utility of this novel approach. None of theseextended approaches independently was sufficient toexpose the entire course of the AN.

A-0359 Ultrasonography of the pretendinous cord inDupuytren’s disease: A pilot study to correlatemorphological patterns before treatment to clinicaloutcome after 2 years

Joakim Stromberg1,2, Petr Vanek3, Jan Friden1,2,4 andYlva Aurell3

1Centre for Advanced Reconstruction of Extremities,Sahlgrenska University Hospital, Molndal, Sweden2Department of Hand Surgery, Sahlgrenska UniversityHospital, Gothenburg, Sweden3Department of Radiology, Sahlgrenska UniversityHospital, Molndal, Sweden4Swiss Paraplegic Centre (SPZ), Nottwil, Switzerland

Objective: The morphology of the pretendinous cordin Dupuytren disease is poorly described in vivo, andespecially in respect to recurrence after treatment.This prospective study was designed to describe themorphology of Dupuytren cords by ultrasound beforetreatment and to correlate the ultrasonographiccharacteristics of these cords to clinical developmentafter treatment.Methods: Thirty-nine patients with a Dupuytren con-tracture of at least 20� in the metacarpophalangealjoint who were scheduled for minimally invasivetreatment in a randomized controlled study wereexamined. The position of the pretendinous cords inrelation to flexor tendons and neurovascular bundleswere categorized. The structure of the cords wasdescribed and characterized as nodular, fibrillary ormixed. The patients were randomized to treatmenteither by needle fasciotomy or collagenase (CCH)injection, and ultrasonography was again performedonce the cord had ruptured. After 2 years, thepatients were examined for recurrence of the con-tracture and presence of a pretendinous cord, andthese outcomes were correlated to the morphologyof the cord as described by ultrasound beforetreatment.Results: The structure of the cord was less organizedthan in the adjacent tendon. A majority of the patients(90%) had cords with both nodular and fibrillary com-ponents, and four patients (10%) had fibrillary cords.The position of the cord in relation to the neurovas-cular bundle and the flexor tendon was variable: in 28cases (72%), the cord was identified exclusively volarto the flexor tendons. In 11 cases (28%), the cord wasidentified in the same depth from the skin as theflexor tendon, crossing over from one side of thetendon to the other. In the transverse projection,the digital blood vessels were visualized in 16cases, whereas digital nerves could only be localizedin 3 fingers.

There was no significant difference between theneedle fasciotomy group and the collagenase groupin either rupture length or mobility gain in the treatedjoint. After 2 years, the clinical results were com-pared to the ultrasonographic findings before treat-ment. Two patients had recurrent contracture, andboth of these patients had cords with nodulesbefore treatment.Discussion: This study showed that the morphologyand position of the pretendinous cords in relation tothe flexor tendons can be well described by ultra-sound. Blood vessels and nerves were, however,more difficult to visualize. Only two of 39 patientshad a recurrent contracture after 2 years, and eventhough both had nodular cords before treatment, the

SS76 Journal of Hand Surgery (Eur) 43(Supplement 2)

study population proved to be to small to establish asignificant correlation.

A-0361 Microsurgical reconstruction after pan-plexus injury: Where is the optimal gracilis distaltendon attachment for elbow flexion?

Andres A. Maldonado, Santiago Romero-Brufau,Robert J. Spinner, Allen T. Bishop and Alex Y. Shin1Department of Plastic, Hand and Reconstructive Surgery,BG Unfallklinik Frankfurt, Frankfurt, Germany2Department of Neurosurgery, Mayo Clinic, Rochester, MN,USA

Introduction: Reconstruction after pan-plexus rootavulsions often includes microsurgical reconstruc-tion using a gracilis free functional muscle transfer(FFMT). For elbow flexion reconstruction, the FFMTdistal tendon is inserted into the biceps tendon ormore distally (i.e. flexor digitorum profundus [FDP]/flexor pollicis longus [FPL] tendons) for combinedelbow and finger flexion; the theoretical drawbackof the latter approach is weaker elbow flexion. Wesought to critically compare elbow flexion strengthwith a biceps tendon versus a FDP/FPL tendonattachment to determine which insertion pointresulted in better elbow flexion.Methods: Thirty-nine patients underwent FFMT witheither a biceps tendon or distal attachment. Thegroups were compared with respect to postoperativeelbow flexion strength, as well as preoperative andpostoperative DASH scores, range of motion, andother surgical and demographic characteristics. Abiomechanical analysis was performed simulatingdifferent tendon attachments to determine whichreconstruction resulted in optimal elbow flexionmechanics.Results: Distal tendon attachment was associatedwith M3 or M4 elbow flexion and greater range ofmotion compared to the biceps tendon attachment(p< 0.05). There were no statistically significantimprovements in DASH scores. Biomechanical ana-lysis demonstrated a 15–30% greater torque with thedistal tendon attachment and with a 10 cm and 15 cmfrom the elbow axis of rotation in the radius attach-ment compared to the biceps tendon.Conclusion: The FDP/FPL tendon attachment of thegracilis FFMT distal tendon was superior in achievingelbow flexion strength. Patients with only elbow flex-ion reconstruction may also benefit from a FDP/FPLtendon attachment or from a more distal attachmentto the radius.

A-0366 Proximal row carpectomy in the treatmentof wrist arthritis: Is it still a valid indication?Evaluation of clinical outcomes

Ana Bispo, Francisco Goncalves, Filipe Machado,Sofia Carvalho, Goncalo Lavareda and Joao NevesHospital Ortopedico Sant’Iago do Outao, Centro Hospitalarde Setubal, Portugal

Proximal row carpectomy (PRC) is an accepted sur-gical technique for the treatment of wrist degenera-tive arthritis. Despite of being a motion-sparingprocedure, patients frequently complain of residualpain and functional limitation.

This study aims to evaluate the clinical outcome ofthe patients with wrist degenerative arthritis treatedby PRC with a minimum of 6-month follow-up.

A total of 22 patients (14 men and 8 women) weretreated by PRC between 1992 and 2015 in our hospi-tal. Of them, 20 underwent a minimum of 6-monthfollow-up examination (two excluded: one died andone didn’t cooperate with the study). Clinical andradiological examinations were performed after aminimum of 6 months post-operatively. We evaluatedthe range of motion (ROM) of the wrist, grip strength,presence of resting pain and pain during physicalactivities and the patient’s satisfaction with the treat-ment. ROM was measured with handheld goniometerand grip strength was measured with dynamometerand compared with the opposite side. The pain inten-sity was graded according to the visual analoguescale (VAS) and DASH score was applied. By radiolo-gical examination, we assessed radiocapitate jointdegeneration and translation of the capitate bone inrelation to the lunate facet of the radius.

Twenty patients (90.9%) with a mean age of 61.2years (43–75 years) were evaluated with a meanfollow-up of 13.4 years (minimum of 6 months andmaximum of 23 years). In 10 patients, PRC was per-formed for SNAC or SLAC-wrist conditions. Otheretiologies were Kienbock disease (five cases), rheu-matoid arthritis (three cases), post-traumatic (threecases) and psoriatic arthritis (one case). Pain relief atrest and during physical activities was statisticallysignificant. At the follow-up examination, mostpatients (87%) reported an overall improvement.Pain with strenuous activity was reduced by 52%and resting by 87%. Improvement of ROM and gripstrength several months after operation have beenobserved. The flexion–extension ROM varied between60� and 90�, the radial deviation varied between 0�

and 15� and the ulnar deviation varied between 15�

and 35�. The average grip strength was 64.4% of theunaffected side. There was an improvement from preop DASH score of 75.0 (48.2 to 84.0) to a

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postoperative DASH score of 20.8 (11.2–28.0). In thisretrospective analysis of the functional postoperativeoutcome of PRC, all patients showed radiologicaldecreased of the radiocapitate articular space with-out functional impact.

As shown by our results as well as the publisheddata, PRC is an effective surgical procedure for thetreatment of wrist degenerative arthritis. Thisapproach is favoured by its technical simplicity andthe good functional outcomes, as shown by the main-tenance of wrist motion, satisfactory grip strengthand pain relief. We still favour PRC as a salvage pro-cedure in order to offer the patient some wristmotion, ensuring that there is no osteoarthritis overthe capitate and the lunate facet preoperatively.Despite having some functional limitation and pro-gression of the degeneration of the radiocapitatejoint, the patients are globally satisfied with surgicalresult, which is in accordance with previous studies.

A-0369 Pollicization in mirror hand

Mohammed Tahir Ansari and Swapnil SinghAll India Institute of Medical Sciences, New Delhi, India

Background: Thumb reconstruction with pollicizationin mirror hand is technically challenging proceduredue to its wide variation in anatomy and complexity.Mirror hand is rare entity to be deal with, even attertiary care centre. Proper pre-operative planningand meticulous surgical technique increase its suc-cessful outcome.Case report: Here we are representing 2.5 year oldmale with ulnar dimelia type 1 of left side with 2 ulnaand 8 fingers without thumb. Patient was planned forpollicization in our hand unit. Patient has active rangeof motion at elbow 0�–10� of flexion while at wrist20�–30� of flexion. After proper radiograph, DSAwas done to rule out any vascular anomaly.Operative technique: A decision was made to ampu-tate two radial most fingers while pollicizing thirdradial most finger. Following Ezaki incision, radialvessel for targeted finger followed from commonorigin to proximal 1 cm and ligated away from bifur-cation. Most radial syndactyly fingers were removedafter their vessels ligation and subperiosteal dissec-tion of metacarpal bones. Dorsal and palmar inter-ossei attached to respective lateral band. Distalphysis cut with knife and proximal metaphyseal cutat flare. Both end sutured with Ethibond 3.0 in flexedposition so that final position was extension, 45� ofabduction and 110� of pronation. The redundantthumb was removed in second stage and transversemetacarpal ligament was reconstructed. With this

approach, we will be able to give the patient a func-tional thumb and four fingers.Conclusion: Pollicization with other fingers amputa-tion in same sitting in patients with mirror hand givesacceptable cosmetic and functional results. Theelbow of suck patients remains an enigma still. Thecase is being presented in the conference to discussthe rarity of such entity and to discuss the advancesurgical planning to reconstruct the whole upperextremity.

A-0377 Donor site morbidity of vascularized bonegrafts from the medial femoral condyle

Victoria F. Struckmann1, Giuseppe Rusignuolo1,Ursula Trinler2, Ulrich Kneser2, Thomas Kremer3 andBerthold Bickert1

1Department of Hand-, Plastic and Reconstructive Surgery,BG Trauma Center Ludwigshafen, Germany2Laboratory for Clinical Movement Analysis – BG TraumaCenter Ludwigshafen, Germany3Department of Plastic Surgery and Hand Surgery, ClinicSt. Georg, Leipzig, Germany

Objective: The transplantation of vascularized bonegrafts from the medial femoral condyle is an estab-lished microsurgical procedure to improve bonehealing and restore vascularization of osseousdefects. To date, objective data concerning thedonor site morbidity are rare. We present the find-ings in 22 patients.Methods: From 2008 to 2016, a medial femoral con-dyle bone graft was raised in 33 patients for micro-vascular transplantation. In the follow-up study, thefunctional state of the donor site was analyzed by theLower Extremity Functional Scale (LEFS), the OAKscore of the orthopaedic knee working group of theswiss orthopaedic society, and a 3-D gait analysis(Bertec, FP 4060-08-200). Scar quality was assessedby the Vancouver Scar Scale (VSS). The Visual AnalogScale was used to ask for postoperative and toassess actual pain.Results: Of the 33 patients, 22 (67%) consented toparticipate in this study (4 female and 18 malepatients). The indications were eight scaphoid non-unions, two metacarpal and one digital bone defectas well as nine avascular necrosis of the talus, onebone defect of the tibial pilon and one of the contral-ateral distal femur. Mean follow-up time was 35.8(12–98) months and mean age was 30 (16–52)years. Mean in-patient time was 11.1� 7.7 days.One minor surgical revision was performed at thedonor site for hematoma. Mean LEFS score was74.9� 9.5 and OAK score was 92.4� 9.6. Scar quality

SS78 Journal of Hand Surgery (Eur) 43(Supplement 2)

was rated to average 1.8� 1.3 on VSS.Retrospectively, the postoperative pain was esti-mated by the patient as 3.2� 2.8 on VAS (resting)and 4.9� 3.1 on activity. At follow-up examination,pain was adjusted as 0.1� 0.2 (resting) and 0.6� 1.4(activity) on VAS. The 3-D gait-analysis showed reg-ular gait cycles in all 22 patients.Conclusion: Transplantation of a medial femoral con-dyle bone graft is associated with a low donor sitemorbidity. In the midterm follow-up, the functionalityof the knee joint and the gait were almost unim-paired. Donor site morbidity can be considered asbeing of minor concern in the decision-making for afree microvascular medial femoral condyle bonegraft.

A-0381 Reconstruction of the spinal accessorynerve with selective fascicular nerve transfer ofthe upper trunk

Johannes A. Mayer1, Laura A. Hruby1,Stefan Salminger1,2, Gerd Bodner3 andOskar C. Aszmann1,2

1Christian Doppler Laboratory for Restoration of ExtremityFunction, Medical University of Vienna, Austria2Division of Plastic and Reconstructive Surgery,Department of Surgery, Medical University of Vienna,Austria3Private Ultrasound Center Vienna (PUC), Austria

Objective: Spinal accessory nerve palsy is frequentlycaused by iatrogenic damage during neck surgery inthe posterior triangle of the neck. Due to late pre-sentation, treatment often necessitates nerve grafts,which often results in a poor outcome of trapeziusfunction, due to long regeneration distances. Here wereport of a distal nerve transfer using fascicles of theupper trunk related to axillary nerve function forreinnervation of the trapezius muscle.Methods: In this study, five cases are presentedwhere accessory nerve lesions were repaired usingselective fascicular nerve transfers from the uppertrunk of the brachial plexus.

Outcomes were assessed at 18� 8 months aftersurgery, documenting active and passive range ofmotion as well as pain levels using the visual analo-gue scale (VAS).Results: All five patients regained good to excellenttrapezius function (four patients M5, one patient M4).The AROM of shoulder abduction improved from55� � 18 before to 151� � 37� after nerve reconstruc-tion. In all patients, unrestricted shoulder arm move-ment was restored with loss of scapular wingingwhen abducting the arm. Pain levels decreased

from 6.8 to 0.8 on the visual analogue scale (VAS)and subsided in four of the five patients.Conclusions: Restoration of accessory nerve functionwith selective fascicle transfers related to axillarynerve function from the upper trunk of the brachialplexus is a good and intuitive option for patients whodo not qualify for primary nerve repair or presentwith a spontaneous idiopathic palsy. This concept cir-cumvents the problem of long regeneration distanceswith direct nerve repair and has the advantage ofcognitive proximity to the target function of shouldermovement.

A-0384 HaptiVisT: The concept of a haptic and visualassisted training simulator for complex bonedrilling in the minimally invasive hand surgery

Johannes Maier1, Michaela Huber2, Uwe Katzky3,Jerome Perret4, Thomas Wittenberg5, Rebecca Wohl2

and Christoph Palm1,6

1Regensburg Medical Image Computing (ReMIC),Ostbayerische Technische Hochschule Regensburg (OTHRegensburg), Germany2Department of Trauma Surgery & Emergency Department,University Hospital Regensburg, Germany3szenaris GmbH, Bremen, Germany4Haption GmbH, Aachen, Germany5 Fraunhofer Institute for Integrated Circuits IIS, Erlangen,Germany6Regensburg Center of Biomedical Engineering (RCBE),OTH Regensburg and Regensburg University, Germany

Objective: In the minimally invasive hand surgery,surgeons perform complex bone drilling in the oper-ating room to fix tiny fractures with K-wires almostwithout a sight and without hurting any risk struc-ture. In contrast to time-consuming and unrealistictraining methods, we will offer surgeons an innova-tive opportunity to train their theoretical and practicalskills by connecting virtual reality elements andhaptic man-machine interaction to a compact hapticand visual-assisted training simulation system(HaptiVisT).Methods: To track the position of a drill in real spaceand to transfer its position to the computer, a hapticdevice with force feedback is used. Through addingan algorithmic calculated force feedback, virtualobjects, which are only visible on the computerscreen, become tactile. Preprocessed and segmen-ted CT data of a human hand with its risk structuresas well as the driller and K-wire model are visualizedin a virtual three-dimensional (3D) space via trans-mitting surface and volume rendering data to anautostereoscopic single-user 3D-monitor to generatea 3D-depth effect. In contrast to common

FESSH Abstracts SS79

3D-visualization techniques, no glasses are needed,because of an eye tracking bar mounted on top of themonitor. An additional touchscreen monitor providesa graphical user interface (GUI) to choose differenttools, alter the rotation speed and create an X-rayimage for checking the actual K-wire position. For abimanual haptic and feeling of important markerpoints on the hand, a haptic arm phantom will be3D-printed by using rapid prototyping. For detectingthe transfer and rotation of the haptic phantom, spe-cial markers will be attached and tracked by astereoscopic real-time tracking camera. Hence thevisualization on the monitor will follow the recordedmovement.Results: The software for the training system is devel-oped within chai3d (www.chai3d.org), an open sourceCþþ library for computer haptics. To create a realisticdrilling simulation, a collision detection between thedrill model and the human bones is essential. Theused collision detection of the chai3d haptic points[5] is combined with the bullet physics library(www.bulletphysics.org) to firstly enable an interactionbetween the K-wire tip and single voxels of the bonevolume and secondly to simulate collisions of rigidbodies and thirdly to calculate their resulting forces.Therefore, during the drilling process, it is possible tointeract and remove several voxels (volume pixels)from bone objects. The drilling process itself is sepa-rated in several drilling modes to emulate the correctdrilling behavior during the intervention.Conclusion: Our training system for complex bonedrilling in the minimally invasive hand surgeryshould close the gap to existing training systemsand give surgeons the possibility to train their skillsin preparation of real interventions. The software ofthe drilling process with its collision detection and alltechnical relevant components (haptic device, hapticphantom, 3D-monitor, tracking camera) are com-bined into a compact overall system. The effective-ness and resulting improved ability of a surgeonmust be carefully evaluated.

A-0388 Implant-related joint infections of the hand

Rahel Meier1, Esther Voegelin1 and Parham Sendi21Department of Plastic, Institute of Infectious Diseases,Bern University Hospital and University of Bern,Switzerland2Department of Hand Surgery, Institute of InfectiousDiseases, Bern University Hospital and University of Bern,Switzerland

Objective: Successful management of implant-related infections (IRI) requires combined surgical

and antimicrobial therapy. There are few publisheddata and the management is not standardized.Methods: We reviewed charts of patients with IRI thatwere treated at the Inselspital from 2006 to 2016.Infection was grouped in osteosynthesis-relatedinfection (ORI) and arthroplasty-related infection(ARI). Definition of IRI required criteria is asdescribed previously (Open Forum Infect Dis (2017)4(2): ofx058.). The interval from device implantationto symptoms was used to categorize infection in early(4 weeks) and late (>4 weeks). Pathogenesis wascategorized in exogenous and haematogenous.Results: We identified 25 patients with 28 implant-related joint infections. Thirteen (52%) were men,and the median age was 51 years (IQR 41–65). ORIaccounted for 14 (56%) and ARI for 11 (44%) of theepisodes. The majority of episodes were late (21,82%). There were 17 (68%) exogenous and 8 (32%)haematogenous categorized infections. Most ORIswere exogenous (13; 93%), 64% of ARI were haema-togenous. In ORI, the third and fourth digits (each 5;32%) and the DIP joint (12; 75%) were most commonlyaffected. In 7 (59%) of the ARI, a silicon arthroplasty ofa small joint, in 4 (33%) patients a total arthroplasty ofthe wrist and in one (8%) patient there was an ulnarhead arthroplasty involved. In 92% of the cases, apathogen could be identified. Staphylococcus aureuswas the most commonly found species (12, 48%) fol-lowed by Streptococcus spp. (5, 20%). The infectionwas successfully treated with 1 intervention in 17(68%) episodes; in 7 (28%) episodes more than 1 inter-vention was required. In ORI, all implants wereremoved, whereas in ARI, 5 (41%) implants wereretained. The median duration of antibiotic treatmentwas 42 (IQR 34–72) days for both ORI and ARI. Onepatient was treated with antibiotic suppressive ther-apy. Twenty-two (88%) episodes were cured with 1 or2 interventions and 42 (IQR 34–72) days of antibiotics.Ten (91%) episodes with ARI showed resolution, five(45%) with remaining implant.Conclusion: Most episodes were categorized as lateinfections with an exogenous pathogenesis andcaused by S. aureus. Eighty-eight percent of episodeswere cured with one or two surgical interventionsand 42-day duration of antibiotics.

A-0397 Anatomy and treatment of thenar musclesin primary surgery for radial polydactyly

H. L. Stark, J. Maraka, S. Stevenson and B. CrowleyRoyal Victoria Infirmary, Newcastle-upon-Tyne, UK

Objective: Radial polydactyly encompasses a diversegroup of congenital anomalies. The variable and

SS80 Journal of Hand Surgery (Eur) 43(Supplement 2)

often complex anatomy needs to be recognized bythose carrying out reconstructive surgery. Thereare limited data within the literature regardingthenar anatomy in radial polydactyly. Our review con-tributes to the current knowledge of thenar anatomy.Method: A review of prospectively collected, opera-tive anatomical data in patients undergoing primarycorrection of radial polydactyly.Results: Thenar muscle anatomy and its treatmentwere recorded systematically in 44 thumbs duringprimary surgery for radial polydactyly. Wasselgroups II–VII were represented. Abductor pollicisbrevis muscle inserted into the radial duplicatein 18, ulnar duplicate in 11 and both duplicates innine. There were six Wassel group II thumbs inwhich the thenar muscles inserted normally, proxi-mal to the polydactyly. Thenar muscles were found tohave variable insertions anywhere from the metacar-pal base (Wassel IV, V and VII) to the distal phalanx(Wassel III n¼ 1) and flexor sheath of dominant ulnarduplicate. Anomalous musculature, anomalous ten-dons and hypoplastic muscles were more prevalentin proximal levels of duplication and in the triphalan-geal cohort. The commonest procedure undertakenwas elevation of the thenar muscles with a periostealflap and transfer from radial to ulnar duplicate.Division of anomalous tendons of abductor pollicisbrevis and adductor pollicis was also required toremove deforming forces.Conclusion: Our findings demonstrate the variabilityin thenar muscle anatomy in radial polydactyly.Variability in insertion site, anomalous muscles andtendons were observed. We advocate careful anato-mical exploration of thenar muscles at the time ofprimary surgery to guide treatment.

A-0399 Elbow flexors spasticity: Combined musclelengthening and hyperselective neurectomy

Paolo Panciera1, Daniele Gianolla2 andCaroline Leclercq3

1Ospedale Villa Salus, Venezia-Mestre, Italy2Ospedale San Giacomo, Castelfranco Veneto (Treviso),Italy3Institut De La Main, Paris, France

Objective: Surgical treatment of the spastic elbowtypically involves muscle lengthening when musclecontracture is present. It has been our experiencethat early satisfactory results often deteriorate aftera few months when spasticity of the involved mus-cle(s) is severe.

The purpose of this prospective study was toassess the results of combining hyperselective

neurectomy (HSN) with the muscular release inspastic elbows presenting with muscle contractureand severe spasticity.Methods: Over a 5-year period (2012–2017), 16patients (16 elbows) were treated by tendons length-ening associated with HSN. Spasticity was assessedby the Ashworth and the Tardieu scales. Evaluationincluded active and passive ranges of movement(AROM and PROM), elbow muscles strength (MRCscale), functional goal, House scale and patient/care-giver satisfaction (VAS scale).

Criteria of inclusion were elbow flexion contracturegreater than 20� with severe spasticity (Ashworth� 2)Results: The study involved 12 male and 4 femalespastic patients, 7 of which suffered from stroke, 6from CP, and 3 from traumatic brain injury. Mean ageat brain lesion was 24.6 years (0–71), and mean ageat surgery was 39 years (6–74). Average delay to sur-gery was 14.6 years (3–32). Four patients had noactive movement.

Hyperselective neurectomy involved the musculo-cutaneous nerve in 15/16 patients and the motorbranch of the radial nerve to the brachioradialis in7/16. Muscle lengthening involved the biceps in allcases, the brachialis in 14/16 and the brachioradialisin 3/16. During the same operative session, six otherprocedures were associated: HSN of the wrist flexors(1), FCR and FCU lengthening (2), PT release (2), FDS,FDP and FPL lengthening (1).

One patient was lost to follow-up. The averagefollow-up for the remaining 15 patients was 17months. Spontaneous posture of the elbow improvedfrom 137� to 67�. The AROM improved by 23�, whilethe AROM midpoint gain was 36�; the PROM andPROM midpoint gain was 28� and 26.6�; there wasvirtually no loss of strength of the elbow flexors(4.03 to 3.96), with a significant decrease of spasticity(Ashworth from 2.67 to 0.56; Tardieu V3 from 97� to43�). There were no complications. The preoperativegoal was achieved in all patients but 1 (nursingincomplete). The average House classificationimproved from 0.83 to 1.70

The average satisfaction (VAS) was rated 9.2 bypatients and 9.3 by their caregivers.Conclusions: To the best of our knowledge, this is thefirst report of the association of tendon lengtheningand HSN in the spastic upper limb.

Our results show that when severe spasticity isassociated with elbow flexors contracture, HSN, byacting on the spastic component of the deformity,contributes to the improvement of the tendon length-ening procedures, with a lasting effect at 17 monthsfollow-up. A prospective comparison betweenlengthening alone and lengtheningþHSN would

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theoretically be needed in order to reinforce thesefindings.

A-0403 Predicting clinical outcome after surgicaltreatment in patients with carpal tunnel syndrome

M. C. Jansen1,3, S. Evers1,3, H. P. Slijper1,2, K. P.de Haas2, X. Smit1,2, S. E. Hovius1,2 and R. W. Selles1,3

1Department of Plastic, Reconstructive and Hand Surgery,Erasmus Medical Center, Rotterdam, The Netherlands2Xpert Clinic, Rotterdam, The Netherlands3Department of Rehabilitation Medicine, Erasmus MedicalCenter, Rotterdam, The Netherlands

Purpose: Carpal tunnel release (CTR) is typicallyoffered to patients with moderate electrophysiologi-cal abnormalities when night splints no longer pre-vent waking with numbness, and preferably beforethere is any static numbness, weakness, or atrophy.The ability to predict the amount of symptom reliefafter CTR could be beneficial for managing patientexpectations and therefore improve treatment satis-faction. Therefore, the aim of this study is to identifypredictors for the outcome of CTR and to determinetheir contribution in predicting outcome at sixmonths postoperatively.Methods: A total of 1049 patients that requested CTRbetween 2011 and 2015 at one of eleven Xpert Clinicsin the Netherlands were asked to complete onlinequestionnaires at intake, 3 months and 6 monthspostoperatively. Patient demographics, comorbiditiesand baseline scores were considered potential pre-dictors for the effect of surgery on the Boston CarpalTunnel Questionnaire (BCTQ) score and its domains.Results: A low score on the BCTQ at intake, a co-diagnosis of a trigger finger, ulnar nerve neuropathy,carpometacarpal-1 arthrosis, or instability of thewrist were associated with a smaller improvementin the BCTQ domains after a CTR at 6 months post-operatively and accounted for 35–42% of the variancein our multivariable regression models.Conclusions: Results of our study can be used as atool to pre-operatively manage patient expectation onsymptom relief from surgical treatment. Since only arelatively small (approximately 40%) of the variancecan be explained using the present variables, we sug-gest that future research on predictive factors forsymptom relief after CTR show focus on other fac-tors, including non-physical factors such as mentalhealth, pre-operative expectations and diseaseawareness.Type of study: This prognostic study is a retrospec-tive cohort study which can be classified as a 2B levelof evidence.

A-0405 Item reduction of the Boston Carpal TunnelQuestionnaire using decision tree modelling

M. C. Jansen1,3, M. J. W. van der Oest1,3, H. P. Slijper1,2,J. T. Porsius1,2,3 and R. W. Selles1,3

1Department of Plastic, Reconstructive and Hand Surgery,Erasmus MC, Rotterdam, The Netherlands2Xpert Clinic, Rotterdam, The Netherlands3Department of Rehabilitation Medicine, Erasmus MC,Rotterdam, The Netherlands

Background: The patient experience of disease isbecoming more important in both clinical practiceand research. A widely used patient-reported out-come measure (PROM) to assess the severity ofcarpal tunnel syndrome (CTS) is the Boston CarpalTunnel Questionnaire (BCTQ). While measuringPROMs could improve care, lengthy questionnairescan be burdensome for patients. Therefore, the aimof this study is to reduce questionnaire length of theBCTQ by using the �2 automatic interaction detection(CHAID) algorithm to produce a decision tree versionof the BCTQ while maintaining a minimum loss ofinformation.Method: For this study, all BCTQs that were com-pleted as a part of routine outcome measurementbetween January 2012 and September 2016 bypatients who were treated for CTS at one of theclinics of Xpert Clinic were used for the analyses.Completed questionnaires were randomly dividedinto a development and a validation data set in athree-to-one ratio. Optimization of the CHAID algo-rithm was performed in the development data set tofind the best parameters for the development of thedecision tree version of the BCTQ (DT-BCTQ). The ICCwas calculated between the original BCTQ scoresand the predicted (sub)scores by the DT-BCTQ inthe validation data set. Bland–Altman plots weremade to analyse the agreement between the BCTQand the DT-BCTQ.Results: By using 10,055 completed questionnaires,we were able to develop a DT-BCTQ that reduced thenumber of questions needed to ask a patient from 11to maximally 3 for the symptom severity scale (SSS)domain and from 8 to maximally 3 for the functionalstatus scale(FSS) domain. The ICC between the ori-ginal BCTQ and the DT-BCTQ was 0.94. The meandifference between the BCTQ and the DT-BCTQ forthe SSS was 0.05 (CI¼�0.48, 0.57), 0.02 (CI¼�0.45,0.49) for the FSS and 0.04 (CI¼�0.31, 0.39) for thetotal BCTQ score.Conclusion: By creating the DT-BCTQ, we success-fully reduced the amount of questions needed to aska patient from 18 to a maximum of 6 questions whenadministering the BCTQ. This DT-BCTQ might reduce

SS82 Journal of Hand Surgery (Eur) 43(Supplement 2)

patient burden by shortening answer time and couldtherefore increase response rate when used for rou-tine outcome measurement. Further research shouldfocus on the clinical implementation of the DT-BCTQand the experiences of patients with the electronicDT-BCTQ. This way, the collection of data in clinicalpractice and CTS research by using the DT-BCTQ canbe optimized.

A-0408 Characteristics of radiocarpal dislocationsat a level 1 trauma center: A 9-year review

James Paul Hovis, Alexandria L. Case,Raymond A. Pensy, W. A. Eglseder, Ebrahim Paryaviand Joshua M. AbzugUniversity of Maryland School of Medicine, Baltimore,Maryland, USA

Objective: Radiocarpal dislocations are uncommonand only reported in the literature in case reportsand small retrospective studies. The purpose of thisstudy was to investigate the overall incidence andvarious patterns associated with radiocarpal disloca-tions at a high-volume level 1 trauma center.Methods: A retrospective review was performed ofall patients presenting to a level 1 trauma centerover a 9-year period to identify those with radiocarpaldislocations. Patients were identified utilizing thetrauma registry to isolate ICD-9 codes specific forradiocarpal dislocation. Factors assessed forincluded incidence, injury mechanism, associatedinjuries, mortality, Injury Severity Score (ISS), lengthof hospital stay (LOS), treatment, complications, andneed for subsequent procedures. Peri-lunate andlunate dislocations were excluded.Results: Twenty patients were identified, with anaverage age of 39.5 years. Eighty percent of theradiocarpal dislocations identified were closed inju-ries. Eighty-five percent of these radiocarpal disloca-tions (17/20) had high-energy mechanisms, such asmotor vehicle or motorcycle collisions. Concurrentinjuries with radiocarpal dislocations included ipsi-lateral upper extremity fractures or dislocations,high-energy lower extremity long bone fractures,neurovascular trauma, and tendon injuries aboutthe hand/wrist. There were no associated mortalities.Complications occurred following surgical interven-tion in 45% of the patients, primarily the inability toinitially close the surgical wounds (44%, 4/9). Returnto the operating room was required for 55% (27%,11/20) of the patients, most often for removal ofhardware (55%, 6/11), wound closure (36%, 4/11) orpartial or complete wrist fusion (27%, 3/11). Both ISSand LOS were lower for closed dislocations (ISS:

15.6; LOS: 7.6 days) in comparison to open disloca-tions (ISS: 26.5; LOS: 15 days). Radiocarpal disloca-tions with concomitant wrist fractures increased thechance of lengthened hospitalization when comparedto purely ligamentous injuries. There was no differ-ence between the ISS of dislocations with fractureversus those with only ligamentous involvement(p¼ 0.91).Conclusions: Radiocarpal dislocations can be char-acterized as high-energy mechanism injuries, fre-quently involving concomitant visceral or long bonetrauma, and more often seen in males.Neurovascular and bony/soft tissue wrist injuries,especially distal radioulnar joint injuries can be asso-ciated. ISS and LOS are variable and do not appear tohave any significant relationships to injury character-istics. Infection, distal radioulnar joint instability,inability to primarily close surgical wounds, andneed for removal of hardware were observed in ourseries and can guide providers in setting expecta-tions for these patients.

A-0412 TRIGGER trial

Anita Dijksterhuis1,2, Matthew Gardiner3,Jeremy Rodrigues3, Richard Pinder4, Jan Debeij5,Zaf Naqui6, Henk Coert2, Abhilash Jain3 andBrigitte van der Heijden1

1Jeroen Bosch Hospital, ‘s-Hertogenbosch, TheNetherlands2UMC Utrecht, Utrecht, The Netherlands3University of Oxford, Oxford, The Netherlands4Hull & East Yorkshire Hospitals NHS Trust, Hull, UK5Erasmus MC, Rotterdam, The Netherlands6Salford Royal NHS Foundation Trust, Salford, UK

Objective: TRIGGER is the first international, multi-center, multidisciplinary RCT on the management ofa very common hand condition: trigger fingers. Theprimary objective of TRIGGER is to compare the effectof steroid injections and surgery in the managementof trigger fingers in adults – the top research priorityin the BSSH guidelines.Methods: TRIGGER is being executed in severalphases: (1) clinician survey; (2) patient and partici-pant involvement (PPI); (3) pilot RCT; (4) final RCT;and (5) guideline revision. This abstract describesresults from the first two workstreams.

A bespoke electronic clinician survey comprisingbranching logic was developed and applied to rele-vant groups (general surgeons, orthopaedic sur-geons, plastic surgeons, rheumatologists andgeneral practitioners) using the methods previouslydeveloped by the RSTN to support high completion

FESSH Abstracts SS83

rates. The survey items explored the current treat-ment of trigger fingers, patient pathways and clini-cian preferences. The information from the surveyand PPI will be used to refine the RCT protocol andto support trial funding applications.Results: The clinician survey was posed to profes-sionals from over 80 hand centres in the UnitedKingdom and the Netherlands. The results demon-strated variation in patient pathways, referral strat-egy, preferred treatment, operation technique, typeof injection and thoughts on specific patient groups(i.e. diabetes and rheumatoid arthritis). Based on therecent BSSH guideline, this variation is not based onhigh quality evidence.

The provisional RCT design will compare steroidinjection to surgery for the treatment of adults withtrigger fingers with follow-up of 1 year. TRIGGER isvery pragmatic and clinicians may use their own pre-ferred type of injection and operating technique. Theprimary outcome is resolution of triggering.Secondary outcomes are level of pain, hand function(PROM), costs and complications. The scale of thestudy will make it possible to run several subgroupanalyses: type of surgery, type of injection, thumbversus long digits, diabetes and rheumatoid arthritis.Conclusions: The clinician survey shows trigger fin-gers are managed very different between doctors inboth the United Kingdom and the Netherlands. Thisreinforces the need for an improved evidence base toinform guidelines on trigger finger management,which the design of TRIGGER should make possible.

A-0413 Distal radius non union: A challengingproblem

Kebrle Radek1, Alena Schmoranzova1 andVodicka Zdenek2

1UPCHR Vysoke nad Jizerou, Czech Republic2Ortopedicke oddeleni, Nemocnice Ceske Budejovice,Czech Republic

Introduction: Distal radius nonunion is an extremelyrare complication of distal radius fractures (DRF).Etiology of nonunion is not well understood, althoughmost nonunions are the result of open and infectedDRFs. Anamnesis of the nonunion is mostly long(from 12 months to 15 years) with frequent softtissue complications including CRPS, nerve entrap-ment and tendon adhesions or ruptures. Most of thecases have multiple surgical procedures foregoingbefore definitive treatment. Due to the great bonecomminution, osteomyelitis, DRUJ derangementand soft tissue adhesions, treatment of distal radiusnonunion is a challenging problem. Distal radius

reconstruction and salvage procedure are maintreatment modalities. The purpose of this study wasto evaluate results of 14 cases treated with specialattention to heal distal radius and realign DRUJ andlongitudinal stability of the forearm bones.Patients and Methods: We reviewed 14 cases ofdistal radius nonunions treated between 2003 and2017. Ten cases were treated by radius nonuniontreatment and ‘‘anatomical’’ DRUJ reconstructionvia concomitant massive ulnar shortening. In fourcases, salvage procedures were performed. Theyconsisted of two DRUJ arthroplasties, one wristfusion and one bone forearm. All ulnar abreviationswere from 5 mm to 15 mm. In three cases, additionalsoft tissue reconstructions followed after bony heal-ing. Pre and postop X-rays, CT scans, concomitantsoft tissue pathologies, previous medical history,range of motion and pain scores were studied in allcases. The functional results were evaluated byDASH.Results: All radius nonunions healed. In 12 cases,radiocarpal motion was preserved, and forearm rota-tion was restored to 80% of contralateral side in 13.Pain score and DASH decreased significantly, gripstrength increased, and visual deformity hasimproved to close to normal alignment. Althoughforearm was shortened at the end of treatment com-pared to contralateral side, longitudinal stability waspreserved in 10 cases where ‘‘anatomical recon-struction’’ was pursued by ulnar shortening as addi-tional procedure to nonunion treatment. X-rays at theend of treatment were not anatomical and showedsome degenerative changes in all segments of wristjoint but no signs of clinical instability or pain in loadwere present in 10 cases. In two cases, signs ofradio-ulnar instability were present having no influ-ence on forearm function.Discussion: Most distal radius nonunions are mas-sive bony deformities with DRUJ derangement andsoft tissue adhesions. Size of distal fragment issmall. The aim of nonunion treatment is healing theradius, realigning forearm stability, reconstruction ofanatomy and improving function of the forearm. Thismay be gained by concomitant radius reconstructionand ulnar shortening. Due to the degree of radiusmalalignment and soft tissue scarring, ulnar short-ening ranges from 5 mm to 15 mm. Forearm anatomyis then restored. In our series, no problem with heal-ing of ulnar osteotomy appeared and forearm stabi-lity was restored in 9 of 10 cases of anatomicalreconstruction and 2 cases of DRUJ arthroplasty.

SS84 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0416 Short to intermediate results of the Motectotal wrist arthroplasty

Edwin Ooms1, Duncan McGuire2, Tim Sluis-Cremer2

and Michael Solomons2

1Centre for Orthopaedic Surgery OCON, Hand and Wristunit, Hengelo, the Netherlands2Martin Singer Hand Unit, Groote Schuur Hospital,University of Cape Town, South Africa

Objective: Degenerative conditions of the wrist jointresult in pain and mechanical dysfunction. The role oftotal wrist arthroplasty in the management of degen-erative wrist conditions is still being defined. Thereare many different implant designs available for usein wrist replacement surgery. The Motec Wrist uses aball and socket type of articulation. Few reports onperformance of this prosthesis are available. Ourgoal was to evaluate the clinical and radiological out-come of this type of wrist arthroplasty.Methods: We performed a retrospective review of 16consecutive wrists that underwent total wrist arthro-plasty with the Motec prosthesis (SwemacOrthopaedics AB, Sweden) between 2011 and 2016.Patients were assessed for pain (VAS) and function(ROM, Quick Disability of the Arm Shoulder and Hand(QuickDASH) and Patient-Rated Wrist Evaluation(PRWE). Complications and revision surgery werenoted. Standardized radiographs were taken toassess osteolysis, loosening, and subsidence. Thedifference between the optimal center of rotation(COR) of the wrist and the center of rotation of theimplanted prosthesis was determined, since webelieve that failure to restore the optimal COR ofthe wrist negatively contributes to performance ofthe prosthesis.Results: The Motec prosthesis was implanted in 16wrists (15 patients, 10F/6M, 11R/5L). Mean age was55.6 years (39–71). Rheumatoid arthritis was themost common indication for surgery (10). Other indi-cations included SNAC (2) and SLAC (1) wrist, mal-united distal radius fracture (1), dysplasia (1), andKienbocks disease (1). Mean follow-up was 28months (5–55). One prosthesis had a single compo-nent revision due to impingement after 6 months. Todate, one prosthesis has shown distal componentloosening but the patient is asymptomatic and hasnot been revised. There have been no cases ofinstability, dislocation or implant breakage.

The COR of the prosthesis and measured devia-tions of the optimal COR of the wrist showed differ-ences on the X-axis (radio-ulnar) of 0.1–5.7 mm. Forthe Y-axis (proximal–distal). differences were 0.3–13 mm.

QuickDASH scores show a mean of 24 (range 0–68). Mean for the PRWE is 30 (range 0–76) and for theVAS 2 (range 0–8).

Mean flexion of the wrists is 42�and extension 38�,with a mean arc of motion of 80�. Mean radial andulnar deviation are 10 and 15�, respectively, with amean arc of motion of 25�. One of the 16 wristsshowed an ROM that does not meet the minimumcriteria for normal ADL.

Overall, two distinct groups could be defined: onegroup of 11 wrists that had excellent functional out-come in DASH and PRWE scores and 1 group of 4wrists that underperformed.

The last group showed greatest differencesbetween optimal COR and COR of the prosthesis.Conclusion: Fair to excellent short to intermediateterm results were achieved using the Motec wristarthroplasty in a mainly rheumatoid arthritis groupof patients. The suggestion that re-establishing thecenter of rotation coincides with a good outcome isconfirmed in this study.

A-0417 The effect of wrist position on tendon loadsfollowing pulley sectioning and operativereconstruction

Mohammad Haddara1,2, Brett Byers2, Louis Ferreira1,2

and Nina Suh2

1Department of Biomedical Engineering, University ofWestern Ontario, London, ON, Canada2RothjMcFarlane Hand and Upper Limb Centre, St.Joseph’s Hospital, London, ON, Canada

Objective: Post-operative rehabilitation after surgicalreconstruction following pulley rupture is vital andmust balance potential rupture of the pulley recon-struction due to aggressive therapy from adhesionformation due to overly cautious protocols. The pur-pose of this study is to identify the optimal wrist posi-tion required for rehabilitation followingreconstruction using tendon load as a metric forstrain at the pulleys.Methods: Fourteen digits comprised of the index,long, and ring fingers were tested from five cadavericspecimens on a validated novel in vitro finger motionsimulator devised to actively achieve full finger flex-ion and extension. Servo-motors were used to gen-erate motion through the tendons under load orposition control using a closed-loop feedbacksystem. The simulator is designed to measure andrecord tendon forces, joint ROM, and tendon excur-sion. FDP loads were measured sequentially withnative intact pulleys, A2 and A4 pulleys sectioned,and finally with reconstructed A2 and A4 flexor

FESSH Abstracts SS85

tendon pulleys. Each pulley condition was tested inwrist neutral, and 30� of wrist flexion and extension.Using the simulator to measure FDP tendon load, theeffects of wrist position on sectioned and recon-structed A2 and A4 pulleys were analyzed using a3-way repeated-measures ANOVA.Results: With the wrist in neutral, FDP tendon loadswere 8.5 N, 6.2 N, and 7.8 N with pulleys intact, sec-tioned, and reconstructed, respectively. With a flexedwrist, the loads were 8.5 N, 4.7 N, and 5.4 N. Whenthe wrist was extended, the loads were 8.7 N, 5.2 N,and 6.7 N. With pulleys reconstructed, the wrist posi-tion had a significant effect on tendon load(p¼ 0.030). The flexed wrist position resulted in a31% reduction of FDP load compared to the neutralwrist position (p¼ 0.010). Wrist extension also pro-duced an apparent reduction, though not statisticallysignificant.Conclusions: Sectioning of the A2 and A4 pulleysresulted in a significant reduction in FDP tendonload as compared to the intact state. Subsequentreconstruction, however, restored loads to withinno significant difference of the intact state, whichsupports the decision to reconstruct. Placing thewrist in 30� flexion resulted in a reduction oftendon load after reconstruction. These results maysuggest that rehabilitation of surgically recon-structed flexor tendon pulleys should be carried outwith the wrist flexed in order to reduce strain onpulley reconstructions.

A-0420 Limitations of fixation with single volarlocking plates in marginal fractures of the distalradius

Hidemasa Yoneda, Shigeru Kurimoto,Katsuyuki Iwatsuki, Michiro Yamamoto,Masahiro Tatebe and Hitoshi HirataDepartment of Hand Surgery, Nagoya University, Nagoya,Japan

Objective: In marginal fractures of the distal radius,osteosynthesis of the lunate fossa fragment (LF) is animportant process to prevent postoperative subluxa-tion of the wrist joint, but the fragment size that canbe fixed by volar locking plate (VLP) alone has yet tobe determined. In this study, we used three-dimen-sional computer-aided design (3D-CAD) to demon-strate the limitation of fixation by a single VLP formarginal fractures with different shapes.Methods: We made seven bone models with differentmorphologies. To specify each model, the promi-nence of the volar rim in the sagittal plane was digi-talized and designated the volar offset (VO). Using a

3D scanner, three locking plates with screwsmounted were scanned: Biomet DVR (plate D),Acumed Acu-Loc distal (plate A), and MedartisADAPTIVE 2 (plate M). Plate M is a polyaxial plate inwhich the surgeon can set the screw position arbi-trarily; thus, the screw was set toward the mostproximal direction. In 3D-CAD, the plate wasinstalled on the bone just below the watershed line.The axis of the bone on the coronal plane wasmatched with the long axis of the plate. If thescrews protruded intraarticularly, the plate wasadjusted to the most distal installable position with-out protrusion. The three plates installed on each ofthe seven bone types yielded 21 digital models. Wemeasured the length of volar cortex between thescrew insertion site and the articular surface in thesagittal plane and referred to it as the fragmentlength (FL). This indicated the smallest bone frag-ment size that could be fixed. We also measuredthe volar protrusion of the plate (VP) from the bone.VP> 2 mm is demonstrated to be a risk factor forpostoperative flexor tendon ruptures according toseveral past studies.Results: The average VO was 9.3 mm (7.2–12.1 mm).Intraarticular screw protrusion occurred when plateD was installed on bones with VO greater than 9 mm.The screw protrusion was resolved when the platewas relocated more proximally (FL> 9.8 mm). Inplates A and M, protrusion did not occur, and FLwas >7.1 mm. In plates A and M, bones withVO< 8 mm showed VP> 2 mm, but plate D did notshow VP> 2 mm.Conclusions: These results indicate that bone frag-ments less than 9.8 mm cannot be fixed with a prox-imal VLP. Distal or polyaxial plates are indispensablefor fixation of small LF. Moreover, fixation of bonefragments measuring 7.0 mm or less is impossiblewith the VLP alone, and alternative fixation like awrist spanning plate should be considered. Thisstudy also clarifies the challenges associated withplate installation given differences in bone anatomy.We demonstrated that the screw tends to protrudeintraarticularly when applying the plate distally on abone with a large volar rim. Protrusion of the VLP,which can cause flexor tendon irritation, should becarefully examined when fixing bones with a smallvolar rim.

SS86 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0430 Minimal important change and patientacceptable symptom state for the brief MichiganHand Outcomes Questionnaire in patients after PIPjoint arthroplasty

Miriam Marks1, Stefanie Hensler1, Daniel B. Herren2

and Stephan Schindele2

1Department of Teaching, Research and Development,Schulthess Klinik, Zurich, Switzerland2Department of Hand Surgery, Schulthess Klinik, Zurich,Switzerland

Objective: The interpretation of study results shouldnot only be based on statistical significance, but onwhat is relevant for patients. In this respect, theminimal important change (MIC) or smallest changeafter treatment that patients perceive as importanthas become increasingly prevalent. Yet reaching theMIC does not necessarily imply that patients feel wellafter treatment. A corresponding measure is thepatient acceptable symptom state (PASS) defined asthe value beyond which patients consider themselveswell. The concept of PASS has rarely been studied inpatients with hand disorders. Therefore, our studyobjective was to determine the MIC and PASS of thebrief Michigan Hand Outcomes Questionnaire (briefMHQ) for patients 1 year after PIP joint arthroplasty.Methods: We used data from our prospective registryincluding patients who underwent PIP or thumb IParthroplasty with the CapFlex prosthesis (KLSMartin Group, Tuttlingen, Germany). Patients com-pleted the brief MHQ (score 0–100) before surgeryand 1 year after surgery. At follow-up, patientsanswered a question about the perceived change oftheir hand condition compared to before surgery.Based on this answer, we used the anchor-basedmean change method to determine the MIC.Another question about satisfaction with the treat-ment result was used to calculate the PASS withreceiver operating characteristics (ROC) curves. ThePASS for the entire group as well as for subgroups oflow (baseline brief MHQ scores less than or equal tothe median score) and high function (baseline scoresabove the median) was calculated.Results: We included 124 patients with 128 operatedfingers. The median brief MHQ baseline score was 44(range 6–83). It improved from mean 44 points(95%CI: 41–47) at baseline to 71 (95%CI: 66–75) at 1year (p 0.001). The MIC was 20 points. The PASSscore for all patients was 64 points (sensitivity¼ 0.79;specificity¼ 0.93; area under curve (AUC)¼ 0.86).Patients with low baseline scores had a PASS of 52(sensitivity¼ 0.88; specificity¼ 0.86; AUC¼ 0.87) andthose with high baseline function had a PASS of 72points (sensitivity¼ 0.73; specificity¼ 1; AUC¼ 0.87).

Of all patients, 67% reached the PASS as well as 64%and 74% of the low and high function patients,respectively.Conclusions: The clinical relevance of the MIC andPASS is important when interpreting treatment out-comes in both daily practice and clinical trials.Patients after PIP arthroplasty, who improve by 20points or more in the brief MHQ, experience a rele-vant change. Patients with a postoperative score of64 points or higher can be considered as having anacceptable symptom state. However, the PASSdepends on the preoperative patient status.

A-0435 Retrograde free venous flap for thereconstruction of the hand: Report on 16 large flapsfor the dorsum of the hand

Thomas Giesen, David Jann, Olga Politikou,Pietro Giovanoli and Maurizio CalcagniDivision of Plastic Surgery and Hand Surgery, UniversityHospital Zurich, Zurich, Switzerland

Free venous flap for the reconstruction of the hand isslowly becoming a common practice for the recon-struction of the hand. Free venous flaps plugged tothe donor artery, against the direction of the veinvalves (known as retrograde free venous flaps),demonstrated in our practice a valuable solution forlarge and composite defects to the dorsum of thehand.

From March 2010 to June 2017, we performed 16retrograde free venous flaps to reconstruct thedorsum of the hand and digits. All flaps were largerthan 20 cm2 with the largest being 104 cm2. Patientswere 12 males and 3 females with an average age of40 years (range 17–67).

We reconstruct two web spaces, six dorsum of thehand, eight large defects to the dorsum of the digitswith one flap covering two digits.

The donor site was always the palmar surface ofthe forearm.

We followed the patients for 6 months, looking forthe rate of survival of the flaps, partial and completeloss, rate of acute and late revisions. We measuredthe function according to the part of the hand wereconstructed.

We observed no complete loss, 2 partial skinlosses (no fat necrosis) with no need for a secondarycovering procedure. As secondary procedures, wehad to perform a separation of a syndactyly in acase of multiple finger coverage. One case neededthe ligation of a late onset of an arteriovenousshunt. Two flaps for finger defects needed a correc-tion because of some redundancy of the flap.

FESSH Abstracts SS87

We think that retrograde arterialized free venousflaps are a valid option in the reconstruction of thedorsum of the hand, even for large defects. The sizeof a retrograde free venous flap seems to be animportant factor influencing the rate of survival:with this subgroup of relatively large flaps, weachieved a rate of survival of 100%.

A-0440 Complications after a simple operation: Thetrigger finger

Balazs Lenkei, Adrienn Lakatos and Zsolt SzaboHand Surgery Center Miskolc, Hungary

We believe that after a little trigger finger operation,the patients heal well and fast. Despite of this, ourprospective data collection system shows many com-plications in our daily practice.

We have run a prospective data collection on trig-ger finger patients in the last 2 years. Since the startup, we collected data about 272 patients. We registerthe pain level at the site of the operation, the woundstatus, the satisfaction, the lack in range of motion ofthe fingers or any other complications after surgery.The type and duration of physiotherapy is alsorecorded.

Forty-two patients were excluded because of lack ofdata. We registered the following temporary compli-cations: excessive scar formation causing complaintsfor the patients in 13.7%, decreased range of motioncausing need for physiotherapy in 61.2% and severepain (more than 5 VAS points) in 11.2%. All these com-plications influenced the satisfaction of the patients.

Despite of the small incision and the simplicity ofthe procedure, some complications occurred in 43%of the patients. Fortunately, none of the mentionedproblems lasted more than 3 months and we did nothave any permanent or long-term complications.Dissatisfaction of the patients may be reduced byinforming them about these possible temporaryinconveniences.

A-0443 Upper extremity penetrating wounds:Prevalence and etiology

Jaime Piccaro Erazo, Rodrigo Guerra Sabongi,Vinicius Ynoe de Moares, Joao Baptista Gomes dosSantos, Flavio Faloppa and Joao Carlos BellotiFederal University of Sao Paulo, Escola Paulista deMedicina, Sao Paulo, Brazil

Introduction: Upper limb is one of the most commonsites of penetrating injuries due to its frequent

interaction with the surrounding environment anddirect contact with harmful agents. Penetratingtrauma usually produces musculotendinous and neu-rovascular injuries, fractures and amputations.Objective: To evaluate the epidemiology, causes andfrequency of upper extremity penetrating injuriesfrom a hand surgery center.Materials and Methods: Data of a 2-year period (May2014 until May 2016) from the outpatient clinic wereacquired and patients were invited for a survey.Records from demographics, site of injury and etiol-ogy were obtained. Descriptive statistics and com-parison of proportions with �2 test was performed.Results: Database search retrieved 1648 records, ofwhich 598 were included in the study after exclusioncriteria. Most were males (77.8%), right-handed(95.82%), with mean age of 37.27 years. Manualworkers were the most injured (50.00%) and fingerswere the most affected site (51.84%). Among etiolo-gic agents, glass was the most frequent (33.77%).Prevalence of amputation was higher in machineryinjuries (p< 0.05) when compared with otheragents. Younger patients (<18 years) had moreglass-related injuries while older patients (>60years) had more traumas caused by power tools(p< 0.05). Women had more injuries resulting fromblades and glass (p< 0.05). Manual workers hadhigher frequency of machinery trauma and amputa-tions (p< 0.05).Conclusion: The most frequent etiology was glass,especially in minors (<18 years). In women andolder patients (>60 years), there was high frequencyof traumas caused by blades and power tools,respectively. More severe injuries were caused bymachinery and related with work activity.

A-0444 Distal radio ulnar joint assessment:Reliability and validity of forearm torque

Peter Axelsson1 and Johan Karrholm2

1Department of Hand Surgery, Institute of ClinicalSciences, Sahlgrenska Academy, Gothenburg University,Sweden2Department of Orthopaedics, Institute of Clinical Sciences,Sahlgrenska Academy, Gothenburg University, Sweden

Objective: Physical assessment of the distal radio-ulnar joint (DRUJ) has traditionally been confined tomeasurement of grip strength and range of motion.Forearm rotational strength is rarely assessed eventhough facilitating forceful rotation is a major func-tion of the DRUJ. We hypothesized that measuringforearm torque could provide useful information inthe evaluation of DRUJ disorders and treatments.

SS88 Journal of Hand Surgery (Eur) 43(Supplement 2)

We therefore designed a simple method to easilyrecord forearm torque in the clinical situation. Wereport the results of a study performed to evaluatethe reliability and validity of the new test method.Methods: Forearm torque was measured in standingposition using the commercially available BaselineWrist Dynamometer (Fabrication enterprises, Whiteplains, NY, USA) equipped with a shovel handle. Thedynamometer was attached to vertical, wall mountedrails to enable adjustment according to the individualheight of the subject. Thereby all subject could betested with the elbow by their side and flexed to90�. Two raters measured maximum isometric fore-arm torque on 30 healthy subjects on three occa-sions. One rater also measured the sameindividuals on three occasions using the Baltimoretherapeutic equipment (BTE; Baltimore, MarylandUSA) as a standard reference in order to evaluatevalidity. The ICC model 2.1 was used to calculateintraclass correlation coefficients (ICCs).Results: Intrarater ICCs for rater 1 were 0.96 forsupination torque and 0.92 for pronation torque.

Corresponding values for rater 2 were 0.95 and0.91. ICCs for rater 1 when measuring torque withthe BTE were 0.94 (supination) and 0.91 (pronation).Interrater ICCs for supination torque were 0.94 andfor pronation torque 0.88. ICCs for comparisonbetween the baseline and BTE were 0.88 for supina-tion torque and 0.74 for pronation torque.Conclusions: Our test method could consistentlymeasure forearm torque and proved valid when theBTE was used as a reference. The test method iseasily applied in the clinical setting and has a poten-tial to improve evaluation of DRUJ function.

A-0447 Iatrogenic nerve injuries of the upperextremity in childhood

Ulrike Schnick and Richarda BoettcherUnit for reconstructive Surgery in Brachial Plexus Injuries,Tetraplegia and Cerebral Disorders, UnfallkrankenhausBerlin, Germany

Objectives: Iatrogenic neurovascular injuries includ-ing compartment syndromes are serious complica-tions in the treatment of fractures in childhood.These can result in significant functional limitations.

Children disorders like pain and loss of sensoryare frequently neglected. This is a specific problemin childhood and often leads to delayed diagnosis andtherapy.Materials and Methods: Fifteen patients with severecomplications after trauma of the upper limb in child-hood were treated from 2004 to 2017.

Seven patients presented symptoms of an acute orundergone compartment syndrome. Three of themwere seen primal as adults with long-term conse-quences of missed compartment syndrome resultingof an upper limb fracture.

Five patients with injuries of the ulnar nerve andtwo with injury of median nerve were treated – all ofthem operatively. One patient with lesion of the radialnerve was treated conservatively.

In addition, a review of literature was performed.Results: In most cases of nerve lesion or compart-ment syndrome, clear symptoms were primaryneglected and complaints of children were nottaken seriously. Therefore, the diagnosis wasdelayed or missed.

Mechanical problems like pinching the nerve byfracture or osteosynthesis, vascular lesions or estab-lished compartment syndrome mostly were ignoredfor days to several months – even in cases of explicitfindings. Severe functional deficits remained, whichrequired delayed necrectomy and functional recon-struction by tenodeses and muscle transfers.

In four cases of nerve injuries, reconstruction withnerve grafts was necessary due to the long-termmechanical problems. Three times a neurolysis wasadequate. Only one of these seven children – with aneurolysis – had a complete remission. The othersshowed only partial reinnervation.

In the literature, dislocated supracondylarhumerus fractures of children are associated withcomplications such as neurovascular collateraldamage and iatrogenic nerve lesions in up to 36%of cases. Iatrogenic lesions of the ulnar nerve arereported with a frequency of 2.5–6% and of theradial nerve with a frequency of 5 and more %.

There is only limited literature about nerve lesionscombined with other fractures of the upper extre-mity. In an analysis of iatrogenic lesions of theradial nerve, the lesion occurred in 50% after treat-ment of forearm shaft fractures, in 39% after distal-metaphyseal radius fractures and in 11% after radialneck fractures. In 15% the motor branch and in 5%the main trunk was affected.Conclusions: Every disorder after untreated or trea-ted fracture such as swelling, pain, loss of sensory orpaleness are potential signs of severe complicationssuch as compartment syndrome or lesions of vesselsor nerves. Complaints like dysfunction or paraesthe-sia always have to be taken seriously. Ultrasound andMRI are established methods to diagnose nerve orvascular lesions in time, while compartment syn-drome is mainly detectable by clinical signs. Earlysurgical treatment after consequent diagnostics isrequired. Thus good results are possible.

FESSH Abstracts SS89

In case of missing early treatment, several surgicalsteps including necrectomy, muscle and tendonrelease and muscle transfers can become necessaryto reconstruct limited function.

A-0449 Microsurgical flow-through flaps forreconstruction of volar tissue defect of fingers

Chao Chen, Liwen Hao and Zengtao WangShandong Provincial Hospital affiliated to ShandongUniversity, Jinan, China

Objectives: Composite tissue defect of the volar sur-faces of fingers is frequently associated with digitalvessel damage. Different reconstructive methodswere used for such injuries, like digital artery flapfrom adjacent finger, A-A typed flow-throughvenous flap, or vein graft combined with a regionalflap. Flow-through glabrous flaps can provideesthetic tissue coverage as well as revascularization.Methods: Between June 2010 and April 2017, we pro-spectively studied the use of microsurgical flow-through glabrous flaps to achieve simultaneouslydigital revascularization and soft tissue coverage in21 fingers of 18 patients who experienced volar inju-ries, comprising 7 great toe fibular flaps, 4 medialplantar flaps, 3 pedis medialis flap, 3 hypothenarflaps and 4 thenar flaps. The nerve passing throughthe great toe fibular flap or medial plantar flap wasused to repair digital nerve defects.Results: All flaps survived completely. During amean follow-up period of 13.6 months, the majorityrecovered excellent appearance and function. Theflaps had the characteristics of normal finger volarskin: hairless, with similar texture and color. Thesensation of finger pulp which repaired with neuro-vascular flap gained satisfactory recovery.Conclusions: Glabrous flow-through flaps provideexcellent reconstruction for fingers with volar inju-ries associated with digital vessel damage. The greattoe fibular flap and the medial plantar flap are reli-able and useful options for complicated finger inju-ries associated with digital vessel and nerve injuries.Flow-through thenar flap is our first choice if thepatient denied to harvest flap from foot.

A-0450 The effect of adipose derived mesenchymalstem cells on neoangiogenesis in processed nerveallografts

Femke Mathot1,2, Nadia Rbia1, S. E. R. Hovius1,A. T. Bishop2 and A. Y. Shin2

1Erasmus Medical Center, Rotterdam, The Netherlands2Mayo Clinic, Rochester, MN, USA

Improved blood supply can provide additional biolo-gical support for nerve regeneration to processednerve allografts by enhancing the local delivery ofgrowth factors. The purpose of this study was tomeasure the effect of mesenchymal stem cell(MSC) seeding of processed nerve allografts on theneoangiogenesis in the nerve allograft in a rat model.

Sciatic nerve grafts of 10 mm were obtained fromSprague-Dawley rats, decellularized and trans-planted back into a 10 mm sciatic nerve gap modelin Lewis rats. Before transplantation, each nerveallograft was seeded for 12 h with either nothing, 1million undifferentiated MSCs or 1 million MSCs dif-ferentiated into Schwann cell-like cells. These threegroups were compared with a control group thatreceived a nerve autograft. Sixteen weeks after thesurgery, five recipient rats per group were sacrificed.To study the trend of neoangiogenesis over time, fiveextra rats were sacrificed after 12 weeks for bothMSC groups. After the sacrifice, the vasculature ofthe nerve was preserved by aortic infusion ofMicrofil. The nerve grafts were dissected and withthe use of micro-CT (Inveon Multiple Modality PET/CT scanner) and conventional photography (Canon 5DMark III) of the sciatic nerves from both sides of eachrat, respectively, the volume and the surface area ofthe vasculature were measured. All volumes andsurface areas were measured as a percentage ofthe total nerve volume/area and are presented as aratio of the untreated side.

The average vascular surface area ratio after 12weeks was 0.72 in the group with undifferentiatedMSCS seeded on the allograft and 0.99 for thegroup with differentiated MSCs seeded on the allo-graft. After 16 weeks, both ratios were increased to0.80 and 1.27, respectively. In the autograft group,the ratio was 0.84 after 16 weeks and the ratio ofthe allograft group was 0.59. The volume ratioobtained by micro-CT after 16 weeks was 2.04 inthe autograft group compared to 0.69 in the allograftgroup, 1.82 in the allografts seeded with undifferen-tiated MSCs and 2.31 in the allografts seeded withdifferentiated MSC. The vascular surface area ratiosand the vascular volume ratios are positively corre-lated to each other, implementing that both methods

SS90 Journal of Hand Surgery (Eur) 43(Supplement 2)

can be used trustfully in the in vivo analysis of neoan-giogenesis in nerve grafts.

Compared to ‘plane’ processed nerve allografts,the neoangiogenesis is significantly enhanced byseeding either differentiated or undifferentiatedMSCs on processed nerve allografts. The degree ofneoangiogenesis in the autograft is equalled by bothMSC groups, of which the group with differentiatedMSC has a significantly enhanced neoangiogenesiscompared to autografts. This study not only demon-strates proper methods for analysing neoangiogen-esis in nerve grafts, it also shows that seeding MSCon the surface of nerve grafts results in an enhancedblood flow. This knowledge can be of great impor-tance in the process of improving outcomes of per-ipheral nerve repair in the future.

A-0464 Microsurgical and non-microsurgical tricksin thumb replantation

Teodor Stamate, Radu Budurca, Camelia Tamas,Mihaela Pertea, Ionut Topa and Ionut AtanasoaeDepartment of Plastic and Reconstructive Microsurgery,University of Medicine and Pharmacy ‘‘Gr.T.Popa,’’ Iasi,Romania

Objective: We analyze the peculiarities of the thumbreimplantation with modified algorithm depending onthe level and mechanism of amputation and tricks toreduce the operative time and enhance the successrate and functional outcome.Methods: From 1067 replantations over a 27-yearinterval (1990–2017), 132 involved the thumb: 107males (81.06%) and 25 females, 68 sharp amputa-tions, 37 crushings, 27 avulsions. Peculiarities:Bone shortening avoided vascular grafts and pro-vided thumb stability in IP destruction prioritizingstability over length conservation. In IP level amputa-tions combined with EPLT and/or FPLT teno-muscu-lar avulsion, IP arthrodesis was performed. Whenarterial anastomosis was not possible, various com-pensatory procedures were employed: rerouting of anearby vessel, vascular extensions based on anasto-motic vessels, venous grafts (avulsions). In proximalamputations (base M1) with retracted pollicis brevisartery, no attempts to retrieve it, instead reroutingnearby arteries is preferred. Longer vascular graftscan be used when necessary allowing a proximalanastomosis up to the radial artery or its palmarbranch both for safety and ease of positioning. TheRobbins cuff technique reduced the anastomosistime. In trans-ungueal amputations (Ishikawa II–III),for better access, replantation begins with nerve andartery anastomosis followed by bone fixation.

We prioritize the quality of the neural anastomosis.If direct anastomosis was not feasible, nearby sensi-tive nerve rerouting or nerve grafting was performed.Vein gaps were occasionally resolved by turning oneproximal vein with a pivot point at an anastomoticbranch with another vein. Skin defects were coveredwith flaps or skin grafts. To cover both skin anddorsal vein defects, 11 Foucher port vein kite flapand 7 Simonetta flaps were used. The concept offinger bank was applied for thumb reconstruction inpluridigital amputations. Follow-up of the vasculari-zation of the reimplanted segment was done thru a‘‘skin window’’ used also for local heparinization(‘‘biochemical leech’’).Results: The success rate was 84.84% with 2PD 8–14 mm. Thumb-digital pinch was possible in all cases(Kapandji scale 4–10). In FPLT and EPLT avulsions,resection associated with TFS 4 and TEP2 transfer donot affect the quality of the recovery. The use of thererouting of a nearby vessel and Robbins techniqueshortened the operative time. The use of the ‘‘bio-chemical leech’’ for 5–8 days led to improvement ofthe results in distal reimplantations, 18 nail deformi-ties (14.6%), 20 failed cases, and in 5 we covered thedistal phalanx with a Littler flap (ulnar side of thethird finger).Conclusions: The algorithm for thumb replantationmust be adapted to the type of lesion, the level andmechanism of amputation in order to improve thesuccess rate and functional outcome. Bone shorten-ing is indicated especially in trans-IP amputations. IPfusion provides solidity of a shorter thumb withoutfunctional damage. Avoiding Pulvertaft in FPLT and/or EPLT avulsion and IP arthrodesis are good strat-egy when tendons are avulsed from their muscles.Using nearby sensitive nerve, vessel rerouting andRobbins cuff, shortening the operative time andimprove results

A-0468 Immediate rehabilitation after distal radiusfractures stabilized by volar locking plate: A pro-spective randomized trial

Stefan Quadlbauer1,2,3, Christoph Pezzei1,Josef Jurkowitsch1, Tina Keuchel1, Thomas Beer1,Thomas Hausner1,2,3 and Martin Leixnering1

1AUVA Trauma Hospital Lorenz Bohler – European HandTrauma Center, Vienna, Austria2Ludwig Boltzmann Institute for Experimental and ClinicalTraumatology, AUVA Research Center, Vienna, Austria3Austrian Cluster for Tissue Regeneration, Austria

Objective: Distal radius fractures (DRFs) are verycommon and operative treatment by volar locking

FESSH Abstracts SS91

plate became the standard therapy in the lastdecade. Main reason for open reduction and stabili-zation with a palmar locking plate is the possibilityfor early postoperative mobilization. There are only afew studies that compare early postoperative mobili-zation after DRF with immobilization. The main aim ofthis study was to compare early postoperative mobi-lization after DRF with a 5-week cast immobilization.Methods: Hundred patients with an isolated distalradius fracture treated by open reduction and inter-nal fixation by a volar locking plate were prospectiverandomized in two groups. One group (‘‘early mobili-zation’’; EM) received a removable thermoplasticsplint for 1 week and was allowed to move thewrist directly postoperative. The other group(‘‘immobilization group’’; IM) received a not remova-ble cast for 5 weeks. Both groups underwent phy-siotherapy 2 times a week. At 6 weeks, 9 weeks, 3months, 6 months and 1-year post surgery ROM, gripstrength and radiographs had been evaluated.Additionally, Quick Disability of the Arm, Shoulderand Hand (QuickDASH) questionnaire, Patient-ratedWrist Evaluation (PRWE), modified Green O’Brien(Mayo) score and pain according to the VAS (visualanalog scale) score was analyzed.Results: Patients in the EM group had significantbetter range of motion in the extension/flexion andgrip strength up to 1 year, in the radial/ulnar devia-tion up to 9-weeks, in supination/pronation up to 6months. As well QuickDASH and PRWE score hadbeen better up to 6 months post surgery. The mod-ified Green O’Brien score differed significantly up to 1year. No differences in respect of loss of reduction,pain, duration of physiotherapy and sick leave couldbe found.Conclusion: Early wrist mobilization after distalradius fractures, stabilized by a volar locking plate,is a save post surgery treatment and leads to animproved range of motion and grip strength up to1-year post surgery compared to a 5-weekimmobilization.

A-0471 Reconstructive surgery for the types V andVI of duplicated thumbs

Soojin Woo1, Byungjun Kim1, Hyeonwoo Kim1,Sung Tack Kwon1 and Sang-Hyun Woo2

1Seoul National University Hospital, Seoul, South Korea2W Hospital, Daegu, South Korea

Purpose: It is technically challenging to correct theWassel types V and VI duplicated thumbs, whichinvolve thumb metacarpus. The retrospective clinicalstudy was performed to present preoperative status,

surgical technique, and postoperative results inpatients with type V or VI duplicated thumbs.Materials and Methods: Surgical procedures wereperformed including the osteotomy for the duplicatedmetacarpus, repositioning of the thenar muscles,releasing of the first web space and adductormuscle, and on-top plasty in 42 patients with type Vand in 15 patients with type VI duplicated thumbs. Intype V patients, the osteotomy of the metacarpus andrepositioning of the thenar muscles were performedin all cases. The narrow first web space was cor-rected using Z-plasty or 5-flap Z-plasty along withthe release of adductor muscle. In type VI patients,on-top plasty was performed which combinedthumbs of radial and ulnar side to make one thathad good nail appearance and durable bone andtendon. In some cases, tendon transfer was per-formed to reconstruct EPL and FPL tendon. Also,corrective osteotomy with K-wire fixation was doneto make a reasonable axial alignment. Wires wereremoved at 3 weeks postoperatively, and thumbspica splint was applied to prevent progressivethumb deformity.Results: The operation was conducted when thepatients were 11 months (10–25 months).Secondary corrective surgery was performed inthree patients to correct soft tissue repositioning.The range of motion in the metacarpophalangealjoint and the interphalangeal joint was 60� (20–80�)and 20� (15–40�), respectively. Subjective satisfactionscore of the guardians were 75 (60–95) points out of100 points. The average DASH score was calculatedas 4.5.Conclusion: The purpose of reconstructive surgeryfor the types V and VI of duplicated thumb is notjust removing remnant thumb, but making a func-tionally and aesthetically acceptable one by combin-ing better components between two thumbs.Reinforcement of the opposition and secure firstweb space are also important. Clinical experiencesand creative surgical plan are required to obtain goodpostoperative results in treating type V and VI dupli-cated thumbs.

A-0478 Types of thumb opposition loss andapproach to surgical tactics demarcate

S. Strafun, M. Oberemok, A. Lysak and S. TymoshenkoState Institution ‘‘Institute of Traumatology andOrthopedics of NAMS of Ukraine,’’ Kyiv, Ukraine

Objective: There is a necessity for a differentapproach to the choice of treatment in patients witha thumb opposition violation. It is important to

SS92 Journal of Hand Surgery (Eur) 43(Supplement 2)

correlate opposition violation degree with upper limbstructural losses. This will give us a complex classi-fication of the opposition loss, close to the surgicalneeds of restoration method choose.Methods: Structural and functional state of upperextremity in 120 patients with thumb opposition vio-lation was evaluated. All patients more than 6month’s opposition loss history. Type and degree ofopposition violation and impairment of various upperlimb structures (in attitude of their influence on theopposition, and as a resource for transpositionneeds) have been estimated.

Twenty-one patients – isolated nerve injury, 23 –several nerves, 16 – brachial plexus injury, 51 – mul-tistructural injury, and 9 – severe ischemic contrac-ture of the hand.

According to the pragmatic treatment tactics,patients are divided into four main groups:

Zero-group – compensated violation of thumbopposition, associated with carpal canal syndrome,median nerve demielienization or axonal injuries.Presented minor violations of rotation and abduction,which do not require opponensplasty. As additionalprocedures are possible not resource-based meth-ods (Gamitz).

Group 1: Patients with low, mistreated mediannerve injury, or low median and ulnar nerve traumawith incomplete re-innervation. There is a notablelack of thumb rotation and abduction. Traditionalmethods of transposition (Thompson, Brand, Huber)most likely will proper.

Group 2: Significant functional failure of the thumb,patients with high, neglected damage of the medianand ulnar nerve. Thumb does not participate in hand-grips. Appropriative transpositions of extensors ordouble tendon transpositions (Taylor, Burkhalter,Tubiana)

Group 3: Structural and functional disorders gobeyond of first finger muscles paralysis.

Group 3a: Thumb joints contracture. Most apparenttreatment – simultaneous joints mobilization andopponenosplasty with early active rehabilitation (or2-stage restoration).

Group 3b: Opposition loss associated with struc-tural integrity damage of thumb or long fingers func-tional disability. Opponenosplasty can be provided,after an anatomical reconstruction, or IP or PIPthumb joint fusion.

Group 3c: Substantial violation of thumb structuralintegrity, significant deficit of muscle-donors withthumb anesthesia – saddle joint fusion, metacarpalrotation osteotomies, or restoration of lateral gripthumb-to-index, as alternative – practice of splintsor orthoses.

Conclusion: Presented approach conceptuallydemarcates the therapeutic tactics, especially incomplex cases; therefore, it can be taken as aviable basis.

A-0479 Super microsurgery: Open guide techniqueis the appropriate technique for microvascularanastomosis to be integrated into a microsurgicaltraining process?

Fidel Cayon1,2,3 and German Hernandez1,4,5

1Universidad El Bosque, Bogota, Colombia2Centro de Especialidades Ortopedicas, Quito, Ecuador3Hospital Metropolitano, Quito, Ecuador4Sura ARL, Bogota, Colombia5Clinica Los Nogales, Bogota, Colombia

The microsurgical anastomosis has historicallyrepresented a challenge of certain complexity,which has been related to the surgeon’s skillfulnessand experience. There are supermicrosurgical ana-stomosis techniques that have shown encouragingresults, which makes us think that may be repro-duced by ‘‘in training’’ surgeons. It was necessaryto determine whether the open guide technique isthe one with the best results, it is suitable for theprocess of training and if microsurgeons in trainingare able to achieve satisfactory results using the pro-posed technique during their training. An experimen-tal study of microvascular suture with open guidetechnique was developed, by comparing the resultsof an expert surgeon with the results of ‘‘in training’’microsurgeons, to determine if this technique is sui-table for its integration into a process of microsurgi-cal training. Eighteen New Zealand small rabbitswere used for this study in which we performed 34flaps of the superficial inferior epigastric artery dis-secting and checking the diameter of it, we foundarteries of 0.6 mm in diameter or less, after we sec-tioned the artery we performed an anastomosis witha 10 zeros monofilament suture. The flaps were eval-uated daily until completion of five assessments todetermine their vitality, resulting in 100% viability ofthe flaps of the expert surgeon against an 88.23%viability of the flaps performed by the inexperiencedsurgeons.

We concluded that the open guide technique couldbe performed by surgeons in training with a highsuccess rate and can be included in a training pro-gram in microsurgery.

FESSH Abstracts SS93

A-0482 Pisiform excision: A solution for along-term ulnar sided wrist pain. A retrospectiveanalysis, comparing pre- and postoperativemeasurements

M.V. van Burink, S. Al Shaer, J. van Rossen, A. Fink,H. Slijper, T. M. Moojen, H. Rakhorst, G.van Couwelaar, R. Feitz and O. T. ZophelXpert Clinic, The Netherlands

Objective: Chronic pain in the pisotriquetral area isoften caused by pisotriquetral arthritis. Other causessuch as tendinitis of the flexor carpi ulnaris and post-traumatic pain from the pisiform bone might alsoresult in chronic ulnar-sided wrist pain. When con-servative treatment is insufficient, a pisiform excisionis often performed. The aim of this study is to eval-uate the postoperative outcome after pisiformexcision.Methods: This study is a multicenter retrospectiveanalysis, in which all patients after pisiform excisionwere included between 2011 and 2015. The primaryoutcome was pain, measured in visual analoguescale (VAS). Secondary outcomes were range ofmotion of the wrist (ROM), strength of the wrist inkilogram (JAMAR), wrist function and limitationsmeasured with the Patient Rated Wrist/HandEvaluation (PRWHE) and complications. A repeatedmeasurement and Sidak analyses were used for thestatistical analysis of the VAS. For the analysis of theROM and strength, a paired sample t-test was used.A Wilcoxon signed rank test was used for the analysisof the PRWHE.Results: One hundred and seventy-five patients wereincluded (79% women) with an average age of 49years; 67% had pisotriquetral arthritis. There was asignificant decrease in pain perception up to 3months postoperative (p< 0.05). Three months post-operative, a mean improvement of 13� (p< 0.001) pal-marflexion/dorsiflexion was achieved and 18%increase in strength (p< 0.001). Twelve months post-operative, the wrist function measured with thePRWHE improved from a mean of 64 to 25(p< 0.001). Two complications occurred: one post-operative wound infection and one thrombosis ofthe operated arm.Conclusion: To date this is the largest, in literaturepublished, postoperative analysis after pisiform exci-sion. Effectiveness was analyzed using patient-related outcome measurements. The results showthat pisiform excision is an effective and safe treat-ment for ulnar sided wrist pain related to the piso-triquetral joint when conservative treatment fails.

A-0484 Does cognitive capacity interfere with theoutcome of Oberlin transfer?

Fernando A. S. Azevedo Filho, William Z. Santos,Thomaz G. Oliveira, Yussef A. Abdouni,Antonio C. Costa and Patrıcia M. M. B. FucsSanta Casa de Sao Paulo, Sao Paulo, Brazil

Background: To determine the relationship betweenthe functional outcome obtained with Oberlin trans-fer and the patient’s cognitive level, and the timeelapsed between trauma and surgery.Methods: Eighteen patients were evaluated, of whom17 (94.4%) were males and one was female (5.6%),with a mean age of 29.5 years (17–46 years), with atraumatic injury to the brachial plexus (C5–C6 andC5–C7). We evaluated the active range of motion,elbow flexion strength and ASH (Disabilities of theArm, Shoulder and Hand) and determined the corre-lation between the outcome obtained and thepatient’s cognitive level, as assessed by the Mini-Mental State Exam (MMSE).Results: We found statistically significant correla-tions between the MMSE scale and strength recovery(84.4%, p< 0.001), which was classified as excellent;between the MMSE and BMRC scales (78.4%,p> 0.001), classified as good.Conclusions: We found a positive correlationbetween the cognitive capacity and functional out-come of patients submitted to Oberlin surgery. Thetime elapsed between trauma and the surgical pro-cedure has an inversely proportional correlation.

A-0490 A prospective clinical trial on NEUROLACnerve conduits for nerve repair in hand trauma

Nefer Fallico1,2, Anna Maria Spagnoli1 andNicolo Scuderi1

1Sapienza University of Rome, Department of Plastic andReconstructive Surgery, Rome, Italy2Guy’s and St. Thomas’ Hospital, Department of PlasticSurgery, London, UK

Objective: Traumatic nerve injuries of the upper limband particularly the hand are one of the mostcommon and most challenging surgical problems intrauma centres worldwide. The majority of patientswith such injuries are at the peak of their employ-ment productivity, as such satisfactory functionalrecovery is crucial.

When the transected nerve ends are amenable forprimary tensionless repair, traditional epineurialneurorrhaphy is the gold standard for peripheralnerve injuries. In cases where the gap cannot be

SS94 Journal of Hand Surgery (Eur) 43(Supplement 2)

bridged by direct epineural suturing (>5 mm), thesurgical options will include nerve grafting or nerveconduit bridging techniques.

The objective of this observational study is todescribe the clinical results of the reconstruction ofperipheral nerve traumatic lesions in the upperextremity by using bioresorbable copolyester polyDL-lactide-"-caprolactone nerve conduits(NEUROLAC�, Polyganics B.V., Groningen, theNetherlands) in emergency or in elective surgerywithin 6 months after trauma.Methods: This three-arm observational studyincluded 30 patients with upper limb injuries as aresult of a sharp object. Patients were divided intothree equal treatment groups: one group with nervegaps 5–20 mm received NEUROLAC for the nerverepair, one group with nerve gaps <5 mm were trea-ted with neurorrhaphy and an additional NEUROLACas wrap, and the third group with gaps <5 mm actedas control group and received neurorrhaphy.

Main outcome measures of the study were sensoryand motor nerve recovery. Recovery was measuredby muscle/grip strength measurement (motor), 2PDand monofilament tests (sensory), and gradedaccording to the criteria of the Nerve InjuriesCommittee of the British Medical Research Councilmodified by Mackinnon–Dellon. Recovery of mixednerves was assessed using the Sakellarides gradingsystem. Electrical conductivity (motor and sensory)was measured with a nerve conduction test.

Primary outcome assessment of all parameterswas performed at 6 and 12 months after surgery.Results: Between December 2014 and June 2015, 30patients were enrolled in the trial (21M/9F; aged 18–70 years). The three groups were comparable con-sidering their demographics. Sensory recovery wasS2 in the NEUROLAC conduit group and >S3 in theNEUROLAC wrap group. Motor recovery was >M2 inall groups. Mixed nerve recovery was >M2/S2 in boththe neurorrhaphy and the NEUROLAC conduit groupand >M3/S3 in the NEUROLAC wrap group. Electricalconductivity showed a reduced latency time in bothNEUROLAC groups opposed to unvaried latency inthe neurorrhaphy group. Two complications wererecorded consisting in granulomas on the fingers.Conclusions: At 6 and 12 months after implantation,the NEUROLAC conduit shows similar results interms of motor and mixed nerve recovery when com-pared to neurorrhaphy, while the sensory recoveryshows better outcomes than neurorrhaphy alone.When NEUROLAC is applied as a wrap around therepair zone, the recovery in small nerve gapsseems to be further improved. Electrical signaltransduction is quicker in both situations whereNEUROLAC is used, suggesting an intrinsic recovery

over suturing alone. These results indicateNEUROLAC to contribute to sensory and motornerve recovery and signal conduction.

A-0492 Classification of distal radio-ulnar jointpathology in rheumatoid arthritis

Grey Giddins and Reda RamadanRoyal United Hospital, Bath, UK

Objective: To develop a classification of distal radio-ulnar joint (DRUJ) destruction in rheumatoid arthritis(RA) based on radiographs in order to guidetreatment.Methods: Following approval by the hospital auditcommittee, we reviewed the most recent wrist radio-graphs of 100 patients (117 wrists) known to have RA.The inclusion criteria were adults with a diagnosis ofrheumatoid arthritis with some radiological DRUJabnormality and no previous wrist or DRUJ surgery.The exclusion criteria were other inflammatoryarthritis and inadequate radiographs, that is, nogood postero-anterior (PA) or lateral views. Wherepatients had changes on radiographs of both wrists,then both were assessed separately giving a total of117 sets of wrist radiographs. We used the latestradiograph as the one for the classification notleast as some earlier radiographs showed no orminimal radiographic changes.

We recorded demographic data including age (inyears) at the time of the radiographs and gender. Inthe wrist, we recorded the Larsen grade and the pre-sence of any erosion of the ulnar side of the lunate.For the DRUJ, we assessed ulnar variance, and sub-luxation of the DRUJ (shown by ulnar head subluxa-tion relative to the distal radius), the presence of asecondary shelf, that is, volar radial prominence ofthe distal radius usually helping support the radiusand, based upon prior observations, whether theulnar head was supporting the lunate, that is,acting as a proximal buttress with evidence of theforce transmission shown from the lunate to theulnar head. Where possible this was confirmed on aCT scan.

The data were recorded in an excel spreadsheetand analyzed to assess for associations betweenthe data sets.Results: We assessed 117 wrists in 100 patients witha mean age of 53 years. There were 19 men and 81women; we assessed 94 right and 25 left wrists. TheLarsen grades were 0–5; they did not correlate wellwith DRUJ destruction. There was lunate erosion in31 (26%).

FESSH Abstracts SS95

In the DRUJ, the ulnar variance was a mean of 0(range �2 to þ2) mm. There was DRUJ subluxation in59 (50%), shelf formation in 60 (51%) and the ulnarhead was supportive in 7 (6%).Conclusion: DRUJ destruction is gradable and canprovide guidance for treatment. Grade 1 shouldavoid ablative surgery. Grades 2 and 3 typicallyneed ulnar head excision with or without ulnar headreplacement. Grade 4 is so destroyed that only aDarrach’s procedure is warranted. A new finding ofa supportive ulna head occurred in 3%. It is bestconfirmed on a CT scan. The significance is unclearbut suggests these patients may benefit from aSauve–Kapandji procedure or an ulnar head replace-ment rather than a Darrach’s procedure to reducethe risk of carpal collapse or carpal stabilizationsuch as a Chamay procedure. This would also helpexplain why most patients have a Darrach’s proce-dure do not have increased carpal collapse butsome do.

A-0496 Direct sutures in extended upper obstetricbrachial plexus reconstruction

Jorg Bahm, Ann Gkotsi, Wissam ElKazzi andFrederic SchuindDepartment of Orthopedics, ULB Erasme UniversityHospital, Brussels, Belgium

Introduction: Severe upper and total obstetric bra-chial plexus lesions must be explored and recon-structed within the first months of life. Thefrequently encountered non-conducting neuroma incontinuity are routinely excised and grafted by suralinterposition fascicles. In specific cases, when thegap is around 1 cm and the mobilization of thedistal plexus is achievable, a direct coaptation ofboth the proximal and distal nerve stumps after his-tographic control is feasible – we present thosecases among our patient series.Materials and Methods: We performed direct (intra-plexic) coaptations in 12 children between 2013 and2015: 4 combined upper and middle trunk, 3 onlyupper trunk, in 3 C5 or C7 were sutured onto theC8 contribution to the lower trunk, in 2 partialupper trunk.

All patients were followed clinically and videodocumented.Results: We observed good functional improvementin all cases, comparable to autologous grafts. Inupper lesions treated by direct coaptation of theupper trunk, an additional spinal to suprascapularnerve transfer seems to improve passive and activeshoulder lateral rotation much better.

Discussion: In selected cases with short gap afterneuroma resection, the direct stump coaptation isfeasible and appealing. Suture tension is reducedby 8/0 sutures and a more adducted-elbow flexedlimb position and immobilization. Clear advantagesare the missing need for sural nerve harvest andthe coaptation of thick, fiber rich nerve stumps ofgood regenerative capacity. Potential drawbacks arethe risk of suture rupture and intraneural fibrosis;also do we observe some more coactivation. So farour clinical results are promising and feared compli-cations are rare.

A-0499 Radial to brachioradialis nerve transfer,does it improve elbow function in upper brachialisplexus injuries?

Reza Sh. Kamrani1,2

1Tehran University of Medical Sciences2Joint Reconstruction Research Center of TUMS

Objective: Oberlin procedure improved dramaticallythe results of upper brachial plexus injuries (UBPI)with root avulsion. Modification of this procedure byadding nerve transfer for brachialis further improvedthe results. The third component of the elbow flexionmeans brachioradialis has been overlooked yet. Weevaluated the results of our patients with C5–C6 rootavulsion who underwent a fascicle of median nerve tobiceps, one fascicle of ulnar nerve to brachialis, andcompare between patients who underwent transferof one fascicle of radial nerve to barchioradialis andthose without this transfer.Method: We reviewed our patients with C5–C6 rootavulsion who underwent modified Oberlin procedurebetween January 2005 and December 20015. From 42patients, 7 cases had an additional procedure withtransferring a fascicle of radial nerve to brachiora-dialis nerve. We reviewed the anatomical finding inthe operating note and compared the results of thesepatients with the patients without this additionaltransfer with respect to force of elbow flexion andthe speed of elbow flexion. At the final follow–up,the additional transferred group underwent electro-myographical examination to be assessed for rein-nervation of the brachioradialis muscle.Results: In two patients with radial to brachioradialistransfer, we failed to anastomosis of this transferbecause of thinness of the recipient nerve whichwas branched before exiting of the radial nerve. Inthe other five cases, the mean force of the elbowflexion was 5 kg which was more than the othergroup with 3.8 kg, but the differences were not sta-tistically significant. The mean speed of the elbow

SS96 Journal of Hand Surgery (Eur) 43(Supplement 2)

flexion was 16 s for 10 full range of motion of theelbow in additionally transferred group and 21 s inthe other group. In all of these five patients, electro-myography patients showed reinnervation ofbrachioradialis.Conclusions: Radial to brachialis transfer can help toimprove the results of the classic modified Oberlinprocedure in C5–C6 avulsion for elbow flexion, butthis improvement is not significant. This transfer istheoretically helpful in the cases with C5–C6 avulsionthat neuromuscular junction of biceps and brachialishas been injured due to the primary trauma.

A-0502 Validity and reliability of a hand-helddynamometer for measuring forearm rotationstrength compared to the Biodex

Anouk van Ham, Sander Brink, Gertjan Kroon,Elske Bonhof and Raoul WinterIsala Hand and Wrist Centre, Zwolle, the Netherlands

Objective: In order to evaluate the effect of treatmentconcerning forearm rotation, rotational musclestrength is assessed using, for instance, theBiodex�, an expensive and spacious machine, or ahand-held dynamometer named the Baseline�

hydraulic wrist dynamometer (BHWD), a portableand convenient device. Unfortunately, the clinimetricproperties of the BHWD are unknown. Therefore, theaim of this study was to determine the concurrentvalidity, the intra- and inter-rater reliability of theBHWD compared to the Biodex, a gold standard.Methods: An observational test–retest design wasset up. Healthy participants without neurological ill-ness or injury of the hand, wrist or elbow in the last 6months were included. During four sessions, prona-tion and supination strength were measured threetimes per session on both arms using the BHWD(three sessions) by two observers and using theBiodex (one session). Concurrent validity was estab-lished using Pearson’s correlation coefficient (r) forthe parametric measurements and Spearman’s rankcorrelation coefficient (rs) for the non-parametricmeasurements. Intra- and inter-rater reliabilitywere established using intraclass correlation coeffi-cients (ICC) for both rotational directions. To deter-mine the agreement within one observer andbetween two observers using the BHWD, Bland–Altman plots with limits of agreement (LoA) weregenerated.Results: Twenty-one healthy participants (42 arms)were included. Concurrent validity for pronationstrength was r¼ 0.650 (p¼ 0.000) and for supinationstrength rs¼ 0.677 (p¼ 0.000). Intra-rater reliability

for pronation strength was ICC¼ 0.912 (p¼ 0.000)with a mean difference of �2.57 (LoA: �33.28;28.14) and for supination strength was ICC¼ 0.967with a mean difference of 4.48 (LoA: �21.08; 30.03).Inter-rater reliability for pronation strength wasICC¼ 0.888 (p¼ 0.000) with a mean difference of0.76 (LoA: �34.68; 36.19) and for supination strengthwas ICC¼ 0.958 (p¼ 0.000) with a mean difference of4.43 (LoA: �24.46; 33.32).Conclusions: The BHWD used according to the mea-suring procedure in this study cannot replace theisometric mode for pronation and supination strengthof the Biodex.

A-0503 Treatment of complex distal radius fracturenonunion with posterior interosseous bone flap

Reza Sh. Kamrani1,2 and Amir reza Farhood1,2

1Tehran University of Medical Sciences2Joint reconstruction Research Center of TUMS

Objective: Nonunion of distal radius fractures is dis-abling. Treatment is difficult and the results are notpredictable. However, posterior interosseous boneflap (PIBF) has been successful in treating forearmnonunion. To treat distal radius fracture nonunionwith PIBF as a new procedure.Methods: This prospective non-randomized cohortstudy was performed at two hospitals in Tehranbetween January 2011 and September 2015. PIBFswere applied in nine patients (10 nonunions) with amean age of 55 years. Union success rate, gripstrength, wrist range of motion, and forearm rotationwere then evaluated.Results: Although four of the patients had a history ofinfection, all participants achieved fracture union at amean time of 3.8 months. Grip strength improved by12.4 kg. There was also 36� improvement in wristflexion, 20� improvement in wrist extension, 60�

improvement in forearm supination, and 46�

improvement in forearm pronation. The range ofmotion and grip strength improvements weresignificant.Conclusions: Pedicled PIBF is a new option for treat-ing distal radius fracture nonunion. The results arepredictable in achieving union and good function, andthis technique can be successfully used in cases withextensive soft-tissue damage or infection.

FESSH Abstracts SS97

A-0505 Are there unfavorable results after colle-gians treatment?

Esther VoegelinUniversity Hospital, Inselspital, Bern, Switzerland

Objective: Unfavorable results of collagenase includeadverse effects of the drug and unsatisfactory resultsout of the patients’ and surgeons’ view. There are fewpublished data.Methods: One hundred and forty-six applications ofcollagenase (120 patients) were analysed between2015 and 2016. In 10 patients, 2 infiltrations(0.78 mg) and in 2 patients, 3 infiltrations (0.78 mg)were administered. In 16 patients, 2 simultaneousinfiltrations (1.16–1.56 mg) were applied. Thefollow-up included a minimum of 6 months afterthe last treatment.Results: Nineteen patients reported unsatisfactoryresults. One patient was treated with a painfulnodule of the plantar aponeurosis. Two heavy smo-kers did not respond after one respective two appli-cations with a remaining extension deficit of 70,respectively, 50� at PIP joint level. Seven patientsshowed improvement of the MCP extension butworse PIP joint flexion and extension. These patientsdemonstrated CRPS like reactions after the infiltra-tions or had a diabetes. In four other patients with asevere diathesis of Dupuytren’s disease and multipleprevious surgeries, one collagenase infiltrationimproved the extension deficit only for 1�3 years,but was felt to be more acceptable than recurrentsurgery. Two patients did not improve after 1,respectively, 2 infiltrations of collagenase in thefifth digit and wanted surgery with good success. Intwo patients with severe spasticity and Dupuytren’sdisease, collagenase was administered as off labeluse with only moderate success in one patient. Inone of four patients with painful nodule-like diseasewithout extension deficit, collagenase was appliedand did not work. Radiation instead could decreasepain.Discussion: Risk for non-responders of collagenasetreatment are severe smokers, diabetic patients andpatients with diffuse nodular painful Dupuytren’s dis-ease, as well as probably the M. Ledderhose.Insufficient responders after one treatment of col-lagenase without CRPS reaction may benefit from asecond or third treatment or limited surgery.Radiation is probably more effective to control painin nodule-like disease without extension deficit thancollagenase.

A-0507 Opinions regarding the management ofpyogenic flexor tenosynovitis (tendon sheathinfection)

L. E. Bolton and L. C. BainbridgePulvertaft Hand Centre, Royal Derby Hospital, Derby, UK

Background: Pyogenic flexor tenosynovitis (PFT) haslong been recognized as a severe infection of thehand with the potential for disastrous outcomes ifinadequately treated. The mainstay of treatment forover a century has been with emergent surgicalwashout. More recent evidence suggests a potentialrole for conservative management with a combina-tion of intravenous antibiotics, elevation and splint-ing. We aim to assess current management ofpyogenic flexor tenosynovitis to guide further educa-tion and research into this potentially devastatingcondition.Method: An electronic survey was distributed viaemail to all surgeons on the Pulvertaft database.The survey was compiled by a group of hand sur-geons and piloted within a tertiary centre for handsurgery prior to dissemination. The questions werefocused on three clinical vignettes describing pyo-genic flexor tenosynovitis of increasing severity. Theresponses were analysed using SurveyMonkey.Results: Almost 50% of respondents would proceedto surgical decompression and washout even inpatients diagnosed within a few hours of onset. Thisincreased to 88% of respondents when treating apatient who has had symptoms for several days andfailed a trial of oral antibiotics. The majority ofrespondents would not consider flexor sheathaspiration regardless of the clinical scenario. Forthose advising surgical intervention, the majorityfelt this should be performed within 24 h in allthree scenarios. More than 50% of respondentswould advocate active mobilization either immedi-ately or as soon as possible regardless of the severityof the infection. Almost all of the respondents woulduse either general or regional anaesthesia for theprocedure and a two-incision technique with catheterirrigation.Discussion: Our survey demonstrates a huge varia-tion among clinicians in the management of pyogenicflexor tenosynovitis. Advice from the pre-antibioticera of emergent surgical debridement continues tobe followed by many and a proportion of surgeonscontinue to use an open technique. The importanceof immobilization is often stated throughout the lit-erature but many clinicians advocate early activemobilization. Further study into the managementand outcomes of pyogenic flexor tenosynovitis is

SS98 Journal of Hand Surgery (Eur) 43(Supplement 2)

required to establish best practice guidelines for thisrare but potentially devastating condition.

A-0508 Defining displacement thresholds forsurgical intervention for distal radius fractures:A Delphi study

Nick Johnson, Paul Leighton, Charles Pailthorpe,Distal Radius Fracture Study Group and Joseph J DiasUniversity Hospitals of Leicester, UK

Aim: Distal radius fractures (DRF) are very commonyet controversy exist regarding which require treat-ment and this is reflected by significant variation inthe surgical intervention rate. Evidence regardingwhich fractures would benefit from intervention isvaried and largely poor quality.

This study had three aims: to identify which radio-graphic parameters in distal radius fractures areclinically important; quantify the threshold of displa-cement at which intervention should occur and inves-tigate which patient factors influence the threshold ofthe decision to intervene.Method: A modified three round Delphi study wascarried out and responses were qualitativelyanalysed.Participants: The Delphi panel was composed ofthree groups of national and international expertsurgeons:

1. Hand and wrist surgeons2. Trauma surgeons3. International researchersForty-six participants initially agreed to take part.

Forty-three completed the first round and all thencompleted three rounds.

Participants were asked questions based aroundcase vignettes in patients of three ages (38, 58, 75years). They were asked to rank radiographic para-meters in order of importance, the threshold of dis-placement at which they would intervene and rankwhich patient factors influenced their decision tooperate. Free text comments were sought through-out and explored.Trial registration: The protocol was registered withClinicalTrials.gov (Identifier: NCT03126474).Results: For all age groups, ulnar variance wasranked as the most important extra-articular para-meter followed by dorsal tilt, step was ranked as themost important intra-articular parameter.

Agreed thresholds were the same for all para-meters for patients aged 38 and 58. Surgeonswould intervene in patients aged 38 and 58 withþ2 mm ulnar variance, 10� dorsal tilt, 2 mm stepand 3 mm gap. In patients aged 75, the agreed

thresholds were 20� dorsal tilt, 3 mm step and4 mm gap, consensus was not achieved for ulnarvariance.

Mental capacity, pre-injury functional level and med-ical co-morbidities were ranked as the three mostimportant factors influencing the decision to intervene.Qualitative analysis suggested that pre-injury functionwas the main theme within these factors.Conclusions: Our findings provide useful advice aboutwhich parameters should be measured and radio-graphic thresholds for intervention. These thresholdsmay then be modified depending on important patientfactors. This information can help guide clinicians withmanagement decisions and reduce variation.

A-0510 Short to long-term follow-up of surfacereplacement MCP arthroplasties

Allan Ibsen Sørensen and Anders NilssonSahlgrenska University Hospital, Gothenburg, Sweden

Introduction: Resurfacing of the MCP joint with flex-ible implants is considered to be the Golden Standardof the MCP joint arthroplasties. So far, few reports ofSR-MCP arthroplasty has been presented.Material: This prospective study includes 79 patientsmean age 59 years (22�86). One hundred and thirty-seven SR-MCP cemented arthroplasties with afollow-up 62 months (2�137). Main indications wererheumatoid arthritis (RA) 104 joints and osteoarthritis(OA) 33 joints. In the RA group, severe conditions withvolar sub- or volar dislocation were included.Moreover, 7 Tupper arthroplasty and 2 joints flexiblesilicone arthroplasties have been revised to SR-MCP.Results: Preoperative ROM MCP mean was 45� (0–88) and at last follow-up (FU) ROM was 41� (0–98),p¼NS. VAS of pain at rest/activity was preop 51/46 mm versus 7/16 mm at last FU, p< 0.01. Gripstrength preop 16 kgF (2�60) and at last FU 15 kgF(0�44), p¼NS. Pinch grip preop 1.8 kgF (0.5�5.2)and at last FU 2.4 kgF (0�5.8), p< 0.01. QDASHpreop 57 (20�95) and at last FU 35 (2�89), p< 0.01.Complications: No infections were recorded. Twoprostheses were revised to silicone implants due toloosening and two due to instability. Estimated survi-val for 11 years was 95%. Eight RA patients with 13joints had later joint instability due to insufficient col-lateral ligament and the collateral ligaments werethen reconstructed. Three of these joints still sufferfrom instability.Conclusions: SR-MCP arthroplasty in OA and RApatients with stable joints have few complicationsand improved significantly regarding qDASH, painand pinch. ROM were unchanged. For instable joints

FESSH Abstracts SS99

in RA patients, silicone prosthesis may be the firstchoice option.

A-0511 Comparison between donor nerves tomotorize the free gracilis muscle transfer forelbow flexion: A retrospective study of 55consecutive cases in traumatic adult brachialplexus injuries

Alvaro Baik Cho, Gustavo Bersani Silva, Marina JustiPisani, Jairo Alves, Raquel Bernardeli Iamaguchi,Teng Hsiang Wei and Marcelo Rosa de RezendeHospital das Clınicas da Faculdade de Medicina daUniversidade de Sao Paulo, Instituto de Ortopedia eTraumatologia, Sao Paulo, Brazil

Objective: The authors seek to determine whichdonor nerve (spinal accessory, intercostal, medianor ulnar) results in better elbow flexion after micro-surgical reconstruction.Methods: Between February 2003 and October 2014,59 patients with traumatic brachial plexus injurywere submitted to a free gracilis muscle transfer torestore elbow flexion. Four patients were excludeddue to vascular failure of the transferred muscle,infection or follow-up of less than 12 months. Thefinal study population was 55 patients. The patientswere divided in four groups according to the nervetransferred to the gracilis: spinal accessory nerve(SAN), intercostal nerve (ICN), motor fascicles ofthe median nerve (MED) and motor fascicles of theulnar nerve (ULNAR). The British Medical ResearchCouncil (BMRC) scale was used to evaluate elbowflexion strength.Results: Of the 55 patients enrolled, 54 were males(98.2%) with a mean age of 28.9 years. The meanfollow-up period was 28 months. Thirty-six casesobtained muscle strength M3 or M4 (65.4%): 6 M0(10.9%), 4 M1 (7.2%), 10 M2 (18.2%), 13 M3 (23.6%)and 21 M4 (38.2%). The mean interval to firstrecorded M3 muscular strength was 16 months.Patients stratified by donor nerve achieving¼M3had the following distribution: SAN 83.3% (15/18)SAN graft 50% (2/4), ICN 60% (3/5), ICN graft 33.3%(1/3), MED 60% (3/5) and ULNAR 60% (12/20).Conclusion: The comparison between different donornerves did not reveal a statistical superiority for anyof them in free gracilis muscle transfer in traumaticlesions of the brachial plexus. However, the SANtransfer showed a tendency to perform better fol-lowed by the ulnar nerve transfer.

A-0512 Short to 11-year follow-up of SR-PIParthroplasty

Allan Ibsen Sørensen and Anders NilssonSahlgrenska University Hospital, Gothenburg, Sweden

Introduction: Arthroplasty of the PIP joint with SR-PIP has been an option to flexible prostheses orarthrodesis. A number of complications have earlierbeen reported related to SR-PIP arthroplasty.

The aim of this study is to report results of unce-mented and cemented SR-PIP arthroplasties.Material: This study is a prospective study of 93women and 15 men and includes 126 SR-PIP arthro-plasties with a follow-up to 11 years (115 joints with aminimum of 1-year follow-up (FU)). Median age 63years (26�83). Main indications are rheumatoidarthritis (RA) 25 joints. Osteoarthritic (OA) joints 89and 13 other indications. In the RA group, few caseswith severe Boutonniere deformity or MCP arthro-plasty in the same finger were included in the earlypart of the study. Mean values are presented.Results: Preoperative PIP joint ROM 37� (0–75) and at1-year follow-up (FU) ROM was increased to 52�

(�16�120) (p¼NS) and at last FU 47 (0�120)(p¼NS). VAS of pain at rest/activity preoperative44/60 mm and at 1 year 6/18 (p< 0.01) and at lastFU 6/16 (p< 0.01). Grip strength preoperative 17kgF (2�42) and at 1 year 18 kgF (1�40) (p¼NS)and at last FU 17 (1�40) (p¼NS). Pinch grip preo-perative 2.4 kgF (.0�5.7) and at 1 year 2.7 kgF(.5�9.0) (p¼NS) and at last FU 2.6 (.5�6.8)(p¼NS). Preoperative qDASH/PRWE 46/52 and at 1year 31/28 (p< 0.05) and at last FU 35/31(p< 0.05).Patients’ satisfaction at last FU was 69 mm (1�100).Eleven years estimated survival of implant in RA is52% and OA 91%.Complications: No infections. Loosening around thestem of 15% of the prostheses at last FU. Elevenjoints revised to arthrodesis, three due to dislocationin severe RA. Tenolyses in seven joints due toadhesions of the extensor tendon. One stem wasre-positioned postoperatively due to incorrect posi-tion. Seven FDS tenodesis performed due tohyperextension.Conclusions: Arthroplasty with SR-PIP prosthesishas unchanged ROM of PIP joints and strength butpain and PROM improved significantly. A high amountof soft tissue problems postoperatively is reported.Survival of the prosthesis is high in OA but low in RA.Severe RA cases with Boutoniere deformity should beavoided.

SS100 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0513 Six-month to seven-year results of revisionof a wrist arthroplasty to new wrist arthroplasty

Allan Ibsen Sørensen, Peter Axelsson andChrister SollermanSahlgrenska University Hospital, Gothenburg, Sweden

Introduction: The aim of this study was to review ourresults of revision wrist arthroplasty to a new wristarthroplasty.Methods and Materials: Maestro and Remotionimplants are two modular total wrist joint pros-theses. These two prostheses were used for revisionof former KMI/UTW. All cases were bone grafted andsome combined with cementing. In 11 cases, almostthe whole carpus was gone and a new technique forreconstruction of carpus with a structural bone blockwas used.

Patients were evaluated pre- and postoperativelywith ROM, grip strength, visual analogue scores of0�100 mm (VAS) of pain and satisfaction. Functionaland general outcomes were evaluated using theQuick-DASH and PRWE questionnaires.Radiographs were obtained pre-operatively and atfollow-up.

The procedure was performed in 18 patients: 5men and 13 women. Median age was 6 years(32�76). All diagnosis except one were RA. Medianfollow-up was 33 month (range 4�84).

Revision arthroplasty was performed with theMaestro implant in 11 cases and the Remotionimplant in seven cases. Cement was used in sixcases.Results: Wrist extension and flexion was preopera-tively 29/27� and at follow-up 35/15. Radial/ulnardeviation was 0/29� versus 12/24 postoperatively.Grip strength, in kgF, was preoperatively 7 (range2�18) and at follow-up 16 (7�26). VAS pain was pre-operatively at rest/activity; 26/44 and at follow-up;27/35. Quick DASH and PRWE scores were preopera-tively 56, respectively, 57 and at follow-up 45 and 37.VAS satisfaction at latest follow-up was 69 (0�98).Seven years estimated survival is 87%.

No infections or dislocations were encountered,but radio-graphically loosening of two Remotionprostheses occurred and they were consequentlyrevised to total wrist arthrodesis. One excision ofan exostosis in carpus.Conclusions: The short-term to midterm outcome ofthis heterogeneous case series indicates that revi-sion wrist arthroplasty could be an alternative torevision to a total wrist arthrodesis.

A-0515 Fractional lengthening of the volar forearmmuscles: An anatomical study

Ahlam Arnaout and Caroline LeclercqInstitut de la Main, Paris, France

Objective: Fractional lengthening is one of the surgi-cal options for treating muscle contractures asso-ciated with spasticity of the upper limb. It consistsin multiple transverse tenotomies at the musculo-tendinous junction (MTJ). The goal is to lengthenthe tendon, yet preserving the continuity of themuscle-tendon unit. The main pitfall of this techni-que is over-lengthening, and subsequent post-opera-tive disruption of the muscle-tendon unit.

The aim of this anatomical study was to measurethe length of the muscle-tendon overlapping zone foreach individual volar forearm muscle, to define theuseful zone (UZ) for carrying out fractional lengthen-ing, and to evaluate its feasibility for each flexor.Methods: Dissections have been performed on 20fresh adult cadaveric upper limbs. All the forearmflexor muscles have been studied.

We defined for each muscle, the length of overlap-ping at the MTJ, and the UZ in which lengthening isfeasible without risk of disruption. A 3D mapping ofthe tendon location within the musculo-tendinousunit has been also performed after cross-sectioningthe MTJ.Results: The UZ average length was 3.5 cm for theFCR, 12.2 cm for the FCU, 4.4 cm for the FDS II,5.9 cm for the FDS III, 4.9 cm for the FDS IV, 2.7 cmfor the FDS V, 6.5 cm for the FPL, and 7.6 cm for theFDP.Conclusions: According to our results, fractionallengthening appears reliable, reproducible, andeffective for those muscles whose UZ is relativelylong (>5 cm), with homogenous results, that is, theFCU (longest UZ of all the flexors), the FPL, the FDP,and the FDS III. Regarding the FCR, the FDS II, andthe FDS IV, whose UZ is shorter and variable, thefeasibility of the procedure and the number of teno-tomies should be carefully evaluated intraopera-tively, on a case by case basis. And finally, the FDSV useful zone is very short, with a thin and fragiletendon in all cases, leading to a major risk of rupture.

A-0520 Metacarpal corrective osteotomy in patientswith Wassel type IV radial polydactyly

Jihyeung Kim, Seong Hwa Hong, Kee Jeong Bae,Hyun Sik Gong, Young Ho Lee and Goo Hyun BaekDepartment of Orthopaedic Surgery, Seoul NationalUniversity, College of Medicine, Seoul, South Korea

FESSH Abstracts SS101

Background: In the surgical management of Wasseltype IV thumb duplication, correction of the angula-tion deformity in the thumb metacarpophalangeal(MCP) joint is one of the most important proceduresin order to prevent recurrence of the deformity andinstability in the joint. The purpose of this study is toevaluate the correction of the angulation deformity ofthe thumb MCP joint after metacarpal osteotomy andthe maintenance of the joint angle 2 years aftersurgery.Methods: We retrospectively reviewed 34 patientswith Wassel type IV thumb duplication who under-went surgical treatments and were followed up formore than 2 years. Of them, 13 patients who under-went both soft tissue procedures and metacarpalosteotomy for the reconstruction of the thumb MCPjoint were enrolled in this study. The average age atthe time of surgery was 11 months. We measured theangle between the anatomical axis of the first meta-carpal and that of the proximal phalanx of the thumbon thumb posteroanterior (PA) radiographs at initialvisit. We repeated the measurement on PA radio-graphs immediate after surgery and 2 years aftersurgery.Results: The average angulation deformity of thumbMCP joint was 25 (range 16–34)� preoperatively.During surgery, we performed metacarpal closingwedge osteotomy at the level of metacarpal neckafter excision of the extra-digit and fixed the meta-carpal bone with longitudinal K-wire. We removedthe K-wire 3 weeks after surgery. The average angu-lation of thumb MCP joint was improved to 2 (range0–5)� immediate after surgery. However, the averageangulation of the joint was worsened to 5 (range 0–10)� 2 years after surgery.Summary: Metacarpal osteotomy is a very usefulprocedure to correct the angulation deformity of thethumb MCP joint effectively in patients with Wasseltype IV thumb duplication. Considering the residualangulation deformity of thumb MCP joint 2 years aftersurgery, 5� of overcorrection can be recommendable.

A-0531 Interpretation of ulnocarpal stress test indifferent forearm rotations

Hanvit Kang1, Jin Hyung Lim2, Il Jung Park1 andJoo Yup Lee1

1Department of Orthopedic Surgery, The CatholicUniversity of Korea2Department of Orthopedic Surgery, Gyeongsang University

Purpose: Ulnocarpal stress test is an essential phy-sical examination for differential diagnosis ofulnar-sided wrist pain. However, there were some

debates on the interpretation of the results of ulno-carpal stress test according to different forearmrotation positions. The aim of this study was to ana-lyze the correlation of positive results of ulnocarpalstress test in different forearm rotations with specifictender point of the wrist joint.Methods: From March 2015 to February 2017, 54patients who were diagnosed as ulnar impaction syn-drome or ulnar styloid impingement syndrome byMRI or arthoscopy were included. We performedulnocarpal stress test in forearm supination and pro-nation position and checked tenderness on dorsallunate and ulnar head area (point A) and ulnaraspect of triquetrum and ulnar styloid area (pointB). We analyzed odds ratio and statistical significancebetween positive physical examination and sites oftenderness using Fisher’s exact test; p values0.05 were considered statistically significant.Results: Forty-six patients had tenderness on thepoint A and finally diagnosed as ulnar impaction syn-drome through consistent radiologic findings; sub-chondral sclerosis, subchondral cysts, and‘‘kissing’’ lesions of the lunate, triquetrum, andulnar head. Among them, 40 of 46 patients had posi-tive ulnocarpal stress test in forearm supinationposition. Odds ratio of positive ulnocarpal stresstest in forearm supination and tenderness of pointA was 8.25 and it was statistically significant. Eightpatients had tenderness at point B and were diag-nosed as ulnar styloid impingement syndrome withradiographic chondromalacia between proximal tri-quetrum and the ulnar styloid. Six of eight ulnar sty-loid impaction syndrome patients had positiveulnocarpal stress test in forearm pronation position.There were 12 patients who were diagnosed as ulnarimpaction syndrome had positive ulnocarpal stresstest in both supination and pronation positions.Conclusion: Patients who had positive ulnocarpalstress test in forearm supination tend to have a ten-derness on the luno-triquetral joint area and be diag-nosed as ulnar impaction syndrome, and who hadpositive ulnocarpal stress test in forearm pronationtend to have a tenderness on the ulnar aspect of thetriquetrum and ulnar styloid area and be diagnosedas ulnar styloid impingement syndrome.

A-0532 Physeal bar resection under guidance with anavigation system and endoscopy for correction ofdistal radial deformities after growth plate arrest

Yoshinori Takemura1, Narihito Kodama1, Kosei Ando2,Kensaku Kuga3, Yoichiro Kuyama4 and Shinji Imai11Department of Orthopaedic Surgery, Shiga University ofMedical Science

SS102 Journal of Hand Surgery (Eur) 43(Supplement 2)

2Department of Orthopaedic Surgery, Yasu Hospital3Department of Orthopaedic Surgery, Japan CommunityHealth Care Organization Shiga Hospital4Department of Orthopaedic Surgery, Shiga Medical Centerfor Children

Objective: Growth arrest after trauma may be causedby the formation of a physeal bar across the physealcartilage. Without treatment, the resulting angularand longitudinal growth disturbance will progressthroughout the remainder of a child’s growth periods.Langenskiold introduced physeal bar resection toreestablish growth and to prevent progressive limbshortening and angular deformity. However, thismethod is a demanding procedure and is notalways successful. The extent and location of thephyseal bar should be determined accurately. Inaddition, the physeal bar must be resected comple-tely and the normal physis must be retainedundamaged.

Navigation systems have been introduced forintraoperative guidance to obtain better accuracywhile endoscopy has been introduced to allow mini-mally invasive surgery. An endoscope has an intrinsiclight source and the ability to magnify images of anarrow or closed space. Their use enables intra-operative identification of the extent of a physealbar and allows more accurate surgery.

We describe illustrative cases of premature distalradius physeal arrest treated by Langenskiold’smethod using a navigation system combined withendoscopy.Methods: During the operation, we used a3-dimensional imaging system (ARCADIS Orbis 3D;Siemens, Munich, Germany), with the capacity tocreate a 3-dimensional image (axial, coronal, sagit-tal). These scan data were transferred to the CT-based navigation system (Kolibli navigation station2.0; BrainLAB, Feltkirchen, Germany). The operationwas performed under general anesthesia. Then, twothreaded pins were inserted into the shaft of theradius. A fixed-based tracker was connected tothese pins. A high-speed handpiece attached to a 4-mm diameter drill was connected to the universaltracker. Using this navigation system, we were ableto identify the location of the physeal bar and thedirection of drilling in three dimensions (axial, coro-nal, sagittal). The drill was passed into the physisalong the physeal bar under navigation. Then thecavity made by drill was irrigated and dried with anarrow suction tip, and a 1.9-mm, 30� endoscope(Stryker, Kalamazoo, MI, USA) was introduced dryinto the canal produced to check the accuracy of direc-tion and resection of the physeal bar. This maneuver(drilling under navigation, followed by irrigation,

suction, and endoscopy of the canal) was repeateduntil the physeal bar was completely resected. Afterresection of the physeal bar, the cavity in the bone wasfilled with bone wax. After operation, the wrist wasimmobilized in a cast for 2 weeks and checked byradiography at outpatient department visits every 6months until the growth plate close.Results: We performed this method for prematuredistal radius physeal arrest cases. After operation,the deformities of all cases have been improved.The recurrence of physeal arrest dose not happened.Conclusion: Growth arrest after trauma causessevere deformity and loss of function.Langenskiold’s method provides excellent treatment,but is very demanding. We consider that the combi-nation of both tools is more suitable than the techni-cally demanding Langenskiold’s method alone.

A-0533 Influence of distal radius fracture internalfixation on social and psychological patients well-being in late post-operative period

Maksim E. Sautin1, Bella Gazimieva2 and Igor Golubev3

1European Clinic of Sports Traumatology and Orthopaedics(ECSTO), Moscow, Russia2Sechenov First Moscow State Medical University (FMSMU),Moscow, Russia3N.N. Priorov National Medical Research Center ofTraumatology and Orthopaedics (CITO), Moscow, Russia

Objectives: The aim of the study was to analyze theattitude of patients to surgical treatment of distalradius fractures by fixation with plates and itsimpact on their social and psychological conditionin a late postoperative period.Methods: We have proposed a questionnaire of 19questions, assessing the quality of life of patientsafter distal radius fracture fixation. Questions con-sider patients’ concerns while planning surgicaltreatment, rehabilitation and life after surgery.

We questioned 31 patients after open reductionand internal fixation of distal radius fractures withDVR or VA-LCP plates from 2010 to 2017.

Among the participants, the number of malepatients was 9 (29%), female – 22 (71%). The averageage was 55 years, with median of 59, minimum – 27,maximum – 82 years. Mean time elapsed sinceoperation was 1183 days, with a minimum of 95 andmaximum of 2442 days. The study included patientsundergoing surgery both with and without wristarthroscopy. Removal of the plate was consideredan exclusion criterion.Results: We analyzed the patients’ answers.

FESSH Abstracts SS103

-61.3% (19) believe their lives changed after theoperation.

-41.9% (13) of patients think about the plate routi-nely or during physical activity.

-74.2% (23) of patients frequently discuss theiroperation, 83.9% (26) would easily joke about it.

-16.1% (5) of patients use the operated hand less.-77.4% (24) think the strength in the hand did not

change after the operation, in 22.6% (7) it becameweaker.

-12.9% (4) of patients think the limb would movebetter without fixator.

-83.9% (26) see no visible difference in their hands.-6.4% (2) needed to cover the surgical scar.-19.4% (6) feel the plate under the skin.Only 12.9% (4) consider removing the implant. For

most of them (51.6% – 16), secondary surgery wasthe main reason not to. If it was, hypothetically,removed, 74.2% (23) of the questioned would throwit away rather than keeping it.

-3 (9.7%) of the patients had encountered any com-plications while passing the airport metal detectors.

-12.9% (4) had the need of written confirmation ofhaving the implant.

-1 patient (3.2%) was denied an MRI due to havingan implant.

Finally, none of the patients doubted choosing sur-gery and all of them, faced with the choice again,would choose the same.Conclusion: The results of the study confirm theeffect of the operation and implant presence on thesocial and psychological well-being of patients.Subjects actively and in detail answered the ques-tions. The questionnaire helped to form an idea ofthe attitude of patients to having metal implants intheir bodies and its effect on their daily life.

A-0539 Avanta Preflex silastic implant inmetacarpophalangeal joint arthroplasty inrheumatoid arthritis

Shosuke Akita, Shigeyoshi Tsuji, Koji Yachi,Takaaki Noguchi and Jun HashimotoOsaka Minami Medical Center, Kawachinagano, Japan

Background: Silicone metacarpophalangeal (MP)joint arthroplasty is a valuable option for the treat-ment of ulnar drift in the hands of patients with rheu-matoid arthritis (RA). There are two designs forsilicone MP joint arthroplasty. One is the straighttype (Swanson or Avanta/Sutter), and the other isthe preflexed type (NeuFlex or Avanta Preflex).There are many reports of the results with eachimplant. However, to the best of our knowledge,

there have been no previous reports about theresults of the Avanta Preflex implant.Objectives: The purpose of this study was to evaluatethe short-term outcomes when the Avanta Prefleximplant was used to treat RA patients with ulnar drift.Methods: A retrospective review of Avanta Preflexsilicone MP joint arthroplasties was performed in26 patients (32 hands, 128 implants) with RA.Patients were evaluated at an average of 48 months(minimum follow-up period, 24 months). Objectiveresults included grip strength, ulnar drift, extensorlag, and arc of motion measurements at the MPjoints. Preoperative and postoperative data for gripstrength, ulnar deviation, and finger motion werecompared using the paired two-group t-test. Thelevel of significance was set at p< 0.05.Anteroposterior and lateral radiographs wereobtained at the time of latest follow-up for all fingers.The radiographs were reviewed for erosions adjacentto the silicone implant and implant fractures.Subjective results were evaluated with visual analo-gue scale (VAS) scores, which measured pre- andpostoperative pain at rest and during use, hand func-tion, and cosmetic appearance. Patient satisfactionwas noted.Results: The mean grip strength improved from5.0 kg preoperatively to 6.5 kg at the time of finalfollow-up (p¼ 0.023). The mean ulnar drift improvedfrom 33� preoperatively to 14� at the time of finalfollow-up (p< 0.001). The mean arc of motion of theMP joints improved from 28.4� preoperatively to 45.1�

at the time of final follow-up (p< 0.001). The meanextension deficit of the MP joints improved from 55�

preoperatively to 20� at the time of the final follow-up(p< 0.001). At the final follow-up examination, radio-graphic evaluation revealed that 4 (3%) of theimplants were definitely fractured and 98 (77%)were intact or mild angulation. The VAS assessments(0�10) showed overall decreases in pain at rest andwith use and improvements in hand function and cos-metic appearance. Statistical analysis showed a sig-nificant improvement in cosmetic appearance(p¼ 0.01). Twenty-three patients (90%) were satisfiedwith their results.Conclusions: Arthroplasty of the MP joints with theAvanta Preflex implant provides a more functionalarc of motion and improvement of grip strength andappearance in short-term follow-up. The AvantaPreflex implant appears to give similar results tothose obtained with other silicone implants in RApatients.

SS104 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0545 fingertip reconstruction with occlusivedressing: Clinical results and biological analysis ofthe dressing contents

Isabelle Pluvy, Daniel lepage, Marie Panouilleres,Damien Feuvrier, Laurent Obert and Francois LoiselOrthopedic, Traumatology and Hand Surgery Unit,University Hospital CHRU Besancon, France; ResearchUnit, Nano Medicine, Medical School, University ofBourgogne, Franche-Comte, France

Aim: To evaluate the fingertip reconstruction withocclusive dressing and explore the mechanismsand the mediators of this ‘‘fingertip regeneration.’’Patients and Methods: Thirty-eight patients, 4females, with a mean age of 47.2 (22�73) who sus-tained a fingertip injury (amputation 20% amputationwith crush: 80% – Zone1: 50%, Zone 2: 40%, Zone 3:10%) have been treated with occlusive dressing(occlusive dressing – tegaderm – each 6 daysduring 3�6 weeks). Two evaluations have been con-ducted: (1) prospective clinical analysis with a finalassessment at 1 year by an independent operator tomeasure the aesthetics and functional results(Weber, Semmes Weinstein monofilament, QDash;(2) a biologic analysis of the dressings in order tosearch microorganisms, cytokines, and growth fac-tors (19 cases). Statistical tests have been conductedon quantitative and qualitative variables.Results: Of 38 patients, 33 have been reviewed with amean follow-up of 16.4 months (12�25) Among the33 patients reviewed, the healing was acquired in 4.1weeks (3�6) with 4 dressings (3�6). The thickness ofthe fingertip was excellent in 40% and good in 60%.Eight percent of patients were satisfied or very satis-fied. Weber test reached 5 mm for the fingertipreconstruction (3 mm for the opposite side),Semmes Weinstein was 4.1 (3.7 opposite side).Quick dash reached 13.8 (11�20). Twenty percenthave cold intolerance without correlation with injuryor functional results. Forty percent of patients haddysesthesia during 1.2 months (1�2). Bad smellwas considered as a problem in 20% of cases.There were no infections on this series. The delayto return to work was 5 weeks (3�6 weeks). Theanalysis of the dressing exudates brings to light apullulement of saprophyte bacterium of the skin butalso pathologic species, different at each week, andpresence of angiogenic factors (PDGF, VEGF, EGF).Discussion and Conclusions: 17 publications, 14series (2 comparatives) with 382 patients have beenpublished concerning occlusive dressing with goodand reproducible results. Before 2001, authors(Mennen, Quell) have reported large series with

weber of 4 mm after 2 months of dressing with noinfection.

After 2001, the use in Burn (Prommersberger),assessment by US (Hoigne) of the regenerated fin-gertip and biological analysis of the containt of thedressing (Lasserre) have been published. The occlu-sive dressings remain a reliable and reproduciblealternative for treatment of fingertip injuries inzones 1 and 2. This reconstruction seems to dependon bacterium pullulement and cellular growth fac-tors liberation. Our work is the first to report clinicaland biological assessment.

A-0546 Anatomical study of the anconeus muscle

Veronica Jimenez-Dıaz, Lorena Garcıa-Lamas,Miguel Angel Porras-Moreno and David Cecilia-Lopez12 de Octubre University Hospital, Madrid, Spain

Objective: The aim of this anatomical study was toclarify the anatomy of the origin of the anconeus inthe lateral epicondyle and to define the anatomicalvariants and innervations patterns of this muscle aswell as the distance of nerve branch in relationshipwith the lateral epicondyle.Methods: Fifty-five elbows from 30 formulated cada-vers with Cambridge solution were dissected.

Thirteen cadavers were males and seventeen werefemales with ages between 62 and 98 years. Meanage was 76 years. Twenty-eight elbows were rightand twenty-six were left. We studied the macrosco-pical shape of the anconeus muscle, the exact originin the epicondyle and insertion in the ulna as well asthe innervation patterns and the relationships withthe surrounding structures. Measurements weremade with a digital calibrator (TopCraf).Results: We observed a close relationship betweenthe lateral joint capsule of the humero-ulnar jointand anconeus muscle. We observed a clear continuitybetween medial head of triceps and anconeusmuscle in 19 specimens. We observed a doubleinnervation pattern in anconeus muscle through arecurrent branch of posterior interosseus nerve in15 of 54 elbows.

The entry point of the branch into the anconeusmuscle was measured in relationship with posteriorborder of epicondyle at 0�, 30�, 45�, and 90� of elbowflexion. The horizontal distance was 11.36 mm(9.3�12.87), 12.5 mm (10.18�13.91), 13.98 mm(11.76�15.59), and 16.87 mm (14.56�19.04), respec-tively. The vertical distance, in relationship withtransepicondylar axis, was 2.34 mm (0�7.57),4.21 mm (0�8.61), 8.21 mm (4.92�11.32), and13.32 mm (11.58�15.59 mm).

FESSH Abstracts SS105

These data demonstrate a growing horizontal andvertical distance between the entry point of the anco-neus nerve branch with the increase of elbow flexiondegrees. This distance is higher in men.Conclusions: This complete anatomical study ofanconeus muscle with the description of the relation-ship between the anconeus motor branch and thelateral epicondyle and its variation with elbow flexion,as well as its possible involvement in the lateral painof the elbow and the demonstration of the existenceof a pattern of double innervation to the anconeusthrough a recurrent branch of the posterior inteross-eous nerve can help to better understand of both theanatomy of this muscle and the possible causes ofpain in this area.

A-0547 A novel use of QR code stickers afterorthopaedic plaster application

G. Fieraru, A. T. Gough, R. Middleton, P. Gafney,M. Butler and R. J. KincaidTrauma and Orthopaedic Department, The Royal CornwallHospital, Truro, UK

Objective: We have developed a novel solution toensure that information and contact details arealways available while a patient is in plaster. A rollof tape is applied over the outside of the plaster con-taining both phone numbers and a Quick Response(QR) code. When scanned with a smartphone, thecode loads the plaster team’s webpage from the hos-pital website, containing information and videosincluding enhancing patient recovery.Methods: A unique roll of tape was designed anddistributed to apply on all plasters. On returning tothe plaster room, patients filled in a questionnaireabout their use of the tape. A total of 101 patientswere surveyed between November 2015 andFebruary 2016. The questionnaire contained 10binary questions.Results: Ninety-seven per cent had a sticker on theirplaster when they returned to clinic; 19% of patientsscanned the QR code; 56% of patients had a smartphone, which could be used a QR code reader; 95% ofthe people who scanned the QR code found the infor-mation useful; and 9% of patients used the contactdetails on the plaster to seek advice.Conclusion: The use of the QR code for advice aboutplaster problems has not been previously used. Ourresults show that this is an effective tool in theproactive management of plaster problems andpatient reassurance. Now we are developing a port-folio of information accessible to our patients usingthe QR code.

A-0551 Bone defect at hand level solved by theinduced membrane (Masquelet) technique

Isabelle Pluvy1, Gauthier Menu1, Agathe Alvernhe1,Damien Feuvrier1, Marie Panouilleres, Laurent Obert1,Vivien Morris2, A. Tchurukdichian2 andFrancois Loisel1

1Orthopedic, Traumatology, and Hand surgery Unit,University hospital CHRU Besancon, France2Research Unit, Nano Medicine, Medical School, Universityof Bourgogne, Franche Comte, France

Introduction: Twenty-six cases of bone defects in thehand were treated using the induced membranetechnique, thereby avoiding the need for allograft,microsurgery and amputation.Methods: Twenty-three patients (mean age 51.7years, 85% males, 65% work-related accident) with26 bone defects in the hand were included prospec-tively in the study at three participating hospitals.Nineteen cases were traumatic and seven wereseptic. The bone defect was at least one phalanxlong and averaged 2 cm (0.5–7) in length. Thirty-eight percent of the injuries were extra-articular.All cases were treated using the induced membranetechnique which consisted of stable fixation (with flapif necessary) and filling the void created by the bonedefect by a cement spacer (PMMA). The second stageof the treatment was performed 3.7 months (1–14)after the first stage; the cement was removed andthe void filled with cancellous bone taken from thedistal radius in 22/26 cases. Bone union was evalu-ated prospectively on X-rays and CT scans (if needed)of each case by a surgeon not involved in the treat-ment. Failure was defined as nonunion at 1 year oruncontrolled sepsis at 1 month.Results: Two of the bone defect cases failed toachieve union. No septic complications occurredand all initially septic cases had resolved. Boneunion was achieved in 5 months (1–14) in 92% ofcases. Two biopsies provided evidence that osteoidtissue was created by the Masquelet technique.TAM of injured finger reached 114� (20–250). TheQuickDASH was 19 (4–40) and return to work waspossible after 6 months (1–24).Conclusion: Masquelet first described 35 cases oflarge tibial nonunion defects treated by the inducedmembrane technique in which the defect was filledwith cancellous bone. The cement spacer induces aforeign body membrane (neo-periosteum) that actsas a biological chamber. In animal models,Pellissier and Viatteau showed that this membranesecreted growths factors (VEGF, TGFbeta1, BMP2)

SS106 Journal of Hand Surgery (Eur) 43(Supplement 2)

and was osteoinductive for cells. This technique canbe used in emergency or septic conditions where thebone defect cannot be treated by shortening. It allowsearly mobilization and does not require microsurgeryto achieve bone union.

A-0553 Mechanisms of failure in base of thumbimplant arthroplasty: A systematic review

David J Hunter-Smith, Dasun Ganhewa, Rui Wu,Michael P Chae, Vicky Tobin and Warren M Rozen1Department of Plastic and Reconstructive Surgery,Frankston Hospital, Peninsula Health, Frankston Victoria,Australia2Monash University Plastic and Reconstructive SurgeryGroup (Peninsula Clinical School), Peninsula Health,Frankston, Victoria, Australia

Objective: The objective of the current systematicreview was to identify the complications leading toimplant failure in basal thumb arthritisMethods: The systematic review was performedaccording to the Preferred Reporting Items forSystematic reviews and Meta-Analyses (PRISMA)guidelines. The medical data bases PubMed,Medline, Embase and Cochrane data base of sys-tematic reviews were searched on 27th May 2017using a Boolean combination of key word and Meshterms. A bibliographic hand search was done for allarticles included for full-text review and all relevantreview articles in the past 10 years.

The identified implants were grouped by designconcept in to five groups: Total joint replacement,hemiarthroplasty, interposition with no, partial andtotal trapezial resection. The number of reportedcomplications was combined for each implantdesign group and overall by simple addition.Implant-years were calculated by multiplyingnumber of arthroplasties in each study by the studymean length of follow-up. The rate of each complica-tion was calculated for each implant design group,and an overall rate as a proportion of the numberof cases with each complication divided by the totalnumber of Implant-years for each design group. A10-year rate of complication was calculated subse-quently and expressed as a percentage.Results: A total 128 articles were included post fulltext review. Four articles were level I, 1 level II, 21level III, 102 level IV. A total of 5299 arthroplasties in5576 patients were identified; 82% were done onfemales and 55% on the dominant hand. The meanage of the patients ranged from 51 years to 71 years,and the mean length of follow-up of the studiesranged from 4 months to 196 months (16 years). A

total of 54 separate implant types for base of thumbarthritis were identified; 20 total joint replacements,5 hemiarthroplasty, 12 interposition with partial tra-pezial resection, 15 interposition with total trapezialreplacement, and 2 interposition with no trapezialresection.

Eleven implant-related complications were identi-fied which lead to at least revision of one implant.The overall 10-year revision rate for all implantscombined from most common to least common:Aseptic loosening (6.19%), dislocation (5.43%), per-sistent pain (3.77%), subluxation (1.03%), fracture ofimplant (0.91%), peri-prosthetic fracture (0.83%), for-eign body reaction (0.79%), infection (0.59%), osteo-lysis (0.48%), implant subsidence (0.44%), andperiprosthetic ossification (0.16%)Conclusions: The evidence supporting the use ofimplant arthroplasty must be improved by means ofprospective studies with long-term follow-up. Manytypes of implants of different design concepts, mate-rials used, and methods of fixation have beeninvented to over the past 50 years. The top threecomplications leading to implant failure were asepticloosening, dislocation, and persisting pain. Designssusceptible to aseptic loosening were total jointreplacements and hemiarthroplasties. All designswere susceptible to dislocation. Implant revisiondue to persisting pain was higher in designs usedwith partial trapezial or no trapezial resection andlowest in the total joint replacement and interpositionwith total trapezial resection groups.

A-0554 Wide-awake flexor pollicis longus anddigital nerve repairs on patients in the proneposition

Thomas Apard1, Yann Erwan Favennec1,Gilles Candelier1, Daniel Mckee2 and DonaldH. Lalonde2

1Center of Hand Surgery, Private Hospital of Saint Martin,Caen, France2Plastic Surgery, Dalhousie University, Saint John, NewBrunswick, Canada

Objective: Wide-awake, local anesthesia, no tourni-quet hand surgery is a growing field of hand surgerywith many advantages described in the literature.The goal of this study is to validate this techniquewith the patient in prone position for the flexortendon and nerve repairs of the thumb.Method: We describe our first experience using thistechnique with eight patients positioned on his abdo-men (prone) under WALANT anesthesia. We per-formed a primary repair of a laceration of flexor

FESSH Abstracts SS107

pollicis longus (FPL) and both palmar digital nerves(DN) at the level of the proximal phalanx for threepatients, a FPL repair for two patients, a DN repairfor two patients and an exploration of the wound forone patient. The patients were positioned in a proneposition during the injection of local anesthesia andfor surgery. We injected local anesthesia (20 cc of 1%lidocaine with 1:100,000 epinephrine: 2 cc of bicarbo-nate 8.4%) using tumescent local anesthesia techni-que. Waiting at least 30 min after injection andbefore cutting is important to achieve maximalvasoconstriction.Result: There was no need for any additional localanesthesia injections or sedation. No tourniquet wasrequired, and visualization was excellent.

In the usual supine position with the patient on hisback, the wrist is supinated and the thumb positioncauses the surgeon to tilt his head to accommodate.We found the prone position offered improved expo-sure of the palmar thumb because it tends to lay flatagainst the table. This was especially advantageouswhen we performed wide-awake microsurgical digi-tal nerve repair.

The prone position can also be helpful to decreasehand movement during local anesthetic needle inser-tion. Two patients were somewhat anxious in thebeginning, so the prone position was helpful since itmade it harder for them to look at his hand. Thepatients were comfortable lying on their abdomenwith a pillow under the shoulder for head comfort.After the repair, he was able to move the thumb with-out difficulty when we asked him to so we could per-form the intraoperative total active movementexamination.Conclusion: With wide-awake surgery, we were ableto enjoy the advantages of prone position for thumbFPL and digital nerve microsurgery repair, whileavoiding the risks associated with prone position inpatients under general anesthesia. We were able toeducate the patient with verbal postoperative instruc-tions as we closed the skin and applied the splint.

The ideal patient positioning for wide-awake handsurgery is where both the patient is fully comfortableand the surgeon gains technical advantages andimproved visualization from the positioning. We sug-gest that surgeons consider the prone position forthumb surgery in the wide-awake patient.

A-0556 Dual mobility trapeziometacarpalprosthesis for active people

Thomas Apard, Yann-Erwann Favennec andGilles CandelierCenter of Hand Surgery, Private Hospital Saint Martin,Caen, France

Objective: Despite of good results at midterm follow-up, implantation of a trapeziometacarpal prosthesis(TMP) in active patients is still controversial. The aimof this prospective monocentric study was to analyzethe outcome of a dual mobility TMP permitting a spe-cific early active rehabilitation program, and thus toevaluate the duration of sick leave.Method: Between June 2015 and June 2016, 15 work-ing female patients, aged between 43 and 63 years,have been treated with a dual mobility TMP Maia�

(LepineTM, France) for thumb arthritis after failureof conservative treatment (intra-articular steroidinjection and customized splint). At 48 h post opera-tive, self-active motion was encouraged in the day-time and splinting was advised at night during 1month.

All the patients have been evaluated clinically(mobility, visual analogue scale of pain, PRWEscore), and radiologically at 1-month and 1-yearfollow-up. The duration of sick leave and the condi-tion of the return to work were noted.Results: Clinically, the PRWE and VAS scores were77.7 and 8.3 before surgery, 13.9 and 1.14 at 1-monthfollow–up, and 3.9 and 1.0 at 1-year follow-up. Therewas no infection and no complex regional pain syn-drome. The Kapandji score of opposition of the firstcolumn was 10 for all the patients.

The radiological examination at 1-month and 1-year follow-up did not showed any mobilization orradiolucent lines of the cup or stem. The mean dura-tion of the sick leave was 52.5 days (extremes 30 and60). Thirteen patients returned to work at the samejob and two changed their activity.Conclusion: There is no study about the treatment ofbasal thumb arthritis with a TMP in working popula-tion. Theorically, the trapeziometacarpal prosthesiswould be the best option for a faster return to workin comparison with a trapeziectomy, but the implan-tation of a total arthroplasty in young people is stillcontroversial.

Furthermore, the 3 to 4 weeks immobilization ofthe thumb column is usually recommended afterTMP implantation: The risks are the dislocation(maybe resolved with a dual mobility) and the lackof osteointegration of the cup coating. In this study,the dual mobility with early active rehabilitation per-mitted to have 52.5 days of sick leave. There was no

SS108 Journal of Hand Surgery (Eur) 43(Supplement 2)

problem of osteointegration of the cup at 1-yearfollow-up in this short series. The dual mobility tra-peziometacarpal prosthesis is a very good option forworking people.

A-0557 Ultra-thinned pedicled groin flap to salvagedegloved ring fingers: A report of four cases

Adeline Cambon-Binder, Violaine Beauthier-Landauer,Alain-Charles Masquelet and Alain SautetSaint-Antoine Hospital, Paris, France

Objective: Non-replantable ring finger avulsionsgenerally require amputation at the first phalanx orthe metacarpal level. Our purpose was to report ourexperience of salvage of degloved fingers, class IIIaccording to the Urbaniak classification (J HandSurg Am 1981) using a pedicled ultra-thinned groinflap.Methods: Four slim patients aged from 16 to 24 yearshad a complete degloving of their ring finger withintact interphalangeal capsuloligamentous appara-tus. The amputated fragment included the distal pha-lanx. It was lost in two patients and not suitable forreplantation in two others. The groin flap was har-vested from the lateral groin area with an 8 cm longtubed pedicle and immediately defatted to a meanthickness of 4 mm (3–5 mm). It was then wrappedaround the digit. All donor sites were closed primar-ily. Postoperatively, the patient mobilized the fingerimmediately at least 30 min twice per day. Flap divi-sion of the pedicle was performed after 3 weeks. Lastfollow-up examination included measurement of thepain level, the cold tolerance, the total active motion(TAM), and aesthetic evaluation by the patient.Results: Finger salvage was successful in allpatients. A partial flap loss occurred after 10 dayspostoperatively in one patient, at the junction withthe recipient area. After excision of ischemic tissues,the flap could cover the volar aspect of the digit,while a full-thickness skin graft was applied on thedorsal aspect. At a mean follow-up of 8 months (6 to14), all the patients were satisfied with the aestheticresult and reported no pain or cold intolerance. TAMwas 180� in average (range 170 to 190�).Conclusions: Ultra-thinned groin flap is a viableoption to cover degloved digits when replantation isnot feasible or failed, avoiding additional loco-regio-nal donor site morbidity. The functional and aestheticresults were satisfactory in all our cases.Requirements are integrity of the proximal interpha-langeal joint, the flexor superficialis tendon and thecentral slip of the extensor tendon. An intensive

postoperative physiotherapy regimen is crucial toachieve a complete arc of motion of the digit.

A-0558 A double plating technique to treat proximalulnar comminuted fractures: A retrospective mul-ticentric study

Gauthier Menu, Camille Echalier, Agathe Alvernhe,Severin Rochet, Julien Boudard, Daniel Lepage,Gregoire Leclerc, Pauline Sergent and Francois LoiselOrthopedic, Traumatology and Hand surgery Unit,University Hospital CHRU Besancon, France; ResearchUnit, Nano Medicine, Medical School, University ofBourgogne, Franche-Comte, France

Introduction: Comminuted fractures of the proximalulna are severe injuries often associated with boneand ligament injuries of the elbow joint (Monteggialesion, radial head fractures, dislocation or theelbow). The treatment of these fractures is verydemanding and the functional results often fair dueto associated injuries.

In a multicentric retrospective study, we report theresults of the treatment of these fractures fixed by adouble plate technique. The aim was to evaluate thefiability of the fixation and to compare it with otherseries fixed by two plate in term of bone union, func-tion of the elbow joint, and complications due toplates).Method: Twenty-four patients with an average of ageof 45 years (32�67 years) sustained a comminutedproximal ulna fracture between 2002 and 2012. Thefractures were associated in five cases with aMonteggia type lesion, in two cases with elbow dis-location, and in four cases with a Mason 3 radial headfracture. Four patients had an open fracture. Thesecomminuted ulna fractures included nine Mayo ClinicIIIB fractures. Bone fixation was performed withthird-cylinder tubular plates or anatomical Medartisplate, one plate on each side of the proximal ulnaallowing more versatile solutions for screw insertion.Results: With a minimum follow-up of 2 years (24�56months), 21 of 24 patients achieved bone union with adelay of 3.5 months. No septic complicationsoccurred. In 72% cases, Morrey score indicatedexcellent to good results with a mean score of 84.Mean flexion reached 128� (90��140�), lack of exten-sion reached 15� (0��35�). Pronation reached 84�

(65��90�) and supination 70� (10��90�). Two non-unions with stiffness have been treated by arthrolysisand new fixation.Discussion: In the reported series of fixation by plateof proximal ulna fracture, 20% of patients need theremoval of the plate. On the other hand, the anatomyof proximal ulna has been rediscovered recently with

FESSH Abstracts SS109

the definition of the PUDA (posterior angulation). Asingle straight plate on the dorsal crest remain unlo-gical due to the posterior angulation of the proximalulna (6� on the first 6 cm of the ulna in 96%of patient).There is no report in the literature of technical pointof fixation concerning complex fracture of ulna. Twoplates mean twofold more solution of fixation. Thisfixation remains easy to perform and allow with astable anatomic reconstruction of the ulna to wintime to solve others injuries in the spectrum of com-plex injuries of the elbow.

A-0560 Periphalangeal steel wire loop pullouttechnique in proximal interphalangeal joint fracturedislocation

Ho-Jung Kang1, Won-taek Oh2, Sang-yun Lee1,Jung Jun Hong1, Il-hyun Koh3 and Kam Jinhwa1

1Gangnam Severance Hospital, Seoul, South Korea2Severance Hospital, Seoul, South Korea3Yong-in Severance Hospital, Yong-in, South Korea

Introduction: The purpose of this study was to ana-lyze the clinical results of seven PIPJ fracture dislo-cation patients treated with periphalangeal steel wireloop pullout technique.Material and Methods: From May 2002 to November2016, among 108 patients with PIPJ fracture and dis-location, we retrospectively analyzed 7 patients (3men and 4 women) underwent surgical treatmentwith periphalangeal wire loop pullout with 4�0steel wire (ETHICON, Somerville, USA). Amongseven cases, one female patient was operated atanother hospital and after revision surgery at outhospital. The mean follow-up period was 36 weeks,with an average age of 32.4 years (range 13–68years). Two of the seven cases were in the fourthfinger and five cases were in the fifth. The centralslip avulsion was in four cases and the volar plateavulsion was in three cases. In four cases, wireloop pullout was performed alone. In two cases, theassociated fracture was fixed with K-wire and exten-sion block pinning was added in one case. In allcases, wire was removed 4 weeks after surgery.The radiologic results were evaluated by plain radio-graphs, and then fracture fusion and postoperativesubluxation of the joint were assessed. Clinicalresults were evaluated by modified Green andO’Brien score, which included range of motion, VASscore, and grip strength.Results: Three cases of volar avulsion were hyper-extension injuries, and four cases of dorsal avulsionwere injured by direct contact injury. In two caseswith fracture fixation with K-wire, the fracture

involved approximately 20% of the joint surface andwas performed for additional stabilization. In allcases, the pain decreased (VAS 6.9 to >1.7) and theactive range of motion of the PIPJ was restored toabout 80% of the normal range (0�120), with a flexionaverage of 99� and extension average of �5.7�. Inevaluating through modified Green and O’Brienscale showed excellent results in four cases, goodin two cases, and fair in one case. Mild flexion con-tracture and buttonhole deformity occurred in oneeach case, but the treatment was completed afterthe dynamic splint. Imaging results showed that thejoint congruency was maintained without subluxationin all cases. Fragmentation and resorption of bonefragments occurred in one each case, but the clinicaloutcome was not affected.Conclusion: In the treatment of PIPJ fracture dislo-cation involving less than 20�30% of the joint sur-face, periphalangeal steel wire pullout technique issimpler than the conventional method, no damage tothe neurovascular bundle, and can easily adjust thetension because the wire is passed through the skinand fixed outside the body using a button. Treatmentwith this method has satisfactory clinical and radi-ological results and is considered as a recommendedtreatment method.

A-0564 Joint arthroplasty with osteochondralgrafting from the knee for posttraumatic ordegenerative hand joint disorders

Narihito Kodama, Yoshinori Takemura, Kosei Ando andShinji ImaiShiga University of Medical Science, Shiga, Japan

Objective: To describe the operative procedure andreport the clinical outcomes of articular surfacereconstruction for various hand joint disordersusing autologous osteochondral grafts from theknee.Methods: Twelve patients underwent articular sur-face reconstruction for hand joint disorders withautologous osteochondral grafts from the patellofe-moral joint. Mean patient age was 36 years (range15�54 years). The patients were followed for an aver-age of 46 months (range 12�89 m).Metacarpophalangeal joint arthroplasty was per-formed in five cases and proximal interphalangealjoint in seven cases. The patients’ clinical outcomeswere evaluated with joint range of motion, visualanalog scale (0�10 points), and Disabilities of theArm, Shoulder, and Hand (DASH) score. Histologicalexamination was performed in three cases aftersurgery.

SS110 Journal of Hand Surgery (Eur) 43(Supplement 2)

Results: Graft union was confirmed in all cases with-out radiographic evidence of resorption or necrosis.Follow-up radiographic examinations showed goodgraft incorporation without signs of osteoarthritissuch as joint space narrowing. The finger flex-ion�extension arc improved significantly from anaverage of 20� to 62�. The mean visual analog scalealso improved significantly from 7.0 to 1.5. The meantotal active motion showed a significant improvementfrom 149� preoperatively to 205� postoperatively, andthe mean DASH score improved significantly from 33to 12. There were no significant differences for thearc of finger motion and DASH score between meta-carpophalangeal and proximal interphalangeal jointdisorders or between hemi and total joint arthro-plasty. Histological examination revealed viablechondrocytes in the implanted cartilage.Conclusion: Autologous osteochondral grafting fromthe patellofemoral joint provided satisfactory out-comes and may be a useful option for joint surfacereconstruction of traumatic or degenerative handjoint disorders.

A-0570 Arthroscopic diagnosis and treatment ofinjured collateral ligaments in the thumb metacar-pophalangeal joint

Masaya Tsujii1, Yoshinori Makino2, Takahiro Asano1,Kazuya Odake1 and Akihiro Sudo1

1Mie University, Tsu, Japan2Nagai Hospital, Tsu, Japan

Objective: A limited number of reports was found forarthroscopic surgeries and diagnostic tools forthumb metacarpophalagenal joint (MCPJ), regard-less of usefulness for reduction of displaced ulnarcollateral ligament (UCL) and synovectomy forpatients with rheumatoid arthritis. The purposes ofthis study were (1) to report the arthroscopic anat-omy of the uninjured ligaments and other articularstructures and (2) to describe the arthroscopic find-ings of the injured UCL and radial collateral liga-ments (RCL).Methods: The study group consisted of 26 patients(6 women and 20 men) who underwent arthroscopicsurgery for collateral injury of MCPJ. We included 18UCL and 8 RCL injuries. Surgery proceeded undervertical traction. Arthroscopic anatomy was evalu-ated from video during surgery regarding the unin-jured articular tissues, including the collateralligament of the unaffected side, sesamoids, andpalmer plate. In addition, we examined the injuredUCLs and RCLs with respect to the degree of injuredligaments, tear site, or reduction of ruptured or

displaced ligaments. The degree of injury wasdefined as follows: incomplete, complete, and dis-placed. Furthermore, the site of the ligament injurieswas classified into distal, proximal, or midsubstance.Results: At uninjured site, both UCL and RCL withtwo bundles were clearly visible to obliquely runacross the joint and have synovial plica-like meniscusat the rim of the phalangeal joint surface in allpatients. The radial sesamoid was clearly visible inall patients, whereas the ulnar sesamoid and palmarplate were difficult to be observed due to coverage ofsynovial tissues with rich vascularity. In the injuredligaments, the UCL and RCL had complete tear in 16and 8 cases, respectively. In addition, all but one haddistal injury in the UCLs, whereas the injured site ofthe RCL was not uniform with three midsubstances,three proximal, and two distal injuries. The distribu-tion of the injured site was statistically significantbetween the RCLs and UCLs. Furthermore, thedegree of UCL injury was incomplete, complete,and displaced in two, nine, and seven patients,respectively. Of seven patients with displaced UCLs,five were successfully treated under arthroscopy.Following the reduction, the ligaments were stabi-lized at the synovial plica-like meniscus. By contrast,the RCLs were completely ruptured without dis-placed ligaments in all eight patients. Furthermore,six injured RCLs at the proximal of the synovial plica-like meniscus fell into the joint.Conclusions: This arthroscopic finding showed thatboth UCL and RCL had synovial plica-like meniscusat the rim of the phalangeal joint surface. AlmostUCLs were stabilized at the synovial plica-like menis-cus even in complete and displaced injuries afterreduction. On the other hand, RCLs were injured atthe proximal to the synovial plica-like meniscus in sixof eight patients and needed to be repaired in opentechnique due to difficulty of preservation of reduc-tion under arthroscopy. We believe that the synovialplica-like meniscus could play an important role forstabilization of injured UCL and RCL in the thumbMCPJ.

A-0572 McCash and Jacobsen – open palmtechnique – versus reverse hypothenar flap for thetreatment of advanced Dupuytren’s disease

Teodor Stamate, Camelia Tamas, , Radu Budurca,Ionut Topa and Ionut AtanasoaeUniversity of Medicine and Pharmacy ‘‘Gr.T. Popa’’ Iasi,Department of Plastic and Reconstructive Surgery, Iasi,Romania

FESSH Abstracts SS111

Objective: This study intends to analyze the optimalsurgical approach that allows to have a safe and fea-sible flap, to ensure a good mid-palm covering whichpermits tendon sliding, avoiding the McCash orJacobsen (open palm) technique with a long post-operative care, using the reverse hypothenar flap(RHF).Methods: Between 1988 and 2017, we operated 517patients with Dupuytren’s disease of which 296Tubiana stages I�II and 221 with stage III�IV retrac-tions. In all cases with retraction of fingers below 90�,we used V�Y plasty (Brunner) and more than 90� weused Z-plasty in 94 patients, open surgical technique(McCash) in 55 and in 8 cases Jacobsen procedure(L-shaped skin flap), in 30 we used Patton skin graft,16 laterodigital flaps, 7 skin grafts after Hueston der-mofasciectomy, and in 54 RHF. To improve the exten-sion, we performed the release of the check-reinligaments at PIPJ in 25 cases using Z plasty and ele-vation of A3 pulley.

Postoperative hand therapy included static anddynamic splinting, exercises, edema control (handelevated, intermittent Coban wraps, hourly fingermotion) and scar management and the main objectivebeing to maintain the range of motion gainedintraoperative.Results: For the patients with the mid-palm defect>2 cm, we used the classic methods, skin grafts orMcCash (opening technique), the late onset of func-tional reeducation determined a period of incapacitymore than 14 weeks and an extension deficit of20�45�. Using the Jacobsen technique, we applieda dynamic splint for 10 weeks to avoid a progressiveflexion deformity. In 5 cases with 30� flexion defectremaining, we performed release of the check-reinligaments at PIPJ to improve extension. For the RHFpatients, physiotherapy started immediately post-operative and they had an average of 6 weeks workdisability and an overall deficit of 25� (28 cases 20�,24 cases 25�) extension and 30� in 2 cases. From 54RHF cases, only in 2 cases postoperative evolutionwas with flap tip necrosis. For this reason, inrecent years, we limited to the minimum the indica-tions of classic, skin grafts or McCash technique infavor of RHF. We indicate the RHF for advancedstages (3�4) of Dupuytren disease for ulnar digitalrays to assure early functional reeducation andsocio-professional reintegration. The mean QuickDash score was 23.1 preoperatively improving by amean of 8.1 points to 15.0 after surgery.Conclusions: RHF for skin closure in Dupuytren dis-ease is a safe and feasible technique, shortening thehealing time compared to classic methods, skingrafts and open palm technique – McCash orJacobsen procedure – and allow the immediate

functional reeducation improving the final results.RHF is a simple technique insuring a good mid-palm covering which permit tendon gliding with alow donor site morbidity. The more intensive physicaltherapy program for the RHF is improving the finalresults, as we tested at 8 weeks postoperative. Eachtechnique doesn’t exclude the other, each with itsown advantages and disadvantages, but patientselection will determine the technique choosing.

A-0576 An outcome study of microvascular replan-tation in 1013 multi-level complete traumatic fingeramputations: A tertiary trauma center experience

Yi-Chun Huang1, Charles Loh2, Shih-Heng Chen2,Cheng-Hung Lin2, Yu-Te Lin2 and Chung-Chen Hsu2

1Surgery, Chang Gung Memorial Hospital, Taiwan2Department of Plastic and Reconstructive Surgery, ChangGung Memorial Hospital, Taiwan

Objective: To compare replantation results of trau-matic complete finger amputation at various levelsand functional outcomes in a single trauma center.Method: From January 2009 to December 2015, aretrospective review of 600 patients with a total of1013 replanted digits was performed. Patient demo-graphics, trauma history, comorbidity, injurymechanism including surgical and functional out-comes were noted. Inclusion criteria were age >18years old, amputation with phalangeal bone involve-ment, amputation level distal to metacarpophalan-geal joint (MPJ). Exclusion criteria were pulpamputation only, degloving soft tissue injuries, ser-ious concomitant trauma. SPSS v17 was used for thestatistical study.Results: There were 522 male and 78 female patientswith a mean age of 39 years; 52% of patients had asingle finger amputation, 22% multiple fingers, 20%only thumb, 4.3% with thumb and finger(s), 0.8%bilateral finger amputations. Most injuries (94%)were work-related. Crushing injury accounts for87%, clean cut 10.5%, avulsion 2.2%. Annual replan-tation patient number was between 68 and 106 with afailure rate between 13 and 21% (average 17.28%).

We found crush (OR¼ 2.218, p¼ 0.01) and avulsion(OR¼ 8.108, p< 0.001) injuries significantly corre-lated with an increased failure rate whereas age(OR¼ 1.002) and comorbidity were not. Level ofamputation from the middle phalanx distal to PIPJincluding the DIPJ (middle phalanx level) may berelated to higher failure rate. The mean follow-uptime was 7.29 months. The average injured handgrip power was 20.21 kg and key pinch power was5.21 kg. Compared to the contralateral normal

SS112 Journal of Hand Surgery (Eur) 43(Supplement 2)

hand, the resulting ratio of grip power was 63%, theratio of key pinch power was 57% irrespective of digitreplanted.

In 518 single digit replantations, middle phalanxlevel type injuries resulted in a statistically signifi-cant limited DIPJ ROM of 14.98� compared with theother more distal level type injuries (p< 0.05).Conclusion: Stable and higher successful digitalreplantation success rates are achievable today. Oldage and comorbidity are not absolute contraindica-tions. Amputations distal to the mid-section of themiddle phalanx were associated with an increaseddifficulty of re-vascularization, difficulty in maintain-ing venous bleeding/outflow, and a greater degree ofROM limitation. After careful assessment, we maygive up avulsion injury without absolute indication.Hands with digit replantation have a moderate lossof grip and pinch power and patients should be pre-warned.

A-0577 Patterns of radial notch fracture in elbowfracture dislocations with proximal ulnacomminution

Natsumi Saka1, Hirotada Matsui2, Hideki Tsuji2,Yoshiaki Kurata2, Hideaki Miyamoto1, Gen Sasaki1 andTaketo Kurozumi1

1Department of Orthopaedics, Teikyo University, Japan2Orthopaedic Trauma Center, Sapporo Tokusyukai Hospital,Japan

Objective: Recent studies have revealed the relation-ship between type of coronoid fractures and injurymechanism of elbow fracture dislocations. Althoughthese progresses made prognosis of elbow fracturedislocation better, the treatment of elbow fracturedislocation with proximal ulna comminution, suchas posterior fracture olecranon dislocation, hasremained the challenging problem. Proximal radio-ulnar joint plays an important role in elbow function;however, the patterns of radial notch fracture in ole-cranon fracture dislocation have not been clarified.The purpose of this study is to assess the size andlocation of radial notch fractures in elbow fracturedislocation with proximal ulna comminution and toanalyze the difference among injury patterns.Methods: We analyzed the 2-dimensional and3-dimensional computed tomography of 14 patientswith elbow fracture dislocation with proximal ulnacomminution. Injury patterns were classified as ante-rior olecranon fracture dislocation (AOFD) (n¼ 5),posterior olecranon fracture dislocation (POFD)(n¼ 6), posterior Monteggia injury associated withterrible triad fracture dislocation (n¼ 3). Number of

articular fragments, longitudinal diameter of eachfragment, and fracture location in the radial notchjoint surface were assessed.Results: Fractures in radial notch were noted in allcases. Articular surface of radial notch was mostcomminuted in POFD group. In AOFD group, fourcases had two articular fragments and one casehad one fragment. In POFD group, five cases hadthree fragments and one case had two fragments.In posterior Monteggia group, all cases had two frag-ments (p¼ 0.03). With regard to the location of thefracture line, three of five cases in AOFD group had afracture line in lower 1/3 of joint surface, four of sixcases in POFD group had fracture lines in bothmiddle and upper 1/3 of joint surfaces. In posteriorMonteggia group, two cases had a fracture line inupper 1/3 and one case had a fracture line in lower1/3 of the joint surface. Mean longitudinal diameter ofeach fragment was 6.7� 1.7 mm in AOFD group,9� 3.1 mm in POFD group and 11� 4.9 mm in poster-ior Monteggia group (p¼ 0.1).Conclusions: In POFD, fracture in radial notch ismore complexed, compared to other type of instabil-ity pattern with proximal ulna comminution. In thetreatment of POFD, attention must be paid to recon-struct the radial notch by open reduction and fixation.Comminution of the radial notch joint surface mightaffect the stability of radial head and congruency ofthe proximal radioulnar joint.

A-0586 The fascia lata graft: A new technique formultiple extensor tendon defect repair

M. Yavari, S. Shahrokh, M. Moosavizadeh andS. AlhosseiniShahid Beheshti University of Medical Science, Tehran, Iran

There are many challenges for extensor tendondefects reconstruction, specifically when there is along gap. We attempt to introduce our new methodfor these cases with use of facial late inter positiongraft. Between 2009 and 2016, we have used fromTFL graft for eight patients with extensor tendongap larger than 6 cm. We follow them for at least 1year and we recorded extension lag and flexion lossfor them. Also we follow them for any complication.In five patients, there is three-finger involvement,and in three patients, we have four-finger involve-ment. Three cases (35%) had synchronous softtissue damage that repaired with reversed radialforearm flap at the same time.

The total extension loss was between 5 and 20(mean: 15), and total flexion loss was between 0and 10 (mean: 5), both of them are acceptable.

FESSH Abstracts SS113

A-0589 Effectiveness of application of variablesplinting devices in postoperative movementrehabilitation in patients with posttraumatic elbowcontractures

I. M. Kurinnyi, O. S. Strafun and A. S. LysakState institution ‘‘Institute of Traumatology andOrthopedics of NAMS of Ukraine,’’ Kyiv, Ukraine

Fractures in the elbow joint constitute only 5�6% ofall skeletal injuries, but the level of unsatisfactoryresults of treatment and contractures of this arearemains very high and reaches 20�25%.

In our study, we compared the efficacy of move-ments development during postoperative rehabilita-tion in patients with posttraumatic elbowcontractures. A retrospective analysis was per-formed on 69 patients with elbow contractures, whounderwent the arthrolysis surgery. Patients weredivided into two groups: group 1 – active rehabilita-tion program without using any fixing devices; andgroup 2 – restoration of movements using two plastersplints on the upper limb in the position of maximumflexion and extension of the mobilized elbow.

As a result of surgery and of our postoperativelocomotor rehabilitation, final degree of flex-ion�extension movements in the first group ofpatients (active movements in the elbow joint)increased by 59.58� (from 44.69� � 12.25� before sur-gery to 104.28� � 9.42� in 6 months after surgery),while in the second group of patients, who used twosplints, movements increased by 70.7� (from48.05� � 12.15� before surgical intervention to118.75� � 14.11� in 6 months after surgery). Thesame results were obtained on the Mayo ElbowPerformance Score. In the first group, patientsreceived an average of 75� 7.3 points for the MayoElbow Performance Score in 6 months after surgery,and in the second group of patients, 84.6� 10.5points. The gain of elbow function according toMEPS in group 1 was 42.8� 8.9 points, in group 2 –49.3� 10.9 points.

Treatment of posttraumatic contractures of theelbow joint is extremely complex and unsolved pro-blem and requires an individual approach for treat-ment and rehabilitation. Comparison of theeffectiveness of rehabilitation of patients in the twogroups showed a statistically significant increase ofmovements and better functional outcome by MEPSin patients, who used two plaster splints.

A-0594 Time to union of scaphoid waist fracturestreated by percutaneous screw fixation

Vera Fischer, Christoph Stern, Marco Canova andSilvia SchibliCantonal Hospital of Graubunden, Chur, Switzerland

Objective: Traditionally our treatment regime of non-or minimally displaced scaphoid waist fractures fixedby a percutaneous compression screw insertedthrough a volar approach included a scaphoid splintfor 6 weeks and active motion for 12 weeks withoutweight. At week 12, the fracture union was assessedby CT scan and patients were allowed to return backto manual work. Based on recently published studies,we suggested that this treatment regime is toorestrictive and sufficient fracture union may beachieved within 6 weeks. Our goal is to assess thetime to union of scaphoid waist fractures treated bypercutaneous screw fixation.Methods: This retrospective study investigated 34patients with acute scaphoid waist fractures betweenJune 2015 and August 2017, which were treated by apercutaneous compression screw (SpeedTipCannulated Compression Screws 3.0, Medartis)osteosynthesis through a volar approach followedby active motion for 6 weeks without weight.Exclusion criteria were fractures of the poles, a dis-placement >2 mm, the age <16 years, a delayedtreatment >1 month, concomitant injuries at the ipsi-lateral hand and wrist and lost to follow-up. Twelvepatients were excluded. CT scans were used at day 0to categorize each fracture and at week 6 to assessthe union. A musculoskeletal radiologist evaluatedthe CT scans using the sagittal slices. The length ofthe united bone was compared with the width of thescaphoid at the fracture line. Two measurementswere used to quantify the union based on the follow-ing methods: The mean percentage union describedby Singh et al. and the weighted mean percentageunion described by Grewal et al. A fracture wasdefined to be united if overall bone contact wasmore than 50%.Results: Sixteen of the 22 included fractures wereclassified as non- or minimally displaced (1 mm);15 of these fractures showed a union rate of morethan 50% at week 6 CT scan; 4 included fractureswere moderate (>1 mm <1.5 mm) displaced. Allshowed a union rate of more than 50% at week 6CT scan. Two fractures were severely (�1.5 mm2 mm) displaced, one with a union rate of morethan 50% at week 6 CT scan and one with a poorunion rate at weeks 6 and 12 CT scan. The unionrate was more than 50% at month 5 CT scan.

SS114 Journal of Hand Surgery (Eur) 43(Supplement 2)

Conclusions: We demonstrate that the majority ofnon- or minimally displaced scaphoid waist fracturestreated by percutaneous screw fixation through avolar approach show a fracture union at week 6 CTscan. Time off work can be reduced considerably bythis treatment regime.

A-0596 Clinical and neurophysiological results 2years after transfer of the interosseous anteriornerve to the deep motor branch of the ulnar nerve

Rasmus Thorkildsen1, Frode Thu1, Lars-Eldar Myrseth1, Ellen Jørum2, Inge PetterKleggetveit2, Lise Maurstad3, Bjørg Bolstad3 andMagne Røkkum1,4

1Upper Extremity and Microsurgical Unit, Department ofOrthopaedics, Oslo University Hospital, Oslo, Norway2Neurological Department, Oslo University Hospital, Oslo,Norway3Department for Clinical Service Orthopaedics, OsloUniversity Hospital, Oslo, Norway4University of Oslo, Oslo, Norway

Objectives: The AIN transfer to the DBUN mayimprove results after proximal ulnar nerve injuries.We have used this transfer since 2015 and have fol-lowed our patients prospectively both clinically andneurophysiologically. We present the results after 2-year follow-up for the first eight patients.Methods: Patients with the ulnar nerve at the elbowor proximally with a healthy median nerve are candi-dates for the procedure at our hospital. Six weremales, median (with range) age at nerve transferwas 39.0 (55.9). All were right-handed, five had leftsided injuries. There were three sharp, and oneuntidy injury at elbow level, two plexus injuries, onedegloving injury to the upper (irreparable ulnarnerve), and one permanent deficit after removal ofan axillary schwannoma. Four out of eight injuriesunderwent primary nerve repair at elbow level, withprimary grafting in one case. Nerve transfer was per-formed at a median time of 220 (534) days after theprimary surgery (end-to-side in six cases and end-to-end in two). Concomitant long flexor tenodesis wasperformed in three cases and nerve transfer of atriceps branch to the axillary nerve in one case. Thepatients were examined pre- and post-surgically withtesting of grip strength, key-, tip-, and tripod pinchstrength as well as assessment of intrinsic handfunction (Rosen score) and scoring with Quick dash(QDASH). The patients have been assessed neuro-physiologically according to a specific protocol bothpreoperatively and at follow-up. EMG registrationwas performed in the ulnar nerve innervated

muscles while the median nerve was stimulatedproximally as suggested by Chan et al.Results: Median observation time is 2.1 (1.3) years.Patient 8 will be completing the 2-year follow-up inDecember 2017. QDASH preoperatively (sevenpatients) was median 36.4 (36.3), QDASH at the finalfollow-up 2.3 (56.7). The motor Rosen score was 0.24(0.05) preoperatively, 0.31(0.11) at 6 months, 0.39(0.39) at 12 months and 0.62 (0.32) (7 patients) at 2years. We found no significant improvement in theQDASH, but the Rosen motor score was significantlyimproved at both 1 and 2 years compared to baseline(p< 0.05, Wilcoxon signed rank test). All patients hadmade improvements both clinically (including claw-ing and the Fromment sign) and neurophysiologicallyat the last follow-up, but a clear effect of the nervetransfer could only be shown in 3/7 cases.Conclusion: Our patients have made a significantimprovement in intrinsic function at the finalfollow-up. However, we were only able to showclear effect of the transfer electrophysiologically inthree cases. Two of these were direct end-to-endtransfers and the last had an irreparable proximalinjury (but probably had a pre-existing MartinGruber anastomosis). The best clinical results wereseen among the group with end-to-side transfers,but it would seem this is a result of the proximalnerve surgery. A ‘‘baby-sitting mechanism’’ hasbeen suggested for this method (2), but we wereunable to confirm this in our study.

A-0597 Early loosening of the Elektra trapezial cup:A histological study

Rasmus Thorkildsen1, Carina B. Johansson2,Johan Høgmalm3 and Magne Røkkum1,4

1Oslo University Hospital Upper Extremity- andMicrosurgical Unit, Oslo, Norway2Odontological Institute, Gothenburg University,Gothenburg, Sweden3Institute for Geological Science, Gothenburg University,Gothenburg, Sweden4University of Oslo, Oslo, Norway

Objectives: To study possible mechanisms behindthe high rate of cup loosening seen after theElektraTM total joint replacement in the basal jointof the thumb.Methods: Six female patients were reoperated withsalvage trapeziectomies after earlier implantation ofan Elektra joint replacement. The indications for thejoint replacement were primary osteoarthritis in fiveand arthritis secondary to SLE in one, and the median(with range) age at the time of surgery was 61.7

FESSH Abstracts SS115

(10.7). The trapeziectomies were performed atmedian 16.8 (39.6) months after the original jointreplacement during the period November 2009 toApril 2012. The indication for revision surgery wascup loosening (three cases) or recurrent disloca-tions/instability (three cases). Of six cups, five werethe original Chrome Cobalt Elektra cup and one wasthe second-generation bimaterial cup. At trapeziect-omy, the bone was removed in one piece and con-served in formalin. The six trapezia were thenembedded in resin and sectioned for further studyunder the light microscope. In addition, three of thecups were analysed with two spectroscopy methodsto confirm the presence of metallic waste products inthe periprosthetic bone.Results: There was almost complete loss of thehydroxyapetite (HA) coating on the three loose cups.The three remaining cups were still osteointegrated,but a low proportion of the metal was covered withbone in the central section that we studied (40–66%)and much of the HA was also gone on these cups. Inall six samples, we saw a general osteopenic bonestructure and large lytic areas particularly under-mining the cups. In these lytic areas, and in the peri-prosthetic tissue around the cup surface, we foundlarge amounts of macrophages with dark intracellu-lar content. In addition, we saw disordered boneremodelling around the cups. Three cups wereselected for further studies with laser ablation induc-tively coupled plasma mass spectroscopy (LA-ICP-MS) and scanning electron microscopy with energydispersive spectroscopy (SEM EDS) were we con-firmed that the dark staining content in the periarti-cular cells/tissue consisted of metallic wasteproducts.Conclusion: We found an early and aggressive metal-losis around these six cups. The process seems toinvolve many inflammatory cells and metallic wasteproducts and is particularly advanced in the boneundermining the cups. This is most likely due tothe cannulated design of the first generation of theElektra cups. The metal on metal design for thearticulation seems to be another unfortunate choicecontributing to the high rate of loosening that otherauthors have published after using this prosthesis.

A-0598 Proximal interphalangeal joint denervation:Is it an alternative and efficient surgical procedurefor proximal interphalangeal joint arthritis?

Michel Chammas1, Michael Bouyer2, Jefferson BragaSilva3, Jorge Boretto4, Cyril Lazerges1 andBertrand Coulet1

1Hand surgery unit, Lapeyronie University Hospital,Montpellier, France2Michallon University Hospital, Grenoble, France3Hand Suregry Unit, University Hospital, PontificalUniversity Catholic of Rio Grande do Sul, Porto Alegre,Brazil4Hand Surgery unit, Italian hospital, Buenos Aires,Argentina

Objective: Proximal interphalangeal (PIP) jointdenervation is an alternative procedure to arthro-plasty and arthrodesis in cases of osteoarthritiswith preserved mobility. Here, we aimed to explorewhether PIP joint denervation allows for significantpain reduction in the long term in individuals withpreserved mobility in PIP joint OA and rheumatoidarthritis. Secondary objectives were to determinethe prognostic criteria for the reduction in pain.Methods: We assessed the results of 40 PIP jointdenervations in 22 patients (21 women) (mean age63 years (range 39�77)) with PIP joint osteoarthritis(67%) or rheumatoid arthritis (33%) with a meanfollow-up of 66 months (range 16–137).Results: Patients who had another surgery after PIPjoint denervation, such as arthrodesis (five cases) orPIP joint arthroplasty (five cases), were consideredtreatment failures (five patients).

For the 30 remaining cases (17 patients), painscore, decreased by 71% of the preoperative value,was correlated with improved QuickDASH score(�¼ 0.05; p< 0.01), which was decreased by 47%(SD 42%) of the preoperative value. The mean post-operative range of motion was 52� (SD 21�). Arthrosiscontinued to progress (increase in Kellgren andLawrence score by 1.1 (SD 0.8) points) and the axialdeviation of the PIP joint progressed by 3.5� (SD 4.3�).The amount of axial deviation of the PIP joint, a veryadvanced radiographic OA stage and rheumatoidarthritis origin were poor prognostic factors.Posttraumatic arthritis origin and the amount ofpain and functional discomfort before surgery weregood prognostic factors. For 22/30 cases, individualswere satisfied. Overall, four cases showed transientneurologic disorders and four were consideredfailures.Conclusion: We recommend PIP joint denervation forindividuals with osteoarthritis and preserved mobi-lity, especially if the pain and discomfort are

SS116 Journal of Hand Surgery (Eur) 43(Supplement 2)

significant and there is no pronounced joint deviation.However, in case of very advanced radiographic OAstage, severe axial deviation or rheumatoid arthritisan alternative procedure may be considered.

A-0599 Clinical results of a SL-reconstructionthrough a dorsal approach creating a three liga-ment tenodesis with ECRB: A 5-year follow-up

Simon Oeckenpohler, Britta Wieskotter,Thorben Royeck and Martin Franz LangerDepartment of Trauma, Hand and Reconstructive Surgery,University Hospital Munster, Germany

Objective: Scapholunate ligament injuries are fre-quently initially misjudged or overlooked with a highpotential of developing an SLAC wrist within time.Many treatment techniques have been described pre-viously for the reconstruction of the scapholunateligament. In this study, we present a not yet pub-lished treatment option using ECRB for a three liga-ment tenodesis through a dorsal approach and its 5-year follow-up clinical data of 38 patients.Methods: The clinical data of 38 wrists in 36 patients(30 men, 6 women, mean age 53 years), operated by asingle surgeon, treated for a scapholunate instabilitywith a nonrepairable SL distance of at least 5 mmwere evaluated and compared with known datafrom similar studies.

We evaluated VAS pain, DASH score, Krimmerscore, Mayo score, relative grip strength (Jamardynamometer and pinch gauge) and ROM of thewrist. In addition, X-ray images were evaluated pre-operatively, immediately postoperatively and on aver-age 5 years after surgery concerning SL-angle, SL-distance and wrist-arthritis.Results: The 5-year results of this large study group(n¼ 38) with a relatively high patient age (53 years –literature 36�43 years) showed a very good mobilityof about 80� 1.7% of the opposite (uninjured) side inflexion/extension (literature 40�75%).

The grip strength of approximately 87.5� 9.4% inrelation to the opposite side is also higher than theaverage values of comparable studies (65�80%).

The scores: DASH score (22� 20), Krimmer score(80� 16) and Mayo Wrist Score (76� 17) – supportthese good results, demonstrating the high overallsatisfaction of 8.2� 2.5 of 10 on the numericalrating scale.

The radiological findings immediately postopera-tively of both SL angle and SL width show a signifi-cant correction of the pathological SL position.Similar to other studies, these values become

worse over time but do not return to the preoperativevalues.

No patient in this series had to be reoperated andtreated with a total wrist arthrodesis.Conclusions: The SL reconstruction using a dorsalthree ligament tenodesis with ECRB shows – in a5-year follow-up – good to very good functionalresults with a high patient satisfaction and goodfunction of the wrist in the everyday life of thepatients. This technique should be considered a rea-sonable treatment option even in relatively oldpatients with an already developing SLAC wrist.

A-0600 Functional outcome after constraint distalradioulnar joint replacement

Hans TromborgHand Surgery/Orthopedic, Odense University Hospital,Denmark

Objective: It is well known that the distal radioulnarjoint (DRUJ) is important for the function of the handand wrist. We studied the functional outcome 1 yearafter constraint distal radioulnar joint replacement(Aptis).Methods: We included all patients (n¼ 68) who hadan Aptis in a cohort, regardless of diagnosis.Disability of Arm Shoulder and Hand, grip strength,and EQ-5D were compared before and 1 year aftersurgery. Statistics were performed with paired t-testwithout correction for repeated measurements.Results: Age of patients: 43 (14) (years (SD)). Patientshad a relatively high DASH score before surgery of 58(14) and this is relatively high compared to normal10(14); DASH score dropped significantly to 33(16)and this is an improvement of 25 (12) (p<<0.01).Grip strength of the affected arm improved 10 (9)kg to 24 (8)kg (p<<0.01). EQ-5D was not significantlyimproved; it fell from 0.12 (0.50) to value 0.46 (0.40)(p¼ 0.07).Conclusions: Aptis joint replacement yields goodfunctional results 1 year after surgery in a cohort ofpatients with mixed indications and relatively big pre-operatively functional disabilities due to DRUJproblems.

A-0610 The reading level of surgical consent formsin hand surgery

Kevin Mertz, Sara Eppler and Robin KamalStanford University School of Medicine, Palo Alto, USA

FESSH Abstracts SS117

Objective: Because approximately half of US adultsare functionally illiterate or marginally literate(eighth grade reading level and lower), many healthagencies, including the NIH, suggest that all patient-directed healthcare material should be written at asixth to seventh grade reading levels. This studyassesses the reading level of surgical consentforms given to patients to determine if they fallwithin this suggested reading level range.Methods: A retrospective chart review of charts fromseven hand surgeons at a single academic medicalcenter was conducted. We created a cohort of 210surgical patients (30 patients from each surgeon)who had surgery from 26 June to 1 October 2017.All information written on the consent form by thesurgeon was assessed for reading level and read-ability using the following validated tools: FleschReading Ease, Flesch-Kincaid Grade Level, GunningFog Index, SMOG Index, and Automated ReadabilityIndex. The consent form template was also analyzedusing these tools.Results: The mean Flesch-Kincaid Grade Level was10.6 (physician range 6.9 to 13.5). The mean FleschReadability score was 32.7 (scale 0 to 100, physicianrange 13.2 to 54.5). The mean scores for GunningFog, SMOG, and Automated Readability were 11.8,8.42, and 11.7, respectively (physician ranges: 7.4 to15.5; 5.2 to 9.9; 8.5 to 14.6). The consent form tem-plate has a Flesch-Kincaid Grade Level of 17.1 andFlesch Readability score of 20.8. The consent formtemplate scores for Gunning Fog, SMOG, andAutomated Readability were 21.6, 16.2, and 19.5,respectively.Conclusions: The average reading level of hand sur-gery consent forms is considerably higher than thesuggested level from governing bodies. It is likelythat most patients are unable to understand consentforms and common terminology used during handsurgery. This raises concerns about the informedconsent process. Further effort is needed from phy-sicians and health systems to simplify consent formterminology.

A-0611 Double oblique osteotomy and rotation oftrapezo-metacarpal joint block (DOOR procedure):A surgical technique about 88 cases

Jean-Luc Roux and Amirouche DahmamInstitut Montpellierain de la Main, Clinique Sain Roch,Montpellier, France

Introduction: Double oblique osteotomy and rotationof trapezo-metacarpal joint block (DOOR) procedureconsists in harvesting the trapezo-metacarpal (TMC)

joint in block, after double oblique osteotomy of thetrapezium and the base of the first metacarpal. Thevascularization is preserved on the radial pedicle.Then the articular block is turned by 180�along thelongitudinal axis of the thumb, repositioned andosteosynthesized. This procedure is indicated in thetreatment of early TMC-joint osteoarthritis asso-ciated with instability and dysplasia in young patients.

88 cases have been performed since 2000.Surgical technique: The procedure is performedunder axillary block, tourniquet control without com-plete vascular draining in order to visualize the smallvessels. A modified Gedda–Moberg approach is used.All the tendon bundles of the abductor pollicis longusare cut near their insertion, placed on wire andretracted proximally. The TMC joint is released bystarting on the palmar side, at the deep face of theabductor pollicis brevis and then dorsally passingunder the extensor tendons. The peri-articular vas-cular network is preserved in continuity with theradial artery. When the joint and the pedicle arereleased, the direction and level of the osteotomiesare marked by pins. X-rays control is essential. Theosteotomies are performed with a fine oscillatingsaw, 5 mm below the joint spacing for first metacar-pal and at the middle part of the trapezium. The com-plete release of the articular block is not easy; thepins can be used as joystick to facilitate the extrac-tion. When the joint is harvested, the tourniquet isreleased to check the blood supply and to controlhemostasis. We rotate the articular block 180� onthe longitudinal axis of the thumb, and the articularsurface between the trapezium and the second meta-carpal is an excellent reference. The osteosynthesisis performed by pins (two proximal and two distal).After radiographic control, the tendon of the abductorpollicis longus is reinserted on the periosteum of thefirst metacarpal basis and on the abductor pollicisbrevis aponeurosis. The closure is done without drai-nage. The post-operative immobilization is 1 monthand then the rehabilitation is started.Results: The technique is demanding but perfectlyreliable; 88 cases have been performed since 2000.The clinical results are very satisfactory on pain andstrength with a long follow-up. In all cases, the radio-graphic examination shows a stabilized TMC jointwith a perfect alignment of the axis of the scaphoid,trapezium and first metacarpal.Conclusion: DOOR procedure is our choice solutionfor early stages of TMC-joint arthritis in youngpatients (before 50), particularly in cases of dysplasiaof the trapezium and TMC-joint instability.

SS118 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0612 Glenohumeral fusion in adults with seque-lae of obstetric brachial plexus palsy: A report of 8cases

Amar Belkacem Djeffel1, Adeline Cambon-Binder2 andZoubir Belkheyar3

1Public Hospital Djelfa, Algeria2Saint Antoine Hospital Paris, France3Mont Louis Clinic Paris, France

Objective: Deformation of the gleno-humeral jointresulting from obstetrical brachial plexus palsyincludes glenoid retroversion and loss of the humeralhead sphericity. As a result, patients may show pos-terior dislocation of the humeral head and significantupper limb functional impairment. There is no con-sensus as to the optimum treatment of the residualparalytic shoulder after the end of the growth. Thepurpose of this study was to assess the surgical andfunctional outcomes of glenohumeral fusion per-formed in adulthood.Methods: We reviewed eight patients with completeobstetric brachial plexus palsy who had shoulderarthrodesis. The mean age of patients was 28 yearsold (16�55). All patients had active periscapularmuscles and elbow flexor muscles. Preoperatively,glenohumeral morphology was analyzed with com-puted tomography scanning of the affected shoulder.Mean shoulder flexion, abduction and external rota-tion were, respectively, 26�, 25� and �13�. The sca-pulohumeral joint was fused using a non-lockingplate in 30� of medial rotation if the hand was func-tional, and without rotation if the hand was not.Postoperatively, upper limb was splinted in abductionfor 6 weeks. Outcome assessment included a video-assisted measurement of the active range of motionof the shoulder, patients’ satisfaction and time tofusion.Results: At an average follow-up of 7 months (2 to 17months), the active range of motion in flexion, abduc-tion and external rotation of the affected shoulderwere, respectively, 78� (p< 0.005), 67� (p< 0.005)and 21� (p¼ 0.03). All the patients were satisfiedwith the intervention. Fusion was obtained between3 and 6 months and no patient had residual pain.Conclusions: Shoulder fusion improved the active arcof rotation, flexion and abduction in adults with resi-dual obstetric brachial plexus paralysis. In patientswith deficient abduction and external rotation,whether they had or not previous surgical attemptsto restore shoulder function, shoulder arthrodesiscan improve both shoulder range of motion andstrength.

A-0617 Can patients predict their postoperativedisability after elective hand surgery?

Aaron Alokozai1, Sara Eppler1, Laura Lu1,Nicole Sheikholeslami1, Sarah Lindsay1, Sanj Kakar2

and Robin Kamal1

1Stanford University School of Medicine, Palo Alto, CA, USA2Mayo Clinic, Rochester, NY, USA

Objective: Forecasting is a model commonly used bybusinesses where past experiences and beliefsinform a projection for future outcomes. This studyassessed patients’ ability to forecast their postopera-tive pain and disability.Methods: Upon Institutional Review Board approval,patients undergoing hand surgery completed a ques-tionnaire before their procedure that (1) measuredtheir current hand disability (QuickDASH), (2)recorded pain (Numerical Pain Scale from 0�10),and (3) assessed their forecasted hand disabilityand pain at 2 weeks postoperatively. The question-naire also queried the following psychological factorsas explanatory variables: Pain Catastrophizing Scale(PCS), General Self Efficacy Scale (GSE-6), andPatient Health Questionnaire Depression Scale(PHQ-2). At the 2-week follow-up appointment,patients completed the Quick DASH and NumericalPain Scale to assess their realized disability and painlevels. Bivariate analyses were performed to deter-mine the associations among psychosocial factors,demographic characteristics, and number of priorsurgeries with differences in forecasted and realizedhand pain and disability.Results: Sixty patients undergoing hand surgerywere evaluated. Bivariate analysis using thePearson correlation coefficient demonstrated thatthere is a statistically significant correlation(r¼ 0.65; p< 0.001) between forecasted disabilityand realized disability at 2 weeks after surgery.Patient forecasted pain did not correlate with rea-lized pain (r¼ 0.34; p> 0.05). Catastrophic thinkinghad a statistically significant correlation with differ-ence in forecasted and actual disability (r¼ 0.31;p¼ 0.01) and pain levels (r¼ 0.27, p¼ 0.03).Depression correlated with difference in forecastedand actual pain levels (r¼ 0.32; p¼ 0.01). Self-effi-cacy and number of prior surgeries did not affect apatient’s ability to forecast their postoperative dis-ability and pain.Discussion: Patients are able to forecast their post-operative disability after surgery, but not their pain.Surgeons can use a patient’s ability to forecast theirpostoperative disability to inform preoperative andpostoperative interventions to optimize patient-reported functional outcomes.

FESSH Abstracts SS119

A-0619 Good results 7 years after wristarthroplasty revision surgery in 28 patients

Ole Reigstad1, Trygve Holm-Glad1,2, Siri Roness3,Christian Grimsgaard1, Rasmus Thorkildsen1,2 andMagne Røkkum1,2

1Upper extremity and microsurgical unit, Division ofOrthopaedic Department, Oslo University Hospital, Norway2Institute of Clinical Medicine, University of Oslo, Oslo,Norway3Physiotherapy Unit, Department for Clinical Service,University Hospital of Oslo, Norway

Objective: Wrist arthroplasties fail due to loosening,instability, malposition, pain and infection. Olderdesigns showed unacceptable failure rates andthese failures were inevitable converted to arthrod-esis. Modern wrist arthroplasties demonstrate goodmid- to long-term results similar to ankle, shoulderand unicondylar knee arthroplasties. There are fewreports on wrist arthroplasty revision to new compo-nents. We have used the Motec� wrist arthroplastysystem for revision of failed arthroplasties since2006. Results with a minimum 1-year follow-up arepresented.Methods: All patients operated with a wrist arthro-plasty in our department are included in a prospec-tive follow-up study. Since 2001, approximately 150primary arthroplasties have been performed.Twenty-eight patients (18 men), 17 right wrists, 59(27�83) years old had revision arthroplasties (2were referred to us) 1.4 (0.4�11.0) years after pri-mary arthroplasty surgery. The causes of wristarthrosis were SNAC/SLAC (14), lunate malacia (5),distal radius fracture/extensive hand injury (4), pri-mary arthrosis (4) and hemophilia (1). Fourteenpatients had altogether 30 wrist surgeries prior toprimary wrist arthroplasty surgery. The causes ofrevision were distal component loosening (17), bothcomponents loosening (4), proximal component loos-ening (2), pain (2), inflammation (2) and infection (1).The revised arthroplasties were ELOS (13), Motec�

(11), Remotion� (3) and Amandys� (1). All wererevised using the Motec wrist arthroplasty system.The patients were examined prior to revision surgeryand at annual follow-up including QDASH, PRWHE,VAS score, AROM, grip strength and key pinch.Radiographs were examined for bone–implant con-tact, osteolysis and subsidence/loosening.Results: The latest follow-up was 7 (1�13) yearsafter revision surgery. One patient died after 7years follow-up (unrelated cause, arthroplastyresults included). One patient was lost to follow-up.During the follow-up period, 10 patients had furtherrevision surgery to arthrodesis (7) or new

components (3) due to infection (3), inflammation(3) or loose components (4). At the last follow-up,QDASH (50 vs 20), PRWHE (39 vs 10) VAS painscores at rest (63 vs 17) and activity (65 vs 25), gripstrength (10 vs 22 kg) and AROM (76 vs 120�) hadimproved significantly compared to preoperatively(p< 0.05). Key pinch was similar at the follow-up.One distal component demonstrates osteolytic linessurrounding the distal component (average clinicalresult), and the remaining wrist arthroplasties areradiologically well fixed without signs of loosening/subsidence.Conclusions: The revision surgery was complicatedand further revision surgery was necessary in 25% ofthe patients. Still, successful revisions lead to highpatient satisfaction and pain relief, as well as goodfunctional result similar to the results reported afterprimary arthroplasty surgery. Infections/inflamma-tions are a problem in revision surgery, we did cul-tures on all revisions, and still there was a high rateof infections/inflammations (6) among the rerevisionpatients. Whether infection was present at revision(but not diagnosed) or caused by the revision hasbeen difficult to determine since low-grade arthro-plasty infections are notoriously difficult to diagnose.

A-0622 Bone healing in scaphoid fracture nonunion: Correlation of CT and histopathology

Gernot Schmidle, Rohit Arora and Markus GablDepartment for Trauma Surgery, Medical UniversityInnsbruck, Innsbruck, Austria

Purpose: The aim of the study was to assess thebiological healing capacity of scaphoid nonunions(SNU) and to compare the results to time intervalsafter fracture, fracture location and radiologicalsigns of bone healing.Materials and Methods: Thirty-three patients (28males and 5 females) who were operated for delayedunion or SNU were included. Samples of SNU weretaken during surgery and evaluated histologically.Parameters for bone healing were defined and abone healing activity score was calculated. The heal-ing activity was assessed and the results were cor-related to time intervals after fracture.

Radiological examination was done prior to sur-gery. The location of SNU was assessed on 3D CTreconstructions and grouped in three zones depend-ing on the potential blood supply: a white/white zone(WW), red/white zone (RW) and red/red zone (RR). 2DCT reformations were analyzed for bone density, tra-becular structure, sclerosis and fragmentation. Theresults were compared to the histological findings.

SS120 Journal of Hand Surgery (Eur) 43(Supplement 2)

Results: The healing activity for the distal fragmentdecreased significantly over time. The analysis of theproximal fragment did not show a correlation to theage of SNU. A reduced healing potential wasobserved at the proximal part already at early timepoints.

The bone healing activity was worst in the proximalfractures of the WW zone. Increased radiodensity wasfound in the proximal fracture zone and with increas-ing age of SNU.

Proximal fractures with normal trabecular struc-ture on 2D CTs had a higher bone healing score inhistology and a higher prevalence of active bonehealing parameters.

The bone healing score was not significantly differ-ent for cases with and without sclerosis of the prox-imal fragment. The prevalence of active bone healingparameters was significantly less in cases withsclerosis.Conclusion: The bone healing activity of scaphoidnonunions can be defined by histological healingparameters. Bone healing activity changes overtime. It depends on the location of the fracture visua-lized by 3D CT reconstructions. 2D CT findings ofbone density, sclerosis, trabecular structure andfragmentation correspond to bone healing activity ofthe proximal fragment.

This knowledge can be useful in predicting healingpotential of SNU and may be helpful for preoperativeplanning to choose the least invasive procedure toachieve union.

A-0623 The patient perspective on shared decision-making: Should all decisions be shared?

Aaron Alokozai, Sarah Lindsay, Sara Eppler,Paige Fox, Catherine Curtin, Michael Gardner,Raffi Avidian, Ariel Palanca, Geoffrey Abrams,Ivan Cheng and Robin KamalStanford University School of Medicine, Palo Alto, USA

Objective: Prior studies on shared decision-makingin surgery have been primarily focused on treatmentdecisions. We assessed the extent to which patientswant to be involved in decision-making in the diag-nosis, treatment, and postoperative management of atypical musculoskeletal disorder.Methods: We conducted a prospective, cross-sec-tional study of preoperative and postoperativepatients who presented to an outpatient orthopaedicclinic. Patients were asked to complete a question-naire containing sociodemographic questions. Theywere also asked to rate their preferred level of invol-vement on 25 decisions that are made during

surgery, such as decision to have surgery, the dateand time of surgery, the type of implant, dischargelocation, and the use of postoperative imaging.Questions were scored from 0 to 10 (0 no involve-ment, 5 shared involvement between patient/sur-geon, and 10 full involvement). We performedbivariate correlations, analysis of variance (ANOVA),and �2 to assess the associations among patientdemographics, general mean patient involvementscore, and mean patient involvement score for pre-operative, operative, and postoperative decisions.Alpha level of 0.05 was the threshold for significance.Results: Sixty-four preoperative or operative patientswere evaluated. Mean patient involvement score was2.5� 1.70. Patients wanted to be most involved decid-ing when the surgical treatment should be scheduled(4.67� 2.98) and least involved deciding the size ofthe incision (1.17� 2.17). Age and education werenot significantly correlated with mean patient invol-vement score (p> 0.05). Age had a statistically sig-nificant correlation to mean patient involvementscore for postoperative decisions (r¼�0.26;p¼ 0.03), but not for mean preoperative and operativedecisions. ANOVA demonstrated that there was a sta-tistically significant (p< 0.001) difference in meanpatient involvement score between preoperative(3.01� 1.78), operative (1.73� 1.81), and post-opera-tive (2.44� 1.95) decisions.Conclusion: The results of our study demonstratepatients prefer minimal involvement regarding thechoices made during an episode of surgical care.They also desire to be less involved in operative deci-sions related to their care than in pre and postopera-tive decisions. This also suggests that there arelimits to shared decision-making – patients may notwant all decisions to be shared. Older patients in ourcohort preferred less involvement in postoperativedecisions, which warrants further exploration infuture studies.

A-0624 Factors accounting for variation in thebiomechanical properties of flexor tendon repairs

Lasse Linnanmaki1, Harry Goransson2,Jouni Havulinna3, Teemu Karjalainen4 andOlli V. Leppanen1,2

1University of Tampere, Tampere, Finland2Tampere University Hospital, Tampere, Finland3Pohjola Hospital, Tampere, Finland4Central Finland Central Hospital, Jyvaskyla, Finland

Objective: The means of the biomechanical para-meters are compared in most studies investigatingflexor tendon repairs, whereas the variation within

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the parameters is disregarded. Variation should beregarded because a repair method that has relativelylow variation ruptures less frequently than a repairmethod with a similar mean strength but a highervariation. The purpose of this study was to investigatefactors that cause variation in the mechanical prop-erties of flexor tendon repairs.Methods: The study consisted of hundred samplesthat were divided in groups of 10 based on repairedmaterial and repair method. Fifty homogenousabsorbent sticks were repaired with a simple loop,an Adelaide repair, a peripheral over-and-overrepair, or a combination of the latter two repairs.Ten of the absorbent sticks were repaired with a jigto reveal the variation of the testing methodology.The group served as a baseline group to the othernine groups. Moreover, 50 porcine flexor tendonswere repaired with the same methods. Contrary tothe other nine groups, one group of 10 porcinetendon repairs was performed by several surgeonsinstead of by a single investigator. The samples wereloaded statically until failure. Variations for the spe-cific groups and partial variations for each factorwere calculated. To make variations comparable,coefficients of variation were used.Results: The overall variation of the tendon repairsconsisted of partial variations derived from testingmethodology, tendon properties, surgical perfor-mance, and inter-surgeon performance. Variation ofthe testing methodology was 13.8%. For example,partial variations for the combined repair were18.2% (performing the repair) and 17.4% (tendonproperties). The effect of tendon material propertieson the overall variation was generally less than theeffects of surgical performance. The variation derivedfrom repair method consisted of both core and per-ipheral suture: Sum of the overall variations of bothcomponents of the repair was of the same magnitudeas the overall variation of the combined repair (22.5%vs 25.2%, respectively). However, the additionalinter-surgeon variation was relatively small (13.9%).Conclusion: Based on the study, a hand surgeon canhave a significant impact on the resulting repair.Because the variation of tendon material cannot beaffected, a surgeon can reduce the failure rate of therepair by performing more uniform repairs. Loweringthe variation of the repair by third leads to decreaseof the failure rate to half. Finally, none of the partialvariations was markedly greater than the other. Thevariation of the combined repair is sum of its partialvariations, at least with the Adelaide core repair andover-and-over peripheral repair.

A-0630 Assessment of scaphoid fracture patternsusing a 3D-CT model

Gernot Schmidle, Rohit Arora and Markus GablDepartment for Trauma Surgery, Medical UniversityInnsbruck, Innsbruck, Austria

Introduction: The scaphoid plays a central role incarpal kinematics. It is prone to injury and reportedto be the most frequently fractured carpal bone. Thecomplex shape of the scaphoid and its tenuous bloodsupply increase the risk of non-union. The main goalin scaphoid fracture treatment is anatomical recon-struction to avoid long-term consequences ofosteoarthritis and pain. Therefore, imaging has todisplay the fracture patterns as exact as possible.

Fracture gaps and angular deformities can be welldemonstrated and measured using 2D CT imaging.To give an exact picture of fracture patterns andareas important for stability and blood supply, 3Dimaging is necessary.Method: We developed a technique for measurementof intraosseous rotation of the scaphoid for daily clin-ical use based on surface landmarks on a 3D CTmodel using common volume rendering software.

Based on this method, we assessed the prevalenceof intraosseous malrotation of scaphoid fractures(SF) and scaphoid non-unions (SNU). Forty-fivepatients (41 males and 4 females) who were treatedfor a SF (25) or SNU (20) were included. CT scans ofboth wrists were made and rotation was assessed.The amount of malrotation was compared to fractureclassifications, kind of treatment, healing processand age of fracture.

In a second study, we investigated which additionalinformation the 3D CT measurement can provideregarding fracture patterns, stability and vitality.This was investigated in 68 patients (57 men and 11women) who were treated for SF and SNU. Forty-twopatients were treated for SF and 26 for SNU. X-rays,2D CT and 3D CT images were compared on how wellthey could reflect the real situation regarding frac-ture gap, fracture location, fracture plane and courseof the fracture.Results: Our results show that malrotation is acommon fracture pattern. In the SF group, wefound it to be greater than 4� in 25% of the casesas opposed to 47% in the SNU group. Malrotation isan additional stability pattern that may impact ontreatment decisions.

The 3D analysis of fracture patterns provides addi-tional information in comparison to 2D imaging. 3Dimaging enables exact information about fracturelocation and the course of the fracture line in relationto relevant anatomical landmarks. The correlation of

SS122 Journal of Hand Surgery (Eur) 43(Supplement 2)

fracture patterns to anatomical regions can giveimportant information on stability and vitality of frac-ture fragments. This may be especially helpful in pre-operative planning.

A-0651 Reconstructive surgery of gunshot andexplosive wounds of the upper limb

Alexander Sukharev, Fiodorov Konstantin,Yazerski Konstantin and Kheylick Serhey432 Chief Military Clinical Medical Center, Belarus

Objective: Combat wounds of limbs are an actual andunresolved issue of modern surgery of injuries. Inconnection with the variety of damaging factors andthe complex anatomy of the upper limb, each casecan be considered unique and requires an individualapproach.Methods: In our study, patients with gunshot andexplosive wounds of the upper limb were included.A total of 18 patients participated in the study. Thefollowing indicators were analyzed: the mechanismof injury, the level of damage, the operations per-formed, the need for osteosynthesis, the need forplastic surgery, the duration of treatment, early andlong-term functional results.Results: The analysis of the obtained data showed forall patients, regardless of the area of damage, treat-ment began with debridement, application of negativepressure wound therapy from 24 h from admission,monitoring of wound condition (soft tissues), andfrom 5 to 7 days closure of the soft tissue defectwas performed.

There were revealed such feature in the treatmentof hand injuries as dissection of the carpal ligamentto all patients with wounds in the hand area; primaryosteosynthesis was performed using K-wires; in halfthe cases, the use of reconstructive-plastic methodsfor restoring soft tissue defects (primary closure,plastic with local flaps, Italian plastic), as well ason the bones (e.g. four-finger pollicization) wasrequired; restoration of tendons, the suturing ofnerves and vessels was postponed until the edemaand the ability to close the soft tissue defect werereduced.

For the forearm, the principles are similar; in onecase, bilocal osteosynthesis of the forearm bones inthe external C-frame (Ilizarov apparatus) was per-formed with a significant defect in both bones.

Patients with lesions in the shoulder regionrequired primary osteosynthesis by an external fixa-tion. Significant soft tissue defects were restored atthe same time by the displacement of the thoraco-dorsal artery perforator flap (in two cases, the

technique was supplemented by taking a flap with arib to restore the bone defect). The final osteosynth-esis was performed not earlier than the soft tissuestabilization, in three cases free bone implantationwas used with an autograft from the iliac crest. Intwo cases, posttraumatic neuropathy of the radialnerve was identified, for the correction of which theflexor tendons were transposed to the extensorposition.Conclusions: The approach in the treatment ofpatients with severe trauma to the upper limbshould be comprehensive, according to the principlesof orthopaedic damage control, osteosynthesisshould be consistent, the main role in assessingthe severity and prognosis of treatment is played bysoft tissues.

A-0655 A 5-year prospective outcome study ofPyrocardan� arthroplasty for the treatment ofthumb carpometacarpal joint osteoarthritis

Deborah Royaux1, Phillipe Bellemere2,Etienne Gaisne2, Thierry Loubersac2, Yves Kerjean2

and Ludovic Ardouin2

1C.H.U. Pellegrin, Bordeaux, France2Clinique Jeanne d’Arc, Nantes, France

Objective: The purpose of this study was to evaluatethe results of arthroplasty using the pyrocarboninterposition implant (Pyrocardan�) in the treatmentof early and intermediate stage trapezometacarpalosteoarthritis with a minimum follow-up of 5 years.Methods: It was a prospective and continuous study.The evaluation focused on bilateral objective criteriaof mobility (M1�M2 angle antepulsion and abduction,flexion and hyperextension of MP and IP, Kapandjiand retro-Kapandji), strength (tip-pinch, key-pinchand grip at Jamar), pain (VAS), functional self-ques-tionnaires (Quick-DASH and PRWE) and standard X-ray. We evaluated a possible subsidence of theimplant by the measurement of trapezial and meta-carpal indices. All the implants were placed accord-ing to the same operative technique by one operator.Results: Sixty-two implants in 58 patients wereincluded with an average age of 57 years and amean follow-up of 64 months (56 to 78 months).There were four reinterventions: two for implantremoval associated with trapeziectomy and two fora size change of an under-sized and painful implantafter 1 and 2 years. The PRWE and the quick-DASHscores were 60 and 52.27 preoperatively and 4(p< 0.0001) and 6.82 (p< 0.0001) at 5 years. Themean VAS was 7 preoperatively and 0.6 to 5 years(p< 0.0001). The average tip pinch at 5-year follow-

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up was 6.5 kg (p¼ 0.02). The other results onstrength and mobility were not modified by the inter-vention. However, they were comparable to the con-trolateral side both before and after the interventionat the last follow-up. The average recovery time was12 weeks; 95% of patients were very satisfied andsatisfied. Radiologically, there were three significantsubsidence of the implant at the trapezium and threeat the metacarpal level without any clinical impact.Conclusions: All patients increased strength andquality of life significantly with significantly reducedpain, sustained mobility and early resumption ofactivities. The overall satisfaction of patients washigh. A therapeutic alternative is always possible incase of failure (3% in the series).

Trapezometacarpal interposition arthroplasty withthe Pyrocardan implant is a minimally invasive andeffective medium-term solution for the treatment ofearly and intermediate-stage rhizarthrosis.

A-0656 The extensor mechanism in radialpolydactyly: Anatomical findings and anatomicaltreatment at primary surgery

J. Maraka, H. L. Stark, S. Stevenson and B. CrowleyRoyal Victoria Infirmary, Newcastle-upon-Tyne, UK

Objective: Radial polydactyly (RP) comprises adiverse range of anomalies. Anatomical complexitymay be underestimated resulting in poor outcomesfrom primary surgery and secondary deformity.There is little description in the published literatureon the variability of extensor tendon anatomy and itstreatment in RP.Materials and Methods: A prospective anatomicalstudy of 52 primary operations for RP. Systematicrecording of operative anatomical findings and pro-cedures performed for the extensor mechanism.Results: Fifty-two operations in 45 patients, sevenbilateral, M¼F, Wassel groups II�VII represented.Age at surgery 7 months to 10 years. Extensor polli-cis longus (EPL) inserted into both duplicates in 54%(28/52), ulnar duplicate only in 40% (21/52), radialduplicate only in 4% (2/52), and not present in 2%(1/52). Extensor pollicis brevis (EPB) inserted mostfrequently onto the radial duplicate. Anatomicalanomalies included interconnections between flexorand extensor 24% (12/50), interconnections betweenextensor duplicates, extensor connections to skin,hypoplastic tendons, and EPB with anomalous inser-tion to distal phalanx acting as EPL. Variability wasobserved between and within Wassel groups.Procedures for EPL included division of anomalousconnections, use of non-dominant duplicate extensor

to augment EPL, centralization of EPL, and resectionof EPL non-dominant duplicate. The most frequentprocedure for EPB was reinsertion on the ulnarduplicate.Conclusion: There is marked variability of extensoranatomy between and within Wassel groups. Weadvocate an anatomical approach to treatment. Thisoptimizes results from primary surgery, providesuseful prognostic information, and guides manage-ment of late deformities.

A-0657 Clinical outcome of collagenase Clostridiumhistolyticum in Dupuytren’s disease independent offibrosis diathesis score?

Katrien Cootjans, Ilse Degreef, Anton Borgers,Luc De Smet and Maarten Van NuffelUniversity Hospital Leuven, Belgium

Objective: Collagenase Clostridium histolyticum(CCH) injection is an alternative to surgery forfinger contractures in Dupuytren’s disease (DD).Recurrence rate after surgery in DD range from 0%to 71%. Some patients have a benign and limited dis-ease and others have a widespread and progressingform. The term diathesis relates to certain featuresof Dupuytren’s disease indicating an aggressivecourse. Patients with a severe diathesis have moreaggressive forms of the disease with an elevatedpostoperative risk for recurrent contractures. Thefactors related to Dupuytren’s diathesis are age ofonset under 50 years, bilateral disease, history ofsurgical treatment for fifth ray involvement,Ledderhose disease, knuckle pads and first rayinvolvement.

Our aim was to present the outcomes of patientswith DD contractures treated with CCH injections atour institution and to investigate the relation betweenthe clinical outcome of collagenase Clostridium his-tolyticum treatment and the patients’ diathesis score.Methods: We reviewed all patients treated with CCHinjections for contracture in DD in our institutionfrom September 2011 to July 2014. In all patients,the cords were injected with CCH and the fingerswere manipulated 2 days later. One to four yearsafter CCH injection patients completed a diseaserecurrence questionnaire at home. Three to sixyears after the treatment patients without evidenceof recurrence on chart review or questionnaire wereinvited for a follow-up visit with clinical examinationand questions in order to calculate the fibrosis dia-thesis score.

Recurrence was defined as patients who soughttreatment for a return of symptoms or a contracture

SS124 Journal of Hand Surgery (Eur) 43(Supplement 2)

greater than 20� in the setting of a palpable cord afterinitial full or partial contracture correction.Results: Sixty-seven patients with a total of 79affected hands were treated with CCH infections (57males; 10 females; age: 27�87 years). The diseaserecurrence questionnaires showed a relatively highrate of self-reported recurrence (58%) at a meanfollow-up of 21 months. All patients participated inthe questionnaire. No correlation was found betweenthe diathesis score and the DD.

Of the 67 patients (79 hands) who were treated, 12patients (13 hands) were lost to follow-up. A chartreview showed that 29 hands had already been oper-ated for recurrent disease. Recurrence was alsoreported in 10 hands on an earlier clinical visit, atleast 2 years after treatment, but these patients pre-ferred no further treatment. The remaining 24patients (27 hands) were invited for clinical examina-tion; 11 hands showed no recurrence, 17 hands hadrecurrence. There was a general high recurrencerate (84%) with a mean follow-up of 48 months.Conclusions: Our study demonstrated a high rate ofself-reported recurrence of DD after treatment withCCH injections at a mean follow-up of 21 months,which did not seem to be correlated with the fibrosisdiathesis score. The clinical recurrence rate at amean of 48 months was even higher and probablyalso not correlated with the fibrosis diathesis score.However, not all patients with recurrence requiredadditional treatment with CCH or surgery.

A-0659 Arthroplasty of the wrist with the Amandysimplant: Results of a monocentric series of 38 caseswith a minimal follow-up of 5 years

Catherine Maes-Clavier1, Philippe Bellemere2,Etienne Gaisne2, Thierry Loubersac2 andYves Kerjean2

1CHU Amiens, France2Clinique Jeanne-d’Arc, Nantes, France

Objective: The arthroplasty with Amandys implant isindicated in large articular wrist destruction. Thegoal of this study was to evaluate the midtermresults of this implant and to know if the postopera-tive results persist over time.Methods: The concept of the Amandys arthroplasty isthat of a free interposition radiocarpal and midcarpalspacer implant made out of pyrocarbon. The mono-centric series included 38 Amandys implant with aminimal follow-up of 5 years.Results: Two patients died and four were lost offollow-up. The mean follow-up was 64 months. Atthe last follow-up, the mean grip strength was

21 kg (67% of the controlateral grip strength and13 kg before surgery), the mean range of motion inflexion�extension was 75� (66� before surgery), andthe mean inclination values was 35� (34� before sur-gery). The mean total PRWE was 26/100 (62/100before surgery), the mean Quick-DASH was 28/100(64/100 before surgery) and the mean pain was 3/10(6.5/10 before surgery). The grip strength, the PRWEand the QDASH were significantly improved betweenthe follow-up of 2 years and the follow-up of 5 years.No migration or impaction of the implant wasobserved on X-rays at the last follow-up. Six revisionsurgeries were necessary to correct malposition ofthe implant, always in the first year after surgery.Conclusions: This study confirms that this implant iswell tolerated clinically and radiologically and pre-sents a surgical option for treatment of advancedwrist destruction. Its stability depends of the bonesresection, the capsuloligamentous tension and thesize of the implant but does not change with time.The function of the wrist and the grip strengthimproves over time.

A-0662 Therapy of fingertip injuries: The semi-occlusive dressing as an alternative option to localskin flaps

Stefan Quadlbauer1,2,3, Christoph Pezzei1,Josef Jurkowitsch1, Tina Keuchel1, Thomas Beer1,Thomas Hausner1,2,3 and Martin Leixnering1

1AUVA Trauma Hospital Lorenz Bohler, European HandTrauma Center, Vienna, Austria2Ludwig Boltzmann Institute for Experimental and ClinicalTraumatology, AUVA Research Center, Vienna, Austria3Austrian Cluster for Tissue Regeneration, Austria

Objective: Fingertip injuries are very common inemergency departments and the reconstruction is acentral aim of their management. According to theliterature, finger tip injuries in the level of Allen IIIand IV should be treated by local skin flaps. The mainpurpose of this study was to evaluate the outcomeafter semi-occlusive dressing therapy in respect ofsoft tissue cover, recovery of sensibility and durationof sick leave.Methods: One hundred and fourteen fingertips inju-ries from 2009 to 2011, treated with semi-occlusivedressing, were retrospectively analysed. In all of thecases, the injured fingers were only cleaned, deb-rided and covered with an occlusive dressing. Thebone was not shorted, even if the bone was up thewound level. The primarily occlusive dressing wasleft as long as possible and had been, when neces-sary, obdurated. The different types of fingertip

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injuries were classified according to the levels set byAllen. Furthermore, the treatment time with thesemi-occlusive dressing and the period of disabilitywas recorded. On every patient, a Semmes–Weinstein test was performed to document the sen-sitive outcome.Results: A total of 114 patients were treated with asemi-occlusive dressing. The mean age was 36� 14years, and the mean treatment duration 21� 10 days.The mean period of disability was 30� 17 days. Aftertaking off the semi-occlusive dressing, the mainperiod of disability was 8� 13 days. According toAllen, following composition of fingertip injuriesoccurred: 49% Allen 1, 33% Allen 2, 13% Allen 3and 5% Allen 4. All patients developed a satisfactorytissue cover and the sensibility was, according to theSemmes–Weinstein test, normal. There were nocomplications like tissue infections, neuroma orosteitis. Also no secondary flap supply wasnecessary.Conclusion: The semi-occlusive dressing is an idealtherapy for all kind of fingertip injuries, regardless ofthe amputation level. There may be even boneexposed on the wound level. It is an easy, cheapand safe therapy with no complications and leads toan excellent result in function, sensibility and carry-ing capacity. The semi-occlusive dressing is a suita-ble alternative in treating fingertip injuries.

A-0663 Atypical cleft hand: Surgical technique forgrasping improvement

Edgard N. Franca Bisneto, Emygdio J. Leomil de Paula,Rames Mattar Jr, and Laura LorimierInstitute of Orthopaedics and Traumatology University ofSao Paulo, Sao Paulo, Brazil

In this article, we present cases of children with aty-pical cleft hand classified as oligodacytic (Blauth andGekeler), type IIA (Foucher) or multidactyly(Woodside and Light), all of them with the absenceof the second finger but the corresponding metacar-pal is present and normal. Some children have thumbmetacarpal-phalangeal (MP) instability. Clinicallythey have lack of pulp to pulp pinch due to MP liga-ment insufficiency and difficulty in grasping largeobjects since first web is narrowed.

Six children between 2 and 13 years old, four girlsand two boys, with unilateral atypical cleft hand wereincluded for this analysis. All of them have thumb andulnar fingers or ‘‘nubbins.’’ Second finger is absent inall cases but one, second metacarpal were presentand normal. All children have normal global functionconsidering respective ages for daily living activities.

Three of them have thumb metacarpal-phalangeal(MP) instability and lack of pulp to pulp pinch.

All children have difficulties in grasping largeobjects.

Second metacarpal resection and Z-plasty createda wide first web that allowed large objectsprehension.

The second ECD tendon transfer improves stabilityof thumb MP joint that makes pinch grip with fifthfinger possible.

The surgical technique presented in this article didimprove function in oligodactyly or type IIA atypicalcleft hands allowing grasp of large objects

A-0678 Delayed primary repairs of the flexor ten-dons had better outcomes than primary repairs inzone 2: An outcomes analysis in a single unit

Xiang Zhou1, Jun Qin1, Xiang Rong Li1 and Jing Chen2

1People’s Hospital of Jiangyin, Jiangsu, China2Jiangsu Medical Research Center, Nantong, Jiangsu,China

Objective: We reviewed our patients with completedivisions of zone 2 finger flexor tendons using asix-strand core M-Tang suture with early activemobilization from a single unit and aimed to assessand analyze the different functional recovery of fin-gers treated with the delayed primary and primaryrepair.Methods: We repaired 80 flexor digitorum profundus(FDP) tendons (80 fingers) of 66 patients fromNovember 2013 to May 2017. There are 52 men and14 women. The patients aged 17 to 65 years, withaverage of 35 years. Thirty-six fingers were repairedafter a delay a mean of 4 (2 to 10) days with primaryskin closure and later tendon repair in a non-emer-gency surgical setting. Forty-four fingers wererepaired primarily with 12 h after injury. The FDPtendon was exposed through a Bruner’s incisionand the tendon was repaired with the 6-strand M-Tang repair using 4-0 looped suture and sparselyplaced simple running peripheral suture with 6-0 or5-0 nylon. After surgery, the fingers were immobi-lized for 3�4 days and partial range digital activemotion was initiated after that. The patient wasencouraged to actively move the fingers interphalan-geal joints and metacarpophalangeal joint to about ½of the total motion range in the first 1�3 weeks. Thenthe patient proceeded to full range of active motionaround the end of week 3. The primary repair in ourseries was performed during the late afternoon ornighttime, while the delayed primary repair was atdaytime. We compared the functional results and

SS126 Journal of Hand Surgery (Eur) 43(Supplement 2)

demographics and injury factors (gender, age,accompanied injuries, and follow-up lengths)between patients treated with primary repair anddelayed primary repair using the Student t-test,Kruskal–Wallis rank sum test and Fisher exact test.Results: Among the total of 80 fingers, the meanrange of motion (ROM) of the proximal (PIP) anddistal interphalangeal (DIP) joints was 153� 29 withfollow-up of 5 to 27 months. According to theStrickland and Glogovac criteria, 46 fingers (57%)were rated as excellent, 19 (24%) good, 11 (14%)fair and 4 (5%) poor. There were no tendon ruptures.The mean ROM in the 36 fingers with delayed primaryrepair was 161� 25�, which is significantly betterthan that of 44 fingers with primary repair of146� 30� (p¼ 0.018). There are 25 excellent, 7good, 3 fair, 1 poor in the fingers with delayed pri-mary, and 21 excellent, 12 good, 8 fair, 3 poor withprimary repair using the criteria of Strickland andGlogovac. We found no significant differences indemographics and injury factors (gender, age,accompanied injuries and follow-up lengths) betweenthe two groups.Conclusions: A primary repair in the late afternoon ornighttime has worse outcomes than delayed primaryrepair as a selective procedure, performed a fewdays after trauma. We conclude that in order toobtain a better functional recovery, surgeons musthave sufficient energy and less fatigue. We suggestthat delayed primary flexor tendon divisions are pre-ferable than primary repair in the late afternoon ornighttime.

A-0686 New arthroscopic classification of TFCCinjuries

Toshiyasu Nakamura and Koji AbeDepartment of Orthopaedic Surgery, School of Medicine,International University of Health and Welfare, Tokyo,Japan

Objectives: Palmer’s classification described in 1989which was based upon findings of radiocarpal jointarthroscopy is now widely used. Due to severalreports of other types of TFCC injury that was notin Palmer’s classification, such as the dorsal or cor-onal tear or due to recent development of DRUJarthroscopy, we need new thorough classificationboth includes RCJ and DRUJ sides. We tried to clas-sify our case series of consecutive 213 TFCC lesionsin a year period.Methods: From July 2014 to September 2015 (1 yearand 2 months period), 213 wrists of 211 TFCC injurypatients who underwent first-look arthroscopy both

in the RCJ and DRUJ were included in this study.There were 123 males and 88 females, right wristof 116, left of 93 and 2 bilateral. Average age ofarthroscopy was 39.1 year (range 13–72). All datawere recorded on cards and DVDs.Results: On radiocarpal arthroscopy, 191 TFCC inju-ries were categorized as traumatic: in which A as thecentral lesion: slit (13), flap (2), double transverse slit(1), oblique (2), coronal (1), bucket handle (2); B asthe ulnar peripheral (150); C as the palmar distal (1);D as the radial: within the disc (4), radial rim (1); E asthe dorsal: dorsal isolated (2),extended dorsal toulnar (8); F as the palmar (2); and G as the horizontal(2). Degenerative tear was found in 48 wrists as simi-lar to Palmer’s classification; wear of the disc (9),wear þ the LT tear (7), perforation (21), perforationwith chondral lesion of the lunate and/or triquetrumcartilages (11). On DRUJ arthroscopy, traumaticTFCC injuries were found in 19 wrists, subclassifiedwith A (proximal slit) (1), B (partial RUL avulsion) (1),and C (complete RUL avulsion) (17). Degenerativefindings on the proximal side of the TFCC werefound in five wrists with DRUJ arthroscopy, in whichdegenerative fibrillation on the proximal surface ofthe TFCC in 2, and relaxed RUL in 3. Isolated injurywas found in 144 wrists (67%), in which the RCJ-Btype (classical Palmer 1B) tear were 90, followed byDRUJ-C type (complete RUL avulsion) in 17. Doublelesions were found in 65 wrists (30%), in which com-bination of RCJ-B and DRUJ-C (presumable com-plete ulnar lesion) was the most in 19 wrists. Tripleinjuries were found in four wrists, all included RCJ-Btear and three wrists included DRUJ-C type.Conclusion: We classified TFCC lesion based uponRCJ and DRUJ arthroscopic findings. In the isolatedinjuries, RCJ-B type (classic Palmer 1B) was the most,followed by DRUJ-C type (complete RUL avulsion).One third of our series indicated combined double ortriple lesion that included lesions onto the RCJ andDRUJ. To diagnose TFCC lesion thoroughly, bothRCJ and DRUJ arthroscopy are necessary.

A-0691 Nerve transfer for restoring pinch strengthin high median nerve injuries

Margarita Kateva1, Kalin Angelov1 andNikola Simeonov2

1UMHAT ‘‘Sofiamed’’ – Department of Orthopedics,Traumatology, Hand Surgery and Reconstructive Surgery,Sofia, Bulgaria2SU ‘‘St. Kliment Ohridski’’ – Faculty of Medicine, Sofia,Bulgaria

FESSH Abstracts SS127

Objective: Our goal is to evaluate the possible recon-struction of thumb flexion in a way to get pinch in thehand using nerve transfer of the motor branch of theextensor carpi radialis brevis muscle (n. radialis) tothe n. interosseous anterior (n. medianus) reinervat-ing m. flexor digitorum profundus and m. flexor pol-licis longus.Method: This is clinical presentation in a series offive patients with high injury of n. medianus-inner-vated muscular paralysis with duration of 8–14months.

Operative intervention is a nerve transfer under amicroscope magnification of the motor branch (n.radialis) of m. extensor carpi radialis brevis (ECRB)to n. interosseous anterior (n. medianus) with clinicaloutcome-possible pinch in the hand. S-shapedapproach is used in proximal 1/3 of the anterior fore-arm. The branches of n. radialis are found one by onewith operating microscope – n. superficialis (sen-sory), m. extensor carpi radialis brevis (motor), m.supinator (motor) and n. interosseous posterior.The motor branch to the m. extensor carpi radialisbrevis is tracked maximally distal and is resected justbefore entering the muscle. The coaptation is made(end-to-end) to n. interosseous anterior (n. media-nus) using surgical suture 9-0. Also nerve transferof dorsal sensory nerve (n. radialis) to the volar sen-sory nerve (n. medianus) is made in a way to restoresensibility of the volar part of the digital pulp of thethumb and index finger.Clinical Results: First clinical manifestations arefound 9 months postoperatively. As all patientsachieved pinch M4 (in MRC) in 18 months postopera-tive and maintained the active wrist extension.Conclusion: This is one good suggestion for restoringthe pinch of the hand using nerve transfer in patientswith high nerve injury.

A-0705 Validity of the patient-rated wrist evaluationquestionnaire in rheumatoid hand

Zeynep Tuna1, Oguzhan Mete2, Gizem Tore1,Songul Baglan Yentur1, Deran Oskay1 andAbdurrahman Tufan3

1Gazi University Faculty of Health Sciences Department ofPhysiotherapy and Rehabilitation, Ankara, Turkey2Yildirim Beyazit University Faculty of Health SciencesDepartment of Physiotherapy and Rehabilitation, Ankara,Turkey3Gazi University Faculty of Medicine Department of InternalMedicine Division of Rheumatology, Ankara, Turkey

Patient-Rated Wrist Evaluation (PRWE) is a patient-reported questionnaire focusing on the symptoms

and functions in wrist pathologies. It consists of 15questions of pain and functional activities of thewrist. Rheumatoid arthritis (RA) is a multi-systemicdisease involving primarily the inflammation of thewrist and hand joints. Therefore, this study aims totest the validity of PRWE in patients with RA.

Seventy-five patients with RA from one outpatientclinic participated in the study. Patients filled out theMichigan Hand Outcomes Questionnaire (MHOQ) andgross grip strength was measured for both hands.Patients filled out the PRWE questionnaire for eachright and left hand consecutively. Questions of PRWEwere asked to the patients regarding dominant andnon-dominant hand. Correlations between PRWE andMHOQ and gross grip strength scores were analyzedby Spearman’s correlation to assess validity ofPRWE.

Our results demonstrated that PRWE had negativeand strong correlation with MHOQ for dominant hand(p¼�0.83, p< 0.001) and had negative and moderatecorrelation with MHOQ for non-dominant hand(p¼�0.79, p< 0.001). PRWE showed negative andfair correlation with grip strength for both hands.All correlations were statistically significant(p< 0.05).

PRWE is a valid tool for evaluating the wrist invol-vement in patients with RA. PRWE may be preferredin the clinical setting for its simple and short ques-tions. Additionally, it may provide a sensitive follow-up process for patients with its subscales regardingpain and function separately.

A-0712 Long-term outcomes of the use of aspherical ulnar head prosthesis for failedSauve-Kapandji procedures

Margaret Fok1, Diego Fernandez2 andJorg van Schoonhoven3

1Department of Orthopaedics and Traumatology, QueenMary Hospital, The University of Hong Kong, Hong Kong2Department of Orthopaedic Surgery, Lindenhof Hospital,Bern, Switzerland3Clinic for Hand Surgery, Bad Neustadt an der Saale,Bavaria, Germany

Objective: The use of a spherical ulnar head prosthe-sis (UHP) for the treatment of symptomatic radio-ulnar convergence after Sauve-Kapandji (SK) proce-dure has shown promising results in the short term.This study aims to evaluate the long-term outcome ofthe original cohort of patients treated with thistechnique.Methods: Seventeen patients with confirmation ofunstable ulnar stumps both clinically and

SS128 Journal of Hand Surgery (Eur) 43(Supplement 2)

radiographically were studied. The etiology for theinitial SK procedure included post-traumatic distalradioulnar joint incongruity, primary DRUJ arthrosisand dysplastic DRUJ. All but three patients had aminimum of two and a maximum of six operationsprior to having a spherical UHP. All patients sufferedfrom severe pain with difficulty in performing workand daily activities. Ceramic UHP was used for allpatients except two of which cobalt chrome headwas used.Results: The average follow-up was 6 years (range4–17 years). The reduction of pain was statisticallysignificant with 11 patients who remained pain free.The range of motion of the wrist and power grip wasmaintained to and showed a statistically significantimprovement at the late follow-up. The DASH scorealso significantly improved from 77 to 41 with ap¼ 0.03. The average patients’ satisfaction scorewas 9 of 10.

No signs of loosening of the prosthesis were notedat the late follow-up. The only two patients who hadreceived cobalt chrome head prosthesis developedsignificant osteolysis as well as pain and had to berevised to the Scheker total DRUJ prosthesis. Twopatients who suffered from traumatic dorsal sub-luxation of the prosthesis were treated with radialosteotomy, both with a satisfactory result.Conclusion: This study illustrates that the lateresults of ceramic spherical ulnar head prosthesisfor failed SK procedures in this small but represen-tative patient series are encouraging.

A-0719 Wide-awake hand surgery: Limits andcomplications

Kai Megerle, Julia Jakobus, Ursula Kraneburg andHans-Gunther MachensClinic for Plastic Surgery and Hand Surgery, TechnicalUniversity of Munich, Munich, Germany

Wide-awake hand surgery or WALANT has beenestablished as a safe and cost-efficient alternativeto traditional hand surgery. However, there is onlyfew information on complications or limits of thisapproach. We report a single surgeon’s experiencein 318 cases.

Between 2012 and 2017, the presenting author per-formed 318 acute and elective hand surgical proce-dures utilizing 1% Ultracain with 1:200,000epinephrine. All cases were retrospectively reviewedfor intraoperative or postoperative complications. Inaddition, we conducted telephone interviews with thepatients after a mean of 7 months after the

procedure and asked about further complicationsand the overall experience.

In two cases of tenolysis of the palm and forearm,respectively, there was incomplete anesthesia, pre-sumably due to incomplete diffusion because ofextensive scarring. Both cases were intraoperativelyconverted to general anesthesia. One patient withdelayed sagittal band reconstruction demonstrateda rash on the dorsum of the hand for several days,another patient-reported prolonged swelling of theinjection site. An 87-year old patient developed tran-sient coronary spasm without evidence of myocardialischemia 3 h after injecting 14 ml of anesthesia forcarpal tunnel release. Two patients reported thatthey would have preferred a different form ofanesthesia.

Vascular anastomoses demonstrated a highly vari-able degree of flow during WALANT, ranging from noflow to normal perfusion.

The WALANT approach can be utilized in many dif-ferent hand surgical procedures. In our experience,anesthesia may be unreliable in cases with extensivepreexisting scarring. Patients who are ambiguousabout the concept of being awake during surgeryshould not be persuaded. The WALANT approachshould not be performed in cases with preoperativelyimpaired finger perfusion.

A-0720 Lower recurrence rate of Dupuytren’scontracture in metacarpophalangeal joints follow-ing collagenase Clostridium histolyticum treatmentcompared with percutaneous needle fasciotomy in arandomized controlled study: Preliminary results

Stig Jørring and Claus Hjorth JensenHand Clinic, Department of Orthopedics, Herlev-GentofteUniversity Hospital of Copenhagen, Denmark

Objective: Few studies report on recurrence ratesfollowing treatment with collagenase histolyticuminjections (CI) of Dupuytren’s contracture (DC) incomparison to other treatment modalities. To evalu-ate CI against another minimally invasive treatmentmodality, an RCT comparing CI and percutaneousneedle fasciotomy (PNF) of the MCP-joints in DCwas initiated.Methods: Sixty-two patients suffering from DC withisolated extension deficit �30� in a MCP-joint wereinvited to participate in the RCT. The patients wereallocated to either CI injection in accordance with themanufacturer’s guidelines or PNF. Only one treat-ment pr. patient entered the study.

FESSH Abstracts SS129

Patients were followed for 1–3 years. Recurrenceof DC� 30� and/or reoperation of the treated digitwere considered failure of the treatment.Results: Thirty-two patients were allocated to CI and30 to PNF. Four patients in the CI group withdrewtheir consent to participate prior to treatment leaving28 patients in the CI group. In two patients in the PNFgroup, rupture of the cord was unsuccessful (<20�

improvement of contracture) leaving 28 patients forfollow-up (FU). Fourteen were female and 48 weremale patients.

At FU, four patients in the CI group and 14 patientsin the PNF group were considered failures. �2 8.2,p< 0.005.Conclusion: CI yields superior results as comparedto PNF at FU at 1–3 years in the treatment of isolatedDC in MCP-joints as the recurrence rate is signifi-cantly lower.

Longer follow-up is needed to evaluate themedium and long-term recurrence rates.

A-0722 Use of a photodynamic polymer for intra-medullary osteosynthesis of metacarpal fractures:A 3-year experience

Carsten Surke, Rahel Meier, Luzian Haug, Tom Adlerand Esther VogelinDepartment of Plastic and Hand Surgery, Inselspital,University Hospital Bern, University of Bern, Switzerland

Patients and Methods: From December 2014 untilNovember 2017, 76 patients with metacarpal frac-tures have been treated with an intramedullarilyapplied photodynamic polymer (IlluminOssTM). Theindications for surgical treatment were either multi-ple mc fractures, fracture angulations greater than40� and/or malrotation of digits. All patients with anIlluminOss osteosynthesis and a clinical and radiolo-gical follow-up of at least 12 weeks were included inthis study (n¼ 57 patients with n¼ 61 fractures). Thecohort includes fractures of a single metacarpal aswell as multiple metacarpal fractures. Cases withmultiple injuries to the same hand, which were trea-ted by a combination of osteosynthesis, were alsoincluded.Results: Eight cases had shaft fractures. In all othercases, subcapital fractures were treated. In threecases, multiple metacarpal fractures were treated.In four cases, adjuvant osteosynthetic material wasused. All IlluminOss fractures were healed at week12. No implant-related infection was seen. In fivecases, mild to moderate secondary dislocation wasseen but surgical revision was not necessary. In onecase with a particularly comminuted fracture,

implant failure occurred requiring surgical revision.In two cases of split head fractures, intraarticularprotrusion of the implant was seen necessitatingoperative shortening of the implant. Range of move-ment was compared to the contralateral uninjuredside and improved in the course of clinical follow-up, but was dependent on severity of the injury.Subjective satisfaction measured by the Quick-DASH score was good in all patients.Conclusion: Osteosynthesis by means of a photody-namic polymer is a safe and stable method to treatmetacarpal fractures allowing an early mobilizationand minimizing cast treatment. Due to the intrame-dullary implantation, surrounding soft tissues arepreserved. We observed a steep learning curve interms operating time and use of the implantsystem. We found a low complication rate compar-able to other established paths of treatment, but ingeneral implant removal is not necessary.

A-0730 Influence of plate types on clinical andradiological outcomes of ulnar shortening osteot-omy in patients with idiopathic ulnocarpal impactionsyndrome

Jong-Pil Kim, Sung-Bae Park and Dong-Ho LeeDepartment of Orthopaedic Surgery, Dankook UniversityCollege of Medicine, Cheonan, South Korea

Background: The purpose of this study was to assessinfluence of plate types on clinical and radiologicaloutcomes of ulnar shortening osteotomy in patientswith ulnocarpal impaction syndrome by comparingAO 3.5 dynamic compression plate, 3.5 limited con-tact-dynamic compression plate and ulnar osteotomyplate. In addition, the effect of interfragmentaryscrew fixation during ulnar shortening on radiologicoutcomes of ulnar shortening osteotomy wasassessed.Materials and Methods: Seventy-eight patients whounderwent ulnar shortening osteotomy using platefixation and were followed-up at least 1 year wereenrolled. Three types of plates were consecutivelyused: AO 3.5 dynamic compression plate (group 1,n¼ 31), AO 3.5 limited contact-dynamic compressionplate (group 2, n¼ 19), AO 2.7 ulnar osteotomy plate(group III, n¼ 28). The patients were also divided intotwo groups based on performing interfragmentaryscrew fixation: interfragmentary screw fixationgroup (n¼ 27) and without interfragmentary screwfixation group (n¼ 51). The clinical outcomes wereevaluated by disability of arm, shoulder and hand,Patient-related wrist evaluation. Radiological out-comes including time to bone union, presence of

SS130 Journal of Hand Surgery (Eur) 43(Supplement 2)

delayed union which was defined when the union wasnot observed until 12 weeks, and re-fracture aftermetal removal were assessed. Other possible factorsthat might affect bone union such as smoking andunderlying disease were assessed.Results: All patients showed union at the finalfollow-up. There were no statistically significant dif-ferences in both clinical and radiological outcomesaccording to the types of plates. When comparingthe groups treated with and without interfragmentaryscrew fixation, time to bone union was shorter in theinterfragmentary screw fixation group (7.56� 2.56weeks vs 9.79� 6.59 weeks, p¼ 0.038). Delayedunions were only observed in 8 of 51 patients treatedwithout interfragmentary screw fixation (15.68% vs0%, p¼ 0.045). In ulnar shortening without interfrag-mentary screw fixation group, 5 of 43 patients(11.62%) who removed the plate had experiencedre-fracture of the ulna by low energy trauma afterplate removal. However, there was no significant dif-ference of clinical outcomes between the interfrag-mentary screw fixation group and withoutinterfragmentary screw fixation group (Table 2).Conclusion: Types of plate did not influence the clin-ical and radiological outcomes of ulnar shorteningosteotomy in the patients with idiopathic ulnocarpalimpaction syndrome. However, interfragmentaryscrew fixation with plating for ulna shorteningosteotomy has several advantages such as earlybony union and prevention of re-fracture aftermetal removal.

A-0733 Dupuytren disease 7-day manipulationfollowing collagenase: Safety, efficacy andoutcomes

David J. Hunter-Smith, Bethany Reynolds, Vicky Tobin,Michael P. Chae and Warren M. RozenDepartment of Plastic and Reconstructive Surgery,Frankston Hospital, Peninsula Health, Frankston Victoria,Australia; Monash University Plastic and ReconstructiveSurgery Group (Peninsula Clinical School), PeninsulaHealth, Frankston, Victoria, Australia

Objective: Determine the safety, efficacy and out-comes of 7-day manipulation following the use ofinjectable collagenase Clostridium histolyticum(CCH) for Dupuytren disease.Methods: Patients presenting with Dupuytren’ dis-ease were offered treatment with collagenase injec-tions. Baseline demographic and medical data werecollected. In addition, total passive extension deficit(TPED) and patient-reported outcome measures(PROMS) were recorded prior to treatment, and at 6

weeks, and 6-month post-manipulation. Patientsunderwent a standard treatment protocol of injectionD0 and manipulation D7 under local anaesthetic onan outpatient basis. Results were collected prospec-tively and analysed.Results: One hundred and thirty-nine patients (98males, 74.2%) with a mean age of 65.7 years (range38.6–87.7) have been treated to date. In 34% of cases,the disease represented a recurrence.Anticoagulants were taken by 63% of patients.There was a significant improvement in PED acrossinjected rays (p< 0.001). In addition, patients demon-strated highly significant improvement in functionand quality of life on Southampton (p< 0.001),URAMS (p< 0.001) and ‘‘Patient SET’’ (p< 0.001)questionnaires. A typical spread of minor complica-tions and no major complications were encountered.Conclusions: Our data suggest that 7-day manipula-tion following injection of collagenase is safe to usein patients with Dupuytren’s disease. It demonstratessignificant improvements in objective and subjectivemeasures of hand function. These data suggest thatit is safe and efficacious to manipulate, following col-lagenase up to 7 days post injection.

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A-0737 Tendon subluxation after surgical releaseof the first compartment in de Quervain disease: Aprospective randomized controlled study compar-ing simple midline incision and dorsoulnar incisionfor elevating radial flap

Jong-Pil Kim, Seg-Won Yang and Dong-Ho LeeDepartment of Orthopaedic Surgery, Dankook UniversityCollege of Medicine, Cheonan, South Korea

Purpose: To evaluate tendon subluxations usingultrasonography after release of the first compart-ment in patients with de Quervain disease and tocompare the clinical and functional outcomesbetween the midline incision and dorsoulnar incisionfor elevating radial flap.Methods: This randomized prospective study invol-ving 46 patients with de Quervain disease whorequired surgical release of the first compartmentwere divided into two groups: group 1 with midlineincision and group 2 with dorsoulnar incision. Toevaluate tendon subluxation, the sliding distance ofthe extensor pollicis brevis (EPB) in five wrist posi-tions were measured at 12 and 24 weeks using ultra-sonography: neutral deviation, radial deviation, ulnardeviation, dorsiflexion, and volar flexion of the wrist.Clinical outcomes of the patients were evaluatedusing the Disabilities of the Arm, Shoulder andHand (DASH) score, Visual Analogue Scale (VAS),

and grip strength at 4, 12, and 24 weeks aftersurgery.Results: In wrist flexion, volar displacement of EPBwas 1.37� 0.63 mm in group 1 and 0.31� 0.85 mm ingroup 2 at 12 weeks after surgery (p< 0.001),1.25� 0.61 mm in group 1 and 0.36� 0.69 mm ingroup 2 at 24 weeks (p< 0.001). The change oftendon subluxation between 12 and 24 weeks wasnot significant (p> 0.05). In wrist extension, dorsaldisplacement of the tendons was 0.56� 1.36 mm ingroup 1 and 1.92� 1.75 mm in group 2 at 12 weeksafter surgery (p¼ 0.024) and at 24 weeks (p¼ 0.069).Otherwise, no significant difference between twogroups was found in the other position of the wrist.Clinical outcome measures including DASH score,VAS, and grip strength showed no difference betweenthe groups. There were no significant correlationsbetween tendon subluxation and clinical outcomemeasures (p¼ 0.618).Conclusion: Tendon subluxation after first compart-ment release for de Quervain disease is moreincreased during wrist flexion in the simple midlineincision and during wrist extension in the dorsoulnarincision elevating the radial flap. However, tendonsubluxation after first compartment release doesnot affect clinical outcomes.Level of evidence: Level 1, Therapeutic.

A-0740 Early radiological results of arthroscopictreatment of the scaphoid nonunion

Igor Golubev, Maxim Merkulov, Oleg Bushuev,Galina Shiryaeva, Andrey Maximov, Ilya Kutepov andOlga HozyainovaDepartment of Hand and Microsurgery, N.N. PriorovNational Medical Research Center of Traumatology andOrthopaedics (CITO), Moscow, Russia

Objective: To evaluate the union rate and wrist mala-lignment correction of arthroscopic bone grafting ofscaphoid nonunion in the early postoperative period.Methods: The study included 41 patients who wereoperated from 2015 to 2017. Nonunion was locatedin middle third in 33 and proximal third in 8 cases.Average age of nonunion was 25 month (from 8 to48). Evident DISI with radio-lunate angle more than30� was noted in 32 (78%) of cases. All patients under-went arthroscopic resection of nonunion and bonegrafting from midcarpal joint. Scaphoid fragmentsfixation was done by 3 K-wires. Union was noted byCT done in 8 weeks after operation and K-wires wereremoved. Before, soon after and in 10 weeks afteroperation, there were noted consolidations, radio-lunate (RL) and scapho-lunate (SL) angles.

SS132 Journal of Hand Surgery (Eur) 43(Supplement 2)

Results: Union in 10 weeks after procedure wasachieved in 38 (92.7%) patients. There were one fail-ure of union in middle and two in proximal scaphoidthird cases. The average RL angle before the opera-tion was 40.7� (15�–50�), immediately after – 23.5�

(0�–45�) and in 10 weeks after the removal of K-wires 27.7� (0�–45�). The SL angle before surgerywas 67.7� (from 60� to 90�), immediately after�50.2� (30�–50�) and it 10 weeks after – 53.4� (45�–60�). The data comparison shows statistical signifi-cance in both angels in both period of measurement– soon after operation and in 10 weeks after it(p 0.01).Conclusion: Arthroscopic management of scaphoidnonunion shows not only high union rate but alsosignificant correction of carpal DISI deformity inearly postoperative period.

A-0741 Does bowstringing affect hand function inpatients treated with A1 pulley release for triggerthumb: A randomized trial comparing percutaneousversus open technique

Jong-pil Kim, Kwang-hee Park and Jae-wook JungDepartment of Orthopaedic Surgery, Dankook UniversityCollege of Medicine, Cheonan, South Korea

Purpose: The purpose of this study was to determinethe extent to which the release of the A1 pulleycauses bowstringing in the treatment of triggerthumb, and how the percutaneous technique is ben-eficial to bowstringing and clinical function over opentechnique.Methods: A total of 31 patients with resistant triggerthumb were prospectively randomized to undergoeither percutaneous release (17 patients) or openrelease of the A1 pulley (14 patients). We quantifiedbowstringing of the digit by measuring furtherpalmar displacement of the flexor pollicis longus(FPL) tendon during thumb IP joint power flexionusing ultrasonography at 12 and 24 weeks after sur-gery. Pain on the visual analogue scale, Disabilities ofthe Arm, Shoulder and Hand, pinch power, and gripstrength were assessed and analyzed to correlatewith the ultrasonographic measurements.Results: Each cohort showed a significant improve-ment in all clinical outcomes (p< 0.05), with no dif-ference between the groups at each follow-up(p> 0.05). The bowstringing was greater increasedat 12 weeks after surgery in both groups, and theaverage value of the open release group was greaterthan those of the percutaneous group compared tobefore surgery (6.11� 1.04 mm vs 5.20� 0.79 mm,respectively) (p¼ 0.041). However, the difference of

those values was not significant at 24 weeks’follow-up (4.18� 0.93 mm vs 3.92� 0.77 mm, respec-tively) (p¼ 0.671) There was no significant correlationbetween the bowstringing of the flexor tendon andany clinical outcome measures (p> 0.271).Conclusion: Open A1 pulley release of the thumbcaused greater bowstringing than percutaneoustechnique early after surgery. However, bowstringingdid not affect clinical hand function in patients trea-ted with either percutaneous or open technique fortrigger thumb.Levels of evidence: Level 1, Therapeutic.

A-0742 Positive experience with the treatmentprocess associated with better outcome after sur-gery for carpometacarpal osteoarthritis

Jonathan Tsehaie1,2, Mark van den Oest1,2,Ralph Poelstra1,2, Ruud W. Selles1,2,3, Reinier Feitz2,Harm Slijper2, Steven Hovius1,2, Jarry T. Porsius1,2,3

and The Hand-Wrist Study Group1Department of Plastic, Reconstructive and Hand Surgery,Erasmus Medical Center Rotterdam, The Netherlands2Hand and Wrist Surgery, Xpert Clinic, The Netherlands3Department of Rehabilitation Medicine, Erasmus MedicalCenter Rotterdam, The Netherlands

Background: Currently, literature indicates thatexperience with the delivered healthcare influencestreatment outcome. However, the relationshipbetween experience with the delivered healthcareduring the treatment of CMC-1 osteoarthritis andoutcome is unknown. Therefore, the aim of thestudy is to investigate what the association isbetween patient experience around the CMC-1 sur-gery and treatment outcomes in terms of patient-reported outcomes (PROMS) and therapist-reportedoutcomes (TROMS).Methods: Patients who received a Weilby procedurefor their CMC-1 osteoarthritis between 2011 and 2017during regular care delivery in 17 outpatient clinicswere included. Before and 12 months after surgery,patients completed a PROM: the Michigan HandOutcomes Questionnaire (MHQ) and a (TROM):strength measurements. In addition, a patient-reported experience measure (PREM) was filled inat 3 months. Regression analyses were used toexamine to associations of the different subscalesof the PREM on the one hand and the MHQ changescores and strength on the other hand, while adjust-ing for confounders. Multiple regression analysis wasused to determine how much of the variation in treat-ment outcome between patients could be explainedby the PREM scores.

FESSH Abstracts SS133

Results: Two hundred and thirty-three patients wereincluded in the analysis. There were positive associa-tions between the PREM and the PROM (the MHQ).The strongest associations were determined for theexperience with information provided, communica-tion of the physician and the post-operative caredelivered. No associations were found betweenpatient experience and TROMS (strength measure-ments). The PREM could explain 3.2–8.4% of the var-iation between patients in MHQ outcomes, dependingof the PREM subscale.Conclusion: This study shows a positive associationbetween experience with the healthcare delivery andpatient-reported treatment outcome in surgicaltreatment of CMC1 osteoarthritis, but no positiveassociation between experience with the healthcaredelivery and strength outcomes. These findings sug-gest that patient-reported treatment outcome inCMC1 osteoarthritis can be improved by improvingthe experience with the healthcare delivery.

A-0743 Computed tomography angiography allowsthe classification of the first dorsal metatarsalartery

Xu Lin1, Tan Haitao1, Wei Pingou1, Luo Xiang1 andChaitanya S. Mudgal2

1Department of Hand and Foot Microsurgery, Guigang CityPeople’s Hospital, Guigang, Guangxi, China2Department of Orthopaedic Surgery, Orthopaedic Handand Upper Extremity Service, Massachusetts GeneralHospital, Boston, Massachusetts, USA

Background: Conventional angiography is an invasivetechnique. Submillimeter computed tomographyangiography (CTA) has been shown to be an effectivealternative for peripheral artery branches. This studyaimed to assess the use of CTA to guide the choiceand design of foot donor area for finger or thumbreconstruction.Methods: This was a retrospective study of 79patients who underwent finger or thumb reconstruc-tion between January 2011 and March 2014. All thesepatients underwent preoperative CTA to determinethe exact blood supply at the donor site.Preoperative imaging and intraoperative findings atthe donor site were compared.Results: Among the 79 patients (158 feet), 474 arterysegments (dorsalis pedis artery (DPA), first dorsalmetatarsal artery (FDMA), and toe web artery(TWA)) were evaluated using CTA. Image satisfactionrates of the vessels were 100.0� 0.0%, 89.2� 3.2%,and 60.1� 5.0% for DPA, FDMA, and TWA, respec-tively. Among the 158 feet, 90 were Gilbert type I

(57.0%), 52 were Gilbert type II (32.9%), 13 wereGilbert type III (8.2%), and three were with poor vis-ibility and could not be classified (1.9%). In all 79patients, the CTA image of the FDMA was consistentwith the intraoperative observations. All recon-structed fingers survived. Follow-up was availablefor 69 patients. After a 6- to 18-month follow-up,the reconstructed fingers and donor area recoveredwell, and the reconstructed fingers had strong hold-ing power, without pain.Conclusion: CTA can produce three-dimensionalimages for extremity arteries, allowing the preopera-tive assessment of blood supply and planning ofdonor site.

A-0744 Hyphenated technique of CT angiographywith color Doppler ultrasound for accurate posingbefore anterolateral thigh flap transplantation in 19clinical cases

Xu Lin1, Tan Haitao1, Wei Pingou1, Luo Xiang1 andChaitanya S. Mudgal2

1Department of Hand and Foot Microsurgery, Guigang CityPeople’s Hospital, Guigang, Guangxi, China2Department of Orthopaedic Surgery, Orthopaedic Handand Upper Extremity Service, Massachusetts GeneralHospital, Boston, Massachusetts, USA

Background: CT angiography (CTA) and colorDoppler ultrasound (CDU) have been widely appliedin recent years for the vessel positioning.Objective: We aim to explore the impact of hyphe-nated technique of CTA with CDU in free anterolat-eral thigh perforator flap repair surgery in patientswith hand-foot skin injury.Methods: From March 2014 to December 2015, a pro-spective study on free anterolateral thigh perforatorflap repair surgery in 19 patients in the Departmentof Hand-foot Microscopic Orthopaedic, GuigangPeople’s Hospital was done. Using CTA scan, the pre-operative vessel positioning was done in anterolat-eral thigh area, validated by CDU detection. Theappearance of donor site and the appearance, tex-tures, color, blood supply of skin flaps in the recipientarea were monitored after surgery. The functionallevel in recipient areas of hand and foot weregraded by TAM (Total Active Movement) system eva-luation method.Results: Fifty-four perforator vessels detected indonor site of anterolateral thigh area with hyphe-nated technique of CTA with CDU, while 58 perforatorvessels (54 detected vessels and 4 small vessels withdiameters <0.5 mm) were observed during surgery.Flaps survived without vascular crisis in all patients.

SS134 Journal of Hand Surgery (Eur) 43(Supplement 2)

The postoperative follow-up lasted 6 to 13 months,and the survived flaps exhibited soft texture, goodblood supply, good appearance, and skin color wascloser to normal skin.Conclusion: The hyphenated technique of CTA withCDU can detect the perforator vessels accurately,providing a new approach for preoperative estimationof accurate locations of perforator vessels.

A-0746 Clinical application of 3D printingtechnology for preoperative planning of thumbreconstruction using donor toe

Xu Lin1, Tan Haitao1, Wei Pingou1, Luo Xiang1 andChaitanya S. Mudgal2

1Department of Hand and Foot Microsurgery, Guigang CityPeople’s Hospital, Guigang, Guangxi, China2Department of Orthopaedic Surgery, Orthopaedic Handand Upper Extremity Service, Massachusetts GeneralHospital, Boston, Massachusetts, USA

Background: Although thumb reconstruction surgeryhas been developed for years and the surgical tech-nology gradually matured, there are still many chal-lenges, including the preoperative design of theprosthesis.Objective: To explore the clinical application of pre-operative precise design for 3D printing and thumbreconstruction.Methods: This was a retrospective study of 20patients who underwent the surgery of harvestingtoe transplant and thumb reconstruction at theGuigang People’s Hospital between January 2015and December 2016. The 3D model of the thumbdefect was created and printed. The dimensions ofskin and bones from donor site were preciselydesigned as reference for surgical operation. Thesurgery was performed according to the model.Results: Perfect repair of defects was achieved withsatisfying appearance and function. The recon-structed thumbs all survived (survival rate of 100%).Partial skin necrosis was found in two patients, butcomplete healing was eventually achieved. Follow-upwas 3–9 months. The maximum dorsiflexion was8–30� and the maximum flexion was 38–58�. Thetwo-point sensory discrimination was 9–11 mm. TheMichigan Hand Outcomes Questionnaire (MHQ) was26–45%. Grip power was 31–54%. There were 17 andthree patients with satisfaction of ‘Excellent’ and‘Good’ each for the reconstructed thumb and handfunction, respectively. The satisfaction rate was 85%.Conclusion: Preoperative digital design and 3D print-ing according to the donor and recipient sites alloweda tailored operation. The operation was more precise,

the appearance of the reconstructed thumb wasgood, and the donor injury was minimal.

A-0751 The natural course of triangular fibrocarti-lage complex tear without distal radioulnar jointinstability

Bong Cheol Kwon, Jae-Yeon Hwang and Seon Jong LeeHallym University Sacred Heart Hospital, Anyang, SouthKorea

Objective: Triangular fibrocartilage complex (TFCC)tear is a common cause of ulnar side wrist pain.However, its natural course has not been understood.The purposes of this study were to determine thenatural course of TFCC tear without distal radioulnarjoint (DRUJ) instability and to identify risk factors forthe poor outcome after conservative treatment of theTFCC tear.Methods: We retrospectively analyzed the electronicmedical records of the patients sustaining TFCC tearwithout DRUJ instability. We evaluated the patientswith pain visual analogue scale (VAS) and patient-rated wrist evaluation (PRWE) at the initial visit, 4weeks, 8 weeks, 12 weeks, and over 6 months afterthe initial visit. The PRWE score 20 points was con-sidered complete recovery, and the PRWE score >20was considered poor outcome. We used Kaplan–Meier survival analysis and Cox regression modellingto estimate the time to complete recovery and toidentify predictors of poor outcome.Results: A total of 104 consecutive patients with anaverage age of 39.8 years (range 18–70) wereincluded in this study. A complete recovery wasachieved in 54 patients at an average follow-up of26� 28 weeks. Estimated probability of completerecovery was 40.8% at 6 months and 57.6% at 1year. Older age significantly reduced the risk ofpoor outcome (adjusted hazard ratio (HR), 0.969;95% CI, 0.947–0.992; p¼ 0.009), while dominanthand involvement significantly increased the risk ofpoor outcome (adjusted HR, 2.062; 95% CI, 1.081–3.934, p¼ 0.028). Notably, ulnar plus variance(p¼ 0.246) and the mode of tear (traumatic vs degen-erative, p¼ 0.5)) were not significant risk factors.During a mean of 16 months of follow-up, 12 patientsunderwent surgical treatment, 6 patients changedtheir vocation, and 8 patients changed their preferredrecreational activities due to wrist pain.Conclusion: This study demonstrates that whilemore than half of the patients with TFCC tear withoutDRUJ instability show a self-limiting course, about40% of the patients still have pain and disability at 1year. Younger age and dominant hand involvement

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are significant independent risk factors for poor out-come after being adjusted for possible confoundingfactors.

A-0755 Update and increase the quality of analgesiaand anesthesia in animal research

Belen Garcıa-Medrano1, Fernando Moreno Mateo1,Clarisa Simon Perez1, Angel Jose Alvarez Barcia2,M. J. Gayoso Rodrıguez3 and Martın-Miguel Ferrero1

1Orthopaedic Surgery, Hand Unit, Hospital Clınico,Valladolid, Spain2Animal Welfare and Research Department, Faculty ofMedicine, University of Valladolid, Valladolid, Spain3Cell Biology and Histology Department, Faculty ofMedicine, University of Valladolid, Valladolid, Spain

Introduction: Rodents are widely utilized in manytypes of surgical research and academic procedures.Interest in animal welfare it’s been increasing in thelast decades due to regulatory and ethical considera-tions. Recent studies have also shown better resultsand clinical outcomes when appropriate therapieshad been applied to prevent animal pain and stress.Intraperitoneal injectable anesthetic protocols areused in rodents to avoid inhalant anesthesia limita-tions. Animals are potentially exposed to the highestlevels of pain during the procedures. That’s why ismandatory to find a suitable and reproducible proto-col for these kind of procedures.Purpose: The aim of the present study was to assessand compare the level of anesthetic plane and post-operative pain obtained from rats with differentanesthesia and analgesia protocols.Materials and Methods: Animals were selected inthe setting of another clinical trial consisting on scia-tic nerve critic defect and its ulterior reparation bytwo different methods. Female Wistar rats were used(n¼ 27, weight 214–292 g, age 8–12 weeks). The ani-mals were randomized in 9 groups: combinations ofdifferent anesthetics and analgesics. Thus, therewere three anesthesia groups (medetomidineþketamine, fentanilþmedetomidine, ketamineþxylazine) and another three analgesia groups (tra-madolþ ibuprofen, mepivacaineþ ibuprofen, trama-dol imþ tramadol poþ ibuprofen).

Anesthetic parameters measured were inductiontime, loss of pedal reflex, signs of pain during sur-gery (withdrawal reflex, tachycardia/tachypnea,sounds emitted) and recovery time. Analgesic para-meters: respiratory rate, height, feeding, feces, chro-modacryorrhea, movement, grooming, position andresponse to stimuli. Numeric value was assigned toeach category to compare different groups and

analysis of variance was used to compare thesedata between groups.Results: Notable differences were found comparedanesthetic protocols. Statistically significant(p< 0.05) differences were observed when signs ofpain during surgery were studied, with best scorein pain scale punctuation in the MK group (0.44) fol-lowed by FM (2) and KX (2.33). The longest and short-est induction times were observed in the KX and KMgroups, respectively, but the difference was not sig-nificant. The shortest recovery time was in the FMgroup, followed by KM and the longest was MK, last-ing in some cases more than 6 h.

Regarding the pain score punctuation after sur-gery, no significant differences were observed inthe fifth postoperative day. In the first postoperativeday, the best analgesic protocol was TTI (4.66),whereas TI (9.13) and MI (10.14) groups were verysimilar. The main significant differences betweenthree analgesic protocols were found in the secondpostoperative day TTI (3.4), TI (6.71), and MI (9.5),(p< 0.05). Five exitus have to be reported (two inKXþ TI group, one in FMþMI group, and two inFMþMI group).Conclusions: Medetomidine plus ketamine regimenanesthetic protocol shown to be the most reliable,safe, and effective method. Long recovery time com-plication could be management with appropriatecare, including respiratory and heart rate and tem-perature monitoring; electric blanket is recom-mended. MK anesthesia could also be reversed byatipamezole. TTI analgesia regimen is stronglyrecommended in the light of these results.

These both regimens have shown to be safer, witha low exitus rate.

A-0756 Post-traumatic interosseous-lumbricaladhesions, diagnosing may be difficult but surgeryis easy

Daniel Muder1,2 and Torbjorn Vedung1,2

1Department of Surgical Sciences, Uppsala University,Uppsala, Sweden2Department of Orthopedic and Hand Surgery, UppsalaUniversity Hospital, Uppsala, Sweden

Objective: Adhesions between the tendons to theinterosseous muscles, the lumbrical muscles andthe deep transverse metacarpal ligament (dTML) cancause decreased range-of-motion (ROM) in the meta-carpo-phalangeal (MCP) joints and chronic discomfortin the distal part of the hand. Diagnosing the conditionmay be difficult and is often made by exclusion.

SS136 Journal of Hand Surgery (Eur) 43(Supplement 2)

Methods: Adhesions at the level of the lumbrical-interosseous junction makes it narrow, reducing itsproximal excursion which causes symptoms in theintrinsic plus position of the fingers. If the dTML isinvolved in the adhesions, the distal excursion of thejunction is also hampered, for example, the intrinsicminus finger position. We identified five patients withclinical findings suggesting the latter situation. Allpatients experienced pain and swelling in the distalpart of the hand during manual load. The ROM in theneighboring MCP joints was decreased and painful.The pain free ROM was on average limited to only 0/35� (extension/flexion). The condition was eithercaused by a distortion or contusion trauma to thedistal part of the hand (four cases), or by an infection(one case). Three patients were examined with anMRI without any specific findings. No other possibleexplanation to the condition was found and thepatients went on to surgery. The time betweentrauma to surgery was on average 24 months(range 6–60).Results: The lumbrical–interosseus junction wasexposed through a volar approach. Adhesionsbetween the dTML and the junction were confirmedin all cases with passive motion of the fingers.Release of the adhesions and resection of the distalthird of the dTML resulted in normal passive excur-sion of the muscles and the tendon junction.Immediate postoperative physiotherapy followed.Four patients experienced an immediate decreasein the symptoms. One patient experienced minorpain and swelling during the first 3 months after sur-gery. At the 6-month follow-up, all patients had painfree and near normal ROM (mean 4/89�) in the MCPjoints.Conclusions: Surgical release of symptomatic inter-osseous-lumbrical adhesions is a relatively simpleand safe procedure, with potential to normalize thefunction of the hand. Diagnosing the adhesions is thedifficult part. The condition is not recognized widelyin Europe, which may be explained by the sporadicreporting that almost exclusively originates from out-side Europe. All five patients in our series wererecruited within less than 2 years, which may suggestthat the condition is more common than reflected bythe literature.

A-0759 Analysis of interfragmentary motion inscaphoid fractures by 4-dimensional computedtomographic imaging

Marieke G. A. de Roo1,2, Johannes G. G. Dobbe2, GeertJ. Streekstra2 and Simon D. Strackee1

1Department of Plastic, Reconstructive and Hand Surgery,Academic Medical Center (AMC), University of Amsterdam,Amsterdam, The Netherlands2Department of Biomedical Engineering and Physics,Academic Medical Center (AMC), University of Amsterdam,Amsterdam, The Netherlands

Objective: A scaphoid fracture is the most commoncarpal fracture and is notorious for problems withhealing. When healing of the fracture fails (non-union), a specific pattern of osteoarthrosis occurs,resulting in pain, restricted wrist motion and disabil-ity. Scaphoid fracture classification systems recog-nize scaphoid fragment instability as an importantfactor associated with the development of nonunion.Since conventional static imaging cannot reveal thisdynamic problem, an imaging technique is requiredthat can analyze wrist motion in three-dimensionalspace over time. To this end, four-dimensional (4D)computer tomographic (CT) imaging is used to con-duct two observational studies. In one study, we aimto quantify and compare interfragmentary motionbetween displaced and non-displaced acute scaphoidfragments. We hypothesize that fragment displace-ment is not correlated to fragment instability. In asecond study, we analyze if scaphoid nonunion frag-ment instability depends on the position of the frac-ture line relative to the scaphoid apex. Wehypothesize that instability is increased if the fractureline runs distal to the scaphoid apex.Methods: Eight adult patients were included with aone-sided acute scaphoid fracture or scaphoid non-union and no history of trauma of the contralateralwrist, which serves as the kinematical reference. Onepatient with a non-displaced acute scaphoid fractureis included. Seven patients are included with a sca-phoid nonunion; six with the fracture line distal to thescaphoid apex and one proximal to the scaphoid apex.Both wrists are scanned with a regular dose CT scan-ner to obtain 3D images. Guided by a wrist motiondevice, 4D-CT images are acquired during 10 s ofactive wrist motion in a flexion–extension and subse-quent radio-ulnar deviation plane. The 3D and 4Dscans are used to quantify interfragmentary motionover time.Preliminary Results: No interfragmentary motionwas found in the patient with an acute non-displacedscaphoid fracture. Time to union was 6 weeks.Regarding interfragmentary motion in scaphoid

FESSH Abstracts SS137

nonunion patients, no differences were found in frag-ment instability. In scaphoid nonunion patients withthe fracture line distal to the scaphoid apex, thedistal fragment motion ranged for each individual,from (2–12, 0–6, 1–8, 1–7) degrees for extension, flex-ion, ulnar-, and radial deviation, measured relative tothe proximal fragment. For the patient in which thefracture line runs proximal to the scaphoid apex,these angles were (4, 6, 4, 3) degrees.Conclusion: Fragment instability of scaphoid non-union fragments did not depend on the position ofthe fracture line with respect to the scaphoid apex.Dynamic imaging of joints is a new and promisingtrend, creating opportunities to quantitatively evalu-ate normal and pathological wrist kinematics. With4D-CT imaging, we can quantitatively differentiatebetween stable and instable scaphoid fractures.

A-0760 Complications after toe to hand transfers inchildren with pathology of the hand

T.I. Tikhonenko, S.I. Golyana, A.V. Govorov andN.V. ZaytsevaThe Turner Scientific and Research Institute for Children’sOrthopedics, St.-Petersburg, Russia

Background: Currently, there is no common approachto treatment complications after microsurgical toe tohand transfer, which is an actual problem.

The aim of the study was to analyze ischemic com-plications after the microsurgical operations in chil-dren with a pathology of the hand to improve thequality of surgical treatment.Materials and Methods: From 2007 to 2016, we did210 microsurgical toes to hand transfer (306 trans-plants). And 267 (87.3%) of these, in patients withcongenital pathology and 39 (12.7%) with posttrau-matic deformities of the hand. In total, 352 fingerswere reconstructed.Results: According to our study, the blood supplydisturbance of the toes transplants was in 19 (6.2%)cases of 306. The most of them caused in the earlypostoperative period (73.7%). The main cause ofmicrocirculatory disorders was thrombosis of thevenous or arterial trunks (eight cases). In sixpatients, the blood supply disturbance occurred asa result of thrombosis of autovenous insertions.Two patients had necrectomy at 7 and 18 daysbecause conservative and operative treatment wasnot successful.Conclusion: The method of choice for the appearanceof the first signs of the blood supply disturbance intransfer toe is conservative therapy, which includesdisaggregants, anticoagulants and hirudotherapy.

The effect of conservative therapy should be per-formed in 3 h from the beginning of ischemia, if it isabsent, the patient must be operated.

The operation includes soft tissue decompression,the mechanical pumping across of vascular anasto-moses, and if it necessary, excision of abnormal partof the vessel with subsequent autoplasty.

A-0764 Finger and hand injuries in a pediatricemergency department: A 17-month review from aSwiss tertiary hospital

Carsten Surke1, Michael Kunzli2, Esther Vogelin1 andRuth Lollgen2

1Department of Plastic and Hand Surgery, Inselspital,University Hospital Bern, University of Bern, Switzerland2Paediatric Emergency Department, Inselspital, UniversityHospital Bern, University of Bern, Switzerland

Introduction: Hand and finger injuries in children arevery common in the paediatric emergency depart-ment (PED). Even though demographics and injurypatterns have been described previously, scarcedata exist on the type of treatment and its outcome.In our institution, the paediatric emergency physi-cians initiate treatment of all paediatric injuries.Thus, depending on the type of injury, children areeither treated in the PED or referred to the depart-ment of paediatric or hand surgery. While fracturesand injuries to the extensor tendons are mainly trea-ted by the paediatric surgeons, complex injuries andinjuries affecting the palm of the hand are treated bythe hand surgeons. This study was designed to eval-uate possible differences in outcome depending onthe treatment received in PED or by surgery subspe-cialties. Also, based on the study results, a referralpathway was designed to improve efficient patientflow from the PED to subspecialty.Patients and Methods: All children presenting to thePED with hand/finger injuries or infections over a 17-month period were included in this retrospectivestudy. Patients with polytrauma, injuries proximal tothe wrist, systemic infections or allergic reactionswere excluded. Demographics (age, sex), date andtype of injury, treatment modality in PED and subspe-cialty referral and subsequent treatment wereretrieved from the electronic hospital database. Forhospitalized patients admitted to the paediatric orhand surgical ward, length of in-hospital stay(days), detailed information about definitive treat-ment and administration of antibiotics was collectedand where applicable, compared between thesedepartments. Finally, a written feedback form wasdeveloped and collected from parents of all

SS138 Journal of Hand Surgery (Eur) 43(Supplement 2)

inpatients regarding the outcome of their child’sinjury after termination of treatment.Results: From November 2015 until March 2016, 932children with hand/finger injuries were admitted tothe PED. The most frequent reasons for presentationwere hand contusion (25.5%), fracture (20.8%) andsuperficial lacerations (14.9%). Admission to theward was required for 87 children (9.3%) followingmultiple hand/finger injuries (19.4%), infections(18.4%) finger fractures (12.6%) and fingertip ampu-tations (11.5%). In this subgroup, 51 children weretreated by paediatric (58.6%) and 37 by hand sur-geons (41.4%), respectively. Mean duration of hospi-tal stay was 3.37 days (range 1–23 days). Antibioticswere administered to 57 patients (65.5%) with a meanduration of 6.96 days (range 1–21 days). The feedbackform was returned in 75.8% of cases reflecting agood overall satisfaction.Conclusion: Our data are similar to previous studiesregarding patient age and sex and type and distribu-tion of injuries in different age groups. This studydemonstrates an overall good parental satisfactionwith treatment. At current, paediatric hand/fingerinjuries are treated by paediatric emergency, paedia-tric or hand surgery subspecialty in our institutiondepending on the injury pattern and from case tocase decision. Like in adult surgery, a subspecialitymight be desirable for the treatment of paediatrichand injuries. Furthermore, the aptitude and limitsof treatment by PEM physicians should be defined.Based on our results, we suggest the implementationof a clear referral pathway to improve and expeditetreatment of more complex injuries are treated in aninpatient setting.

A-0765 The use of titanium miniature plates andscrews for the treatment of intra and extra-articular fractures of the hand

Sokratis Varitimidis, Zoe Dailiana, Ioannis Antoniou,Dimitris Agorastakis, Stratis Athanaselis andKonstantinos MalizosDepartment of Orthopaedic Surgery, University ofThessalia, Larissa, Greece

Objectives: Operative treatment of metacarpal andphalangeal fractures is reserved for unstable, irre-ducible, comminuted, intraarticular, and open frac-tures. The purpose of this study was to evaluate theoutcome of hand fractures treated with titanium, lowprofile plate and screws.Methods: Ninety patients (79 men and 11 women)with 114 hand fractures were treated with titaniummini plates and screws. There were 46 phalangeal

and 68 metacarpal fractures in the cohort. Meanage of the patients was 36 years (range 11–75).Most of the patients (57 patients, 63%) were manualworkers and the mechanism of injury involved a workaccident. The dominant hand was injured in 50patients (55%)

The distribution of the fractures was as follows:One hundred and fourteen fractures involved 113rays. Thirty-two were open, 27 were intra-articularand12 both open and intra-articular fractures.Twenty-three of the 32 open fractures involved com-bined hand injuries and in 11 patients open fractureswere associated with incomplete (six) or complete(five) amputations (severe damage to one or bothneurovascular bundles, respectively).

The fracture was fixed after a mean of 2.9 days(range 0–28) from injury. Regional anaesthesia wasutilized in 85 patients and only five patients receivedgeneral anaesthesia. Combined plates and screwswere used in 85 fractures, while in the remaining29 fractures internal fixation was performed onlywith screws. Fixation with screws was selected forcondylar or intra-articular fractures of the base ofmetacarpals and phalanges, and for long oblique orspiral diaphyseal fractures.Results: Mean follow-up time was 39 months (rangefrom 30 to 57). Apart from one case, all fractureswere successfully fixed. Grip strength was measuredas high as 89% compared to the uninjured hand evenin cases of intra-articular fractures. Open intra-articular fractures had the worst outcome in gripstrength (67% of the contralateral hand). Withregards to tip pinch, open intra-articular fractureshad the least favorable outcome (68% of the contral-ateral pinch strength). No difference was observedbetween intra-articular and extra-articular fracturesfor grip strength and for total active motion. DASHscore was 8.7 in the intra-articular group andreached 15.6 in the open intra-articular group.Finally, pain as measured with the visual analogscale reached a maximum of 2.3 in all groups,except for open intra-articular fracture, whichdemonstrated a mean of 3.2. There was no statisti-cally significant difference in grip strength (p¼ 0.25)or total active motion (p¼ 0.849) between extra andintra-articular fractures. TAM and grip strength werestatistically different between open and closed frac-tures (p¼ 0.001 for TAM and p¼ 0.013 for gripstrength, respectively).Conclusions: Low profile plates and screws can beused successfully to establish union and restorealignment of the hand skeleton while achieving satis-factory clinical outcome. Factors that influenced thefinal outcome included the severity of the initial injury(open vs closed) and not the anatomic location (intra

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or extra-articular, metacarpal or phalangeal) of thefracture.

A-0766 Toward standardization of an anatomicalcoordinate system for the radius in 3D imaging:Reliability of automatic and manual placement

Marieke G. A. de Roo1,2, Johannes G. G. Dobbe2, GeertJ. Streekstra2 and Simon D. Strackee1

1Department of Plastic, Reconstructive and Hand Surgery,Academic Medical Center (AMC), University of Amsterdam,Amsterdam, The Netherlands2Department of Biomedical Engineering and Physics,Academic Medical Center (AMC), University of Amsterdam,Amsterdam, The Netherlands

Objective: In the last decades, promising techniqueshave been proposed to plan corrective surgery for theradius in 3D space. In many cases, repositioningparameters are expressed in terms of a CT coordi-nate system. However, since the arm is not alwaysplaced in the same way inside the scanner, the posi-tioning parameters do not have a clear relationshipwith the anatomy. By defining an anatomical coordi-nate system for the radius (RCS), repositioning para-meters can be expressed in more logical terms. If theRCS is accurately defined, repositioning parameterscan be compared between individuals, but alsobetween studies. Unfortunately, the RCS is usuallypoorly defined and often based on a partial scan.Since the repositioning parameters depend on theRCS, an accurate placement of the RCS is important.The purpose of this study was to answer the followingresearch questions: (1) To what extent does thelength of the radial shaft influence the positioningerror when the RCS is placed by a computerizedalgorithm? (2) Are physicians better in placing theRCS compared to the placement by a computerizedalgorithm, if only a partial radius is available? (3) Towhat extend do anatomical variances of the radius(i.e. segmentation, gender, age, presence of growthplate, left/right wrist) affect the automatic placementof the RCS? We hypothesize that the length of theradius significantly affects the positioning error ofthe RCS.Methods: Coordinate systems were placed onhealthy radii of 85 individuals. A radius was eligiblefor inclusion when there was no history of fracture orgrowth defect. The segmented radii are digitally cutat 9 levels. In each cutting step, 10% of the proximalradial surface is removed. At the final level, only 10%of the distal radial surface remains. A new RCS isplaced on each cut radius by the algorithm. TheRCS placed by the algorithm on a complete radius

acts as the gold standard. Three physicians posi-tioned the RCS manually on three randomly selectedradii cut at nine levels. The positioning error of any ofthe RCS is determined by calculating the RCS-to-RCStransformation matrix and extracting the translationerror (�x, �y, �z) and rotation error (’x , ’y , ’z ; rota-tion sequence: y, x, z) from the matrix for comparisonto the gold standard.Results: Shortening of the radius had a significanteffect on the translation error (p 0.001) and rotationerror (p 0.001). Medical doctors positioned the RCSmore accurately than the algorithm when 10% of thedistal radial surface remained. Segmentation,gender, age, presence of a growth plate, and left/right wrist did not significantly affect the translationor rotation error.Conclusion: The main findings of this study are (1)when using the computerized algorithm, the RCS isslightly affected by the length of the radius, althoughthe error gets substantial if less than 20% of thedistal radius is available in the scan. (2) When only10% of the distal radial surface remains, the RCSshould be placed manually. (3) Anatomical variancesdo not influence the RCS positioning.

A-0769 Quantifying the positioning error of 3Dprinted patient-specific surgical guides for theradius

G. Caiti1, J. G. G. Dobbe1, G. J. Strijkers1, S.D. Strackee2 and G. J. Streekstra1

1Department of Biomedical Engineering and Physics,Academic Medical Center, University of Amsterdam,Amsterdam, The Netherlands2Department of Plastic, Reconstructive and Hand Surgery,Academic Medical Center, University of Amsterdam,Amsterdam, The Netherlands

Objective: Corrective osteotomy is a common surgi-cal treatment option for symptomatic malunion of theradius. Computer-assisted three-dimensional (3D)preoperative planning techniques are based on abilateral computed tomography (CT) scan of theradii and use the mirrored contralateral bone asreference to optimally plan the reconstruction. Inorder to transfer the virtual preoperative plan tothe patient during surgery, an accurate navigationtechnique is fundamental. Customized 3D printedsurgical guides are an attractive surgical navigationstrategy, which is becoming more commonly adopteddue to the rapid developments in additive manufac-turing technology. However, navigation errors occurif the guide is not properly positioned at the targetbone location, compromising the surgical outcome.

SS140 Journal of Hand Surgery (Eur) 43(Supplement 2)

Quantitative measurements of guide positioningerrors are rarely reported and have never beenrelated to the design of the guide and to the under-lying bone anatomy. Our objective is to evaluate thepositioning accuracy of two different guide designs(standard vs an innovative design with lateral exten-sion) at different fitting locations (distal, mid-shaftand proximal) on the volar side of the radius.Methods: Six 3D virtual bone models of healthy rightadult radii and two sets of three patient-specific guides(standard and extended) were 3D printed. In each set,the three guides, respectively, fit the distal, mid-shaft,and proximal surfaces on the volar aspect of theradius. Four surgeons positioned each set of patient-specific surgical guides on each radius model. Thisassembly was subsequently CT scanned and the posi-tioning accuracy was then quantified with a CT-basedimage analysis technique. Positioning errors wereexpressed in terms of the mean target registrationerror (mTRE), total translation error (�T) and totalrotation error (�R) by comparing the actual guide posi-tion with the preoperatively planned position. Threegeneralized linear regression models were con-structed to evaluate the influence of the fitting locationand the guide design on the positioning errors.Results: When positioning mid-shaft guides, posi-tioning errors (mTRE, �T and �R) were significantlyhigher (p¼ 0.0001, p¼ 0.0001 and p¼ 0.001) com-pared to distal guides. The novel guide design, fea-turing a lateral extension, significantly reduced themTRE, �T and �R errors in all the volar radius loca-tions (p¼ 0.001) except for �R in the mid-shaftregion (p¼ 0.0001).Conclusion: Our study shows that the positioningaccuracy of patient-specific 3D printed guidesdepends on the radius fitting location. This shouldbe carefully taken into account when considering3D printed patient-specific guide technology in sur-gery of the mid-shaft. The use of extended guides isrecommended for future utilization in distal andproximal radius regions, since it increases the accu-racy and precision of surgical navigation.

A-0773 Early sensory re-learning improves sensoryoutcome even in a long-term perspective: An RCTwith 7-year follow-up

Pernilla Vikstrom, Birgitta Rosen, Ingela Carlsson andAnders BjorkmanDepartment of Hand Surgery, Lund University, Malmo,Sweden

Objective: Early sensory relearning improves sen-sory outcome regarding discriminative touch/tactile

gnosis 6 months after surgical repair of median orulnar nerve injury. The aim of this randomized con-trolled trial (RCT) was to evaluate objective and sub-jective outcome in median or ulnar nerve repair froma long-term point of view.Methods: Twenty patients, 16 men and four women,with median/ulnar nerve injuries who had been ran-domized to early sensory relearning (n¼ 9) or tradi-tional relearning (n¼ 11) were assessed at a medianof 7 years (range 4–9) after the nerve repair.Objective outcomes were assessed with the Rosenscore. Subjective outcomes were assessed with andself-reported single-item questions regarding func-tion and activity, and the DASH and the CISS ques-tionnaires. T-test between groups was used forRosen score and numerical rating scales. TheMann–Whitney U-test was used to analyze differ-ences between groups for the DASH and the CISS.Results: The group who had performed early sensoryrelearning had significantly better results in sensorydomain of the Rosen score – and specifically, discri-minative touch/tactile gnosis and dexterity. Theseresults were supported by the subjective ratingsaccording to clumsiness, grip function and finemotor skills. No differences were found for theDASH or the CISS.Conclusions: Early sensory relearning appears toimprove long-term sensory function following nerverepair.

A-0776 Long-term results of treatment ofscapho-trapezium-trapezoid arthritis by use ofpyrocarbon implant

Enrico Carita, Alberto Donadelli and Landino CugolaClinica San Francesco, Italy

Background: Scapho–Trapezium–Trapezoid (STT)arthritis is commonly treated by isolated distal sca-phoid resection or plus biologic interposition.Isolated distal scaphoid resection can reduce carpalheight developing DISI deformity in long-term follow-up. Scapho trapezium pirocarbon implant (STPI) isused as a spacer to maintain carpal height andreduce long-term DISI deformity. Good tolerance ofpyrocarbon and profile of the implant give good lifeexpectancy.Aim: In this retrospective study, the authors describetheir experience with the use of a pyrocarbon implantfor distal scaphoid in STT arthritis.Materials and Methods: From January 2007 toSeptember 2017, 39 wrists (Viegas 1 and 2) of 30patients were treated. All cases were evaluated preand post-operatively with MMWS, PRWHE and DASH

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scores with an average follow-up of 62 months (min3–Max 125). Four cases were treated bilaterally.Results: There was an average relief from pain, nosignificant improvement in flexion extension ROMand significant improvement grip and pinch strength.At the follow-up, there was an average reduction ofpain from 7.01 to 2.7 VAS. There was an improvementof grip and pinch force from 51% to 88% of contral-ateral side. Eighty-five percent of the patients weresatisfied with the results and were able to return tothe precedent activities. Improvement of DASH from89 to 29 and of PRWHE from 101 to 27.8.Radiographic controls revealed six cases of compli-cation with one case of dislocation of the implant,light reduction in carpal height in 4 pz and averageradio-lunate angle passed from 11� pre-operativelyto 14� post-operatively.Discussion and Conclusion: Replacement of distalpole of scaphoid with STPI can restore a good func-tionality of wrist and pinch, a complete range ofmotion free from pain in patients affected from STTarthritis maintaining carpal height and avoidingincrease of capito-lunate angle or collapse.

A-0778 Single or double V-flap over a direct-flowhomodigital island flap: An alternative techniquefor volar fingertip injuries of long fingers

Thomas Jager and Joao Paulo MussiInstitut Europeen de la Main, France

Objective: The use of the direct-flow homodigitalisland flap for coverage of fingertip injuries usuallyleads to a flexion contracture of the proximal inter-phalangeal joint for achieving the distal advancementneeded for covering the soft tissue-loss, as well assometimes the need for donor area skin grafting. Ourstudy presents a different technique that couldaddress these two shortcomings.Methods: We did an anatomic study in 8 upper limbspecimens (32 long fingers) where we created a volardefect 54% of the pulp (50%–57%) and sequentiallywe performed 5 procedures measuring on each theadvancement of the flap and the area of the flapisland. The procedures were a direct-flow homodigi-tal island flap with the dissection distal to the PIPjoint (group 1), then a V-flap over that island (group2), then a second V-flap over the distal flap (group 3),then the dissection of the neurovascular bundle untilthe proximal phalange (group 4) and finally suturingthe V-flaps and creating a traditional direct-flowhomodigital flap (group 5) to compare the differentoptions.

Results: Group 1 had the lowest values in terms ofadvancement with 9.7 mm (5–15 mm) and a surface of23.15 mm2 (16.8–25.5 mm2). When added one V-flap(group 2), the advancement was of 15.75 mm (10–21 mm) and the surface was 28.35 mm (18–36mm2). Group 3 had the advancement of 18.62 mm(13–23 mm) and the surface of 30.81 mm2 (20–37.8mm2). Group 4 presents the biggest advancementvalues with 20.56 mm (12–27 mm).Conclusions: The usage of either one or two V-flapsover an island flap dissected distal to the PIPJ can,respectively, produce an increased advancement of 4and 7 mm over the classic direct-flow homodigital flapbut without crossing the PIPJ, thus decreasing theprobability of flexion contracture. Furthermore, theapplication of one or two V-flaps can increase the cov-ered area in 22% and 33%, respectively, thus decreas-ing the need of a donor site skin graft.

A-0779 A genome-wide association study of carpaltunnel syndrome

Akira Wiberg1,2, Michael Ng1, Annina Schmid3,Georgios Baskozos3, David Bennett3 andDominic Furniss1,2

1Nuffield Department of Orthopaedics, Rheumatology, andMusculoskeletal Science, University of Oxford, Oxford, UK2Department of Plastic and Reconstructive Surgery, OxfordUniversity Hospitals NHS Foundation Trust, Oxford, UK3Nuffield Department of Clinical Neurosciences, Universityof Oxford, Oxford, UK

Background: Carpal tunnel syndrome (CTS) is thecommonest entrapment neuropathy, with an esti-mated population prevalence of 5–10%. Despitebeing such a common condition, the pathophysiologyof CTS is poorly understood, and even less is knownabout the genetic contribution to the disease. CTS is acomplex disease, whereby genetic and non-geneticfactors interact to affect overall phenotypic expres-sion. The current best method for locating geneticvariants that predispose to a complex disease is agenome-wide association study (GWAS).Methods: With the aim of discovering genetic variantsthat confer risk to CTS, we undertook a GWAS insubjects with CTS using the UK Biobank resource, aprospective cohort study of approximately 500,000individuals from the United Kingdom, aged between40 and 69, who have had whole-genome genotypingundertaken and have allowed linkage of this data totheir medical records. After quality control, wedefined 12,106 participants of white British ancestryfrom this cohort with at least one diagnostic code forCTS as our cases and used the remaining 387,347

SS142 Journal of Hand Surgery (Eur) 43(Supplement 2)

white British participants as controls in the associa-tion analysis.Results: We discovered genome-wide significant asso-ciations (p 5� 10�8) at 13 loci across the genome.Of the top three associated variants, rs72755233(p¼ 9.1� 10�15) is a missense mutation inADAMTS17, rs62621197 (p¼ 1.0� 10�13) is a missensemutation in ADAMTS10, and rs3791679 (p¼ 3.8� 10�13)resides in an enhancer region in an intron of EFEMP1.All three genes are important in extracellular matrixmodulation, and we have demonstrated expression ofthese genes in tenosynovium collected from within thecarpal tunnels of patients undergoing carpal tunneldecompression surgery. rs72755233, rs62621197 andrs3791679 have been reported in previous GWAS stu-dies to be associated with human height, and we foundthat on average, UK Biobank CTS patients are >2 cmshorter than the controls.Conclusion: This study sheds new light on the patho-physiological mechanisms that underlie CTS, and it isthe first ever study to do so through genome-wideassociation. While functional assays will be requiredto confirm whether the candidate genes identified arecausally implicated in CTS susceptibility, our findingsraise the intriguing possibility that the genetic sus-ceptibility to CTS may arise from aberrant connectivetissue architecture or from anthropometric factorssuch as height, hand and wrist proportions, ratherthan from rendering peripheral nerves intrinsicallymore vulnerable to increased pressures.

A-0782 1 or 2 K-wires in surgical treatment ofmetacarpal-5-fractures?

Adrian Obladen, Romy Spitzmueller,Jenny Dornberger, Esther Henning, Simon Kim andAndreas EisenschenkUnfallkrankenhaus Berlin, Germany

Objective: Currently, no guidelines or evidence forthe treatment of fractures of the metacarpal V areavailable and therefore therapeutic regimes arebased on individual decisions. The aim of the studywas to compare the clinical outcome of osteosynth-esis with one versus two Kirschner wires in the treat-ment of dislocated or malrotated fractures of themetacarpal V.Methods: We conducted a prospective, randomizedmulticenter trial in 13 hospitals. Ethic votes wereobtained in all federal states of which hospitalstook part in the study.

Patients with dislocated fractures of the metacar-pal V and therefore need a surgical intervention wererandomized either to receive osteosynthesis with 1

K-wire (group 1) or 2 K-wire (group 2). Block strati-fication with n¼ 8 were used for randomization.Primary endpoint was the functional outcome 6month after surgical intervention, measured by theDisability of the Arm, Shoulder and Hand (DASH)Score. Secondary endpoints to evaluate the clinicaloutcome were malrotation >5�, shortening of themetacarpus >2 mm, palmar angulation >30�,delayed union, limitations of fist closure, limitationsof extension (extension¼ 0�)/flexion (flexion< 70�),pain (<10 VAS), operation time, revision rates, infec-tions rates, time of inability to work. For statisticalanalysis, non-inferiority of the 1 K-wire versus 2 K-wire osteosynthesis with a tolerable alpha error of5% and beta error of 15% were assumed.Hypotheses were tested by inclusion of confidenceinterval, including a full analysis set. SPSS 22.0 wasused for all tests.Results: A total of 292 patients were recruited: 146patients were randomized to group 1, 144 to group1. Sixty-two patients from group 1 were excludedfrom data analysis, 73 from group 2 (due to lost tofollow-up, withdrawal, protocol, deviations, etc).Baseline data of both groups were comparable. Ingroup 1, the mean DASH score was 3.8 (6.9), ingroup 2 4.4 (9.4). Regarding the secondary endpoints,no significant differences between the groups wereobserved. Serious adverse events demanding a surgi-cal intervention occurred in both groups: two in group1 and three in group 2. Those were three dislocationsafter surgery, one in group 1 and two in group 2. Allwere treated with surgical revision and 2 k-wires.Other SAEs were a second trauma with a finger frac-ture in one patient without harm to the study-relatedsurgical outcome and a tendovaginitis stenosans ofthe ring finger with was treated with surgery.Conclusions: Non-inferiority of the osteosynthesiswith 1 K-wires versus with 2 K-wires can beassumed. Both treatment options reveal a good clin-ical outcome.

A-0783 Patient-reported outcome measures fortoe-to-hand transfer: A prospective longitudinalstudy

Cheng-Hung Lin, Tzong-Yun Tsai, C Anton Fries,Jo-Chun Hsiao, Chung-Chen Hsu, Yu-Te Lin,Shih-Heng Chen, Chih-Hung Lin and Fu-Chan WeiDepartment of Plastic and Reconstructive Surgery, ChangGung Memorial Hospital, Chang Gung Medical College andChang Gung University, Taipei, Taiwan

Background: Patient-reported outcome measures(PROMs) are an important metric in evaluating

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treatment efficacy of reconstructive surgery. Toe-to-hand transfer can restore vital prehensile function;however, this surgery is complex, extensive rehabili-tation is required, and there are concerns aboutdonor site morbidity. This study longitudinallyexplores the benefits of this procedure, from thepatients’ perspective, using PROMs.Methods: Twenty-three patients who underwent freetoe-to-hand transfers from 2012 to 2015 were eval-uated pre- and post-operatively using the followingvalidated questionnaires; the Michigan HandOutcomes Questionnaire (MHQ), the 36-Item ShortForm Health Survey (SF-36), and the Lower LimbOutcomes Questionnaire (LFQ). Subgroup analysiswas performed between dominant and non-dominantreconstructed hands.Results: Mechanism of injury was crush in 83%; theremainder sustained cutting, avulsions, and burninjuries. Thirty-four toes were transferred; 9 greattoes, 20 second toes, and 5 third toes. All patientsrequired secondary procedures for aesthetic and/orfunctional improvement. MHQ results showed signif-icant improvement in overall activities of daily living,work, aesthetics, and patient satisfaction (p< 0.05).SF-36 results showed significant improvements inphysical and emotional roles (p< 0.05). The LFQshowed no deterioration of foot function (p¼ 0.55).Subgroup analysis showed significantly greaterimprovement in PROMs for patients undergoingdominant hand reconstruction.Conclusion: PROMs demonstrate the significant utilityof toe-to-hand transfer procedures in both functionaland psychosocial domains that there are relativelygreater benefits in reconstructing the dominant handand that donor site morbidity is well tolerated.

SS144 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0785 Distal sensory to distal motor nerveanastomosis can protect lower extremity muscleatrophy in a murine model

Mohammad Ali Hosseinian and Ali GhribianBeheshty University, Emmam Hossein Hospital, Tehran,Iran

Background: Delayed reinnervation of denervatedmotor neuron has irreversible consequences. Weintroduced distal motor to distal sensory anastomo-sis (DDSA) as a practical, time-saving method to pro-tect injured motor neurons and its target tissues.Methods: Two experimental groups of Wistar ratswere studied. In DDSA group, the distal end of thetibial sensory nerve of the left leg was anastomosedto the distal common peroneal nerve. The samenerves were dissected without anastomosis in thecontrol group. Four months later, visual functionalassessment of sciatic nerves was performed, andhistological structures of the nerves and musclesand ultra-structure of nerves were evaluated.Results: Significant enhancement was seen in inter-mediate toe spread factor in DDSA group (p< 0.05),but toe spread factor and subsequently sciatic statis-tic index demonstrated no significant improvement.The surgical procedures resulted in an ipsilateralrehabilitation in DDSA group with statistically signifi-cant (p< 0.05) improvement in muscle weight andmyelinated axon count. Light and electron micro-scopy evaluations of the histological specimenshowed obvious prevention of nerve and muscle tis-sues degeneration following anastomosis.Conclusions: Overall, DDSA showed a peripheralnerve could repair, survive, and protect target tissuesfrom degeneration without connection to their cellbodies and central nervous system. Some possibleexplanations for these positive results could be therestorative role of electrochemical signaling directlyfrom the skin sensory nerve receptors and stimula-tion of Schwann cell to convert to its regenerativephenotype.

A-0787 Patients’ treatment experience influencepost-operative results in Dupuytren’s disease

Ralph Poelstra1,2,3, Ruud W. Selles1,3, HarmP. Slijper2, Mark J. W. van der Oest1,2,3, Reinier Feitz2,Steven E. R. Hovius1,2 and Jarry T. Porsius1,2,3

1Department of Plastic, Reconstructive and Hand Surgery,Erasmus MC, Rotterdam, The Netherlands2Hand and Wrist Center, Xpert Clinic, The Netherlands3Department of Rehabilitation Medicine, Erasmus MC,Rotterdam, The Netherlands

Objective: In modern practice, both physical treat-ment outcomes, as measured by a clinician, as wellas patient-reported outcome measures (PROMs) areused to evaluate health outcomes after treatment.Most recently, patient-reported experience mea-sures (PREMs) were added to this evaluation. ThesePREMs focus on items such as respect and dignity,communication by physicians and cleanliness orhygiene of facilities. All these factors represent dif-ferent aspects of the treatment context. Besidesbeing useful in the evaluation of treatment, PREMscan be helpful in clarifying the relation between phy-sical treatment outcomes and PROMs. Previousresearch has demonstrated that physical treatmentoutcomes and PROMs are only moderately corre-lated, which suggests the influence of the psychoso-cial context surrounding a treatment, such aspatient–physician interaction and expectation of theoffered treatment. To better understand the role ofthis treatment context, this study examines the asso-ciation between patient experiences with treatmentcontext and treatment outcomes after Dupuytren’ssurgery, using both patient-reported outcome mea-surements as well as clinician-recorded straightnessof the finger as treatment outcomes.Methods: Patients undergoing limited fasciectomy orpercutaneous needle fasciotomy for Dupuytren’scontractures between 2011 and 2016 were selectedfrom a prospectively collected database. Patientscompleted the Michigan Hand OutcomesQuestionnaire (MHQ) before and 3 months after sur-gery, together with a patient-reported experiencemeasure (PREM) while hand therapists assessedthe straightness of the finger with a goniometer.Regression analyses were used to examine associa-tions of the different subscales of the PREM with theMHQ change scores and residual extension deficit.Results: A total of 836 patients were included in thefinal analysis. There was a positive associationbetween the experience with the treatment andboth patient-reported functioning and objectivelymeasured straightness of the finger. The associa-tions between experience with healthcare deliveryand PROMs were roughly twice as strong as thosebetween experience with healthcare delivery andphysical treatment outcomes. Strongest associationswere seen with communication of the physician,post-operative care and information about thetreatment.Conclusion: This study demonstrates a positive asso-ciation between treatment context and treatmentoutcome in Dupuytren’s disease. These findings sug-gest that treatment outcomes in Dupuytren’s diseasecould be improved through improving the treatmentcontext.

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A-0791 Multiple intermetacarpal perforators flapfor dorsal long fingers reconstruction: an anato-mical study and clinical applications

Regina Sonda, Andrea Monticelli, Franco Bassetto andCesare TiengoClinic of Plastic Surgery, Padova, Italy

Objective: We investigated the anatomical vascularbasis of a multi-perforant dorso-metacarpal flapand reported our clinical experience in the recon-structive surgery of the dorsal long fingers as analternative to microsurgical solutions.Methods: In 10 fresh frozen upper limbs, injectedwith acrylic resin, the dorsal surface of the handwas dissected. The intermetacarpal spaces anddorsal long fingers were evaluated for the character-istics (number, diameter, site and interval of origin,and course) of volar-dorsal perforator vessels. Wideperforator flap, based on multiple intermetacarpaldistal perforators, was used for the contempora-neous reconstruction of the all dorsal long fingers.Results: The mean number of perforators of inter-metacarpal space was 3.5, mainly septal-type.Proximally to juncturae tendinum, the vessels wereless numerous. In one case, there was no interme-tacarpal artery. Some anatomic anomalies werefound, especially no Quaba perforator or the absenceof commissural artery. The average distancebetween the Quaba perforator and the metacarpal-phalangeal joint was 1.15 cm (DS 0.58), between theQuaba and the commissural artery was 1.61 cm (DS0.66). Proximally to Quaba, constant perforators havebeen encountered at a mean distance of 28 mm,37.84 mm, 46.42 mm, and 45.5 mm. The meannumber of branches for dorsal cutaneous networkat the level of long finger was 9 (range 5–15) arisingfrom the proper digital artery. There was no symme-try between radial-ulnar sides or opposite side of aninterdigital-space. In four patients, a multi-perforatorflap, based on these findings, has been used to coverall the dorsal surface of the long fingers. A goodaesthetic and clinical result has been achieved at 6months of follow-up.Conclusions: The anatomical study allowed us toidentify a constant intermetacarpal perforator net-work and to perform a reliable distally based inter-metacarpal flap. Thermal-crush injury often involvedmultiple dorsal finger surface forcing the surgeon toa challenged reconstruction. To obviate to a micro-surgical flap reconstruction, we propose to raise theentire subcutaneous surface of the dorsal hand in amultiperforator flap. The flap was then mobilized as aturn-over flap to cover the long fingers and thengrafted. This autologous functional reconstruction

of all involved fingers allows an early and intenserehabilitation to achieve a better recovery.Subcutaneous surface guarantees tendons andjoints gliding, with minimal donor site morbidity,avoiding the use of microsurgical solution.Anatomical knowledge achieved, showed a reliablevascular network, able to support a wide adipo-fas-cial flap.

A-0792 Interobserver reliability study of theclassification of scaphoid waist fractures usingcomputer tomography

Rasmus Wejnold Jørgensen, Anders Klahn,Johannes Heindl, Lars Solgard, Lars Vadstrup,Dejan Susic, Robert Gvozdenovic, Stig Jørring andClaus Hjorth JensenHand Clinic, Department of Orthopedics, Herlev-GentofteUniversity Hospital of Copenhagen, Denmark

Objective: Conventional radiographs have beenshown to yield unreliable results in classifying sca-phoid fractures. Computer tomography (CT) has beenclaimed to be the tool of choice in determining thetreatment. The use of CT for diagnosing fractures andhealing of scaphoid fractures has shown only mod-erate interobserver reliability. We have thereforeundertaken a study of the reliability of the classifica-tion of waist fractures of the scaphoid among specia-lists of orthopedic surgery with a particular interestin hand surgery.Methods: From 2009 to 2014, CT scans were routi-nely obtained in patients with fractures of the carpalscaphoid shown on radiographs. Among 186 positiveCT scans, 116 were excluded as the fracture wasmore than 4 weeks old or due to incomplete dataset of the CT. Among the remaining 70 scans, weidentified 51 scaphoid waist fractures. Sagittal andcoronal planes of the long axis of the scaphoidwere available in all scans. Seven orthopedic sur-geons with a particular interest in hand surgery inde-pendently scrutinized the scans classifying each inundisplaced, minimally (<2 mm) displaced, or dis-placed and suggested a treatment of 4 weeks immo-bilization, 8–12 weeks immobilization, or screwfixation. Fleiss Kappa values using SPSS v. 24 werecalculated and interpreted according to Landis andKoch.Results: On the average, 38.5% were classified asundisplaced, 41% as minimally displaced, and20.5% as displaced. On average, 79.5% of the frac-tures were suggested treated non-operatively and20.5% operatively.

SS146 Journal of Hand Surgery (Eur) 43(Supplement 2)

The reliability of the classification showed an over-all Kappa value of 0.50. However, the distinctionbetween undisplaced and minimally displaced frac-tures showed a Kappa of only 0.38, whereas the relia-bility was 0.61 when classifying between <2 mmdisplaced or >2 mm displaced. Selecting betweenoperative or non-operative treatment showed aKappa of 0.58.Conclusions: Selecting the best treatment of sca-phoid waist fractures remains a challenge. The useof CT showed substantial reliability in the distinctionbetween <2 mm displaced and >2 mm displacedfractures. However, only moderate reliability wasfound when choosing between non-operative andoperative treatment.

A-0795 Complications after elbow terrible triadsurgical treatment

Juan Maria Pardo Garcia1, Veronica Jimenez Diaz1,Lorena Garcia Lamas1,2, Miguel Porras1,2,3 andDavid Cecilia1,2,3,4

Hospital Universitario Doce de Octubre Madrid, Spain

Introduction: Terrible triad injury of the elbow (TTIE),comprising elbow dislocation with radial head andcoronoid process fracture, is notoriously challengingto treat and has typically been associated with com-plications and poor outcomes despite performing aprotocolized surgical treatment by expert surgeonsfollowed by adequate immobilization times and initia-tion of early and controlled elbow motion.Objective: Identify and analyze the appearance ofcomplications after protocolized surgical treatmentof TTIE, assessing its functional outcomes and propor-tion of patients who required surgical reoperation.Materials and Methods: Our study uses the databaseof the Hospital Universitario 12 de Octubre (Madrid,Spain) during the period between 2005 and 2015.Characteristics of the patient, fracture, surgical pro-cedure, associated complications, active range ofmotion (aROM), as well as the evaluation of the out-comes through the Mayo Elbow Performance Score(MEPS), Broberg and Morrey rating system and theDisabilities of the Arm, Shoulder and Hand score(DASH) were collected. A structured protocol of sur-gical treatment was performed in all cases.Results: A total of 62 patients with TTIE wereobtained, of which 25 presented complications, 19of whom were males and 6 were women. Meanfollow-up after surgery was 24 months, rangedfrom 3 to 85 months. The average age was 47,ranged from 29 to 77. The most frequent injury

mechanism was fall from own-height and 7 werepolytrauma patients.

The majority had a radial head fracture Mason typeIII (15) and O’Driscoll type II (8) at the level of thecoronoid process of the ulna. All patients underwenta lateral approach: Kocher (15) or Kaplan (10). Onecase required an additional medial approach.

The most common complication (a total of 36 in 25patients) was heterotopic ossification (12) followed byarthrosis (10). Other complications were surgicalwound infection (4), neurovascular injury (4), ulnarneuropraxia (1), incomplete axonotmesis, radialnerve (2), complete lesion of the posterior inteross-eous nerve (1) and incomplete axonotmesis of theulnar nerve (1) and median (1), radial head asympto-matic loosening (4), radial neck periprosthetic frac-ture (1) and cubital-carpal impaction syndrome (1).

Surgical reoperation was required in 4 of the 25(16%) cases of complications. Most frequent surgicalprocedure was elbow arthrolysis (2) to treat stiffness.

The mean aROM was 120�/�30�. Mean MEPS was82 ranged from 70 to 95. Mean Broberg–Morrey scorewas 88, ranged from 77 to 97 and mean DASH scorewas 16, ranged between 0 and 56.Conclusions: According to our experience andreviewing the literature, in TTIE still treated in a pro-tocolized manner, a high percentage of complicationspersists (up to one third of patients). In spite of this,functional outcomes after surgery are generallysatisfactory.

Further research is warranted to determine whichsurgical techniques optimize functional outcomesand reduce the risk of complications.

A-0799 The use of local vascularized adipofascialflaps for joint capsule reconstruction after con-tracture release

Che-Hsiung Lee, Charles Y. Y. Loh and Yu-Te LinDepartment of Plastic and Reconstructive Surgery, ChangGung Memorial Hospital, Chang Gung University, College ofMedicine, Taoyuan and Keelung, Taiwan

Objective: Post-traumatic finger joint contractureaffects daily activities of the patients. After therelease of finger joint contracture, relapse of thejoint contracture usually occurs in clinical practice.Fibrosis of the divided joint capsule which heals bysecondary intention is a possible cause of re-con-tracture. Recently, we employed a novel idea toreduce the scar formation of the joint capsule, inwhich the divided rough surface was reconstructedby a local vascularized adipofascial flap (LVAF). The

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results were compared to similar cases withoutreconstruction retrospectively.Methods: This technique was applied in cases of con-tracture of the metacarpophalangeal joints and flex-ion contracture of the proximal interphalangealjoints. The LVAF was based on a random patternflap, with the arterial inflow based at the lateral sur-face of the proximal phalanx, and from the dorsalmetacarpal artery. A wide base ensures the vascu-larity of the adipofascial flap. The flap was thenrotated to cover the rough surface of the joint. Afterthe surgery, this group of patients followed the samerehabilitation instructions as those of the standardcapsulotomy method. The arc of motion of the PIPjoint was measured during follow-up.Results: Patients were followed for 7 months andwith age of 36.6 years old on average. Significantpost-operative gain in the arc of motion (AOM) wasobserved in all cases. Although no statistical signifi-cance in post-operative range of motion was found,the group of LVAF showed more promptness inimprovement when compared to the group with stan-dard capsulotomy technique (gain AOM 40.0� 8.9� vs24.3� 19.9�, p¼ 0.138). Less pain during the earlymobilization was reported by the patients with LVAF.Conclusions: The short-term outcomes of the LVAFtechnique showed an equivalent result when com-pared to those of the standard capsulotomy group,even though there was no significant difference, thegain of AOM appeared slightly better in the LVAFgroup than in the standard capsulotomy group.Significant pain reduction during early mobilizationcould be one of the reasons why patients with LVAFexperienced a faster improvement in AOM. A longerterm of follow-up will be done to know the rates ofrelapse.

A-0802 Tendon transfers and brain plasticity:Results after BR to FPL tendon transfers

Leiv M. Hove, Knut Wester, Roger Brandon,Alexander Richard Craig-Craven and Kenneth HugdahlHaukeland University Hospital and University of Bergen,Norway

Objective: Tendon transfers are common in handsurgery. However, to our knowledge, no human stu-dies have dealt with cortical re-modelling in the brainafter a tendon transfer. In this article, we present amodel that allows us to study the effect on corticalorganization after surgical induced change in motorfunction of the arm and hand. We also present theresults after brachioradialis (BR) to flexor pollicislongus (FPL) tendon transfers to create a key grip

in patients with cervical spinal cord injury(tetraplegia).Methods: The model in brief: We have studied thecortical representation of the brachioradial musclebefore and after a tendon transfer that changed itsfunction from an elbow flexor to a thumb flexor (BRto FPL-transfer). The MR imaging was performedwith a 3.0 Signa HDx MR scanner. Before the study,we had to design a ‘‘muscle map’’ of the motorcortex. The participants have some ‘‘disturbing’’muscle activity from respiratory muscles and mus-cles responsible for head motion etc. Activity fromthese muscles had to be ‘‘washed’’ away to visualizethe MRI patterns from the elbow flexor muscles andthe thumb muscles. The series consisted of fourpatients with tetraplegia and three healthy controlsubjects. The patients were examined preoperativelyand a few months postoperatively. The participantswent through a sequence of alternating exercisesand rest blocks, each lasting for 30 s. Preoperativeexercises were elbow flexion and postoperative exer-cises were thumb flexion. Data from the non-oper-ated healthy controls allowed typical spatial patternsof activation for each of the motor actions to bedetermined by means of cluster analysis. For eachmap, the centre-of-mass location of the five mostsignificant clusters was noted and any othersdiscarded.Results: Results overall indicated that the post-operative key-grip movements in the tetraplegicpatients were elicited from a similar brain region asin healthy controls, despite an alternative muscle(BR) being deployed. This may indicate that controlof that muscle (BR) shifts from a brain region typi-cally associated with elbow movements to one typi-cally associated with hand movements.Conclusions: To our knowledge, the findings in thepresent series are the first indications that thehuman cortex is capable of reorganizing itself spa-tially as a consequence of surgically altered motorperiphery after transfer of a muscle tendon fromthe arm to the hand. This postoperative cortical reor-ganization, with the representation of an elbow flexormoving ‘‘down’’ from the preoperative elbow areatowards the cortical hand area, appears to reflectthe process behind the effect of the training to usethe muscle in a new way, to obtain a hand gripinstead of flexion of the elbow. Moreover, this corticalreorganization seems to occur within the time frameof the patients’ ‘‘learning’’ of the new movements,that is, a few months after the tendon transfer.

SS148 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0808 Oxidative protein damage and extracellularmatrix changes in diabetic trigger finger patients

Nazmi Bulent Alp1, Gulsum Karduz2, Kubra Vardar2

and Ugur Aksu2

1Istanbul Bahcelievler State Hospital Ortopedics andTraumatology Department, Turkey2Istanbul University, Science Faculty, Biology Department,Istanbul, Turkey

Chronic hyperglycemia underlies cellular complica-tions in diabetes. The mechanisms leading to cellularcomplications are not fully understood. Additionally,no relation between diabetes and trigger fingerpathogenesis yet to be identified.Methods: To evaluate the effect of chronic hypergly-cemia on oxidative protein damage and extracellularmatrix changes, we studied trigger finger in patientswith (n¼ 20) and without (n¼ 15) diabetes. Pulley tis-sues were collected after trigger finger surgery and(1) tissue total thiol (T-SH), advanced oxidation pro-tein products (AOPP) levels as markers of oxidativeprotein damage; (2) tissue sialic acid (SA) content asmarkers of extracellular matrix changes were mea-sured. We measured plasma C-reactive protein(CRP) level. Additionally, histological evaluation ofpulley tissues was performed.Results: T-SH, AOPP and SA levels of pulley tissueswere significantly different in nondiabetic individualscompared to diabetic individuals (p< 0.05).Nondiabetic versus diabetic values for T-SH were22.7þ 1.6 versus 38.9þ 5.2 nmol/mg protein and forAOPP they were 175.6þ 9.9 versus 472.5þ131.6 mmol/g protein. Diabetic and nondiabeticvalues for SA were 0.63þ 0.12 versus 0.35þ0.03 nmol/mg protein. The level of CRP (1.6þ 0.5 vs3.5þ 1.0 mg/L) was increased in diabetic group withrespect to its control (p< 0.05). No significant differ-ences in nondiabetic patients were found in histolo-gical evaluation compared to diabetic patients.Conclusion: Diabetes contributes to the redox imbal-ance of the pulley tissue proteins and extracellularmatrix changes. Hence, diabetes could furtherincrease the trigger finger complications. For thisreason, controlling diabetes may help reducing cel-lular damage in diabetic trigger finger patients.

A-0812 How far the indication can be pushed forlocal perforator flaps in complex defects of theupper limb?

Alexandru Georgescu, Ileana Matei, Maria Nedu andMarius PrunaUniversity of Medicine Iuliu Hatieganu Cluj Napoca,Romania

Objective: The use of free flaps in complex defectsall-over the body represents the gold standard forreconstruction. Moreover, the great expansion ofperforator flaps in the last decades solved one ofthe more questionable problems of using free flaps,that is, the donor site morbidity. Even if the use oflocal perforator flaps brings together a lot of advan-tages (replacing like-with-like, shorter procedure),some surgeons consider that their use should belimited to simple and small/medium defects, andthat they add supplementary donor site morbidityvery close to the originally injured area. Despitethese facts, we consider that local perforator flapsrepresent a good indication in very well-selectedcases, sometimes even in very complex defects, inwhich the first goal is represented by the quality offunctional recovery.Material: We present our experience in using localperforator flaps, as both V-Y advancement and pro-peller flaps in covering complex acute or chronicdefects in the upper limb. We take into consideration37 cases, 13 acute and 24 chronic, in which we per-formed such a flap in the last 5 years.Results: All the flaps survived; we registered anuneventful evolution in 18 cases, and a venous con-gestion of the flap in 19 cases, which progressedtowards spontaneous healing in 11 cases, epidermo-lysis followed by secondary healing in 5 cases, andsuperficial necrosis needing covering by another sur-gical procedure in 3 cases. The functional recoverywas good in all the cases.Conclusion: We consider that the local perforatorflaps can be successfully used in well-selectedcases, even in very complex injuries. In such a verydamaged hand, the aspect of the donor site is of sec-ondary importance if the price is a good regain offunctionality.

A-0813 Supermicrosurgical free perforatorflaps for reconstruction of soft tissue defect offinger pulp

Liwen Hao, Chao Chen and Zengtao WangShandong Provincial Hospital affiliated to ShandongUniversity, Jinan, China

FESSH Abstracts SS149

Objectives: Soft tissue defect of finger pulp or thevolar surfaces of fingers are common injuries ofhand. Different reconstructive methods were usedfor such injuries, like digital artery island flap, V-Yadvanced flap, dorsal metacarpal flap, pedicledgroin flap, and so on. But these methods haveobvious disadvantages: bad esthetic outcome or bigdonor site injuries.Methods: Between November 2008 and January2017, we prospectively studied the use of supermi-crosurgical perforator flaps to reconstruct soft tissuedefect of finger pulp or volar side of finger in 14 fin-gers, comprising 8 thenar perforator flaps and 6 digi-tal artery perforator flaps. We only harvest theperforator branch of proper digital artery and thecutaneous branch in thenar area for the flaps and asuperficial vein for each flap. The nerve branch isharvested with flap to recover the sensation.Results: All flaps survived completely. We did follow-up 6 months to 3 years post operation, the majorityrecovered excellent appearance and function. Theflaps had the characteristics of normal finger volarskin: hairless, with similar texture and color. Thesensation of flaps recovered well.Conclusions: Supermicrosurgical free perforatorflaps provide excellent reconstruction for fingerswith soft tissue defect of finger pulp or volar side.The colour, texture and hairless fit well with recipientsite. With supermicrosurgical technique, we need notto harvest digital artery or superficial branch of radialartery, which can decrease donor site injuries. Thesensation of flap can also be recovered by detectingthe nerve branch to the flap.

A-0815 Extended dynamometry

Hayley Smith and H. J. C. R. BelcherEast Kent Hospitals NHS Trust, Canterbury, Kent, UK

Objective: The assessment of power is an importantpart of the assessment of hand function for both sur-geons and therapists. The most widely used methodis the measurement of grip strength using a Jamardynamometer, which is an adjustable hand-helddevice that measures grip strength over five differentpositional widths. The power that can be applied overthe five settings of the Jamar dynamometer usuallyexhibits a skewed bell-shaped curve; the maximumpower being almost always achieved at either setting2 or 3.

There is the expectation that most patients willperform dynamometry to the best of their abilitiesbut this cannot, however, be assumed in patientswho are undergoing work-place and medico-legal

assessments. It is observed that patients produceatypical effort curves and variations in grip strengthon repetitive testing even when there is no structuralor neurophysiological explanation. Dynamometryprotocols therefore need to be designed to assesscapacity as well as to detect sub-maximal effort.We have therefore developed an extended testingprotocol that by repetition mitigates but does notignore the effects of variation.Methods: The test protocol comprised two tests ateach Jamar position. The sequence starts from thefirst and narrowest position on the right hand, fol-lowed by the first position on the left hand, thesecond position on the right hand, and so on.Following the fifth test on the left hand at thewidest Jamar setting, the sequence is reversed.The largest value for the two attempts at any givenside and position is used for the purposes of analysis.Consistency is assessed by calculation of the meancoefficient of variation (CoV) for each pair of attemptsfor a hand ((standard deviation/mean)� 100).Results: Dynamometry was undertaken in 242 volun-teers (male:female, 124:118) with a median(range) of39(18–82) years. Normative data have been obtainedfor sex and age ranges. Grip strength was signifi-cantly influenced by sex, age, height and occupation.Hand dominance did not affect maximum gripstrength but the right hand was significantly strongerthan the left in right-handed individuals, whereas thesides were comparable in left-handed individuals.The maximum power was achieved at position 2 or3 of the dynamometer in 96% of patients. There was asignificant difference in maximum handle positionbetween women and men in the left hand only. Themedian consistency was 6.5% and was unaffected bysex, age, height and occupation.Conclusion: These results serve as a standard bywhich patients can be judged when undergoing dis-ability assessment.

A-0819 Terrible triad injury of the elbow:Interobserver and intraobserver reliability ofcomputed tomography versus plain radiography inthe preoperative planning

Isabella Fassola, Kay Kruger, Benedict Kunz,Jens Hahnhaußen, Wolfgang Ertel and Senat KrasniciDepartment of Orthopedic, Trauma and ReconstructiveSurgery, Charite-Universitatsmedizin Berlin, CampusBenjamin Franklin, Berlin, Germany

Introduction: The benefit of CT scan in the preopera-tive planning for the ‘‘Terrible Triad Injury’’ (TTI) ofthe elbow is still unknown. The aim of this study was

SS150 Journal of Hand Surgery (Eur) 43(Supplement 2)

to evaluate the interobserver and intraobserver relia-bility for the preoperative planning of these complexinjuries using plain radiographs alone and with theaddition of computed tomography (CT) scans.Materials and Methods: In the first part of the study,four observers (all specialized orthopaedic surgeons)were shown the plain radiographic images of eachpatient in random order and asked to answer a ques-tionnaire referring to approach and treatment strate-gies. The radiographic images of the patients werethen randomly shuffled and presented to the sameobservers at an interval of minimum 2 weeks. In thesecond part of the study, conducted at a minimum of 2weeks from the last radiographic session, the samefour observers were shown the corresponding CTimages of each patient in random order, such thatthey could not be associated with the correspondingplain radiographs. CT images were inclusive of axial,sagittal and coronal cuts. The observers were asked toanswer the same questions and were blinded to theirown answers at the time of the radiographic evalua-tion. The CT images of the patients were again ran-domly shuffled and presented to the same observersat an interval of min 2 weeks. In total, 1568 answerswere recorded. Changes in treatment plan and opera-tive approach were recorded. We determined intra-observer and inter-observer reliability and analyzedwhether the use of the CT scans helped to increasethe adherence to a treatment plan. Kappa coefficientsof intra-observer and inter-observer reliability fortreatment plans were generated.Results: The preoperative recommendation for thesurgical approach, of the coronoid process fracture,and of the radial collateral ligament changed afterreviewing CT scans. The availability of CT scans didnot affect the preoperative planning for the radialhead and for the medial collateral ligament. Themean intra-observer correlation coefficient (ICC)overall for preoperative planning based on X-raysalone increased by 24% points after adding CT scans.Conclusion: In these complex cases, the use of CTscans in addition to the plain radiographs increasesthe intra- and interobserver reliability.

A-0820 Are the superficial transverse palmar liga-ment and the septa of Legueu and Juvara involvedin Dupuytren’s disease? Histological and immune-histochemical study

Isabella Fassola, Benedict Kunz, Kay Kruger,Wolfgang Ertel and Senat KrasniciDepartment of Orthopedic, Trauma and ReconstructiveSurgery, Charite-Universitatsmedizin Berlin, CampusBenjamin Franklin, Berlin, Germany

Introduction: The longitudinal fibers (FL) of thepalmar aponeurosis (PA) represent the classic siteof development of nodules and chords characteristicof the Dupuytren’s disease (DD). The role of the othertwo components of the PA, the superficial transversepalmar ligament (FT) and of the Septa of Legueu andJuvara (SLJ), is still controversial and the presenceof myofibroblasts in these fibers has not been inves-tigated. Its finding could indicate that both tissues arealso involved in the formation of the Dupuytrencontracture.Purpose: To determine the histological and immuno-histochemical characteristics of the three compo-nents of the PA and to determine whether the threecomponents are equally affected by DD.Materials and Methods: Tissue samples from thethree components of the PA (FL, FT and SLJ) wereobtained from 15 DD patients, all men, aged between59 and 75 years (average 67.4 years) during palmarfasciectomy. They all had Dupuytren’s diseaseTubiana stage II (71%) or stage III (29%).Immediately after removal, each of the three tissueswas prepared for histological and immunohisto-chemical analysis. Immunohistochemistry for TGF-b(transforming growth factor beta), smooth muscleactin (a-SMA), fibronectin, and other extracellularmatrix (ECM) components of the PA, such as CD90,Col1, Col2, and Col1, were carried out.Results: The results showed that the expression ofTGF-b was high in FL, FT, and SLJ while the expres-sion of a-SMA was similar in all three tissues,although at lower level than TGF-b.Immunohistochemical expression of fibronectin wassimilar in all three components of the PA, althoughnot as constant as TGF-b and a-SMA. In addition, theexpression of markers for other ECM componentswas equally high in all the three components of thepalmar aponeurosis. Col3 was expressed in half ofthe tissues, although its distribution was similar inFL, FT and SLJ. None of the patients showed signs ofrecurrence of the disease at the latest follow-up.Discussion and Conclusions: The FL are the site oftransformation of fibroblast into myofibroblast.Recent studies suggest that TGF-b1 plays an impor-tant role in this differentiation, by stimulating thesynthesis of a-2 type I collagen and by inhibiting thedegradation and a-1 type III collagen. The expressionof TGF-b1 is increased at the level of Dupuytren’snodes and chords. In addition, a-SMA, expressed bythe myofibroblasts of the Dupuytren contracture andconsidered a marker for these cells, plays a role inthe contracture of PA. Its expression is induced byTGF-b1. Lastly, the myofibroblasts synthesize fibro-nectin, an extracellular glycoprotein that binds the

FESSH Abstracts SS151

myofibroblasts to each other and to the ECM byintegrins.

The preliminary results of our study suggest thatall the three components of the PA (FL, FT and SLJ)may be affected, even though they appear macrosco-pically unaffected. Further studies are necessary toquantify the number of cells present in each tissue. Amodification of the therapeutic approach used for thetreatment of DD should be considered according tothe results.

A-0823 Confirmation of the feasibility of ex vivocreation of a novel human multichimeric cellstherapy for tolerance induction in vascularizedcomposite allotransplantation

Joanna Cwykiel, George Rafidi and Maria SiemionowUniversity of Illinois at Chicago, Chicago, USA

Objective: Various stem cell-based therapies havebeen proposed as supportive treatments for patientsfollowing solid organ and vascularized compositeallotransplantation (VCA) to achieve donor-specifictolerance and eliminate the toxic, systemic, life-long, multi-drug immunosuppression. We introducea novel cellular therapy of ex vivo created umbilicalcord blood derived multi-chimeric cells (mCC) as analternative approach to bone marrow–based thera-pies in support of VCA. The aim of this study was toestablish the ex vivo fusion protocol and characterizein vitro the phenotype, genotype, viability and prolif-erative potential of fused human mCC.Methods: Twenty-two ex vivo fusions of human umbi-lical cord blood (UCB) cells were performed.Mononuclear cells (MNC) were isolated from UCBoriginating from three unrelated donors. Next, MNCwere stained separately by PKH26, PKH67 andeFluor670 proliferation dye and fused using polyethy-lene glycol (PEG). Triple PKH26/PKH67/eFluor670stained mCC were sorted and assessed by confocalmicroscopy and flow cytometry for the efficacy of thecell fusion procedure. The viability of mCC (Trypanblue and LIVE/DEAD cell viability assay) and distribu-tion of hematopoietic surface markers (CD4, CD8,CD19, CD45 and CD90) were performed by flow cyto-metry. PCR-rSSOP (Antigens: A, B, C, Bw, DRB1,DQB1, DR51, DR52 and DR53) and STR-PCR (Loci:TH01, D21S11, D5S818, D13S317, D7S820, D16S539,vWA, TPOX) characterized the genotype of mCC.Proliferative potential of mCC was assessed bycolony forming unit (CFU) assay.Results: Flow cytometry and confocal microscopyanalysis confirmed UCB fusion and creation ofhuman mCC. Using PCR-rSSOP and STR-PCR

assays, we determined that human mCC are sharingHLA class I and class II antigens, as well as selectedloci specific for all three UCB donors used for fusion.After fusion, 90–95% of cells were viable. Phenotypecharacterization showed similar percentage and pat-tern of hematopoietic markers distribution on thesurface of mCC and UCB donors. Maintenance of pro-liferative properties of mCC was confirmed by CFUassay.Conclusions: We have successfully confirmed thefeasibility of ex vivo fusion procedure and creationof human mCC. We characterized the phenotype,genotype, viability and proliferative potential ofmCC. This unique concept of mCC introduces anovel universal therapy for tolerance induction insolid organ and VCA transplantation.

A-0830 The effect of electromyographic biofeed-back training on electrical muscle activity andfunctional status in zones I–III flexor tendoninjuries: Preliminary results

Umut Eraslan1, Ali Kitis1 and Ahmet Fahir Demirkan2

1Pamukkale University, School of Physical Therapy andRehabilitation, Denizli, Turkey2Pamukkale University, Medical Faculty, Department ofOrthopaedics and Traumatology, Denizli, Turkey

Objective: In this study, it was aimed to investigatethe effect of electromyographic (EMG) biofeedbacktraining applied in addition to early passive mobiliza-tion protocol on electrical muscle activity and func-tional status in zone I–III flexor tendon injuries.Methods: This prospective randomized studyincluded 14 cases aged between 18 and 56(31.93� 12.22) years and operated for the injury ofat least one of the flexor digitorum superficialis(FDS) or flexor digitorum profundus (FDP) tendonsin zone I–III. Tendons were repaired with modifiedKessler technique using 3-0 or 5-0 Prolene by thehand surgeon. The cases were divided into twogroups by block randomization. Early passive mobili-zation method (modified Duran protocol) to the firstgroup and EMG biofeedback training by surface elec-trodes in addition to early passive mobilization to thesecond group were applied. The cases started usingthe dorsal blocking splint on postoperative days 3 to5. The same physiotherapist applied the exerciseprogram three times a week, until 12th week. EMGbiofeedback training was given to the second groupfor 4 weeks. Splint use was terminated at 6 weekspostoperatively. Demographic and medical informa-tion of the cases were recorded at the beginning ofthe study. Pain intensity (by visual analog scale),

SS152 Journal of Hand Surgery (Eur) 43(Supplement 2)

range of motion (ROM, by modified Strickland classi-fication), electrical muscle activity (by EMGBiofeedback device), hand function (by MichiganHand Outcomes Questionnaire) were assessed atpostoperative 5th and 12th weeks; grip and pinchstrength at 12th weeks. Two groups were comparedby Mann–Whitney U test.Results: There were tendon injuries in 15 fingers of 14patients. Of the patients, seven were females andseven were males (each 50%). The dominant hand ofall cases except one was right. The injury was in thedominant hand in seven patients and in the non-domi-nant hand in the rest (each 50%). Six cases (42.9%)had injury in second, 5 cases (35.7%) in third, 2 cases(14.3%) in fifth and 1 case in both second and thirdfingers (7.1%). Additionally, 11 cases had injury in zoneII (78.6%) and 3 had in zone III (21.4%). Only FDP in 2fingers (13.3%) and, both FDS and FDP in 13 fingerswere cut. In the EMG biofeedback group FDS and FDPelectrical muscle activity, hand and pinch gripstrength were higher at 12th week. However, therewas no significant difference between the twogroups in terms of ROM, electrical muscle activity,hand function, hand and pinch grip (p> 0.05).Conclusions: In conclusion, we think that EMG bio-feedback training applied after isolated flexor tendoninjuries was a useful training method in facilitatingtendon excursion and in increasing electrical muscleactivity. However, in order to be able to interpret theresults more clearly, there is a need for studies withlarge sample sizes.

A-0832 Retrospective study of secondary surgeryafter trapeziometacarpal joint arthroplasty

Romain Detammaecker, Sophie Sabau, Lionel Athlani,Hugo Maschino and Gilles DautelDepartment of Hand Surgery, Plastic and ReconstructiveSurgery. Centre Chirurgical Emile Galle CHU, France

Objective: Trapeziometacarpal (TMC) joint replace-ment is increasingly being performed for the treat-ment of rhizarthrosis. Our goal was to analyze theincidence and the indication of secondary surgeryfollowing trapeziometacarpal joint arthroplasty inorder to avoid them and to improve long-termimplant survival.Methods: The charts from patients who underwentsuch an arthroplasty between January 2010 andNovember 2017 were reviewed. All the cases ofpatients who were scheduled for any type of second-ary surgery were identified.Results: All the patient have been operated in ourhand unit by 24 surgeons; however, 4 senior

surgeons took care of 78% of all patients. Duringthe period, 890 TMC total joint prostheses wereimplanted in 757 patients, with a mean follow-up of38 months. The implants used were single or dualmobility cups (Maıa�, Moovis�, Touch�). The jointsurvival was 98% after the mean follow-up.Secondary procedures were scheduled in 18 prosthe-sis of our patients (2%) and in 6 prosthesis whichwere implanted in others hospitals. Causes of revi-sion surgery were 10 cases of loosening (7 trapeziumcups, 2 stems, 1 bipolar), 3 osteophytes formations, 6cases of dislocation (acute or chronic), 1 trapeziumfracture, 2 incorrect implant positions, 1 cam effect, 1instability of the thumb. Only 4 revisions required atrapeziectomy. Surgery targeting soft tissues andosteophytes or replacement of one of the implants(usually with a larger size) gave good outcomeswith quick recovery of activities as good as primaryarthroplasty.Conclusion: With this study, unlike some articles inthe literature, we show that this technique is a safeand reliable procedure and revisions are rarelyrequired. It has the potential for long-term survivalrates. Most of the revisions lead to an implant repla-cement, which allows the patient to keep the benefitsof the prosthesis. Fear of higher complication rate ofusing a trapeziometacarpal implant has slowed usfor a long time to choose this indication comparedwith trapeziectomy. Yet, the early outcomes of thetrapeziometacarpal joint arthroplasty show fasterrecovery and this has completely changed our post-operative rhizarthrosis consultation. In light of thisstudy, in order to avoid revision surgery, the surgicaltechnique must be perfect (learning curve, experi-ence, feeling). Patient education is also essentialwith a long follow-up. The better understanding ofthe trapeziometacarpal joint and the improvementof the prostheses could further reduce our recoveryrates.

A-0834 Congenital trigger digits: Results of surgicaltreatment

Nikos Rigopoulos, Ioannis Antoniou,Stratis Athanaselis, Zoe Dailiana, Konstantinos Malizosand Sokratis Varitimidis.Department of Orthopaedic Surgery, University ofThessalia, Larissa, Greece

Background/aim: Congenital trigger digit is a condi-tion often missed from parents’ attention and mis-diagnosed by paediatricians during the first year oflife. In the literature, both conservative and surgicalmanagement are favoured. The purpose of the study

FESSH Abstracts SS153

was to review surgical management and outcomes inpatients with congenital trigger digits.Methods: Sixty-two children (35 boys and 27 girls)with 66 trigger digits (58 thumbs six indices andtwo ring fingers) underwent surgical treatmentbetween 2000 and 2015. Mean age was 26 months(range 8–54 months). An open release of A1 pulley,through a small incision, was carried out after recog-nition and protection of the digital nerves. Generalanaesthesia, tourniquet and magnification loopswere used routinely for all procedures. Mobility andsensitivity of trigger digits were recorded pre- andpostoperatively.Results: Follow-up period was 29 months (range 16–44 months). Forty-nine patients presented after thefirst year of life. The involved digits were thumbs inthe majority of patients. Postoperatively all patientshad full range of motion and normal sensitivity. Therewere no recurrences of triggering and no infections.Conclusion: Surgical management of congenital trig-ger digits provides excellent results, especially inpatients who present in older children where conser-vative treatment has doubtful outcomes. Specialattention is needed during surgery due to smallsize of the neurovascular bundles

A-0836 A systematic review of dressing outcomesafter fingertip injuries

Eva O’Grady, Ojas Pujji and Jill WebbQueen Elizabeth Hospital, UK

Objectives: To review the available literature to iden-tify the optimum type of dressing for fingertip injuriesin terms of the outcomes of patient pain and adher-ence on dressing change, patient-reported comfort indressing and time to healing of wound.Methods: A systematic search using search terms‘‘finger’’ and ‘‘dressing’’ was performed onMEDLINE, CINAHL and EMBASE databases. Tworeviewers read full-text articles for inclusion anddata regarding the outcomes of interest wasextracted. Grouped analysis of comparative studiesassessing similar dressing regimes was performed.Results: Eight studies assessing 476 patients wereselected for inclusion. The majority of these studieswere small (median 42.5 patients per study) and ofrelatively limited methodological quality.

The most commonly examined dressing was par-affin gauze (examined in five studies). Mepitel� dres-sing, polyurethane foam dressing and silversulphadiazine were examined in two studies each.Remaining dressings examined were polymericmembrane dressing, lipocolloid dressing, traditional

gauze dressing, Adaptic� finger dressing and fucidingauze dressing.

Paraffin gauze was reported as inferior to compar-ison dressings in terms of patient pain adherence ondressing change in the majority of studies. In termsof time to healing, it was reported as equivalent orsuperior to comparisons.Conclusions: Insufficient high-quality evidence existsto recommend a single type of fingertip dressing;however, available evidence suggests that paraffingauze may be more likely to perform poorly in out-comes of patient pain and dressing adherence ondressing change. Further research in this areashould include patient-reported outcomes or patientexperience measures as well as clinical outcomes.

A-0838 Osseointegrated thumb prostheses as analternative for toe to thumb transfers

Katarzyna Kulbacka-Ortiz, Kerstin Caine-Winterberger, Yan Li and Rickard BranemarkCentre for Advanced Reconstruction of Extremities (CARE),Sahlgrenska University Hospital, Gothenburg, Sweden

Objective: Loss of a thumb is associated with impair-ment of hand function. Fitting patients with conven-tional socket prostheses can be particularlychallenging due to short stumps. Secondary recon-structive procedures (pollicization, toe to thumbtransplantation and lengthening) are the most com-monly used techniques. Osseointegrated treatmentand rehabilitation for amputees has been used fortransmetacarpal I level since 1990. This retrospectivestudy presents adverse events, outcome measuresand cumulative success rate of this alternativetreatment.Methods: The study includes pre- and postoperativedata collected from 13 transmetacarpal I amputees(10 male, 3 female) treated with osseointegratedprostheses. Reasons for amputation were trauma(11) and tumor (2). The patients mean residual extre-mity length was 41 mm (30–50). Patients were trea-ted with an experimental implant 1990–2004 atBranemark Osseointegration Center (7), and with astandardized treatment protocol 2005–2017 atSahlgrenska University Hospital (6). During the sur-gery, a threaded titanium implant (fixture) is insertedinto the residual bone. An abutment is then coupledinto the distal end of the fixture and secured with ascrew (abutment screw). The healing process takesabout 4 weeks after which the patient is supplied witha prosthesis.Results: The average prosthetic usage time was 9.5years (0.25–25). Two patients were withdrawn from

SS154 Journal of Hand Surgery (Eur) 43(Supplement 2)

the study for unrelated reason (death from unrelatedcause). There were 4 non-implant users; one stoppedusing the prostheses 1 year after surgery S2; twopatients had failed osseointegration; one patienthad an infection between surgeries S1 and S2 thatled to loosening and these 3 patients had theirimplant removed. One patient had a fall in 2006 lead-ing to a tetraplegic condition and has for obviousreason limited function, although the patient isusing the thumb prosthesis daily. Overall 19 compli-cations were reported. The two most common com-plications were change of an abutment (eight in threepatients) and superficial infections (seven in fivepatients). A total of five patients had no adverseevents. The cumulative success rate was 57% and100% for patients treated at the BranemarkOsseointegration Center and Sahlgrenska UniversityHospital, respectively. The longest functional implantfollow-up time was 25 years.

A total of seven patients with ossointegratedthumb prostheses were tested for functionality. Allpatients were prostheses users and were able tofeel sensation with their osseointegrated prosthesis(2.83–6.65) measured with monofilament. Handstrength tests outcomes: In Jamar grip test showedmedian 28.3 versus 40.4; B&L pinch test showed 6versus 9.1; B&L lateral pinch test showed 6.5 versus9.2 with affected and unaffected hand, respectively.Hand function was 95% of normal function measuredwith Sollerman’s grip-function test.Conclusions: Experience with the early experimentalimplant design and treatment protocol has led to thestandardized treatment with a considerable highersuccess rate. Adverse events were few and manage-able except for implant loosening in the early group.The patients have 70% of grip strength, 95% of handfunction compared with the unaffected hand andmeasurable sensation via the osseointegrated pros-thesis. The reported results indicate that osseointe-grated thumb prostheses might be considered analternative to other thumb reconstructiontreatments.

A-0839 Open reduction and internal fixation forMason type III radial head fractures: Is it differentfrom that for Mason type II fractures?

Seung-Han Shin, Young-Hoon Kang, Yong-Suk Lee andYang-Guk ChungSeoul St. Mary’s Hospital, The Catholic University of Korea,Seoul, South Korea

Background: We have been preferentially performingopen reduction and internal fixation (ORIF) for Mason

type III radial head fractures (RHFs), rather thanradial head arthroplasty (RHA). The question in thisstudy is whether ORIF really is a ‘less’ favorableoption for Mason III RHFs, as compared to ORIF forMason II RHFs or RHA. To answer this, we reviewedthe outcomes of RHFs of Mason type II and type IIIand evaluated whether ORIF in fact is a good optionfor Mason III RHFs.Materials and Methods: A total of 87 patients whowere treated surgically for a radial head fracturewere reviewed. The fractures were Mason type II in39 (44.8%) patients and type III in 48 (55.2%) patients.The surgery for Mason type II RHFs was ORIF in allcases. The surgery for Mason type III was ORIF in 40(83.3%) patients, RHA in 7 (14.6%) patients, andresection in 1 (2.1%) patient. Radiololgic and func-tional outcomes at final visit were evaluated andcomplications were reviewed.Results: When comparing Mason II RHFs and MasonIII RHFs treated by ORIF, no significant differencewas observed in extension, flexion and Quick-DASHscore (p¼ 0.408, 0.740, and 0.082, respectively),although pronation/supination was significantlybetter in Mason II RHFs. However, when comparingMason II RHFs and Mason III RHFs treated by RHA,the Quick-DASH score was significantly better(lower) in Mason II RHFs (p¼ 0.006). Also, the ROMwas significantly better in flexion, pronation, andsupination, in Mason II compared to Mason III treatedby RHA (p¼ 0.009, 0.006, and 0.006, respectively).When ORIF and RHA are compared within Mason IIIRHFs, there was no significant difference in ROM andQuick-DASH score between ORIF and RHA, except forsignificantly more flexion deficit in RHA (p¼ 0.007).Conclusion: ORIF is a good option for Mason III RHFs,which produces outcomes not very different fromoutcomes of Mason II RHFs. When compared toRHA, ORIF produces similar or better outcomes inMason III RHFs.

A-0840 Ulnar-sided carpometacarpal articularfractures

Camilo Chaves1,2 and Thierry Dubert2,3

1Universite Paris Sud, Le Kremlin Bicetre, France2Hopital Prive Paul d’Egine, Champigny sur Marne, France3Clinique Jouvenet, Paris, France

Objective: Ulnar-sided carpometacarpal articularfractures are frequent. Diagnose is often delayed orincomplete and there is no treatment consensus.This systematic review reports the state of the artand possible improvement in diagnosis andtreatment.

FESSH Abstracts SS155

Methods: Following PRISMA guidelines, terms used inWeb of Science database for the research were ‘‘car-pometacarpal’’ ‘‘joint’’ ‘‘fourth finger,’’ ‘‘fourth meta-carpal,’’ ‘‘fifth finger,’’ ‘‘fifth metacarpal,’’ ‘‘smallfinger,’’ ‘‘little finger,’’ ‘‘ring finger,’’ ‘‘hamatum,’’‘‘hamate,’’ ‘‘fracture,’’ ‘‘dislocation,’’ ‘‘articular,’’‘‘base fracture’’. Quality of the articles was assessedwith the Moga checklist. Epidemiological, clinical, andradiological data were analysed.Results: Five hundred articles were found on thedatabase. After exclusion of case reports and articlestreating multiple lesions, 16 articles were selected.Based on the Moga assessment tool, three articles(19%) were of acceptable quality. Series included 22patients in average, 87% affected the dominant handfollowing a direct punch in 52% and falls in 22%. Maledominance was 95%. Age was 32 years (9–93). Whenpresent, metacarpal dislocation was always dorsal.X-ray views were posteroanterior, lateral and differ-ent degrees of supination/pronation. CT scan wasused in five studies (31%). Five classifications wereproposed but were unable to describe all the lesionsor were too complicated to use in every-day practice.Average delay of treatment or diagnose was reportedin three articles and was 19 days. Initial misdiagnosiswas reported in 21%.

A variety of lesions were described, the most fre-quent being a dorsal metacarpal dislocation withpalmar metacarpal impaction. Hamate fractureswere mainly dorsal impaction. Eight articles did notreport any hamate fracture (50%).

Average follow-up was 27 months (1–168). Fixationincluded closed reduction and internal fixation (CRIF)by K-wires for articular stability and ORIF by K-wires,mini-screws and miniplate for articular fragments.Thirteen (81%) studies used ORIF, 11 (69%) articlesused CRIF, and 11 (69%) articles used a nonoperativetreatment.

Radiological evaluation included fusion, displace-ment, metacarpal shortening, osteoarthritis and theKellgren–Lawrence scale. Four (25%) articles did notreport any radiological assessment. Postoperative CTscan was never reported.

Clinical assessment was performed for pain in 44%and grip strength in 81% of the series. A specificquantitative measure instrument was used in 6 and81%, respectively; 77% of patients were painless.

Functional assessment was performed in five(31%) articles. DASH in 2 (12%), Michigan hand out-come questionnaire in 6% and Kumar criteria in 6%of the series. DASH score was between 1 and 9,Michigan questionnaire was between 75 and 98 andKumar was good or excellent. All questionnaireswere between fair good and excellent.

Participation assessment showed that 84% of theoverall average patients returned to their previousactivities/work (43–100%) between 3 weeks and 3months.Conclusions: This review outlines a poor quality ofmost of the articles and consequently a low level ofevidence of the results. It appears that systematicoblique views and CT would help detecting adjacentmetacarpal and hamate lesions. There is a need forcomprehensive classification. Indications for directarticular fracture fixation stay controversial.

A-0842 A novel stem cell therapy of dystrophinexpressing chimeric cells of myoblast andmesenchymal stem cell origin for enhancement ofmuscle regeneration and function

Maria Siemionow, Joanna Cwykiel, Ahlke Heydemann,Jesus Garcia-Martinez and Erzsebet SzilagyiUniversity of Illinois at Chicago, Chicago, IL, USA

Objective: Allogeneic stem cell therapies aim torestore muscle tissue after traumatic loss or mus-cular dystrophies. Limited engraftment due to allo-geneic rejection is a major challenge. Muscle-derivedchimeric cells (MDCC), created via ex vivo fusion ofmyoblast (MB) and mesenchymal stem cells (MSC),represent a promising therapeutic option. The aim ofthis study was to characterize human MDCC in vitroand to assess MDCC efficacy in engraftment andrestoration of muscle function in Duchenne musculardystrophy (DMD) MDX/SCID mice model.Methods: MDCC proliferation, dystrophin expression,and myogenic differentiation were tested.

Lymphocyte proliferation assay was performed toevaluate MDCC immunogenicity. To test the efficacyof MDCC in vivo, MDX/SCID mice received intramus-cular injections to gastrocnemius muscle (GM):Group 1 – vehicle (60 ml phosphate-buffered saline),Group 2 – 0.25� 106 of MSC and 0.25� 106 MB, Group3 – 0.5� 106 of MB/MSC MDCC. Therapeutic effectwas monitored by muscle function tests (wire hang-ing and grip strength tests, in vivo in situ and ex vivomuscle force measurement). DE was evaluated atdays 7 and 90 after MDCC delivery.Results: Parent cells genotype, dystrophin expres-sion, proliferation and differentiation to mature ske-letal myocytes of MDCC were confirmed.Proliferation of responder lymphocytes after stimu-lation with MDCC was 5.49% (SI¼ 3.15) comparedwith the positive controls of 55% (SI¼ 31) after sti-mulation with third-party lymphocyte and 10%(SI¼ 5.8) after stimulation with MB parent cells.MDCC survival and engraftment to GM was confirmed

SS156 Journal of Hand Surgery (Eur) 43(Supplement 2)

by dystrophin expression of 17.7% at day 7 and20.26% at 90 days.

Moreover, dystrophin, HLA-ABC and mature myo-cyte-specific markers were co-expressed by MDCCconfirming human origin and differentiation ofMDCC after transplant. MDCC recipients showedincrease in muscle force (p¼ 0.04) and improved fati-gue tolerance compared to vehicle group.Conclusion: This study confirmed efficacy of MDCCtherapy in restoration of muscle function, which cor-related with dystrophin expression in the GM of MDX/SCID mice. MDCC therapy represents a novel, uni-versal approach for restoration of muscle functionin muscular dystrophy, traumatic loss and for regen-eration of muscle components of VCA.

A-0846 Resurfacing capitate pyrocarbon implantassociated with first row carpectomy: It should bean alternative to 4CF and scaphoidectomy in SLAC-SNAC stage III wrists?

Ferrero Matteo1, Giacalone Francesco1, Cosentino PierLuigi1, Di Summa Pietro2 and Battiston Bruno1

1S.C. Ortopedia e Traumatologia II a indirizzo Chirurgiadella Mano, Citta della scienza e della salute Torino, Italy2CHUV, Lausanne, Switzerland

Objective: Four-corner fusion (4CF) is probably thegold standard procedure for the treatment ofadvanced stages of carpal collapse, when thelunate facet of the radius is still intact. However, inthe past decade, the RCPI associated with first rowcarpectomy (FRC) proved his efficacy in such arthriticwrists. We retrospectively compared our case seriesof RCPI associated with FRC vs 4CF, for the treat-ment of SLAC-SNAC stage III wrists.Methods: Forty-three patients who underwent sur-gery for SLAC-SNAC stage III wrist OA in our HandSurgery Department, between 2007 and 2015, wereretrospectively selected. All cases had a minimumfollow-up of 2 years. Twenty-five patients underwentFRCþRCPI implant (Group A) and 18 patients under-went 4CF with dorsal plate (Group B). The follow-upwas 42 months (min 24, max 96) for Group A and 38months for Group B (min 26, max 58). All patientswere clinically (pain, range of motion and gripstrength) and radiographically evaluated. PRWEscore and DASH score were assessed. Similarly,return to previous working and sport activities wasinvestigated.Results: In Group A, patients showed consistent painrelief (VAS 2.52), while preserving wrist mobility(mean flexion–extension 26.5�–32.6�, radial–ulnarinclination 12.1�–26.5�) and grip strength (55%

compared to contralateral side), with a satisfactoryrecovery allowing previous working activities. Meanoperative time was 76 min. The average DASH scorewas 19.5 and the average PRWE score was 28.2. Noimplant mobilization or capitate fracture wasdetected during the follow-up. One patient presentedvolar carpal dislocation 1 week after surgery andunderwent immediate open reduction and stabiliza-tion. One case of persistent pain leads to total wristarthrodesis 1 year later. No acceleration of distalradial OA was observed.

In Group B, mean VAS was 3, flexion–extension27.7�–37.7�, radial–ulnar inclination 16.1�–21.1� andgrip was 62.3% compared to contralateral side. Meanoperative time was 97 min. The average DASH scorewas 22.7, and the average PRWE score was 27.56. Intwo cases, non-union of the arthrodesis wasobserved, and the patients underwent revision withtotal wrist fusion.

No statistically significant difference was under-lined by statistical analysis among Groups A and Bfor all the measured outcomes and scores, except fora better radial inclination (p< 0.05) in Group B.Consistently, DASH and PRWE scores were notfound to be statistically different. Grip strength,which has always been the major criticism to FRC,has been slightly lower in Group A but without anystatistical difference. Operative time was significantlylower in Group A, while patients’ age was signifi-cantly higher (54 vs 43 years).Conclusions: Based on these outcomes for the treat-ment of advanced stages of OA (SNAC/SLAC stageIII), RCPI associated with FRC proved to be a reliablealternative to 4CF and scaphoidectomy, the mostwidely spread technique, even in older patients. Thelack of grip strength that has historically been attrib-uted to FRC seemed to be not significant. On thecontrary, the surgical time appears to be lower andthere are no risks of non-union.

A-0852 Efficiency of hyaluronic acid in prevention ofadhesion formation after flexor tendon tenolysis

Libor Streit1,2, Tomas Kubek1,2, Eva Vitovska2,Igor Stupka1, Sarka Stiborova1,2, Zdenek Dvorak1,2,Pavel Novak1, Tomas Vyska1 and Jiri Vesely1,2

1Department of Plastic and Aesthetic Surgery, St. Anne’sUniversity Hospital Brno, Czech Republic2Faculty of Medicine, Masaryk University, Brno, CzechRepublic

Objective: Standard treatment for symptomaticflexor tendon adhesions is tenolysis and early activemobilization. Appropriate rehabilitation may reduce

FESSH Abstracts SS157

but cannot prevent their formation or recurrence.Auto-cross-linked hyaluronic acid polymers are con-sidered to have an antiadhesive effect.Methods: This prospective, randomized, single-blindclinical trial was conducted from January 2013 to May2015. Thirty-six patients indicated for flexor tenolysisafter previous replantation and revascularization withtendon suture in zone II were enrolled. In the experi-mental group, hyaluronic acid gel (Hyaloglide�) wasapplied directly to the flexor tendon just before skinclosure. No antiadhesives were used in the controlgroup. All patients were evaluated by testing totalactive motion (TAM) and DASH questionnaire beforethe surgery, at postoperative day 14 and 1, 2, 3 and 6months postoperatively.Results: No significant improvement of TAM in per-cent (TAM%) or DASH were detected between theexperimental and the control group (p> 0.05). Themean improvement of TAM% in sixth postoperativemonth was 18% in the experimental group and 21%in the control group. On the contrary, we havedemonstrated that the smokers have significantlylower improvement of TAM% in the both groups(p< 0.05). The mean improvement of TAM% was16% in smokers and 23% in no-smokers 3 monthspostoperatively.Conclusions: We did not show any improvement infunctional outcomes of flexor tenolysis associatedwith the use of hyaluronic acid gel (Hyaloglide). Wehave demonstrated a direct correlation betweensmoking and poor results.

A-0853 The advantages of using WALANT anesthe-sia for hand and wrist fractures: Personalexperience

Daniel Vilcioiu1, Dragos Zamfirescu2, Andrei Ursache1

and Ioan Cristescu1

1Clinical Emergency Hospital of Bucharest, Bucharest,Romania2Zetta Clinic, Bucharest, Romania

Objectives: The objectives of this study were to (1)compare the advantages of this type of anesthesia,which allows full hand movement during surgery, (2)present the exact technique and highlight patientbenefits, and (3) compare the obtained resultsincluding hand therapy protocols with literature.Materials and Methods: In a prospective manner, 48patients suffering from hand fractures or even wristfractures were treated using wide-awake hand sur-gery (WALANT) anesthesia. The fracture includesmetacarpal fractures, hand fractures, and evenwrist fractures. This allowed us to discharge the

patients after few hours. This technique can be per-formed with no preoperative testing, no intravenousinsertion, and no monitoring and is similar a dentalprocedure.

The patients could talk with the surgical team andto see the immediate hand movement after skinclosure.Results: We were able to check the fracture reduc-tion and the implant stability, with active motion ofthe hand. This helped us to decide whether to allowearly protected movement after surgery. The patientscould see the reduction of their bone on fluoroscopyand they could watch themselves achieve a full rangeof motion during the surgery. They remember thisand know that this will be achievable if they will beso motivated during hand rehabilitation. Most of ourfracture reductions were anatomical and the stablefixation was possible with plates and screws.Conclusions: There are multiple advantages of usingthis safe technique, both for the patient and for thesurgeons. All the patients considered their surgeriesa good experience and they were more motivated inhand rehabilitation.

A-0859 Kinesiophobia and its relation withfunctional outcomes in hand injuries

Ozge Buket Cesim, Burcu Semin Akel andCigdem OksuzHacettepe University, Ankara, Turkey

Objective: Kinesiophobia is defined as an ‘‘excessive,irrational, and debilitating fear of physical movementand activity resulting from a feeling of vulnerability topainful injury or reinjury.’’ Kinesiophobia had beenwidely assessed in various conditions including neu-rologic and orthopedic injuries. However, little isknown about the relation of kinesiophobia and func-tional outcomes of hand. The aim of this study is tostate the relation of kinesiophobia with hand functionoutcomes.Methods: Twenty-six patients (14 women and 12men) with soft tissue injuries (tendon, muscle andligament injuries) completed the TAMPA scale forkinesiophobia. Disability of the Arm, Shoulder andHand (DASH) questionnaire was used to state upperextremity-specific disability level. Hand dexterity,strength and pain intensity were assessed with theuse of Jebsen Taylor Hand Function Test (JTT),Purdue Pegboard Test (PPT), hand dynamometerand Visual Analog Scale (VAS). All the assessmentswere done at 8–12 weeks after diagnoses.Correlation coefficient was calculated with SPSS 21

SS158 Journal of Hand Surgery (Eur) 43(Supplement 2)

programme to assess the relation betweenoutcomes.Results: The age interval of the patients was between18 and 71 years with the mean age of 39.19� 13.91years. The mean score of TAMPA scale was39.31� 5.05 (minimum 32, maximum 51). The rela-tion was not significant between the TAMPA scaleand DASH (p¼ 0.43, r¼ 0.16), JTT page turning subt-est (p¼ 0.79, r¼ 0.05), JTT simulated feeding subtest(p¼ 0.52, r¼ 0.13), JTT stacking checkers subtest(p¼ 0.10, r¼ 0.32), JTT picking up large light objectssubtest (p¼ 0.48, r¼ 0.14), JTT picking up large heavyobjects subtest (p¼ 0.13, r¼ 0.30), JTT writing subt-est (p¼ 0.34, r¼ 0.26), PPT (p¼ 0.69, r¼ 0.08), gripforce (p¼ 0.93, r¼ 0.01) and VAS (p¼ 0.76, r¼ 0.06).Kinesiophobia was found to be only significantlyrelated with picking up small common objects subt-est (p¼ 0.02, r¼ 0.43).Conclusions: The kinesiophobia score of the patientsvaried between moderate to high; however, it was notrelated to hand functioning outcomes. This resultmay have a relation with the type of diagnosis,patients with soft tissue injury may perform well inhand outcome measures than other injuries like frac-tures, nerve injuries. The low number of the partici-pants may also lead to this result. Assessments weredone in the subacute or chronic phase of the injuryfor letting the patient to use the hand. Meanwhileduring that period hand functioning may be recov-ered. Therefore, the relation of kinesiophobia maybe investigated in also acute phase and with otherinjuries.

A-0861 Is there a relation between kinesiophobiaand sense of coherence in hand injuries?

Ozge Buket Cesim, Elif Cimilli, Cigdem Oksuz andBurcu Semin AkelHacettepe University, Ankara, Turkey

Purpose: The sense of coherence (SOC) is defined as‘‘The extent to which one has a pervasive, enduringthough dynamic, feeling of confidence that one’senvironment is predictable and that things will workout as well as can reasonably be expected.’’ It has asignificant influence on patients with traumatic handinjuries. Patients with low SOC have lower qualityof life and satisfaction in daily occupations.Kinesiophobia is ‘‘fear of movement’’ as a result ofa feeling of susceptibility to painful injury or reinjury.Recently, the interest of kinesiophobia is increased inthe literature. Therefore, this pilot study wasdesigned with the aim of investigating the relation

of kinesiophobia with SOC in patients with differenttype of hand injuries.Methods: Twenty patients (11 men and 9 women)with hand injuries completed the TAMPA scale forkinesiophobia and SOC questionnaire with the follow-ing three components: comprehensibility, manage-ability, and meaningfulness. All the assessmentswere done at the first session of the patients.Correlation coefficient was calculated with SPSS 21programme to assess the relation between TAMPAand SOC questionnaire.Results: The age interval of the patients was between18 and 61 years with the mean age of 38.20� 13.45years. The mean score of TAMPA scale was38.90� 5.04 (minimum 32, maximum 51). The meanSOC score of comprehensibility component was20.75� 6.37 (minimum 12, maximum 31), manage-ability component was 17.30� 3.81 (minimum 8,maximum 23), meaningfulness component was18.60� 6.26 (minimum 4, maximum 27). The relationwas not significant between the TAMPA scale andmanageability component (p¼ 0.07, r¼ 0.40), mean-ingfulness component (p¼ 0.94, r¼ 0.01) of SOC.Comprehensibility component of SOC was found tobe significantly related to TAMPA scale (p¼ 0.03,r¼ 0.46).Conclusions: It has been shown in the literature thatlow SOC significantly related to an increased risk ofhaving worse clinical and functional outcomes inpatients with moderate orthopedic injuries. Wefound kinesiophobia was related to comprehensibilitycomponent of SOC. Comprehensibility is the cognitiveelement of the SOC and it means that individualsperceive the internal or external stimuli in under-standable, predictable and regular order. Therefore,in hand injuries, the cognitive statement of thepatient may be important due to the possible effecton the kinesiophobia and it may thus have potentialaffect on the recovery process.

A-0863 Pyrocarbon partial scaphoid prosthesis(APSI): Why, when, how

Francesco Giacalone, Matteo Ferrero,Maddalena Bertolini, Alessandro Fenoglio andBruno BattistonHand Surgery Department, CTO Hospital, Torino, Italy

Introduction: Proximal scaphoid non-unions havealways been a challenging surgical problem, espe-cially when there is necrosis of the proximal pole.Many techniques aim at the revascularization or sub-stitution of the avascular pole, trough-out pedicled orfree bone-grafts stabilized with small screws of

FESSH Abstracts SS159

K-wires. In young patients, these reconstructivetechniques are the goal standard, but they are tech-nically demanding, they require a long post-operativeimmobilization with sometimes poor final wristmotion and their rates of failure and non-union areconsiderable. In selected cases, before attemptingmore aggressive treatments such as proximal-rowcarpectomy (PRC) or scaphoidectomy and four-corner fusion (4CF), a pyrocarbon proximal polespacer (APSI) can be used to allow early wrist mobi-lization while preventing carpal collapse and degen-erative changes, even in cases when there is alreadysome chondral damage (ICRS I–II) on the scaphoidfacet of the radiusMethods: All patients (16 cases) who underwent APSIimplant for proximal pole non-unions, in our HandSurgery Department between 2007 and 2015, wereretrospectively evaluated, both clinically (pain,range of motion, grip strength) and radiographically.PRWE score and DASH score were assessed. Themean follow-up was 47 months; all patients withless than 2-year follow-up were excluded from thestudy. Return to previous working and sport activitieswas investigated.Results: Patients showed consistent pain relief (VAS1.7), while preserving good wrist mobility (mean flex-ion–extension 66.5�–72.6�, radial-ulnar inclination16.1�–33.5�) and grip strength (81% compared to con-tralateral side), with a satisfactory recovery allowingprevious working activities. Mean operative time was43 min. The average DASH score was 13.5 and theaverage PRWE score was 16.2. One patient presenteddorsal dislocation of the implant 3 weeks after sur-gery and underwent scaphoidectomy and 4CF (herefused revision). One case of persistent pain andpoor functional recovery led to scaphoidectomy and4CF 3 years later. In about 40% of the cases, afterseveral years, some radiographical osteoarthriticchanges were observed on the radial side of the capi-tate (conflict between two convex surfaces), but onlyone was clinically symptomatic.Conclusions: according to these outcomes, for treat-ment of scaphoid non-unions with a necrotic proxi-mal pole, hemi-scaphoidectomy and APSI implantcould be a reliable alternative to scaphoid recon-struction in selected cases (patients unwilling morecomplex procedures and needing a fast return towork), even when some arthritic changes are presenton the radial scaphoid fossa. Should the benefitsworsen with time, it would still be possible to per-form implant removal and more aggressive surgicalprocedures (PRC or 4CF). It is certainly necessary alonger follow-up to better evaluate the role of theseimplants in the future.

A-0871 Characteristics of trigger finger in children

Wiebke Hulsemann1, Max Mann1 and Karl-Heinz Kalb2

1Children’s Hospital Wilhelmstift, Handsurgery, Hamburg,Germany2Rhon-Klinikum AG, Handchisurgery, Bad Neustadt/Saale,Germany

Trigger finger of the thumb, the pollex rigidus, isfrequent in young children and easy to treat byrelease of the A1 pulley. Trigger finger of other fin-gers is less frequent and has often a different pathol-ogy. The stenosis may be localized more distally andmust therefore treated different.Patients and Methods: In a retrospective analysis,children who underwent surgery for trigger fingersin two specialized centers were evaluated. In thecohort of 42 children with a total of 63 trigger fingersin 12 patients with 17 affected fingers, the pathologywas a stenosis distal to the A1 pulley. They weretreated by a widening at the A2 pulley level mostlyby a resection of one limb of the sublimis tendon orwidening of the A2 pulley at the age of mean 3.7 years(0.6 to 3.7 years). Patients and their parents wereinterviewed by phone call and chart review at amean follow-up of 4.8 years (1.2 to 11.8 years) post-operative looking for functional impairment, persis-tent pain, satisfaction and complications.Results: All patients treated by A1 pulley release andresection of one limb of the sublimis tendon hadexcellent results. One patient had a recurrence andanother patient developed a contracture of the PIPjoint. In both patients, the widening of the tendonsheath had been performed by widening of the A2pulley in addition to the A1 pulley release.Conclusion: Surgeons should be aware that trigger-ing of a finger can be caused by a stenosis distal tothe A1 pulley. Persistent triggering intraoperativeafter A1 pulley release should be treated by resectionof one limb of the sublimis tendon and not by widen-ing of the A2 pulley.

A-0872 Surgical treatment of acute injuries of theposterior bundle of the medial elbow collateralligament

Arman Sard, Elisa Dutto, Matteo Ferrero,Stefania Vanni and Bruno BattistonDepartment of Orthopedic and Traumatology 2, AOU Cittadella Salute e della Scienza, PO CTO, Turin, Italy

Objective: Elbow stability is provided by static anddynamic components. Medial collateral ligament(MCL), composed by an anterior, a posterior and a

SS160 Journal of Hand Surgery (Eur) 43(Supplement 2)

transverse bundle, plays a central role between 30�

and 110� of elbow flexion. Several authors high-lighted the undisputed importance of the anteriorbundle (AB) as a stabilizer against valgus stress.The aim of this study is to demonstrate that a com-plete posterior elbow dislocation does not occur untilthe posterior bundle (PB) is sectioned.Methods: The biomechanical study on cadavers wascarried out in anatomical laboratories with the colla-boration of the Department of Mechanical andAerospace Engineering of the Politecnico di Torino.Sixteen elbows in 8 cadavers (10 women and 6 men;average age 74 years) were included in the study.Clinical evaluations in supination valgus and prona-tion varus in compression and slight flexion wereperformed in three conditions: with an intact MCL,with a sectioned AB and with a section of both theAB and the PB.Results: The biomechanical studies showed that acomplete posterior elbow dislocation does notoccur until the PB is sectioned. Indeed, if the MCLis intact, the application of a force in supinationvalgus and pronation varus in compression andslight flexion of the elbow is not sufficient to causean elbow dislocation. The section of the AB alonecauses an elbow instability in valgus stress, but nota dislocation. Only after sectioning also the PB, weobtain a posterior elbow dislocation with a medialrotatory movement: this dislocation is incomplete ifthe lateral collateral ligament is intact.Conclusions: The PB of the MCL has a primary role inelbow stability against valgus stress and it preventselbow posterior dislocation at all flexion angles; so,in case of injuries the reconstruction of the PB isnecessary to restore elbow stability.

A-0876 Diagnosis of hand and forearm fractures inwhole body CT after polytrauma

Friederike Munn1, Andreas Eisenschenk1,2,Martin Lautenbach3, Tobias Topp3 and Simon Kim1

1Universitatsmedizin Greifswald, Greifswald, Germany2Unfallkrankenhaus Berlin, Berlin, Germany3Krankenhaus Waldfriede Berlin, Berlin, Germany

Objective: To assess the amount of identified andmissed fractures of the upper extremity of intubatedpatients who received a whole body CT (WBCT) scandue to assumed polytrauma and the number of visi-ble but neglected fractures.Methods: In a retrospective design, the electronicchart and diagnostic procedures were reviewed ofpatients who received a whole body scan in twolevel 1 trauma centers between January 2013 and

December 2015. Only patients who were intubatedand had an accident that could cause a polytraumawere included. Epidemiologic data and radiographicreports were analyzed. We looked for missed injuriesthat were diagnosed in follow-up examinations andreviewed the initial whole body CT for visibility of theinjury and the reason for follow-up.Results: Of the 2826 patients who received a wholebody scan, 426 patients met the inclusion criteria.Sixty-six (15.5%) patients had fractures of the handand/or forearm, with a total of 132 fractures (79 fore-arm, 53 hand). Patients with fractures of the upperextremity were younger than those without.Fractures of the upper extremity were mostcommon in patients who fell from a height >3 m(24.0%) or were involved in vehicle accidents(23.5%). Of those vehicle accidents, 42% weremotorcyclists.

In all, 74.2% of fractures of the upper extremity(n¼ 98) were diagnosed by initial WBCT that is notconsidered a standard detecting injuries of the extre-mities; 39.6% (n¼ 21) of all hand fractures and 16.5%(n¼ 13) of all forearm fractures were not detectedinitially; 89.4% of all fractures of the upper extremitywere detected within the first 24 h after admission: 11fractures were diagnosed by X-ray within the firsthour after WBCT, 7 fractures between 1 to 24 hafter WBCT. Sixteen fractures were diagnosed laterthan 24 h after WBCT. Reviewing the WBCT for frac-tures that were not mentioned initially, 22 fractureswere visible, 9 fractures were not visible and 3 frac-tures were not included in the scan window. Of the 18fractures diagnosed within 24 h, 11 were visible onWBCT, 5 not visible and 2 not included in the scanwindow. Sixteen fractures were detected more than24 h after WBCT with 11 visible, 3 not visible and onenot in the scan window.Conclusion: Reevaluation of WBCT for injuries of theupper extremity would have increased the detectionrate of fractures within the first 24 h from 89.4% to96.2%, only evaluating the hands and forearms inWBCT without using X-ray would have resulted in90.9%. This shows the importance of reassessmentof WBCT with focus on the extremities. From motorcycle accidents or after fall from great height needspecial attention for injuries of the hand or forearm.

FESSH Abstracts SS161

A-0880 Vascularized versus non-vascularized bonegrafts in the treatment of scaphoid non-union

Emre Gazyakan, Christoph Hirche, Ling-Yun Xiong,Christian Heffinger, Amir Bigdeli, Berthold Bickert andUlrich KneserDepartment of Hand, Plastic and Reconstructive Surgery,University of Heidelberg, BG Clinic Ludwigshafen,Ludwigshafen, Germany

Introduction: Conventional non-vascularized bonegrafts as well as vascularized bone grafts are usedto treat scaphoid non-union (SN). Due to limitedavailable studies, the field of application using bothgrafts for SN still remains controversial. The aim ofthis study was to evaluate a treatment algorithm forthe use of both vascularized versus non-vascularizedbone grafts based on clinical outcomes and quality oflife (QoL) to improve the level of evidence.Materials and Methods: Based on a retrospectivecohort study, including 28 patients with vascularizedand 45 patients with conventional bone grafts, func-tional parameters, radiological outcome, Mayo WristScore, and QoL by SF-36 were applied to statisticallycompare the outcome of these two techniques.Results: Time between the last procedure or traumaand the study group scaphoid reconstruction wasalmost double in the vascularized bone graftinggroup. Comparable union rates were achieved withvascularized as well as non-vascularized bonegrafts. Significant differences were observedbetween both groups for grip strength and radial–ulnar active range of motion. Further functional out-comes, radiological outcomes as well as QoL werefound similar for both techniques in patients withsurgical union.Discussion and Conclusions: In order to achievecomparable and appropriate treatment results, vas-cularized bone grafts are recommended for patientswith delayed treatment, impaired scaphoid vascular-ity, and revision surgery. Even in preselected, com-plex cases, the results are comparable toconventional grafts, which are the basis for furtherpatient education and approve the powerful role ofsurgical angiogenesis of vascularized bone grafts.

A-0884 Long-term outcomes for early stages ofKienbock’s disease treated with radius coredecompression

Pablo De Carli, Ezequiel Zaidenberg,Agustin Donndorff, Gerardo Gallucci and Jorge BorettoHospital Italiano, Buenos Aires, Argentina

Objective: This study was designed to analyze thelong-term clinical and radiological outcomes of aseries of patients with Kienbock’s disease stage IIand IIIA treated with radius core decompression.Methods: This retrospective study included 23patients with Kienbock’s disease (Lichtman stagesII and IIIA) who received distal radius metaphysealcore decompression between 1998 and 2005 andwere followed-up for at least 10 years. Patient withother stages (I, IIIB or IV) or skeletally immaturewere excluded. At the last follow-up, the patientswere evaluated for comparative wrist range ofmotion and grip strength. The overall results wereevaluated by the modified Mayo Wrist Score andvisual analogue scale pain score. We also comparedthe radiological changes between the preoperativeand final follow-up in their Lichtman classificationand the modified carpal height ratio (CHR).Complications were recorded. Statistical analysiswas performed.Results: The mean follow-up period was 14 years(range 10–19). Nine were female and 14 were male.Fifteen were stage IIIA and 8 were stage II. Based onthe modified Mayo Wrist Score, clinical results wereexcellent in 9 patients, good in 13 patients and poor inone patient who required a proximal row carpectomyas revision surgery. The mean preoperative painaccording to VAS was 7 (range 6–10) and was 1.1(range 0–6) at the final follow-up, showing a signifi-cant improvement (p> 0.05). Moreover, at the finalfollow-up, 18 of the 23 patients had VAS either 0 or1. No statistical differences were reported in VAS ormodified Mayo score improvement between the stageII and IIIA. Compared with the opposite side, the aver-age flexion/extension arc was 78% and the gripstrength was 81%. All patients, except one, returnedto their original employment.

Radiographic disease progression according to theLichtman classification occurred from stage II to IIIAin two patients and from stage IIIA to IIIB in anothertwo wrists; while the others 19 patients remained inthe same stage as preoperatively.

The average preoperative CHR in stage II was 1.52(1.48–1.58) and in stage IIIA was 1.38 (range 1.5–1.28). The average posoperative CHR in stage II was1.50 (1.40–1.58) and stage IIIA was 1.34 (range 1.42–1.25), showing no statistical decreased in the lunateheight (p< 0.05). No complications related to thecore decompression were reported.Conclusions: Radius core decompression demon-strated favorable long-term results and could beconsidered as a surgical alternative for stage II andIIIA of Kienbock’s disease.

SS162 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-0887 Movement imagery skills and its relationwith hand functioning in guitar students

Elif Ciminli, Ege Temizkan, Ozge Buket Cesim,Cigdem Oksuz and Burcu Semin AkelHacettepe University, Faculty of Health Sciences,Department of Occupational Therapy, Ankara, Turkey

Objective: Musicians use their upper extremities toperform the most difficult tasks when playing theirinstruments. Studies reported guitar players are athigh risk among musicians because guitar playingincludes awkward, repetitive movements. When per-forming professionally, musician should educate thebody and be aware of the body without visual feed-back to use it efficiently during performance.Movement imagery skill is therefore important forefficient motor and sensory use of the body struc-tures. In this study, we aimed to investigate themovement imagery skills and its relation with upperextremity motor performance.Methods: Eighteen guitar bachelor students fromState Conservatory (3 female and 15 male) partici-pated to the study. Movement Imagery Skill wasassessed with Movement Imagery Questionnaire-3(MIQ-3) and Upper Extremity Motor Performancewas assessed with the Upper Extremity Range ofMotion Assessment of the Valpar Work Samples.Results: The mean age of the participants was22.61� 4.48 years (minimum 18, maximum 38).Three participants were at preparatory class, fourparticipants were at first class, five participantswere at second class, one participant was at thirdclass and five participants were at fourth class.Thirteen participants were right handed and fivewere left handed. Mean daily practice time was4.00� 1.49 h. Mean age for starting to play theguitar was 13.33� 2.27 years. Mean music educationtime was 7.11� 2.94 years. Intrinsic Visual Imagerymean score was 6.54� 0.59, Extrinsic Visual Imagerymean score was 6.63� 0.54 and Kinesthetic VisualImagery mean score was 6.43� 0.74. Mean workrate score obtained from Valpar was 92.91�19.03%. There was a significant correlation betweenleft hand preference and Intrinsic Visual Imageryscore (p¼ 0.025, r¼�0.527). No significant relationwas observed between the upper extremity handfunctions and the movement imagery skills (p> 0.05).Discussion: Analysis of visual imagery skills andkinesthetic imagery skills showed that visual imageryskills of musicians were advanced, which is consis-tent with related literature. When the motor perfor-mance assessment results were analyzed, it wasseen that the mean score obtained from UpperExtremity Range of Motion test was lower than the

mean score of individuals with disabilities (data aboutindividuals with disabilities were obtained fromValpar Booklet). It can be interpreted that enduranceis a major barrier for guitarists in repetitive and awk-ward motions and positions. This thought was sup-ported with guitarists’ feed-backs during theassessments; stating that discomfort and loss of per-formance become prominent during the UpperExtremity Range of Motion Assessment. It wasexpected to see a negative correlation betweenVisual Imagery Skills which are advanced in guitar-ists and Upper Extremity Motor Performance which islimited. It is suggested to perform more detailedassessments to evaluate movement imagery skillsand upper extremity functions. All of the participantswere using right-handed guitars regardless of theirhand preference. Significant correlations betweenleft hand preference and visual imagery skillsrevealed that using right handed guitar as a left-handed person may do harm to visual imageryskills. Therefore, it is suggested to regard imageryskills as an important area to focus in non-dominantguitar players.

A-0888 Treatment of fingertip amputation by com-posite graft and temporary dermo-dermal fusion tothe palm in children

Max Mann and Wiebke HulsemannChildren’s Hospital Wilhelmstift, Handsurgery Department,Hamburg, Germany

Introduction: In fingertip amputation in toddlers orchildren of preschool age is frequent. Loss of morethan half of the nail bed and exposure of bone asksfor coverage and reconstruction of nail bed andlength. In small children, the reconstruction bymicrosurgical replantation is impossible. In adults,Paavilainen described 2009 a successful reconstruc-tion by refixation of the tip by composite graft andtemporary dermo dermal fusion of the deepithelia-lized fingertip to the palm to improve blood supplytemporarily. We wanted to check whether this tech-nique is efficient in the not cooperating young chil-dren too.Materials and Methods: From 2000 to 2016, we per-formed the dermo dermal fusion in 22 children with amedian age of 5.3 years. In one case, the amputationlevel was in zone 2 of Ishikawa classification, 3 inZone 3 and 1 in zone 4. The amputations werecaused by squeezing and avulsion in19 fingers andby a clean-cut in 3 patients. Postoperatively, theywere immobilized in fist bandage pressing the tipinto the palm and a forearm finger cast for 4 weeks.

FESSH Abstracts SS163

Results: In 18 of 22 cases, the fingertip refixation wassuccessful and the major part of the pulp and naillength could be preserved. In three cases, the chil-dren had torn their finger out of the palm in the first10 days postop ahead of time. These three patientshealed secondarily with a good result in two and asatisfying result with some shortening of the tip inone patient. In three patients, the fingertip was lostdue to necrosis and infection.Conclusion: This technique is a good tool to gainbetter length of the distal phalanges and nail bedlength in comparison to treatment with semi-occlusive dressings and local flaps. In the aftercare,it is essential to protect the injured finger againstpull out.

A-0890 Long-term follow-up after pyrocarbon discinterposition for CMC thumb joint osteoarthritis

C. M. C. A. van Laarhoven1,2,3, J. S. E. Ottenhoff3,A. H. Schuurman3 and E. P. A. van der Heijden2

1Erasmus Medical Center, Rotterdam, The Netherlands2Jeroen Bosch Hospital, ‘s Hertogenbosch, TheNetherlands3University Medical Center, Utrecht, The Netherlands

Introduction: The pyrocarbon disc has been designedfor the surgical treatment of CMC thumb jointosteoarthritis Eaton, Littler and Glickel grade 2 to3. It is hypothesized that interposition of the implantwill preserve height, stability, strength and move-ment after surgery as much as possible.

Since the introduction of the pyrocarbon disc, thistechnique is used in the Jeroen Bosch Hospital (JBZ)in ‘s Hertogenbosch and the University MedicalCenter Utrecht (UMCU) in the Netherlands. Ourstudy evaluates the long-term results after pyrocar-bon disc implant as interposition hemi-arthroplastyfor CMC thumb joint osteoarthritis.Methods: Between 2006 and 2014, 237 thumbs wereoperated in the JBZ and UMCU. After approval fromthe medical ethical committee, all 237 patients havebeen approached to participate in the study. As pri-mary outcome, patient-reported outcome measure-ments are obtained, such as pain, function,satisfaction and quality of life. These are measuredwith five questionnaires (PRWHE, MHQ, DASH, SF-36and questions to measure satisfaction). As secondaryoutcome, power, range of motion and position of thedisc in the thumb are evaluated. These data will beobtained by hand measurements and radiology eva-luation. Statistical analysis will be done.Results: At this moment, 163 thumbs are included. Atthe time of the congress, all patients will be included

and all analysis will be done. At this moment, theaverage follow-up is 6.0 years (range 2 to 11 years).The mean age at operation was 59.4 years. Of the 163thumbs, 9.2% was removed because of ongoing com-plaints. The preliminary results show a median DASHof 18 and a median PRWHE of 14.5. The MHQ had atotal score of 74. Satisfaction with operation andresult scored 9.0 (on a Likert scale 1–10). Themedian JAMAR was 21.9 (100% of the contralateralgrip power), the key pinch was 4.8, the tip pinch was3.2 and the three-point pinch was 4.0 (98%, 98% and97% of the contralateral hand, respectively). Range ofmotion with Kapandji was 9.0.Conclusion: To our knowledge, this is the first studywith long-term follow-up after pyrocarbon disc inter-position for the treatment of CMC1 osteoarthritisgrade 2–3 in more than 150 patients. The preliminaryresult show a high level of patient satisfaction, pre-servation of movement and strength without losingheight of the first metacarpal and low dislocation ofthe implants during the follow-up period of average 6years.

A-0893 Treatment of postoperative pain for distalradius fractures: Corticosteroids versus non-steroidal anti-inflammatory drugs. A prospectivestudy

Francisco Cuadrado Abajo, Manuel Sanchez Crespo,Gonzalo Garcıa Portal, Marıa de los Angeles de la RedGallego, Jose Couceiro Otero, Olga Marıa Velez Garcıa,Higinio Ayala Gutierrez and Fernando Javier del CantoAlvarezMarques de Valdecilla Universitary Hospital

Background and Objectives: Surgical treatment withblocked plates for fractures of distal radius is one ofthe most important causes of admission in trauma-tology service, requiring hospital stays of severaldays.

The aim of our study was to compare two protocolsof postoperative analgesia (NSAIDs vs corticoster-oids) with the intention of unifying a protocol andcorrecting admission times, which in our center is48 h.Materials and Methods: A comparative randomizedprospective study is designed. All patients operatedin our hospital with a blocked plate due to distalradius fracture between April and October 2017were included.

Inclusion criteria: >18 years and having answeredthe postoperative questionnaire.

Exclusion criteria: postoperative analgesia infusionpump, polyfractured, reosteosynthesis, cognitive

SS164 Journal of Hand Surgery (Eur) 43(Supplement 2)

deterioration, diabetes mellitus, allergy to drugs ofthe protocol and kidney failure.

Fifty patients, who were randomly assigned intotwo groups, were included:

- NSAIDs (n¼ 25): paracetamol 1 g/8 h; dexketo-profen 50 mg/8 h alternating with paracetamol; tra-madol 50 mg/8 h as a rescue; morphine 5 mg/mlevery 8 h if necessary.

- Corticosteroids (n¼ 29): paracetamol 1 g/8 h;methylprednisolone 40 mg/8 h alternating with para-cetamol; tramadol 50 mg/8 h as a rescue; morphine5 mg/ml every 8 h if necessary.

The following variables were collected: age(average 60.2 years), sex (79.6% women), dominance(64.81% non-dominant hands, n¼ 35), work activity(50% of active patients), AO classification, time fromfracture to surgery (average 15.3 days), type ofanesthesia (96.3% plexus block anesthesia), type ofplate used and ischemia time (average 71.35 min).

The patient was evaluated at 24 and 48 postopera-tive hours collecting: pain using the visual analoguescale (VAS), need for morphic rescues, type ofmorphic used, need for bandage opening. In addition,patients were asked if they would be discharged andif they were satisfied with pain control.

The statistical analysis was carried out with SPSSstatistical software considering p< 0.05 assignificant.Results: No statistically significant differences werefound between the two groups for the demographicvariables (sex, age, work activity and dominance).There were no differences in the time from fractureto surgery, type of plate, type of anesthesia, AO clas-sification or ischemia time.

Regarding postoperative pain, it was similar in bothgroups (p¼ 0.81 at 24 h and p¼ 0.132 at 48 h).

No differences were observed in the rescuesrequired (p¼ 0.164) nor in the medication used forthis. In the first 24 h, there were no significant differ-ences for the need to open the bandage, although itwas statistically higher for patients in the NSAIDsgroup at 48 h (p¼ 0.04).

In all, 79.63% of patients were satisfied with paincontrol at 24 h and 98.14% at 48 h; 64.81% of patients(n¼ 35) would agree to be discharged after 24 h.Conclusions: The use of both protocols had similarefficacy, which could increase the analgesic arma-ment in those patients who can not be administeredNSAIDs (allergic, kidney failure, etc.)

Most of the patients answered that they would gohome in the first 24 h after surgery, which makes usreconsider the average time of admission of thesepatients.

A-0894 Arthroscopic distal hemitrapeziectomyversus open distal hemitrapeziectomy withoutinterposition in osteoarthritis of the first CMC joint:Two-year follow-up results of a randomized con-trolled trial

C. M. C. A. van Laarhoven1,2, M. Baas2, J. M. Zuidam1,2

and A. R. Koch3

1Franciscus Gasthuis, Rotterdam, The Netherlands2Erasmus Medical Center, Rotterdam, The Netherlands3Haga Hospital, The Hand and Wrist Center, Hague, TheNetherlands

Introduction: A variety of different treatment modal-ities are available for osteoarthritis of the CMC jointof the thumb. To date, trapeziectomy alone is seen asthe treatment with the least complications and istherefore described as the most favored treatment.Because of removal of the total trapezium in trape-ziectomy, there is a higher chance to shortening andcollapse of the thumb, which can give less post-operative strength. Distal hemitrapeziectomy doesnot have these drawbacks. The last years there is agrowth in experience in arthroscopic techniques, alsofor the CMC thumb joint. Arthroscopic techniquesoffer the potential benefit of earlier recovery.

This study compares arthroscopic hemitrapeziect-omy with open hemitrapeziectomy without tendoninterposition in a multicenter randomized controlledclinical trial. At the FESSH congress 2016, we pre-sented our preliminary data of 1-year follow-up; wewill now have our 2-year follow-up data to present.Materials and Methods: Since 2014, we perform amulticenter randomized controlled trial in two hospi-tals. All patients with Eaton and Littler grade 2 or 3,with unsuccessful conservative therapy, are asked toparticipate in the study. After informed consent isobtained, patients are randomized to either open orarthroscopic distal hemitrapeziectomy. Patients areasked to fill in the PRWHE and hand measurementswere done in preoperative setting and at 3, 6, 12 and24 months postoperative.Results: The 1-year results showed a PRWHE of 20.6of the open group (pain 11.4, function 9.2) and 18.8(pain 11.5 function 7.3) of the arthroscopic group.This score was 56.5 preoperatively in the opengroup (pain 28.5 and function 28) and 45.3 in thearthroscopic group (pain 22.8 and function 22.5).The preoperative grip power (measured with theJAMAR dynamometer) was for the open group 18.4and after 1 year 24. For the arthroscopic group, thiswas 26.1 preoperatively and 34.8 after 1-year follow-up. The Kapandji was 8 in the preoperative setting forboth groups and improved to 9.7 and 9.8 for the openand arthroscopic groups, respectively. Of the patients

FESSH Abstracts SS165

in the arthroscopic group, 88% would undergo theoperation again versus 70% of the open group.After 1 year, there were 3 complications in the opengroup after 1 year (29 patients) and 1 complication inthe arthroscopic group (36 patients). Statistical ana-lysis of the results will be done at the time of thecongress.Conclusion: We will present the results of at least 80patients with a minimum of 1-year follow-up and 50patients with a minimum of 2 year follow-up. Earlierresults show a slight patient preference for thearthroscopic hemitrapeziectomy after 1 year, butthe pain and function scores and hand measure-ments showed equal improvement. Key grip strengthand grip strength seem to be significantly strongerthan in similar studies for treatment of CMC I arthri-tis in the literature. Our goal is to enroll 90 patients,45 per group as calculated with our power analysis.

A-0901 Three-dimensional virtual planning ofcorrective osteotomies for paediatric malunitedforearm fractures: A prospective study

Kasper Roth1,2, Filip Stockmans3, Edwin Oei2, Eline vanEs2, Max Reijman2, Jan Verhaar2 and Joost Colaris2

1Amphia Hospital, Breda, The Netherlands2Erasmus Medical Centre, Rotterdam, The Netherlands3KU Leuven, Leuven, Belgium

Objective: Malunited both-bone forearm fractures inchildren commonly involve complex three-dimen-sional (3D) deformations in different planes, whichmay not be acknowledged on conventional radio-graphs. The aim of this study was to evaluate theclinical outcomes after 3D-planned corrective osteo-tomies with use of 3D-printed patient-specific guidesfor symptomatic malunited both-bone forearm frac-tures in children as alternative for conventional cor-rective osteotomies, which are traditionally preparedusing X-rays and then executed freehand.Methods: Prospective study in which we performed3D-planned corrective osteotomies on participantswith paediatric, malunited both-bone forearm frac-tures. Inclusion criteria were a symptomatic mal-united forearm fracture, sustained duringchildhood, with a deficit in pronosupination (pro- orsupination of <50�), unsatisfactory clinical improve-ment after 6 months of conservative treatment and aminimum age of 10 years at inclusion. Exclusion cri-teria were a congenital or traumatic osseous defor-mity of the contralateral forearm. Participantsmeeting the inclusion criteria underwent a 3D-planned corrective osteotomy according to the fol-lowing steps: (1) CT scans of both forearms are

obtained; (2) the location and degree of deformity isdetermined by overlaying a virtual model of the mal-united forearm bones on a mirrored version of theunaffected contralateral forearm bones; (3) virtualcutting planes are set within the malunited forearmbones, which can be angulated, rotated and trans-lated to best match the contralateral side; (4)patient-specific drilling and sawing guides are 3D-printed to help achieve the planned correctionduring corrective osteotomy. Our primary outcomemeasure was gain in pronosupination at 6-monthfollow-up. Our secondary outcome measures werea patient-reported outcome measure on daily func-tioning (quickDASH), patient-reported scores on painand cosmetic appearance and the complication rate.Results: Between 2016 and 2017, six participantsunderwent 3D-planned corrective osteotomies forpaediatric symptomatic malunited both-bone fore-arm fractures. There was a median age at traumaof 8.9 (interquartile range of 6.5–10.4), a medianage at osteotomy of 14.3 years (IQR 12.4–18.5) anda median time between trauma until osteotomy of 5.9years (IQR 3.5–9.1). Preoperatively there was a meanpronosupination of 58� � 15� compared to 143� � 9� ofthe contralateral side, a deficit of 85� � 17�. At 6-month follow-up, there was a pronosupination of113� � 19�, a gain in pronosupination of 55� � 9�.There was a decrease in quick-DASH disability/symp-tom score from 28� 16 pre-operatively to 22� 17 at6-month follow-up. Patients reported a decrease inpain score from 2.8� 3.3 to 1.8� 1.6 and a decreasein score regarding cosmetic deformity from 5.6� 2.5to 3.8� 1.6. A low complication rate of 16.7% wasseen (1 delayed union).Conclusions: This prospective study demonstratesthat limitations in forearm rotation and patient-reported outcome measures (PROMs) can reliablyand safely be improved using 3D-planned correctiveosteotomies for paediatric malunited both-bone fore-arm fractures.

A-0904 Which factors affect limitation ofpronosupination after both-bone forearm fracturesin children? The long-term follow-up of aprospective study

Kasper Roth1,2, Leon Diederix2,3, Max Reijman2,Jan Verhaar2 and Joost Colaris2

1Amphia Hospital, Breda, The Netherlands2Erasmus Medical Centre, Rotterdam, The Netherlands3Reinier de Graaf Hospital, Delft, The Netherlands

Objective: When a child presents him/herself at theemergency department with a both-bone forearm

SS166 Journal of Hand Surgery (Eur) 43(Supplement 2)

fracture, it is important for the clinician to realize ifthere is a high risk of developing a persisting func-tional limitation. The aim of this study is to investi-gate which clinical factors are associated with apersisting limitation of pronosupination at long-term follow-up after a both-bone forearm fracturein a child.Methods: A prospective multicentre long-termfollow-up study was performed in which all consecu-tive children (<16 years) who presented themselvesat the emergency department with a both-bone fore-arm fracture between 2006 and 2010 were included.These participants were included in various rando-mized controlled trials: distal metaphyseal fractureswithout need for reduction were treated with below-elbow cast (BEC) versus above-elbow cast (AEC);displaced distal metaphyseal fractures which under-went closed reduction were treated with or withoutK-wires fixation; diaphyseal fractures without needfor reduction or stable after reduction were treatedwith AEC or AEC followed by BEC; and unstable dia-physeal fractures were treated with 1 or 2 intrame-dullary nails. The short-term follow-up study of thiscomplete cohort revealed that a refracture and a dia-physeal located fracture were associated with a func-tional limitation in children with a both-bone forearmfracture at short-term follow-up. For the currentstudy, we invited all participants to revisit the ortho-paedic outpatients’ clinic for long-term functionalassessment after a minimum follow-up of 5 years.One-way analysis of variance (ANOVA) and multivari-ate logistic regression analysis were used to assessthe relationship between a limitation of pronosupina-tion (�15�) and the following factors: age at trauma,length of follow-up, dominance of the affected side,location and type of fracture, severity of angulation,number of reductions performed, occurrence ofrefracture(s) and undergoing of physiotherapy.Results: Of the 410 participants (77%), 315 wereincluded for long-term follow-up after a meanfollow-up of 7.2 (�1.4) years. There was a limitationof pronosupination �15� in 51 of 315 participants.Analysis of variance revealed that in participantswho had a limitation of pronosupination �15�

versus those who did not, there were the followingstatistically significant differences: more completefractures (51% vs 36%, p¼ 0.039), greater angulardeformity of the radius (28� vs 23�, p¼ 0.030), moreinitial closed reductions (86% vs 73%, p¼ 0.045) andmore re-fractures (27% vs 12%, p¼ 0.003). A diaphy-seal location of the fracture was seen more often(59%) in participants who had �15� limitation of pro-nosupination versus those who did not (44%); how-ever, this difference was not statistically significant(p¼ 0.058). Multivariate logistic regression analysis

revealed that, when analyzing the effects of variousfactors simultaneously, one factor was statisticallysignificantly associated with a limitation in pronosu-pination: the occurrence of a re-fracture (odds ratioof 1.9).Conclusions: The occurrence of a refracture was theonly factor associated with a limitation of pronosupi-nation at long-term follow-up after a paediatricboth-bone forearm fracture. Although extensive phy-siotherapy and a diaphyseal location of the fracturewere statistically significantly associated with asuperior functional outcome at short-term follow-up, these factors were not associated with superioroutcomes at long-term follow-up.

A-0907 Novel use of a vascular flow system toenhance in vitro training in microsurgical vesselrepair with biological material

Hazem Alfeky1, David Bell2 and Partha Vaiude2

1Whiston Hospital, Liverpool, UK2Surgical Art Education Institute, UK

Introduction and Aims: The gold standard for teach-ing microsurgical vessel repair is using a live animalmodel. This is expensive, requires animal licensingand is not readily accessible at short notice to mosttrainees. The aim was to develop a simple in vitroflow system where the patency and integrity of avessel repair could be assessed.Materials and Methods: A simple balloon-baseddevice was designed to allow the flow of colouredwater in a low pressure system. It could accommo-date both end-to-end and end-to-side repairs and beused under an operating microscope. The field forthe repair was set low to allow easy hand placementfor stable working, key to good microsurgical techni-que. Water is used as the circulating fluid, which hasa very low viscosity and so deficiencies in repair tech-nique were readily identified. Porcine arteries andveins were used for training in vessel repair andanastomosis.Results: It was possible to perform end to end, end toside, and differential size anastomoses with thismodel and check the patency of these repairs.Feedback from both faculty and delegates indicatedthat the device meets the training requirements forbasic and intermediate levels very well.Conclusion: This novel device works well as a noviceand intermediate level training tool to develop micro-surgical instrument and vessel handling skills. Useof artery and different sizes of veins made it acces-sible for trainees of different grades and experience.

FESSH Abstracts SS167

A-0914 Comparative study of different incisiontypes in trigger finger release

Beata Bajdik, Balazs Lenkei and Zsolt SzaboHandsurgery Center of Miskolc, Hungary

In our unit, three different incision types are used:transverse, longitudinal, or zig-zag incision. Ouraim was to compare the results of the differenttechniques.

Continuous prospective data collection has beenrunning in our unit since 2015; 240 patients wereincluded in our study; 56 patients had to be excludeddue to incomplete data. Three groups were formedaccording to the incision type (zig-zag, transverse,longitudinal). The patient’s satisfaction (VAS 1-10),the pain level (VAS 1–10), the range of motion wasregistered four times after surgery (at 1 week, 2weeks, 4 weeks, 2 months). Significance was mea-sured with Student’s t-test (p¼ 0.05).

The patient satisfaction was 9.5 points for zig-zag,9.01 for transverse incision, and 8.49 for longitudinalincision group at 1 week. At 2 months, these valueswere 9.5, 9.2, and 8.35, respectively. The pain levelwas 2.2 for zig-zag, 2.4 for transverse and 3.3 pointsfor longitudinal group at 1 week. Extension deficit ofmore than 20� was registered at 2 months as follows:for the zig-zag group, no extension deficit, for trans-verse incision group 3 patients, for longitudinal group10 patients.

(In conclusion, longitudinal incision caused higherpain levels and lower satisfaction for the patientscompared to zig-zag or transverse incision.)

Compared to the zig-zag group, longitudinal inci-sion resulted in significantly higher pain and signifi-cantly lower satisfaction levels after 1 week and 2months as well. Compared to the group with trans-verse incision, no significant difference was found.

Range of motion was also influenced by the inci-sion type. The best result could be achieved by zig-zag incision, followed by the transverse and longitu-dinal ones.

A-0921 Triphalangeal thumb: A diversephenomenon

Lisa Ng, Emma Reay, Susan Stevenson andBrid CrowleyDepartment of Plastic and Reconstructive Surgery, RoyalVictoria Infirmary, Newcastle upon Tyne Hospitals NHSFoundation Trust, Newcastle upon Tyne, UK

Introduction: Triphalangeal thumb is an uncommonphenomenon. By definition a thumb with three

phalanges, this basic definition belies the great diver-sity of clinical presentation. The triphalangeal thumbspectrum includes patients with fully functioninghands with five digits and an opposable thumb,radial polydactyly, hypoplastic thumb and the three-digit hand. We present our experience and evolutionof practice in treating this condition.Methods: A retrospective study of 18 patients pre-senting with 27 triphalangeal thumbs was performed.Clinical, photographic, radiological and detailed ana-tomical operation records were reviewed.Results: A wide range of clinical presentations wasobserved. Five-digit opposable hands (eight thumbs),radial polydactyly (14 thumbs), three-digit hands(three thumbs) and hypoplastic (two thumbs).Median age at presentation was 2 years (range 8weeks to 14 years). Twenty-three thumbs underwentsurgery. Skeletal procedures included joint excisionand fusion, excision of additional phalanges, osteo-tomies and first metacarpal shortening. Soft tissuesurgery included first web deepening and proceduresto address anomalous tendon and muscle anatomy.We observed more complex patterns of anatomicalanomalies in the radial polydactyly cohort. Choice ofprocedure was guided by mobility and stability ofjoints, length and longitudinal alignment of thumb/first metacarpal, opposition potential, musculotendi-nous units and skin. Variability between thumbs wasobserved in all bilateral cases.Conclusion: We advocate detailed anatomicalexploration of these complex anomalies at the timeof primary surgery. This guides primary treatmentand has a useful prognostic role. We favour mid-lat-eral incisions, which offer excellent surgical accessand cosmesis.

A-0922 An anatomical study of triphalangeal thumbin radial polydactyly

L. Ng, S. Stevenson, M. Alrawi, P. Kalu, J. Littler,J. Ahmad and B. CrowleyDepartment of Plastic and Reconstructive Surgery, RoyalVictoria Infirmary, Newcastle upon Tyne Hospitals NHSFoundation Trust, Newcastle upon Tyne, UK

Objective: Radial polydactyly encompasses a wideand diverse group of anatomical anomalies, includingthe presence of triphalangeal thumb. A number ofclassifications have been reported based on skeletalanatomy. The complexity may be underestimatedresulting in poor results from primary surgery andlate deformity.Methods: A prospective anatomical study comparingour triphalangeal radial polydactyly cohort with our

SS168 Journal of Hand Surgery (Eur) 43(Supplement 2)

non-triphalangeal radial polydactyly cohort. We alsocompare our triphalangeal radial polydactyly cohortwith a referenced study in the literature. Diagnosis oftriphalangeal thumb is made on the basis of preo-perative clinical assessment, radiographic findingsand thorough exploration at time of surgery.Detailed systematic operative records of anatomicalfindings and procedures undertaken are recordedusing defined anatomical headings. We have pre-viously presented anatomical findings in our totalradial polydactyly cohort and now focus on our tri-phalangeal radial polydactyly group.Results: Radial polydactyly total: 47 patients, 54thumbs.

Triphalangeal radial polydactyly: 10 patients, 14thumbs.

M:F ratio 1:1. Four cases bilateral. The triphalan-geal duplicate was ulnar 6/14, radial 2/14, both dupli-cates 6/14. Of the six cases of unilateraltriphalangeal radial polydactyly, three had a contral-ateral triphalangeal thumb without polydactyly. Whencompared to the literature, we saw a larger propor-tion of Type IVA of which both duplicates were tripha-langeal. In contrast, Wood saw a greater proportionof Type VIIC.

Skin: Variability in the pattern of skin envelopesharing was observed, which did not always correlatewith the underlying skeletal anatomy; 5/14 (36%) hadfirst web tightness requiring surgical release.

Joint anatomy: Variables noted included reducedmotion at the IPJ, dual facet at the MCPJ andshared CMCJ.

Thenar muscle: Insertion on radial duplicate (10/14), ulnar duplicate(4/14).

Dominant thumb: In our total radial polydactylycohort, the ulnar duplicate was most commonlydominant (47/54). The incidence of radial dominanceobserved was greater in triphalangeal group (5/14).

Tendons: In the triphalangeal group flexor pollicislongus insertion on the radial duplicate only wasseen in 3/14. This flexor pattern was not observedin non-triphalangeal cases. While extensor pollicisbrevis inserted more frequently on the radial dupli-cate, insertion on both duplicates/ulnar only was alsoobserved. Extensor pollicis brevis insertion on theulnar duplicate only was observed in 3/14 triphalan-geal, 1/40 non-triphalangeal.

Surgical procedures: In 12/14 cases, the triphalan-geal component was retained. Procedures unique tothe triphalangeal cohort included removal of thedelta bone (2/14) and DIPJ excision and shorteningto correct the triphalangeal component (3/14).Conclusion: Our study demonstrates complexity andvariability of anatomy in radial polydactyly. Greateranatomical complexity is seen in triphalangeal

versus non-triphalangeal cases. Wood previouslysuggested that the triphalangeal thumb be excisedregardless of dominance but our experience differs.Compared to radial polydactyly (Wassel I–VI), a tightfirst web and dominant radial duplicate was morecommon. There are significant limitations in using askeleton-based classification and we would advocatean anatomical approach to treatment. Systematicexploration of anatomy at primary surgery has akey prognostic role to aid surgical planning and opti-mize functional outcome.

A-0925 Histological, immunohistochemical, andmicrostructural assessment of flexor tendon graftsfor pulley reconstruction: A cadaver study

Tobias Fritz1,2, Pascal Ducommun3, Urs Hug3,Tim Pohlemann2, Maurizio Calcagni4, MichaelD. Menger1, Wolfgang Metzger2 and Florian S. Frueh1,4

1Institute for Clinical and Experimental Surgery, SaarlandUniversity, Homburg/Saar, Germany2Department of Trauma, Hand, and ReconstructiveSurgery, Saarland University Hospital, Homburg/Saar,Germany3Department of Hand and Plastic Surgery, CantonalHospital Lucerne, Lucerne, Switzerland4Division of Plastic Surgery and Hand Surgery, UniversityHospital Zurich, Zurich, Switzerland

Objective: Flexor digitorum superficialis (FDS) andpalmaris longus (PL) tendons are routinely used inhand surgery to reconstruct deficient pulleys.However, little is known about the structural eligibil-ity for this purpose. The present cadaver study wasinitiated to analyze histological, immunohistochem-ical, and microstructural characteristics of humanFDS and PL tendons and to compare these to flexortendon pulleys.Methods: FDS (n¼ 16) and PL (n¼ 4) tendons as wellas A2- and A4- pulleys (n¼ 8) were harvested from 4fresh-frozen cadaver hands. For histological ana-lyses, the specimens were stained with hematoxy-lin–eosin. Polarized light microscopy of Sirius red-stained sections was performed to analyze the col-lagen network. In addition, scanning electron micro-scopy was performed to illustrate the microstructureof the tendons and pulleys. Finally, microvasculardensity in the center as well as in the synovial layerof the tendons and pulleys was assessed by immu-nohistochemical staining with the endothelial cellmarker CD31. Data were analyzed for normal distri-bution and equal variance. Differences betweengroups were tested using one-way analysis of var-iance. Values were expressed as mean� standard

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error of the mean. Statistical significance was set top< 0.05.Results: FDS tendons as well as A2- and A4-pulleysexhibit a highly hierarchical and tightly interwovennetwork of collagen fibers. In contrast, PL tendonsshow a lower degree or structural organization. Inline with these findings, immunohistochemical ana-lyses revealed that FDS tendons as well as A2- andA4-pulleys are characterized by a comparably micro-vessel density within the synovial layer (FDS84� 15 mm�2, A2 105� 21 mm�2, A4 78� 30 mm�2;p¼ 0.57).Conclusions: The findings of this study indicate thatFDS tendon slings are particularly suitable for pulleyreconstruction due to the microstructure and immu-nohistochemical characteristics. Additionally, scan-ning electron microscopy reveals insights into themicrostructure of human flexor tendon pulleys.

A-0926 Pulsed radiofrequency is a new chance totreat neuropathic pain after traumatic peripheralnerve injury

Ernesta Magistroni1, Valter Verna2, Ilaria Da Rold1,Daniele Molino1, Maddalena Bertolini1 andGiuseppe Massazza1

1University Hospital\‘‘C.T.O. – Citta della Salute e dellaScienza\’’, Turin, Italy2Alba-Bra Hospital – Cuneo, Italy

Objective: Pulsed radiofrequency (PRF) developedwith the goal of providing reduction in pain from theuse of electrical fields in the absence of neural injury,because of temperature is always under 42�C.Prospective trials have shown a benefit in pain reduc-tion with the use of PRF in a variety of chronic painstates. Studies in literature concluded that has a bio-logical effect unlikely to be related to overt thermaldamage and that it targets small diameter C and Adelta nociceptive fibres but the action is on smallfibres’ mitochondria. Use of ultrasound guidance forright positioning PRF in carpal tunnel syndrome hasrecently reported too. Neurophatic pain (NP) is acomplex, chronic pain state that usually is due todamaged, disfunctional or injured nervous tissue,especially peripheral. Post-traumatic nerve injuriesare often complicated by NP. In this study, we analyzethe efficacy of PRF on neuropathic pain due to per-ipheral nerve traumatic injury.Method: Our prospective clinical study included 70patients (39 male; 31 female) mean age 42 years,all affected by NP after peripheral nerve injury(nerve lesion and surgery repair). They were treated,using ultrasound (US)-guide, with PRF procedure

(pulsed dose). At follow-up, they were evaluated atT0 (before-PRF) and at 1-, 3-, and 6 months aftertreatment with these instruments of evaluation:VAS (visual analogue scale) for pain and SF-36(Short Form of Health Survey) for quality of life.Results: After the procedure, all the patientsreported a reduction in pain measured by VAS scaleabout 38%. Follow-up assessment during patients’rehabilitation treatment confirms relief of pain withimprovement in rehabilitation program. A gradualreturn to pain was observed after a 3- to 4-monthperiod. We measured using validated scales suchas SF-36 quality of life that improved both inPhysical and in Mental score (PCS and MCS).Conclusion: Radiofrequency treatment in thesecases was not only an alternative to pharmacologicaltherapy in NP relief but a new chance when pharma-cological therapy isn’t enough to control pain. PRFprocedure should be considered such as an alterna-tive treatment for all post traumatic nerve injuries, atany level, which are complicated by NP. They are safein locations where conventional RF (continuousradiofrequency) are potentially hazardous becauseof high temperature (70–80�) that cause irreversibledamage to the nervous tissue, while for PRF therearen’t clinical and EMG evidences of any nervedamage. It’s useful to control NP during mobilizationand sensibility rehabilitation after nerve injury surgi-cal repair. And such as here demonstrated it can beapplied in more than one district without complica-tions. Especially in young patients, it would representan alternative to opioid therapy that compromisetheir every day life.

A-0929 An alternative to pollicization: Foerster’sarthrodesis and callus distraction

Martin Franz LangerUniversity Clinic, Munster, Germany

In Blauth 3b thumb hypoplasia, many parents, forvarious reasons, could not decide whether to ampu-tate the hypoplastic thumb and have an index fingerpollicization.

What results can be achieved with this method ofoperation, what are the advantages anddisadvantages?

A meaningful use of the hypoplastic thumb is in thestabilization and extension. In 1930, Otfried Foersterstabilized the thumb in paresis of the thumb mus-cles. He performed an extra-anatomic arthrodesisbetween Metacarpal I and Matakarpale II with abone graft. Other authors also followed this methodfor thumb hypoplasia.

SS170 Journal of Hand Surgery (Eur) 43(Supplement 2)

In the last 10 years, we have operated on sevenchildren between the ages of 3 and 14 years. Thebone graft was removed from the iliac crest and sta-bilized with plate osteosynthesis.

All bone grafts healed. When the fibrous cordbetween metacarpal 1 and trapezium is cut, thethumb can already be extended by about 20%. Allchildren put their thumbs in daily life. A later correc-tion osteotomy or a callus distraction was performedin four children. All patients (parents) reported thatthey would have this operation done again.

Advantages: (1) No thumb amputation, (2) obtainingthe very important clamping grip between forefingerand middle finger, (3) low-risk intervention, (4) manycorrection options

Disadvantages: (1) Fixed rigid thumb, (2) problemswith unstable thumb ground joint

A-0934 Evidence-based operative treatment ofbasal thumb arthritis: Has the evidence affected thetreatment choices of hand surgeons?

Petros Mikalef1, Dominic Power2 and David Warwick3

1Southampton NHS Treatment Centre, Southampton, UK2Birmingham Hand Centre, Birmingham, UK3University Hospital Southampton, Southampton, UK

Objective: Thumb base arthritis is one of only a fewconditions facing the hand surgeon that has beensubjected to rigorous and extensive research with aclear evidence base for surgical management.Sufficiently powered comparative randomized con-trolled studies have reported no advantage to liga-ment reconstruction when compared to simpletrapeziectomy. The degree to which this evidencehas affected the selection of operative treatment bypracticing hand surgeons is being investigated andthe results are presented.Methods: An online survey was performed betweenMarch and July 2016. The survey was performedusing the SurveyMonkey tool and consisted of 10questions on the subject of the surgical managementof thumb base arthritis. The link was advertisedthrough a social media platform (LinkedIn) andthrough the BSSH Bulletin. Hand surgeons werequestioned regarding their surgical approach, tech-nical details of their favoured procedure and theirknowledge of the evidence base for operative man-agement of basal thumb arthritis. They were askedhow the evidence had affected their practice.Results: Sixty-eight hand surgeons from 27 countriesreplied to the survey; 92.65% of the participantsstated that they were aware of the published evi-dence for the treatment of trapezio-metacarpal

arthritis, suggesting that the results of simple trape-ziectomy, trapeziectomy and K-wire stabilization andtrapeziectomy with ligament reconstruction are notdifferent in the short or long term; 61.76% of parti-cipants were not aware of the evidence that patientsafter prosthetic replacement of the trapezio-metacarpal joint recover quicker than following a tra-peziectomy; 78.13% of the participants were awarethat there is no evidence that prosthetic replacementof the trapezio-metacarpal joint has better resultsthan trapeziectomy; 78.13% of the participants saidthat the above-mentioned evidence did not makethem change their practice in any way. The reasonsgiven are reported and demonstrate the requirementfor larger pragmatic studies or registry studies inhand surgery using a standardized outcome dataset reached through consensus.Conclusion: The results of the survey suggest thatmost hand surgeons are aware of evidence sur-rounding the surgical management of thumb basearthritis but the evidence has not been persuasiveenough for many of them to change their currentpractice. The results are brought to the attention ofthe European hand surgery community in the hopethat future collaborative research can be developedto address these concerns.

A-0937 Pain and hand functioning differencesduring music education in bachelor guitar students

Burcu Semin Akel1, Ege Temizkan1, Elif Cimilli1,Onur Seyrek2 and Onur Urganoglu3

1Department of Occupational Therapy, Faculty of HealthSciences, Hacettepe University, Ankara, Turkey2Department of Physical Therapy and Rehabilitation,Faculty of Health Sciences, Hacettepe University, Ankara,Turkey3Ankara State Conservatory, Main Art Branch of Piano, ArtBranch of Guitar, Hacettepe University, Ankara, Turkey

Objective: Playing-related musculoskeletal pain wasreported to be at high rate with the percentage ran-ging from 60% to 90%. Most of the musicians demon-strate pain during the last 3 months, and some arecomplaining from permanent pain. It is suggestedthat music-related illnesses start impairing instru-mental play at an early stage in music education.Endurance and speed are important parameters formusicians. And these parameters may be affectedbecause of pain; or musician can hurt self whiletrying to improve endurance and speed. It is won-dered when is the pain getting higher and how isthe hand endurance and speed improving duringmusic education. Therefore, it is aimed to investigate

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pain intensity and hand dexterity of bachelor guitarstudents and compare results between classes.Methods: All the guitar students getting bacheloreducation during 2017 fall semester at HacettepeUniversity Conservatory invited to the study.Individuals were excluded from the study if theyhad any neurological disease, any chronic disorderthat causes constant pain, any psychiatric illness orcognitive dysfunction. We set these criteria to under-stand only playing-related problems. Eighteen stu-dents (3 women and 15 men) participated in thestudy, and only 3 students did not want to volunteer.Pain was assessed with The Musculoskeletal PainIntensity and Interference Questionnaire forMusicians (MPIIQM). Upper Extremity MotorPerformance was assessed with the UpperExtremity Range of Motion Assessment, fine fingerdexterity, simulated assembly of the Valpar WorkSamples Test. SPSS 21 program was used for statis-tical analysis.Results: The mean age of the participants was22.61� 4.48 years (minimum 18, maximum 38). Theaverage pain score was 0.00 at preparatory class,25.25� 9.28 at first class, 12.40� 13.97 at secondclass, 21� 0.00 at third class and 7.20� 16.095 atfourth class. There was a significant correlationbetween pain scores and left hand preference(p¼ 0.037, r¼ 0.495), between pain scores andmusic education time (p¼ 0.020, r¼�0.542). UpperExtremity Range of Motion test of Valpar indicatedmore discomfort during assessment; however, itsrelation with pain was not significant (p> 0.05).Hand dexterity assessments showed a decline withyears of education, most of the students stopped testbecause they get tired or had pain. Controversial,none of the Valpar test score showed significant cor-relation with pain scores.Discussion: Pain intensity differs between classes, itwas remarkable that students at first class reportmore pain. The endurance is also getting worsewith the presence of pain during testing. It was sur-prising that pain was not correlated with hand dex-terity results, because during testing guitaristshardly completed the tests as their classes areincreasing. This result may reflect musicians maynot want to complete questionnaires or did notwant to express pain intensity due to emotional rea-sons. It was obvious that musicians have problemsduring their education and an efficient health caredelivery system should be established forconservatories.

A-0941 Review of the relevance of the Soong clas-sification with 200 implant removals after palmarplate fixation of distal radius fractures

Yekta Goren, Annika Arsalan-Werner, Julia Sebald,Dennis Wincheringer, Reinhard Hoffmann andMichael SauerbierBG Unfallklinik Frankfurt am Main, Frankfurt am Main,Germany

Purpose: After palmar plate fixation of distal radiusfractures, the implant positioning to the watershedline has been recently associated with increasedpostoperative complications. Soong et al. publishedin 2011 a classification concerning the prominence ofpalmar T-plates. The purpose of this study was toanalyze the relationship between the Soong stage ofthe palmar plate and the rate of postoperative com-plications in a level I Trauma Center.Methods: Two-hundred patients who underwentpalmar plate removal after a distal radius fracturefixation between 2010 and 2016 in our institutionwere included in the study. Patients were first clas-sified based on the position of the palmar plate inrelation to the watershed line (Soong classification)using the postoperative lateral X-ray images. Thecomplications for each patient (including pain,restriction of range of motion (ROM), neurologic com-plications and complaints) were analyzedretrospectively.Results: Twenty-three patients fulfilled the criteria ofSoong stage 0 (Group 0), 110 patients of Soong stage1 (Group 1) and 67 of Soong stage 2 (Group 2). InGroup 0, 30.4% of the patients presented pain and17.3% restriction of the ROM. In Group 1, the rateof the patients who suffered from pain was 32.7%and 24.5% presented restriction of ROM. One patient(0.9%) in this group reported an irritation of the flexortendons of the finger. In Group 2, 38.8% of thepatients presented pain and a restriction of ROMwas documented in 16.4% of the patients in thisgroup. Furthermore, 6 patients (8.9%) in Group 2reported an irritation of the flexor pollicis longus(FPL) tendon or other finger flexor tendons. Amongthose, 2 patients (2.9%) had a laceration of the FPLtendon which was confirmed by the intraoperativefindings. In 2 other patients (2.9%), a rupture of theFPL tendon after the palmar plate osteosynthesisoccured. Consequently, the patients in Group 3 pre-sented a statistically significant higher rate of FPLtendon laceration/rupture compared to the patientsin group 0 and 1 (p< 0.05).Conclusions: Palmar plates for distal radial fracturefixation classified as Soong stage 2 presented anincreased risk of FPL tendon rupture/laceration.

SS172 Journal of Hand Surgery (Eur) 43(Supplement 2)

We recommend an early Soong stage 2 palmar plateremoval after fracture healing is observed. In Soongstage 1, situations a removal of the plate may also beoffered to the patients.

A-0942 Functional outcomes and complications rateof surgical treatment of unstable fractures of theneck of fifth metacarpal with condylar blade plateversus locking anatomical plate

Grigorios Kastanis, Petros Kapsetakis,George Velivasakis, Eirini Trachanatzi,Idomeneas Makrigianakis and Nikolaos BounakisGeneral Hospital of Heraklion – Venizeleio, Greece

Objectives: The fracture of the neck of fifth metacar-pal also call Boxer fractures occurs in young menwith intense activity and constitutes a complex pro-blem in orthopaedic regarding the surgical techniqueand the type of implant. The purpose of this study isto compare the postoperative results of those frac-tures with condylar blade plate versus locking anato-mical plate.Materials and Methods: Forty-eight patients (44 menand 4 women) with an average age of 34.5 years wereoperated on with closed unstable fracture of neck offifth metacarpal. The indications for operative treat-ment were (a) angulations� >40�, (b) rotatory mala-lignment, (c) shortening and (d) failure to maintainreduction. The mean time period to internal fixationvaried from 2 to 10 days. The patients were separatedin two groups: in group A (cases 27), the fracturewere fixated with convectional condylar blade plate2.3 mm and in the group B (21 cases) with anatomicallocking plate 2.3 mm. The surgical approach was thesame in both groups (dorso-ulnar), and the plate wasplaced in the lateral side of the metacarpal. A palmarsplit leaving PIP joint free for early motion wasplaced in both groups of patients postoperatively.After 7 days, postoperative patients were allowed toperform daily activities to the rate of tolerance.Results: The average follow-up was 17 months(range 11–23 months). The DASH Score, TotalActive Motion (TAM) of the digit, radiographic para-meters (shortening, angulations, time to healing)complication rates, time to return to previous workwere to measure the outcomes. The median DASHscore were in group A 7.9 and in B 7.4, the medianTAM 235� in A and 239� in group B. The median periodto radiographic healing was the same in both group,which was 4.6 (4�6.5) weeks. Among the complica-tions in group A were 1 case with malunion, 1 casewith hardware failure, 1 case with complex regionalpain syndrome, while in group B were 1 case with

hardware failure, 2 cases shortening and malunion,1 case with cellulites of the wound. The major differ-ent between the two implant was the cost: the bladeplate cost 150 euro and locking plate cost 550 euro.Conclusion: The fracture of the fifth neck metacarpalaccounts to 20% of all hand fractures. Unstable frac-tures have indication for surgical treatment. Openreduction and internal fixation is the treatment ofchoice. Both implants achieve stable fixation, lowpercentage of complications and good functionalresults. The final cost of implant is the main differ-ence between the two methods.

A-0943 Do patients with an inferior subjectiveresult 12 months after a distal radius fractureimprove over time? A long-term 2- to 12-yearregister follow-up

Marcus Landgren1, Vendela Teurneau1,Antonio Abramo2, Mats Geijer3,4 and Magnus Tagil1,2

1Department of Orthopedics, Clinical Sciences, LundUniversity and Skane University Hospital, Lund, Sweden2Department of Hand Surgery Malmo, Skane UniversityHospital, Malmo, Sweden3Department of Radiology, Faculty of Medicine and Health,Orebro University, Orebro, Sweden4Department of Clinical Sciences, Lund University, Lund,Sweden

Objective: Most patients recover well from a distalradius fracture (DRF). However, in our prospectiveregister, approximately one-fifth still had severe dis-ability at 12 months when evaluated using a patient-reported outcome score. In the present study, weevaluated the longer term subjective outcome inthe subgroup of patients with inferior outcome andhypothesized that the patient-reported outcomewould improve with time.Methods: Since 2001, all DRFs in patients 18 yearsand older at the Department of Orthopaedics, SkaneUniversity Hospital in Lund, are prospectively regis-tered in the Lund Wrist Fracture Register. TheDisability of the Arm, Shoulder and Hand (DASH)questionnaire was distributed to the patients after12 months. In the present study, we defined aDASH score above 35 as suboptimal at the 12-month follow-up. We identified 17% of the patients(445/2571) in the register between 2003 and 2012 toexceed the cut-off. In December 2014, 2�12 yearafter the fracture, a new DASH questionnaire wassent to the 346/445 patients still alive.Results: Of the 346 patients, 269 (78%) patientsreturned the DASH questionnaire at 2�12 years(mean 5.5) after the fracture. Seventy-three (27%)

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patients had been treated surgically and 196 (73%)conservatively. The overall median DASH scoreimproved from 50 (IQR 42�61) at 12 months to 36(IQR 20�55) at the 2�12-year follow-up, (p< 0.05).Forty-seven percent had improved over time toreturn to a DASH score below the cut-off 35. Fifty-three percent remained at a high suboptimal levelabove 35. Men improved more than women (median52 at 12 months to 25 at follow-up), compared towomen (median 50 to 39 (p< 0.05)).Conclusions: Subjective outcome after a DRFimproves over time for patients with an inferiorresult at 12 months, but more than half of thepatients continue to have major disability. Everyeffort should be made to improve the early outcome.

A-0947 Early mobilization after foveal reinsertionof TFCC: A prospective study of stability and func-tional outcome

Anders Wallmon and Karin LindHandCenter Goteborg, Sweden

Objective: Reinsertion of the dorsal and volar radio-ulnar ligament of the TFCC in the foveal region ofulna in patients with ulnar sided wrist pain, instabilityover the DRU joint and positive hook test on wristarthroscopy is nowadays a relatively widespreadtreatment. The postoperative regime is often immo-bilization of the wrist in all directions for a longperiod of time, compared to various ligament proce-dures in other joints.

The aim of this study is to evaluate the outcomes ina prospective study of early, controlled mobilizationafter TFCC reinsertion.

Our hypothesis is that early, controlled mobiliza-tion is safe in terms of stability and gives a goodfunctional outcome after foveal TFCC-reinsertion.Methods: Fifty patients with ulnar-sided wrist pain,DRU joint instability and positive hook test duringwrist arthroscopy were included.

Preoperative measurements included ROM, gripstrength (Jamar) in neutral position, pronation andsupination, Quick-DASH (The Disabilities of theArm, Shoulder and Hand Score) and PRWE (Patientrated wrist evaluation)

The foveal reinsertion was in all patients per-formed either via a mini-open technique orarthroscopically.

Patients were postoperatively immobilized in anabove elbow cast. One week postoperatively, anorthosis was applied that allows flexion/extensionof the elbow but prevents rotation of the forearm.At that point, active flexion/extension of the wrist

and controlled activation of the muscles in the fore-arm were started. After 3 weeks, the above-elbowpart of the orthosis was removed and free elbow-movement started with controlled pronation/supina-tion of the forearm. Gradually exercises for proprio-ception and strength were added. Six weekspostoperatively, a shorter splint was used during‘‘risk-activities’’ and night-time for another 6weeks. Free mobilization after 3 months.

A follow-up with a minimum of 1 year was per-formed with the same protocol as before surgeryincluding DRU joint stability tests. The patient satis-faction on a 4-graded Likert scale was assessed.Results: Forty-three patients met all the inclusioncriteria for 1-year follow-up. Seven patients wereexcluded due to concomitant repair of other ligamentstructures during surgery. Two patients were initiallystable but developed instability over time and werereoperated. One of them had a car accident with anew injury to the wrist. Forty-one patients werestable in all directions. One failure out of 43 equals2.3%.

The median value for Quick-DASH decreased from40.9 to 9.3 and for PRWE from 46.5 to 11.8. Patientsatisfaction was rated 4 (fully satisfied) in 26 patients,3 (partly satisfied) in 11 patients and 2 (partly dissa-tisfied) in 3 patients.

ROM in pronation were 96% of uninjured side andsupination 93%. Grip strength (% of uninjured side) inneutral position 91%, supination 88% and pronation89%.Conclusion: Early mobilization after foveal reinser-tion of the TFCC gives, in this study, an excellentfunctional outcome despite one failure out of 43patients. This study show that early mobilization issafe and encourage us to further develop and studyeven more faster rehabilitation protocols.

A-0950 Causative organisms and management inpaediatric paronychia: A 4-year retrospectivereview at a single centre in the United Kingdom anda national survey assessing variation in clinicalpractice

Andrew Roy McKean, Georgina Williams,Akinyemi Idowu and Catherine MilroySt George’s Hospital, London, UK

Objectives: Paediatric paronychia is the commonestinfection affecting the hand and frequently managedby plastic surgery departments. In the UnitedKingdom, the National Institute for Health and CareExcellence (NICE) guidance suggests the underlyingcausative organism is usually Staphylococcal and

SS174 Journal of Hand Surgery (Eur) 43(Supplement 2)

advises flucloxacillin as first line antibiotic therapy.We aimed to investigate the causative microorgan-isms in paediatric paronychia, its subsequent man-agement and complications observed within our unit.We surveyed all UK plastic surgery units to ascertainnational practices in this condition and adherence toNICE guidance.Methods: Consecutive patients with paronychia aged16 years were identified over 53 months (January2012 to June 2016) using clinical coding data. Patientand microbiological data were collated throughpaper/electronic case note review. A telephonesurvey of on-call Senior House Officers (SHOs) atall UK plastic surgery units was conducted.Descriptive analysis was performed.Results: Eighty-four children underwent incision anddrainage for paronychia over the study period. Themedian age was 5 years (range 5months to 16years). Commonest antibiotics prescribed (wheredata available) were co-amoxiclav in 62% (33/53)and flucloxacillin in 32% (17/53). Commonest micro-organisms isolated were Staphylococcus aureus in18% (35/66), Staphylococcus epidermis in 12% (8/66), Beta-haemolytic Streptococcus in 9% (6/66),and no growth in 8% (5/66). Our national survey high-lighted the variation in antimicrobial prescribingpractices across the United Kingdom.Conclusions: Antibiotic prescribing in our unit wasnot consistent with NICE guidance. Our nationalsurvey reiterated this and suggests lack of aware-ness of advised guidance. Although frequently man-aged, wide variation in clinical practice exists inantimicrobial management of paediatric paronychia.

A-0951 Magnetic resonance arthrographyclassification of the lesions of the dorsal capsulo-scapholunate septum of the wrist: Arthroscopiccorrelations

Luc Van Overstraeten1,2, Maryam Shahabpour3,Emmanuel J. Camus4 and Fabian Moungondo2

1Hand and Foot Surgery Unit, Tournai, Belgium2ULB Erasme University Hospital, Brussels, Belgium3Universitair Ziekenhuis Brussel (UZ Brussel), Brussels,Belgium4SEL Chirurgie de la Main et du pied, Lesquin, France

Purpose: The dorsal capsulo-scapholunate septum(DCSS) is an anatomical structure linking the scapho-lunate ligament (SL) and the dorsal capsule of thewrist. It should be a predynamic scapholunate stabi-lizer. The authors, using their experience for thearthroscopic lesional classification and for extrinsicligaments MRA evaluation, suggest a MRA

classification of lesions of the DCSS. As arthroscopicclassification, the status of DCSS could be graded infour stages according to the magnetic signal and tothe fiber attachment.Materials and Methods: High-resolution MRI, espe-cially using isotropic three dimensional sequenceswith orthogonal multiplanar reconstructions on 3TMR systems, allows detailed depiction of DCSS.Recognition of ligament abnormalities is improvedby intra-articular or intravenous injection of contrastbefore the examination.

They report a preliminary study on a series of 53arthroscopies made between January 2014 andDecember 2015 with evaluation of SL instability andDCSS laxity.Results: There is a significant correlation betweenthe lesional stage of the DCSS and the arthroscopicpre-dynamic scapholunate instability stage(p< 0.001).

- Stage S0: The DCSS presents an intact aspect.- Stage S1: The DCSS presents a hypersignal with

an aspect of microganglion cyst at dorsal side of sca-pholunate interosseous ligament (SLIOL).

- Stage S2: The DCSS present a large tear withpreservation of small connections between dorsalcapsule and scaphoid and lunate.

- Stage S3: The DCSS is completely disappeared.On this series, MRA imaging of the DCSS was ana-

lysed and correlated with the arthroscopicevaluation.Conclusion: A lesional classification of DCSS withMRA procedure is now available.

A-0952 Contribution of ultrasound in the preo-perative assessment of partial wrist denervation:A cadaveric and comparative study

Vanessa Costil and Thomas ApardUltrasound Surgery of the Hand, Private Hospital ofVersailles, France

Objective: Local anesthetic injections are advocatedas a key to the presurgical evaluation in patients withchronic wrist pain to determine which patients willbenefit from partial wrist denervation. The injection iscurrently performed using anatomic landmarks asproposed by Berger. The purpose of this cadavericstudy is to evaluate the contribution of an ultrasound(US)-guided injection of the posterior (PIN) and ante-rior (AIN) interosseous nerves.Methods: We performed US-guided injections ofmethylene blue on 10 wrists to simulate the localanesthetic injection of the PIN (with a dorsalapproach) and AIN (with an anterior approach).

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In 10 other wrists, we used the Berger procedureto inject the liquid by a single dorsal approach.

For each wrist, the dissection of the two branchesconfirmed if the methylene blue was around thenerves or not.Results: In the US group, the injection was effectivefor all the AIN (10/10) and for all but one for the PIN.In the Berger group, the injection was effective for 7/10 and 8/10, respectively, for the AIN and PIN. Thesize of the groups was too small to conclude to sig-nificant differences in both groups.Conclusion: This cadaveric study is the first one todescribe this ultrasound procedure. The US-guidedtechnique seemed to be more precise than a blindinjection for the AIN and PIN at the wrist. As it isobserved with the steroid injection, the ultrasonogra-phy should be used for the injection of local anes-thetic in denervation tests but we need clinicalcomparative studies to confirm it.

A-0958 Comparison of clinical and radiologicaloutcomes of AO 3.5 dynamic compression plate,3.5 limited contact-dynamic compression plate and2.7 ulnar osteotomy plate for ulnar shorteningosteotomy in patients with idiopathic ulnocarpalimpaction syndrome

Sung-Bae Park1, Joing-Pil Kim1,2 and Dong-Ho Lee1,2,3

Dankook University College of Medicine, Cheonan, SouthKorea

Background: The purpose of this study was to com-pare the clinical and radiological outcomes of AO 3.5dynamic compression plate, 3.5 limited contact-dynamic compression plate and 2.7 ulnar osteotomyplate for ulnar shortening osteotomy in patients withidiopathic ulnocarpal impaction syndrome. In addi-tion, the effect of interfragmentary screw fixationon radiologic outcomes of ulnar shortening osteot-omy was assessed.Materials and Methods: Seventy-eight patients whounderwent ulnar shortening osteotomy using platefixation and followed up at least 1 year were enrolled.Three types of plates were consecutively used: AO 3.5dynamic compression plate (group 1, n¼ 31), AO 3.5limited contact-dynamic compression plate (group 2,n¼ 19), AO 2.7 ulnar osteotomy plate (group 3,n¼ 28). The patients were also divided into twogroups based on performing interfragmentaryscrew fixation: interfragmentary screw fixationgroup (n¼ 27) and without interfragmentary screwfixation group (n¼ 51). The clinical outcomes wereevaluated by Disability of Arm, Shoulder and Hand,Patient-Related Wrist Evaluation. Radiological

outcomes including time to bone union, presence ofdelayed union which was defined when the union wasnot observed until 12 weeks, and re-fracture aftermetal removal were assessed. Other possible factorsthat might affect bone union such as smoking, under-lying disease were assessed.Results: All patients showed union at the finalfollow-up. There were no statistically significant dif-ferences in both clinical and radiological outcomesaccording to the types of plates. When comparingthe groups treated with and without interfragmentaryscrew fixation, time to bone union was shorter in theinterfragmentary screw fixation group (7.56� 2.56weeks vs 9.79� 6.59 weeks, p¼ 0.038). Delayedunions were only observed in 8 of 51 patients treatedwithout interfragmentary screw fixation (15.68% vs0%, p¼ 0.045). In without interfragmentary screwfixation group, 5 of 43 (11.62%) patients who removedthe plate had experienced refracture of the ulna bylow energy trauma after plate removal. However,there was no significant difference of clinical out-comes between the interfragmentary screw fixationgroup and without interfragmentary screw fixationgroup.Conclusion: Types of plate did not influence the clin-ical and radiological outcomes of ulnar shorteningosteotomy in the patients with idiopathic ulnocarpalimpaction syndrome. However, interfragmentaryscrew fixation with plating for ulna shorteningosteotomy has several advantages such as earlybony union and prevention of refracture after metalremoval.

A-0960 Dynamic radiostereometric analysis forevaluation of kinematics in the distal radioulnarjoint before and after TFCC lesions

Janni Kjærgaard Thillemann1,2, Sepp De Raedt3,Peter Bo Jørgensen2, Emil Toft Nielsen1,2,Lone Rømer4, Torben Bæk Hansen1,2 andMaiken Stilling1,2

1Department of Orthopaedics, University Clinic of Hand, Hipand Knee Surgery, Hospital Unit West, Denmark2Department of Clinical Medicine, Aarhus University,Denmark3Nordic Roentgen Technique, Aarhus, Denmark4Department of Radiology, Aarhus University Hospital,Denmark

Objective: Traumatic triangular fibrocartilage com-plex (TFCC) injuries can lead to dynamic distal radioulnar joint (DRUJ) instability, pain and restrictedhand function. Increased translation due to DRUJinstability is difficult to grade by clinical examination

SS176 Journal of Hand Surgery (Eur) 43(Supplement 2)

and since image diagnostic methods for evaluation ofTFCC lesions and DRUJ instability is currently insuf-ficient, wrist arthroscopy is the gold standard to diag-nose and differentiate between lesions of distalcomponent (dc-TFCC) and proximal component (pc-TFCC).

Dynamic radiostereometry (dRSA) can record func-tional joint kinematics precisely and can potentiallybe used to grade DRUJ instability.

We hypothesized increased DRUJ instability aftercutting the dc-TFCC and the pc-TFCC in comparisonwith the intact TFCC and aimed to evaluate the DRUJkinematics using dRSA.Methods: Ten human donor arms, mean age 78 years(63–90), were evaluated. A motorized fixture simulat-ing in vivo DRUJ movements was developed and fore-arm pronation to supination was performed in astandardized setting.

Specimens were recorded with 10 Hz dRSA beforeand after cutting the dc-TFCC at the ulnar styloid,and next the foveal pc-TFCC insertion. Ligamentlesion interventions were fluoroscopically visualizedand checked with wrist arthroscopy.

Subject-specific CT-based bone models were usedfor kinematic analysis with non-commercial soft-ware. Kinematics of the forearm was calculatedusing standardized anatomical axes and coordinatesystems.Results: Rotation in the DRUJ is a combined motion;the distal radius pivots around the ulnar head center,the ulnar head translates in anterior and posteriordirection in the sigmoid notch and the radius pistonsin respect to the ulna.

Kinematic analysis of the anterior and posteriortranslation in the native DRUJ show a sinusoidalsmooth movement of ulnar head in the radial sigmoidnotch during forearm rotation. The ulnar head trans-late in the sigmoid notch reaching the most volarposition in supination, and the most dorsal positionduring rotation of the forearm from pronation to neu-tral rotation.

In neutral forearm rotation, a combined lesion ofdc-TFCC/pc-TFCC results in ulnar head translationto a more dorsal position compared with the intactTFCC (p< 0.05).

Forearm rotation from neutral to pronation resultin a significant volar translation-shift of the ulnarhead in the sigmoid notch after combined dc-TFCC/pc-TFCC lesion (p< 0.05).

During forearm rotation, pistoning of the radiuschanges the ulnar variance, which increases in pro-nation compared to neutral or supinated forearmrotation (p< 0.05). Lesion to the dc-TFCC/pc-TFCCdoes not affect the ulnar variance during forearmrotation compared to the intact TFCC (p> 0.05).

Conclusion: Combined dc-TFCC/pc-TFCC lesionincreased translation in the DRUJ. During pronation,a volar translation shift was observed in cadaverarms. This finding may be equivalent to the clinicalpainful ‘‘giving way symptoms’’ often described bypatients during forceful forearm pronation.

This is the first study of DRUJ kinematics by use ofdRSA, a non-invasive, high-precision radiological ana-lysis method. dRSA can evaluate DRUJ kinematics andquantify DRUJ instability in patients during sympto-matic motions and may potentially become a diagnos-tic tool evaluating DRUJ instability in the future.

A-0961 Distal radioulnar joint instability and injury

Greg T. Pickering and Grey E. D. GiddinsRoyal United Hospital Bath NHS Foundation Trust, Bath,UK

Objective: Distal radioulnar joint (DRUJ) instability isincreasingly recognized as a clinical entity postinjury. Using a novel in vivo measurement device,we assessed instability post various types of forearmtrauma.Methods: A measurement rig was developed,improved upon and then validated both on cadavericspecimens and against current values from othermodalities of measurement in the literature. In vivoDRUJ translation, as a proxy for DRUJ instability, wasmeasured in 410 uninjured, non-symptomatic wriststo establish the ‘normal’ healthy range. Using thesame device and technique, DRUJ translation wasmeasured in four additional groups. Measurementswere recorded in 100 clinically lax and symptomaticpatients (irrespective of cause), 100 patients post uni-lateral distal radius fracture, 50 patients post unilat-eral radial head fracture and 50 patients postunilateral scaphoid fracture. The concept of DRUJtightening being dependent on hand and forearmpositioning was also tested in each of the injuredand uninjured groups. Measurements for each limbwere compared against the contralateral uninjuredlimb and an expanding database or ‘normal’ data.Results were assessed for significance with pairedt-test analysis at p< 0.005.Results: Average DRUJ translation in a healthy, unin-jured, mixed sex population is 6.5 mm (range 5–8 mm). Translation is not affected by gender, handdominance or forearm length. Radial and ulnardeviation of the hand, alongside prosupination ofthe forearm all reduced DRUJ translation. Clinicallylax individuals have increased DRUJ translation(mean 14.6 mm), with a range that does not overlapthat of the normal population. The tightening

FESSH Abstracts SS177

phenomenon of hand and forearm positioningremains in this group, but again never returns tonormal (p< 0.005).

Post-distal radius fracture, DRUJ translation isalso increased (mean 12.3 mm). The measuredrange for the group again does not overlap that ofthe normal population (p< 0.005). Patients who aresymptomatic post fracture have values within therange of the clinically lax population.

Individuals post-radial head fracture had a meanDRUJ translation of 8.7 mm. Those who underwentnon-operative or open reduction, internal fixation(i.e. Mason I or II) had an increased mean translationbut a range that overlapped the ‘normal’ range.Individuals treated with radial head replacement orexcision had significantly increased measurements,with the largest measurements recorded in anygroup to date seen in the excision population (mean18.1 mm). Again the three-dimensional tighteningtheory was demonstrated.

DRUJ translation was not altered from ‘normal’ inany of the post scaphoid fracture patients tested,irrespective of severity or treatment modality.Conclusions: DRUJ translation lies on spectrum andall individuals post distal radius or radial head(Mason II or worse) fractures have a degree ofincreased translation. DRUJ tightening throughhand and forearm positioning exists and persistspost injury. Clinically symptomatic DRUJ instabilitycorrelates with measured translation >12 mm andis never within the asymptomatic range. These newfindings contradict some of the established concepts.While changes post injury are common, they areminimally symptomatic, and treatments need notaim to restore pre-injury translation but purely adegree of tightness below the established clinicallysymptomatic threshold.

A-0962 Functional outcome comparing a dualmobility cup to a standard cup in total jointarthroplasty of the trapeziometacarpal joint

Lone Kirkeby1,2, Lene Dremstrup1, Maiken Stilling1,2,3

and Torben Bæk Hansen1,2

1Regional Hospital West Jutland, Holstebro, Denmark2Aarhus University, Aarhus, Denmark3Aarhus University Hospital, Aarhus, Denmark

Objective: Dual mobility cup design in total jointarthroplasty may result in increased mobility andfewer dislocations. In 2013, a dual mobility cupdesign was introduced to be used with the Elektrastem for total joint arthroplasty of the trapeziometa-carpal joint. The aim of the present study was to

determine the functional outcome after trapeziome-tacarpal total joint arthroplasty comparing a dualmobility cup to a standard (single mobility) cup.Methods: The patients were prospectively included.All patients had Eaton grade 2 or 3 osteoarthritis inthe trapeziometacarpal joint. Patients operated onfrom June 2010 to March 2015 using the Elektrabimetal cementless screw cup (standard cup,Elektra group) were compared to patients operatedon from June 2013 to March 2015 using the MoovisElektra dual mobility press-fit cementless cup(Moovis group). In bilateral cases, only the first oper-ated hand was included. The Disability of the Hand,Shoulder and Arm (DASH) score, pain using a contin-uous 100-mm visual analog scale (VAS), gripstrength, Karpandji score and extension of thumbwere registered preoperatively and at 3 and 12months after surgery.Results: Sixty-two patients (13 male/49 female), meanage 56.5 years (SD 7.0), in the Elektra group and 66patients (10 male/56 female), mean age 57.9 years (SD7.7), in the Moovis group completed the study. The twogroups were comparable apart from preoperativeDASH score, that was significantly higher in theMoovis group (p¼ 0.002). At 12 months, the patientsin both groups had significant improvement in allareas compared to the preoperative measurements.However, at 12 months, the Elektra group had signifi-cantly better grip strength (p¼ 0.036), extension of thethumb (mean 1 cm, p¼ 0.037), VAS at activity(p¼ 0.048) and DASH score (p¼ 0.015) compared topatients in the Moovis dual mobility group. We foundno significant difference in the rate of improvement inDASH score, grip strength, Karpandji score, extensionof thumb or VAS from preoperative to 12 months post-operative in the two groups. No dislocations wererecorded in the observation period.Conclusion: Dual mobility cup in total trapeziometa-carpal arthroplasty does not result in better mobilityor functional outcome than a standard cup. No dif-ference in dislocation rate was recorded.

A-0964 Twenty-five-year experience ofmicrosurgical thumb reconstruction in children

Sergei Goliana, Anton Govorov andTatyana TikhonenkoTurner Institute for Children’s Orthopedics, St. Petersburg,Russia

Function restoring of the thumb is one of the mostimportant conditions for the normal development ofthe child, because the thumb participates practicallyin all kinds of the pinch due to the opposition factor.

SS178 Journal of Hand Surgery (Eur) 43(Supplement 2)

Congenital defect of this segment leads to theimpairment of the workability of the hand on 40–50%. It also delays the process of the social andintellectual development of child.

One of the most effective methods of the thumbreconstruction is microsurgical toe-to-hand transfer.But, according to the literature, this surgical proce-dure is very rarely used in children with congenitalhand pathologies. To apply this operation, there mustbe strict indications. An effective alternative to thismethod is operation of pollicization and the transpo-sition of other fingers of the hand.

In the past 25 years, 128 toe-to-hand transfers, 355pollicizations, 28 finger transpositions for variouscongenital malformations and post-traumatic dis-eases of the hand and foot have been performed atthe Turner Institute for Children’s Orthopedics, St.Petersburg, Russia (Department of ReconstructiveMicrosurgery and Hand Surgery). As autografts forthe thumb reconstruction we used second toe ofthe foot – in 109 cases; the fifth finger (from conge-nital cleft foot) – 16 cases; the thumb (also from thecleft foot) – 2 cases; additional great toe with its con-genital duplication – 1 case. In 28 cases, the graft wastaken with a fragment of metatarsal bone.

We did not use great toe principally because of theprofound damage of the donor site in this case.

Six grafts (4.7%) did not survive because of thedisturbance of the blood supply. Among them, fivewere fifth toes and one was second toe. In cases ofunfree finger movements during pollicization andtransposition, the survival rate of grafts is 100%.

The analysis of the results showed good and excel-lent functional and cosmetic results in 76.5% ofcases. As for the child’s best age for such operations,it should be noted that an early reconstruction of thethumb will provide the fastest restoration of the handfunction. The formation of the thumb feeling is com-pleted before the 12-month age, so we consider thisage to be optimal for the reconstruction of thumb forchildren.

X-Ray studies showed the continued growth of thetoe, which was transferred to the hand, we observedboth acceleration of growth and its slowing down. Ithink that this effect should be investigated in thefuture.Conclusion: Microsurgical toe-to-hand transfer tothe thumb position is the most effective method oftreatment, because it provides a strong, moving, sen-sitive and stable thumb. The method of choice is thepollicization or transposition of other fingers of thehand.

A-0967 The use of RegJoint in first CMC jointarthrosis, Eaton 2�–3� stages: A review of 50 caseswith personal technique

Gaetano CarriereVilla Erbosa Hospital, Bologna, Italy

RegJoint is a biodegradable joint scaffold, in polylac-tic acid bioabsorbable in 20–24 months. It consists ofa porous biodegradable polylactide copolymerimplant (BPI) that is round and disc shaped, with adiameter that varies from 8.0 mm to 18 mm and athickness that ranges from 3.6 mm to 4.5 mm.

The function of scaffolds is to create and maintaina space between the bone ends. The surroundingtissue preferably invades the pores of the scaffoldsand fills in the empty space. The tissue will laterfunction as a neo-joint.

I reviewed the first 50 cases, 36 women (four bilat-eral case) and 10 men, aged 45–77 years, average 64years women and 68 years men.

They were affected by thumb carpo-metacarpalarthritis (Eaton-Littler stage 2�–3�), with a follow-upfrom 46 to 6 months (average 20 months)

The scaffold replace, the space created cutting thebase of 1� metacarpal and the saddle of trapezium,then I pass one third of FRC in the holes created inthe base of trapezium, in the RegJoint spacer andfrom the base to the diaphysis of 1� metacarpal.

Then, the split was used to restore the dorso-radial ligament, besides the abductor tendonattached on the base of 1� metacarpal, was fixeddorsally on the new joint.

So it lost the subluxated action on the 1� metacar-pal and transfers this action on the new joint.

This technique restores the high on the first ray,reduces and stabilizes the joint and decreases thesublussante action of the abductor pollicis longus.

I reviewed clinically at 15, 30, 60 and 120 days, 10patients with pain or casually, were submitted atRMN study, the first 20 cases did an rx after 2years minimum.

The results were Kapandy 8-10 (average 9).Pain: VAS 1.5 average (range 1–4), was 5.5 before

surgery.Pinch 4.6 (was 3.4 before surgery because of pain)

similar to the other hand.Grip: average 20 kg (was 16 before surgery), 22 kg

the value of the other hand.All patients compiled the quick-DASH (Short dis-

ability of Harm-Shoulder and Hand) questionnaire,the average value was 17.5 point (from 13 to 28).

All patients reached their best range of motion andwere able to restart the normal work-related activ-ities in 2 to 4 months (average 2.4 months).

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Only four patients have had pain insurgent at 4–8months from surgery, without outward signs clini-cally evident. Their RMN and rx showed intensiveinflammatory reaction in RegJoint place.

The pain disappeared slowly in 2 months, only withrest, thermal therapy and painkillers. The prelimin-ary results are highly encouraging despite the lownumber of patients treated. The better results with-out fail may be favorable from stability of the scaffoldand the stability of joint, which resist to the strengthdeveloped during thumb activity.

A-0972 One-to-thirteen-year follow-up of totalwrist arthroplasty

Allan Ibsen Sørensen1,2, Peter Axelsson1 andChrister Sollerman1

1University Hospital Sahlgrenska, Gothenburg, Sweden2University Hospital Gentofte/Rigshospitalet, Copenhagen,Denmark

Introduction: The aim of this study was to review ourshort-term results to long-term results of wrist-arthroplasty from two centers.Methods and Materials: Remotion implant is a mod-ular total wrist joint prosthesis. Un-cemented tech-nique used except for two cases.

Patients evaluated pre- and postoperatively withROM, grip strength, visual analogue scores of 0–100 mm (VAS) of pain and satisfaction. Functionaland general outcomes were evaluated using theQuick-DASH and PRWE questionnaires. Radiographswere obtained pre-operatively and at follow-up.

One hundred and sixty-two prostheses performedin 147 patients and 15 patients had a bilateral pros-thesis, 40 men and 110 women. Mean age was 59years (24–86). Diagnosis was rheumatoid arthritis(RA) in 101 cases, degenerative arthritis in 34 andposttraumatic arthritis in 25. Mean follow-up was 6years (range 1–13).Results: Wrist extension and flexion was preopera-tively 35/35� and at follow-up 35/30. Radial/ulnardeviation was 10/25� versus 10/30 postoperatively.Grip strength, in kgF, was preoperatively 13 (range0–64) and at follow-up 17 (0–50), p< 0.01. Key pinch,in kgF, was preoperatively 4.4 (range 0.8–10) and atfollow-up 5.2 (0.5–5.2), p< 0.05. VAS pain was preo-peratively at rest/activity; 41/68 and at follow-up; 14/28, (p< 0.01). Quick DASH and PRWE scores werepreoperatively: 58 respectively 67 and at follow-up:37 and 31 (p< 0.01). VAS satisfaction preoperativelywas 17 mm (0–100) at latest follow-up 73 mm (0–100),p< 0.01. Overall estimated survival 10–13 years is87%, in RA 88% and in OA 81%.

One superficial infection and one deep infectionencountered. Twelve prostheses were revised.Arthrodesis performed in five cases and in sevencases some or all of the components were revisedto new components.Conclusions: The short-term to long-term outcomeindicates that total wrist arthroplasty is a viableoption with unchanged ROM and improvement ofpain, grip strength, Quick DASH, PRWE and satisfac-tion. Complication rate is acceptably low.

A-0976 Effects of various selective nerve transferson the adult and neonatal motor unit

Matthias E. Sporer, Martin Aman, KonstantinD. Bergmeister, Dieter Depisch, Krisztina Manzano-Szalai, Bruno K. Podesser and Oskar C. AszmannCD-Laboratory for Restoration of Extremity Function,Department of Surgery, Medical University of Vienna,Austria

Objective: Selective nerve transfers (SNTs) havebeen used extensively for the past decade to treatslow nerve regeneration, neuroma pain and improveprosthetic control. SNTs change the motor unitextensively by connecting motor neurons to newfunctional targets. Good outcomes have beenreported. Even though frequently applied in clinicalroutine, little is known of the structural and func-tional effects following SNTs. Our laboratory hasconducted several experimental studies to investi-gate the effects on the different motor unit levels.Therefore, an overview of the latest results shall bepresented.Methods: In male Sprague-Dawley rats, the ulnarnerve (UN) was selectively transferred to the longhead of the biceps after neurotomy of the bicepsmotor branch. In another experimental group, aneven more selective fascicular group, the deepbranch of the ulnar nerve, was used to restoreelbow function. These transfers were not only per-formed in 20 adults but also in 20 neonatal ratswithin 24 h after birth applying different anaesthesiamethods. Additionally, the equivalent nerve transferswere conducted in 15 Thy1-GFP (neonates: n¼ 5,adult: n¼ 10) rats to analyze formation of neuromus-cular junctions. After 12 weeks of nerve regenera-tion, neurophysiological effects were explicitlyassessed on each level of the motor unit by tetanicmuscle force, MUNE (Motor Unit NumberEstimation), retrograde labelling, muscle fibretyping and neuromuscular junction staining.Furthermore, sensory and motory axon quantificationwas performed by immunhistochemical staining.

SS180 Journal of Hand Surgery (Eur) 43(Supplement 2)

Results: The various nerve transfers successfullyreinnervated the biceps muscle in all animals, asindicated by muscle force and neurotomy reaction.Dropouts only occurred in the neonatal group dueto dam cannibalization. Compared against the ulnarnerve transfer in the fascicular nerve transfer group(deep branch), equivalent regeneration was found.Retrograde labeling, muscle fibre typing and neuro-muscular junction staining revealed impressivechanges on all levels of the motor unit. Most inter-estingly, functional and structural hyperinnervationof the muscle was thereby evaluated. Sensory andmotory axon quantification of the ulnar nerve andits deep branch covered valuable clues on howmuch donor nerve is needed to restore elbowfunction.Conclusion: Transferring not only a high capacitydonor nerve but also an even more selective fascicu-lar group and exploring the effects on the motor unitprovides us with a deeper understanding of the neu-ronal plasticity of the peripheral nervous system.Especially when comparing the neonatal to theadult rat model, a glimpse of the enormous plasticitycan be catched. As selective nerve transfers play amajor role in extremity reconstruction, findings ofthese studies might further help to improve clinicalapproaches.

A-0978 Arthroscopic management of painful dorsalwrist ganglion

Mathilde Gras1,2 and Christophe Mathoulin1

1Institut de la Main – Clinique Bizet, Paris, France2Institut Nollet, Paris, France

Objective: The dorsal ganglion of the wrist is acommon pathology that has long been neglected. Arecent study has proven the value of arthroscopicmanagement. In the light of anatomical work, thedorsal capsulo-ligamentous complex septum(DCSS) has been demonstrated as an anatomicalstructure. Painful ganglia appear to be related to alesion of this DCSS, after trauma or not. It thereforeseemed legitimate to repair this lesion by arthro-scopic dorsal capsuloplasty. This study presents theresults of this technique.Methods: This retrospective study reported thepatients operated for painful dorsal wrist ganglion.The ganglion was resected and capsulo-ligamentoussuture was performed under arthroscopy. Range ofmotion, pain, strength and DASH score were reportedbefore and at the last follow-up between February2011 and April 2017.

Results: Thirty four patients (10 men and 24 women)had the surgery, one patient on both side, mean age24.9 years old (15-41). Only three were manualworker but most of them had contributing factors,especially sports. All but five had RMI before thesurgery. A splint was worn on average 6.2 weeks(5.5 to 8) after surgery. The average follow-up was8.4 months (2.5 to 48.5). Range of motion andstrength improved. Pain decreased from 1.4 at rest(0 to 6) and 6.3 on stress (3 to 9) before surgery, to 0.1at rest (0 to 2) and 0.8 on stress (0 to 6). The averageDASH went from 27.3 (6.81 to 68.18) to 6.7 (0 to29.54). There was only one recurrence.Conclusions: The dorsal capsule-ligamentous repairassociated with resection of dorsal wrist ganglion is asimple technique reliable. It allows repairing a lesionof the DCSS causing the pain, associated with theganglion. Arthroscopic technique avoids stiffness.Our promising results still require a larger seriesand longer follow-up to ensure that the results aresustainable.

A-0992 Use of second dorsal metacarpal artery skinflaps for treating retractions in the first handcommissure

Samuel Ribak, Helton Hirata, Sergio Gama,Alexandre Tietzmann and Frederico ZinkPontifical Catholic University of Campinas, Campinas,Brazil

Purpose: To describe and present the results of asurgical technique that uses the second backflowdorsal metacarpal artery skin flap to treat retractionsin the first hand commissure and, when necessary,apply longer flaps to cover the palm of the hand.Methods: The surgery was performed on 16 patientswith retraction of the first commissure. Six of thesepatients also had scar retraction of the palm in addi-tion to the commissure. Preoperatively, the openingangle of the first commissure was measured, and thedegree of retraction was divided into three cate-gories: mild, moderate and severe. Eleven caseswere considered severe and five moderate. The sur-gical technique used is described in detail.Results: All 16 flaps (100%) survived. Three casesexperienced transient ischemia with partial sufferingof 10% of the distal flap area, and two cases experi-enced epidermolysis, but these issues were all satis-factorily resolved. On average, the dimensions of theflaps varied by 10 cm in length and 2.2 cm in width.There was complete closure of the donor area in 14cases (87.5%). The opening of the first commissureranged from 51� to 83� (mean, 73.5�).

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Conclusion: The skin flap from the second dorsalmetacarpal artery can be reliably and successfullyused to treat retractions of the first commissure. Itcan be considered a good option for cases that pre-sent with palm retraction in addition to commissureretraction.

A-0993 Polydactyly: Putting together development,evolution and pathologies

Brıd Crowley1, Rui Diogo2, Victoria Lockwood3,Lucie Wright1, Lisa Ng1 and Susan Stevenson1

1Department of Plastic and Reconstructive Surgery, TheNewcastle upon Tyne Hospitals NHS Foundation Trust,Newcastle upon Tyne, UK2Department of Anatomy, Howard University MedicalSchool, Washington, DC, USA3Center for the Advanced Study of Human Paleobiology,Department of Anthropology, The George WashingtonUniversity, Washington, DC, USA

Objective: Evolutionary Developmental Pathology, orMacroevolutionary Medicine, a new biological field,aims to connect study of evolution, development, andhuman pathologies. An original component of thissubfield is the focus on both the study of model organ-isms to illuminate human pathologies and study ofhumans themselves to test current developmentaland evolutionary theories. Access to human anatomi-cal data is crucial. Information about soft tissue anat-omy of polydactyly in humans is scarce. We present acollaborative study of preaxial radial polydactylyexamining clinical anatomical findings from the per-spective of Evolutionary Developmental Pathology.Methods: A detailed study of 68 anatomical operativerecords of pre-axial polydactyly of hands and feet isdiscussed in the context of current models of limbdevelopment based on theoretical studies and stu-dies of model organisms, including ideas on predict-able topological muscle attachment and derivedsimilarity versus serial homology of upper andlower limbs. Findings are tabulated and also pre-sented as schematic models.Results: We identified a decoupling between the ske-letal level of duplication and muscle/tendon anatomy,as predicted by current Evo-Devo models. Contrary tothese models, the topology of muscle attachment ishighly variable even within the same polydactylygroups.

In hands, abductor pollicis brevis insertionfavoured the radial duplicate but also inserted onboth duplicates/ulnar only. While extensor pollicisbrevis (EPB) inserted more frequently on the radialduplicate, insertion on both duplicates/ulnar only

was also observed. EPB insertion on the ulnar dupli-cate only was observed in 3/14 triphalangeal radialpolydactyly and 1/40 non-triphalangeal radial poly-dactyly. Greater overall complexity of anatomy wasrecorded in the triphalangeal cohort vs non-tripha-langeal cohort.

In feet, abductor hallucis insertion favored themedial duplicate, and insertion on the lateral dupli-cate was observed in 1 of 14 feet.

In bilateral cases of pre-axial polydactyly, lowerlimbs displayed more symmetric patterns thanupper.Conclusions: Application of clinical anatomicalknowledge to test current models/theories of limbdevelopment lends support to some models, chal-lenges/contradicts others. This collaborative workreinforces the need to include detailed clinical ana-tomical data to address implications for medicine butalso for development and biological evolution in gen-eral. These data provide a unique opportunity tofurther our understanding of complex subjects.

A-0998 Dynamic MRI at 3T can determine the via-bility of the lunate bone in patients with Kienbock’sdisease

Anders Bjorkman1, Sven Mansson2, Markus F. Muller3,Martin Johansson4 and Gunilla Muller3

1Department of Hand Surgery, Lund University, SkaneUniversity Hospital, Malmo, Sweden2Department of Medical Radiation Physics, Lund University,Skane University Hospital, Malmo, Sweden3Department of Radiology, Lund University, SkaneUniversity Hospital, Malmo, Sweden4Pathology Department of Translational Medicine (1-4),Lund University, Skane University Hospital, Malmo, Sweden

Background and Objectives: The basic abnormalityof Kienbock’s disease is thought to be an impairedvascular supply to the lunate. Thus, a diagnosticmodality capable of assessing vascularity in thelunate would probably improve both the diagnosticcapability and the possibility of monitoring the effectsof different treatment regimes. Radiographic exami-nations are unreliable in assessing vascularity. MRwith contrast has identified three different patternsof contrast enhancement of the lunate in patientswith Kienbock’s disease. These were areas withnecrotic bone without enhancement, a hypervascu-larized repair zone, and areas of normal bone. Thehyper-enhancement, seen in the repair zone, hasbeen suggested to indicate areas with a good healingprognosis, whereas areas with hypo-enhancementare thought to indicate non-viable bone with a poor

SS182 Journal of Hand Surgery (Eur) 43(Supplement 2)

prognosis. Dynamic contrast-enhanced (DCE) MRimaging at 3T has been successfully used for assess-ment of perfusion in normal carpal bones. However,DCE MR imaging has not been used to assess perfu-sion in patients with Kienbock’s disease.

The aim was to investigate perfusion in the lunatebone in patients with Kienbock’s disease, usingdynamic contrast-enhanced (DCE) MRI, and to com-pare the perfusion pattern with histopathology inpatients operated with lunate excision in order todetermine whether increased perfusion indicatesviability.Methods: DCE MR examinations at 3T and radiogra-phy were performed in 14 patients (8 men and 6women, mean age 45 years; range 21–66) withKienbock’s disease. One patient had Lichtman stageI, two had stage II, and 11 had stage III (4 stage IIIaand 7 stage IIIb). Six patients all with stage IIIb wereoperated with lunate excision, allowing histologicalexamination of the entire lunate bone. Features ofthe enhancement curves, time to peak (TTP), maxi-mal slope (MS), and maximal intensity (MI) wereassessed and compared with those in 19 healthyvolunteers in a control group.Results: Our results indicate that patients withKienbock’s disease have a higher degree of perfusionin the lunate bone than healthy controls. Significantdifferences in the perfusion parameters of the lunatebone were seen in patients with Kienbock’s diseasecompared to the control group regarding TTP(p¼ 0.024), MI (p¼ 0.0001) and MS (p¼ 0.0001).Histopathological examination showed a diverse pic-ture; in the border of the fragmentation, new boneformation and resorption, central fatty bone marrowwith necrotic areas, and peripheral, more normalbone trabeculae were seen. The perfusion wasincreased both in the area of bone repair and in theareas of necrosis.Conclusions: DCE MRI at 3T can diagnose pathologi-cal perfusion in patients with Kienbock’s disease. Theperfusion was increased in areas of bone repair andbone necrosis, whereas normal bone structureshowed sparse perfusion. Using DME, it was possibleto demonstrate that the increased perfusion com-pared to the normal carpal bones corresponds histo-logically not only to areas of bone remodeling butalso to areas of fibrous osteoid and necrosis.Increased perfusion is therefore not a marker ofviability.

A-0999 Poor surgical outcomes in camptodactylycorrection using total anterior teno-arthrolysis orosteotomies

Michelle C. L. Baker, Roisin T. Dolan and Henk P. GieleDepartment of Plastic and Reconstructive Surgery, OxfordUniversity Hospitals NHS Trusts, Oxford, UK

Objectives: The surgical management of camptodac-tyly is poorly described with little data to support avariety of surgical techniques. The aim of this study isto correlate functional results of total anterior teno-arthrolysis (TATA) or osteotomies for camptodactylycorrection.Methods: We performed a retrospective review of aprospectively maintained database comprising of allpatients presenting consecutively to a tertiary centrefor paediatric hand surgery for the surgical manage-ment of camptodactyly. All patients were clinicallyassessed by the senior author at the John RadcliffeHospital, Oxford University Hospitals Trust between1997 and 2012. Each patient fulfilled indications forsurgery including contracture greater than 50�, func-tional loss, symptomatic, progression, and failure ofconservative therapy. Duration and severity of symp-toms, previous failed treatment including splintingand surgery, X-ray changes were considered whendeciding the optimal procedure for each patient.Starting mean contracture, improvement of contrac-ture (extension angle), loss of flexion and complica-tions were assessed.Results: Twenty-eight patients (n¼ 28) underwentTATA or osteotomies for camptodatyly correction. Inthis cohort, there was an equal number of male andfemale patients; 16 had an isolated little finger camp-todactyly. The mean starting contracture was 81�

(60–100�). N¼ 24(86%) had an improvement in exten-sion angle but n¼ 22 (79%) had a loss of flexion.N¼ 4 (14%) were lost to follow-up. N¼ 8 (29%)patients (or parents of patients) found there was noimprovement in camptodactyly. Complications werecommon including n¼ 6 with pinsite infection, n¼ 2wound infection, n¼ 4 wire loosening, n¼ 2 boneloss, n¼ 8 bone stiffness.Conclusions: Camptodactyly is a complex multifac-torial problem with a range of affected biology.Outcomes in this series are worse than in reportedliterature, but mean starting contracture was alsolarger. There is an observed change in functionfrom a predominately flexor grip to greater extensorstrength in the operated finger. Outcomes are worsein the older patient, fixed PIPJs, X-ray changes, thosewith multiple digit involvement, finger involvementother than the little finger or syndrome-related

FESSH Abstracts SS183

syndactyly. A single surgical solution is not suitable,and an individualized approach must be considered.

A-1000 Pirodisk in first CMC joint arthrosis: 120cases, follow-up from 1 to 9 years

Gaetano CarriereVilla Erbosa Hospital, Bologna, Italy

I used Pirodisk scaffold in 102 patients, (18 bilateralcases) with thumb carpometacarpal arthrosis (stage2�–3� Eaton-Littler classification), 86 women (4 bilat-eral), 16 men (4 bilateral), aged 36 to 74, average age61 years.

Pirodisk is a round pirocarbonic disc, with a dia-meter that varies from 14 mm to 18 mm and a thick-ness that ranges from 5.5 mm to 8 mm.

Pirodisk surgery technique, a Pellegrini–Eatonmodified technique, entails the reconstruction ofpalmar oblique and dorsoradial CMC ligaments, sowe can obtain joint alignment and first ray highrestoring and maintenance.

After surgery, I used splint with thumb in, for 15days, than they started therapy.

I reviewed clinically at 15, 30, 60 and 120 days andsome at 180 days, all patients reached their bestrange of motion and were able to restart thenormal work-related activities in 2.5 to 4 months(average 3 months).Results: Of the 95 hands, 85 reached a full range ofmotion (Kapandji 9–10) and 25 only 7–8 Kapandji.

Pain: average VAS 2.5 (range 1–6), VAS was sixbefore surgery, 3 patients reporting pain duringwork-related activities (1 cook and 2 waiters).

Pinch average 4.8 kg (3.5 kg before surgery), simi-lar to other hand.

Grip average 20 kg (16 kg. before surgery), 4 kgmore than the other affected hand and 1 kg less thenon-affected one.

Eighty patients compiled the quick DASH (Disabilityof Harm-Shoulder and Hand) questionnaire, the valuewas 22 points (from 14 to 51)

All patients reported mild pain for 1 to 6 months(average 2.5 months).

Only 12 cases had joint low-middle-pain during themovement at all.

All patients reached their best range of motion andwere able to restart the normal work-related activ-ities in 2 to 4 months (average 3 months).

Eight patients had sensitive problems on dorsalskin for 6 months caused by sensitive radial collat-eral nerve compression.

Eight patients had one more surgery for clickthumb after a period of 3 to 8 months from first,

and three other patients had surgery for deQuervain tendinitis in the same wrist.

I had 10 cases of moderate instability and one caseof mobilization with painful sub-luxation, 44 yearsold.

Reoperated with RegJoint scaffold interposition.I think that Pirodisk used, in middle-old age

patients, with carpometacarpal arthrosis stage 2�-3� Eaton-Littler, with an active work, is to be pre-ferred to trapezium excision arthroplasty, becauseof it preserve the trapezium and maintain first rayhigh. Besides the use of Pirodisk leave the arthro-plasty salvage treatment open in case of failure.

The limit is represented by its cost.

A-1003 Can subjective patient-reported outcomepredict objective timed Sollerman Hand FunctionTest?

Amin Kheiran, Harvinder P. Singh, Joseph J. Dias andGrey GiddinsUniversity Hospitals of Leicester, Leicester, UK

Background/aim: Patient-reported outcome mea-sures (PROMs) and objective functional tests inhand surgery are central to assess health-relatedquality of life along with patient’s estimation of dis-ability, pain, overall satisfaction, the natural historyof disorders and monitor improvement after treat-ment, especially surgery. Currently, data are limitedto support how these assessment scores correlatewith each other. The main aim of this study was toquantify whether subjective Michigan HandQuestionnaire (MHQ) can predict objectiveSollerman hand function test (SHFT).Methodology: We conducted a retrospective reviewof completed MHQ and SHFT for 34 adults aged 18and older, right hand dominant with post traumaticwrist arthritis underwent four-corner arthrodesis.Rheumatoid hands, neuropathic disease and acutetrauma were excluded. Pearson coefficient wasused to test strength of correlation between thesetwo hand tests.Results: Mean time to complete 20 tasks in SHFTwas 3.76 (SD, 0.8) and 3.79 (SD, 0.6) min for theright and left hands, respectively. Average MHQ was85.02 (SD, 12.2; range 49.1–100) for the right handand 82.9 (SD, 14.7; range 53.4–100) for the lefthand. Average of MHQ raw hand function test (asses-sing volar, diagonal and transverse grip along withpulp and lateral pinch) was 76.03 for the right hand(SD, 15.9; range 50–100) and 73.8 (SD, 16.7; range 30–100) for the left hand. These tasks in MHQ were com-pared to similar tasks in SHFT. The correlation

SS184 Journal of Hand Surgery (Eur) 43(Supplement 2)

between SHFT and MHQ for right (R: �0.1986) andleft (R: �0.2051) hand was weak (Pearsoncoefficient).Conclusion: Our study shows that Michigan HandQuestionnaire could not predict SHFT. Patient-reported outcome measures could introduce bias interms of patient perception and inaccurately esti-mate function despite the convenience of its use.

A-1015 Do two venous anastomosis decrease freeflaps complications in anterolateral thigh flap forlimb reconstruction?

Raquel Bernardelli Iamaguchi, Renan Lyuji Takemura,Gustavo Bersani Silva, Jairo Andre de Oliveira Alves,Alvaro Baik Cho, Teng Hsiang Wei, Marcelo Rosa deRezende and Rames Mattar JrUniversity of Sao Paulo, Sao Paulo, Brazil

Objective: The question of how many veins in freeflaps surgeries for limb reconstruction and howdoes it influence the results is still unanswered. Inthis report, we evaluate the results of one versus twovenous anastomoses in anterolateral thigh flaps forlimb reconstruction.Methods: A cross-sectional study was conductedwith consecutive inclusion of all patients undergoinganterolateral thigh (ALT) flap for upper and lowerlimb reconstruction at our institution, between July2014 and July 2017. Patient demographics (age,gender and comorbidities), location and indicationsof wounds were studied. Perioperative informationwas recorded and groups were divided in twogroups according to number of venous anastomosis:group 1 (one venous anastomosis) and group 2 (twovenous anastomoses). Intraoperative and postopera-tive complications were studied. Statistical analysiswas performed with SPSS 20.0 (SPSS Inc�, Chicago,IL, USA). All tests were two-tailed, and statisticalsignificance was defined as p< 0.05. Qualitativedata were analyzed by Pearson �2 test or Fisherexact test. Mann–Whitney U test was used for quan-titative nonparametric data.Results: Thirty-eight patients were included in thisstudy. Thirty-two patients were males. The meanage was 33 years (15–69 years). The indication wastrauma in 35 patients and tumor in three patients.The most common accident was motorcycle accident(25 free flaps), followed by three patients run over bya car, three patients had work-related accident, andtwo patients had a car accident and others. Accordingto mean hemoglobin levels in immediate preopera-tive was 10.88 g/dl (SD 1.88 g/dl) and postoperativewas 9.85 g/gl (SD 1.46 g/dl). The mean platelet

count levels in preoperative was 372.34� 103/mm3

(SD 166.7� 103/mm3). The mean intraoperativeischemia time of microsurgical flap was 113.7 min(SD 44.5). Group 1 included 17 patients and group 2included 21 patients. The mean ischemia time (whichwas defined as the time between the section of thepedicle in the donor area and the release of clampsof the artery and at least one vein) was similar in bothgroups (p¼ 0.245) and complications were morecommon in one venous anastomosis with 47% ofcomplications versus 24% in group 2, but not statis-tically significant (p¼ 0.065). No risk factor for com-plications or total flap loss was identified. Revision ofthe anastomosis was performed in five patients (fivecases of group 1) and three were successfullyrevised. The overall success rate was 92% with ALTflaps for limb coverage for extensive wounds thatcould not be covered with local flaps.Conclusion: We concluded that two venous anasto-mosis in ALT free flaps for limb reconstruction hadlower rates of complications but not statisticallysignificant.

A-1017 A cadaveric study on the accuracy of anindividualized guiding template to assist placementof scaphoid screws using computed-assisted designand three-dimensional printing technique

Yang Guo, Guanglei Tian and Liying SunBeijing Jishuitan Hospital, Beijing, China

Purpose: The aim of this study was to evaluate fea-sibility and accuracy of scaphoid screw placementusing computer-assisted design and three-dimen-sional (3D) printing surgical guiding template. Wedescribed a procedure by using virtual planningsystem to select an appropriate position for thescrew guide wire in the scaphoid surface model.Based on further calculations, a surgical templatewith guiding holes was generated in the system andthis simulation was transferred to the patient byusing 3D printing technique.Methods: Eight fresh-frozen cadaveric upper extre-mity specimens were utilized. The DICOM data of thepreoperative CT scans of the wrist were importedinto surgical planning system. A 3D surface modelof guiding template with holes was generated byBoolean calculations in this system. A screw guidewire may be placed in the central area in the sca-phoid through these holes. This 3D model wasprinted and then put back to the wrist cadaver. Ascrew guide wire was inserted through the palmarguide hole and then the wrist received post-operativeCT scan. These postoperative data were introduced

FESSH Abstracts SS185

into the surgical planning system. Angular and lineardeviations between the preoperative guide wiresimulation and postoperative guide wire were mea-sured in the system to assess the drilling accuracy.Results: Mean angular deviation was3.58� 1.52(1.56�5.18), and linear deviations of eightspecimens were less than 1.1 mm. No specimenrequired a repeat drilling of the scaphoid. All thescrew guide wires considered to be centrally placedin the scaphoid.Conclusions: The use of computer-assisted 3D print-ing surgical guide template to assist screw place-ment for scaphoid fracture showed acceptableaccuracy in cadaver wrists.Clinical relevance: Our technique may provide asimple and effective method for the guidance ofscrew insertion in scaphoid fracture surgery.

A-1021 Outcomes of distal radius fractures asso-ciated with triangular fibrocartilage complex injury

Katerina Kasapinova and Viktor KamiloskiUniversity Surgery Clinic ‘‘St. Naum Ohridski,’’ Departmentof Traumatology, Skopje, Republic of Macedonia

Objective: Clinical studies that evaluate the correla-tion between associated lesions of triangular fibro-cartilage complex (TFCC) and outcome of distalradius fractures expressed with the patient-rateddisability are missing.

The aim of this study was to evaluate the outcomesof distal radius fractures associated with or withoutan injury of the triangular fibrocartilage complex.Methods: Patients undergoing operative treatmentfor distal radius fracture were prospectively enrolled(n¼ 70). TFCC was examined by wrist arthroscopyand injuries classified according to Palmer.Comparative analyses were performed on 45 patientswith TFCC injury (injured group) and 25 patients withintact TFCC (intact group). The outcome measuresincluded the Patient-Rated Wrist Evaluation (PRWE)and the Disabilities of the Arm, Shoulder and Hand(DASH) questionnaires, 3 and 12 months after injury.Results: TFCC was injured in 45 (64%) patients. Inpatients with intact TFCC mean total PRWE scorewas 27 (3 months) and 16 (12 months), compared topatients with TFCC injury with 40 (at 3 months) and 24(at 12 months). Mean DASH scores were 26 and 13 at3 and 12 months for the intact group and 39 and 27for the injured group. PRWE and DASH resultsshowed significant difference at 3 and 12 monthswhen compared with the Mann–Whitney test.Conclusions: Disability outcomes were worse indistal radius fracture patients where TFCC was

injured. TFCC injuries are important co-factor affect-ing the outcome of distal radius fractures.

A-1022 Lumbrical plus or paradox finger extensionsyndrome: Case report and review of the literature

Andreas Gohritz and Dirk J. SchaeferPlastic, Reconstructive and Aesthetic Surgery, HandSurgery, University Hospital, Basel, Switzerland

The lumbrical plus phenomenon produces a paradoxextension of the interphalangeal joints duringattempted finger flexion. The underlying mechanismis thought to be a contraction of the injured orscarred deep flexor tendon transmitted via the lumb-rical muscles towards the extensor system.

We present an impressive case of this rare syn-drome with a review of the only 30 cases to befound in the literature to date.

A 26-year-old plumber suffered a severe contusionof his left hand causing a fourth metacarpal fracture.He developed a functionally disturbing extensionphenomenon of the adjacent little finger wheneverflexion was attempted. This phenomenon persisteddespite three surgical procedures (neurolysis andtransposition of the ulnar nerve, flexor tendon teno-lysis) and repeated occupational therapy. The patienthad been off work for almost 4 years.

To exclude voluntary extension of the finger, weused a proximal radial nerve block. Then we per-formed resection of the fourth lumbrical muscleand additional tenolysis of the fifth superficial anddeep flexor tendon under local anesthesia with epi-nephrine (wide awake). Already intraoperatively, thepatient was able to fully close his finger again. Rapidwork place reintegration followed.

A review of the literature revealed that the lumb-rical plus syndrome mostly occurs after rathersimple hand injuries, such as contusions or repetitivemild trauma. Notably, in our case, the diagnosis wassignificantly delayed by various clinicians, leading tomultiple unsuccessful surgeries and several years ofunemployment until simple resection of the lumbri-cal muscle solved the problem.

In conclusion, although the lumbrical plus syn-drome is rare, every hand surgeon should be awareof this posttraumatic disorder in order to avoid treat-ment delay and unnecessary surgeries.

A-1025 Saddle deformity: A case report

David Jann, Maurizio Calcagni and Thomas GiesenUniversity Hospital Zurich, Zurich, Switzerland

SS186 Journal of Hand Surgery (Eur) 43(Supplement 2)

Adhesions between the interosseous and lumbricalmuscles involving the deep transverse metacarpalligament (dTML) can be a cause of chronic pain andreduced range of motion. New reports on this condi-tion are rare, even though two large studies wereperformed in the 1970s and 1980s, first describingthis condition as ‘‘saddle deformity.’’ Adhesionsmostly occur after direct trauma to the hand, butthere are also post-infectious or inflammatorycases. The lack of objective findings may prolongmaking the diagnosis. Average time betweentrauma and surgery is often long. The Chicarillireport shows an average of 19 months. MRI mightin some cases be helpful. We present a case ofsaddle deformity that was recognized and operated6 months after the first presentation in our clinic withan optimal final outcome.

We present a 50-year-old woman with chronic painon the dorso-ulnar aspect of the third metacarpalhead and a concomitant flexion deficit. Symptomsoccurred 1 year after suffering from a closed malletinjury on the DIP joint of this finger, which was trea-ted conservatively. Eleven years earlier, she was alsotreated conservatively for a closed rupture of theradial extensor hood of the MCP joint on this finger.Ultrasound and MRI only showed a slight synovitis ofthe flexor tendons. Physiotherapy and local cortisoneinfiltrations did not show major improvement. Weeventually performed a surgical exploration andfound interosseous–lumbrical adhesions involvingthe dTML. The dTML was resected, the adhesionswere released and hand therapy was started imme-diately after surgery. The patient gained full activerange of motion 3 months postoperatively and waspain-free.

Adhesions of the interosseus and lumbrical mus-cles are probably more common then thought, butoften not recognized. It is important for physiciansto keep it in mind and look for it in cases with chronicintermetacarpal pain. MRI might help to exclude dif-ferential diagnosis, but it is mostly diagnosed by clin-ical examination. Major causes are posttraumatic(contusion or crush injuries), inflammatory and alsoinfectious conditions. The surgical procedure issimple and seems to lead to good results.

A-1026 Culture and transplant of human fibroblastcells (allograft) on amniotic membrane for treat-ment of epidermolysis bullosa

Mohammad Javad Fatemi1, Siamak Farokh Forghani1,Zahra Orouji1, Saeid Shafieyan2, Ehsan Taghi Abadi2

and Mitra Niazi11Burn Research Center, Iran University of MedicalSciences, Tehran, Iran2Royan Institute for Stem Cell Biology and Technology,ACECR, Tehran, Iran

Background: Epidermolysis bullosa (EB) is a geneticdisease with skin fragility and instability at the junc-tion of dermis to epidermis. Severe deformity ofhands because of scars and adhesions leads to losethe proper function of hand which affects the qualityof patients’ life. Covering the wound after openingadhesion is the major problem in the way of recon-structive surgeons. Our purpose in this study is touse allogeneic fibroblasts amnion after surgery as acover in patients to prevent further adhesion.Materials and Methods: This is an interventionalstudy on six patients who suffer from epidermolysisbullosa with deformity and adhesion. We took a skinsample from back of one of parents’ ear. Then fibro-blast was separated, cultured and transferred to theamniotic membrane. After separating the full adhe-sion, all parts without skin were covered with theallogeneic fibroblast amnion. Furthermore, speed,quality, recovery time of wound were examined aswell as range of motion in finger joints and the pres-sure on the skin.Results: The results showed us wound healingimproved and time of healing varied between 15and 29 days. The average time of treatment was23.1 days with the standard deviation of 77.3.Restored skin could perfectly tolerate the pressureof rehabilitation activities and splint.Conclusion: Allogeneic fibroblast with a scaffold likeamnion can reduce the need for skin graft in patientswith epidermolysis bullosa. Normal allogeneic fibro-blast and disability of releasing collagen seven inthese patients can be considered as an effective fac-tors in wound healing and show better results thanautogenic fibroblasts.

A-1030 Non-operative management of fingertipinjuries with the IV3000 dressing

Adil Khan, Kaz Nassar, Daniel Jordan, Fiona Hogg andStuart WaterstonNinewells Hospital (NHS Tayside), Dundee, UK

FESSH Abstracts SS187

Objective: The optimal management of fingertip inju-ries is controversial with multiple surgical andnon-surgical options. Conservative treatment withdressings is one such management option and theIV3000 dressing, being semi-occlusive with a highreactive moisture vapour transmission rate (MVTR),has been found to be comparable to other alterna-tives. We present our findings with the use of theIV3000 dressing to treat adult and paediatric fingertip injuries with good outcomes.Method: Patients were recruited from the traumapatients presenting to the Department of PlasticSurgery at NHS Tayside in the 2-year period betweenJuly 2015 and July 2017. The study was prospectivebut not randomized. Patients were counselledregarding their injuries and if conservative manage-ment was considered feasible, they were given thechoice of the IV3000 dressing. Inclusion criteriawere a fingertip injury with loss of part or whole ofthe pulp, nail bed, nail plate and a patient that wantedconservative management. There were sevenpatients with exposed bone that were included inthe study based on patient choice. All patients werefollowed up in a nurse led dressing clinic and werefollowed up for a least a month after healing wascomplete.Results: Sixty-four fingertip injuries (61 adult and 3paediatric patients) were treated with the IV3000dressing and included in the analysis. The treatmentoutcome of 40 injuries was rated as ‘excellent’ by thepatients, 19 as ‘satisfactory’, while 5 were rated as‘indifferent’. No patient reported their outcome as‘unsatisfactory’. On complete healing of the digit,five patients had cold intolerance, two had somedegree of hypersensitivity and three had a naildeformity.Conclusion: At 7 pence per piece, the IV3000 dressingprovides an affordable option to conservatively treat-ing finger tip injuries. Patients can be taught to applythis dressing easily and this reduces dressing clinicattendance rates. Overall, the IV3000 dressing pro-vides satisfactory outcomes when used to treat fin-gertip injuries in our cohort (which included its usefor diabetic patients as well as children), and therewas a 60% reduction in total costs and an averagereturn to work in 1 week across injuries.

A-1031 Three-dimensional versus two-dimensionalpreoperative planning of corrective osteotomy forextra-articular distal radius malunion: A multicen-ter randomized controlled trial

Geert A. Buijze1,2, Natalie L. Leong3,Filip Stockmans4,5, Peter Axelsson6, Rodrigo Moreno7,Allan Ibsen Sorensen8 and Jesse B. Jupiter2

1Academic Medical Center, Department of OrthopaedicSurgery, Amsterdam, The Netherlands2Massachusetts General Hospital, Department ofOrthopaedic Surgery, Boston, MA, USA3Rush University Medical Center, Department of OrthopedicSurgery, Chicago, IL, USA4AZ Groeninge, Handgroep Groeninge, PresidentKennedylaan, Kortrijk, Belgium5KULeuven Campus Kortrijk, Kortrijk, Belgium6Department of Hand Surgery, Institute of ClinicalSciences, Sahlgrenska Academy, University of Gothenburg,Gothenburg, Sweden7Christine M Kleinert Institute for Hand and Microsurgery,Louisville, KY, USA8Department of Hand Surgery, Institute of ClinicalSciences, Sahlgrenska Academy, University of Gothenburg,Gothenburg, Sweden

Objective: Malunion is the most common complica-tion of distal radius fracture. It has previously beendemonstrated that there is a correlation between thequality of anatomical correction and overall wristfunction. The primary aim of this study was to com-pare patient-reported outcome measures (PROMs)after corrective osteotomy for malunited distalradius fractures with and without three-dimensional(3D) planning and use of patient-specific surgicalguides.Methods: From September 2010 to May 2015, 40adult patients with a symptomatic extra-articularmalunited distal radius fracture were randomized to3D computer-assisted planning or conventional two-dimensional (2D) planning for corrective osteotomy.The primary outcome was the Disability of the Arm,Shoulder, and Hand (DASH) score. Secondary out-comes included the Patient-Rated Wrist Evaluation(PRWE) score, pain and satisfaction scores, gripstrength and radiographic measurements at 3, 6,and 12 months postoperatively.Results: From baseline to 12 months follow-up, thereduction in mean DASH score was �30.7� 18.7points for the 3D planning group compared to�20.1� 17.8 points for 2D planning (p¼ 0.103).Secondary functional outcome by means of thePRWE resulted in a similar reduction of�34.4� 22.9 points for the 3D planning group com-pared to �26.6� 18.3 points for 2D planning(p¼ 0.226). There were no significant differences in

SS188 Journal of Hand Surgery (Eur) 43(Supplement 2)

pain, satisfaction, range of motion and grip strength.Radiographic analysis showed significant differencesin mean residual volar angulation (3.3, p¼ 0.04) andradial inclination (2.7, p¼ 0.028) compared to thetemplated side; in favor of 3D planning and guidance.Time of pre-operative planning and surgery as wellas complications rates were comparable.Conclusions: Although there was a trend towards aminimal clinically important difference in PROMs infavor of 3D computer-assisted guidance for correc-tive osteotomy of extra-articular distal radius malu-nion, it did not attain statistical significance due to(post hoc) underpower. Despite the challenge of fea-sibility, a trial of large magnitude is warranted todraw definitive conclusions regarding clinical advan-tages of this advanced, more expensive technology.Level of evidence: Level-I.

A-1038 Injuries of the soft tissues in intra-articulardistal radius fractures: Arthroscopic assessmentand correlation with various fracture classes

Steven Roulet1,2, Ludovic Ardouin1 and Marc Leroy1

1Clinique Jeanne-d’Arc, Hand Institute Nantes Atlantique,Nantes, France2Medical University Francois Rabelais of Tours, Tours,France

Objective: The aim of this study is to analyse theprevalence of soft tissues injuries associated withintra-articular wrist fractures by arhroscopic assess-ment and to correlate theses injuries with variousfractures classes.Methods: From January 2013 to April 2017, 57 intra-articular radius fractures, whether or not associatedwith an ulnar styloid fracture, were operated on witharthroscopy. Each injury was documented by a preo-perative radiographic and CT scan. After osteosynth-esis of the radius fracture, a soft tissue arthroscopictesting was performed: radiocarpal and mid-carpaltesting (TFCC, scapholunate (SL), lunotriquetral). Thelesions were repaired. There were 23 women and 34men. The mean age at surgery was 43 years (range18–64 years). The classification of fractures was basedon CT analysis and DOI classification.Results: Osteosynthesis was performed in 32 caseswith a volar plate, 14 cases with plateþ pins, 9 caseswith pins, one case with screws and one case withexternal fixatorþ plateþ pins. In 39 cases (68.4%),there was at least one ligament injury. Preoperativeradiographs had no predictive value for interosseousligament injury. Indeed, 25% of SL tears havingnormal preoperative X-rays, including for severelesions (EWAS 3).

No significant correlation was found between thevarious fractures classes and the incidence of softtissues injuries.

In 72.7% of cases of pure two-part fracture verticalrim, there was an associated SL tear. And in 60% ofcases (15/25 cases) of fractures with at least onelateral vertical rim component, there was an asso-ciated SL tear. TFCC lesions were associated in 28%of cases (16/57 cases) with an intra-articular radiusfracture and in 52% of cases (14/27 cases) with anulnar styloid fracture.

Ulnar styloid fractures (base or tip) and TFCClesions were statistically significant relationship(p< 0.0001). Palmer 1d TFCC lesions were asso-ciated in 100% of cases (6 cases) with both a styloidfracture and a radial avulsion.

Among 42 patients assessed in consultation by anindependent examiner: 24 (57%) were free of pain;the others reported episodic pain of a mean 2.27/10on VAS (range 1–4). The average quick-DASH scorewas 6.3 (range 0–22.7). Patients were very satisfiedwith the result in 14 cases (33.5%) and satisfied in 28(66.5%). In all cases, the SL and TL stress testing waspainless. For one patient, the TFCC test was painful,and it was initially a repaired lesion 1b.Conclusions: The prevalence of soft tissue injuriesassociated with intra-articular radius fractures is68.4%. However, there is no statistically significantrelationship between various radius fracturesclasses and ligaments tears. On the other hand, anulnar styloid fracture is predictive of a TFCC tear.

A-1045 Effect of knot position in Adelaide flexortendon repair

Matthias Vanhees, Nicholas Cardillo, Belinda Smith,Elizabeth Clarke and Mark HileDepartment of Hand Surgery and Peripheral NerveSurgery, Royal North Shore Hospital, Sydney, Australia

Objective: Core suture failure in flexor tendon repairmost commonly occurs around the knot, by suturebreakage or unravelling of the knot. The purpose ofthis study was to investigate the effect of suture knotlocation on Adelaide flexor tendon repair strengthand mode of failure.Methods: Twenty-four FDP tendons (index, middle,ring and little) were harvested from 6 fresh frozencadavers and randomly assigned to one of two treat-ment groups. All tendons were sharply transectedand repaired with a 4-strand, 1-window Adelaideconfiguration as the core suture, using a 4-0 Ticronsuture. No epitenon suture was used.

FESSH Abstracts SS189

In Group 1 (n¼ 12), the knot was positioned in therepair site; in Group 2 (n¼ 12), the knot was posi-tioned away from the repair site.

The repaired tendons were secured in an Instronpneumatic clamp (80 psi) and were loaded at 40 mm/min (250 N load cell) until pull-out. A camera cap-tured images at a frequency of 1 Hz.

The force (N) at failure was recorded. The mechan-ism of failure was documented by inspecting the ten-dons during and after testing and reviewing thecaptured images.Results: The mean force at failure of repair in Group1 (internal knot) was 42.85 N (SD: 5.89). In all 12tendons, the repair failed due to the suture snappingat the knot site.

The mean force at failure of repair in Group 2(external knot) was 65.68 N (SD: 7.23), statisticallysignificantly higher than that of Group 1 (p< 0.05).Two repairs failed at the knot, 7 failed elsewherewithin the suture construct, and 3 sutures pulled out.Conclusions: This study demonstrates that placingthe knot away from the repair zone generates astronger construct. The knots placed externally hada lower incidence of failing at the site of the knot,suggesting that the placement protects this weakestcomponent of the repair.

With the Adelaide repair configuration gainingpopularity, this knowledge could influence clinicalpractice when treating flexor tendon injuries.

A-1050 Perioperative risk factors for complicationsof free flaps in traumatic wounds

Raquel Bernardelli Iamaguchi, Renan Lyuji Takemura,Gustavo Bersani Silva, Jairo Andre de Oliveira Alves,Luciano Ruiz Torres, Alvaro Baik Cho, Teng HsiangWei, Marcelo Rosa de Rezende and Rames Mattar jrUniversity of Sao Paulo, Brazil

Purpose: Despite the good results of microsurgicalfree flaps, a higher incidence of complications isexpected when treating traumatic wounds. Few arti-cles have examined the perioperative risk factors ofthe complications of free flaps for these wounds,prompting us to describe and find possible riskfactors.Methods: From July 2014 to January 2017, patientswho received microsurgical free flaps at a single hos-pital were consecutively included in this study. Data onpersonal medical history, intraoperative microsurgicalprocedure, and laboratory tests were collected.Patients were followed until the final result.Results: A total of 62 free flaps for the treatment oftraumatic lesions in 60 patients were studied.

We observed a higher rate of complications inpatients who underwent surgery 7 or more daysafter the trauma (p¼ 0.017), patients with obesity(p¼ 0.038), when used recipient veins from thesuperficial system for drainage of the flap(p¼ 0.035) and in those in whom the ischemia timeof the free flap was higher (p¼ 0.011). The presenceof thrombocytosis was associated with partial flaploss (p¼ 0.037).Conclusions: We identified the use of veins from thesuperficial system for drainage, obesity, ischemiatime of the flap greater than 2 h, and a delay in defi-nitive microsurgical treatment after 7 days as perio-perative risk factors for complications of free flapsfor traumatic wounds. The time between the trau-matic lesion and microsurgical flap should be asshort as possible to minimize complications.

A-1051 Results of anatomic ligamentous recon-struction of post-traumatic subluxated ulnar headusing half strip flexor carpi ulnaris tendon

Muhammad A. QuolquelaDepartment of Orthopaedics, Tanta University, Tanta, Egypt

Objective: Instability of ulnar head usually resultsfrom traumatic rupture of ligamentous stabilizers ofthe joint especially and ulnocarpal (ulno-lunate andulno-triquetral) ligaments and triangular fibro-carti-lage (TFC). Patients usually present with dorsallyprominent ulnar head, little if any pain, limitedprono-supination especially the latter and markedweakness of hand grip strength. This study aims atsurgical reconstruction to rebuild both componentsof TFC and Ulnocarpal (specifically ulno-triquetral)ligaments using half strip of flexor carpi ulnaris(FCU) tendon distally attached to the pisiform asthe latter is closely related to the triquetrum toeasily mimic the ulno-triquetral ligament.Methods: Sixteen patients with post-traumatic dor-sally subluxated ulnar head were treated throughligamentous reconstruction using FCU tendon. Theyhad an average age of 23 years. Average total wristdorsi-palmar flexion was 70�. Average prono-supina-ton range was 50�. In all patients, ulnar head wasdorsally prominent and grip strength had an averageof 30% of normal side. Through a dorsal approach,the capsule was opened and the fibrous remnant ofTFC was excised. With a very small drill bit, a drillhole was made in the triquetrum from dorsal to volarexiting through the pisiform. Other two drill holeswere made through the distal ulna with a commonopening distally at the fovea and two separate open-ings proximally at the ulnar neck. Through another

SS190 Journal of Hand Surgery (Eur) 43(Supplement 2)

volar skin incision along FCU tendon and after isola-tion and protection of ulnar nerve and vessels, theradial half of the tendon was stripped and left attacheddistally to the pisiform. This FCU half tendon waspassed with a twisted stainless steel wire throughthe piso-triquetral tunnel and was retrieved in thedorsal wound. The FCU tendon was passed throughcommon opening of the two tunnels in the distal ulna,coming out proximally at the ulnar neck to be passedthrough the other tunnel from proximal to distal to beretrieved at the fovea thus reconstructing the Ulno-triquetral ligament. The ulnar head was reducedmanually to the radial sigmoid notch with the handalmost fully supinated and pinned to the radius withtwo K-wires. The FCU half tendon was split into twoequal halves; one half was passed through a drill holemade through the dorsal ridge of the radial sigmoidnotch and the other half was retrieved into the volarwound and passed through a drill hole made throughthe volar ridge of the same notch. The arm wassplinted in a long arm slab for 6 weeks followed byK-wire removal and gradual mobilization.Results: Patients were followed up for an average of34 months. Average post-operative total wrist move-ment was 90�. Average prono-supinaton range was85�. Grip strength had an average of 70% of otherside. Mayo modified wrist score improved from anaverage of 45 points preoperatively to 80 postopera-tively (p¼ 0.05).Conclusions: Anatomic reconstruction of post-trau-matic ligamentous disruption of DRUJ using FCUtendon half strip results in a stable reduced ulnarhead with reasonable prono-supinaton and improvedhand grip strength.

A-1052 Distal scaphoidectomy and radio-scapho-lunate arthrodesis using multiple Herbert screwsas a motion preserving procedure in radiocarpalarthritis

Muhammad A. QuolqulaDepartment of Orthopaedics, Tanta University, Tanta, Egypt

Objective: Arthrosis limited to the radio-carpal jointis uncommon and is amenable to radio-scapho-lunate arthrodesis rather than total wrist fusion.Use of Herbert screws rather than Kirschner wireswas suggested to increase compression forces at thefusion site. This also enhanced fusion mass healingrate and allowed early wrist movements to avoidstiffness. Resection of distal scaphoid was suggestedto improve motion at the midcarpal joint as the jointwas converted into a simple C shaped articulationrather than an S shaped complex one.

Methods: Seventeen patients (seventeen wrists) withan average age of 28 years and radio-carpal arthritiswere treated surgically. Nine wrists were rheuma-toid, two were villonodular synovitis and six wristswere post distal radial fracture. Average dorsiflexionwas 16� and average palmar flexion was 24�. Gripstrength had an average of 35% of contralateralside. Through a dorsal approach, distal half of sca-phoid was resected followed by cartilage debride-ment of distal radius, proximal surfaces of lunateand remaining scaphoid. Two Herbert screws wereinserted across radio-lunate and radioscaphoidjoints in a retrograde fashion. Raw surfaces werepacked with cancellous bone graft from iliac crest.Splinting was done for 3 weeks postoperatively, fol-lowed by gradual active wrist movements.Results: Average follow-up period was 29 months.Average dorsi-flexion was 27� and 30� for averagepalmar-flexion. Grip strength had an average of58% of contralateral side. Joint fusion was confirmedradiologically within 8.6 weeks. Modified May wristscore improved from an average of 48 points preo-peratively to 72 points post-operatively.Conclusions: Radio-scaphoid-lunate fusion usingHerbert screws with distal scaphoidectomy yieldedmobile strong painless wrist.

A-1053 Extensor aponeurosis – bone–tendon con-nection. New insights into the extensor digitorumcommunis insertion: A cadaveric study

Pernille Nygaard Vedel1, Lars B. Dahlin2,Jørgen Tranum-Jensen3, Elisabeth Brogren2 andNiels Henrik Søe4

1Department of Orthopedics, Bispebjerg Hospital,Copenhagen University, Denmark2Department of Translational Medicine – Hand Surgery,Lund University and Dept Hand Surgery, Skane UniversityHospital, Malmo, Sweden3Institute for Cellular and Molecular Medicine,Panuminstitutte, University of Copenhagen4Section of Hand Surgery, Herlev and Gentofte UniversityHospital, Gentofte Hospital, Hellerup, Denmark

Introduction: The mid-line position of the extensordigitorum communis tendon on the four ulnar digitsis stabilized by the bony insertion to the base of thefirst and second phalanx, by the sagittal bands (SB)over the MCP joint and by the conjoined aponeurosisof the intrinsic lumbrical and dorsal interosseousmuscles.

The aim of this study was to clarify whether thereis any additional bone-to-tendon connection from theproximal phalanx to the central slip of the extensortendon; and if so, what its function may be.

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Methods: Forty fingers from 10 fresh-frozen upperlimbs were dissected. The central slip was dividedjust distal to the MCP joint and just proximal to thePIP joint and were cut free along their lateral mar-gins from the SB and from the conjoined aponeuro-sis, thus isolating the 2–3 cm of the central tendon,spanning the dorsal side of the shaft of the proximalphalanges. In one of the specimens, the radial andulnar artery was cannulated and injected with bluedyed VasQtec Pu4ii diluted with 1.5 volumes ofmethyl-ethyl-ketone to lower the viscosity. Ten milli-liter was injected simultaneously in each arteryunder high manual pressure applied to the 10 ml syr-inges. Fingertips turned blue and filling wasobserved in dorsal veins of the palm. The specimenwas dissected after 4 h curing of the injectate.Results: A bone-to-tendon connection was consis-tently found in all 40 fingers. The connections hadthe shape of a vinculum attached to the full lengthof the shaft of the proximal phalanges and to themidline of the tendons. The isolated slips were freeto slide 4–6 mm in distal direction, but only about halfas much in proximal direction with a distinct stop inboth directions indicating the oblique orientation ofthe collagen fibers in the mesotendinum. The vascu-lar injection showed small vessels passing from theperiost to the tendon, but no vessels were found onthe dorsal (cutaneous) side of the tendons.Conclusion: We consistently found a vinculum con-necting the central slip of the extensor digitorumtendon to the shaft of the proximal phalanx of thefour ulnar digits. The vinculum adds to stabilizationof the tendon and provides vascular supply to thetendon and its insertion.

A-1054 DIP joint arthrodesis with headlesscannulated screw: A review of 24 cases

Davide SmarrelliHumanitas-Gavazzeni, Bergamo, Italy

Objective: End-stage distal interphalangeal joint(DIPJ) arthritis, instability, and/or deformity are com-monly treated with arthrodesis. DIPJ arthrodesisrequires stabilization of the middle and distal pha-langes until fusion occurs, usually within 6 to 10weeks after surgery. Current techniques includeKirschner wire (K-wire) fixation, headless compres-sion screws, mini-plates, and tension-band wiring.

We report our experience of 24 cases with a follow-up from 6 to 48 months treated with cannulatedheadless screws.

Materials and Methods: From January 2013 up toJuly 2017, we treated 18 patients for an account of24 fingers with arthrodesis with cannulated screw.

In four patients, fingers were multiple even no morethan two in a single operation. The indications wereprimary and secondary osteoarthritis, rheumatoidarthritis, defect lesions, septic joint destruction, post-traumatic joint deviation, fatal joint instability, fataltendon lesions after failed treatment for mallet finger.

All cases were performed with a dorsal little inci-sion on the DIP joint and a minimal bone resection ofboth articular faces, and then fixated with a cannu-lated K wire-guided screw under fluoroscopy, in localanesthesia.

Finger splint in a Stacks fashion is taken for 4–5weeks after arthrodesis.

Patients were referred for clinical evaluation, forpreoperative and postoperative pain evaluation byVAS scale, and clinical outcome was assessed byDASH score; X-rays were performed routinely after6 weeks and after 3 months.Results: We had one infection; two mild and transientinfections, one delayed healing of the arthrodesis,obtained after 6 months; one radiologically non-union, without any clinical findings as well as painor instability. In only two cases, we noted a mild rota-tion of the nail.

During the first 3 weeks, commonly mild swelling ofthe DIPJ was reported, healing spontaneously withinfew further weeks. The outcome parameter DASH (dis-abilities of arm, shoulder and hand) score was on aver-age 26 (range 1–60). VAS scale showed a significantdecrease of the pain from 8 up to 0-1 in mostly cases.

The patients answered to a simple question: wouldyou do it again? 17 answered yes.

The majority showed relief from symptoms within2–3 months.Conclusion: Among several techniques, the arthrod-esis proved to be reliable and safe with a low com-plication rate and a good functional outcome: The useof the K-wire cannulated screw requires a moredemanding technique and intraoperative care butreveals to be safer and faster in recovery.

A-1065 Joint survival analysis and clinical outcomeof total joint arthroplasties with the ISIS implant inthe treatment of trapeziometacarpal osteoarthritis:Multicenter prospective continue case series

Gauthier Menu, Etienne Boyer, Francois Loisel,Daniel Lepage and Laurent ObertOrthopedic, Traumatology, and Hand Surgery Unit, CHRUBesancon, University of Bourgogne, Franche-Comte, BdFleming, Besancon, France

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Purpose: The new generation of ISIS TMC total jointarthroplasty is a modular, semi retentive, uncemen-ted ball-and-socket hydroxyapatite-coated implant. Itwas introduced in 2007 for the treatment of sympto-matic trapeziometacarpal (TMC) osteoarthritis. Theprimary outcome of this retrospective study is toreport the medium- to long-term joint survival ofthis prosthesis. Our secondary outcomes are theclinical and functional results.Methods: This multicenter retrospective studyinvolved 89 patients who underwent 107 ISIS TMCprosthesis implantations from November 2006 toSeptember 2009 and who had a minimum of 1-yearfollow-up. Indications for the procedure were painfulTMC joint osteoarthritis affecting activities of dailyliving and a failure of at least 6 months of nonsurgicaltreatment. Clinical and radiological assessment wasrecorded prospectively: before surgery and in thefirst year by the surgeon, and at 5 years or moreafter surgery by an independent operator. We com-pared the means of the Kapandji index (assessing thethumb range of motion and opposition), the gripstrength, the pinch strength, ADL, q-DASH, beforesurgery and at the latest follow-up. Clinical and radi-ological complications were registered. The Kaplan–Meier method was used to estimate implant survivalover time.Results: We included 107 prostheses in the survivalanalysis with a mean follow-up of 45.6 months (range12–120 months). No prostheses required revision sur-gery and no implant failed. No dislocation was pointed.For the survival analysis, we made two survivalcurves; in the first curve, survival means that theprosthesis has not been removed; the survival aftera mean of 45.6 years was 100% (95% confidence inter-val 90-97). In the second curve, indication for revisionwas the marker of failure; the survival after a mean of45.6 years was 86.9%. A total of 107 arthroplastiesfrom 89 patients were included in the clinical analysis.The mean age at surgery was 63.1 years (range 42–84years) and the median follow-up was 76 months(range 60–102 months). At 5-year follow-up, themean quick disabilities of the arm, shoulder, andhand score improved from 61.3� 17.1 to 17.5� 16.The mobility of the thumb was restored to a range ofmotion comparable with that of the contralateralthumb. Opposition, defined by the Kapandji score,was almost normal (9.2 of 10; range 6–10), as wasthe final mean key pinch and grip strength, whichimproved by 26% and 43%, respectively.

Among the 26 preoperative reducible Z-deformi-ties, only 5 (19.2%) were not totally corrected aftersurgery.Conclusions: In our series, the ISIS prosthesis of thethumb TMC joint has proven to be a reliable and

effective implant. Mean motion and strengthincreased, whereas pain decreased after surgeryand these results remained constant within thefollow-up period.

A-1067 Intraneural electrodes in bionic handreconstruction and their effects on nerve andmuscle architecture

Martin Aman1,2, Matthias E. Sporer1,2,Christopher Festin1, Martin Schmoll3,Hermann Lanmuller3, Krisztina Manzano-Szalai1,Anna Willensdorfer1, Roman Ruff4, KlausP. Hoffmann4, Michael F. Russold5, Christian Hofer5

and Oskar C. Aszmann1,6

1CD Laboratory for Extremity Reconstruction, Departmentof Surgery, Medical University Vienna, Austria2Department of Biomedical Research, Medical UniversityVienna, Vienna, Austria3Department of Medical Physics and BiomedicalEngineering, Medical University Vienna, Vienna, Austria4Fraunhofer Institut, St Ingbert, Germany5Otto Bock Healthcare Products GmbH, Vienna, Austria6Department of Plastic and Reconstructive Surgery,Department of Surgery, Medical University Vienna, Vienna,Austria

Objective: The interface between man and machine isan essential part of current research. Intraneuralelectrodes could thereby help to improve prosthesescontrol and provide sensory feedback for patients.The aim of this study was to evaluate longitudinalintraneural thin film electrodes and their effects onnerve and muscle architecture.Methods: In 20 Sprague-Dawley rats, longitudinal thinfilm electrodes were implanted into the sciatic nerveand compared to standard cuff electrodes. Variousgroups were assessed over a time period from 4-12weeks for impedance, muscle force and histologicalanalyses of nerve and corresponding muscles.Results: Histological assessments show significantchanges in muscle and nerve architecture. Muscleweight and maximum force is decreased comparedto healthy controls, due to histological verifiedmuscle atrophy. Analyses of the nerve show fibrosisat the insertion point and over the whole length of theelectrode within the nerve. Assessed biocompatibilityshowed no immunological problems.Conclusion: Intraneural electrodes are a sophisti-cated possibility to interface with the peripheral ner-vous system of a patient. However, shownhistological and functional effects after insertionand chronic stimulation should be considered forpossible clinical implementations and in combinationwith emerging high-density EMG control.

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A-1068 Scapholunate ligament reconstruction: One-year follow-up using the SLAM procedure in 22patients

Lars Soelberg VadstrupGentofte Hospital, Copenhagen, Denmark

Objective: To evaluate scapholunate ligament recon-struction using the ScaphoLunate Axis Method(SLAM) in patients with a dynamic or reduciblestatic scapholunate ligament tear.Methods: Between June 2014 and March 2017, 22consecutive patients have been operated using theScaphoLunate Axis Method (Arthrex) for reconstruc-tion of a scapholunate (SL) ligament tear. Averagetime from the initial injury to the reconstruction pro-cedure was 11 months (range 0.5–36 months). All thepatients had undergone X-ray investigations of theinjured and contralateral wrist. The SL lesion wasidentified by wrist arthroscopy, as the scaphoid redu-cibility was identified prior to final open ligamentreconstruction in a single session. Twenty men andtwo women underwent surgery, mean age 27 years(range 16–40). Seventeen patients underwent surgeryof their dominant hand and five of the non-dominant.All patients were immobilized post-operatively for 6weeks in a dorsal splint, whereupon they werereferred to hand therapy with lightweight-bearingexercises started. Full weight-bearing activity wasallowed at 6-month follow-up. Follow-up was 12months. Evaluation preoperatively and at 3, 6 and12 month after surgery included assessment ofrange of motion (ROM), grip strength andDisabilities of the Arm, Shoulder and Hand (quick-DASH) Score.Results: There were three complications during sur-gery, the operative procedures or the recovery/handtherapy. All patients improved in the patient-reportedoutcome measure at 12 month as quick-DASH valuesimproved significantly (p< 0.05). Mean quick-DASHvalue pre-operatively was 38 (range 12–78), and 21(range 0–34) post-operatively. ROM and grip strengthwere unchanged at 12 months compared to preo-perative measures. Mean grip strength was42 kilogram-forces (kgF) preoperatively, and 43 kgFpostoperatively (80% strength of the contralateralside).Conclusions: Short-term results of the SLAM proce-dure for patients with a dynamic or reducible staticscapholunate ligament tear provided satisfactoryresults with a few observed complications. The pre-sented technique using a tendon autograft (PL or partof the FCR) placed along the axis of rotation of the SLjoint, fixated in both the scaphoid and the lunate,

minimize loss of the obtained SL reduction andreconstruct the critical dorsal SL ligament.

A-1070 Total wrist fusion and total wristarthroplasty in patients with end-stageosteoarthritis: A qualitative analysis ofexpectations, involvement and appraisal of results

Sara Larsson1,2, Ingela Carlsson1,2,Hans-Eric Rosberg1,2, Anders Bjorkman1,2 andElisabeth Brogren1,2

1Department of Hand Surgery, Skane University Hospital,Malmo, Sweden2Department of Translational Medicine, Lund University,Malmo, Sweden

Objective: For patients with painful and advancedwrist osteoarthritis (OA), total wrist fusion (TWF) isthe standard surgical treatment, although total wristarthroplasty (TWA) has become a plausible alterna-tive. The aim of the present study was to explorepatients’ own experiences of living with a painfulwrist, expectations, involvement in surgical decision,appraisal of results and adeptness to a TWF or TWA.Methods: Thirteen surgically treated patients(between 2009 and 2014) with end-stage wrist OA(seven TWF and six TWA) were selected using purpo-sive sampling with a variation in gender (eight menand five women) and age (range 38–75 years). Semi-structured interviews were conducted and the tran-scripts were analysed using content analysis.Results: Unbearable, constant pain forced the parti-cipants to a breakpoint where surgery was their onlyoption and to become pain free was the primaryexpectation. To be involved in the discussion regard-ing different surgical options was highly desired.Most participants who received a TWF expressedthat becoming pain free was worth more than tryingto preserve some of the motion. Participants who stillhad a significant range of wrist motion before theTWF surgery and participants who were neveroffered TWA as an option were more concerned bythe loss of motion. Heavy activities caused pain in amajority of participants who received a TWA, but wasexpressed as something they could control. Having aTWF was seen as an end station and all participantswith a TWA appreciated the motion they still had left,although not at any cost. If the pain would increase, aTWF was seen as the better alternative. The partici-pants developed a variety of different problem-andemotion-based coping strategies to manage theirevery-day life, including compensatory movementpatterns, switch of handiness, asking for help butalso avoidance and protective behaviour. A positive

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and open mind-set, stubbornness and to be able toaccept the situation were pointed out as importantabilities.Conclusion: To patients with painful and advancedwrist OA who were susceptible for surgery, themain expectation was to get rid of the pain, whichmade anticipations on range of motion secondaryalthough preserved motion was seen as beingcloser to a normal life. Having reasonable expecta-tions and involvement in the discussion regardingsurgical options affected the patients’ expectationsand appraisal of the results.

A-1071 Evaluation of finger proximal inter-phalangeal joint fusion using mini Herbert screws

Muhammad A. QuolqulaDepartment of Orthopaedics, Tanta University, Tanta, Egypt

Objective: Proximal inter-phalangeal (PIP) joint ofthe most pivotal joint in a finger as it is the centraljoint with the greatest movement range comparedwith the other finger two joints. Painful stiff PIPjoint especially in a dominant hand can be a serioushandicap. PIP joint arthrodesis is an appealing optionfor those patients as it eliminates pain and correctsany finger deformity due to PIP joint pathology withmore efficient work of other finger joints andimprovement of hand function as a whole. Idealmethod of joint stabilization till fusion should allowmaximal compression so there is no need for bonegraft and the patient can move other finger joints assoon as possible. The use of two mini Herbert screwsseem to fulfill these requirements.Methods: Twenty-three fingers in 19 patients withpost-traumatic painful stiff PIP joints were operatedupon in the form of arthrodesis using mini Herbertscrews. Average age of patients was 27 years old andthe dominant hand was involved in 16 patients. Of thefingers involved, 10 fingers were the middle ones, 9fingers were ring and 4 indices. Average hand powergrip was 70% of the other hand. All patients wereneurologically intact. Through dorsal approach, thejoint was opened and the cartilage covering bothsides of the joint was removed. The joint was immo-bilized in a partially flexed posture (40�–80� flexion)comparable to that of the finger in the same positionin the other hand. Two almost parallel mini Herbertscrews were inserted across the joint in an antegradefashion. No bone graft was needed. Active movementof the fingers was permitted as soon as pain wastolerable typically within few days.Results: Average follow-up of the patients was 40months. All patients were pain free and 90% of

them returned to their previous jobs. Average handpower grip improved to 92% of the other side. All thepatients were happy about the cosmetic appearanceof their operated upon fingers. PIP joint fusion wasconfirmed radiologically in all patients within anaverage of eleven weeks.Conclusions: PIP joint fusion using mini Herbertscrews is an easy technique that allows efficientcompression at the fusion site to obviate the needfor bone grafting and to allow early fingermobilization.

A-1075 Extensor tendons adhesions: The role ofdifferent anti-adherent agents. Preliminaryevidences from an Italian multicentric study

Alfio L. Costa1, Franco Bassetto2,Francesco Monticelli2, Mario Cherubino3,Luigi Valdatta3, Bruno Battiston4, Alessandro Crosio4,Davide Ciclamini4, Ferdinando Stagno d\’Alcontres1,Francesco Zanchetta1, Valerio Licciardello1,Mara Franza1, Giorgio Lo Giudice1, Pietro Micieli1,Antonina Fazio1, Mariarosaria Galeano1,Gabriele Delia1 and Michele R. Colonna1

1Department of Human Pathology of the Adult, the Childand the Adolescent, University of Messina, Messina, Italy2Clinic of Plastic Surgery, Padua University Hospital,Padua, Italy3Division of Plastic and Reconstructive Surgery,Department of Biotechnology and Life Sciences (DBSV),University of Insubria, Varese, Italy4Depatment of Traumatology, Azienda OspedalieroUniversitaria Citta della Salute e della Scienza di Torino,Turin, Italy

Tendon gliding after injury and surgical repair isessential to produce the best functional recovery.Adhesions are one of the major postoperative com-plications in extensor tendon repair and may be pro-duced by suture techniques, contact with mortifiedtissues, infections, loss of substance, bone fracturesand loss, use of plates and screws. The aim of thisstudy is to point out the importance of the use of anti-adhesion materials in complex injuries involving theextensor apparatus together with skin and soft tis-sues and/or the underlying bone. We reviewed theliterature and did not find any paper about this sub-ject; indeed, several papers had been publishedshowing promising results about the use of anti-adhesion materials in both flexor tendon and periph-eral nerve repair.

In the period 2013–2017, we treated 22 (3 Insubria,4 Messina, 10 Turin, 5 Padua) complex lesions ofextensor apparatus complicated by bone fractureand/or soft tissue mortification/infection. The injuries

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occurred in zone 2 (1 case), in zone 3 (1 case), in zone4 (15 cases), in zone 5 (4 cases), and in zone 7t (1case). Repair was performed in finger and dorsum ofthe hand with horizontal mattress together with epi-tendinous continuous sutures; in the first extensorcompartment of the wrist, a modified Kesslersuture was performed.

We used different anti-adhesion materials: carbox-ymethylcellulose film (CMC) (10 cases, zone 4),cross-linked hyaluronate (2 cases one zone 2, onezone 7t), collagen–glucosaminoglycans (GAG) tem-plate (5 cases, one zone 3, four zone 5), CMC andpolyethylenoxide (PEO) (5 cases, zone 4).

After surgery, all patients were treated with astatic immobilization regime for 3 weeks.

All patients were examined blindly by anothersenior surgeon and administered a quick DASH ques-tionnaire in each center at 15, 30, 60, 90 days andafter 4 years. In a long-term follow–up, our resultswere satisfying in most cases, even if not statisticallyrelevant. Gel-treated tendons showed a better func-tional recovery than those treated with collagen; inone case, in an anti-platelet administered patienttreated with collagen wrap, important adhesionsoccurred due to post-operative bleeding, producinga significant extensor lag (>25�). This adverse eventwas treated removing the tendon segment and pla-cing a tendon graft, while wrapping avoided bleedingproducing a better scar and less adhesions in 10cases.

Some anti-adhesion materials seem to contrastextensor tendons adhesions, especially whentendon repair is associated with a trauma involvingbones. The role of collagen (whether added orinduced by other materials such as CMC or hyalur-onate) looks to be important in producing a soft andgliding peritendinous tissue after repair and avoidingscars. Further researches will focus, starting fromthe experimental field, on early and late collagendeposition and on the type of collagen involved.CMC and PEO gel looks perhaps among the mosthandling materials in topical application and remainsin situ 4 weeks before degradation, protecting tendonrepair in the critical third week of strongest collagendeposition.

A-1076 The scapholunate gap increases withforearm supination: A laboratory study

Mireia Esplugas1, Guillem Salva-Coll2,3,Marc Garcia-Elias4, Alex Lluch-Bergada4,5 andManuel Llusa-Perez6

1Hospital Activamutua, Tarragona, Spain2Hospital Son Espases, Mallorca, Spain3IBACMA, Mallorca, Spain4Institut Kaplan, Barcelona, Spain5Hospital Vall d’Hebron, Barcelona, Spain6Departament d’Anatomia, Universitat de Barcelona,Barcelona, Spain

Objective: Under axial load of the carpus in scapho-lunate ligament deficient wrists, the scaphoid bonerotates into pronation and flexion while the tandemlunate-triquetrum moves into supination and exten-sion; this scapholunate misalignment provokes thescapholunate gap seen on PA radiographs view.Forearm rotation may modify the carpal bones align-ment and distance between bones through forearmmuscles and ligaments action.

Is there any forearm rotation able to accentuatethe degrees of scaphoid and lunate misalignmentsin scapholunate ligament incompetence?

The purpose of this cadaveric biomechanical studyis to analyse scaphoid and luno-triquetral behaviourduring forearm rotations to find out a simple radiolo-gical stress scapholunate joint view, with maximalscapholunate gap, to improve the radiological diag-nosis in dynamic scapholunate dissociation.Methods: The kinetic effect of forearm rotation oncarpal bones was analysed on eight fresh normalcadaver arms, before and after sectioning the sca-pholunate ligament, in two forearm rotations: 45� ofsupination and 45� of pronation. A custom-designedtesting apparatus was used to hold the wrist in neu-tral position. A 6 degree-of-freedom electromagneticmotion tracking device with sensors attached to thescaphoid, triquetrum and capitate monitored spatialchanges in bone alignment. The rotation and eleva-tion sustained by the scaphoid and the triquetrumwere measured in each condition.

Kolmogorov–Smirnov and Shapiro–Wilk tests wereapplied to check the probability of normal distributionof the measured data.

Analysis of variance and Wilcoxon signed-ranktests were used to compare the average rotationand elevation sustained by scaphoid and the trique-trum in different forearm rotations. Statistical signif-icance was set at p< 0.05.Statistically significant results: In forearm prona-tion, all proximal carpal row bones rotate into

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supination and flexion, whether the scapholunateligament is sectioned or not:

- Intact scapholunate ligament: scaphoid supina-tion x: 2.28 SD: 4.16; scaphoid flexion x: 2.96 SD2.55; triquetrum supination x: 1.43 SD: 2.48.

- Sectioned scapholunate ligament: scaphoid supi-nation x: 3.44 SD: 4.12; triquetrum supination x: 2.50SD: 2.67; triquetrum flexion x: 3.35 SD: 2.2.

In forearm supination, scaphoid rotates always intopronation whether the scapholunate ligament is sec-tioned or not, while the tandem triquetrum-lunatemoves into supination and extension when the sca-pholunate ligament is sectioned:

- Intact scapholunate ligament: scaphoid pronationx: 1.18 SD: 2.75

- Sectioned scapholunate ligament: scaphoid pro-nation x: 2.36 SD: 3.48; triquetrum supination x: 1SD: 2.84; triquetrum extension x: 0.33 SD: 1.1.Conclusions: Forearm pronation reduces the sca-pholunate misalignment secondary to a scapholunateligament incompetence; so, an unloaded PA wristradiograph probably will not put on evidence adynamic scapholunate dissociation although the liga-ment is completely torn.

Conversely, active forearm supination generatesdistraction forces to the scapholunate joint, accent-uates the degree of scaphoid pronation and lunatesupination/extension malposition and, consequently,widens the scapholunate gap; so, a simple active APwrist radiograph may put on evidence a dynamic sca-pholunate dissociation.

Based on these data, an AP view of the wrist takenwhile the patient is actively supinating the forearm isanother form of scapholunate joint stress.

A-1077 Global brachial plexopathy: High-levelupper limb amputation and prosthetic rehabilitationafter surgical improvement of the biotechnologicalinterface

Laura A. Hruby1, Agnes Sturma1, Johannes Mayer1,Stefan Salminger2, Anna Pittermann3 andOskar C. Aszmann1,2

1Christian Doppler Laboratory for Restoration of Extremityfunction2Division of Plastic and Reconstructive Surgery,Department of Surgery, Medical University of Vienna3Department of Psychology, General Hospital of Vienna

Objective: Primary and secondary reconstructionsmay restore sufficient shoulder and arm function inthe majority of patients with global brachial plexopa-thies including nerve root avulsions. In a fewpatients, however, function is not improved. The

concept of bionic reconstruction, which includes theelective amputation and prosthetic replacement ofthe functionless limb, has already been describedfor the transradial level. Here we present for thefirst time functional outcome data after electivetranshumeral amputation and prosthetic arm recon-struction in patients, in whom residual myoactivityhad not been found in the forearm but instead moreproximally in the upper arm and shoulder girdle,which could be used to control a prosthetic arm.Methods: Since nerval supply and functional muscletissue are sparse in patients with multiple nerve rootavulsions, the identification of myosignals needed forprosthetic control may be complicated. To improveprosthetic usage selective nerve and, in somecases, muscle transfers were performed. Objectiveoutcome data included global upper extremity func-tion, which was assessed using the SouthamptonHand Assessment Procedure (SHAP) and the ActionResearch Arm Test (ARAT). Subjective disability wasassessed with the DASH questionnaire.Deafferentation pain was evaluated with the visualanalogue scale (VAS). Baseline measurements wereperformed with the impaired plexus arm beforeamputation. Follow-up measurements were per-formed after final prosthetic fitting.Results: Preliminary data in five patients treated withbionic reconstruction at transhumeral level will bepresented at this year’s FESSH congress.Conclusions: The more distal the amputation, themore limited the prosthetic control. The reconstruc-tion, however, of simple prosthetic functions such aselbow flexion and hand closing represent majorimprovements for patients who have lived withoutany arm function for years or even decades.

A-1078 Predicting complete finger extension aftersurgery for patients with Dupuytren’s disease

Ralph Poelstra1,2,3, Jarry T. Porsius1,2,3,Christianne A. van Nieuwenhoven1, Harm P. Slijper2,Reinier Feitz2, Steven E. R. Hovius1,2 andRuud W. Selles1,3

1Department of Plastic, Reconstructive and Hand Surgery,Erasmus MC, Rotterdam, The Netherlands2Hand and Wrist Center, Xpert Clinic, The Netherlands3Department of Rehabilitation Medicine, Erasmus MC,Rotterdam, The Netherlands

Objective: In an era where shared decision-makingand personalized medicine are becoming the hall-mark of the patient-centered care, reliable and accu-rate information about treatment options and theiroutcome are of great importance. For patients with

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Dupuytren’s disease, complete extension of thefinger after surgery is one of the most importanttreatment outcomes. Knowing which patients willachieve complete extension of a finger after surgeryis likely determined by pre-operative characteristics,such as extension deficit and number of affected fin-gers, which vary widely among patients. Insight inthese processes is important in shared-decision-making and will be helpful in managing expectations.Therefore, the aim of this study is to explore to whichextent patient characteristics prior to surgery canreliable predict the change of postoperative straight-ness of a finger in Dupuytren’s disease.Methods: Patients undergoing limited fasciectomy orpercutaneous needle fasciotomy for Dupuytren’scontractures between 2011 and 2016 were selectedfrom a prospectively collected database. Patientswere included if they had pre-operative goniometryand post-operative goniometry 3months after sur-gery. Patients who were treated because of recurrentdisease were excluded. If multiple fingers were trea-ted, the most affected finger was selected. Thenumber of affected fingers and the most affectedjoint were determined in each patient. Furthermore,patient characteristics, such as age and medical his-tory, and pre-operative MHQ scores were retrievedfrom the database.

Based on the bivariate logistic regression analysis,significant determinants (p 0.10) were selected forthe subsequent development of a multivariate logis-tic model predicting complete active extension of afinger postoperatively, which was defined as lessthan 5� of extension deficit at 3 months post-surgery.The final model was evaluated for goodness-of-fitwith the Hosmer and Lemeshow goodness-of-fittest and for discrimination with the area under theROC-curve (AUC).Results: A total of 1150 patients were included in thestudy of which 253 achieved complete active exten-sion of their finger after surgery. The predictors atbaseline in the final model were the extension deficitof the most affected finger, the most affected finger,the most affected joint and the age of the patient.Addition of any more predictors, such as MHQscores or type of surgery, did not significantlyimprove the model. As an example of the model, an60-year old patient with a 20� contracture in theMCP-joint of the ring finger has a 65% chance ofachieving complete active extension of a finger aftersurgery, compared to a 23% chance for a similarpatient but with a 70� contracture. The Hosmer andLemeshow goodness-of-fit test had a p-value of 0.57,indicating a good goodness-of-fit and AUC of 0.81.Conclusions: This study demonstrates that with alimited set of readily available baseline

characteristics, a reliable prediction can be madewhether complete active extension of a finger canbe achieved post-operatively. Most notably, type ofsurgery and baseline MHQ scores had no significantinfluence on this prediction. The results of this studycan be used in shared decision-making when inform-ing patients about their treatment options and post-operative outcome in Dupuytren’s disease.

A-1079 Interactive mobile training app after nervetransfer or amputation of the upper extremity

Cosima Prahm, Eric Morth, Agnes Sturma andOskar AszmannMedical University of Vienna, Austria

Objective: Conventional rehabilitation methods afternerve transfer or amputation of the upper extremityare based on performing repetitive exercises duringwhich the patient’s long-term motivation and effortare difficult to sustain. To keep patients engaged andeven increase their performance during training, theycan receive EMG biofeedback enveloped in a game-based smartphone app. This kind of engaging reha-bilitation intuitively trains those muscles needed forproper motor control.Methods: A clinically oriented, mobile virtual envir-onment has been developed that trains and evaluatesthe patient’s neuromuscular capacity pre- and post-interventionally for (1) maximum voluntary contrac-tion, (2) proportional fine muscle control, and (3) iso-lated activation of different muscle groups. Datawere analyzed using a Bonferroni corrected pairedsamples t-test for multiple comparisons on thesame data. Contrary to previous studies, participantsnot only conducted repetitive flexor and extensormotions but also trained continuing muscle contrac-tion over varying periods of time, perform preciselytimed contractions and execute simultaneous con-tractions of both muscle groups. Because of themobile aspect of the intervention, so far two patientsand two able-bodied participants could train at homefor a period of 4 weeks, training 5 days a week. Theapp’s modularity serves patients with upper andlower arm deficits alike as it operates not only thepatient’s own prosthesis but also commercially avail-able electrode arrays. In addition, motivation, effort,and patient performance were collected during thestudy and compared to a standard myoelectric reha-bilitation training device, the MyoBoy.Results: All participants achieved a significantimprovement in all motor control evaluation criteria:maximum voluntary contraction (p< 0.01), propor-tional control (p< 0.01) and muscle separation

SS198 Journal of Hand Surgery (Eur) 43(Supplement 2)

(p¼ 0.02) over 40 measurement instances.Motivation, effort and performance were higherduring the mobile training compared to the MyoBoy.Conclusions: This study represents the first long-term intervention in rehabilitation of nerve transfersor after amputation of the upper extremity using amobile game-based app. The integration of virtualelements into the rehabilitation process has a posi-tive effect on the motivation of the patients as well astheir motor performance during and after the inter-vention. Since the mobile game-based app is moreengaging than using a standard tool for training myo-signals and patients invest more effort while doingso, this study shows the potential for mobile apps toestablish a new standard in motor rehabilitation.

A-1080 Long-term implant of intramuscular sen-sors and targeted muscle reinnervation for naturalwireless control of prosthetic arms in above elbowamputees: A prospective case series

Stefan Salminger1,2, Agnes Sturma2,3,Christian Hofer2,4, Melissa Evangelista5, Mike Perrin5,Konstantin D. Bergmeister2, Aidan D. Roche2,6,Timothy Hasenoehrl3, Hans Dietl4, Dario Farina7 andOskar C. Aszmann1,2

1Division of Plastic and Reconstructive Surgery,Department of Surgery, Medical University of Vienna,Austria2Christian Doppler Laboratory for Restoration of ExtremityFunction, Medical University of Vienna, Austria3Department of Physical Medicine and Rehabilitation,Medical University of Vienna, Austria4Otto Bock Healthcare Products GmbH, Vienna, Austria5Alfred Mann Foundation, California, United States6Department of Plastic Surgery, Southmead Hospital,North Bristol NHS Trust, United Kingdom7Department of Bioengineering, Imperial College London,London, UK

Background: Prosthetic fitting in transhumeralamputees is challenging. The conventional 2-signalcontrol limits speed and natural fluency of move-ments. Additionally, myoelectric signals picked upfrom the skin surface are susceptible to noise intro-duced by the environment, movement between theelectrode and the skin as well as cross talk betweendifferent muscles as well as changes in the skinimpedance due to perspiration. Therefore, theAlfred Mann Foundation has designed a fullyimplanted myoelectric sensor system (IMES) forwireless control of the prosthetic device.Methods: Three transhumeral amputees wereimplanted with IMES sensors while undergoing rou-tine TMR surgery to demonstrate functional benefits

of intramuscular recorded EMG used as signals inprosthetic control. Global upper extremity functionwas evaluated using the Southampton HandAssessment Procedure (SHAP), the Clothespin-Relocation Test (CPRT) and the Box and BlocksTest (BBT), which monitor hand and extremity func-tion closely related to activities of daily living.Results: Successful implantation of the myoelectricsensors combined with targeted muscle reinnerva-tion was performed in the three participants. Fulluse of the implanted system with 5–6 myosignalswas achieved already at 4 months postoperatively.The clinical evaluations were done over a period of2.75� 0.25 years, during which the participantsshowed a mean improvement in Southampton HandAssessment Procedure from 33� 7.94 to47.00� 4.36, in clothespin relocation test from84.45� 33.88 to 27.58� 13.76 s, and in Box andBlock Test from 7.67� 5.13 to 12.33� 2.52.Additionally, outcome scores using the implantedsystem were superior to those obtained with surfaceelectrodes.Conclusion: This is the first report of a longitudinalanalysis of implanted myoelectric sensors togetherwith targeted muscle reinnervation to reach naturalcontrol of multiple degrees of freedom in aboveelbow amputees. The implanted system does nothave a percutaneous interface, thus eliminating theconstant risk of infection and was tested over a 2.5-year period. The outcome measures demonstratedthe superiority of implantable intramuscular sensorscompared to standard surface pickup.

A-1081 Arthroscopic classification of scapho-lunateand luno-triquetral tear

Jane C. Messina, Nicolas Dreant, Riccardo Luchetti andChristophe Mathoulin1Hand Surgery Unit Gaetano Pini Orthopaedic Institute,Milano, Italy2Nice Hospital, France*3Hand Surgery Unit, Rimini, Italy4Institut de la Main, Paris, France

Objective: The development of wrist arthroscopy haslead to the early identification of intracarpal ligamentinjuries that are underdiagnosed by standard X-raysand MRI.

While diagnostic imaging can be mute, the patientis frequently symptomatic with pain, reduction of gripstrength and inability to do manual work or sportsactivities.

Partial and complete ligament lesions have beentreated in different ways as shrinkage, capsulodesis

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(open or arthroscopic), reconstruction techniqueswith pinning or screw fixation. Anatomical studieshave identified different parts of SL and LT inteross-eous ligaments (anterior, proximal and posteriorparts) that have different resistances to strength.

It is well known that lack of early diagnosis ofthese injuries can develop a chronic instability lead-ing to degenerative arthritis of the wrist.

Arthroscopic examination allows early identifica-tion of acute and chronic injuries that can be severeand more challenging for the surgeon to treat. Theaim of this study is to obtain a thorough definitionacute and chronic injuries, identifying differentkinds of partial and complete tears of scapho-lunate and luno-triquetral tears using the EuropeanWrist Arthroscopy Society Classification (EWAS)developed since 2009.Materials and Methods: Ninety eight symptomaticpatients underwent arthroscopy of the wrist.Scapholunate injuries were present in 80 patientsand lunotriquetral injuries were present in 18patients. The mean age of patients was 44 years(range 16–72 years old). There were 67 males and31 females.

There were 36 sports injuries, 4 road traffic inju-ries, 30 accidental injuries, 23 working injury, and 5unknown. The lesions have been identified and clas-sified according to EWAS classification: Stage Iattenuation, stage II, partial injury to membranousportion, stage IIIA partial tear of anterior part ofinterosseous ligament, IIIB partial tear of dorsal por-tion of interosseous ligament, IIIC complete tear,Stage IV passage of arthroscope between thebones; stage V interosseous gap visible on X-rays.The dominant hand was involved in 66 cases.Results: The acute lesions were 13, while the chronicwere 85.

The arthroscopic findings showed a scapho-lunateinjury as follows: 1 stage I, 10 stage II, 13 stage IIIA,16 lesions stage IIIB, 27 lesions were stage IIIC, 7lesions stage IV and 6 stage 5. Statistical analysisrevealed significant differences (p< 0.001) betweenstages II and IIIA-B between stages IIIA-B and IIIC,between stages III and IV.

The lunotriquetral injuries were identified as fol-lows: no stage I-II, 1 stage IIA, 10 stage IIB, 2 stageIIIC, 5 stage IV, 2 stage V.

No lesions lacked classification nor hesitation inclassifying were reported by the authors.

The authors propose treatment option in eachstage.Conclusions: The EWAS classification can be used toclassify a variety of acute and chronic scapho-lunateand luno-triquetral tears, improving definition of par-tial and complete injuries. This allows a better

understanding of the complexity of traumatic andpost-traumatic injuries and possibly treats themearly addressing a proper treatment in each stage.

A-1083 Management of distal radius and ulnarfractures: ORIF versus external fixation of distalulna

J. C. Messina, F.V. Palumbo, Pedrini, U. Dacatra, P. DelBo, S. Odella, F. Torretta and P. TosHand Surgery and Reconstructive Microsurgery Unit,Gaetano Pini Orthopaedic Institute-CTO, Milan, Italy

Objective: Fracture of the ulnar head and neck canbe rarely associated with distal radius fractures insevere trauma of the wrist. This is an additionalinstability factor to the distal radius fracture.Different surgical options exist for stabilization ofdistal ulna as internal fixation with plate andscrews or external fixation. The aim of this retro-spective study is to evaluate the clinical results ofthe patients operated between 2006 and 2016 in ourdepartment with this fracture association with differ-ent techniques and if possible describe advantagesand disadvantages of internal fixation versus externalfixation of the distal ulna in addition to distal radiusfixation.Methods: Of the 1298 patients affected by distalradius fracture (DRF), we studied our cohort of 45patients affected by distal radius and ulnar fractureretrospectively by means of Mayo wrist score, DASHscore and PRWE. Mean age was 65 years (range 26–89), 39 were females and 6 males. Fracture pattern isstated by means of Biyani classification. Internal fixa-tion with plate and screws of distal radius and ulnawas performed in 29 patients (group I) (Synthes,Mikai, Acumed, Martin). In 11 cases, internal fixationof distal radius was performed with K-wires stabi-lized with external fixation of distal ulna (Joshi fixa-tor) (group II). We recorded the operating time of allprocedures and immobilization period after surgery.All patients were followed at 30, 60, 90 days post-operatively and then at a mean follow-up of 21months (range 1–6 years).Results: All patients of the first group (internal fixa-tion of distal radius and ulna) obtained excellentresults at the Mayo score, with quick recovery offull ROM and absence of pain. In two patients, aslight reduction of grip was recorded (of 15%),mean DASH was 5.3 (0–10.8), and mean PRWE was10 (0-38). Mean operating time was 95 min (90–115).In group II, excellent results were obtained in 10cases at and good in 1 case according to the Mayoscore. Mean DASH was 9 (5–18). Mean PRWE was

SS200 Journal of Hand Surgery (Eur) 43(Supplement 2)

13.5 (2–19). Rehabilitation was delayed until 50–60days postoperatively. Mean operating time was70 min (65–80). Immobilization was removed at 30days in the first group, at 50–60 days in the secondgroup. One non-union occurred in group II that wastreated with a distal ulnar hemiarthroplasty and inone case mobilization of pins was observed andpins removed.Conclusions: Modern treatment options allow stabi-lization of the fractures of distal radius and ulna.Early mobilization is possible with double plating,while the use of pinning or external fixation delaysthe rehabilitation up to 50–60 days but have a shorteroperating time. The indications of the two techniquesare not always the same and we developed somesuggestions on this topic. If the head is multifrag-mented, it is not always easy to fix and in thosecases plating is not stable and external fixation isadvised, while if ulnar diaphysis is involved or multi-fragmented plating is preferred.

A-1084 The myth of the ‘uninjured’ side after handinjury

_Ilkem Ceren Sıgırtmac, Ozge Buket Cesim,Burcu Semin Akel and Cigdem OksuzHacettepe University Faculty of Health Sciences,Occupational Therapy Department, Ankara, Turkey

Objective: The change of the peripheral organs maycause changes in the cortical map as well. The soma-tosensorial cortex and motor cortical map are reor-ganized on the affected (hand) side due to conditionssuch as long-term immobilizations or motor or sen-sory loss. The changes in the cortical map are notlimited with the affected hemisphere. The changes ofcortical map in one hemisphere are reflected in thecontralateral hemisphere. On the basis of this theory,especially in stroke patients, it is shown that not onlythe lesioned side is affected but also the non-lesioned side. However, there is no study about thefunctional status of the unlesioned side in the ortho-pedic hand conditions. The purpose of this study is toassess the hand function of unlesioned side in patientwith hand injury.Methods: There were 85 patients (42% female and58% male) with hand injury and 162 healthy (60%female and 40% male) subjects. Subjects’ hand func-tion were assessed by using Purdue Pegboard Test(PPT). PPT unilateral subset scores were comparedwith PPT unilateral subset scores of healthy subjectsusing independent t-test.Results: Mean age was 37 years (range 18–64; stan-dard deviation, 13.4) in subjects with hand injury; 47

patients had dominant hand injury and 38 patientshad non-dominant hand injury. Mean age of healthysubjects was 38 years (range 20–65; standard devia-tion, 10). A statistically significant difference wasfound between the uninjured (dominant) hand’s PPTscore of nondominant hand injured subjects (mean ofpeg, 14; standard deviation, 2) and the PPT dominanthand scores (mean of peg, 15; standard deviation,2)of the healthy subjects (p< 0.001). A statistically sig-nificant difference was also found between the unin-jured (non-dominant) hand PPT score of dominanthand injured subjects (mean of peg, 11; standarddeviation, 3) and the PPT scores of non-dominanthand of the healthy subjects (mean of peg, 15; stan-dard deviation,1) (p< 0.001).Conclusions: Our data demonstrate changes in thefunction of the unaffected side after hand injuries.This change may be interpreted either as a modula-tory influence of the affected hemisphere on effer-ences of the unaffected side or as a modulation of theunaffected hemisphere itself. For this reason, itshould be kept in mind that the therapist shouldnot only focus on the injured hand. They shouldhave some intervention strategies for the uninjuredhand in rehabilitation sessions as well.

A-1087 Scapholunate realignment using localtendon grafts: Qualitative vector analysis of the twopotential donors (FCR and ECRL)

Mireia Esplugas1, Marc Garcia-Elias2, Alex Lluch-Bergada2,3, Nuria Fernandez-Noguera4 and Inma Puigde la Bellacasa5

1Hospital Activamutua, Tarragona, Spain2Institut Kaplan, Barcelona, Spain3Hospital Vall d’Hebro, Barcelona, Spain4Hospital Josep Trueta, Girona, Spain5Hospital Universitari Mutua Terrassa, Barcelona, Spain

Objective: Reducible scaphoid subluxations are oftentreated by threading a distally based strip of FlexorCarpi Radialis (FCR) tendon through an anteropos-terior tunnel across the distal scaphoid. The goal isto create a volar-distal tether that constrains thescaphoid tendency to rotate into flexion.

Another alternative consists of using a strip ofextensor carpi radialis longus (ECRL) passed acrossan oblique tunnel from the anterolateral corner ofthe scaphoid tuberosity to the posteromedial edgeof the scaphoid. In this case, the tenodesis aims atpreventing both flexion and pronation of the sublux-ing scaphoid.

We have performed a three-dimensional qualita-tive vector analysis of the two options (FCR or

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ECRL) to ascertain which of the two is more likely toprevent scaphoid flexion and pronation.Methods: Sixteen X-rays (eight posteroanterior andeight lateral) and eight axial tomograms were ran-domly selected from the files of our institutions.

We measured the angle of attack of the two tendonstrips in the three orthogonal planes, assuming thetunnel for FCR option to be parallel to the sagittalplane and perpendicular to the frontal plane. Thetunnel for the ECRL tendon was set to connect theradial most point of the scaphoid tuberosity andthe ulnar most point of the dorsal rim of thescaphoid.

We statistically compared the average angle deter-minations in the three orthogonal planes using ana-lysis of variance, followed by a Tukey HSD test of thevalues obtained for each plane. Statistical signifi-cance was set at p< 0.05.Results: ECRL is better set to resist flexion (sagittalplane), radial inclination (frontal plane) and pronation(transverse plane) than the FCR tendon.

The average� standard deviation (SD) angularmeasurements for the two surgical alternativeswere as follows:

Frontal plane: FCR: 168.7� 8.7�, ECRL:104.8� 6.5�

Sagittal plane: FCR: 61.8� 7.0�, ECRL: 59.0� 8.1�

Transverse plane: FCR: 34.6� 2.4�, ECRL:13.6� 3.4�

An one-way analysis of variance compared theattack-angle of two potential donors (FCR andECRL) ranked by three orthogonal planes (frontal,sagittal and axial). This analysis was found to be sta-tistically significant, p< .0001.

Post hoc comparisons using the Tukey HSD testindicated that the mean angle of attack of the FCRwas significantly wider than that of the ECRL in allthree planes.Conclusions: Assuming that the lesser the ‘‘angle ofattack’’ of a tendon into a bone tunnel, the greater isits mechanical advantage, we conclude that a stripfrom the ECRL is likely to be more efficient in pre-venting flexion and pronation of an unstable scaphoidthan the FCR.

In short, when it comes to decide what tendon isbest to stabilize scaphoid instability, a distally basedECRL over the FCR is recommended.

A-1088 Arthroscopic CM arthroplasty with suture-button suspensionplasty short-term follow-up

Keiji Fujio1, Takumi Hashimura2, Kazuaki Tsuyuguchi1,Hyongyon Kan1 and Masayuki Matsuoka1

1Hand Center and Medical Institute of Kansai ElectricPower Hospital2Orthopaedic Department of Kobe Municipal MedicalCenter

Objective: Surgical techniques for CM arthroplastyhave developed such as arthroscopic hemitrapziect-omy with mini Tight Rope (TR) suspension methodrecently. The aim of current study is to evaluate theresults for more than 1-year follow-up.Methods: Our technique is shaving only subchondraltrapezium and beak osteophyte completely in orderto medialization for first metacarpus. TR is insertedfrom first metacarpal base just volar APL attachmentto second metacarpus. Nineteen cases followed over1 year included 2 male and 15 female were operatedarthroscopic hemitrapeziectomy with TR suspensionmethod. Averaged age was 60.8 years and meanfollow-up period was 18.8 months. Palmar abductionangle and radial abduction were analyzed comparedto contralateral side before operation and finalfollow-up, respectively. Visual analogue score (VAS),Pulp pinch power, and DASH score were evaluated 3months after operation and 6 months after operation,respectively, regarding clinical evaluation. Trajectory(distance between proximal joint space to TR inser-tion point divides length of second metacarpus) wasanalyzed regarding XP evaluation.Results: Postoperative palmar abduction and radialabduction were 91.5% and 93.5%, respectively.Preoperative and final follow-up of VAS were 74.5and 16.0 (p < 0.001), respectively. Preoperative andfinal follow-up of Pulp Pinch (kg) were 3.1 and 4.2(p¼ 0.001), respectively. Preoperative and finalfollow-up of DASH score were 41.8 and 21.5(p< 0.001), respectively. Trajectory was averaged0.35� 0.08. Although there was no correlationbetween trajectory and postoperative ROM(r¼ 0.28), there were weak negative correlationbetween trajectory and VAS (r¼ 0.39).Conclusion: This method may change the axis ofthumb rotation and make suspension effect andhematoplasty effect for CM joint. There was no cor-relation between trajectory and postoperative ROMunder 1/2 of metacarpus. There was a weak negativecorrelation between trajectory and VAS in midtermfollow-up.

SS202 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-1089 Extensor tendon repair and prophylacticextensor retinaculum release for extensor tendonruptures in rheumatoid wrists

Seung-Han Shin, Yong-Suk Lee and Yang-Guk ChungSeoul St. Mary’s Hospital, The Catholic University of Korea,Seoul, Republic of Korea

Background: Extensor tendon rupture is common inadvanced rheumatoid arthritis patients. Currently,tendon transfer is the most common procedure forrheumatoid extensor tendon rupture, because of latedetection and poor tendon quality. However, werepaired ruptured tendons to their original stumps,even in cases with a long history of extension loss.Materials and Methods: A total of 12 rheumatoidarthritis patients who were treated surgically forextensor tendon rupture were reviewed. The patientshad a history of finger extension loss for up to 1 year.Ruptured tendons were extensor digiti minimi (EDM)in 12, extensor digitorum communis (EDC) (littlefinger) in 12, EDC (ring finger) in 8, EDC (middlefinger) in 5, and EDC (index finger) in 1. All tendonswere repaired to their original stumps, while distalstumps of EDM and EDC (little finger) were repairedtogether to proximal stump of EDM muscle. Palmarislongus tendon interposition graft was used in eightpatients. Direct repair was performed for 5 out of 12EDM-EDC (little finger) repair. In all patients, exten-sor retinaculum was released and repaired underextensor tendons to prevent further extensortendon rupture.Results: All patients recovered active finger exten-sion, including independent extension of the littlefinger. No further extensor tendon rupture wasoccurred after the surgery. Although repaired ten-dons were prominent under the skin due to bowstringphenomenon, no patient reported pain in the promi-nent tendon and substantial functional impairmentwas minimal.Conclusion: Extensor tendon repair and prophylacticextensor retinaculum release is a good option forextensor tendon ruptures in rheumatoid wrists. Amuscle with a tendon rupture may work again evenafter 1-year history of extension loss in rheumatoidarthritis patients.

A-1093 Shoulder partial denervation: Anatomicalstudy of the feasibility and surgical perspectives

Laurent Bourcheix1,2, Charles Schlur2 andPatrick Houvet2

1Ecole de Chirurgie du Fera Moulin, Paris, France2Institut Francais de Chirurgie de la Main, Paris, France

Introduction: Articular denervation of the shoulderhas been proposed by few authors in case ofshoulder recalcitrant pain. The source of shoulderpain has never been defined but has been assumedto be related to musculoskeletal injuries or arthritis.Twenty percent of shoulder pains have been reportedafter common surgery. We present an anatomicalstudy to evaluate shoulder denervation and the sur-gical perspectives.Materials and Methods: Thirty specimens (15 fresh/frozen cadavers), all had vascular injections with RTVcolored silicone. The study was conducted by twoprotocols:

(1) Extensive dissections for 10 specimens in orderto identify: nerve landmark and all articular branchesfrom the ansa pectoralis, axillary and suprascapularnerves.

(2) For the following 20 specimens, three surgicalapproaches around the shoulder was performed: (1)anterior subclavicular, (2) axillary fossa, (3) posteriorat scapular spine.Results: The nervous articular branches from thepectoral nerves have been well identified by the ante-rior approach. Capsular branches from axillary nervevaried in numbers, destinated to glenohumeral infer-ior recess. Articular branches from suprascapularnerve vary according to their number and patterndestinated to acromioclavicular and posterior gleno-humeral joints.Conclusion: The execution of these three routes, notextensive and simple, is possible to identify thearticular nerves of the shoulder to practice a partialdenervation in case of recurrent pain of the shoulder.Surgical indications are rare but present. Each casemust be discussed to provide a surgical program ‘‘ala carte’’!

A-1094 Development of a xenogenic hand flexortendon graft

Pierre-Arnaud Aeberhard1, Anthony Grognuz1,Cedric Peneveyre1, Nathalie Hirt-Burri1,Dominique Pioletti2, Wassim Raffoul1 and Lee AnnApplegate1

1Department of Plastic, Reconstructive and Hand Surgery,University Hospital of Lausanne, Switzerland2Ecole Polytechnique Federale de Lausanne, Switzerland

Introduction: Hand tendon rupture is a debilitatingcondition which mostly affects hand flexor tendons.Usual grafting options for tendon reconstruction areautologous tendon grafts. However, autologoustendon tissue is not entirely satisfactory as it is notalways available and sometimes not properly fitted

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for reconstruction. Less often used, allogenic and syn-thetic grafts show low biological integration.Additionally, these tendons graft options show low bio-mechanical properties leading to recurrent surgerieson the long term. More reliable grafting materialwould be beneficial. Depending on their source,tissue-engineered tendons from animal sourcesseem to be able to answer these issues. Their higherbiomechanical properties can be of high interest fortendon reconstruction. Combined with appropriatehuman progenitor tenocytes, we want to developtissue engineered tendon graft that is able to integratein the human body and to sustain adequate loading.Method: Equine superficial digital flexor tendon wasdecellularized with three different protocols: twocommon protocols using detergents and the thirdprotocol using sodium chloride solution. Each tech-nique was also combined with freeze/thaw cycles toallow optimal cell removal. The decellularized graftswere then sterilized with 70% ethanol. Tendons trea-ted with each technique were then tested mechani-cally with a tensile machine to look for elasticmodulus and ultimate strength and strain. We thenassessed the biocompatibility and the migrationpotential with human progenitor tenocytes.Results: Each method was able to lower the DNAcontent thus enhancing biocompatibility of the graft.The method using sodium chloride showed the bestresults and was selected as the method of choice.Biomechanical assessment showed the sodiumchloride treatment to be superior in preserving bio-mechanical properties. The biocompatibility resultsshowed that progenitor tenocytes could be integratedin the graft and were able to migrate.Discussion: Here we present a simple decellulariza-tion protocol which will be easily implemented in theproduction of an off-the-shelve hand flexor tendongraft. The origin of this graft will allow shaping it tothe desired shape and length. The method is not onlysimple but also allows preservation of biomechanicalproperties. The combination of the graft with humanprogenitor tenocytes allows their combined use forthe optimization of our xenogenic graft for in vivointegration. A-1098 A comparative study of the clinical and

functional outcomes Following open autologousbone grafting versus arthroscopic assisted bonegrafting for scaphoid nonunion treatment

Mehmet Ali Acar, Ebubekir Eravsar andEgemen OdabasiDepartment of Orthopaedics and Traumatology, SelcukUniversity, Konya, Turkey

Aim: The aim of the present study was to comparethe clinical and functional outcomes of patients

SS204 Journal of Hand Surgery (Eur) 43(Supplement 2)

treated with open or arthroscopic bone grafted per-cutaneous screw fixation for scaphoid nonunionfractures.Materials and Methods: Twenty-seven wrists of 27patients who underwent open or arthroscopic bonegraft and screw fixation for scaphoid nonunionbetween 2013 and 2017 were retrospectively evalu-ated. The open approach group consisted of 13 wristsand the arthroscopically assisted group consisted of14 wrists. After the splint removal, wrist exercisesinitiated at 6–8 weeks post operation. Pinch strength,power grip and range of motion were evaluated usingthe contralateral wrist as a control. Functional eva-luation was assessed using the patient-rated wristevaluation score (PRWE), Quick DASH score, VASscore and Mayo wrist scoring system.Results: All patients were classified as type C andtype D according to Herbert and Fisher criteria.Fracture union was observed in all patients. Lessrestricted range of movement was observed in thepatient group arthroscopic-assisted grafting per-formed compared to the other group. Additionally, itwas found that they could use their wrists more func-tionally in the post-operational period. Wrist flexionwas significantly better in the control wrists in bothgroups. Moreover, intra-operational arthroscopicexaminations of 14 patients who underwent wristarthroscopy were performed. Intra-articular disse-minated synovitis was observed in 14 patients andarthroscopically debrided. In addition, chondropathywas detected in one of the patients and chondraldebridement was performed. SL and LT instabilitywere detected in two of the patients; in one of themrupture possibility was considered and repaired withopen dorsal capsulodesis, and the other patient wasfollowed conservatively. Two patients had both LTand TFCC ruptures together. In these patients,TFCC was debrided, and the LT ligament wasrepaired by arthroscopic dorsal capsulodesis. Inone patient, isolated LT rupture was observed andrepaired with arthroscopic dorsal capsulodesis. Inone patient, scaphocapitate ligament rupture wasobserved.Conclusions: In the cases of Type C and Type D sca-phoid fractures fixed by arthroscopic-assisted graft-ing, patients were more satisfied with functional andclinical outcomes. Percutaneous fixation is a valuabletreatment method for Type C and Type D scaphoidfractures. Thanks to arthroscopy-assisted scaphoidfixation, wrist ligaments, synovial and cartilaginousstructures can be evaluated intra-operatively. Thus,diagnosis and treatment of carpal instabilities due todamage of ligaments such as scapholunate and luno-triquetral, TFCC ruptures and synovitis can be per-formed together with scaphoid fixation. These can be

considered as the advantages of the wrist arthro-scopy-assisted surgery compared to the opensurgery.

A-1103 High volume, low rupture rate and goodoutcomes: Experiences of flexor tendon repairand appraisal of a trainee-delivered service in auniversity hospital hand surgery unit

Rachael E. Baines, James D. Bedford, Vinay N. Itte andDonald J. Dewar1Department of Hand & Plastic Surgery, Leeds TeachingHospital NHS Trust, UK

Objective: In common with other university hospitalhand surgery units, our department treats largenumbers of hand trauma patients; we aim toensure good clinical outcomes while providing agood training experience to residents and fellows.The literature suggests targets for acceptableflexor tendon rupture rates of 4–17%, andStrickland ‘‘good’’ or ‘‘excellent’’ scores in 30–50%of patients at a long-term follow-up.

The objective of this study was to review our rup-ture rates and active motion outcomes and criticallyevaluate these in the context of our service which isdelivered substantially by trainees under supervision,in order to evaluate whether this model is safe andeffective.Methods: We performed a retrospective notes reviewusing operation notes and therapy records forpatients seen over 20 months until July 2017.Demographics, details, and timings of injury and sur-gical particulars were recorded. We recorded thera-pists’ scores of grip strength, and active motion at 6and 12 weeks and most recent review.Results: Of 120 patients identified, 108 notes wereavailable for review. One hundred and thirty-twoinjured digits with 174 flexor tendon injuries weretabulated (approximately 116 tendons per year).Patients were predominantly males (2.4:1) with amean age of 33. Mean delay to repair was 2.6 days(range 0–33 days). FDP accounted for 106 repairs,FDS for 52, and FPL 16. Most FDP and FPL repairswere in zones 1 and 2, whereas most FDS repairswere in zones 2 and 3. Two thirds of repairs used afour-strand, 3/0 polypropylene core suture with a 5/0polypropylene epitendinous suture.

Most operations were performed by senior trai-nees (48%), followed by junior trainees (33%), con-sultants (14%) and fellows (7%). The overall rupturerate was 3.8% (five FDP repairs) at an average of 4.9weeks post-repair. Three ruptures occurred out ofthe thermoplastic splint, and three while lifting.

FESSH Abstracts SS205

Four were re-repaired, and the fifth patient declinedfurther surgery.

Attendance rate was 79% at 6 weeks, 48% at 12weeks, and beyond 16 weeks was 22%, with an aver-age final review of 21.3 weeks. For zone 2 repairs(excluding thumbs), Strickland ‘‘good’’ or ‘‘excellent’’results were achieved at 6 weeks by 12%, at 12 weeksby 39%, and at final review by 56%. At 12 weeks,‘‘good’’ or ‘‘excellent’’ Strickland scores wereachieved in 50% of consultants’, 46% of senior trai-nees’, and 30% of junior trainees’ repairs.Conclusions: In our unit, 86% of flexor tendon repairsare performed by non-consultant grade surgeons.Our setup provides direct consultant supervision tojunior trainees, with increasing, graded indepen-dence for senior trainees. Hand trauma surgery isperformed in a barn theatre with elective hand sur-gery on an adjacent table; senior supervision is avail-able when required.

Along with a unit preference for strong repair tech-niques, and close working relationships with ourhand therapists, we feel that this graded supervisionhas contributed to our ability to perform repairs in anacceptable timeframe and achieve both a low rupturerate and acceptable active motion scores, both ofwhich are in line with published studies.

A-1104 A palmar bilobed flap for the correction ofradial dysplasia

Ciara Deall, Roisin Dolan and Henk GieleOxford University Hospitals NHS Trust, UK

Objective: The correction of radial dysplasia can beperformed using a palmar bi-lobed flap that leavesless visible scar than a dorsal approach.Methods: This novel modification of the David Evansdorsal bilobed approach is presented, demonstratingthe excellent access, redistribution of the ulnar skinand reduced scar visibility. A review of 20 cases per-formed through the palmar bilobed approach is pre-sented. The aesthetic visibility of the palmarapproach scar was compared to the scar in 20 pre-vious cases performed through the dorsal bilobed ordorsal curved incision by collating inter-observerscores in blinded postoperative photos of the cases.Results: Successful completion of all radial dysplasiacorrections either radialization or centralizations,with successful healing of all bilobed flaps. Twocases of 20 palmar bilobed flaps had tip necrosis ofone of the flaps requiring dressings until healed, butno operative intervention was required. All observersnoted the lack of visible scarring on dorsal views of

the wrist in the palmar bilobed approach compared tothe visible scars with the other approaches.Conclusion: We describe a novel modification of theEvans dorsal bilobed incision for radial dysplasia cor-rection that reduces the visible scarring andimproves the palmar access.

A-1106 The free vascularized pedicled nervefunctioning muscle transfer: A novel concept forbrachial plexus reconstruction

Henk P. GieleDepartment of Plastic & Reconstructive Surgery, OxfordUniversity Hospitals NHS Trust, United Kingdom

Objectives: Free functioning muscle transfers arelimited by the availability and regeneration of neuraldonors.

We explore the novel concept of a free vascularizedbut pedicled nerve muscle transfer (using the rectusabdominus muscle) that overcomes the need forneural regeneration and adds to the reconstructiveoptions in brachial plexus pathology.Methods: Anatomical dissection of the nerve andblood supply of six rectus abdominus muscles inthree cadavers showed that it was possible to elevatethe rectus abdominus on its intercostal nerve supplyand dissect these to the mid-axillary line allowing themuscle to be pedicled on its nerve supply to the arm.We present five clinical cases of reconstruction ofelbow flexion in four cases of complete traumaticbrachial plexus avulsion injuries (C5-T1) and onecase of poliomyelitis.Results: The cadaveric study demonstrated thatneural dissection of the intercostal nerves supplyingrectus abdominus was possible to the axilla, andtherefore transferable. Five clinical cases were per-formed using this technique. There were no perio-perative complications. Surgical outcomesdemonstrated good elbow flexion with M4 – powerand shoulder stability regained in four out of fivecases. Two patients developed post-operativeabdominal wall hernias secondary to denervationrequiring subsequent mesh repair.Conclusions: We describe a novel reconstructiveconcept of a free vascularized pedicled nerve recon-struction adding to our armamentarium in the recon-struction of brachial plexus pathology.

SS206 Journal of Hand Surgery (Eur) 43(Supplement 2)

A-1107 Differences in illness perception in handsurgery patients

M. J. W. van der Oest1,2,3, H. W. Slijper2, R. Feitz2,S. E. Hovius1,2, J. T. Porsius1,2,3 and R. W. Selles1,2

1Department of Plastic, Reconstructive and Hand Surgery,Erasmus MC, Rotterdam, The Netherlands2Department of Rehabilitation Medicine, Erasmus MC,Rotterdam, The Netherlands3Hand and Wrist Center, Xpert Clinic, The Netherlands

Objective: The Illness Perception Questionnaire eval-uates to what extent patients find their disease threa-tening or benign. Previous research has shown thatpatients with a negative illness perception have aworse outcome to treatment and that interventionsto improve illness perceptions lead to better out-comes. To our knowledge, illness perception inhand surgery patients has not been systematicallyinvestigated. Therefore, the aim of the study is (1)to examine the illness perception of patients withcommon chronic hand disorders, (2) compare illnessperception between four major hand surgery popula-tions (Dupuytren’s disease, trigger finger syndrome,carpal tunnel syndrome and thumb base OA).Methods: Between 1 September 2017 and 10November 2017, patients from the four surgery popu-lations presenting at one of 16 hand clinics wereincluded in the study. Patients were asked to com-plete the Brief Illness Perception Questionnaire(Brief-IPQ), which is a validated brief version of theIPQ that measures illness perception on eight sub-scales: Consequences, timeline, personal control,treatment control, identity, concern, coherence andemotional representation. An analysis of covariancewas performed to investigate differences in the ill-ness perception between the four diagnostic groups.Results: Five hundred and fourteen patients wereincluded in the analyses; 87 with thumb base OA,129 with carpal tunnel syndrome, 152 with a triggerfinger and 146 with Dupuytren’s disease. Total illnessperception score was 34.9 (SD 12.1) on a scale fromzero (not threatening or benign) to 80 (maximumscore). Worst scores for the different components,all on a range from 0 to 10, were on the conse-quences (5.8), personal control (6.0) and identityscale (5.6). The components with the largest differ-ences between the different patient populations wereconsequences, identity and emotional representationwith, in all cases, the thumb base OA patients (7.5,6.9 and 5.2, respectively) reporting the most negativeillness perception and the Dupuytren patients (3.5,3.7 and 2.1, respectively) the most positive. Themean score of a subdomain within each patientgroup was 4.4 (SD 2.4).

Conclusions: We found that hand surgery patientshave a illness perception, comparable to otherchronic diseases, such as we found a large variationin illness perception between the patients withthumb base OA, carpal tunnel syndrome, triggerfinger syndrome and Dupuytren’s disease. Evenwithin these diagnostic groups, we found a large var-iation in illness perception. Therefore, illness per-ception might be an important factor to take intoaccount when predicting patient outcome.

A-1108 A bilateral, transmanubrial surgicalapproach to the caudal brachial plexus andsubclavian vessels: Presentation of 10 cases anddiscussion of surgical technique and indications

James D. Bedford1, Vinay N. Itte1, Daniel J. Wilks1,D. J. A. Scott2 and Simon P. J. Kay1

1Department of Hand & Plastic Surgery, Leeds TeachingHospitals NHS Trust, UK2Department of Vascular Surgery, Leeds TeachingHospitals NHS Trust, UK

Objectives: Pathology of the caudal elements of thebrachial plexus and subclavian vessels is uncommon,and surgical access can be challenging.Supraclavicular and axillary exposure provide a lim-ited surgical field for tumour resection and for ade-quate vascular control for vessel reconstruction.

We have found that a transmanubrial, transclavi-cular approach provides wide exposure of thesestructures, unilaterally or bilaterally. The objectiveof this work is to describe the surgical techniqueand its applications and present data on the patientswe have treated so far.Methods: Patients were selected through a jointclinic between hand and vascular surgeons.Informed consent was taken, and the patients wereworked up for theatre including pre-operativeassessment. Multimodal imaging appropriate to theindication was used to plan the procedures. MRI wasused to define the extent of tumour and involvementof plexus elements, and fluoroscopic and CT veno-graphy with 3D reconstructions were used to char-acterize vascular disease.

Through a neck crease incision, osteotomies of theclavicle and the manubrium, followed by division ofthe first costal cartilage, allow this segment to bereflected cranially on the sternomastoid and strapmuscles. This yields excellent exposure for resectionof residual rib elements or tumour, or reconstructionof stenosed or thrombosed segments of the subcla-vian vein with grafts from either internal jugular orsuperficial femoral veins. Clavicular osteosynthesis

FESSH Abstracts SS207

is performed with locking compression plates, andthe manubrium is repaired with sternal wires.Results: Ten patients (five females) were treatedover 6 years. The median age was 29 years (range8–47 years). Two procedures were bilateral.

Indications were- Tumour of caudal brachial plexus or subclavian

vessels (four)- Unilateral recurrent SCV thrombosis after first

rib excision (four)- Unilateral recurrent SCV thrombosis with con-

tralateral first rib excision (two)Median follow-up was 31 months (range 2–55

months), with no deaths and no bony non-union. Asinus over a clavicular plate resolved following sur-gical debridement. Two patients have mildlyrestricted shoulder movement; no patients havesigns or symptoms of plexopathy. No tumours (twosarcomata, one benign chondroid lesion, one fibro-matosis) recurred locally. All six SCV reconstructionsremained patent on repeat venography at a minimumof 6 weeks post-op.Conclusion: As a joint procedure between hand andvascular surgeons, this transmanubrial approachpermits safe exposure of the caudal plexus and sub-clavian vessels in the case of retromanubrialtumours affecting the brachial plexus, and for recal-citrant or recurrent subclavian vein thrombosis thathas failed surgical or interventional radiology treat-ment. This procedure appears to have a high degreeof success with a low-risk profile when conducted byan experienced surgical team.

A-1111 Long-term results with partial fasciectomyin Dupuytren’s disease

Stefano Galli and Guido ZarattiniOrthopaedic Clinic, University of Brescia, Brescia, Italy

Objective: Local treatments of the cord ofDupuytren’s disease, either by collagenase injectionor needle fasciotomy leading to the rupture of thecord, have become increasingly used methods.

The aim of this retrospective study is to reviewpatients with Dupuytren’s disease treated by theclassic treatment of partial fasciectomy, usingIselin–Dieckman or Skoog incision, at our centrefrom 2004 to 2015.Methods: We reviewed 51 patients (42 male and 9female) with a mean age of 68.4 years (range 49–89years) affected by Dupuytren’s disease, at a meanfollow-up of 7.7 years (range 2–13 years).

The distribution of the disease showed 62 hands(34 right and 28 left), 101 rays (34 fifth rays, 41

fourth rays, 16 third rays, 7 second rays, and 3 firstrays), 127 joints: 75 metacarpophalangeal joints(MPJ), 52 proximal interphalangeal joints (PIPJ).

As defined in the International ConsensusConference of Rome of 2013, we evaluate results oftreatment and recurrence rate with the passiveextension deficit (PED) of each treated joint, consid-ering each joint as a separate entity, at time 0 (periodbetween 6 weeks and 3 months after treatment) andat the final follow-up. A PED of more than 20� for atleast one of treated joints, in the presence of a palp-able cord, compared to the result obtained at time 0represented a recurrence. We evaluate amount ofcorrection with the correction coefficient ofThomine. Intraoperative and postoperative complica-tions were also evaluated.Results: Surgical treatment was successful in allcases. At time 0, mean PED was 0� at MPJ with a100% of correction and 6.6� (0–25�) at PIPJ, with a87.97% of correction. There was only one intraoperativecomplication: a nerve lesion, treated during the surgi-cal procedure. A scar contracture in one finger was theonly major postoperative complication registered.

At follow-up, mean PED remained 0� at MPJ with a100% of correction; it was 22.9� (0-95�) at PIPJ, with a58.28% of correction.

Global recurrence was observed in 15 of 127 joints(11.81%), but it was present only in PIPJ (15 of 52joints – 28.84%).

With the application of a personal staging systemwas possible to demonstrate a correlation betweenresidual PED at time 0 and recurrence rate.Conclusions: Although Dupuytren’s disease can nowbe treated quickly with minimally invasive techni-ques, we still consider traditional surgical proce-dures, as partial fasciectomy, extremely effective atmedium and long-term follow-up.

Recurrence rate at PIPJ remains present, but withlower percentages than those reported in the shortterm with minimally invasive treatments

A-1113 CT-scans alter treatment in 33% ofscaphoid fractures deemed undisplaced byconventional X-rays

Johannes Heindl1, Jesper Sonntag2, Per Rasmussen2,Per Hølmer2, Birgit Waschulzik3, Claus Hjorth Jensen4

and Anders Klahn2

1Lakumed Clinic Landshut-Achdorf, Germany2Nordsjaellands Hospital, Hillerød, Denmark3Institute of Medical Informatics, Statistics andEpidemiology, Munich, Germany4Herlev-Gentofte University Hospital of Copenhagen,Denmark

SS208 Journal of Hand Surgery (Eur) 43(Supplement 2)

Objective: Displacement is the single most importantvariable associated with nonunion of scaphoid frac-tures (SF). As conventional X-rays have been shownto be unreliable in determining displacement in SF,CT scan has been recommended as the diagnostictool of choice in determining the best treatment inSF. We investigated how CT scans of initially undis-placed SF diagnosed on X-rays affects the treatmentplan.Methods: Seventy X-ray examinations of acute SFcomprising AP and lateral wrist radiographs andthree scaphoid views were retrospectively evaluatedseparately by two senior hand surgeons. In 51 cases,the observers agreed in classifying the SF as undis-placed. CT scans of the same SF with reconstructionin the sagittal and coronal plane were evaluatedseparately and randomly by the same observers fordisplacement, stability, localization and treatment.Results: In 17 of 51 SF (33%), the treatment sug-gested from the conventional X-rays was altered byeither one (15 SF) or both observers (2 SF) after eva-luation of CT.Conclusion: CT scans should be routinely employedin the diagnosis and treatment of SF, as the treat-ment suggested from conventional X-rays may bealtered in 33% based on the evaluation of CT scans.

A-1118 Spinal accessory to suprascapular nervetransfer in late cases of obstetrical brachial plexuspalsy

Mikhail Novikov, Timur Torno, Andrey Fedorov andDmitry DruzhininYaroslavl State Children’s Hospital, Yaroslavl, Russia

Shoulder abduction and external rotation deficit isthe most common problem of children with sequelaeof obstetrical brachial plexus palsy (OBPP). The stan-dard method to improve the shoulder function in latecases of Erb’s palsy is a latissimus dorsi muscle(LDM) transfer.

However, the strength of latissimus dorsi, teresmajor muscles and all shoulder adductors, whichare spontaneously recovered after middle (C7) andlower (C8, T1) trunks involvement, can be overesti-mated. In these cases, isolated LDM or combinedwith teres major muscle transfer can be not effectivefor shoulder abduction and external rotation. Some ofthese patients can lose an active internal rotation ofthe shoulder.

As a cliche, nerve reconstructions at the age of 24months and older are considered to be not effectivedue to muscle fibers degeneration. In spite of theclinical presentation of the late Erb’s patients, the

supraspinatus and infraspinatus muscles in mostcases have fair neurophysiological conditions. TheEMG needle shows a reduction of frequency andamplitude increase. On one hand, it indicates adecrease in the number of motor units; on theother hand, it demonstrates the increase in thenumber of muscle fibers in each motor unit due toterminal sprouting. The muscles constructed ofenlarged motor units are less effective than the mus-cles with bigger number of motor units of smallersize. It led to an idea of redistribution of availablemuscle fibers into a larger number of motor unitsby providing them with new nerves with biggernumber of axons.

Between 2012 and 2016, 72 patients with OBPPunderwent spinal accessory (SA) to suprascapularnerve (SS). Twenty-seven of them were 24 monthsand older on the day of surgery. All patients had animprovement in shoulder abduction and externalrotation in 12 months after the surgery. The meanpost-operative shoulder abduction was 116� (range75–170�). The mean post-operative shoulder externalrotation was 75� (range 65–110�). EMG study hasshown increase in the number of motor units inboth supraspinatus and infraspinatus muscles in allcases.

Spinal accessory to the suprascapular nerve trans-fer is an effective method to improve shoulder func-tion in late cases of OBPP with involvement of C5–C7or other cases where adductor muscle is not avail-able for transfer. Needle EMG of supraspinatus andinfraspinatus muscles has to be used in all cases toestablish correct indication for this method.

A-1122 NT visual: Developing a 3D software fornerve surgeons

Clemens Gstottner, Cosima Prahm, Johannes Mayerand Oskar AszmannCD Laboratory for Reconstruction of Extremity FunctionMedical University of Vienna Vienna, Austria

Objective: In the last decades, various novel nervetransfer strategies have been described, givingnerve surgeons more possibilities than ever before.Individualized surgical concepts require detailedknowledge of lesion pattern and suitable approaches.The goal of our project was to develop a 3D softwarethat helps clinicians get an overview of complexnerve lesions in the upper extremity, and therebyguide reconstructive decisions.Methods: A 3D model of the brachial plexus nerveswas created in the graphics software Blender andintegrated into Unity3D, in which also the user

FESSH Abstracts SS209

interface and the program logic was implemented.One major advantage is the possibility of transferringthis desktop program to an Android- or iOS-basedapp. Literature on upper extremity nerve transferstrategies and nerve morphology was reviewed.Information that was deemed helpful for decision-making, such as axon count, fascicular structureand nerve width, was included into the program.Results: We established a complete and detailed 3Dmodel of the brachial plexus and all major nervesgoing into the arm, as well as the underlying bonestructures. Our program gives the user the possibility

to visualize all possible upper extremity nerve injurypatterns. In addition, it incorporates up-to-date infor-mation relevant to nerve surgery, such as axon countfor motor and sensory fibres, nerve width, fascicularstructure and nerve function.Conclusions: Our program provides hand surgeonswith a tool to visualize complex upper extremitynerve lesion patterns, as well as further detailedmorphologic and functional information to guidetheir treatment concepts.

SS210 Journal of Hand Surgery (Eur) 43(Supplement 2)

Author Index

Abdouni Yussef A., 94Abe Koji, 127Abe Yukio, 67Abramo Antonio, 173Abrams Geoffrey, 121Abzug Joshua M., 30, 31, 50, 51,

54, 83Abzug Joshua M., 50, 52Adler Tom, 130Aeberhard Pierre-Arnaud, 203Agorastakis Dimitris, 139Agout Charles, 56Agranovich Olga, 17, 27Ahmad J., 168Akita Shosuke, 104Aksu Ugur, 149Al Shaer S., 94Alain Fouque Pierre, 28Alberton Paolo, 66Alfeky Hazem, 167Alfonso Fernandez Ana, 33Alhosseini S., 113Ali Acar Mehmet, 204Ali Hosseinian Mohammad, 145Alokozai Aaron, 119, 121Alrawi M., 168Alvernhe Agathe, 106, 109Alves Jairo, 100Aman Martin, 180, 193Ando Kosei, 102, 110Andre de Oliveira Alves Jairo, 185,

190Andrew Eglseder W., 50, 52Angel Porras-Moreno Miguel, 105Angeles De la Red Gallego Maria,

33Angelov Kalin, 127Angus McGrouther Duncan, 31, 42,

46Angus McGrouther Duncan, 56Ann Applegate Lee, 203Anton Fries C, 143

Antoniou Ioannis, 139, 153Apard Thomas, 107, 108, 175Ardouin Ludovic, 123, 189Arnaout Ahlam, 101Arora Rohit, 120, 122Arsalan-Werner A., 67Arsalan-Werner Annika, 172Asami Saito, 23Asano Takahiro, 111Aszmann Oskar, 198, 209Aszmann Oskar C., 180, 193, 199Aszmann Oskar C., 79, 197Aszodi Attila, 66Atanasoae Ionut, 91, 111Athanaselis Stratis, 139, 153Athanassopoulos Thanassi, 62Athlani Lionel, 153Audige Laurent, 54Aurell Ylva, 76Avery Emma, 52Avidian Raffi, 121Axelsson Peter, 88, 101, 180, 188Ayala Gutierrez Higinio, 164Ayala Gutierrez Higinio, 48Ayala Gutierrez Higinio, 33Azevedo Filho Fernando A. S., 94

Bæk Hansen Torben, 176, 178Baas M., 165Bacle Guillaume, 22, 56Bae Joo-Yul, 40Baglan Yentur Songul, 128Bahm Jorg, 96Baik Cho Alvaro, 74Baik Cho Alvaro, 100, 185, 190Bainbridge L. C., 98Baindurashvili Alexey, 17Baines Rachael E., 205Bajdik Beata, 168Baker Michelle C. L., 183Balti Walid, 28

Baptista Gomes dos Santos Joao,66, 72, 88

Baskozos Georgios, 142Bassetto Franco, 146, 195Battiston Bruno, 159, 160, 195Bauer Andrea, 30Bauer Anna, 25Beauthier-Landauer Violaine, 109Bedford James D., 205, 207Beer Thomas, 91, 125Beerekamp M. S. H., 65Belcher H. J. C. R., 150Belkacem Djeffel Amar, 119Belkheyar Zoubir, 74, 119Bell David, 167Bellemere Phillipe, 123Bellemere Philippe, 125Bennett David, 142Berghs Bart, 24, 27Bergmeister Konstantin D., 180,

199Berkhout M. J., 18Bernard Sintenie Jan, 41Bernardeli Iamaguchi Raquel, 100Bernardelli Iamaguchi Raquel,

185, 190Bersani Silva Gustavo, 100, 185,

190Bertolini Maddalena, 159, 170Bezuhlyi Artur, 44Bickert Berthold, 78, 162Bigdeli Amir, 162Bigorre Nicolas, 28, 47Bihel Thomas, 20, 21Bishop A. T., 90Bishop Allen T., 75, 77Bispo Ana, 77Bjorkman Anders, 141, 182, 194Bo Jørgensen Peter, 176Bodner Gerd, 79Boettcher Richarda, 89Bolstad Bjørg, 115

Journal of Hand Surgery

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2018, Vol. 43(Supplement 2) S211–S219

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Bolton L. E., 98Bonhof Elske, 97Bonnard Chantal, 58Bonte Francis, 24, 27Boretto Jorge, 116, 162Borgers Anton, 124Botelheiro Jose, 19Boudard Julien, 109Bounakis Nikolaos, 173Bourcheix Laurent, 203Bouyer Michael, 116Boyer Etienne, 192Branemark Rickard, 154Braga Silva Jefferson, 116Brandon Roger, 148Brink Sander, 97Broekman Marike L. D., 61Brogren Elisabeth, 191, 194Bruno Battiston, 157Brussel F. A. van, 46Budurca Radu, 91, 111Buijze Geert A., 188Buket Cesim Ozge, 163Buket Cesim Ozge, 158, 159, 201Bulent Alp Nazmi, 149Bushuev Oleg, 132Butler M., 106Byers Brett, 85

Cabanas Jordi Juanos, 19Caekebeke P., 17Caine-Winterberger Kerstin, 154Caiti G., 140Calcagni Maurizio, 59, 60, 72, 87,

169, 186Cambon-Binder Adeline, 74, 109,

119Camus Emmanuel J., 75, 175Candelier Gilles, 107, 108Canova Marco, 114Cardenas Salas Jens, 68Cardillo Nicholas, 189Carita Enrico, 141Carlos Belloti Joao, 88Carlsson Ingela, 141, 194Carriere Gaetano, 179, 184Carvalho Sofia, 77Case Alexandria L., 50, 51, 52, 54,

83Cayon Fidel, 93Cecilia David, 147Cecilia-Lopez David, 105Celigoj Vanja, 73Ceren Sıgırtmac _Ilkem, 201Cerny Michael, 25

Cesari Bruno, 28, 47Cha Jungkwon, 48Chae Michael P, 107Chae Michael P., 131Chahidi Nader, 18, 45Chammas Michel, 116Charruau Bertille, 22, 56Chaves Camilo, 155Chen Chao, 90, 149Chen Jing, 126Chen Shih-Heng, 143Chen Shih-Heng, 112Cheng Ivan, 121Cheol Kwon Bong, 135Cherubino Mario, 195Choi Wan-Sun, 37Choi Yun-Rak, 43Choke Abby, 42, 56Chong Qin Yi Pamela, 46Christiaens Sigrid, 19Chung Sze-Ryn, 31Chung Yang-Guk, 155, 203Chunyawongsak Veeranon, 43Ciclamini Davide, 195Cimilli Elif, 159, 171Ciminli Elif, 163Cipers Marijke, 19Clarke Elizabeth, 189Coert Henk, 83Colaris Joost, 166Colonna Michele R., 195Cootjans Katrien, 124Costa Alfio L., 195Costa Antonio C., 94Costil Vanessa, 175Couceiro Otero Jose, 48, 164Couceiro Otero Jose, 33Coulet Bertrand, 116Couwelaar G. van, 94Cristescu Ioan, 158Crosio Alessandro, 195Crowley B., 80, 124, 168Crowley Brıd, 182Crowley Brid, 168Cuadrado Abajo Francisco, 48,

164Cugola Landino, 141Curtin Catherine, 121Cuylits Nicolas, 18, 45Cwykiel Joanna, 152, 156

Da Rold Ilaria, 170Dacatra U., 200Dahlin Lars B., 191Dahmam Amirouche, 118

Dailiana Zoe, 139, 153Dautel Gilles, 153David Zorman, 19De Carli Pablo, 162de los Angeles de la Red Gallego

Marıa, 164de Muinck Keizer R. J. O., 65De Raedt Sepp, 176de Vries Harm, 71de los Angeles de la Red Gallego

Marıa, 48De Smet Luc, 124Deall Ciara, 206Debeij Jan, 83Degez Frederic, 47Deglmann Claus J., 73Degreef Ilse, 124Del Bo P., 200Del Canto Alvarez Fernando, 33Del Rio Hortelano Julian, 68Delft E. A. K. van, 46, 47Delia Gabriele, 195Depisch Dieter, 180der Bij G. van, 47der Heijden E. P. A. van, 164der Oest M. J. W. van, 82, 207der Oest Mark J. W. van, 145Detammaecker Romain, 153Dewar Donald J., 205Dias Joseph J, 99Dias Joseph J., 184Diederix Leon, 166Dietl Hans, 199Dijksterhuis Anita, 83Diogo Rui, 182Dobbe J. G. G., 140Dobbe Johannes G. G., 137, 140Dolan Roisin, 206Dolan Roisin T., 183Donadelli Alberto, 141Donndorff Agustin, 162Dornberger Jenny, 143Dreant Nicolas, 60, 199Dremstrup Lene, 178Drossos Konstantin, 18, 45Druzhinin Dmitry, 209Dua Karan, 51, 54Dubert Thierry, 155Ducommun Pascal, 169Dudley Porras Antonio, 68Duerinckx J., 17Duerinckx Joris, 19Dutto Elisa, 160Dvorak Zdenek, 157

S212 Journal of Hand Surgery (Eur) 43(Supplement 2)

Echalier Camille, 109Edmond Tyler, 30Eglseder W. A., 83Ehrl Denis, 25Eisenschenk Andreas, 143, 161Elhassan Bassem T., 75ElKazzi Wissam, 96Elliott Charlotte, 22Eppler Sara, 117, 119, 121Eraslan Umut, 152Eravsar Ebubekir, 204Erling Christoph, 72Erne Holger, 25Ertel Wolfgang, 150, 151Erwan Favennec Yann, 107Esplugas Mireia, 196, 201Evangelista Melissa, 199Evans Peter J., 50Evers S., 82

Fahir Demirkan Ahmet, 152Fahmy Fahmy, 22Fain Aleksei, 45Fallico Nefer, 94Fallopa Flavio, 66, 72Faloppa Flavio, 88Farina Dario, 199Farokh Forghani Siamak, 187Farr Sebastian, 26Far-Riera Ana M., 44Fassola Isabella, 150, 151Favennec Yann-Erwann, 108Fazio Antonina, 195Fedorov Andrey, 209Feitz R., 94, 207Feitz Reinier, 133, 145, 197Fenoglio Alessandro, 159Fernandes Marcela, 66Fernandez Diego, 128Fernandez-Noguera Nuria, 201Ferreira Louis, 85Ferrero Martın-Miguel, 136Ferrero Matteo, 159, 160Festin Christopher, 193Feuvrier Damien, 105, 106Fieraru G., 106Fink A., 94Fischer Gabriella, 59, 60Fischer Vera, 114Fok Margaret, 128Fox Paige, 121Franca Bisneto Edgard N., 126Francesco Giacalone, 157Francisco Jimenez Sanchez Juan,

68

Franz Langer Martin, 117, 170Franza Mara, 195Frederic Schuind, 19Friden Jan, 73, 76Fritz Tobias, 169Frueh Florian S., 169Fucs Patrıcia M. M. B., 94Fujihara Nasa, 33Fujihara Yuki, 33, 63Fujii Kenzo, 67Fujio Keiji, 202Furniss Dominic, 142

Goransson Harry, 121Goren Yekta, 172Gabl Markus, 120, 122Gafney P., 106Gaisne Etienne, 123, 125Galeano Mariarosaria, 195Galli Stefano, 208Gallucci Gerardo, 162Gama Sergio, 181Ganhewa Dasun, 107Garcon Johanne, 22Garcia Juan Maria Pardo, 147Garcıa Portal Gonzalo, 164Garcıa-Lamas Lorena, 105Garcıa-Medrano Belen, 136Garcia Lamas Lorena, 147Garcia-Elias Marc, 196Garcia-Elias Marc, 201Garcia-Martinez Jesus, 156Gardiner Matthew, 83Gardner Michael, 121Gayoso Rodrıguez M. J., 136Gazimieva Bella, 103Gazyakan Emre, 162Geijer Mats, 173Georgescu Alexandru, 149Geraedts Hilde, 71Gerosa Thibault, 20, 21Ghribian Ali, 145Giacalone Francesco, 159Gianolla Daniele, 81Giddins Grey, 58, 95, 184Giddins Grey E. D., 177Giele Henk, 206Giele Henk P., 183, 206Giesen Thomas, 72, 87, 186Gilbert Fabian, 42Giovanoli Pietro, 59, 60, 87Giunta Riccardo E., 66Gkotsi Ann, 96Gohritz Andreas, 186Goliana Sergei, 178

Golubev Igor, 103, 132Golyana S.I., 138Goncalves Francisco, 77Gosk Jerzy, 57Goslings Carel, 41Goslings J. C., 65Goslings J. C., 65Gotani Hiroyuki, 49Goubau Jean, 24, 27Goubau Yannick, 24Gough A. T., 106Govorov A.V., 138Govorov Anton, 178Grandjean Amaury, 20, 21Gras Mathilde, 181Gregorio Paulos Renata, 74Grimsgaard Christian, 120Grobet Cecile, 54Grognuz Anthony, 203Gstottner Clemens, 209Guerra Sabongi Rodrigo, 88Guitton Thierry G., 26Guo Yang, 185Gutkowska Olga, 57Gvozdenovic Robert, 146

Høgmalm Johan, 115Hølmer Per, 208Hulsemann Wiebke, 160, 163Haas Elisabeth M., 66Haas K. P. de, 82Haddara Mohammad, 85Hahnhaußen Jens, 150Haitao Tan, 134, 135Hak Roh Young, 69Han Gang, 70Han Lee Yo, 55, 64Hand-Wrist Study Group The, 133Hao Liwen, 90, 149Hariharan Arun, 30Harold Jennart, 19Hartig-Andreasen Charlotte, 41Harvey Ian, 22Hasenoehrl Timothy, 199Hashimoto Jun, 104Hashimura Takumi, 202Haug Luzian, 130Haughton David, 22Hausner Thomas, 91, 125Havulinna Jouni, 121Heffinger Christian, 162Heindl Johannes, 146, 208Henning Esther, 143Henrik Søe Niels, 191Henrique Fernandes Carlos, 66, 72

Author Index S213

Hensler Stefanie, 87Heras-Palou C., 28Hernandez German, 93Herren Daniel B., 87Heydemann Ahlke, 156Hidaka Noriaki, 21Hidetsugu Suzuki, 23Hideyuki Takeda, 23Hile Mark, 189Hiller Michael, 72Hirata Helton, 181Hirata Hitoshi, 33, 86Hirche Christoph, 162Hirt-Burri Nathalie, 203Hjorth Jensen Claus, 129, 146, 208Hjorth Jensen. Claus, 70Ho Christine, 30Ho Lee Young, 64, 101Ho Shin Young, 40Hofer Christian, 193, 199Hoffmann Klaus P., 193Hoffmann Reinhard, 172Hogg Fiona, 187Holm-Glad Trygve, 53, 120Hong Jung-Jun, 43Houpt P., 36Houvet Patrick, 203Hove Leiv M., 148Hovius S. E., 82Hovius S. E. R., 90Hovius S. E., 207Hovius Steven, 133Hovius Steven E. R., 145, 197Hoyen Harry A., 50Hozyainova Olga, 132Hruby Laura A., 79, 197Hsiang Wei Teng, 74, 100, 185, 190Hsiao Jo-Chun, 143Hsu Chung-Chen, 112, 143Huang Yi-Chun, 112Huber Michaela, 79Hug Urs, 169Hugdahl Kenneth, 148Hunter-Smith David J, 107Hunter-Smith David J., 131Hwa Hong Seong, 101Hwang Jae-Yeon, 135Hyun Baek Goo, 55, 64, 69, 101Hyung Lim Jin, 102

Ibsen Sørensen Allan, 99, 100, 101,180

Ibsen Sorensen Allan, 188Idowu Akinyemi, 174IJsselstein C. B., 18

Ikeda Masayoshi, 39Ikeguchi Ryosuke, 63Imai Shinji, 102, 110Isaacs Samuel, 18Ishii Takayuki, 39Islur Avinash, 52Itte Vinay N., 205, 207Iwatsuki Katsuyuki, 86

Jørring Stig, 129, 146Jørum Ellen, 115Jager Thomas, 142Jain Abhilash, 83Jakobus Julia, 129Jakubietz Michael G., 42Jakubietz Rafael G., 42Jalil Hassanin, 19Jan Verleisdonk Egbert, 41Jann David, 87, 186Jansen M. C., 82Jauregui Julio, 31Javad Fatemi Mohammad, 187Javier del Canto Alvarez

Fernando, 164Javier del Canto Alvarez

Fernando, 48Jeong Bae Kee, 55, 64, 101Jermann Diana, 59Jeudy Jerome, 28, 47Jiayu Too Sarah, 31Jie Lao, 40Jimenez Diaz Veronica, 147Jimenez-Dıaz Veronica, 105Jinhwa Kam, 110Johansson Carina B., 115Johansson Martin, 182Johnson Nick, 99Jong Lee Seon, 135Jordan Daniel, 187Jose Alvarez Barcia Angel, 136Jose Edakalathur Jefin, 23Joyce Thomas, 58Jun Hong Jung, 110Jung Jae-wook, 133Jung Kang Ho, 35Jung Park Il, 102Jupiter Jesse B., 188Jurkowitsch Josef, 91, 125Justi Pisani Marina, 100

Karrholm Johan, 88Kunzli Michael, 138Kai Li Chan, 56Kaiming Gao, 40Kakar Sanj, 119

Kalb Karl-Heinz, 160Kalu P., 168Kamal Robin, 117, 119, 121Kamiloski Viktor, 186Kan Hyongyon, 202Kaneshiro Yasunori, 21Kang Hanvit, 102Kang Ho-Jung, 43, 110Kang Sangwoo, 48Kang Young-Hoon, 155Kao Huang-kai, 62Kapsetakis Petros, 173Karduz Gulsum, 149Karjalainen Teemu, 121Kasapinova Katerina, 186Kasparov Boris, 38Kastanis Grigorios, 173Kateva Margarita, 127Katzky Uwe, 79Kay Simon P. J., 207Kearsey Chris, 22Kenta Saito, 23Kerjean Yves, 123, 125Keuchel Tina, 91, 125Khan Adil, 187Kheiran Amin, 184Khusainov Nikita, 24Ki Goorens Chul, 24, 27Ki Lee Sang, 29Kim Byungjun, 92Kim Hyeonwoo, 92Kim Jihyeung, 55, 64, 101Kim Ji-Sub, 43Kim Joing-Pil, 176Kim Jong-Pil, 130, 132, 133Kim Joo-Hak, 37Kim Simon, 143, 161Kim Sung-Jae, 37Kincaid R. J., 106Kirkeby Lone, 178Kitis Ali, 152Kjærgaard Thillemann Janni, 176Klahn Anders, 146, 208Kneser Ulrich, 78, 162Kobayashi Yuka, 39Koch A. R., 165Koch K., 67Kochenova Evgeniia, 27Kochenova Evgeniya, 24Kodama Narihito, 102, 110Koehler S.V., 67Koh Il-Hyun, 43Koh Il-hyun, 110Koltsov Andrej, 33, 38Konstantin Fiodorov, 123

S214 Journal of Hand Surgery (Eur) 43(Supplement 2)

Konstantin Yazerski, 123Kosiyatrakul Arkaphat, 43Kozin Scott H., 50Kruger Kay, 150, 151Kraneburg Ursula, 129Krasnici Senat, 150, 151Kremer Thomas, 78Krimmer H., 67Kritiotis Constantinos, 34Kroon Gertjan, 97Kubek Tomas, 157Kuga Kensaku, 102Kulbacka-Ortiz Katarzyna, 154Kumar Bhaskaranand, 32Kunz Benedict, 150, 151Kurata Yoshiaki, 113Kurimoto Shigeru, 86Kurinnyi I. M., 114Kuroda Max, 19Kurozumi Taketo, 113Kutepov Ilya, 132Kuyama Yoichiro, 102Kwang Kim Jae, 40

Lollgen Ruth, 138Low Steffen, 25Laarhoven C. M. C. A. van, 164, 165Lafosse Thibault, 20, 21Lakatos Adrienn, 88Lalonde Donald H., 107Landgren Marcus, 173Lange Jeppe, 41Lanmuller Hermann, 193Laps Alexandra, 30Larsson Sara, 194Laulan Jacky, 22, 56Lautenbach Martin, 161Lavareda Goncalo, 77Lazerges Cyril, 116Leclerc Gregoire, 109Leclercq Caroline, 81, 101Lee Chang-Hun, 37Lee Che-Hsiung, 147Lee Dong-Ho, 130, 132, 176Lee Kwang-Hyun, 37Lee Sang-Yun, 43, 110Lee Yong-Suk, 155, 203Leenhouts P. A., 65Leenhouts Peter, 41Leeuwen C. N. van, 18Lehanneur Malo, 20, 21Leighton Paul, 99Leixnering Martin, 34, 91, 125Lejeune Anne, 18, 45Lenkei Balazs, 88, 168

Leomil de Paula Emygdio J., 126Leon Gutierrez Andres, 68Leong Natalie L., 188lepage Daniel, 105, 109, 192Leppanen Olli V., 121Leroy Marc, 189Leunen Ine, 19Leversedge Fraser J., 50Li Yan, 154Licciardello Valerio, 195Lim Philip, 62Lim Rebecca, 56Lin Cheng-Hung, 112, 143Lin Chih-Hung, 143Lin Xu, 134, 135Lin Yu-Te, 112, 143, 147Lind Karin, 174Lindsay Sarah, 119, 121Linnanmaki Lasse, 121Littler J., 168Lluch-Bergada Alex, 196Lluch-Bergada Alex, 201Llusa-Perez Manuel, 196Lo Giudice Giorgio, 195Lockwood Victoria, 182Loh Charles, 112Loh Charles Y. Y., 147Loh Meiling, 62Loisel Francois, 192Loisel Francois, 105, 106, 109Lorimier Laura, 126Louage Sofie, 19Loubersac Thierry, 123, 125Lu Laura, 119Luchetti Riccardo, 199Luenam Suriya, 43Lukas Bernhard, 73Lumens David, 45Lysak A., 92Lysak A. S., 114Lysak Andrii, 44Lyuji Takemura Renan, 185, 190

Mansson Sven, 182Morth Eric, 198Muller Gunilla, 182Muller Markus F., 182Munn Friederike, 161Maas M., 65Machado Filipe, 77Machens Hans-Gunther, 25, 129Maes-Clavier Catherine, 125Magistroni Ernesta, 170Mahadevaiah Venugopal Shringari,

32

Maier Johannes, 79Makino Yoshinori, 111Makrigianakis Idomeneas, 173Maldonado Andres A., 75, 77Malizos Konstantinos, 139, 153Mann Max, 160, 163Mannan Choudhury Muntasir, 31, 46Manzano-Szalai Krisztina, 180, 193Mao Hailei, 70Marıa Rapariz Gonzalez Jose, 44Marıa Velez Garcıa Olga, 48, 164Maraka J., 80, 124Marcheix Pierre-Sylvain, 74Marguiles Eric, 54Maria Spagnoli Anna, 94Marks Miriam, 54, 87Martınez Cortavitarte Vanesa, 48Martınez-Galarza P., 28Marteau Emilie, 22, 56Martin Enrico, 61Martynkiewicz Jacek, 57Maschino Hugo, 153Masmejean Emmanuel, 20, 21Masquelet Alain-Charles, 109Massazza Giuseppe, 170Matei Ileana, 149Mathot Femke, 90Mathoulin Christophe, 181, 199Matsuda Shuichi, 63Matsui Hirotada, 113Matsuoka Masayuki, 202Mattar jr Rames, 190Mattar Junior Rames, 74Mattar Rames, 126, 185Matteo Ferrero, 157Maurstad Lise, 115Maxence Krahenbuhl Swenn, 58Maximov Andrey, 132Mayer Johannes, 197, 209Mayer Johannes A., 79McGuire Duncan, 85Mckee Daniel, 107Meex Ingrid, 19Meffert Rainer H., 42Megerle Kai, 129Mehlman Charles, 30Meier Rahel, 62, 80, 130Menger Michael D., 169Menu Gauthier, 106, 109, 192Merkulov Maxim, 132Mertz Kevin, 117Messina J. C., 200Messina Jane C., 199Mete Oguzhan, 128Metzger Wolfgang, 169

Author Index S215

Micieli Pietro, 195Middleton R., 106Miguleva Irina, 45Mikalef Petros, 171Millesi Hanno, 68Milroy Catherine, 174Miranda Ben, 22Mishra Anuj, 34Mitsuzawa Sadaki, 63Miyamoto Hideaki, 113Miyamoto Meirelles Lia, 66Molenaar C. J. L., 46Molino Daniele, 170Monticelli Andrea, 146Monticelli Francesco, 195Moo Heo Youn, 29Moojen T. M., 94Moosavizadeh M., 113Moreno Mateo Fernando, 136Moreno Rodrigo, 188Morris Vivien, 106Moungondo Fabian, 175Muder Daniel, 136Mudgal Chaitanya S., 134, 135Mulders Marjolein, 41Murayama Atsuhiko, 63Muskens Ivo S., 61Myamoto Meirelles Lia, 72Myrseth Lars-Eldar, 115

Nakajima Daisuke, 39Nakamura Toshiyasu, 127Naqui Zaf, 34, 83Nassar Kaz, 187Nedu Maria, 149Neubrech F., 67Neutel N., 36Neves Joao, 77Ng L., 168Ng Lisa, 168, 182Ng Michael, 142Nguyen Thao, 50Niazi Mitra, 187Nilsson Anders, 99, 100Nishida Keiichiro, 55Noguchi Takaaki, 104Novak Pavel, 157Novikov Mikhail, 209Nygaard Vedel Pernille, 191

Oksuz Cigdem, 158, 159, 163, 201Ozyurek Gulhan, 19O’Grady Eva, 154O’Hara Nathan, 30, 51, 54Oberemok M., 92

Oberemok Mykola, 44Oberfeld Elisabeth, 62Obert Laurent, 105, 106, 192Obladen Adrian, 143Oda Hiroki, 63Odabasi Egemen, 204Odake Kazuya, 111Odella S., 200Odgaard Anders, 70Oeckenpohler Simon, 117Oei Edwin, 166of Variation Group Science, 26Oh Won-Taek, 43, 110Ohta Souichi, 63Ohtsuka Aiji, 55Okita Shunji, 55Oliveira Thomaz G., 94Ooms Edwin, 85Orouji Zahra, 187Oskay Deran, 128Ota Hideyuki, 63Ottenhoff J. S. E., 164Ozaki Toshifumi, 55

Pailthorpe Charles, 99Palanca Ariel, 121Palm Christoph, 79Palumbo F.V., 200Panciera Paolo, 81Panouilleres Marie, 105, 106Park Jikang, 48Park Kwang-hee, 133Park Sung-Bae, 130, 176Paryavi Ebrahim, 83Paul Hovis James, 83Paulo Mussi Joao, 142Pedrini, 200Peneveyre Cedric, 203Pensy Raymond A., 50, 52Pensy Raymond A., 83Perelli S., 17Perez-Uribarri Carlos, 44Perret Jerome, 79Perrin Mike, 199Pertea Mihaela, 91Peterson Steven L., 71Petit Alexandre, 28, 47Petter Kleggetveit Inge, 115Pezzei Christoph, 34, 91, 125Piccaro Erazo Jaime, 88Pickering Greg T., 177Pier Luigi Cosentino, 157Pinder Richard, 83Pingou Wei, 134, 135Pioletti Dominique, 203

Pittermann Anna, 197Pluvy Isabelle, 105, 106Podesser Bruno K., 180Poelstra Ralph, 133, 145, 197Pohlemann Tim, 169Politikou Olga, 72, 87Porras Miguel, 147Porsius J. T., 82, 207Porsius Jarry T., 133, 145, 197Poumellec Marie-Anne, 60Power Dominic, 171Prahm Cosima, 198, 209Pruna Marius, 149Puig de la Bellacasa Inma, 201Pujji Ojas, 154Pujol Oliver Tomas, 44

Qin Jun, 126Quadelbauer Stefan, 34Quadlbauer Stefan, 91, 125Quolquela Muhammad A., 190Quolqula Muhammad A., 191, 195

Røkkum Magne, 53, 115, 120Rømer Lone, 176Rohrl Stephan, 53Rabarin Fabrice, 28, 47Radek Kebrle, 84Radius Fracture Study Group

Distal, 99Radotra Ishan, 34Raffoul Wassim, 203Rafidi George, 152Raimbeau Guy, 28Rajaratnam Vaikunthan, 25, 26Rakhorst H., 94Ramadan Reda, 95Ras L., 65Rasmussen Per, 208Rbia Nadia, 90Reay Emma, 168Reigstad Ole, 53, 120Reijman Max, 166Reinholdt Carina, 73Reissner Lisa, 59, 60Renato Nakachima Luis, 66, 72Renfree Kevin J., 37Reynolds Bethany, 131reza Farhood Amir, 97Ribak Samuel, 181Richard Craig-Craven Alexander,

148Rigopoulos Nikos, 153Riley Nick, 18Ring David, 26

S216 Journal of Hand Surgery (Eur) 43(Supplement 2)

Ritt M. J. P. F., 18Roche Aidan D., 199Rochet Severin, 109Rodrigues Jeremy, 83Rodrigues Moreira Saulo, 72Romero-Brufau Santiago, 77Roness Siri, 120Rong Li Xiang, 126Roo Marieke G. A. de, 137, 140Rosen Birgitta, 141Rosa de Rezende Marcelo, 74, 100,

185, 190Rosberg Hans-Eric, 194Rosenauer Rudolf, 68Rossen J. van, 94Roth Kasper, 166Roulet Steven, 56, 189Roux Jean-Luc, 118Roy McKean Andrew, 174Royaux Deborah, 123Royeck Thorben, 117Rozen Warren M, 107Rozen Warren M., 131Ruben Sanchez Crespo Manuel, 48Ruben Sanchez Crespo Manuel, 33Ruff Roman, 193Ruiz Torres Luciano, 190Rusignuolo Giuseppe, 78Russold Michael F., 193

Sanchez Crespo Manuel, 164Sanchez Jimenez Marcos, 44Sabau Sophie, 153Saint Cast Yan, 28Saint Cast Yann, 47Saito Ikuo, 39Saito Taichi, 55Saka Natsumi, 113Saller Maximilian M., 66Salminger Stefan, 79, 197, 199Salva-Coll Guillem, 196Santos Ledo Ciro, 33Santos William Z., 94Sard Arman, 160Sasaki Gen, 113Sasaki Kosuke, 49Sauerbier M., 67Sauerbier Michael, 172Sautet Alain, 109Sautin Maksim E., 103Savina Margarita, 24Schaefer Dirk J., 186Schep N. W. L., 46, 65Schep Niels, 41Schibli Silvia, 114

Schindele Stephan, 87Schlur Charles, 203Schmauss Daniel, 25Schmid Annina, 142Schmidhammer Robert, 68Schmidle Gernot, 120, 122Schmidt Karsten, 42Schmoll Martin, 193Schmoranzova Alena, 84Schnick Ulrike, 89Schroll Lena, 41Schuind Frederic, 96Schuurman A. H., 36Schuurman A. H., 164Scott D. J. A., 207Scott Kelly, 37Scuderi Nicolo, 94Sebald Julia, 172Seger Edward, 31Selles C. A., 65Selles R. W., 82, 207Selles Ruud W., 133, 145Selles Ruud W., 197Semin Akel Burcu, 158, 159, 163,

171, 201Sendi Parham, 80Sergent Pauline, 109Serhey Kheylick, 123Seyrek Onur, 171Sh. Kamrani Reza, 96, 97Shafieyan Saeid, 187Shahabpour Maryam, 175Shahrokh S., 113Shasti Mark, 31Sheikholeslami Nicole, 119Shian Chao Tay, 56Shian Chao Vincent Tay, 46Shimamura Yasunori, 55Shin A. Y., 90Shin Alex Y., 75, 77Shin Seung-Han, 155, 203Shinomiya Rikuo, 38Shiryaeva Galina, 132Shoun Tan, 25Shu Ting Chin, 56Shusterman Igor, 51Shvedovchenko Igor, 33, 38Siemionow Maria, 152, 156Sik Gong Hyun, 69, 101Sik Park Hyun, 35Sik Seok Hyun, 55Sik Gong Hyun, 55, 64Silverio Silvia, 19Simon Perez Clarisa, 136Simeonov Nikola, 127

Singh Harvinder P., 184Singh Sanmeet, 52Singh Swapnil, 78Skotak Cece, 37Slijper H., 94Slijper H. P., 82Slijper H. W., 207Slijper Harm, 133Slijper Harm P., 145, 197Sluis-Cremer Tim, 85Smarrelli Davide, 192Smit X., 82Smith Belinda, 189Smith Hayley, 150Smith Timothy R., 61Soelberg Vadstrup Lars, 194Solgard Lars, 146Sollerman Christer, 101, 180Solomons Michael, 18, 85Sonda Regina, 146Song Xuyang, 51, 52Sonntag Jesper, 208Spinner Robert J., 75, 77Spitzmueller Romy, 143Sponseller Paul, 30Sporer Matthias E., 180, 193Stagno d\’Alcontres Ferdinando,

195Stamate Teodor, 91, 111Stark H. L., 80, 124Stern Christoph, 114Stevenson S., 80, 124, 168Stevenson Susan, 168, 182Stiborova Sarka, 157Stilling Maiken, 176, 178Stockmans Filip, 166, 188Stromberg Joakim, 73, 76Strackee S. D., 140Strackee Simon D., 137, 140Strafun O. S., 114Strafun S., 92Strafun Sergii, 44Stralen K. J. van, 46Strazar Robert, 52Streekstra G. J., 140Streekstra Geert J., 137, 140Streit Libor, 157Strijkers G. J., 140Struckmann Victoria F., 78Stupka Igor, 157Sturma Agnes, 197, 198, 199Sudo Akihiro, 111Suh Nina, 85Sukharev Alexander, 123Summa Pietro Di, 157

Author Index S217

Sun Liying, 185Sun Wenhai, 70Sunagawa Toru, 38Sup Kim Ji, 35Surke Carsten, 130, 138Susic Dejan, 146Syam Kevin, 23Szabo Zsolt, 88, 168Sze Ryn Chung, 46Szilagyi Erzsebet, 156

Tagil Magnus, 173Tack Kwon Sung, 92Taghi Abadi Ehsan, 187Taha Sara, 66Tahir Ansari Mohammed, 78Takagi Takehiko, 39Takamatsu Kiyohito, 21Takemura Yoshinori, 102, 110Takeuchi Hisataka, 63Takuma Wakasugi, 23Tamas, Camelia, 111Tamas Camelia, 91Tanaka Yoshitaka, 49Tang Peter, 50Taras John S., 50Tatebe Masahiro, 86Tchurukdichian A., 106Temizkan Ege, 163, 171Temkit Hamy, 37Teurneau Vendela, 173Thorkildsen Rasmus, 115, 120Thu Frode, 115Tian Guanglei, 185Tiengo Cesare, 146Tietzmann Alexandre, 181Tikhonenko T.I., 138Tikhonenko Tatyana, 178Tobin Vicky, 107, 131Toft Nielsen Emil, 176Topa Ionut, 91, 111Topp Tobias, 161Tore Gizem, 128Torno Timur, 209Toro-Aguilera A., 28Torretta F., 200Tos P., 200Trachanatzi Eirini, 173Tranum-Jensen Jørgen, 191Trinler Ursula, 78Tromborg Hans, 117Tsai Tzong-Yun, 143Tsehaie Jonathan, 133Tsuji Hideki, 113Tsuji Shigeyoshi, 104

Tsujii Masaya, 111Tsukanaka Masako, 53Tsuyuguchi Kazuaki, 202Tufan Abdurrahman, 128Tuna Zeynep, 128Twigt Bas, 41Tymoshenko S., 92Tymoshenko Sergii, 44Tze Yang Tiong Vincent, 62

Urganoglu Onur, 171Ursache Andrei, 158

Vogelin Esther, 62, 130, 138Vadstrup Lars, 146Vaiude Partha, 167Valdatta Luigi, 195Van Boxstael Sam, 19van Burink M.V., 94van den Oest Mark, 133van der Heijden Brigitte, 83van Eerten Percy, 41van Es Eline, 166van Ham Anouk, 97van Nieuwenhoven Christianne A.,

197Van Nuffel Maarten, 124Van Overstraeten Luc, 75, 175van Dieren Susan, 41Van Hoonacker Petrus, 45van Schoonhoven Jorg, 128Vandepitte Catherine, 19Vanek Petr, 76Vanhees Matthias, 189Vanmierlo Bert, 24, 27Vanni Stefania, 160Vardar Kubra, 149Varitimidis Sokratis, 139Varitimidis. Sokratis, 153Vedung Torbjorn, 136Velez Garcia Olga, 33Velivasakis George, 173Verhaar Jan, 166Vermeulen J., 46, 47Verna Valter, 170Vesely Jiri, 157Vikstrom Pernilla, 141Vilcioiu Daniel, 158Vissers Gino, 27Vitovska Eva, 157Voegelin Esther, 80, 98Volkmer Elias, 66Vyska Tomas, 157

Wohl Rebecca, 79

Walch Arnaud, 74Walenkamp M. M. J., 65Walenkamp Monique, 41Wallmon Anders, 174Wang Bin, 70Wang Zengtao, 90, 149Wangdell Johanna, 73Warwick David, 171Waschulzik Birgit, 208Watanabe Kentaro, 63Watanabe Masahiko, 39Waterston Stuart, 187Watts Adam, 23Waxweiler Charlotte, 18, 45Webb Jill, 154Webb Mark, 22Wehrli Laurent, 58Wei Fu-Chan, 143Wei Ping Sim, 25, 26Wejnold Jørgensen Rasmus, 70,

146Wester Knut, 148Whang Jong-Ick, 35Wheatley Michael J., 71Wiberg Akira, 142Wieskotter Britta, 117Wilks Daniel J., 207Willensdorfer Anna, 193Williams Georgina, 174Wincheringer Dennis, 172Winkelhagen Jasper, 41Winter Raoul, 97Wirtz Christian, 62Wittenberg Thomas, 79Woo Choi Shin, 40Woo Hong Seok, 69Woo Sang-Hyun, 92Woo Soojin, 92Wright Lucie, 182Wu Rui, 107

Xiang Luo, 134, 135Xin Zhao, 40Xiong Ling-Yun, 162

Yachi Koji, 104Yagi Hirohisa, 49Yamamoto Michiro, 33, 86Yang Seg-Won, 132Yang Youheng Ou, 46Yano Koichi, 21Yavari M., 113Yen Ling Wang Aline, 62Ynoe de Moares Vinicius, 88Yoneda Hidemasa, 86

S218 Journal of Hand Surgery (Eur) 43(Supplement 2)

Yuan Hui Andrew Chin, 46Yuan Hui Chin Andrew, 31Yudong Gu, 40Yuen Yung Loh Charles, 62Yup Lee Joo, 102Yurie Hirofumi, 63

Zophel O. T., 94

Zaidenberg Ezequiel, 162Zainul Bin Abidin Suraya, 46Zamfirescu Dragos, 158Zanchetta Francesco, 195Zarattini Guido, 208Zaytseva N.V., 138Zdenek Vodicka, 84Zhiren Benjamin Liang, 26

Zhou Shengbo, 70Zhou Xiang, 126Zhu Xiaomao, 50Zijlker H. J. A., 18Zink Frederico, 181Zuidam J. M., 165

Author Index S219