Background: Dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint often lead to stiffness, pain, and post-traumatic osteoarthritis (PTOA). This study evaluated long-term clinical outcomes and radiographic PTOA following surgical treatment of unstable PIP fracture-dislocations. Methods: We conducted a retrospective cohort study of 25 patients (27 fingers) treated with extension block pinning for unstable dorsal PIP fracture-dislocations between 2000 and 2009. Follow-ups in 2010 and 2021 assessed active range of motion (AROM) in PIP and distal interphalangeal (DIP) joints, grip strength, and pain. Postoperative radiographs were analyzed for articular surface involvement and step-off. Post-traumatic osteoarthritis was graded using Kellgren-Lawrence, Kallman, and Osteoarthritis Research Society International scales by 3 blinded hand surgeons, with intraobserver and interobserver reliability assessed. Results: Over a follow-up of up to 16 years, PIP AROM remained stable. Patients aged ≥45 had reduced PIP AROM and more frequent pain. Greater pain was also seen in those with >0.5 mm articular step-off or advanced radiographic osteoarthritis (OA). Osteoarthritis progression was associated with reduced PIP AROM and residual step-off. The Kallman scale showed the most significant OA progression, especially with ≥50% joint surface involvement. Osteoarthritis grading showed substantial intraobserver and interobserver reliability. Conclusion: Long-term function after extension block pinning of dorsal PIP joint fracture-dislocations remained, though age over 45 years and residual step-off predicted reduced AROM, pain, and OA progression.

Background: Restoring the volar lip of the middle phalanx is key to regaining concentric joint gliding after dorsal proximal interphalangeal (PIP) joint fracture-dislocations, but no reliable radiographic assessment currently exists. This study introduces volar tilt as a new radiographic measure. Methods: We evaluated 27 dorsal PIP fracture-dislocations in 25 patients, analysing clinical outcomes, osteoarthritis (OA) and volar tilt on lateral radiographs at injury, after extension block pinning and at 16-year follow-up. Results: Initial volar tilt averaged 22°, improving to 12° after extension block pinning and 9° at follow-up, while adjacent uninjured fingers averaged -2°. Increased residual volar tilt was associated with pain and volar tilt ≥10° revealed significantly poorer Patient-Rated Wrist/Hand Evaluation scores and increased radiographic OA. Conclusions: Volar tilt reflects subluxation in both acute and chronic dorsal PIP joint fracture-dislocations and predicts better long-term outcomes and less radiological OA when properly restored. Level of Evidence: Level IV (Therapeutic).

PURPOSE:Assessing triquetral alignment aids in evaluating carpal instability, but no reliable methods have been established. This study assessed factors affecting the reliability of triquetral angle measurements by experienced observers and used a computer-aided analysis software to establish normal values for triquetral alignment. METHODS:A mathematical modeling-based software analyzed 121 cone-beam computed tomography scans of asymptomatic wrists and measured the radiotriquetral and lunotriquetral angles. Thirty scans were digitally reconstructed into lateral radiographs and measured by hand surgeons without (n = 7) and with (n = 6) illustrated instructions. The second group also measured optimized images with bone overlap removed. Two-axis variants were used: a traditional axial axis and a novel axis perpendicular to the distal articular surface. Intra- and interobserver reliability was assessed using intraclass correlation coefficients. Two patients with volar intercalated segment instability were analyzed using the software. RESULTS:The computer-aided method demonstrated excellent repeatability and was similar to the manual measurements by surgeons. The mean lunotriquetral angle was 22° (SD 8°; range 4° to 51°) using the axial axis and 10° (SD 8°; range -11° to 33°) using the perpendicular axis. Manual measurements using the axial axis showed poor to moderate reliability, while the perpendicular axis in optimized images demonstrated excellent reliability. In a patient with complete lunotriquetral injury, the software detected a decreased lunotriquetral angle (-7°) compared to a normal angle (15°) contralaterally. In a patient with suspected nondissociative instability, the software confirmed the flexion of the entire proximal carpal row. CONCLUSIONS:Manual identification of the traditional triquetral axis is unreliable in summation radiographs, even when aided by instructions. The computer-aided analysis was more reliable than that of experienced observers with optimized images. CLINICAL RELEVANCE:Computer-aided analysis improves the reliability of triquetral alignment assessment and can improve diagnostic accuracy. The established normal values provide a reference for future studies on triquetral pathology.

Purpose: This study aimed to assess how much symptoms resolve during a 6-week continued nonsurgical treatment with an orthosis and after trapeziectomy in people with thumb carpometacarpal joint osteoarthritis (CMC-1 OA) referred for surgical consultation. The data on symptom resolution magnitude and trajectory can help inform patients about postsurgical recovery and assist researchers in designing clinical trials to evaluate surgery’s effectiveness for CMC-1 OA. Methods: We recruited 52 patients with CMC-1 OA referred for surgical consultation. All eligible and willing patients underwent a 6-week treatment period with an orthosis before trapeziectomy. We collected outcome measures at the time of recruitment, after 6-week use of an orthosis (time of surgery), and at 3, 6, 9, and 12 months following the surgery. The Patient-Rated Wrist/Hand Evaluation questionnaire was the primary outcome measure. We used a repeated measures mixed model to estimate the group mean values for continuous outcomes. We compared the estimates with known minimal clinically important difference values. Results: A continued nonsurgical treatment with a 6-week use of an orthosis resulted in no relief from hand disability and pain. After trapeziectomy, a large and clinically important change occurred at 3 months, and a rapid decrease in symptoms continued until 6 months, at which point it was three times the minimal clinically important difference value for Patient-Rated Wrist/Hand Evaluation. Conclusions: This study provides useful estimates for the trajectory and magnitude of the symptom resolution after trapeziectomy. A continued nonsurgical treatment with a 6-week use of an orthosis had a negligible impact on symptoms in patients who were referred for surgical consultation. In contrast, a large improvement can be expected after trapeziectomy. However, it remains unclear how much of this change is attributable to the surgery itself. Type of study/level of evidence: Therapeutic IIb.

OBJECTIVE:To analyze three-dimensional carpal malalignment and height in scaphoid non-union advanced collapse (SNAC) wrists. MATERIALS AND METHODS:Twelve cone-beam CT scans of SNAC wrists were analyzed using computer-aided software to define 3D carpal axes and measure intercarpal angles and carpal height ratio. Comparative data included 121 healthy wrists and 18 wrists with scapholunate advanced collapse (SLAC). RESULTS:SNAC wrists showed dorsal angulation of the lunate and even greater dorsal angulation of the triquetrum, resulting in an increased sagittal scapholunate angle and a decreased sagittal lunotriquetral angle compared to healthy wrists. Compared to SLAC wrists, SNAC wrists had similar sagittal radiolunate and scapholunate angles but a significantly lower lunotriquetral angle. Nonunions in the middle and distal third were associated with greater dorsal angulation of the lunate than proximal third nonunions. In the coronal plane, SNAC wrists showed ulnar tilting of the capitate and hamate compared to healthy wrists. Carpal height ratio was significantly decreased compared with healthy wrists but comparable to SLAC wrists. CONCLUSION:Scaphoid nonunion location influenced alignment, with proximal nonunions associated with reduced dorsal angulation of the lunate. SNAC wrists differ from SLAC wrists in exhibiting a decreased sagittal lunotriquetral angle, indicating a distinct pathomechanism of carpal instability.

Background: Traditional surgical management of trapeziometacarpal (TMC) joint destruction in rheumatoid arthritis involves trapezial resection with tendon interposition. The poly-l-d-lactide RegJoint (Scaffdex, Tampere, Finland) implant offers an alternative with promising short-term results in rheumatoid patients.Methods: This study reports long-term outcomes from a randomized controlled trial comparing partial trapeziectomy with the RegJoint versus tendon interposition TMC arthroplasties in patients with inflammatory arthritis, including seropositive and juvenile rheumatoid arthritis, as well as a few cases of other inflammatory arthritis. A total of 13 patients with the RegJoint implant and 8 with tendon interposition completed a mean follow-up of 14.9 years.Results: At final follow-up, no significant differences were found between the groups in pain, function (measured by visual analog scores), strength, or overall functional ability. However, both groups experienced a significant decrease in grip strength compared with preoperative and 2-year follow-up data, with the RegJoint group also reporting increased pain.Conclusions: Both RegJoint implant and tendon interposition provided comparable long-term outcomes for TMC arthroplasty in this small cohort of patients with inflammatory arthritis. Further studies are needed to confirm these findings.

Tendinopathy involves the inflammation and degeneration of the tendon due to repetitive strain injury. Current treatments primarily target inflammation resolution, yet they do not aim at tissue regeneration. In this study, a microfluidics approach is harnessed to develop a platform of lipid nanoparticles (LNPs) loaded simultaneously with SMAD3 siRNA and collagen I mRNA, aiming to explore its potential dual antifibrotic and regenerative effects in human tenocytes. The developed LNPs displayed size homogeneity and colloidal stability and exhibited high cytocompatibility in human tenocytes. Moreover, LNPs allowed for efficient uptake and transfection efficiency of the RNAs. In the in vitro efficacy studies, the gene expression and production of SMAD3 and collagen I were tested by real-time quantitative chain polymerase reaction and immuno- and intracellular staining, revealing collagen I production enhancement, SMAD3 inhibition, and modulation of other tendon repair factors by the LNPs. Overall, the potential of this platform of RNA-loaded LNPs to be used as a dual therapeutic approach to prevent fibrosis and promote tissue remodeling in late stages of tendon diseases was confirmed.

BACKROUND:Trapeziometacarpal osteoarthritis has been treated with interposition of autologous fascia into the trapezial resection cavity to prevent scaphometacarpal impingement with suboptimal results. Autologous fascia may undergo necrosis and gradual shrinkage due to avascularity. We propose vascularization of the interposed fascia using microvascular techniques as a new alternative to achieve a durable graft with sufficient soft tissue volume. PATIENTS AND METHODS:In this retrospective study, 11 surgeries for 8 patients (6 women, 2 men) (5 primary and 6 revision cases) were performed using vascularized fascial grafts from the anterolateral thigh for interposition in the trapezial resection cavity with microvascular anastomosis for revascularization. Subjective assessment included the short version of the Quick Disabilities of the Hand, Shoulder and Arm and patient related hand wrist evaluation scores. Objective assessment included strength and range of motion measurements. Radiographs were obtained preoperatively and at each follow-up visit. An MRI was done at a mean of 19 months postoperatively. RESULTS:The size of the harvested fascial grafts was 2 × 2-3 cm with a thickness of 1.5-2 cm. There were no postoperative complications apart from one seroma in the graft harvest site. The mean clinical and radiologic follow-up was 2 years and 8 months. The procedure provided pain relief PRWHE pain 32 (SD 13)-9 (SD 12), p < 0.0001, increased tip pinch strength 4 kg (SD3)-6 kg (SD2), p < 0.05, and improved overall function PRWHE 60 (SD28)-16 (SD21), p < 0.0001 and QuickDash 50 (SD21)-13 (SD17), p < 0.0001. Radiographs demonstrated maintenance of the scaphometacarpal space, while MRI scans showed the presence of mildly edematous interposed tissue within the resection cavity. CONCLUSIONS:Although technically demanding, vascularized fascia presents an attractive alternative for the treatment of trapeziometacarpal osteoarthritis. It may be particularly advantageous in complex cases requiring revision surgery and in young patients with high functional demands.

Radiographic measurements play a crucial role in evaluating the alignment of distal radius fractures (DRFs). Various manual methods have been used to perform the measurements, but they are susceptible to inaccuracies. Recently, computer-aided methods have become available. This review explores the methods commonly used to assess DRFs. The review introduces the different measurement techniques, discusses the sources of measurement errors and measurement reliability, and provides a recommendation for their use. Radiographic measurements used in the evaluation of DRFs are not reliable. Standardizing the measurement techniques is crucial to address this and automated image analysis could help improve accuracy and reliability.

PURPOSE:Scapholunate dissociation frequently results in malalignment and scapholunate advanced collapse (SLAC). Previous analyses have relied on visual observations of carpal angles among the scaphoid, lunate, and capitate on lateral radiographs. However, the 3-dimensional carpal alignment during SLAC progression remains unclear. The purpose of this study was to analyze 3-dimensional carpal malalignment in SLAC wrists. METHODS:Using computer-aided cone-beam computed tomography analysis software based on segmentation and numerical modeling, we defined three-dimensional carpal axes and examined alignment and carpal height ratio in 18 SLAC wrists along the radial coordinate (positive in palmar and ulnar directions). These results were compared with previously reported normal alignment values obtained from 121 healthy wrists. RESULTS:In the sagittal plane, mean scapholunate, lunotriquetral, lunocapitate, and capitometacarpal angles were -100° (SD, 11°); 20° (SD, 11°); 7° (SD, 12°); and 18° (SD, 8°); respectively, whereas the angles were -58° (SD, 9°); 12° (SD, 8°); -17°(SD, 11°); and 8° (SD, 6°); respectively, in healthy wrists. The sagittal scapholunate angle exhibited the highest area under the receiver operating characteristic curve (0.999), with a threshold value of ≤-76°, indicating pathology. In the coronal plane, the carpal alignment of SLAC wrists remained unchanged, excluding a minimal ulnar tilt of the capitate. CONCLUSIONS:Carpal malalignment in SLAC wrists not only affects the radio- and midcarpal joints, but also extends to the third carpometacarpal joint, with malalignment evident in both the sagittal and coronal planes. In SLAC wrists, the sagittal lunotriquetral angle increases in the positive direction, due to the lunate angulating more than the triquetrum. CLINICAL RELEVANCE:These findings have potential to contribute to the development of computer-aided diagnostic tools for 3-dimensional imaging technology. In the future, such tools could highlight abnormal values and minimize diagnostic errors in clinical practice.

The purpose of this study was to compare computer-aided analysis and different methods of manual measurements in the evaluation of carpal alignment. The radioscaphoid, radiolunate, radiocapitate and radiometacarpal angles were measured on cone-beam computed tomography (CT) scans of 30 healthy wrists by automated software (Disior Ltd.) and by hand surgeons using lateral radiographs reconstructed from the CT data. Hand surgeons were either given (n = 6) or not given (n = 7) prior instructions on how to perform the measurements. Inter- and intra-observer reliability of manual measurements ranged from good to excellent (intra-class correlation coefficients [ICC] 0.77-0.99), being highest in specialists with standardized methods and in reconstructed radiographs with bone overlap digitally removed. Computer-aided software provided excellent intra-observer reliability (ICC 0.94-1.00) consistently and values that were highly comparable (mean difference range 1 degrees-7 degrees) with the manual measurements made in optimal settings. Computer-aided software provides an accurate and repeatable method to measure carpal alignment in CT scans, minimizing observational errors.

Background: Several carpal pathologies are considered to be related to ulnar variance. Recently, computer-aided computed tomography (CT) analysis software was introduced to quantify three-dimensional (3D) carpal alignment with high accuracy and reliability. Purpose: To determine the association of ulnar variance with 3D carpal alignment and demographics. Material and Methods: A wrist of 121 asymptomatic volunteers (69 men, 52 women; mean age = 38 +/- 10.4 years) was imaged in the neutral wrist position with cone-beam CT. Computer-aided CT analysis software (Bonelogic), based on segmentation and numerical modelling, was used to define ulnar variance and standardized 3D axes for all carpal bones. The association of ulnar variance with 3D carpal alignment, age of the volunteer, and side and dominance of the imaged wrist was assessed. Results: The mean ulnar variance was -1.6 +/- 1.5 mm (range = -5.3 to 2.4 mm). The mean ulnar variance was -1.9 mm and -1.1 mm in men and women (P= 0.007), respectively. Of the imaged 121 wrists, 18 (15%) had positive and 103 (85%) negative ulnar variance. There was no association between ulnar variance and any of the radio- or intercarpal angle values in either the sagittal or coronal plane (.=-0.16.0.17, r=-0.13..0.12). The ulnar variance showed no association with side (P= 0.51) or dominance (P = 0.27) of the imaged wrist. Conclusion: 3D carpal alignment is not affected by ulnar variance. The association of ulnar variance with sex may in part explain the difference in reported prevalence of some carpal pathologies, such as ulnar impaction syndrome and Kienbock's disease.

Assessment of carpal alignment traditionally uses carpal bone axes measured on lateral radiographs. In this study, three-dimensional axes were defined for carpal bones using segmentation and numerical modelling of CT data of 121 neutrally positioned, asymptomatic wrists. The geometric axis was used for radius, scaphoid and capitate, whereas the axis based on a line perpendicular to the articular surface was used for the other carpal bones. Normal values of radiocarpal angles in the radial coordinate and the reliability of the computer-aided analysis are reported. The mean sagittal radiocarpal angles (positive in palmar direction) were as follows: scaphoid 58° (SD 10°), lunate 0° (SD 11°), triquetrum 12° (SD 8°), trapezium 17° (SD 8°), trapezoid −10° (SD 7°), capitate −17° (SD 9°) and hamate 2° (SD 7°). The mean coronal radiocarpal angles (positive in ulnar direction) were −42° (SD 9°), −20° (SD 4°), −49° (SD 4°), −32° (SD 6°), −16° (SD 5°), 2° (SD 7°) and 8° (SD 6°), respectively. The intra-observer reliability of the measurements was excellent (mean intraclass correlations coefficient 0.98). This study provides guidelines on how to measure and quantify carpal alignment three-dimensionally, and a database for the normal values. Together, these may be useful when analysing various wrist pathologies and kinematics of the wrist.

Deep learning algorithms can be used to classify medical images. In distal radius fracture treatment, fracture detection and radiographic assessment of fracture displacement are critical steps. The aim of this study was to use pixel-level annotations of fractures to develop a deep learning model for precise distal radius fracture detection. We randomly divided 3785 consecutive emergency wrist radiograph examinations from six hospitals to a training set (3399 examinations) and test set (386 examinations). The training set was used to develop the deep learning model and the test set to assess its validity. The consensus of three hand surgeons was used as the gold standard for the test set. The area under the ROC curve was 0.97 (CI 0.95–0.98) and 0.95 (CI 0.92–0.98) for examinations without a cast. Fractures were identified with higher accuracy in the postero-anterior radiographs than in the lateral radiographs. Our deep learning model performed well in our multi-hospital and multi-radiograph system manufacturer settings. Thus, segmentation-based deep learning models may provide additional benefit. Further research is needed with algorithm comparison and external validation.

Tendinitis is a tendon disorder related to inflammation and pain, due to an injury or overuse of the tissue, which is hypocellular and hypovascular, leading to limited repair which occurs in a disorganized deposition of extracellular matrix that leads to scar formation and fibrosis, ultimately resulting in impaired tendon integrity. Current conventional treatments are limited and often ineffective, highlighting the need for new therapeutic strategies. In this work, acetalated-dextran nanoparticles (AcDEX NPs) loaded with curcumin and coated with tannic acid (TA) are developed to exploit the anti-inflammatory and anti-fibrotic properties of the two compounds. For this purpose, a microfluidic technique was used in order to obtain particles with a precise size distribution, aiming to decrease the batch-to-batch variability for possible future clinical translation. Coating with TA increased not only the stability of the nanosystem in different media but also enhanced the interaction and the cell-uptake in primary human tenocytes and KG-1 macrophages. The nanosystem exhibited good biocompatibility toward these cell types and a good release profile in an inflammatory environment. The efficacy was demonstrated by real-time quantitative polymerase chain reaction, in which the curcumin loaded in the particles showed good anti-inflammatory properties by decreasing the expression of NF-κb and TA-coated NPs showing anti-fibrotic effect, decreasing the gene expression of TGF-β. Overall, due to the loading of curcumin and TA in the AcDEX NPs, and their synergistic activity, this nanosystem has promising properties for future application in tendinitis.

Scapholunate advanced collapse (SLAC) and scaphoid non-union advanced collapse (SNAC) are common types of wrist osteoarthritis (OA). Non-operative treatment consists of pain medication, splinting, and avoiding activities that induce pain. However, in case a course of conservative treatment is unsuccessful, operative treatment is needed. The two most conventional operative approaches for SLAC/SNAC OA are four-corner arthrodesis (FCA) and proximal row carpectomy (PRC). Although FCA is the gold-standard operative technique and may lead to superior grip strength, the evident benefit of PRC is that it obviates any need for hardware removal and controlling for bony union. To date, no high-quality randomized controlled trial comparing FCA and PRC exists. As clinical outcomes seem comparable, a trial that assesses patient-reported outcomes, adverse events, and secondary operations may guide clinical decision making between these two procedures. Thus, the aim of this multi-institutional double-blind randomized controlled trial is to study whether PRC is non-inferior to FCA in treating SLAC/SNAC OA. We hypothesize that PRC is non-inferior to FCA with lower economic expanses. The trial is designed as a randomized, controlled, patient- and outcome-assessor blinded multicenter, two-armed 1:1 non-inferiority trial. Patients with SLAC/SNAC-induced wrist pain meeting trial inclusion criteria will undergo wrist arthroscopy to further assess eligibility. Each patient eligible for the trial will be randomly assigned to undergo either FCA or PRC. The primary endpoint of this study is the Patient Rated Wrist Evaluation (PRWE) at 1-year after FCA versus PRC. Secondary outcomes include Quick-Disabilities of the Arm, Shoulder and Hand, EQ-5D-5L, pain, grip strength, wrist active range of motion, radiographic evaluation, and adverse events. Trial design, methods, and statistical analysis plan will be presented here. We present an RCT design comparing FCA vs PRC for SLAC/SNAC-induced OA. The results of this trial will assist in decision making when planning surgery for SLAC/SNAC. ClinicalTrials.gov NCT04260165 . Registered February 7, 2020.

The Numerical Rating Scale (NRS) and Patient-rated wrist/hand evaluation (PRWHE) are patient-reported outcomes frequently used for evaluating pain and function of the wrist and hand. The aim of this study was to determine thresholds for minimal important difference (MID) and patient acceptable symptom state (PASS) for NRS pain and PRWHE instruments in patients with base of thumb osteoarthritis. Fifty-two patients with symptomatic base of thumb osteoarthritis wore a splint for six weeks before undergoing trapeziectomy. NRS pain (0 to 10) and PRWHE (0 to 100) were collected at the time of recruitment (baseline), after splint immobilization prior to surgery, and at 3, 6, 9 and 12 months after surgery. Four anchor-based methods were used to determine MID for NRS pain and PRWHE: the receiver operating characteristics (ROC) curve, the mean difference of change (MDC), the mean change (MC) and the predictive modelling methods. Two approaches were used to determine PASS for NRS pain and PRWHE: the 75th percentile and the ROC curve methods. The anchor question for MID was the change perceived by the patient compared with baseline; the anchor question for PASS was whether the patient would be satisfied if the condition were to stay similar. The correlation between the transition anchor at baseline and the outcome at all time points combined was calculated using the Spearman’s rho analysis. The MID for NRS pain was 2.5 using the ROC curve method, 2.0 using the MDC method, 2.8 using the MC method, and 2.5 using the predictive modelling method. The corresponding MIDs for PRWHE were 22, 24, 10, and 20. The PASS values for NRS pain and PRWHE were 2.5 and 30 using the ROC curve method, and 2.0 and 22 using the 75th percentile method, respectively. The area under curve (AUC) analyses showed excellent discrimination for all measures. We found credible MID estimates for NRS and PRWHE (including its subscales), although the MID estimates varied depending on the method used. The estimates were 20-30% of the range of scores of the instruments. The cut-offs for MID and PASS showed good or excellent discrimination, lending support for their use in future studies. This clinimetrics study was approved by the Helsinki University ethical review board (HUS1525/2017).

Background/Aim: Osteoarthritis (OA) at the trapeziometacarpal joint (TMC) is common. However, no published data on the TMC-OA surgery incidence exist. The aim of this study was to evaluate the incidence and trends of TMC-OA surgical treatment. Patients and Methods: A nationwide hospital discharge register-based study was conducted among patients surgically treated for TMC-OA in Finland between 1997 and 2019. Results: A total of 8,728 surgeries were performed. The annual surgery incidence increased 10-fold from 1997 to 2019. The incidence was higher in women and increased the most in the age groups of 50-59 and 60-69 years. TMC resection arthroplasty with or without ligament reconstruction and/or tendon interposition accounted for 91% of all surgeries. Conclusion: The increase in the surgical procedure rates is substantial. It is not explained by advancements in surgical treatment or by the ageing population. The indications for surgery appear to have become broader.