Lipofilling in Operative Hand Fracture Treatment

Perioperative Lipofilling in Operative Treatment of Proximal Phalanx Fractures and Related Tenolysis: Improving Range of Motion

Background:

Hand fractures are a common clinical problem worldwide and account for a substantial economic burden and workload for experienced hand surgeons. With regard to metacarpal and phalangeal fractures, surgery might be indicated in case of dislocation and/or instability to restore functionality through closed or open reduction and adequate stabilization by fixation. Unfortunately, tendon adhesions after operative treatment of these hand fractures remain a common complication; especially after open reposition and internal fixation (ORIF) of proximal phalanx (P1) fractures. This results in postoperative stiffness and thus decreased digital function. In case of insufficient digital function, tenolysis of the flexor and/or extensor tendons could be considered once the fracture is consolidated and competent hand therapy for at least 3 months seems ineffective. Several studies have focused on perioperative measures to prevent tendon adhesions and related stiffness after operative treatment of hand fractures avoiding tenolysis. These prophylactic measures include for example adhesion barriers, anti-adhesion membranes and adipofascial flaps, which could possibly improve the postoperative range of motion if further research is conducted. Only one of these studies, using an adipofascial flap as a tendon-gliding system after ORIF of P1 fractures, found a significant difference regarding postoperative range of motion. Related to the use of adipose tissue, lipofilling has been proven to be a promising technique in the treatment of scars/adhesions, especially in burn wounds. Recent studies even demonstrated the role of fat grafting in hand surgery, including scar management and tenolysis. Despite these promising results, no previous research has evaluated the use of perioperative lipofilling during surgical treatment of hand fractures or related tenolysis. Therefore, it might be that lipofilling could result in an improvement of postoperative motion and prevent and/or improve tenolysis due to providing a gliding surface for tendons.

Aim:

The aim of the two separate studies is as follows:

1. To evaluate the effect of perioperative micronised lipofilling in patients with ORIF of P1 fractures on postoperative range of motion.
2. To evaluate the effect of perioperative micronised lipofilling in patients with tenolysis after operative treatment of P1 fractures on postoperative range of motion.

Study design:

A double-blinded randomized controlled trial

Intervention:

Patients will either receive 1ml of subcutaneous micronised lipofilling or 1ml subcutaneous 0,9% NaCl around the operation site at the end of the ORIF or tenolysis.

Primary outcome measures:

1. In case of an indication for ORIF of P1 fractures the following parameters will be assessed:

   * Preoperative

   • Total active motion (TAM) of the contralateral unaffected digit.

     * 6 weeks, 3 months and 6 months postoperative

   • TAM of the operated digit and the contralateral unaffected digit.

2. In case of tenolysis after operative treatment of P1 fractures the following parameters will be assessed:

   • Preoperative

     - TAM of the affected digit and the contralateral unaffected digit.

   • 6 weeks, 3 months and 6 months postoperative

     • TAM of the operated digit and the contralateral unaffected digit.

Secondary outcome measures:

1. In case of an indication for ORIF of P1 fractures the following parameters will be assessed:

   • Preoperative

     - Active range of motion (AROM) and passive range of motion (PROM) of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal (MCP-, PIP- and DIP) joint of the contralateral unaffected digit.

   • 2 weeks, 6 weeks, 3 months and 6 months postoperative

     - NRS-score of the abdominal donor site.

   • 6 weeks, 3 months and 6 months postoperative

     • AROM and PROM of the MCP-, PIP- and DIP-joint of the operated digit and the contralateral unaffected digit;
     • MHQ-score.

   • 6 months postoperative

     - Radiographic union of the operated digit.

   • During the 6 months postoperative period

     • Postoperative complications, including infection, wound-related problems, and stiffness;
     • Number of secondary procedures, including tenolysis.

2. In case of tenolysis after operative treatment of P1 fractures the following parameters will be assessed:

   • Preoperative

     • AROM and PROM of the MCP-, PIP- and DIP-joint of the affected digit and the contralateral unaffected digit;
     • MHQ-score.

   • 2 weeks, 6 weeks, 3 months and 6 months postoperative

     - NRS-score of the abdominal donor site.

   • 6 weeks, 3 months and 6 months postoperative

     • AROM and PROM of the MCP-, PIP- and DIP-joint of the operated digit and the contralateral unaffected digit;
     • MHQ-score.

   • During the 6 months postoperative period - Postoperative complications, including infection, wound-related problems and stiffness.

Inclusion Criteria:

• Aged 18-65 years

• Indication for one of the following surgical procedures:

  • ORIF due to a single radiologically proven P1 fracture
  • Secondary tenolysis due to limited digital function after former operative treatment of a P1 fracture

• Able to read and speak Dutch

• Mentally competent

Exclusion Criteria:

• Aged below 18 or above 65 years
• Concomitant tendinous or neurovascular injuries
• Prior surgical interventions of the affected digit; other than operative fracture fixation in case of tenolysis
• Prior pathology or surgical interventions of the contralateral digit
• Less than 3 months of competent hand therapy in case of secondary tenolysis
• A known psychiatric condition
• A known systemic disease that will impair wound healing (e.g. diabetes mellitus, known atherosclerosis with an event that required hospitalization, collagen diseases, diseases of the skin, HIV).
• Prednisone or other immunotherapy
• Smoking
• Pregnancy or active child wish