7. Therefore, these patients were included in the surgical group for analysis, as they did have more than 2 years minimum clinical follow-up after surgical treatment. Furthermore, there was no donor site morbidity from autograft harvest sites across all studies. gamekeeper's thumb; skier's thumb; stener lesion; ulnar collateral ligament, NOW OVER 19K FOLLOWERS ON TWITTER. official website and that any information you provide is encrypted In these cases, a new graft may be used to perform a second reconstruction. Obremskey W, Pappas N, Attallah-Wasif E, et al.. Levels of evidence in Orthopaedic Journals. It is attached on one side to the humerus (the bone of the upper arm) and on the other side to the ulna (a bone in the forearm). This injury can have many names such as "skiers thumb", "gamekeepers thumb", and "break dancers thumb.". Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. There were 61 studies eliminated as secondary for being in a language other than English. POST-OPERATIVE WEEKS 22-24. The mean prevalence of postoperative ulnar neuropathy was 12.0% overall after any UCLR procedure at a mean follow-up of 3.3 years, and 0.8% of cases required reoperation to address ulnar neuropathy. Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. important to begin moving your fingers right after surgery and keep them moving to avoid stiffness. Through a small incision along the side of the thumb joint, we will see where the ligament was torn. 15. flexion-extension motion. No Difference in Complications Between Elbow Ulnar Collateral Ligament Reconstruction With the Docking and Modified Jobe Techniques: A Systematic Review and Meta-analysis. Basic knowledge of the anatomy of the finger and a thorough evaluation of the patient can ensure proper diagnosis and treatment. Various complications have been previously documented including transient and permanent neuropathies involving the ulnar, saphenous, and median palmar nerves, neuroma formation, hematoma, infection, donor site harvest tenderness, postoperative stiffness, retear of flexor-pronator muscle, and stress fracture of the ulnar bone bridge. There is, however, agreement on the treatment goals for repair or reconstruction of the UCL, which are to obtain and maintain an anatomic reduction of the MP joint, reproduce the anatomic origin and the insertion of native ligament, ensure sufficient strength to allow early range of motion, and minimize donor site morbidity if autograft is used.19 Although most surgical undertakings result in good clinical and functional outcomes, there are postoperative complications, including stiffness and decreased range of motion (specifically, restricted flexion at the MP joint), failed reconstruction, infection, neuropraxia, continued pain, implant failure, graft failure, loosening, scarring, and arthrosis.30,43,44 It has been well documented that direct suture techniques fail in chronic injuries.33,45 When repair is attempted, nonanatomical repositioning of the UCL may contribute to the loss of joint motion.46. Studies that duplicated patient populations from the same authors were excluded. The ulnar collateral ligament complex is located on the inside of the elbow (pinky or medial side). Wong TC, Ip FK, Wu WC. J Bone Joint Surg Am. In sports or at work, injuries to the collateral ligament of the thumb's metacarpophalangeal (MCP) joint and the proximal interphalangeal (PIP) joints of the fingers are common [].The most common mechanism for a thumb ulnar collateral ligament (UCL) rupture is the forced abduction and hyperextension of the MCP joint of the thumb [2,3,4,5,6,7], which can occur when someone falls on the thumb . Table 1. The overall complication rate after primary thumb RCL and UCL repair was 13.8%. Arnold DM, Cooney WP, Wood MB. PMC 1962;124:396411. Careers. 1994;23:797804. There were 200 acute injuries and 93 chronic injuries. 1995;23:222226. Kozin SH, Bishop AT. Your thumb will be immobilized in a splint and should not be moved until follow up. Sports Health. Long-term results of ligament reconstruction. This systematic review has demonstrated excellent clinical outcomes (pain, strength, motion, and stability) after surgical treatment (repair and autograft reconstruction) of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. Thumb from the common mechanism of falling on the thumb while holding a ski pole. Injury and Surgical Repair to the Thumb This is an injury to the ulnar collateral ligament of the metacarpo-phalangeal (MCP) joint. better/same/worse than preoperative status). The rate of complications after RCL primary repair was higher than UCL repair, however not statistically significant. MeSH 31. The torn thumb ligament is repaired or reconstructed during surgery. Kaplan EB. If the force is too strong, the ligaments can tear. 1989;17:751753. FOIA This includes, but not limited to, self-retrograde massage, cold therapy, and extremity elevation. Reconstruction of the collateral ligaments using the extensor pollicis brevis tendon. Any time there is something concerning you, even if it's a slight concern, always call your surgeon right away. Epub 2019 Mar 21. 2014 Oct;42(10):2510-6. doi: 10.1177/0363546513509051. While ulnar collateral ligament reconstruction (UCLR) of the elbow is an increasingly commonly performed procedure with excellent results reported in the published literature, less attention has been paid to specifically on the characterization of postoperative ulnar nerve complications, and it is unclear what operative strategies may influence the likelihood of these complications. Complications after surgery were rare. Sakellarides HT, DeWeese JW. 8600 Rockville Pike You may be trying to access this site from a secured browser on the server. Sixty nine (86.3%) patients had grade 3 tears. There is also significant performance bias, as there are multiple different methods of treatment, providers, graft, suture, and fixation types, as well as methods and duration of immobilization. The UCL has as its central function maintenance of ulnar stability of the joint, which is paramount for pinch grip. 1987;214:113120. Detection bias was present in the inconsistent use of an invalidated outcomes tool (Glickel grading system), visual measurement of range of motion, different tools for strength and stability measurement, and the subjective nature of reporting weakness and stability. Erickson BJ, Harris JD, Chalmers PN, Bach BR Jr, Verma NN, Bush-Joseph CA, Romeo AA. may email you for journal alerts and information, but is committed Benson LS, Bailie DS. SAGE Open Med. There were 6 studies that reported clinical outcomes after acute UCL repair using different techniques.20,2426,28,29 Repair techniques (Table 4) included pullout suture over button with or without Kirschner wire immobilization, suture anchors, soft tissue periosteal suture, and arthroscopic Stener reduction with K-wire. Usually it is pulled off of the bone (proximal phalanx) on the nail side of the joint. When evaluating the relationship between ulnar and radial ligamentous injury and the presence or absence of complication, there was no significant difference, however trends were noted, X. Study design: National Library of Medicine Thumb sidedness reported in 3 studies (51 thumbs). Most patients have minimal pain by 6 weeks after surgery, with nearly full thumb and hand motion by 3 months. These movements include opposing the thumb to each finger, thumb extension/abduction and full wrist movement. Mean subject age was 33.9 years. Post-traumatic instability of the metacarpophalangeal joint of the thumb. Nonoperative treatment of acute UCL injury (with or without a Stener lesion) frequently fails, leading to chronic pain, instability, and weakness, eventually prompting surgical intervention. The major arc of motion of the thumb MP joint is flexion and extension, although there is some abduction, adduction, and rotation.30 The stability of the MP joint derives from joint congruity, the true and accessory collateral ligaments, the volar plate, and the surrounding intrinsic muscles.31 The adductor pollicis supplies active support on the ulnar aspect, whereas the abductor pollicis brevis and flexor pollicis brevis provide dynamic stability on the radial border. If you log out, you will be required to enter your username and password the next time you visit. 2019 Apr;47(5):1103-1110. doi: 10.1177/0363546519831705. [19] Although most surgical undertakings result in good clinical and functional outcomes, there are postoperative complications, including stiffness and decreased range of motion (specifically, restricted flexion at the MP joint), failed reconstruction, infection, neuropraxia, continued pain, implant failure, graft failure, loosening, scarring, and arthrosis. Unauthorized use of these marks is strictly prohibited. Your message has been successfully sent to your colleague. No significant difference in the outcome was demonstrated between different types of autograft used for UCL reconstruction. Continuous variable data were reported as mean SDs from the mean. National Library of Medicine Here's Advice, Emergency Birth on a Plane: Two Doctors Earn Their Wings, Brachial Plexus Injury in Sports Medicine, Cervical Spine Acute Bony Injuries in Sports Medicine. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. Proximal interphalangeal joint injuries of the hand. Julie Balch Samora, MD, PhD*, Joshua D. Harris, MD, Michael J. Griesser, MD, Michael E. Ruff, MD* and Hisham M. Awan, MD* *The Ohio State University Hand and Upper Extremity Center, Columbus, Ohio; Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois; and Performance Orthopaedics and Sports Medicine, Wilmington, Ohio. This is a strong ligament that supports the thumb when pinching or gripping and if it is damaged may lead to a chronic instability of the thumb which causes problems with function. eCollection 2022 May. Wilk KE, Arrigo CA, Dugas JR, Cain EL, Andrews JR. Furthermore, it is interesting that our study quality results using the Quality Appraisal Tool were as low as they were (mean 54% with a range of 33%-79%). 14. You are being redirected to Medscape Education. Diagnosis of displaced, 43. An example of the search strategy used for PubMed was ((((((ulnar[Title/Abstract]) AND collateral[Title/Abstract]) AND ligament[Title/Abstract])) OR ucl[Title/Abstract])) AND thumb[Title/Abstract]. Each abstract was manually reviewed, with potentially relevant full text of studies scrutinized for study inclusion or exclusion. In addition, basic science, anatomical/histopathological, imaging, biomechanical, surgical technique, and studies on digits other than the thumb were excluded. Please enter a Recipient Address and/or check the Send me a copy checkbox. Throwing status reported in 4 studies. There were 200 acute injuries and 93 chronic injuries. Pain Swelling Bruising A weaker pinch or problems grabbing things when you use your thumb If surgery is needed, the ligament is reconnected to the bone. Ryu J, Fagan R. Arthroscopic treatment of acute complete thumb metacarpophalangeal. This injury happens when an ulnar collateral ligament (UCL) tough and flexible tissue that connect bones in the thumb gets stretched too far or tears. J Hand Surg Glob Online. Rupture of the thumb ulnar collateral ligament (UCL) is a frequent injury of the hand, commonly caused by sports injuries and falls onto an outstretched hand.15 The mechanism of injury usually involves hyperabduction or hyperextension of the metacarpophalangeal (MP) joint of the thumb.6 Disruption of the UCL leads to decreased pinch strength, pain, instability, and ultimately osteoarthritis. fall on outstretched hand and abducted thumb ball or racquet strike Symptoms common symptoms pain at ulnar aspect of MCP joint worse with pinch or grasp most common for UCL tear radial-sided MCP pain most common complaint for RCL tear Physical exam inspection rarely visible deformity of joint palpation J Hand Surg Am. Complication rates after RCL repair (N= 4; 22.2%) were higher than UCL repair (N= 7; 11.3%). Complications after surgical treatment of UCL injury are rare. Chir Main. Thumb collateral ligament injuries. After the nerves exit the spinal cord, they connect from the Axillary (armpit) and upper arm . Some error has occurred while processing your request. doi: 10.1097/JSA.0000000000000322. Early diagnosis and treatment. 4 weeks after surgery: The splint can be removed for basic hand hygiene and light thumb movements (actives only). Purpose. If it is appropriate, then surgical consent probably happened before the surgery. 2021 Mar 10;9(3):2325967121990052. doi: 10.1177/2325967121990052. Ulnar collateral ligament tear represents 60 percent of upper limb problems in skiers and is frequently overlooked and underdiagnosed. Only prospective studies can determine this injury course. Rao S, D'Amore T, Willier DP 3rd, Gawel R, Jack RA 2nd, Cohen SB, Ciccotti MG. Orthop J Sports Med. There are many ways to manage both acute and chronic thumb UCL deficiency, and controversy persists as to the best treatment options. 19. All techniques improved clinical outcomes, including pain, motion, strength, and stability (Table 5). Part I: anatomy and diagnosis. Although many injuries can be managed conservatively, some require more invasive interventions to prevent complications and loss of function. 8600 Rockville Pike 32. Docs Struggle to Keep Up With the Flood of New Medical Knowledge. Simmons underwent surgery, also performed by Shin, to repair a torn UCL in his left thumb (like Trout, Simmons injured his non-dominant thumb). Complications after surgery were rare. Key, pulp, and tip pinch and grip strength were either equivalent or only mildly weak compared with the contralateral thumb and hand in all subjects. Furthermore, the lack of patient-specific data precluded advanced statistical calculations, and weighted means from individual studies were the basis for comparison. ||Injury chronicity not always defined, but we used ,3 weeks for acute injury and .3 weeks for chronic injury. ECRL, extensor carpi radialis longus; IP, interphalangeal; MRI, magnetic resonance imaging; NR, not reported. Catalano LW III, Cardon L, Patenaude N, et al.. Abstract. Abstract Objectives: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. Frykman G, Johansson O. Surgical repair of rupture of the, 46. Conclusion: 2008 Jun;36(6):1193-205. doi: 10.1177/0363546508319053. Please use this form to submit your questions or comments on how to make this article more useful to clinicians. Thus, the true natural history is yet unknown. Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. This systematic review has demonstrated excellent clinical outcomes (pain, strength, motion, and stability) after surgical treatment (repair and autograft reconstruction) of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. Deep infections around the tendons and bones are rare and may need admission to hospital for intravenous antibiotics and further surgery. Riederer S, Nagy L, Buchler U. Therefore, the purpose of this systematic review is to combine patient outcomes from multiple unique studies and analyze the results of treatment of thumb UCL injury to determine the following: The authors hypothesized that no difference exists in clinical outcomes between repair and reconstruction for acute UCL injury. Conclusions: Bone-periosteum-bone graft reconstruction for chronic ulnar instability of the metacarpophalangeal joint of the thumbminimum 5-year follow-up evaluation. [38] Chuter et al[40] contend that surgical repair of acute UCL ruptures is the gold standard of treatment in the presence of gross instability, Stener lesions, or displaced avulsion fractures. Pichora DR, McMurtry RY, Bell MJ. Data collected on each patient included patient demographics, imaging (x-rays and MRI), perioperative data (e.g. The limitations of this systematic review are reliant on the studies analyzed. In Memoriam: Healthcare Workers Who Have Died of COVID-19, Time to Return to Running After Tibial Stress Fracture in Female Division I Collegiate Track and Field, Sports Hernias, Adductor Injuries, and Hip Problems Are Linked. The thumb joint may feel loose and unstable, making it difficult to grasp objects between the thumb and index finger. 2022 Jun;54(2):191-196. doi: 10.5152/eurasianjmed.2022.22024. Modified Jobe Versus Docking Technique for Elbow Ulnar Collateral Ligament Reconstruction: A Systematic Review and Meta-analysis of Clinical Outcomes. Intravenous regional anesthesia is commonly preferred for routine hand and wrist surgeries because it is well tolerated, safe, reliable, and has a rapid onset. sharing sensitive information, make sure youre on a federal 10. 2020 Apr 28;13(4):228-231. doi: 10.1055/s-0040-1709098. Some broken bones do not heal even when they get the best surgical or nonsurgical treatment. Both x-ray and magnetic resonance imaging evidence confirmed no increase in MP joint osteoarthritis at up to 75 months, postoperatively. Wolters Kluwer Health Infection is a rare complication of hand surgery. Physical examination of the thumb demonstrates the instability of the MCP joint, impossibility of opposition of the thumb, and the weakening of gripping force.5,6 Does Weightlifting Improve Cardiovascular Mortality Risk for Older Aged Adults? Clipboard, Search History, and several other advanced features are temporarily unavailable. Ulnar collateral ligament injuries of the thumb: a comprehensive review. Figure 46-1 Muscle-splitting incision through fascia to expose the ulnar collateral ligament. Sollerman C, Abrahamsson SO, Lundborg G, et al.. Functional splinting versus plaster cast for ruptures of the, 41. In this minimally invasive technique, the surgeon makes a small cut over the back of the thumb joint and examines the area around the injury for damage. An official website of the United States government. This systematic review has demonstrated excellent clinical outcomes (pain, strength, motion, and stability) after surgical treatment (repair and autograft reconstruction) of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. NR, not reported. 2022 Jul;50(8):2324-2338. doi: 10.1177/03635465211023952. 2. History. There is, however, agreement on the treatment goals for repair or reconstruction of the UCL, which are to obtain and maintain an anatomic reduction of the MP joint, reproduce the anatomic origin and the insertion of native ligament, ensure sufficient strength to allow early range of motion, and minimize donor site morbidity if autograft is used. Quantitative outcome of surgical repair. For all statistical analysis within all studies analyzed, P < 0.05 was deemed significant. Ritting et al[30] assert that operative management of acute injuries is indicated when the thumb is without an endpoint to valgus stress testing. Trends in Patient, Physician, and Public Perception of Ulnar Collateral Ligament Reconstruction Using Social Media Analytics. 1-8 Nevertheless, UCL injuries have also been described in javelin throwers, tennis players, arm wrestlers, collegiate wrestlers, and quarterbacks. This article provides a review of . Nonoperative treatment led to high patient satisfaction for acute thumb UCL injury in 2 studies.23,29 Thirty-two subjects were treated with thumb-spica immobilization (30 were proximal phalanx avulsion fractures). 2014 Dec;33(6):384-9. doi: 10.1016/j.main.2014.10.003. Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. Further detection bias existed in that not all studies used each clinical outcome (eg, Glickel grade) or radiographic measure postoperatively. Neurological Complications Following Arthroscopic and Related Sports Surgery: Prevention, Work-up, and Treatment. Gamekeeper's thumb. Nonoperative treatment of acute UCL injury (with or without a Stener lesion) frequently fails, leading to chronic pain, instability, and weakness, eventually prompting surgical intervention.. The effect of thumb metacarpophalangeal. CMC joint is a saddle-shaped joint composed of the trapezium and the base of the thumb (1st) metacarpal. Baar H, Baar B, Kaplan T, Erol B, Tetik C. Chir Main. Leland DP, Pareek A, Therrien E, Wilbur RR, Stuart MJ, Krych AJ, Levy BA, Camp CL. A Novel Surgical Reconstruction Technique in the Management of Chronic Ulnar Collateral Ligament Tears with Volar Subluxation. Accurate diagnosis of finger injuries can often be difficult, given the complicated soft-tissue anatomy of the hand and the diverse spectrum of injuries that can occur. Triangular fibrocartilage complex injury is one of the most common causes of ulnar wrist pain and can impair daily activities, such as door opening and handshaking. Am J Sports Med. Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Epub 2013 Nov 12. Thumb sprain may cause bruising, tenderness, and swelling around the base of the thumb. [17,34] Anywhere from 14% to 64% of UCL injuries have associated Stener lesions, which occur when the adductor aponeurosis is interposed between the ruptured end of the UCL and its site of proximal phalanx attachment. 34. If the latter was executed only partially, a score of 1 was assigned. Part II: treatment and complications. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. UCLR case series that contained complications data were included. This site needs JavaScript to work properly. Wolters Kluwer Health, Inc. and/or its subsidiaries. The rate of complications after RCL primary repair was higher than UCL repair, however not statistically significant. Dr. Holt will talk to you about when it is safe to return to work. *The Ohio State University Hand and Upper Extremity Center, Columbus, Ohio; Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois; and. 1976;58:106112. Various levels of pain, bruising, or edema may present at the site of damage. It runs from the outer humerus, around the radial head and attaches to the ulna. Other than 1 postoperative palmaris longus graft rupture requiring MP joint arthrodesis, no significant complications such as neurovascular injury or superficial or deep infection occurred. Orthop Clin North Am. Search for Similar Articles J Hand Surg Br. Eighty patients were included in the study [N=62 (UCL), N=18 (RCL)]. Patel SS, Hachadorian M, Gordon A, Nydick J, Garcia M. J Hand Microsurg. A broken thumb can also cause numbness or tingling. I had a UCL injury (incomplete, didn't require surgery) with a small avulsion fracture to my right thumb in 2015 at the age of 36. Systematic review and meta-analysis. Fusetti C, Papaloizos M, Meyer H, et al.. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. Metacarpophalangeal joint instability was either not observed or mild (up to 9 degrees). 2009;61:623632. 1 Major components of the TFCC are the articular disc (AD), meniscus homolog, radioulnar ligaments, and extensor carpi . [33,45] When repair is attempted, nonanatomical repositioning of the UCL may contribute to the loss of joint motion.[46]. The diagnosis is best established clinically, though MRI is the imaging modality of choice. When assessed, most patients returned to their preinjury employment. Arthritis Rheum. 1995;18:11611165. Because patients can start moving the thumb within days, it also mitigates some of the negative consequences of prolonged immobilization, such as stiffness and muscle atrophy. Posner MA, Retaillaud JL. A secondary purpose was to compare graft choice and surgical technique for reconstruction. Evaluation and management of elbow injuries in the adolescent overhead athlete. This systematic review has demonstrated excellent clinical outcomes (pain, strength, motion, and stability) after surgical treatment (repair and autograft reconstruction) of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. 1999;24:275282. [41] Abrahamsson et al[42] maintain that a proximally displaced ligament, palpated proximal to the MP joint, is a more specific indication for surgery. J Hand Surg Am. Delma S, Ozdag Y, Baylor JL, Grandizio LC, Klena JC. Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%). There were considerable differences in the outcomes collected within the studies and between studies, which precluded the performance of a meta-analysis. The ulnar collateral ligament (UCL) of the thumb is commonly injured by falling onto an outstretched hand or in sports where the thumb metacarpal phalangeal joint (MP) is hyperextended or hyper-abducted. to maintaining your privacy and will not share your personal information without and transmitted securely. This site needs JavaScript to work properly. Am J Sports Med. Moher D, Liberati A, Tetzlaff J, et al.. Please try after some time. There is currently no consensus on treatment of acute or chronic UCL injuries. Orthopedics. 16. After three to four weeks, the joint should heal enough to remove the splint and begin strengthening exercises. 1961;43-A:541546. The range of motion of the MP joint of the thumb following operative repair of the. Methodological quality of the study was assessed using the Quality Appraisal Tool (Table 1). There were 6 studies that reported clinical outcomes after autograft UCL reconstruction.11,18,19,21,22,27 Reconstruction techniques (Table 5) and grafts included palmaris longus via bone tunnels with or without K-wire MP joint fixation, palmaris longus with suture anchor fixation, iliac crest boneperiosteumbone graft with cortical screw fixation, and extensor carpi radialis longus bonetendon ligamentoplasty with titanium screw and suture anchor fixation. Significantly better motion and strength and fewer complications were observed with suture anchors and early mobilization versus suture button and cast immobilization (P < 0.05).20 Only 3 patients in these 6 studies had residual laxity. No study directly compared the clinical outcome between repair and reconstruction of the thumb UCL for acute (less than 3 weeks) or chronic UCL injury. Both repair and reconstruction (autograft and allograft) techniques were inclusive. Some injuries can be associated with a Stener lesion, which is displacement of the ruptured ligament proximal to the adductor aponeurosis, effectively precluding healing without operative treatment.6, Acute injuries can be treated with immobilization or surgically with direct repair using bone anchors, direct repair using bone tunnels and pullout sutures, or tension band fixation of bony avulsions.79 If an injury is chronic, there are several operative treatment options, including ligament reconstruction with tendinous autograft or allograft, bonesoft tissuebone autograft, or even fusion of the MP joint.1012. [30] The stability of the MP joint derives from joint congruity, the true and accessory collateral ligaments, the volar plate, and the surrounding intrinsic muscles. Am J Sports Med. Fourteen articles were included and analyzed (293 thumbs). Rehabilitation and Return-to-Play Criteria Following Ulnar Collateral Ligament Reconstruction. For example, it can be removed when performing . Mitsionis GI, Varitimidis SE, Sotereanos GG. Data sources: The ECRL bone-tendon ligamentoplasty for chronic ulnar instability of the metacarpophalangeal joint of the thumb.
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