Dupuytren Disease Surgical Treatment: A Randomized Clinical Trial Comparing Partial Fasciectomy by Bruner Approach Versus Zetaplasty.

BACKGROUND: Dupuytren is a fibroproliferative pathology leading to contracture of the palmar fascia. Several approaches have been described for the surgical treatment with partial fasciectomy with few comparisons in literature. Our purpose is to compare the functional outcomes between the partial fasciectomy performed by Bruner type incision and zetaplasty incision. METHODS: The method used was a randomized clinical trial including adult patients of both sexes with surgical indication for Dupuytren disease presented to a reference center. Patients were randomly and consecutively allocated in the groups 1:1. We recorded the Disabilities of the Arm, Shoulder, and Hand (DASH) score; range of motion for active and passive extension of the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints; visual analog scale for pain; and complications. RESULTS: In all, 62 patients were included, with 48 patients reaching the minimum follow-up of 6 months with 63 operated fingers. In the Bruner approach group, we obtained a correction of the active and passive extension of the MP of 28° and of the PIP of 23°. In the zetaplasty group, correction of MP was 30° for active and passive, and 18° for active extension and 16° for passive extension of the PIP. The reduction in the DASH score was 10 points in the Bruner group and 22 points in the zetaplasty group. There was no statistically significant effect of the type of treatment on preoperative and postoperative differences in any of the parameters evaluated. CONCLUSIONS: There were no statistically significant differences between the 2 techniques for self-reported functional outcomes or objective measures of physical examination.

Treatment of the humeral shaft fractures--minimally invasive osteosynthesis with bridge plate versus conservative treatment with functional brace: study protocol for a randomised controlled trial.

BACKGROUND: Humeral shaft fractures account for 1 to 3% of all fractures in adults and for 20% of all humeral fractures. Non-operative treatment is still the standard treatment of isolated humeral shaft fractures, although this method can present unsatisfactory results. Surgical treatment is reserved for specific conditions. Modern concepts of internal fixation of long bone shaft fractures advocate relative stabilisation techniques with no harm to fracture zone. Recently described, minimally invasive bridge plate osteosynthesis has been shown to be a secure technique with good results for treating humeral shaft fractures. There is no good quality evidence advocating which method is more effective. This randomised controlled trial will be performed to investigate the effectiveness of surgical treatment of humeral shaft fractures with bridge plating in comparison with conservative treatment with functional brace. METHODS/DESIGN: This randomised clinical trial aims to include 110 patients with humeral shaft fractures who will be allocated after randomisation to one of the two groups: bridge plate or functional brace. Surgical treatment will be performed according to technique described by Livani and Belangero using a narrow DCP plate. Non-operative management will consist of a functional brace for 6 weeks or until fracture consolidation. All patients will be included in the same rehabilitation program and will be followed up for 1 year after intervention. The primary outcome will be the DASH score after 6 months of intervention. As secondary outcomes, we will assess SF-36 questionnaire, treatment complications, Constant score, pain (Visual Analogue Scale) and radiographs. DISCUSSION: According to current evidence shown in a recent systematic review, this study is one of the first randomised controlled trials designed to compare two methods to treat humeral shaft fractures (functional brace and bridge plate surgery).

Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery.

OBJECTIVE: The aim of this study is to evaluate the effectiveness of CS injection, percutaneous pulley release and conventional open surgery for treating trigger finger in terms of cure, relapse and complication rates. METHODS: One hundred and thirty-seven patients with a total of 150 fingers were randomly assigned and allocated into one of the treatment groups, with treatments allocated into 150 opaque and sealed envelopes. We included patients >15 years of age with a trigger on any finger of the hand (Types II-IV) and used a minimum follow-up time of 6 months. The primary outcome measures were cures, relapses and failures. RESULTS: Forty-nine patients were assigned to the conservative group to undergo CS injections, whereas 45 and 56 were assigned to undergo percutaneous release and outpatient open surgery, respectively. The trigger cure rate for patients in the injection method group was 57%, and wherever necessary, two injections were administered, which increased the cure rate to 86%. For the percutaneous and open release methods, remission of the trigger was achieved in all cases. CONCLUSIONS: The percutaneous and open surgery methods displayed similar effectiveness and proved superior to the conservative CS method regarding the trigger cure and relapse rates. Trial registration. Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN19255926.

Treatment of reducible unstable fractures of the distal radius in adults: a randomised controlled trial of De Palma percutaneous pinning versus bridging external fixation.

BACKGROUND: At present, there is no conclusive evidence regarding the best treatment method for reducible unstable fractures of the distal radius. This study compared the effectiveness of two methods used in surgical treatment of such fractures: percutaneous pinning and external fixation. METHODS: We randomly allocated 100 patients into two groups treated surgically with modified De Palma percutaneous pinning and bridging external fixation. Independent but not blinded evaluators administered the DASH quality-of-life questionnaire at postoperative months 6 and 24, performed functional assessment of pain, range of motion, and palm grip strength, and radiographic examinations (volar and radial angle, and height of the radius) before the operation, immediately afterwards, and at 6 and 24 months postoperative. Modified De Palma percutaneous pinning patients used an above-elbow cast whereas external fixation group had unrestricted elbow motion after surgery. Patients who for any reason demonstrated treatment failure or required additional interventions were followed up and their results were included in the group into which these patients had initially been randomised according to the intention-to-treat principle. A significance level of 5% (alpha = 0.05). was used for all statistical tests, such that tests presenting a p-value less than 0.05 were considered statistically significant. RESULTS: Ninety one (58.8 mean age and 66 participants were female) were included in the final assessment at 24 months. The DASH questionnaire evaluation showed a statistically significant result favouring the De Palma group (mean difference = -7.1 p = 0.044) after six months, but this was not maintained at 24 months. There were no statistically differences between the groups with respect to palm grip strength. Analysis of the range-of-motion limitation index (uninjured side minus affected side motion of) showed a statistical difference (mean difference = 2.4 p = 0.043) favoring the external fixator group with regard to the supination movement 6 months after the operation; however, this was not maintained at 24 months. The final results of the radiographic evaluation were similar for the two groups. Overall, five patients developed complications: two with De Palma pinning and three with external fixation. CONCLUSION: There was a small statistically significant difference favouring the De Palma method in early functional at 6 months according to the DASH questionnaire, and for supination movement favouring the fixator group. However, both were not clinical relevant. By 24 months the groups were similar for all outcomes TRIAL REGISTRATION: Current Controlled Trials ISRCTN04892785.

Are classifications of proximal radius fractures reproducible?

BACKGROUND: Fractures of the proximal radius need to be classified in an appropriate and reproducible manner. The aim of this study was to assess the reliability of the three most widely used classification systems. METHODS: Elbow radiographs images of patients with proximal radius fractures were classified according to Mason, Morrey, and Arbeitsgemeinschaft für osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) classifications by four observers with different experience with this subject to assess their intra- and inter-observer agreement. Each observer analyzed the images on three different occasions on a computer with numerical sequence randomly altered. RESULTS: We found that intra-observer agreement of Mason and Morrey classifications were satisfactory (kappa = 0.582 and 0.554, respectively), while the AO/ASIF classification had poor intra-observer agreement (kappa = 0.483). Inter-observer agreement was higher in the Mason (kappa = 0.429-0.560) and Morrey (kappa = 0.319-0.487) classifications than in the AO/ASIF classification (kappa = 0.250-0.478), which showed poor reliability. CONCLUSION: Inter- and intra-observer agreement of the Mason and Morey classifications showed overall satisfactory reliability when compared to the AO/ASIF system. The Mason classification is the most reliable system.