Adjuvant Treatment with Celecoxib after Collagenase Injection for Dupuytren Contracture: A Double-Blind Randomised Controlled Trial.

Background: In patients with a high recurrence risk after treatment for Dupuytren contracture (DC) by Collagenase Clostridium histolyticum (CCH), adjuvant medical therapy may improve the outcome. Non-steroidal anti-inflammatory drugs have been used in the treatment of similar fibroproliferative processes. The aim of this study was to investigate if adjuvant anti-inflammatory medication could improve the outcome of CCH treatment for DC. Methods: In a prospective double blinded randomised trial, the effect of adjuvant peroral celecoxib on the outcome of DC treated with CCH was investigated in 32 patients with a high fibrosis diathesis. Primary outcome was the increase in Total Passive Extension Deficit (TPED)/ray. Secondary outcomes were the TPED of the individual finger joints, Tubiana index, Disability of Arm, Shoulder and Hand score (DASH) and visual analogue scale (VAS) for pain and satisfaction. Results: A significantly greater improvement in the celecoxib group for TPED and metacarpophalangeal contracture was found. For the proximal interphalangeal joint, the effect was much less pronounced. The VAS for pain and satisfaction were better at 6 and 12 weeks in the celecoxib group. The other outcome parameters did not significantly differ between both groups. Conclusions: Adjuvant peroral administration of celecoxib might improve the gain in TPED after treatment with CCH in patients with DC and a high fibrosis diathesis, with a beneficial effect up to 24 months. Level of Evidence: Level II (Therapeutic).

Long-term clinical outcome of collagenase clostridium histolyticum treatment is independent of Dupuytren Diathesis Score.

Collagenase clostridium histolyticum (CCH) is a pharmaceutical, non-surgical treatment option for Dupuytren Disease. However, recurrence is common, and predictors of treatment outcome of CCH treatment are largely unknown. In this retrospective study, we analysed the possible correlation between Abe's Dupuytren Diathesis Score (DDS) and recurrence after treatment with CCH. In a total of 74 patients, with an average follow-up of 5 years, we found an overall recurrence rate of 67% after 5y but no correlation with DDS. Sub-scale analysis indicated that the presence of knuckle pads was associated with a reduced recurrence risk. Patient satisfaction after CCH was high. Deriving from our data, there is no correlation between DDS and recurrence following CCH treatment. Therefore, at this moment, we do not advocate the use of the DDS when informing patients about recurrence rates after CCH treatment. Level of evidence: IV: therapeutic cohort study.

Treatment practice for Dupuytren disease in Belgium before 2020: results from an online survey.

The treatment of Dupuytren disease (DD) continues to evolve. New insights in risk factors for recurrence and new treatment modalities have changed the management strategies for DD over the past decades. However, several differences may remain between these insights and their clinical application. The current tendencies in management of Dupuytren disease, were investigated in a web-based survey. The survey was sent to all members of the Belgian Hand Group, the professional organisation of hand surgeons in Belgium. The participants indicated their preferred treatment for clinical cases and answered questions on the use and timing of splinting, physiotherapy, medication and adapting the management depending on fibrosis diathesis. These findings were compared to recommendations found in the literature. Forty out of 135 surveyed members of the Belgian Hand Group completed the survey and 7 responded incom- pletely, yielding a response rate of 35% for most questions. This is comparable to similar studies. There appeared to be still room for debate on surgical techniques for difficult cases. CCH use increased since reimbursement became available in Belgium, mainly due to satisfying clinical results for patient and surgeon. The survey demonstrated a wide variety in pre- and postoperative splinting protocols, but consensus existed with the literature on postoperative night-time application of orthoses for 7 to 12 weeks.

Functional outcome of ligament reconstruction with tendon interposition after failed first carpometacarpal joint prosthesis.

The purpose is to determine if ligament reconstruction with tendon interposition (LRTI) is a recommendable salvage option for failed total joint prosthesis of the first carpometacarpal joint. Twenty-two patients in our database met the in- clusion criteria for this retrospective study, with at least 6 months follow-up. Fourteen participated and were invited for a clinical examination and asked to fill out two questionnaires. They were evaluated for pain (VAS), impairment (NHS), disability (Quick DASH), opposition (Kapandji test) and grip strength (hydraulic dynamometer). Results of the questionnaires were compared to a cohort study of primary LRTI's. Kapandji test and grip strength were compared to the contralateral side. Compared to primary LRTI's, revision surgery showed mild deterioration of impairment and disability. The average VAS score was 2.9 out of 10. Twelve patients mentioned a sense of strength loss, which could be quantified with the dynamometer : a mean of 15.1 kg (operated thumb) versus 20.5 kg (contralateral). There was a relatively small decline of opposition with Kapandji 8.6 versus 9.9. The overall satisfaction was good for 8 patients, fair for 3 and poor for the remaining 3 (mainly based on strength loss). One patient needed a second revision. Failed first carpometacarpal joint replacement can be salvaged by ligament reconstruction with tendon interposition, providing an acceptable functional outcome in 79% of cases studied. However, compared to the functional outcome of primary LRTI's, mild aggravation of impairment and disability should be taken into account.

Short-term outcome trapeziectomy with ligament reconstruction and tendon interposition versus trapeziometacarpal prosthesis : a literature review.

Trapeziectomy with ligament reconstruction and tendon interposition and trapeziometacarpal prosthesis are two commonly used procedures for first carpometacarpal joint osteoarthritis. The purpose of this study is to compare the short-term outcome of trapeziectomy with ligament reconstruction and tendon interposition to trapeziometacarpal prosthesis. Pubmed, Cochrane library and science direct database were searched with adequate search terms. Used parameters were force, pain, mobility, functionality and complication. All papers describing short-term outcome of ligament reconstruction and tendon interposition or trapeziometacarpal prosthesis were included in this review. Trapeziometacarpal prostheses showed faster pain relief compared with trapeziectomy and ligament reconstruction and tendon interposition. Overall, there was a better strength in the trapeziometacarpal prosthesis group. A lack of information was found about the short- term functionality. The mobility recovers faster in the prosthesis group, although different scoring scales were used for measurement. We could confirm the faster pain relief in the prosthesis group and generally a faster recovery of strength and mobility. In the prosthesis group were more short-term complications. More studies are required to evaluate the short-term recovery of strength, the mobility, functionality and satisfaction.

Four-corner fusion versus proximal row carpectomy : a retrospective review with a minimal follow-up of 9 years.

A retrospective survey on the long-term outcomes of both proximal row carpectomy (PRC) and scaphoidectomy with 4-corner arthrodesis (4CA) was conducted. Seventeen PRC and nine 4CA wrists were retrieved with a minimal follow-up of 9 years. Pain, satisfaction and disability were not significantly different. There was a better flexion and ulnar deviation in the PRC wrists. Conclusion : at long term, the outcome for PRC remains stable despite some series recently reported worsening of the results due to progressive degenerative arthritis. PRC seems to yield comparable clinical results compared to 4CA but a slightly better range of motion than 4CA.

Trapeziectomy with ligament reconstruction and tendon interposition arthroplasty in a male cohort : a retrospective study.

Osteoarthritis of the carpometacarpal joint of the thumb is a common disease, mostly affecting middle aged women. This article presents the results of a trapeziectomy with a ligament recontruction/tendon interposition procedure. We evaluated 60 male patients with 76 operated thumbs. The mean follow- up was 62 months (ranging from 13 to 133 months, with SD of 33 months). The outcome was measured with the disabilities of the arm, shoulder and hand score, a Nelson Hospital score, a Visual analogue scale score and range of motion. The preoperative height of the trapezium was measured and compared with the height of the trapezial space postoperativaly. The disabilities of the arm, shoulder and hand score improved from 25.6 to 16.1. The Visual analogue scale score for pain, satisfaction, dexterity and funcion were correlated with each other. On x-ray, there was an average loss of 67% of trapezial height compared preoperativaly with postoperativaly, but no correlation was found with clinical outcome parameters.

Neurofibromatosis type 1-related pseudarthrosis: Beyond the pseudarthrosis site.

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder affecting approximately 1 in 2,000 newborns. Up to 5% of NF1 patients suffer from pseudarthrosis of a long bone (NF1-PA). Current treatments are often unsatisfactory, potentially leading to amputation. To gain more insight into the pathogenesis we cultured cells from PA tissue and normal-appearing periosteum of the affected bone for NF1 mutation analysis. PA cells were available from 13 individuals with NF1. Biallelic NF1 inactivation was identified in all investigated PA cells obtained during the first surgery. Three of five cases sampled during a later intervention showed biallelic NF1 inactivation. Also, in three individuals, we examined periosteum-derived cells from normal-appearing periosteum proximal and distal to the PA. We identified the same biallelic NF1 inactivation in the periosteal cells outside the PA region. These results indicate that NF1 inactivation is required but not sufficient for the development of NF1-PA. We observed that late-onset NF1-PA occurs and is not always preceded by congenital bowing. Furthermore, the failure to identify biallelic inactivation in two of five later interventions and one reintervention with a known somatic mutation indicates that NF1-PA can persist after the removal of most NF1 negative cells.

Secretan's syndrome: case report.

Secretan's syndrome is a rare clinical condition with recurrent swelling of the forearm and dorsum of the hand, together with flexion contracture of the fingers and a thumb that is spared. The disease is associated with automutilation. We present a typical case of a 42-year old women with Secretan's syndrome.

Long-term follow-up of corrective ulnar osteotomy for missed Monteggia fractures in children.

BACKGROUND: Pediatric Monteggia fractures are relatively rare and are commonly missed. Radial head subluxation can persist with long-term consequences if these fractures are left untreated. We evaluated the long-term treatment outcomes after open reduction with ulnar osteotomy for missed Monteggia fractures during childhood. MATERIALS AND METHODS: Fourteen children were included. Our objective was to assess the clinical and radiographic postoperative outcomes. We evaluated satisfaction by questionnaire. Open reduction of the radial head was performed, combined with an opening-wedge ulnar osteotomy. The mean interval between trauma and surgery was 26.9 months (range, 1-145 months). The mean length of follow-up was 132 months (range, 67-206 months). RESULTS: Only patients with a delay of more than 6 months complained of elbow tenderness. Clinical improvement (except for pronation) was obtained postoperatively, with significance found in the flexion-extension arc (P = .011). In addition, pronation loss (P = .044) and the flexion-extension arc (P = .041) improved significantly in patients with a surgical delay under 6 months compared with patients with a surgical delay of more than 6 months. Radiographically, there were 9 good and 5 fair results. We found a negative association between radiographic outcomes and both age at surgery and delay to surgery (P = .036 and P = .039, respectively). CONCLUSIONS: Good results can be obtained after open reduction with opening-wedge ulnar osteotomy. Lesser clinical and radiographic outcomes can be expected after a surgical delay of more than 6 months. Furthermore, the radiographic outcome seems better if the patient is younger than 6 years.

Salvage of Failed Achilles Tendon Interposition Arthroplasty for DRUJ Instability After Ulnar Head Resection With Aptis Prosthesis.

BACKGROUND: Historically, failed conservative treatment for irreparably damaged distal radioulnar joints (DRUJs) is treated via distal ulnar resection or DRUJ fusion; complications include disabling painful convergence of the radius and ulnar stump during lifting Various treatments for radioulnar impingement include distal radioulnar Achilles tendon allograft interpositional arthroplasty. This technique does not adequately prevent radioulnar impingement and we explore an alternative treatment. METHODS: We report 7 adult patients who failed Achilles tendon interposition, subsequently treated with Aptis total DRUJ prostheses (mean follow-up, 26 months; range, 7-40). RESULTS: Revision to Aptis prosthesis produced clinically stable DRUJ, improved grip strength and painless lifting capabilities, high patient satisfaction, and no major complications. All returned to daily activities and even recreational sports. CONCLUSIONS: Tendon lacks biomechanical features key to the shock-absorbing function of cartilage-features it cannot deliver when used to prevent radioulnar convergence. We report Aptis DRUJ prosthesis as an alternative to the tendon allograft technique.

A clinical trial of tension and compression orthoses for Dupuytren contractures.

STUDY DESIGN: Randomized clinical trial on 2 patient groups with Dupuytren's disease. INTRODUCTION: Despite an unpredictable outcome, surgery remains an important treatment for Dupuytren's disease. Orthotic devices are a controversial noninvasive treatment method to influence the myofibroblasts in the nodules. PURPOSE OF THE STUDY: To detect how much improvement 2 types of orthotic device (tension and compression) as only treatment intervention can provide on a Dupuytren's contracture. Is a compression orthosis better than a tension orthosis? METHODS: Thirty patients with measurable flexion contractures of the fingers were identified. Both primary and recurrence cases were included. Patients were randomized in 2 groups of 15 patients. One group had a standard tension orthosis (Levame), the other group a newly designed silicon compression orthotic device. Patients were instructed to wear the orthotic devices 20 hours a day during 3 months. Data were collected at first visit and after 3 months of orthotic treatment. Primary outcomes were active extension deficit of each joint and total active extension (TAE) of the digit. Secondary outcome was patient satisfaction. Visual Analog Scale (VAS) score of function and esthetics (0-10 points) were recorded at the start and after 3 months. RESULTS: Flexion contracture was reduced at least 5 degrees in all patients. After 3 months, TAE was significantly reduced in both groups (both P < .001).The mean change in TAE was 32.36° in the tension group and 46.47° in the compression group. Although reduction of TAE deficit was bigger in the compression group, this difference was not statistically significant (P = .39). VAS scale of esthetics and functionality was significantly increased in both treatment groups. The functional VAS scale after 3 months was 11% higher in the compression group than in the tension group (P = .03). A major complication of a tension orthotic is skin ulcers. DISCUSSION: Too much tension may cause myofibroblast stimulation and disease progression, whereas continuous limited tension can improve flexion contractures. The idea of a compression device is based on the treatment concept of hypertrophic burn scars. CONCLUSION: Tension and compression orthotic devices can be used as a nonoperative treatment of Dupuytren's disease in both early proliferative untreated hands and aggressive postsurgery recurrence. Although there is no statistically significant difference, compression orthoses appear to be more effective and are better tolerated. Nevertheless, adjustment of orthotic design and research on long-term results are needed. LEVEL OF EVIDENCE: I (Randomized controlled trial, Therapeutic study).

MRI diagnosis of carpal boss and comparison with radiography.

Background A carpal boss is a potentially painful bony mass in the region of the second or third carpometacarpal joint. The combination of clinical examination and radiography is usually sufficient for the diagnosis. Purpose To determine whether magnetic resonance imaging (MRI) examination of the quadrangular joint can assist the diagnosis of persistent pain near a carpal boss. Material and Methods Fifty-seven patients with a carpal boss were retrospectively reviewed using MRI and conventional radiographs and compared to an asymptomatic control group. Results MRI demonstrated a variable morphology and a variety of bone and soft tissue abnormalities associated with carpal boss. Bone marrow edema around the quadrangular joint shows a significant correlation (Fisher's exact test: P < 0.001) and a positive correlation (Pearson's test r = 0.632, significant at the 0.01 level [two-tailed]) with a painful carpal boss. Conclusion MRI offers detailed examination of bone and soft tissue abnormalities associated with a carpal boss. Local bone marrow edema strongly correlates with a painful carpal boss.

Fascial flap surgery for recurrent dorsal ganglion.

Recurrence after primary resection of a dorsal wrist ganglion may necessitate a reintervention. A technique was introduced in 2004 in which a flap of the extensor retinaculum is used to cover the defect left in the wrist capsule following repeat radical excision. This retrospective study presents the follow-up 4.6 years after this surgery in 20 patients. Recurrence, grip strength and possible flexion deficit are measured in 13 patients who attended clinic, as well as pain and satisfaction scores. Disability scores have been evaluated in 18 patients. One refractory patient was ascertained. A flexion deficit ≤ 10° was observed in 7 patients. Overall, mild pain, very mild disability, a flexion deficit of 14.2° and a loss of grip strength of 3.6 kg was observed. The retinaculum flap for recurrent dorsal wrist ganglion is a reliable procedure with limited risk for flexion deficit after surgery, high satisfaction rate and low recurrence risk.

Comparison of surgical treatments for mucous cysts of the distal interphalangeal joint.

Mucous cysts of the interphalangeal joints are common. Several surgical techniques have been described, but none has proven to be superior. We compared three techniques that entail complete removal of the cyst together with the concomitant osteophytes. In group A wound closure was obtained by full thickness skin graft, in group B by primary closure and in group C by a local skin graft. Sixty-four patients with 70 cysts were reviewed. An overall recurrence rate of 8.6% was observed. Forty-five of the studied patients received a full thickness skin graft (4 out of 45 recurred), 23 were closed primarily (2 out of 23 recurred) and 2 by a local skin graft (no recurrences). Full thickness skin graft showed no significant higher recurrence compared to primary closure. Full thickness skin graft showed no significant higher pain or satisfaction compared to primary closure. Patients with a recurrent cyst were less satisfied and had more pain than those without recurrences.

Proximal interphalangeal joint replacement: resurfacing pyrocarbon versus silicone arthroplasty.

Prosthetic replacement of the proximal interphalangeal joints is an operative treatment for osteoarhtritis, to preserve the range of motion and the function of the hand. The purpose of this study is to detect the differences regarding pain and function between a silicone implant using a volar approach and a resurfacing implant, placed through a dorsal approach. Patients were reviewed clinically and scored. We found no significant differences in outcome between the two types of implants. However, the complication rate in the resurfacing group was significantly higher. Also, the economic cost of both implants was significantly different. The resurfacing implants were more expensive than the silicone implants.

Carpal malalignment in malunion of the distal radius and the effect of corrective osteotomy.

Introduction Malunions of the distal radius often induce carpal malalignment. Two different types can be distinguished: an adaptive midcarpal malalignment (so-called CIA wrist: carpal instability, adaptive) and a radiocarpal malalignment (dorsal translation of the whole carpus). The effect of distal radial osteotomy on the carpal alignment has hardly been studied. Material and Methods 31 wrists in 31 patients (mean age 44 years) with malunion of the distal radius after a Colles fracture were treated with a corrective osteotomy. The patients were divided on basis of effective radio-lunate flexion (ERLF) in the two patterns of carpal malalignment. The radiographic changes were evaluated. Results There were 20 patients with midcarpal malalignment (ERLF ≤ 25°) and 11 with radiocarpal malalignment (ERLF > 25°). There was a correction of radial tilt and ulnar variance in both groups. There was a significant improvement of the carpal alignment in the midcarpal malalignment group, up to normal parameters. Neither age nor delay between fracture and osteotomy correlated. In the radiocarpal malalignment group a significant effect on the ERLF was observed. In the patients with dorsal plating 70% of the hardware had to be removed. Conclusion Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and carpal malalignment.

Arthroscopic debridement with and without distal ulnar resection in the treatment of triangular fibrocartilage complex tears.

A retrospective survey for debridement with or without wafer distal ulna resection was performed. Forty six patients responded to a questionnaire on pain, disability and time off work. The mean DASH score decreased from 42 to 28 on average. Thirty two patients were satisfied. The pain was considered severe in 12 patients. There were significant differences in the outcome between debridement only and debridement with wafer resection of the distal ulna.

Primary ulnar superficial slip resection in complicated trigger finger.

Long standing trigger finger, often present for 6 months to years before consulting, can result in a lack of extension, which is often painful and may persist after section of the A1 pulley. The ulnar superficial slip resection (USSR) was introduced by Le Viet to address this problem. It is hypothesised that primary section of the A1 pulley with USSR resolves both extension lack and pain in longstanding trigger fingers with a painful extension lack. This retrospective study reviewed the results of primary USSR for longstanding trigger fingers (6 months or more) with painful extension lack in 18 patients. Locking was resolved and full extension was acquired in all cases (100%). Satisfaction rate was high (89%) and disability returned to normal after surgery. In two patients, satisfaction was low due to residual loss of flexion as a result of osteoarthritis and cold intolerance in another. It is concluded that the USSR procedure is a valuable primary surgical option in complicated trigger finger with painful extension lack caused by flexor tendon tendinosis.