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).

WALANT surgery of the hand: state of the art.

Wide-awake local anesthesia no tourniquet is named the WALANT technique. WALANT has had a major positive impact on cost, convenience, ecology, patient satisfaction, access to surgical care, and outcomes in hand surgery in the last 20 years. Safe and efficient application of the technique is based on two principles. The first principle is the tumescent injection of a large volume low concentration 0.25-1% lidocaine, with 1:100 000-1:400 000 epinephrine. The second principle of WALANT is that the proper injection should be almost painless, with the patient only feeling the first needle poke of a tiny 30G needle. This wide awake patient approach reduces pain, neuropraxia, and systemic side effects of sedation with preservation of motor control, thereby aiding balanced reconstruction in hand surgery.

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.

Ultrasound measurement of subsynovial connective tissue thickness in the carpal tunnel: An intrarater/interrater reliability and agreement study.

OBJECTIVES: Non-inflammatory thickening of the subsynovial connective tissue (SSCT) in the carpal tunnel is commonly found in subjects with carpal tunnel syndrome (CTS), and quantification may shed light on CTS pathogenesis. To date, information on the reliability of ultrasound quantification of SSCT is scarce. Therefore, we investigated intrarater and interrater reliability/agreement for ultrasound quantification of SSCT thickness in subjects with and without CTS, and predictors for tissue thickness. MATERIAL AND METHODS: Two investigators quantified SSCT thickness and thickness ratio on ultrasound in 16 healthy subjects (age, 24-65 years; 16 left/14 right wrists) and 17 subjects with CTS (age, 37-83 years; 14 left/14 right wrists). Intra- and inter-rater reliability/agreement were assessed on intraclass correlation coefficients, standard error of measurement and minimal detectable change. A mixed-effects model was used to evaluate potential predictors for SSCT thickness. RESULTS: Intra- and inter-rater reliability analysis showed good to excellent intraclass correlation coefficients in both groups, ranging from 0.772 to 0.965. The maximum percentage standard error of measurement was 8%. The maximum minimal detectable change was 14% within raters, and 20% between raters. Both intra- and inter-rater reliability values for thickness ratio were poor. Presence of CTS (ß = 0.180; p = 0.015) correlated positively with SSCT thickness. CONCLUSIONS: Ultrasound is a reliable method for quantification of SSCT thickness, but not for thickness ratio. Presence of CTS correlates positively with SSCT thickness.

In Situ Stabilization of the Ulnar Nerve as an Alternative to Transposition in Traumatic Ulnar Nerve Instability: A Case Report.

CASE: We present the case of a 25-year-old male sports climber treated with in situ ulnar nerve stabilization for ulnar nerve instability (UNI) by using 2 fascial flaps. CONCLUSION: Symptomatic UNI has traditionally been managed with subcutaneous or submuscular ulnar nerve transposition. Transposition is relatively invasive and when performed subcutaneously, embeds the ulnar nerve in an exposed location, which may render it prone to mechanical injury in physically active patients. In situ stabilization may be a less invasive alternative to transposition in select patients involved in sports such as rock climbing.

Flexor carpi radialis tendon tear due to scaphoid osteoid osteoma: A case report.

Osteoid osteoma is a benign osteoblastic tumor with a low incidence. Due to its uncommon and often confusing clinical presentation, accurate diagnosis is frequently significantly delayed. We report a case of a 56-year old right-handed woman with a history of increasing pain in her right scaphotrapeziotrapezoidal (STT) joint and distal flexor carpi radialis (FCR). Due to its confusing clinical presentation, the diagnosis of a parosteal osteoid osteoma in the scaphoid and a rupture of the FCR, presenting as a Mannerfelt like lesion, was delayed for 1 year. The patient was treated with surgical exploration and excision. At follow-up, the patient recovered with complete resolution of pain and resumed daily life activities after 2 weeks. A high index of suspicion remains the key point in the diagnosis of osteoid osteoma, certainly in cases of unusual clinical presentation and anatomic localization as presented in this case.

Full-thickness skin grafting in preventing recurrence of Dupuytren's disease: A systematic review.

Dupuytren's disease is a progressive hand disorder characterized by the formation of pathologic nodules and cords in the palm, often leading to progressive flexion contractures. Hand surgery is currently the only efficient treatment to restore hand function, however, reported recurrence rates vary widely. Currently, it remains unclear which type of fasciectomy is associated with the lowest recurrence rate. Therefore, a systematic review was conducted to compare recurrence rates after limited fasciectomy, open palm technique, or dermofasciectomy with a full-thickness skin graft. 79 studies were included, and results suggest that a dermofasciectomy with a full-thickness skin graft is associated with a lower recurrence rate. However, most studies were case series in which a wide range of definitions of recurrence was used. Moreover, all studies had a high risk of bias. Therefore, additional comparative clinical trials are recommended that use an unambiguous definition of recurrence. LEVEL OF EVIDENCE III: .

Microfasciectomy in Dupuytren's disease: microsurgery in the evolution toward safer and more efficient fasciectomy and hand surgery.

In the long term, limited fasciectomy is currently the most reliable treatment for Dupuytren's contracture. The risk for complications is significant, certainly in recurrent disease and in the presence of abundant scar tissue. Meticulous surgical technique is mandatory. Microsurgery increases magnification from four times (with surgical loupes) up to 40 times. Using the microscope in Dupuytren's surgery, a technique named microfasciectomy is likely to increase both safety and efficiency by preventing instead of treating surgical complications. Increased experience with microsurgery will benefit Dupuytren's treatment and hand surgery in general.

The prevalence of frozen shoulder in patients with limited Dupuytren disease.

Evidence from the literature suggests an association between Dupuytren disease and frozen shoulder syndrome, both clinically and histologically. An increased tendency for fibrotic healing after repetitive microtrauma could be an underlying mechanism. However, it remains unclear how strong this association is and if only mild signs of Dupuytren disease would also increase the risk of frozen shoulder. In 61 patients, we examined the hands for signs of Dupuytren disease and the shoulders for pain and limited motion. We found a 21,7% prevalence of frozen shoulder syndrome in patients with signs of Dupuytren disease versus 13,9% in those without. The other way around, in patients with frozen shoulder syndrome the prevalence of Dupuytren disease was 50% versus 36.7% in those without frozen shoulder syndrome. These differences were not statistically significant, contrary to similar research in the literature. However, methodological issues, especially the choice of control group, may explain the differences between our findings and previous studies. We conclude that the clinical association between Dupuytren disease may not be so strong as previously thought, especially in patients with only limited signs of the disease.

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.

Midterm Functional Outcome of the Linked Semiconstrained Distal Radioulnar Joint Prosthesis.

Background A painful unstable distal radioulnar joint (DRUJ) can seriously compromise hand and wrist function. The semiconstrained prosthesis was developed to restore DRUJ function. To date, most outcome reports are coauthored by the designer. Questions Does independent reporting confirm the promising results of the semiconstrained DRUJ prosthesis? Are complication and failure rates acceptable? Patients and Methods We evaluated patients with the semiconstrained DRUJ implant and a minimum follow-up of 2 years. We monitored patient satisfaction and function with functionality questionnaires and measured wrist range of motion, grip, and key pinch strength. Statistical analysis was done using descriptive statistics, Pearson correlation coefficients, linear and logistic regression. Results We included 41 patients with 42 implants. Mean follow-up was 46 months (range: 24-102 months). Eighty percent of wrist had undergone previous surgery. We found a mean pronation of 83 degrees (0-90 degrees), supination of 70 degrees (0-90 degrees), flexion of 42 degrees (0-90 degrees), extension of 49 degrees (0-90 degrees), ulnar deviation of 24 degrees (0-60 degrees), and radial deviation of 14 degrees (0-40 degrees). Grip and key pinch strength were 20.1 (1-50 kg) and 6 kg (1-12 kg), respectively. Average patient-rated wrist and hand evaluation score was 42.7 (0-95), disabilities of the arm, shoulder and hand score was 38 (0-88), and visual analog scale score was 3.6 (0-8). We found a 43% complication rate (mostly minor: ulnar or radial tendinopathy, temporary hypoesthesia) with 24% reoperation and 92% prosthesis survival rate. Conclusion The linked semiconstrained DRUJ prosthesis has its value in the surgical treatment of DRUJ failure. Currently, most implants are used in secondary surgery and multioperated wrists. More research is required to assess the value of the DRUJ prosthesis as a primary procedure. Level of evidence This is a level IV, therapeutic study.

Is DISI Deformity Related to Presence of a Medial Lunate Facet in Patients with Scapholunate Dissociation?

Background Lunate morphology has been suggested to influence carpal kinematics. Purpose We investigate a possible relation between presence of a medial lunate facet and dorsal intercalated segment instability (DISI) of the wrist in patients with a scapholunate (SL) dissociation. Methods We retrospectively reviewed patients diagnosed with SL dissociation between 2000 and 2017. Lunate morphology was categorized based on radiographs and magnetic resonance imaging (MRI), as type I or II according to Viegas and Galley. DISI was defined as radiolunate angle > 15 degrees and SL instability as SL angle > 60 degrees. SL distance > 3 mm was considered as widening and carpal height ratio < 0.5 was considered as carpal collapse. We used descriptive statistics to report on SL instability and DISI in patients with Viegas type I and type II lunates. We calculated kappa to determine agreement between radiographs and MRI and to determine inter- and intraobserver agreement. Results Of 119 patient files, 79 wrists met the inclusion criteria of which 25 were type I lunates and 54 type II. Similar spreading of the data of both groups was found regarding DISI, SL instability, and SL widening based on radiographic classification of the lunate, even after adding MRI findings. In the presence of carpal collapse, capitate-to-triquetrum distance was higher. We found a substantial inter- and intraobserver agreement for lunate classification. Conclusion Our results suggest a similar prevalence of DISI deformity or enlarged SL angle in patients with type I or II lunate in presence of SL dissociation. The Viegas classification is a reliable and reproducible classification system. Level of evidence This is a Level III, cross-sectional study design.

The Impact of Dupuytren Disease on Recovery of Motion at the Knee after Total Knee Arthroplasty.

Background: Arthrofibrosis is a complication of total knee arthroplasty (TKA) that can lead to poor outcome. Idiopathic arthrofibrosis and Dupuytren disease (DD) have similar histological appearance. The aim of this study is to determine the influence of DD on the recovery of motion after TKAy. Methods: Patients older than 50 who underwent a TKA for primary osteoarthritis were examined 1 year later for the presence of DD. They were divided into two groups based on the presence or absence of DD. The groups were compared to each other with regard to arc of motion (AOM) of the operated knee at 6 weeks and 1 year; the need for additional measures to improve the AOM, and the effect of obesity [body mass index (BMI) > 30]. Results: The study included 61 patients of which 25 (41%) had DD. There was no difference in AOM at 6 weeks or 1 year between the two groups. Patients in the DD group required a greater number of additional measures to improve AOM. Also, non-obese patients (BMI < 30) in the DD group had lower AOM at 1 year. Conclusions: Patients in the DD group needed additional physiotherapy or manipulation under anaesthesia (MUA) to achieve the same AOM. This might indicate a possible connection between DD and post-operative stiffness of the knee. Identifying patients with DD in the pre-operative period may help recognise patients who may have difficulty in regaining AOM after TKA. Level of Evidence: Level III (Therapeutic).

Pulley Rupture in Rock Climber after Collagenase Treatment for Dupuytren Contracture.

Pulley injuries and Dupuytren disease are quite common in rock climbing. We report a rock climber who was treated for a Dupuytren contracture with collagenase injection therapy. Two months later, he developed a traumatic pulley injury during climbing and was treated with a ring orthosis. However, the finger contracture deteriorated and both a recurrent pulley rupture and a second pulley rupture were diagnosed. We were unable to find any reports on the use of collagenase in rock climbers with Dupuytren disease. We report a case of pulley rupture in a rock climber, treated for Dupuytren contracture in the treated and an adjacent finger, 2 months after the injection of collagenase. Level of Evidence: Level V (Therapeutic).

Spectacular Accidental Distraction Arthroplasty in Dupuytren Contracture with Good Outcome: A Case Report.

CASE: An exceptional event occurred during gradual extension with an external fixator for recurrent small finger Dupuytren flexion deformity. A massive proximal interphalangeal joint distraction arose, possibly because of the center of rotation misalignment and a hasty patient-controlled correction. The device was removed, and a plaster splint protected the finger for 5 days to prevent dislocation of the unstable joint. It relocated with an acceptable clinical result. CONCLUSION: Gradual extension of Dupuytren contractures with an external fixator may induce severe joint distraction by eccentric placement of the device. On the other hand, the good outcome of this case report may inspire further research on controlled joint distraction in hooked deformity.

Palmar skin elasticity measured by the Cutometer MPA 580 is decreased in mild Dupuytren's disease compared to healthy controls.

Introduction: Involvement of the palmar skin is often seen in patients with Dupuytren's disease (DD) with severe finger contractures. However, skin elasticity may be already decreased earlier in the disease. The Cutometer MPA 580 could provide an objective skin measurement tool to assess this decrease in elasticity. Linking objective skin measurements to functional outcome measures could lead to better prediction of disease progression. We set up a study to investigate if the Cutometer was able to detect differences in skin elasticity between patients with mild Dupuytren's disease and healthy controls. Methods: A cross-sectional analytical study was performed. Three assessors measured skin elasticity (palmar hand) on two sites using the Cutometer on 30 patients with mild DD and 30 healthy controls. Student's t-test was used to evaluate differences in skin elasticity and a linear model to evaluate interactions between the groups and sites. Results: Significant differences in skin elasticity were found between DD patients and controls, as well as differences based on the location examined. Discussion: Similar to other skin conditions, the Cutometer MPA 580 was able to demonstrate a significant lower elasticity in the palmar skin in DD patients compared to healthy controls. A decrease in skin elasticity in different locations of the hand correlated with areas that often pose problems in the treatment of more severe DD. The Cutometer could potentially be a tool to identify these areas earlier in the disease.

Long-term follow-up of the three-ligament tenodesis for scapholunate ligament lesions: 9-year results.

We report on a retrospective cohort of 50 cases of three-ligament tenodesis for scapholunate instability. Fifteen cases (30% of our cohort) needed salvage surgery (11 proximal row carpectomies, 2 partial and 2 total wrist fusions) at an average of 33 months and are considered "failures". Of the 35 remaining cases ("success"), 16 (32% of our cohort) were reviewed at average 111 months and had good functional outcomes (QuickDASH 18/100, PRWE 11/100, pain 1/10, satisfaction 9/10). Return to work was 81% and grip strength was 80% of the opposite side. Radiological review found no significant correction in the short-term: scapholunate angle (SLA) from 72° to 69° (p = 0.544), scapholunate distance (SLD) from 3.4 mm to 3.4 mm (p = 0.833) and radiolunate angle (RLA) from 17° to 13° (p = 0.253). A significant deterioration in SLA from 72° to 80° (p = 0.014), not correlated to function, was seen at final follow-up. Radiographic progression to wrist degeneration was seen in 63% of successful cases. In failed cases, we noticed inferior radiographic parameters in the short-term: SLD of 4.6 mm in failed versus 3.4 mm in successful cases (p = 0.038) and RLA of 22° in failed versus 13° in successful cases (p = 0.046). Complication rate was 10% (2 scaphoid necroses, 1 septic arthritis and 2 complex regional pain syndromes). Despite radiological deterioration of SLA and development of degeneration in most cases, three-ligament tenodesis can give satisfactory wrist function in some patients, but we observed a significant number of failures and a high complication rate. LEVEL OF EVIDENCE: IV.

Patient satisfaction with intravenous regional anaesthesia or an axillary block for minor ambulatory hand surgery: A randomised controlled study.

BACKGROUND: Intravenous regional anesthesia (IVRA) and the axillary brachial plexus block are popular alternatives to general anaesthesia in ambulatory hand surgery. Although both have proven their effectiveness, patients' preferences have never been evaluated. OBJECTIVES: We investigated patient satisfaction with both techniques and hypothesised that satisfaction after IVRA is noninferior compared with axillary brachial plexus block. DESIGN: A prospective, randomised controlled trial. SETTING: Ambulatory surgical day care centre, University Hospitals of Leuven, Belgium, from September 2016 to November 2017. PATIENTS: One hundred and twenty adults undergoing minor ambulatory hand surgery were included in this study. INTERVENTION: Patients received either IVRA with 300 mg lidocaine or an axillary block with 280 mg mepivacaine. MAIN OUTCOME MEASURES: The primary endpoint was the evaluation of patient satisfaction using the 'Evaluation du Vécu de l'Anésthesie Locoregional' (EVAN-LR) questionnaire. Secondary outcomes included different procedural times, block quality, tourniquet discomfort, the incidence of block failure and postoperative nausea and vomiting (PONV), the severity of postoperative pain and the need for postoperative analgesics during the first 24 h. RESULTS: Noninferiority of IVRA was shown for the median [IQR] total score on the EVAN-LR questionnaire, IVRA-group: 92 [87 to 96] vs. axillary brachial plexus block-group: 91[87 to 97]; Hodges--Lehmann estimator (95% confidence interval (CI)] for the shift: -0.25 (-2.60 to 2.20). Induction of anaesthesia and time to discharge, requiring partial recovery of the motor block, were significantly longer in the axillary brachial plexus block group. The IVRA-group had a lower block quality, a higher incidence of tourniquet-discomfort and higher median intra-operative and postoperative pain scores on day 0; 0 [0 to 2] vs. 0 [0 to 0] and 0.8 [0 to 1.8] vs. 0 [0 to 0.25], respectively, but no increase in the need for supplementary analgesics or conversion rate to general anaesthesia. CONCLUSION: IVRA and axillary brachial plexus block result in comparably high patient satisfaction in ambulatory hand surgery. CLINICAL TRIAL REGISTRATION: EudraCT 2016-002325-11.