Recurrent lipoma: an uncommon presentation in the wrist after incomplete excision.

Patient: Female, 58-year-old. Final Diagnosis: Benign recurrent lipoma following incomplete surgical removal. Symptoms: Discomfort, Aesthetic Dissatisfaction. Clinical Procedure: Surgical Revision-Excision-Exploration with Lipoma Extraction. Specialty: Plastic Surgery (Hand Surgery). Objective: Unusual Clinical Presentation and Course. Background: Lipoma is a usually painless tumor composed of adipocytes, of fat cells, arising from mesenchymal tissue. It manifests itself in locations in the body where adipocytes are and has circumscribed growth. Its incidence in the hand is relatively low (1%-4.9%). Despite most lipomas being benign and usually asymptomatic, the location of lipoma can lead to nerve compression symptoms. We report a case of an unusual recurrence of lipoma in the wrist after incomplete excision. Case report: A 58-year-old female presented with a large, soft mass located on the volar side of the wrist, which recurred during the first week following the initial excision. While the patient did not exhibit symptoms of nerve compression, she reported experiencing swelling and pain at the surgical site postoperatively. The patient underwent surgical re-excision of the lesion, and the excised tissue was sent for histological examination. The subsequent histological analysis confirmed the diagnosis of a benign lipoma. The patient expressed satisfaction with the surgical revision, postoperative care, and outcomes, reporting high levels of contentment in pain relief, functional improvement, and cosmetic results. Conclusions: Lipomas often remain asymptomatic for extended periods, only becoming a source of discomfort or concern once they increase in size or impact one's appearance. Although most lipomas are benign and pose little risk to overall health, certain malignant variants exist. Recurrence of lipoma is uncommon and typically suggests an incomplete initial excision. In anatomically complex regions like the hand or wrist, meticulous planning and preoperative imaging are essential to prevent compression, exclude malignancy, and preserve function.

Replacement of a destroyed scaphoimodelled prosthesis.

Preiser disease is a rare condition where ischaemia and necrosis of the scaphoid bone occurs without previous fracture. A female patient in her 30s presented with severe right wrist pain caused by Preiser disease. Initially, she was treated by a pedicled vascularised bone graft, but unsuccessfully. Four years after the initial diagnosis, the affected scaphoid was replaced by a 3D modelled prosthesis. Three years after the operation, the patient had significant pain reduction, good wrist function and grip strength. Final X-rays demonstrated no signs of dislocation of the implant or signs of periprosthetic arthritis. Studies have shown that once scaphoid non-union advanced collapse occurs, treatment should consist of either a proximal row carpectomy or scaphoidectomy and four corner fusion. In our case, despite collapse and previous surgery, replacement of the single affected bone by a 3D modelled prosthesis lead to good return of function.

The Influence of Corticosteroid Injections on Postoperative Outcomes of Carpal Tunnel Release: A Systematic Review.

Background Carpal tunnel syndrome can be treated with corticosteroid injections (CIs) and surgery. In this systematic review, the influence of previous CI on different postoperative outcomes after carpal tunnel release is evaluated. Methods A systematic literature search using several databases was performed to include studies that examined patients diagnosed with carpal tunnel syndrome who received preoperative or intraoperative CIs. Results Of 2,459 articles, 9 were eligible for inclusion. Four papers reported outcomes of preoperative and four outcomes of intraoperative CIs. One study evaluated patients who received both intraoperative and preoperative corticosteroids. Conclusion Intraoperative CIs are associated with reduced postoperative pain after carpal tunnel release and support earlier recovery of the hand function that can be objectified in a faster median nerve conduction speed recovery and lower Boston Carpal Tunnel Questionnaire (BCTQ) scores. Using preoperative CIs did not lead to enhanced recovery after carpal tunnel release, and both preoperative and intraoperative CIs might be predisposing factors for infections.

Dutch Multidisciplinary Guideline on Dupuytren Disease.

Purpose: To provide a comprehensive, evidence-based overview of the treatment for Dupuytren disease, specifically needle techniques, radiotherapy, primary conservative therapy, surgery, lipofilling, operative arthrolysis, salvage techniques, and the postoperative protocol and to make clinical recommendations for health care practitioners and patients. Methods: Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary, and authorization phase. Patients participated in every phase. Multiple databases and existing guidelines up to August 2020 were searched. Studies on Dupuytren disease were considered eligible. Specific eligibility criteria were described per module. To appraise the certainty of the evidence, reviewers extracted data, assessed the risk of bias, and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were as follows: patient values and preferences, costs, acceptability of other stakeholders, and feasibility of implementation. Recommendations were made based on the evidence from the literature and the considerations. The primary and secondary outcome measures were defined per module based on the input of patients obtained in collaboration with the Netherlands Patient Federation and health care providers from different professions. Results: The following 8 specific modules were completed for Dupuytren disease: (1) needle techniques, (2) radiotherapy, (3) primary conservative therapy, (4) surgery, (5) lipofilling, (6) operative arthrolysis, (7) salvage techniques, and (8) the postoperative protocol. Conclusions: Our Dutch multidisciplinary guideline on Dupuytren disease provides 8 modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are provided for needle techniques, radiotherapy, primary conservative therapy, surgery, lipofilling, operative arthrolysis, salvage techniques, and the postoperative protocol. This guideline can assist health care providers and patients in clinical practice. Type of study/level of evidence: Systematic review/I-II.

Scapholunate Ligament Reconstruction without Immobilization Is Safe and Leads to Better Functional Results.

Background Reconstruction of the scapholunate ligament (SL) is associated with a reduction in range of motion. In this study, we compared SL reconstruction and early mobilization with SL reconstruction and Kirschner wires (K-wire) fixation for 6 weeks. Methods We performed a nonrandomized trial involving patients with an arthroscopically confirmed SL ligament injury. In total, 11 patients were assigned to SL reconstruction with internal brace augmentation and early mobilization and 10 were assigned to standard SL reconstruction and K-wire fixation for 6 weeks before mobilization started. We assessed the range of motion, grip strength, functional status, intensity of pain, global perceived effect, and duration until return to work. Results In both groups, there was one traumatic breakout of the reconstructed ligament and two patients in the control group were lost to follow-up. The 10 patients in the internal brace group had a mean increase in wrist flexion of 1.8 degrees at 1 year compared with a decrease in wrist flexion of 13.4 degrees in the seven patients of the control group. Wrist extension increased by 4.5 degrees in the internal brace group and decreased by 4.5 degrees in the control group. In addition, the internal brace group scored 6.1 (much improved) for the global perceived effect and the control group 4.7 (slightly improved), and treatment without immobilization resulted in an earlier return to work (35.1 vs. 73.6 days). Conclusions In SL reconstruction, internal brace augmentation and early mobilization result in improved wrist flexion and extension, higher satisfaction, and earlier return to work.

The effect of carpal tunnel release on health-related quality of life of 2346 patients over a 5-year period.

In this prospective cohort study, the health-related quality of life (HRQoL) from a societal perspective of carpal tunnel syndrome (CTS) patients was determined and compared with other diseases. In addition, the effect of carpal tunnel release (CTR) was analysed 6 weeks postoperatively with regard to mean EQ-5D index value improvement, side-effects of surgery and cost per quality adjusted life year (QALY) gained. We found a baseline mean EQ-5D index value of 0.75 (SD: 0.23), comparable with values seen in other disease like breast cancer, diabetes and asthma. Furthermore, we found that CTR improved HRQoL substantially 6 weeks postoperatively (mean + 0.12, SD: 0.22) and significantly reduced symptom reporting (mean -52%, SD: 53) with a cost per QALY gained of €396.05. In conclusion, CTS has a comparable impact on quality of life as compared with other diseases, and CTR has the potential to substantially improve patient's HRQoL at a fairly modest cost.Level of evidence: III.

Night Orthosis After Surgical Correction of Dupuytren Contractures: A Systematic Review.

PURPOSE: To determine the role of night orthosis use after surgical correction of Dupuytren contracture. METHODS: We searched MEDLINE, EMBASE, CINAHL, AMED, OTSeeker, and CENTRAL for articles published from inception of the databases to August 2015. Assessment was undertaken by 2 independent reviewers (O.A.S. and S.A.). Methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa instrument. RESULTS: Seven studies met the standard for inclusion in this review. A total of 659 patients across these 7 studies were included in the analysis, with follow-up ranging from 3 to 72 months. None of the included studies assessed recurrence. The analysis revealed no significant improvement in range of motion of hand joints for patients who received a static night orthosis after Dupuytren surgery compared with patients without an orthosis. Similarly, no differences were found in patient-reported functional status across the 2 groups. CONCLUSIONS: The current literature does not appear to support the use of static night orthosis in addition to hand therapy after surgical correction of Dupuytren contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Spinal cord stimulation for complex regional pain syndrome type I: a prospective cohort study with long-term follow-up.

OBJECTIVES: Spinal cord stimulation (SCS) is an effective treatment for intractable complex regional pain syndrome type I pain. Long-term data are scarce on effectiveness, degree of pain relief, predictors, and complications. MATERIALS AND METHODS: From 1997 to 2008, 84 consecutive patients who received an implanted SCS system after positive test stimulation were included in the prospective study. Treatment effectiveness was assessed annually as measured by mean visual analog scale pain scores and with the Patients Global Impression of Change scale. Treatment success was defined as at least 30% mean pain relief at end point and treatment failure as explantation of the system. A Cox regression determined if baseline factors were associated with both these outcomes. RESULTS: During 11 years, 41% (95% CI: 27-55) of the patients experience at least 30% pain relief at assessment end point. During 12 years of follow-up 63% (95%CI: 41-85) of the implanted patients still use their SCS device at measured end point. Pain relief of at least 50% one week following test stimulation is associated with a higher probability of long-term treatment success. In 51 patients, 122 reinterventions were performed over 12 years; 13 were due to complications, 44 to battery changes, and 65 reinterventions were equipment related. CONCLUSION: SCS provides an effective long-term pain treatment for 63% (95%CI: 41-85) of implanted patients. Forty-one percent (95%CI: 27-55) of SCS treated patients have at least 30% pain reduction at measurement end point. The number of reinterventions after implantation due to equipment-related problems, battery changes, and complications is 122 over 12 years of follow-up. Sixty-one percent (N = 51) of the patients had at least one reintervention. Mean pain relief of at least 50% (visual analog scale) one week after the test stimulation is associated with long-term treatment success.

The cost-effectiveness of spinal cord stimulation for complex regional pain syndrome.

OBJECTIVES: Health-care policymakers and payers require cost-effectiveness evidence to inform their treatment funding decisions. The aims of this study were to assess the cost-effectiveness of the addition of spinal cord stimulation (SCS) compared with conventional management alone (CMM) in patients with complex regional pain syndrome (CRPS), and to determine the cost-effectiveness of nonrechargeable versus rechargeable SCS implanted pulse generators (IPGs). METHODS: A decision analytic model was used to synthesize data on CRPS patient outcomes and health-care costs over a 15-year time horizon from the perspective of the UK National Health Services. Data were sourced from two SCS randomized controlled trials. Results are expressed as an incremental cost per quality-adjusted life-year (QALY) in 2008 GBP. RESULTS: The incremental cost-effectiveness of SCS compared with CMM was £3562 per QALY, a finding that was robust across sensitivity analyses with an 87% probability that SCS is cost-effective at a willingness to pay threshold of £30,000. When the longevity of an IPG is 4 years or less, a rechargeable (and initially more expensive) IPG is more cost-effective than a nonrechargeable IPG. CONCLUSIONS: In selected patients with CRPS, SCS is cost-effective as an adjunct to CMM. Despite their initial increased expense, rechargeable IPGs should be considered when IPG longevity is likely to be short. These findings support policymakers to extend the use of SCS as a good value for money treatment for CRPS.

Brush-evoked allodynia predicts outcome of spinal cord stimulation in complex regional pain syndrome type 1.

BACKGROUND: Spinal cord stimulation (SCS) has proven to be an effective however an invasive and relatively expensive treatment of chronic Complex Regional Pain Syndrome type 1(CRPS-1). Furthermore, in one third of CRPS-1 patients, SCS treatment fails to give significant pain relief and 32-38% of treated patients experience complications. The aim of the current study was to develop effective prognostic factors for prediction of successful outcome of SCS. METHODS AND RESULTS: The study population consisted of 36 chronic CRPS patients enrolled in a randomized controlled trial of SCS efficacy. We analyzed various prognostic factors in the group of patients treated with SCS and compared baseline values of possible predictors of outcome in the successfully treated and the not successfully treated group. Success was defined as Patient Global Perceived Impression of Change score of at least "much improved" and pain reduction of at least 2.5 on a visual-analogue scale (VAS score 0-10). Univariate analyses showed that patient age, duration of the disease, localization of the disease, intensity of the pain, and the presence of mechanical hypoesthesia did not predict SCS success. The mean and maximum value of brush-evoked allodynia proved to be statistically significant predictors of outcome. Using Receiver-Operating Characteristic (ROC) curve analyses of maximum allodynia values, the diagnostic sensitivity for successful SCS was 0.75 and the specificity 0.81. CONCLUSION: Brush-evoked allodynia may be a significant negative prognostic factor of SCS treatment outcome after 1 year in chronic CRPS-1.

Effect of spinal cord stimulation for chronic complex regional pain syndrome Type I: five-year final follow-up of patients in a randomized controlled trial.

OBJECT: Chronic complex regional pain syndrome-Type I (CRPS-I) is a painful, disabling disorder for which no treatment with proven effect is available. In the present randomized controlled trial, the authors assessed the effectiveness of spinal cord stimulation (SCS) in reducing pain due to CRPS-I at the 5-year follow-up. METHODS: The authors performed a randomized trial in a 2:1 ratio in which 36 patients with CRPS-I were allocated to receive SCS and physical therapy (PT) and 18 patients to receive PT alone. Twenty-four patients who received SCS+PT also underwent placement of a permanent spinal cord stimulator after successful test stimulation; the remaining 12 patients did not receive a permanent stimulator. The authors assessed pain intensity, global perceived effect, treatment satisfaction, and health-related quality of life. Patients were examined before randomization, before implantation, and every year until 5 years thereafter. Ten patients were excluded from the final analysis. RESULTS: At 5 years posttreatment, SCS+PT produced results similar to those following PT for pain relief and all other measured variables. In a subgroup analysis, the results with regard to global perceived effect (p=0.02) and pain relief (p=0.06) in 20 patients with an implant exceeded those in 13 patients who received PT. CONCLUSIONS: Despite the diminishing effectiveness of SCS over time, 95% of patients with an implant would repeat the treatment for the same result.

Duration of preoperative traction associated with sciatic neuropathy after hip fracture surgery.

UNLABELLED: An unknown percentage of patients who have internal fixation for hip fractures have sciatic neuropathy develop. In most cases, the cause for this complication is unknown. We retrospectively reviewed 2202 consecutive patients treated in our hospital for hip fractures to ascertain whether there was any relationship between duration of preoperative traction and postoperative sciatic neuropathy, and to determine the incidence of sciatic neuropathy after surgery for hip fractures. All patients had preoperative skin traction. Patients with and without sciatic neuropathy were compared using nonparametric tests. The median duration of traction was 2.6 days in the group that had sciatic neuropathy develop and 0.9 days in the group that did not. Also, patients in the group that had sciatic palsy develop were older. There seemed to be no other difference between the groups for any of the studied variables. Sixteen patients (0.7 %) had postoperative sciatic neuropathy. Our data suggest sciatic neuropathy after surgery for hip fractures may be related to the duration of preoperative traction. Some investigators have reported that there seems to be no evidence of benefit from skeletal or skin traction. A potential for damage to the sciatic nerve may be an argument to stop routine use of preoperative traction. LEVEL OF EVIDENCE: Diagnostic study, Level III (study of nonconsecutive patients; without consistently applied reference "gold" standard).

The effect of spinal cord stimulation in patients with chronic reflex sympathetic dystrophy: two years' follow-up of the randomized controlled trial.

Chronic reflex sympathetic dystrophy is a painful, disabling disorder for which no treatment with proven effect is available. We performed a randomized trial in a 2 to 1 ratio of patients, in which 36 patients were treated with spinal cord stimulation and physical therapy (SCS+PT), and 18 patients received solely PT. Twenty-four SCS+PT patients were given a permanent spinal cord stimulation system after successful test stimulation; the remaining 12 patients received no permanent system. We assessed pain intensity, global perceived effect, functional status, and health-related quality of life. Patients were examined before randomization, before implantation, and also at 1, 3, 6, 12, and 24 months thereafter. At 2 years, three patients were excluded from the analysis. The intention-to-treat analysis showed improvements in the SCS+PT group concerning pain intensity (-2.1 vs 0.0 cm; p < 0.001) and global perceived effect (43% vs 6% "much improved"; p = 0.001). There was no clinically important improvement of functional status. Health-related quality of life improved only in the group receiving spinal cord stimulation. After careful selection and successful test stimulation, spinal cord stimulation results in a long-term pain reduction and health-related quality of life improvement in chronic reflex sympathetic dystrophy.

What is a meaningful pain reduction in patients with complex regional pain syndrome type 1?

OBJECTIVE: To investigate the degree of pain reduction in patients with complex regional pain syndrome type 1 (CRPS 1) that can be defined as "successful." DESIGN: All patients rated their pain on a visual analog scale (VAS; 0-10) before treatment and on three occasions after treatment, at 6 months, 1 year, and 2 years. Patients also rated a Global Perceived Effect (GPE) for their pain relief at the same time periods. The GPE items were classified as "successful" or "unsuccessful." The mean absolute and relative pain reduction (using the VAS) was calculated for both "successful" and "unsuccessful" GPE classifications for each time period. Sensitivity and specificity analyses were performed. PATIENTS: Sixty-one patients with CRPS 1. RESULTS: The patients defined a relative pain reduction of 58% (SD, 23.4) or more as "successful," whereas in "successful" and "unsuccessful" patient groups the pain was reduced significantly on the VAS. Furthermore, sensitivity and specificity analyses showed that a cut-off point of 50% relative pain reduction and a 3-cm absolute pain reduction on the VAS have the highest likelihood that patients will report their treatment "successful" on the GPE. CONCLUSIONS: Relative pain reduction of 50% or more and an absolute pain reduction of at least 3 cm on the VAS are accurate in predicting a successful pain reduction after a given treatment.

Economic evaluation of spinal cord stimulation for chronic reflex sympathetic dystrophy.

OBJECTIVE: To evaluate the economic aspects of treatment of chronic reflex sympathetic dystrophy (RSD) with spinal cord stimulation (SCS), using outcomes and costs of care before and after the start of treatment. METHODS: Fifty-four patients with chronic RSD were randomized to receive either SCS together with physical therapy (SCS+PT; n = 36) or physical therapy alone (PT; n = 18). Twenty-four SCS+PT patients responded positively to trial stimulation and underwent SCS implantation. During 12 months of follow-up, costs (routine RSD costs, SCS costs, out-of-pocket costs) and effects (pain relief by visual analogue scale, health-related quality of life [HRQL] improvement by EQ-5D) were assessed in both groups. Analyses were carried out up to 1 year and up to the expected time of death. RESULTS: SCS was both more effective and less costly than the standard treatment protocol. As a result of high initial costs of SCS, in the first year, the treatment per patient is $4,000 more than control therapy. However, in the lifetime analysis, SCS per patient is $60,000 cheaper than control therapy. In addition, at 12 months, SCS resulted in pain relief (SCS+PT [-2.7] vs PT [0.4] [p < 0.001]) and improved HRQL (SCS+PT [0.22] vs PT [0.03] [p = 0.004]). CONCLUSIONS: The authors found SCS to be both more effective and less expensive as compared with the standard treatment protocol for chronic RSD.

Comparison of multiple against single pain intensity measurements in complex regional pain syndrome type I: analysis of 54 patients.

OBJECTIVE: To describe the comparison of multiple and single pain ratings in patients with complex regional pain syndrome type I (CRPS I). DESIGN: Correlation, agreement, and reliability analyses were performed between the average pain intensity measured 3 times a day over a course of 4 days and one single pain rating (designated the "recalled average" pain, as assessed by the patient) before treatment and at 1-, 3-, and 6-month periods after treatment. PATIENTS: The patient population consisted of 54 patients with CRPS I in a randomized trial. RESULTS: The results show that both measurements correlate and have excellent agreement. Furthermore, both ratings measure significant pain reduction after treatment; "recalled average" pain, however, reflects greater change in pain intensity. CONCLUSIONS: In patients with CRPS I a single pain rating is an accurate predictor of the average pain measured by a multiple pain-rating test. Moreover, both assessments are accurate enough to determine changes in pain over time with an effective treatment.

The impact of chronic pain on life in the household.

To study what happens in a family where one member suffers from chronic pain, we quantitatively assessed the effect of chronic pain resulting from complex regional pain syndrome type 1 (CRPS) on 1) employment status, 2) time allocation, 3) additional domestic help, and 4) out-of-pocket expenses of Dutch patients (n = 50) and their spouses (n = 43). This study is the first to measure the effect of chronic pain on time allocation by means of a diary assessment technique. The results were compared with normative values for the Dutch population overall. In households containing a male patient, the total employment full time equivalent (FTE) decreased by 47% (P = 0.05), with the result that the mean household income decreased by $4,000 (P = 0.01). In those with a female patient, there was a reduction in FTE of 29% (P < 0.05), causing a decrease of the mean household income by $2,000 (p < 0.001). As compared with controls, patients were found to spend less time on paid employment, and to invest more time in household maintenance and housekeeping. Of 50 patients, 35 received a mean of 4.5 hours per week of domestic help. The mean out-of-pocket expenses related to CRPS amounted $1,350 per patient per year. Spouses were forced to invest more time on housekeeping and household maintenance, which resulted in less time for personal needs and leisure activities. There were only small differences in time allocation between cases where the sufferer was male or female and, similarly, only minor variation between hand-affected or foot-affected patients. Households with either male or hand-affected patients did prove to have higher out-of-pocket expenses as compared with households containing female or foot-affected patients. Those containing female or hand-affected patients required more domestic help than households either with male or foot-affected patients. The present study demonstrates that chronic pain due to CRPS has a profound impact on many aspects of the lives of both patients and their spouses.