Treatments for early-stage Dupuytren's disease: an evidence-based approach.

Current treatments for Dupuytren's disease are limited to late-stage disease when patients have developed flexion contractures and have impaired hand function. They all have limitations, including the risk of recurrence and complications. The use of treatments for early-stage disease, such as intralesional steroid injections or radiotherapy which lack a clear biological basis or evidence of effectiveness based robust randomized, double blind, placebo-controlled trials, highlights the desire of patients to access treatments before they develop significant flexion contractures. A detailed understanding of the cellular landscape and molecular signalling in nodules of early-stage disease would permit the identification of potential therapeutic targets. This approach led to the identification of tumour necrosis factor (TNF) as a target. A phase 2a clinical trial identified 40 mg in 0.4 mL adalimumab as the most efficacious dose and a subsequent randomized, double blind, placebo-controlled phase 2b trial showed that four intranodular injections at 3-month intervals resulted in decrease in nodule hardness and size on ultrasound scan at 12 months, and both parameters continued to decrease further at 18 months, 9 months after the final injection. This type of approach provides clinicians with a robust evidence base for advising their patients.

Outcomes of Free Flap Reconstruction for Chronic Venous Ulceration in the Lower Limb: A Systematic Review.

BACKGROUND: The mainstay of treatment for venous ulceration is conservative wound management and lifelong compression therapy. For patients with recalcitrant ulcers, free flap reconstruction has been proposed as a treatment option to reconstruct the diseased soft tissues as well as the underlying insufficient venous system. This review systematically evaluates the outcomes of free flap reconstruction for chronic venous ulcers in the lower limb. METHOD: A protocol was developed a priori and registered on the PROSPERO database. A systematic search of literature was performed in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), clinical trials registries, and OpenGrey from inception to April 2020 according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies of patients undergoing free tissue transfer reconstruction for chronic venous ulcers in the lower limb were included. RESULTS: A total of 5 noncomparative cohort studies featuring 56 patients with 62 recalcitrant venous ulcers treated with 64 free flaps who had a mean age of 50 years (range, 17-76 years) were included, and a narrative analysis undertaken. Mean defect size following ulcer debridement was 153.3 cm 2 (range, 24-600 cm 2 ). Defects were reconstructed with muscle (n = 39 [60.9%]), fasciocutaneous (n = 23 [35.9%]), and visceral (n = 2 [3.1%]) free flaps, with latissimus dorsi (n = 16, 25%) and rectus abdominis flaps (n = 16, 25%) being the most frequently used. Mean follow-up ranged from 24 to 125 months. Pooled flap survival rate was 95%. No recurrence within the territory of the flap was reported, but there were 20 instances (35.7%) of new ulcers outside of the flap boundaries. CONCLUSION: There is currently an absence of evidence to support the use of free flap reconstruction for recalcitrant venous ulcers compared with conventional management. Although evidence suggests that it is technically feasible, there is no evidence to suggest it prevents ulceration outside the reconstructed region. Further studies are necessary to evaluate its effectiveness for venous ulcers in the lower limb.

Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs.

BACKGROUND: Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes. OBJECTIVES: To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes. MAIN RESULTS: We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement. Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis) One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes. Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis) Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes. AUTHORS' CONCLUSIONS: We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.

Surgical Performance Anxiety and Wellbeing Among Surgeons: A Cross-sectional Study in the United Kingdom.

OBJECTIVE: This national cross-sectional study aims to establish the prevalence and potential impact of performance anxiety among surgeons and investigate its association with psychological traits and wellbeing. SUMMARY AND BACKGROUND DATA: Despite a growing awareness that human factors, non-technical skills and wellbeing in healthcare affect patient outcomes, an area that has remained unexplored is surgical performance anxiety (SPA). METHODS: A prospectively registered, cross-sectional study using mixed methods was conducted across the United Kingdom. Data captured included demographics, surgical specialty, trait anxiety, trait perfectionism, SPA, and surgical perfectionism scores. Wellbeing was assessed using The Short Warwick-Edinburgh Mental Wellbeing Scale, whereas qualitative data were collected regarding surgeons' experiences of SPA. RESULTS: A total of 631 responses were collected. Mean age was 41·2 years and mean surgical experience 15·3 years. A total of 62% were male and 52% of consultant/attending grade. A total of 100% felt that SPA affected surgeons, with 87% having experienced it themselves. A total of 65% reported SPA negatively impacted surgical performance and 96% felt SPA negatively impacted surgeons' wellbeing. Male surgeons reported significantly better wellbeing than female surgeons. Surgeons with SPA reported significantly worse wellbeing compared with surgeons who did not experience SPA. Surgeons in general experienced significantly lower mental wellbeing compared with population norms. Thematic analysis highlighted a reticence to share SPA openly and need for cultural change. CONCLUSIONS: Surgical performance anxiety is a very common and significant challenge among surgeons across all specialties at all levels of experience in the United Kingdom. It is perceived by surgeons to affect surgical performance adversely and is associated with worse psychological wellbeing. A more open culture of sharing and acknowledgment has been identified to be beneficial.

Peripheral nerve decompression in the upper limb in spinal cord injury: experiences at the National Spinal Injuries Centre, UK.

STUDY DESIGN: Retrospective cohort study of consecutive upper limb peripheral nerve decompressions in SCI patients. All procedures were performed at a single National Spinal Injuries Centre between 2015 and 2019. OBJECTIVES: Entrapment neuropathies in the upper limb are underdiagnosed and undertreated in patients with spinal cord injury (SCI). This cohort study represents the first published outcomes of upper limb peripheral nerve decompression in patients with SCI. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire, UK. METHODS: Data collected from electronic medical records included patient demographics, procedures performed, length of inpatient stay, nerve conduction studies, and patient satisfaction. Patients were also contacted by telephone to complete a questionnaire that included patient satisfaction, the NHS 'Friends & Family Test' and validated patient-reported outcome measures (PROMs). RESULTS: Thirty-four decompression procedures (24 carpal tunnel, 10 cubital tunnel) were performed in 24 patients (14 with paraplegia, 10 tetraplegia). 71% of patients had pre-operative nerve conduction studies: 71% of these were graded as severe. Mean length of stay was 14 nights. 91% of patients were satisfied with their procedure at clinic follow-up. Mean Boston Carpal Tunnel Questionnaire (BCTQ) symptom scores were reduced from 3.7 to 1.3 pre- vs. post-operatively (p < 0.001). Patient Reported Ulnar Nerve Evaluation (PRUNE) scores reduced from 49.4 to 23.0 (p = 0.01). CONCLUSION: In our experience, SCI patients tend to present with severe upper limb nerve entrapment syndromes. Operative management is well tolerated with low risk of complications and can result in marked improvements in symptoms and function.