Dupuytren's contracture in Ethiopia.

Dupuytren's contracture is believed to be rare in Africa. We have observed the disease in many patients coming to our hospital. This study aimed to provide information concerning the occurrence of the disease and risk factors in these patients. All 75 patients who were referred to the hospital during a 2-year period because of a hand problem that was diagnosed as Dupuytren's contracture were included. The demographic data of the patients and possible risk factors were recorded and compared with a control group. The male to female ratio was 18:1. The little and ring fingers were most commonly affected. A total of 43 had bilateral hand involvement. The condition affected only the left hand in one patient. Six men also had fibromatosis of the soles of the feet and three of the penis. There was a statistically significant association with hypertension and alcohol consumption, but not with diabetes mellitus. We conclude that there are more cases of Dupuytren's contracture in Ethiopia than previously thought. LEVEL OF EVIDENCE: III.

Remembered preoperative Quick disabilities of the arm, shoulder and hand (QuickDASH) scores.

The Quick disabilities of the arm, shoulder and hand (QuickDASH) patient-reported outcome measure is frequently used to assess disabilities and symptoms of the upper extremity. This study compares real preoperative QuickDASH scores and remembered preoperative QuickDASH scores. Remembered preoperative QuickDASH scores were obtained 45 months (39-67) after surgery. Patient material consisted of 160 patients operated for Dupuytren's contracture, carpal tunnel syndrome, thumb basal joint arthrosis, and shoulder pain. All patients had completed QuickDASH questionnaires before surgery. Paired T-tests, linear mixed models, and limits of agreement were used for analyses. There was a significant difference between remembered and real preoperative scores (mean 7.6, SD 15.6; SEM 1.2). Neither diagnosis, age, gender, nor time between surgery and review influenced the difference significantly. A linear mixed model was constructed to investigate the ability to retrospectively predict preoperative QuickDASH scores. Remembered preoperative QuickDASH cannot be used in individual patients because of the high inaccuracy. LEVEL OF EVIDENCE: III.

The influence of education and income on responses to the QuickDASH questionnaire.

UNLABELLED: We studied the influence of levels of income and education on QuickDASH scores. The scores were collected in a random sample of 1376 residents of Norway. The level of income was divided into four bands and level of education into five bands. The mean QuickDASH score for both men and women fell with every increase in education and income level. For women the mean score was 30 for those with the shortest education and 9 for those with the longest (p < 0.001). The corresponding figures for men were 19 and 7 (p < 0.01). The women with the lowest level of income had a mean score of 23, compared with 8 for women with the highest income level (p < 0.001). For men the corresponding mean scores were 20 and 5 (p < 0.001). Analysis of variance showed that age alone accounted for 16% of the variability of the scores among women and 7% among men. When levels of education and income were added to the analysis, these three factors accounted for 21% of the variability among women and 13% among men. We conclude that socioeconomic factors significantly influence QuickDASH scores. LEVEL OF EVIDENCE: 3.

The DASH and the QuickDASH instruments. Normative values in the general population in Norway.

We collected population-based normative data for the DASH (disabilities of the arm, shoulder and hand ) and QuickDASH questionnaires in order to determine the co-morbidity to be expected in a group of patients. We also studied the correlation between the two scores. A total of 2000 DASH forms and 800 QuickDASH forms were mailed to 1400 men and 1400 women. They were selected randomly in groups of 200 men and women in each age decade from 20-29 to over 80 years old. A total of 50% of the DASH forms and 56% of the QuickDASH forms were returned (p < 0.005). The mean DASH scores for women rose with age from 5 among those aged 20-29, to 22 among those aged 70-79 and 36 for those over 80. The corresponding mean values for men were 5, 13 and 22. The mean DASH and QuickDASH scores extracted from the DASH forms were very similar in each age decade. Spearman's correlation coefficient for the two forms was 0.965 for all 992 forms and 0.930 for the 174 forms with scores of 30 or more. There were, however, wide confidence limits for the agreement between scores in individual patients. The high average scores in the general population, particularly among the elderly, should be borne in mind when evaluating scores among patients. The QuickDASH should be preferred to the full DASH as it gives the same information, but is shorter and completed more often.

The relationship between displacement and clinical outcome after distal radius (Colles') fracture.

We reviewed 260 patients who had been treated non-operatively for a dorsally displaced distal radius fracture a mean 6.3 (range 2.5-12.7) years earlier, in an attempt to find the limits of displacement compatible with a good clinical outcome. We excluded patients with previous or later injuries to the same limb. Bivariate analysis revealed a highly statistically significant relationship between radiographic displacement at review and clinical outcome scores. Correlation coefficients varied between 0.14 and 0.30. However, multiple linear regression analysis using most factors commonly thought to be of importance in determining the clinical outcome as independent variables explained only 23% of the variability of the clinical outcome. Dorsal angulation, ulnar variance, and radial inclination together accounted for only 11% of the variability. We conclude that the final alignment of the distal radius as shown radiologically has only a minor influence on the clinical outcome of Colles' type distal radius fractures.

Cold intolerance after flexor tendon injury. Disposing factors and long term prognosis.

BACKGROUND AND AIMS: cold intolerance after hand injuries is often debilitating. We wished to determine what factors make it more likely to occur and whether it improves or worsens with time. PATIENTS AND METHODS: we retrospectively studied 103 patients who had sustained a simple cut leading to a flexor tendon injury in the finger between 3 months and 20 years earlier. A total of 48 had also injured a digital nerve. At review patients indicated on a VAS scale their dis-comfort during the first winter after injury and the last winter before review and also gave a VAS evaluation of pain in the hand after keeping it in a bath of water at 1-4 degrees centigrade for 60 seconds. RESULTS: cold sensitivity during the first winter after injury was reported by 66% patients. Its development was unrelated to the age at injury. The proportions of smokers, injury of more than one finger, and re-operation or with postoperative complications were significantly higher among patients with cold sensitivity. At review 49% indicated that they had improved, 41% that cold sensitivity was unchanged and 10% that they were worse. CONCLUSIONS: standardized immersion in cold water showed that on average cold sensitivity was slightly worse with time.

Tourniquet use and its complications in Norway.

Over a two-year period, 265 Norwegian orthopaedic surgeons working at 71 institutions performed 63,484 operations under a tourniquet. Their replies to a questionnaire revealed that they mostly followed modern guidelines in their use of the tourniquet. Most felt that the tourniquet could be left on for two hours, and that it could be re-applied after 15 minutes. A total of 26 complications (one in 2442 operations) that might have been due to the tourniquet were reported, of which 15 were neurological. Three were in the upper limb (one in 6155 operations) and 12 in the lower limb (one in 3752 operations). Two were permanent (one in 31,742 operations), but the remainder resolved within six months. One permanent and one transient complication occurred after tourniquet times of three hours. The incidence of tourniquet complications is still at least as high as that estimated in the 1970s.

The position of the tourniquet on the upper limb.

Our aim was to determine if a tourniquet placed on the forearm has any advantage in clinical practice over the usual position on the upper arm. We randomised 50 patients who were undergoing an open operation for carpal tunnel syndrome under local anaesthesia into two groups. One had a tourniquet on the upper arm and the other on the forearm. The blood pressure, pulse, and level of pain were recorded at intervals of five minutes during the operation. The surgeons were also asked to evaluate the quality of the anaesthesia, the bloodless field, and the site of the tourniquet. The patients tolerated the tourniquet on the upper arm and forearm equally well. The surgeons had some difficulties when it was placed on the forearm. We therefore recommend placement of a tourniquet on the upper arm for operations on the hand and wrist which are carried out under local anaesthesia.

[Corticosteroid injection for coccygodynia]. / Injeksjonsbehandling ved halebeinssmerter.

BACKGROUND: Severe coccygodynia is often treated with coccygectomy. In Norway, conservative treatment is usually restricted to avoiding pressure on the painful area. We have used local injection with a mixture of corticosteroid and lidocaine in this condition. MATERIAL AND METHODS: We present 11 patients with coccygodynia treated with local injection. All patients were contacted by telephone three or more years later. RESULTS: At follow-up, one patient was asymptomatic, five patients had improved so much that further treatment was unnecessary, and in one patient the condition was unchanged. Four patients had been operated during the follow-up period. INTERPRETATION: Local injection of corticosteroid and lidocaine is a simple therapeutic option that should be tried before operation.

Duration of thrombosis prophylaxis in orthopaedic surgery.

BACKGROUND: We have given seven to 14 days thrombosis prophylaxis after orthopaedic surgery. Recently, six weeks prophylaxis has been recommended. We wished to evaluate the implications of prolonging prophylaxis. METHODS: We made a very thorough search of the hospital register of diagnoses and the registers of the departments of radiology and nuclear medicine and determined the number of detected thromboembolic complications during a five and a half-year period. RESULTS: We identified 91 cases (0.50%) with thromboembolism during the first six weeks after 18.368 orthopaedic operations: 1.4% after 836 total hip arthroplasties and 1.0% after 1.845 hip fractures. In these two groups 19 thromboembolic complications were registered after the second postoperative week. If it had been possible to prevent all of them by prolonging prophylaxis to six weeks, each avoided thromboembolism would have cost around US $ 23.700 in additional drug costs alone. One hip fracture patient died from probable thrombo-embolism during the second and one during the fourth postoperative week. No hip arthroplasty patients died from a probable thromboembolic complication during the third to sixth postoperative week. CONCLUSIONS: We conclude that the frequency of clinically detectable thrombo-embolism and fatal pulmonary embolus is so low during the third to sixth postoperative weeks that prophylaxis beyond two weeks is unwarranted.

Neurophysiology not required before surgery for typical carpal tunnel syndrome.

Sixty-eight patients with typical carpal tunnel syndrome underwent neurophysiological investigations preoperatively, but these were not assessed until the end of the study. Open carpal tunnel release was performed and the clinical diagnosis of carpal tunnel syndrome was considered as confirmed when there was a prompt resolution of the preoperative symptoms. Sixty-three of the 68 patients responded well to surgery, three had equivocal outcomes and two did not improve, and thus were considered not to have carpal tunnel syndrome. The neurophysiological tests were normal in these two patients, but were also normal in 14 of the 63 patients who improved with carpal tunnel surgery. Preoperative neurophysiology might therefore have led to up to 14 of the 63 cases of carpal tunnel syndrome being turned down for surgery. We conclude that neurophysiological studies contribute little to the diagnosis in typical cases of carpal tunnel syndrome, and are more often confounding than of assistance.

[Injection therapy of trigger finger]. / Injeksjonsbehandling ved triggerfinger.

BACKGROUND: Since 1996 we have treated patients with trigger finger with corticosteroid injection as an alternative to surgery, on the basis of good results from this treatment reported in the literature. We wished to evaluate the results. MATERIAL AND METHODS: 27 patients with 32 trigger fingers were treated with corticosteroid injection. Two injections had been used in 17 fingers. The patients were contacted by mail or telephone median 4 years and 2 months (range 29-56 months) later, and patients with persistent pain were examined clinically. RESULTS: 12 fingers had been operated by the time of the follow-up. 14 fingers were reported to be quite normal, one gave slight discomfort, four were still painful, but less so than before injection, and one was still as bad as before injection. Two of these patients had painful carpometacarpal arthrosis. INTERPRETATION: We suggest that corticosteroid injection should be tried in patients with trigger finger.

AO tension-band osteosynthesis of displaced olecranon fractures.

This study reviewed 31 patients who underwent AO tension-band osteosynthesis of displaced olecranon fractures. Thirteen fractures were comminuted. Postoperative immobilization was short, and the median hospital stay was 3 days. In 2 patients, the stainless steel wire broke and required replacement. In 13 patients, the osteosynthesis material was removed after healing because of pain at the tip of the elbow; this did not influence the final result. Median time out of work was 12 weeks. There was no significant loss of elbow power. There was satisfactory mobility, function, and absence of pain. There were 29 good and 2 fair clinical results. Anatomic reduction was achieved in 24 elbows. Possible arthrosis was detected at follow-up in 5 elbows but these patients had a good clinical result. AO tension-band osteosynthesis of displaced olecranon fractures yields good clinical medium-term results with few serious complications.

[Thrombosis prophylaxis in orthopedic surgery]. / Tromboseprofylakse ved ortopedisk kirurgi.

At Trondheim University Hospital, prophylaxis against thromboembolism after orthopaedic surgery was changed from dextran 70 to low molecular weight heparin in 1992. We wanted to assess whether the frequency of thromboembolic complications has fallen after this change of procedure and to search for any indication that prophylaxis should be prolonged from two to six weeks. Our register showed 97 cases (0.76%) with thromboembolism during the first 12 weeks after 12,711 operations during the dextran 70 period; 99 cases (0.54%) after 18,368 operations during the low molecular-weight heparin period (p < 0.05). A more thorough search identified 121 (0.66%) thromboembolic complications during the low molecular-weight heparin period; 2.2% among patients with total hip arthroplasty and 1.5% among patients with hip fractures. In these two groups, 19 (0.71%) thromboembolic complications were diagnosed during the third to sixth postoperative week. If all these complications had been avoided by prolonging prophylaxis to six weeks, each would have cost around NOK 200,000. Among patients with a diagnosed thromboembolic complication one hip fracture patient and no hip arthroplasty patients died during the third to sixth postoperative weeks. We conclude that there has been a significant fall in thromboembolism following the change from dextran 70 to low molecular-weight heparin. The frequency of thromboembolism and fatal lung embolus is so low during the third to sixth postoperative weeks that prophylaxis beyond two weeks is unwarranted.

Initial experience with the Forte plate for dorsally displaced distal radius fractures.

Open reduction and plate osteosynthesis is occasionally indicated for dorsally displaced distal radius fractures. We reviewed our medium term results with the Forte plate, one of the recently introduced purpose-made implants.Twenty-five patients operated on during the first year were reviewed 19 (12-24) months after surgery. Median age at operation was 53 (28-80) years. There were seven high energy and eighteen low energy injuries. Fourteen fractures extended into the radiocarpal joint.Three patients had a poor clinical result and were re-operated on before review with an arthrodesis, ulnar shortening, or Sauve-Kapandji operation. The remainder had six excellent, twelve good, and four fair results. Irritation of the extensor tendons was a minor problem. Initial radiological correction of deformity was satisfactory, but increased volar angulation of the distal radius was seen at follow up in twenty patients - by more than 10 degrees in nine. Seven patients had 20-30 degrees volar tilt at final review and tended to have a poorer clinical result than other patients. In our patients use of the Forte plate seems to have given satisfactory clinical results, but the increase in volar tilt after surgery is a cause for concern.

No advantage from splinting the wrist after open carpal tunnel release. A randomized study of 82 wrists.

To study the value of postoperative splinting after open carpal tunnel surgery, we randomly selected 82 wrists for 4 weeks of postoperative immobilization or no immobilization. The distributions of scar discomfort or pain and "pillar pain" were equal in the two groups both at 6 weeks and 6 months. Median sick leave was 6 weeks in both groups. Median VAS values for persistent discomfort and pain at 2 weeks, 6 weeks and 6 months were similar in the two groups. Grip strength was reduced compared to preoperative values by about 20% and keypinch strength by about 10% in both groups at 6 weeks and had returned to normal by 6 months. Pinch between the thumb and the tips of fingers 4 and 5 was considerably reduced postoperatively, but similar in both groups. We conclude that 4 weeks of postoperative immobilization confers no detectable benefit.

[Mitchell's osteotomy of hallux valgus]. / Mitchells osteotomi for hallux valgus.

45 patients were included in a prospective study to evaluate the results of Mitchell's osteotomy of hallux valgus. 43 patients complained of pain preoperatively. 44 patients were reviewed after one year, and excellent results were achieved in alleviating pain for 35 of these patients. Four patients developed metatarsalgia after surgery. There was a mean improvement in the hallux valgus angle of eight degrees. The mean shortening of the first metatarsal was 6 mm (1-12 mm). This shortening showed no correlation with postoperative pain. Signs of osteoarthrotic changes in the metatarsophalangeal joint were found in one patient and early signs of osteonecrosis of the first metatarsal head in two. We conclude that in spite of some serious complications this method produces satisfactory results and can be recommended when pain over the medial prominence is the main indication.