Skin grafting prevents recurrence in Dupuytren's disease and extension correlates with fibrosis diathesis score

Full thickness grafting can be considered after fasciectomy for Dupuytren contracture in severe cases with skin shortage or in radical dermofasciectomy. It is a common dogma that these skin grafts may prevent disease recurrence. We reviewed 47 patients after fasciectomy and full-thickness skin grafting for Dupuytren contracture at 3-16 years' follow-up. Recurrence beneath the skin graft and extension of the disease in the rest of the hand were recorded. Age at onset, gender and factors considered to influence the outcome due to fibrosis diathesis, such as bilateral disease, family history and ectopic lesions, were noted. The Tubiana classification was used to grade disease severity at surgery and at follow-up. None of the patients manifested recurrence underneath the skin graft, but the disease did show extension in 83% of cases. Disease extension was more likely in patients with higher fibrosis diathesis scores. We conclude that skin grafting may prevent disease recurrence underneath the grafts, but extension of the disease correlates with fibrosis diathesis. LEVEL OF EVIDENCE: IV, therapeutic cohort study.

Lateral elbow tendinopathy: surgery versus extracorporeal shock wave therapy

Lateral elbow pain caused by tendinopathy - tendinosis - or tennis elbow is a highly prevalent problem. Unfortunately, no treatment method can guarantee clinical success. Inspired by the lithotripsy technique used for kidney stones, extracorporeal shock wave therapy (ESWT) has been introduced as an alternative to surgical treatment 25 years ago. In a randomized prospective study, we compared 15 patients with lateral elbow tendinopathy who were operated and 14 who underwent ESWT. Almost all patients had good or excellent outcomes according to the criteria by Verhaar. Subjective improvement was 57% for the ESWT group and 76% for the surgery group. No significant differences between both groups were found (p = 0.07). We therefore recommend considering non-invasive techniques such as ESWT treatment prior to surgery in tennis elbow.

Trapeziometacarpal total joint arthroplasty: The effect of capsular release on range of motion

It has been suggested that trapeziometacarpal total joint arthroplasty be combined with complete release of the joint capsule to prevent ligament tethering and implant dislocation. Our goal was to evaluate the consequences of capsular release on range of motion. Trapeziometacarpal joint motion was measured with a 3D motion tracking system in seven fresh frozen human cadaver hands before and after capsular release and total joint arthroplasty with subsequently longer neck lengths. Relative to the native trapeziometacarpal joint with intact joint capsule, mean flexion-extension was significantly increased after the arthroplasty with released capsule and lengthening up to 6 mm. Mean abduction-adduction did not increase significantly. Total joint replacement combined with capsular release increases the trapeziometacarpal joint's range of motion, but not beyond the limits of most trapeziometacarpal implant designs. Lengthening of the implant neck progressively decreases the excess motion.

Eaton and Littler Ligament Reconstruction for the Painful first Carpometacarpal Joint : Patient satisfaction

The ligamentous reconstruction according to Eaton and Littler (7) was designed to restore the stability of the carpometacarpal joint of the thumb. We evaluated the patients' satisfaction after an Eaton and Littler-procedure as well as possible risk factors in the development of thumb basal joint instability. A retrospective chart review and clinical assessment or telephone survey are executed in 33 patients, with a mean follow-up of 7 years. Only 45% of the patients were satisfied. Within the group of clinical assessed patients, there were significant differences in thumb function comparing operated with not operated side. Overall joint hypermobility can be a contributing factor for this thumb basal joint instability, but has no effect on the outcome after an Eaton-Littler procedure.

Comorbidity in Dupuytren disease

In this report, a possible association between Dupuytren's disease (DD) and other health problems was investigated. The health problems included in this study are : cardiac ischemia, hypertension, hyper-lipidemia, diabetes mellitus, epilepsy, gout, rheumatoid arthritis, malignancy, asthma and COPD. The data of 725 patients with DD were collected from -Intego, a database including all morbidity presented to the General Practitioners (GPs) in Flanders. The control group of 2900 age and sex matched non-DD patients was selected from the same database. A possible influence of severity of DD was evaluated by comparing the data of 333 patients operated for DD with the group of Integopatients with DD. This study showed a significant association of every single studied health condition with DD. Comparison of the -operated group with the group from Intego with DD, demonstrated only some significant associations, a difference which may be explained by the difference in data collection.

Evaluation of the metaphyseal ulnar shortening technique according to Sennwald

The outcome of a metaphyseal ulnar shortening osteotomy, reported by Sennwald as an alternative option for ulnar abutment syndrome, was evaluated with -regard to the functional results, pain relief and incidence of complications.

METHOD

We conducted a review of 12 patients ; measured parameters were DASH score, PRWE, VAS for pain, grip force and wrist motion.

RESULTS

Only disability improved significantly with a DASH score of 42 (p = 0.03). The function and pain assessment scores did not improve in 3 patients. We found no correlation between change in functional scores and other measured variables. Six patients were reoperated for prominent screw heads or new-onset distal radioulnar joint osteoarthritis.

CONCLUSION

All osteomies healed fast and uneventfully and disability improved in most patients but 25% did not improve and 50% were re-operated. Further investigation is needed to evaluate the value of the metaphyseal osteotomy as an alternative treatment for ulnar abutment syndrome.

Effectiveness and safety of collagenase Clostridium histolyticum in Dupuytren's disease : an observational study in Belgium

Dupuytren's disease is a connective tissue disorder leading to contractures. It can be treated surgically or through injections of collagenase Clostridium histolyticum (CCH). Patients with Dupuytren's contracture (> 20°) and a palpable cord were included in this observational study, aiming to characterise the Belgian patient population and to assess the effectiveness and safety of CCH. Overall, 108 patients (114 joints) received at least one injection of CCH, and 104 patients completed the study. The percentages of joints achieving a degree of contracture of 5° or less, or a relative contracture reduction of at least 50% after the extension procedure were 64.9% and 90.1%, respectively. The mean number of injections per cord was 1.0. The Unité Rhumatologique des Affections de la Main score decreased from 29.4 ± 11.0 to 12.9 ± 6.3 (mean ± SD ; p < 0.0001). CCH was demonstrated to be effective, safe and able to increase quality of life.

Avascular necrosis of the capitate: report of six cases and review of the literature

Avascular necrosis of the capitate is rare. Little is known about the aetiology, disease progression or optimal management. From 1992 to 2012 we treated six patients; four had a scaphocapitolunate arthrodesis and two had a four corner arthrodesis. The average follow up was 9 years (range 1-20). Three patients had good or excellent results, two fair and one poor, based on a visual analogue scale for pain and satisfaction and a Quick-DASH score. The Mayo wrist score was satisfactory in five cases and poor in one. Better results were seen when the arthrodesis fused. In the English, French and German literature 42 other cases were found. The aetiology, patient characteristics, clinical presentation, treatment and outcome were reviewed.

Long term outcome of trapeziectomy with ligament reconstruction/tendon interposition versus thumb basal joint prosthesis

Several surgical techniques to treat thumb basal joint arthritis have been described. In this study we compared the results of a cemented thumb basal joint with trapeziectomy with a ligament reconstruction and tendon interposition. A questionnaire was sent to all 519 patients, 322 (with 382 procedures) responded. No significant differences were found when comparing impairment, pain, patient satisfaction and disability. Given the fact that the superiority of a prosthesis cannot be proven and the cost of the implant is greater, we recommend the trapeziectomy with ligament reconstruction and tendon interposition as opposed to arthroplasty as the first choice in the treatment of basal joint osteoarthritis of the thumb.

Avascular necrosis of the proximal carpal row of the wrist. A possible complication of bisphosphonate administration

Reports of coexisting osteonecrosis of more than one carpal bone are rare. We report an osteonecrosis of the entire proximal carpal row of the wrist, started briefly after intravenous bisphosphonate administration. The use of bisphosphonates for the treatment of osteoporosis is increasing. Osteonecrosis of the jaw (ONJ) is one of the known adverse effects during chronic treatment with bisphosphonates. This case is reported to make clinicians aware of a possible causative link between bisphosphonate use and osteonecrosis of other bones.

Post-vaccination frozen shoulder syndrome. Report of 3 cases

The cause of frozen shoulder syndrome is unknown in most cases, although it can be preceded by minor trauma. Here, we report 3 patients with severe frozen shoulder after an intramuscular vaccination in the deltoid muscle. A distention arthrography resulted in good pain relief and improved the mobility. Frozen shoulder syndrome can be a severe manifestation of vaccination-related shoulder dysfunction. Correct intramuscular administration is crucial to prevent post-vaccination frozen shoulder and on the other hand, physicians' awareness is needed to recognize this feature early on.

Reliability and reproducibility of Kienbock's disease staging

We evaluated the interobserver reliability and intraobserver reproducibility of the Lichtman et al. classification for Kienböck's disease by getting four observers with different experience to look at 70 sets of wrist radiographs at different points in time. These observers staged each set of radiographs. Paired comparisons of the observations identified an agreement in 63% of cases and a mean weighted kappa coefficient of 0.64 confirming interobserver reliability. The stage of the involved lunate was reproduced in 78% of the observations with a mean weighted kappa coefficient of 0.81 showing intraobserver reproducibility. This classification for Kienböck's disease has good reliability and reproducibility.

Enchondroma protuberans of the phalanx

Enchondroma protuberans is a rare tumour that rises from an intramedullary enchondroma with an exophytic growth pattern. Although it causes an interesting clinical picture it is benign, and marginal resection of the tumour with bone grafting of the intramedullary defect is curative. We report a case of an enchondroma protuberans of the fifth middle phalanx of the right hand treated by resection, curettage, and autologous bone grafting, with recovery of the normal function of the hand and fingers.

Dupuytren's disease: a predominant reason for elective finger amputation in adults

Dupuytren's disease (DD) can lead to severe disabling finger contractures resistant to surgical treatment. In some cases, finger or ray amputation is considered, due to a severe functional deficit or vascular injury. To evaluate the weight of amputation surgery in DD, a retrospective study was conducted over a 5-year time interval, outlining all indications for elective finger amputation and its prevalence in the total of surgical interventions for DD. The outcome in DD was compared to post-traumatic amputations. Out of 31 elective finger and ray amputations, 12 (39%) were indicated for DD, all in the 4th or 5th ray, of which 92% were in recurrent disease. In the 646 surgical procedures for DD in the matching time interval, we conclude that almost 2% were elective amputations. The outcome of amputation in DD was similar to post-traumatic amputations. Based on these data, we feel that patients should be informed that sometimes, surgical treatment for Dupuytren's disease can lead to an eventual decision to amputate.

Proximal row carpectomy with or without postoperative immobilisation

Previously published reports have shown good results after proximal row carpectomy in all cases that had a postoperative immobilisation period from 1 to 4 weeks. Immobilisation is thought to be necessary because of the risk of postoperative subluxation of the carpus and for pain relief. There is, however, no evidence of its value. The results in 13 patients who underwent proximal row carpectomy without postoperative immobilisation were compared with those in 25 patients who underwent proximal row carpectomy with postoperative immobilisation for 4 weeks. After a mean follow-up period of 27 months, no significant differences were found for pain, range of motion or return to work between the two groups. We conclude that postoperative immobilisation is not necessary after proximal row carpectomy.

Delayed post-traumatic trigger finger in a 14-year-old boy after blunt trauma. A case report

Although trigger finger is a common phenomenon, it is a rare condition in children and even more infrequently caused by a traumatic event. A case of a 14-year-old boy is reported, who presented with a prominent palmar nodule over a triggering middle finger and progressive flexion contracture, 6 months after a fall on the outstretched hand. An operation with resection of the A1-pulley and resection of the nodule, that showed chondroid metaplasia and calcifications, resolved the problem completely.

Bilateral osteochondroma of the scaphoid causing scapholunate dissociation: a case report

A case with bilateral scaphoid osteochondroma (exostosis) with scapholunate dissociation. In both the cases a proximal row carpectomy was performed with excellent outcome.

Chronic elbow dislocation: a rare complication of tennis elbow surgery. Successful treatment by open reduction and external articular distrator

A case is presented of chronic dislocation of the elbow after tennis elbow surgery combined with posterior interosseous nerve (PIN) release. An open reduction with repair of the collateral ligaments was performed. Postoperative rehabilitation involved the use of an articulated external fixator and there was a successful outcome. Possible causes of the dislocation are discussed.

Responsiveness of the Dutch version of the DASH as an outcome measure for carpal tunnel syndrome

A cohort of 119 patients with carpal tunnel syndrome completed the questionnaire of the Dutch version of the DASH score pre-operatively and one year postoperatively. The mean DASH score decreased from 38.2 to 22.0. There was a significant correlation with the Boston carpal tunnel outcome score (r=0.78). With an effect size of 0.87 and a standardized mean response of 0.69, the Dutch version of the DASH is highly responsive for the evaluation of the outcome of surgery for carpal tunnel syndrome.

Symptomatic pseudo-arthrosis of a trapezial ridge fracture

We present a fracture of the ridge of the trapezium with evolution towards a pseudo-arthrosis.

Heterotopic ossification of the supraspinatus tendon after rotator cuff repair: case report

Heterotopic ossifications of the shoulder are uncommon. Rarely, these ossifications are seen after open or even arthroscopic shoulder surgical procedures. Here, we report a patient who underwent a rotator cuff repair, complicated with an axillary nerve paralysis. Postoperatively he developed substantial ossification of the supraspinatus tendon. A review of the literature was done. To our knowledge no other cases similar to this have been reported.

Outcome of two salvage procedures for posttraumatic osteoarthritis of the wrist: arthrodesis or proximal row carpectomy

PURPOSE

to compare a motion preserving procedure of the wrist with the wrist arthrodesis, the so-called gold standard in patients with posttraumatic wristpain.

DESIGN

non randomized retrospective

SETTING

University Hospital--referral centre

PATIENTS

we studied two groups of patients with posttraumatic wrist pain due to osteoarthritis of the radiocarpal joint: one group of 35 patients underwent a radiocarpometacarpal arthrodesis, the other group of 26 patients a proximal row carpectomy (PRC). There were no significant differences in age and gender or hand dominance distribution.

INTERVENTION

proximal row carpectomy versus radiocarpal arthrodesis.

OUTCOME MEASUREMENTS

DASH (disability of arm, shoulder and hand) gripping force, return to activity, complications and reintervention frequence.

RESULTS

Disability (DASH score) and regaining professional activity was significantly better in the PRC group. There was no significant difference in gripping force between the PRC and the arthrodesis group. Complications were less numerous.

CONCLUSION

A mobility saving procedure as a PRC is preferable over an arthrodesis in patients with posttraumatic wrist osteoarthritis.

Fixation of a periprosthetic humeral fracture with CCG-cable system

We report a case of periprosthetic fracture of the shoulder, treated operatively. A special plate/cable system (ECG) was used with an excellent outcome. This easy technique is recommended for such fractures.

Proximal row carpectomy in advanced Kienbock's disease

This retrospective study assessed the outcomes of 21 patients (16 male and 5 female, mean age 39 years) with advanced Kienbock's disease treated by resection of the proximal carpal row. They were clinically reviewed. The mean follow-up was 67 months, with all but two patients having had a follow-up of 2 years. No or mild pain was being experienced by 13 patients, moderate pain by 3 and severe pain by 5. Grip strength increased from 19 kg pre-operatively to 26 kg postoperatively (or 65% of the normal contralateral side). There was a slight increase of mobility. The DASH score was 22 points (range 0-78) and the Patient Rated Wrist Score (PRWS) was 30 points (range 0-84). Two patients developed Complex Regional Pain Syndrome which was ongoing at the time of review and one developed a superficial wound infection. Proximal carpal row resection arthroplasty gave satisfactory results in patients with advanced Kienbock's disease.

Missed radial head dislocations in children associated with ulnar deformation: treatment by open reduction and ulnar osteotomy

OBJECTIVE

To evaluate the results of open reduction and ulnar osteotomy on missed Monteggia fractures in children.

DESIGN

Retrospective review.

SETTING

Tertiary care center orthopaedic hospital in Pellenberg, Belgium.

PATIENTS/PARTICIPANTS

Six children between 2 and 6 years old who sustained a Monteggia fracture that was initially missed were treated at our institute. They presented in our hospital 5 to 59 weeks postinjury.

INTERVENTION

Open reduction of the radial head was performed, combined with a dorsal opening wedge osteotomy of the proximal ulna and fixation with plate and screws.

MAIN OUTCOME MEASUREMENTS

Mobility of the elbow was measured by an independent observer, evaluating flexion-extension and pronation-supination preoperatively and postoperatively.

RESULTS

All patients regained a normal range of motion, the radial head remained relocated, and the axis of the forearm remained normal.

CONCLUSION

This operation-open reduction of the radial head and osteotomy of the ulna-results in an excellent outcome for a missed Monteggia fracture in children.

Volar dislocation of the proximal interphalangeal joint of the finger: an indication for urgent operative treatment

Two patients are described with persistent acute volar dislocation of the middle phalanx of a finger. Closed reduction was impossible due to intra-articular interposition of the lateral slip of the extensor mechanism, combined with a tear of a collateral ligament. It is important to recognize these injuries at an early stage and an operative treatment is required.