Dupuytren's Contracture Recurrence and Treatment Following Collagenase Clostridium Histolyticum Injection: A Longitudinal Assessment in a Veteran Population

INTRODUCTION

Dupuytren's contracture is a connective tissue disease characterized by an abnormal proliferation of collagen in the palm and fingers, which leads to a decline in hand function because of progressive joint flexion. In addition to surgical and percutaneous interventions, collagenase clostridium histolyticum (CCH, trade name Xiaflex) is an intralesional enzymatic treatment for adults with palpable cords. The objectives of this study are to evaluate factors predictive of recurrence following treatment with CCH and to review the outcomes of repeat treatments with CCH for recurrent contracture.

MATERIALS AND METHODS

An institutional review board-approved retrospective chart review was conducted for patients between 2010 and 2017 who received CCH injections for Dupuytren's contracture at a Veterans Affairs hospital. Demographics, comorbidities, affected finger and joint, pre/posttreatment contracture, time to recurrence, and treatment of recurrence were recorded. Successful treatment was defined as contracture ≤5° following CCH, and improvement was defined as ≥20° reduction from baseline contracture. Study cohorts were followed after their secondary treatment, and time to recurrence was recorded and plotted using a Kaplan-Meier curve. A Cox proportional hazards model was used to compare treatment group risk factors for recurrence with a P-value less than .05 defined as statistical significance.

RESULTS

Of 174 injections performed for the correction of flexion deformities in 109 patients, 70% (121) were successfully treated with CCH, and an additional 20% (35) had improvement. There was a recurrence of contractures in 43 joints (25%). Of these, 16 contractures were treated with repeat CCH, whereas another 16 underwent limited fasciectomy. In total, 75% (12 of 16) of the repeat CCH group and 75% of the fasciectomy group were successfully treated. Pre-injection contracture of ≥25° was found to be predictive of recurrence (P < .05).

CONCLUSIONS

Initial treatment of contracture with CCH had a 70% success rate with 25% recurrence during the study period. Compared with limited fasciectomy, CCH had decreased efficacy. Based on the findings of this study, we believe that the treatment of primary and/or recurrent Dupuytren's contracture with CCH is a safe and less invasive alternative to fasciectomy in the era of telemedicine. CCH treatment requires no suture removal, which allows the ability to assess motion virtually, and the potential consequences of CCH treatment such as skin tears can be assessed and managed conservatively. In the veteran and active duty population, CCH can facilitate faster recovery and return to service. Strengths of this study include a large series of veteran populations with longitudinal follow-up to determine treatment efficacy for primary Dupuytren's contracture and recurrence. Limitations include a smaller sample size compared to previous trials, a lack of standardized follow-up, and the retrospective nature of our study that prohibits randomization to compare outcomes between CCH treatment and fasciectomy efficacy over time. Directions for future research include stratification of patients by joint and specific digit involvement as well as comparison with percutaneous needle fasciotomy, another minimally invasive technique that could benefit the veteran population at increased risk for developing Dupuytren's disease.

Altered patterning of trisomy 21 interneuron progenitors

Individuals with Down syndrome (DS; Ts21), the most common genetic cause of intellectual disability, have smaller brains that reflect fewer neurons at pre- and post-natal stages, implicating impaired neurogenesis during development. Our stereological analysis of adult DS cortex indicates a reduction of calretinin-expressing interneurons. Using Ts21 human induced pluripotent stem cells (iPSCs) and isogenic controls, we find that Ts21 progenitors generate fewer COUP-TFII+ progenitors with reduced proliferation. Single-cell RNA sequencing of Ts21 progenitors confirms the altered specification of progenitor subpopulations and identifies reduced WNT signaling. Activation of WNT signaling partially restores the COUP-TFII+ progenitor population in Ts21, suggesting that altered WNT signaling contributes to the defective development of cortical interneurons in DS.

Ultrasound Imaging Improves Identification of Prominent Hardware in the Surgical Treatment of Distal Radius Fractures: A Cadaveric and Prospective Clinical Study

Background Volarly applied locking plates are one of several current treatment options for displaced fractures of the distal radius. Presently, surgeons use intraoperative depth gauges and fluoroscopy to select and confirm proper screw length. The contour of the dorsal cortex beneath the extensor compartments along with fracture comminution may limit the accuracy of screw length selection. Question/Purpose To evaluate the accuracy of ultrasound (US) and fluoroscopy in the detection of dorsally prominent screws placed during volar plating of experimentally created distal radius fractures and extend this prospectively into the clinical setting. Patients and Methods Distal radius fractures were experimentally induced in fresh cadaveric arms. The fractures were then internally fixated with volar locking plates utilizing fluoroscopic imaging. US imaging of the dorsal surface of the radius was then performed followed by dorsal dissection and direct caliper measurements to quantitate screw tips as recessed, flush, or protruding from the dorsal cortex. A small, prospective clinical study was also conducted to validate the clinical usefulness of using US to provide additional information regarding screw tip prominence. Results Our study demonstrated that US was able to detect dorsally prominent screw tips not visible on fluoroscopy. Cadaveric dissection showed a higher statistical correlation between US imaging and actual prominence than between fluoroscopy and actual prominence. Conclusions US examination after volar plate fixation of comminuted distal radius fractures may detect dorsal screw tip prominence when screw lengths are selected to engage the dorsal cortex. Level of Evidence IV.

The "Thumbs-up" sign and trapeziometacarpal joint injection: a useful clinical indicator

BACKGROUND

Several clinical studies investigating the accuracy and efficacy of trapeziometacarpal injection exist. Some studies utilize anatomical landmarks for proper injection placement while others utilize modalities including ultrasound and fluoroscopy. The changes of limb position that occur at the time of intra-articular injection can provide valuable visual and tactile feedback to the clinician. The purpose of this study is to investigate the occurrence of the "Thumbs-up" sign with injection of the thumb trapeziometacarpal joint as a useful and reliable clinical indicator of intra-articular trapeziometacarpal injection and correlate level and duration of pain relief.

METHODS

Trapeziometacarpal joint injections were performed on twenty-seven thumbs utilizing anatomic landmarks. At the time of injection, the presence or absence of the "Thumbs-up" sign was noted, and needle location was verified after injection with orthogonal mini-C arm fluoroscopic images. Visual analog pain scale scores were obtained pre-injection and by follow-up telephone calls at 1 week, 6 weeks, and 3 months post injection.

RESULTS

Twenty-four of twenty-seven injections demonstrated a positive "Thumbs-up" sign. There were three negative "Thumbs-Up" injections. The thumbs-up sign demonstrated a 92.3 % sensitivity. Eighteen of twenty-seven thumbs had sustained relief at 3 months post injection.

CONCLUSIONS

The "Thumbs-up" sign is a practical clinical tool that gives the practitioner important visual feedback at the time of injection. Patient relaxation and joint compliance are limiting factors. The "Thumbs-up" sign is an inexpensive indicator of successful intra-articular injection and may obviate the need and expense of advanced imaging modalities at the time of injection.

Thrombodynamics of microvascular repairs: effects of antithrombotic therapy on platelets and fibrin

PURPOSE

To evaluate the hypothesis that platelets and fibrin differentially accrue at microvascular anastomoses in arteries versus veins and under different pharmacologic conditions.

METHODS

We evaluated mouse arterial and venous anastomoses with intravital fluorescence imaging, using fluorophore-labeled platelets and anti-fibrin antibodies to measure the extent of thrombus component development in the intraluminal anastomotic site. We evaluated systemic heparin or eptifibatide (platelet aggregation inhibitor) to determine their relative influences on thrombus composition.

RESULTS

Platelets accumulated rapidly in both arterial and venous repairs, and then fell in number after 10 to 30 minutes of reflow. Fibrin had a relatively steady development over 60 minutes in veins, with a more variable increase in arteries. Heparin reduced platelet accumulation in arteries and fibrin development in veins. Eptifibatide reduced platelets in both arteries and veins and had an apparent effect on lowering the amount of fibrin in veins.

CONCLUSIONS

These findings show that platelets have a rapid, transient response, whereas fibrin has a slower, more sustained accrual in both arterial and venous anastomoses. Furthermore, inhibition of either coagulation or platelet aggregation can influence presumably non-targeted components of thrombosis in vascular repairs of both arteries and veins.

CLINICAL RELEVANCE

Preventing replantation failure using antithrombotic therapies requires a better understanding of the effect of each pharmacologic compound on the various aspects of thrombogenesis.

Long-term BMP-2-induced bone formation in rat island and free flaps

Ectopic osteoinduction by exogenous bone morphogenetic proteins (BMPs) is rapid but heretofore characterized as transient. A rat model of carrier-free recombinant human BMP-2 intramuscular implantation was used, followed by creation of either an island flap or transplantation of a free flap. BMP-2 injection into an unaltered gastrocnemius, thigh adductor, or cutaneous trunci (thoracic wall) muscle site led to bone resorption at 4 weeks. In contrast, creation of an island or free flap of the muscle/injection site caused the newly formed ossicle to maintain its bony composition with active osteoblastic presence, from 3-8 weeks. Muscle denervation or sectioning of the Achilles tendon (for gastrocnemius injections) did not prevent bone resorption at 4 weeks. There was little osteoclastic activity within de novo bone sites of island- and free flap-injected muscles at 4 and 8 weeks. These data demonstrate that simple injection of BMP-2 into a surgically isolated flap site results in the prolonged presence of de novo bone. These findings suggest that BMP-injected island or free muscle flaps may be used to generate new bone for reconstruction of a bony defect.

Modeled evidence of force reduction at the extensor carpi radialis brevis origin with the forearm support band

PURPOSE

Although the forearm support band has been hypothesized to reduce force and thus inflammation and degeneration at the extensor carpi radialis brevis (ECRB) origin, little evidence exists to support an actual effect. We present both a cadaveric and clinical model that show the effect and principles of the forearm support band.

METHOD

The cadaver model measured forces at the ECRB origin as various pressures were applied to the forearm support band and while the ECRB tendon was loaded distally. For clinical correlation support band pressure during rest and activity was measured in healthy individuals.

RESULTS

Our results revealed an increased forearm support band effect with increased band pressure and a decreased relative effect with increased force applied distally. For clinical correlation the support band pressure during activity was measured in 21 healthy volunteers while controlling for the application pressure in 2 common support band designs. This resulted in activity pressures ranging from 43 to 192 mm Hg dependent on the starting pressure of application.

CONCLUSIONS

Although further clinical evaluation is necessary to determine the most appropriate clinical indications and application pressures for the forearm support band these combined results suggest that the forearm support band may be most effective when applied to 30 to 50 mm Hg at rest, resulting in up to 120 mm Hg pressure during activity. According to our model this would result in a force reduction at the ECRB origin of approximately 13% to 15% throughout a range of activity levels.

Migration of a K-wire from the distal radius to the heart

K-wires and Steinmann pins are used to provide internal fixation for fractures or osteotomies. In some instances, removal of the implant is planned and the implant is left long to facilitate its removal. In other instances, implant removal is not planned and the implant is cut off at the level of the bone. Migration of these implants to solid organs or body cavities has been reported. Extravascular migration may occur along tissue planes assisted by muscle motion. Large vessel penetration can occur and has been reported with subsequent migration of the implant to the heart. This case report documents the loosening of a K-wire used in the distal radius to supplement the fixation of a complex intra-articular fracture, migration of the implant along tissue planes, penetration into a peripheral vein, and continued migration of the implant to the heart. There are multiple reports documenting wandering bullets, venous catheter tips, and invasive monitoring devices in the extremities. This is only the second case report that the authors are aware of that confirms migration of an implant from the distal extremity to the heart.

Thoracic outlet syndrome

"Thoracic outlet syndrome" is a term ascribed to a complex clinical entity encompassing complicated neurovascular signs, symptoms and pathology of the upper extremity. Controversies exist concerning its causes, diagnosis, and treatment despite years of intense study of hundreds of patients. Although there is no universal agreement on the diagnostic and treatment modalities to be applied to each patient, general guidelines have emerged that can aid hand surgeons in recognizing and evaluating these potentially difficult patients. A review of the anatomy, causes, clinical presentations, diagnostic tests, and treatment options available for thoracic outlet syndrome is presented, followed by an illustrative case.

Benign and malignant vascular tumors of the upper extremity

Vascular tumors of the upper extremity comprise a wide and varied group of pathologies. A variety of benign and malignant tumors exist. Proper diagnosis is imperative for the proper management of these lesions. On occasion, diagnosis can be made by a careful history and physical examination. However, the differentiation of benign from malignant tumors often requires permanent histologic section analysis by an experienced tumor specialist. The malignant vascular lesions, although rare, are aggressive in their behavior and require prompt diagnosis and treatment for patient survival.

Assembly of keratin onto PtK1 cytoskeletons: evidence for an intermediate filament organizing center

Purified keratin, solubilized in 8 M of urea, was added to Triton X-100-extracted PtK1 cells in 5 mM PIPES buffer. The buffer conditions induced assembly of keratin filaments which appear to associate with nuclei of extracted cells. These keratin fibers extend beyond the original margin of the cells and frequently form bridges between adjacent cells. Electron microscopy shows that keratin filaments associate closely with the surface of the nucleus. We suggest that the site of association between keratin and the nucleus may represent an intermediate filament organizing center.