Surgery, Needle Fasciotomy, or Collagenase Injection for Dupuytren Contracture : A Randomized Controlled Trial.

BACKGROUND: Surgery, needle fasciotomy, and collagenase injection are used to treat Dupuytren contracture. The treatment decision requires balancing initial morbidity and costs of surgery against its potential long-term benefits over needle fasciotomy and collagenase. OBJECTIVE: To compare the effectiveness of surgery, needle fasciotomy, and collagenase injection at 3 months and 2 years (secondary time points of the trial). DESIGN: A multicenter, randomized, outcome assessor-blinded, superiority trial. (ClinicalTrials.gov: NCT03192020). SETTING: 6 public hospitals in Finland. PARTICIPANTS: 302 persons with treatment-naive Dupuytren contracture (contracture angle <135°). INTERVENTION: Surgery (n = 101), needle fasciotomy (n = 101), or collagenase (n = 100). MEASUREMENTS: The primary outcome was the success rate, defined as greater than 50% contracture release and patients reaching the patient acceptable symptom state. Secondary outcomes included hand function, pain, quality of life, patient satisfaction, residual contracture angle, finger flexion, risk for retreatment, and serious adverse events. RESULTS: A total of 292 (97%) and 284 (94%) participants completed the 3-month and 2-year follow-ups. Success rates were similar at 3 months: 71% (95% CI, 62% to 80%) for surgery, 73% (CI, 64% to 82%) for needle fasciotomy, and 73% (CI, 64% to 82%) for collagenase. At 2 years, surgery had superior success rates compared with both needle fasciotomy (78% vs. 50%; adjusted risk difference [aRD], 0.30 [CI, 0.17 to 0.43]) and collagenase (78% vs. 65%; aRD, 0.13 [CI, 0.01 to 0.26]). Secondary analyses paralleled with the primary analysis. LIMITATION: Participants were not blinded. CONCLUSION: Initial outcomes are similar between the treatments, but at 2 years success rates were maintained in the surgery group but were lower with both needle fasciotomy and collagenase despite retreatments. PRIMARY FUNDING SOURCE: Research Council of Finland.

Surgical versus non-surgical treatment for carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the wrist. Surgery is considered when symptoms persist despite the use of non-surgical treatments. It is unclear whether surgery produces a better outcome than non-surgical therapy. This is an update of a Cochrane review published in 2008. OBJECTIVES: To assess the evidence regarding the benefits and harms of carpal tunnel release compared with non-surgical treatment in the short (< 3 months) and long (> 3 months) term. SEARCH METHODS: In this update, we included studies from the previous version of this review and searched the Cochrane Neuromuscular Specialised Register, CENTRAL, Embase, MEDLINE, ClinicalTrials.gov and WHO ICTRP until 18 November 2022. We also checked the reference lists of included studies and relevant systematic reviews for studies. SELECTION CRITERIA: We included randomised controlled trials comparing any surgical technique with any non-surgical therapies for CTS. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: The 14 included studies randomised 1231 participants (1293 wrists). Eighty-four per cent of participants were women. The mean age ranged from 32 to 53 years, and the mean duration of symptoms from 31 weeks to 3.5 years. Trial sizes varied from 22 to 176 participants. The studies compared surgery with: splinting, corticosteroid injection, splinting and corticosteroid injection, platelet-rich plasma injection, manual therapy, multimodal non-operative treatment, unspecified medical treatment and hand support, and surgery and corticosteroid injection with corticosteroid injection alone. Since surgery is generally used for its long-term effects, this abstract presents only long-term results for surgery versus splinting and surgery versus corticosteroid injection. 1) Surgery compared to splinting in the long term (> 3 months) Surgery probably results in a higher rate of clinical improvement (risk ratio (RR) 2.10, 95% confidence interval (CI) 1.04 to 4.24; 3 studies, 210 participants; moderate-certainty evidence). Surgery probably does not provide clinically important benefit in symptoms or hand function compared with splinting (moderate-certainty evidence). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (scale 1 to 5; higher is worse; minimal clinically important difference (MCID) = 1) was 1.54 with splint and 0.26 points better with surgery (95% CI 0.52 better to 0.01 worse; 2 studies, 195 participants). The mean BCTQ Functional Status Scale (scale 1 to 5; higher is worse; MCID 0.7) was 1.75 with splint and 0.36 points better with surgery (95% CI 0.62 better to 0.09 better; 2 studies, 195 participants). None of the studies reported pain. Surgery may not provide better health-related quality of life compared with splinting (low-certainty evidence). The mean EQ-5D index (scale 0 to 1; higher is better; MCID 0.074) was 0.81 with splinting and 0.04 points better with surgery (95% CI 0.0 to 0.08 better; 1 study, 167 participants). We are uncertain about the risk of adverse effects (very low-certainty evidence). Adverse effects were reported amongst 60 of 98 participants (61%) in the surgery group and 46 of 112 participants (41%) in the splinting group (RR 2.11, 95% CI 0.37 to 12.12; 2 studies, 210 participants). Surgery probably reduces the risk of further surgery; 41 of 93 participants (44%) were referred to surgery in the splinting group and 0 of 83 participants (0%) repeated surgery in the surgery group (RR 0.03, 95% CI 0.00 to 0.21; 2 studies, 176 participants). This corresponds to a number needed to treat for an additional beneficial outcome (NNTB) of 2 (95% CI 1 to 9). 2) Surgery compared to corticosteroid injection in the long term (> 3 months) We are uncertain if clinical improvement or symptom relief differs between surgery and corticosteroid injection (very low-certainty evidence). The RR for clinical improvement was 1.23 (95% CI 0.73 to 2.06; 3 studies, 187 participants). For symptoms, the standardised mean difference (SMD) was -0.60 (95% CI -1.88 to 0.69; 2 studies, 118 participants). This translates to 0.4 points better (95% CI from 1.3 better to 0.5 worse) on the BCTQ Symptom Severity Scale. Hand function or pain probably do not differ between surgery and corticosteroid injection (moderate-certainty evidence). For function, the SMD was -0.12 (95% CI -0.80 to 0.56; 2 studies, 191 participants) translating to 0.10 points better (95% CI 0.66 better to 0.46 worse) on the BCTQ Functional Status Scale with surgery. Pain (0 to 100 scale) was 8 points with corticosteroid injection and 6 points better (95% CI 10.45 better to 1.55 better; 1 study, 123 participants) with surgery. We found no data to estimate the difference in health-related quality of life (very low-certainty evidence). We are uncertain about the risk of adverse effects and further surgery (very low-certainty evidence). Adverse effects were reported amongst 3 of 45 participants (7%) in the surgery group and 2 of 45 participants (4%) in the corticosteroid injection group (RR 1.49, 95% CI 0.25 to 8.70; 2 studies, 90 participants). In one study, 12 of 83 participants (15%) needed surgery in the corticosteroid group, and 7 of 80 participants (9%) needed repeated surgery in the surgery group (RR 0.61, 95% CI 0.25 to 1.46; 1 study, 163 participants). AUTHORS' CONCLUSIONS: Currently, the efficacy of surgery in people with CTS is unclear. It is also unclear if the results can be applied to people who are not satisfied after trying various non-surgical options. Future studies should preferably blind participants from treatment allocation and randomise people who are dissatisfied after being treated non-surgically. The decision for a patient to opt for surgery should balance the small benefits and potential risks of surgery. Patients with severe symptoms, a high preference for clinical improvement and reluctance to adhere to non-surgical options, and who do not consider potential surgical risks and morbidity a burden, may choose surgery. On the other hand, those who have tolerable symptoms, who have not tried non-surgical options and who want to avoid surgery-related morbidity can start with non-surgical options and have surgery only if necessary. We are uncertain if the risk of adverse effects differs between surgery and non-surgical treatments. The severity of adverse effects may also be different.

Antibiotic Treatment and Surgery for Acute Hematogenous Calcaneal Osteomyelitis of Childhood.

Acute hematogenous calcaneal osteomyelitis characteristically affects children. A recent trend has emerged toward shorter courses of antibiotics. In our randomized, prospective treatment trial of children aged 3 months to 15 years, the intravenous antibiotic (clindamycin or a first-generation cephalosporin) was given only for the first 2 to 4 days and the remainder of the 20- to 30-day course was completed orally. A bone sample for culture was to be taken routinely, but all additional surgery was performed on special demand. We performed a retrospective subanalysis of cases affecting the calcaneus. The follow-up period was 1 year. Of the 14 participants enrolled, 11 completed the 1-year follow-up period, and their data were analyzed. Staphylococcus aureus was the cause of 10 cases; all strains were methicillin sensitive. The median intravenous treatment duration was 3 days. Four patients required open incisional trepanation (trephination). All participants attending the 1-year follow-up examination had fully recovered. The outcome of calcaneal osteomyelitis caused by methicillin-sensitive S. aureus in a child will be good, if the patient seeks treatment early and antibiotic therapy is started promptly. A bone biopsy is needed to obtain a representative sample for bacteriology.

[Childhood septic arthritis]. / Lapsen septinen artriitti.

Childhood acute septic arthritis is most often of hematogenous origin, and usually caused by Staphylococcus aureus. Characteristic symptoms and signs include a swollen, red painful joint, and fever. The diagnosis is confirmed by a joint aspiration. Following a brief 2- to 4-day intravenous phase, the antibiotic course is completed orally to a total of 10 to 14 days. Cephalosporins, clindamycin or staphylococcal penicillins, administered every 6 hours, are recommended as first-line antibiotics because of their appropriate spectrum, excellent penetration, good tolerability in large doses, and moderate price. Operative treatment (arthroscopy, arthrotomy) is not needed routinely, unless the response is tardy.

C-reactive protein versus erythrocyte sedimentation rate, white blood cell count and alkaline phosphatase in diagnosing bacteraemia in bone and joint infections.

AIM: Bacteraemia is common in childhood acute bone and joint infections and demands urgent treatment. Blood C-reactive protein (CRP), erythrocyte sedimentation rate and white blood cell count (WBC) are well known and established markers in these infections. Instead, no information is available on serum alkaline phosphatase whose concentration is known to increase in septic conditions. METHODS: In our large prospective treatment trial comprising of 265 children with acute culture-positive bone or joint infection, all these laboratory indices were monitored on admission to hospital. The predictive value to detect bacteraemia was assessed for each of these four indices. RESULTS: In all, 59% of the patients showed bacteraemia. CRP was significantly (P < 0.05) higher among bacteraemic patients, whereas erythrocyte sedimentation rate, white blood cell count and alkaline phosphatase were not. The area under receiver operator characteristic curve for CRP was 0.588 (CI95% 0.524-0.649) and the significance level P (Area = 0.5) was <0.05. CONCLUSION: None of the markers could reliably diagnose bacteraemia. CRP alone was significantly higher among bacteraemic patients.

Scalpel versus Electrocautery for Surgical Skin Incision in Open Carpal Tunnel Release.

Background: Electrocautery is an option for skin incision for the neck, abdominal or inguinal surgery, but is not generally used for hand surgery. The aim of this study was to clarify whether electrocautery skin incision would be beneficial in open carpal tunnel release (OCTR). Methods: A total of 16 patients with carpal tunnel syndrome underwent skin incision for OCTR using either a scalpel (n = 9) or a microdissection diathermy needle (n = 7). Postoperative pain was assessed using a visual analogue scale (VAS 0-100 mm) daily from postoperative days 1 till 7. Results: The diathermy group reported higher VAS scores (mean 80 mm) on the first postoperative day versus the scalpel group mean of 35 mm (p < 0.001). We continued measuring pain for 7 days after the surgery and found higher VAS scores for the diathermy group in the first 6 days. Conclusions: The use of electrocautery is associated with greater pain score in the first postoperative 6 days following OCTR. Level of Evidence: Level III (Therapeutic).

Arthroscopic Scaphotrapeziotrapezoid Joint Fusion for Osteoarthritis.

Background: Arthroscopic scaphotrapeziotrapezoid (STT) fusion (ASTTF) has emerged in the recent decade as an option for traditional open surgery. This retrospective study describes our technique and results of ASTTF. Methods: Medical records and radiological data of patient who had undergone ASTTF between 2014 and 2022 in two tertiary hospitals were reviewed. Results: Five ASTTF in four patients were identified. The mean age of the patients were 52.4 years. Fusion was achieved in four out of five wrists (80%). The mean postoperative radio-scaphoid angle was 48°, grip 32 kg (70% compared to contralateral hand), extension 54° (86%) and flexion 46° (93%). The mean follow-up time was 18 months (range 5 months to 4 years). One wrist (20%) developed STT non-union requiring a reoperation 2 years after index surgery. Conclusions: ASTTF is a technically challenging procedure with a long learning curve and surgery time. However, ASTTF is less invasive compared to the open procedure and our results were like the open procedures described in literature. Further studies are needed to compare the benefits and results of open and ASTTF in a prospective and randomised setup. Level of Evidence: Level IV (Therapeutic).

Guideline for management of septic arthritis in native joints (SANJO).

This clinical guideline is intended for use by orthopedic surgeons and physicians who care for patients with possible or documented septic arthritis of a native joint (SANJO). It includes evidence and opinion-based recommendations for the diagnosis and management of patients with SANJO.

Shortened hospital stay for childhood bone and joint infections: analysis of 265 prospectively collected culture-positive cases in 1983-2005.

BACKGROUND: In recent decades the treatment of childhood acute bone and joint infections has shifted towards shorter antibiotic courses and rapid transition to oral therapy. METHODS: We prospectively collected 265 culture-positive cases of non-neonatal bone and joint infections in Finnish children during 1983-2005. The duration of antimicrobial treatment and the extent of surgery were defined in the study protocol, but for ethical reasons, the liaison clinician determined the time of discharge using normalization of the serum C-reactive protein (CRP) level as a yardstick. We examined changes during the study in the distribution of causative organisms, severity of disease, and length of hospital stay. RESULTS: Staphylococcus aureus was overwhelmingly the most common causative agent throughout the study, whereas Haemophilus influenzae type b was eliminated soon after the introduction of vaccination. The mean time from initial symptoms to presentation remained the same at 4 days, and no significant change was observed in the severity of disease, CRP, or the rate of sequelae. The mean duration of intravenous antibiotic administration was only 4 days. The average hospital stay shortened significantly from 13 days to 9 days (p = 0.0001). CONCLUSIONS: The shortened hospital stay was not due to a change in the anatomical site of these infections, but to simplified treatment. Considerable savings in hospital stay, and thus costs, are feasible in osteoarticular infections of childhood by using CRP in monitoring the disease and shortening intravenous treatment by a swift move to per oral administration.

Complications of Scheker semiconstrained distal radioulnar joint arthroplasty in a low-volume unit.

Semiconstrained arthroplasty of the distal radioulnar joint (DRUJ) (Scheker prosthesis, Aptis Medical, Glenview, KY, USA) is a treatment option in case of irreparable destruction of the DRUJ. In our unit, a Scheker endoprosthesis was implanted in 5 wrists in 4 patients. 3/5 wrists (60%) in 3/4 patients (75%) underwent revision surgery. Reasons for revision surgery were implant loosening, periprosthetic fracture of the radius and suspicion of periprosthetic infection. Asymptomatic loosening of the screw of the radial head cover was detected in one wrist. Scheker arthroplasty is technically demanding. The prosthesis is prone to failure over the long term. Before implantation, all patients should be informed of the high risk of revision surgery.

Arthroscopic Oblique Partial Ulnar Styloid Resection for Ulnar Styloid Impaction Syndrome.

Background Open or arthroscopic partial resection of the elongated ulnar styloid is the surgical treatment of choice for ulnar styloid impaction syndrome. Case Description A patient with a severely elongated processus styloideus ulnae (PSU) with a chronic impaction of the distal-radial margin against the triquetrum suffered a traumatic triangular fibrocartilage complex (TFCC) Palmer 1B rupture and DRUJ instability. The length of the PSU was 9 mm. After failed conservative treatment, a partial oblique arthroscopic resection of the PSU and simultaneous TFCC reinsertion were performed with uneventful recovery. Literature Review Arthroscopic resection has emerged as an alternative to the traditional open PSU resection for the treatment of styloid impaction syndrome. A transverse resection is described as the treatment of choice. Regarding the extent of resection subtotal ligament sparing resection or resection to the lower margin have been suggested. Clinical Relevance Surgical planning of PSU resection should take into consideration the anatomy of the impingement. The extent of resection should be planned individually, and sometimes an oblique resection may be the preferred option.

Mini-invasive Osteotomy for Pediatric Distal Radius Malunion.

Although most malunions after pediatric distal radius fractures will remodel as the child grows, adolescent patients with severe malunion and limited growth require reduction to restore alignment. The authors technique for a mini-invasive osteotomy is presented. The apex of the malunion is approached from a single 2 cm volar incision through the flexor carpi radialis sheath. Open wedge osteotomy is performed. The osteosynthesis is secured with an individually contoured T-plate. The procedure was used to correct a severe visible malunion in a 12-year-old girl. Normal alignment was achieved with no nerve or tendon injury or irritation, infection, refracture, or any other complication. Mini-invasive osteotomy with a volar plate is a feasible method for experienced hand surgeons for the treatment of distal radius malunion in adolescents.

Treatment Options for Bifid Ulna Deformity Following Galeazzi-equivalent Injury in Adolescents.

A Galeazzi-equivalent lesion occurs in children and adolescents following a traumatic distal radius fracture when the strong radioulnar ligaments and relative weakness of the ulnar physis result in an avulsion-type Salter-Harris III fracture of the distal ulna. In unreduced fractures, the osteogenic nature of the torn periosteal sleeve may result in the formation of a bifid distal ulna. We describe two cases of bifid distal ulna that developed after missed Galeazzi-equivalent lesions. The first case was treated with resection of the volar limb and reduction of the ulnar fracture, whereas the second case was treated with simple resection of the dorsal limb. Negative ulnar variance developed in both cases. Level of Evidence: Level V (Case report).

[Pediatric septic shoulder arthritis. Is routine arthrotomy still necessary?]. / Onko rutiinileikkaus tarpeen lasten septisen olka-artriitin hoidossa?

BACKGROUND: Arthrotomy is recommended as a routine treatment for childhood septic arthritis of the shoulder, although scientific evidence is lacking. Suggested alternatives are arthroscopic lavage, serial aspirations and a mere diagnostic aspiration. MATERIAL AND METHODS: 9 patients with septic arthritis of the shoulder aged 3 months to 12 years underwent a diagnostic aspiration after which large dose antimicrobials were given qid (clindamycin or 1st generation cephalosporin). RESULTS: One child underwent arthrotomy, otherwise all patients recovered normally. There were no sequelae. CONCLUSIONS: Routine arthrotomy for all patients is of questionable value in the emergency treatment of septic shoulder arthritis in children.