Dynamic Compression of the Ulnar Nerve Associated With the Anconeus Epitrochlearis Muscle: Do We Really Know Everything?

Ulnar nerve compression associated with the anconeus epitrochlearis muscle (AE) is an uncommon cause of peripheral nerve compression at the elbow. It is often seen in young women with a hypertrophied or severely edematous muscle. Its causes are unclear. Numerous observed features, such as a hypertrophic AE, a palpable mass on the medial side of the elbow, and the dynamic nature of symptoms, have sparked controversy in the literature. Its clinical presentation is often insidious, and occasionally symptoms only occur in prolonged positions (dynamic compression). EMG tests are usually negative, and a correct diagnosis relies on imaging. We present the case of a 21-year-old student and clarinet player who presented with dynamic compression of the ulnar nerve at the elbow associated with AE. Much remains to be elucidated about the incidence, pathophysiology, and contributing factors of this peripheral form of cubital compression. It may be time to revisit this condition.

Patient Insight With Collagenase Treatment for Dupuytren: A Prospective Study.

PURPOSE: There appears to be controversy regarding differing patient and physician perceptions of adverse effects (AEs) in the treatment of Dupuytren disease with collagenase clostridium histolyticum (CCH). The aim of this study was to compare the number, type, and severity of AEs perceived and reported by patients and by their physician METHODS: To assess AEs following CCH injection in a standardized way, patients were given a list of predefined complications and asked to rate their severity on a 4-point Likert scale ranging from 1 (serious) to 4 (insignificant). RESULTS: Eighty-five patients were included. Patients reported fewer AEs than their physician (mean, 1.48 vs 2.18). There was no agreement between physician- and patient-reported AEs except for skin lacerations, which showed fair agreement (κ = 0.257). CONCLUSIONS: Patients and physicians differ in their evaluation of AEs due to CCH treatment in Dupuytren disease. A fair level of agreement was observed for skin lacerations. CLINICAL RELEVANCE: Greater consensus is needed when defining AEs associated with CCH in the treatment of Dupuytren disease.

A comparison of patient-reported outcome measures for dupuytren disease: A prospective view.

Treatment success in Dupuytren´s disease has traditionally been assessed by clinical examination and physical measures, but based on patient orientation, patient-reported outcome measures (PROMs) can be used to quantify treatment impacts and health-related quality of life. The aim of this study was to compare the most widely used PROMS in Dupuytren´s disease, their psychometric properties, and their association with objectively measured hand function. We show a prospective study in which two disease-specific questionnaires (URAM scale and SDSS) and two hand-specific questionnaires (briefMHQ and PEM) were administered before and a month after the treatment with collagenase. Psychometric properties (construct validity, internal consistency, test-retest reliability, internal and external responsiveness, reliability, and minimal clinically important difference (MCID)) were calculated for all the questionnaires. Ninety-two completed both sets of questionnaires. Pre- and post-treatment scores were strongly correlated (Spearman rho >0.6) for all questionnaires. High internal consistency (Cronbach alpha >0.88) was observed for all the questionnaires. Test-retest reliability was also significant, with an ICC of >0.50 in all cases. The MCID was similar for three of the questionnaires (URAM, 11.528/45=0.256; SDSS, 5.079/20=0.254; and PEM, 21.542/77=0.215) and somewhat lower for the briefMHQ (10.617/60=0.177). No correlations were observed between treatment outcome and treated hand (r = 0.107; p = 0.31), joint (r = 0.163; p = 0.12), or finger (r = -0.151; p = 0.15). In conclusion, we did not find that any one questionnaire performed better than the other in detecting perceived changes in health status among patients with Dupuytren´s disease treated with collagenase.

Sensitivity and Specificity of the Unité Rhumatologique Des Affections De La Main (URAM) Scale for Dupuytren Contracture: A Systematic Review and Meta-Analyses.

BACKGROUND: Unité Rhumatologique des Affections de la Main (URAM) is a novel and disease-specific questionnaire for Dupuytren contracture, a fibroproliferative disease that affects hands causing progressive contracture in flexion of the fingers. OBJECTIVES: To evaluate the sensitivity and specificity of the URAM scale in Dupuytren contracture. MATERIALS AND METHODS: We performed meta-analyses of 10 articles published in PubMed, Embase, Cochrane, Google Scholar, Latin American and Caribbean Health Sciences Literature (LILACS), and in various grey literature databases that describe the use of the URAM and Tubiana scales to assess treatment outcomes in Dupuytren contracture. We built three models: a hierarchical summary receiver operating characteristic (HSROC) model to determine the optimal threshold for defining Dupuytren contracture, a difference in means model to assess the magnitude of the effect of different treatment modalities, and a meta-regression model to determine the effect on patient quality of life questionnaires such as the URAM, according to variations in Tubiana scores after treatment. RESULTS: The HSROC and bivariate models showed a sensitivity of 80.23% (95% CI: 75.66 to 84.14) and an overall specificity of 2.61% (95% CI: 1.11 to 6.05). The second model showed an overall difference in means of 1.95 (95% CI: -2.86 to -1.04) for partial fasciectomy and collagenase Clostridium histolyticum (CCH) injections, and -1.30 (95% CI: -1.77 to -0.83) for partial fasciectomy, and -2.75 (95% CI: -4.73 to -0.78) for CCH. The coefficient obtained in the meta-regression model was -1.666 (95% CI: -4.183 to 0.851). CONCLUSION: The URAM scale is highly sensitive to changes in Dupuytren contracture but has low specificity. It also showed a strong correlation with worsening of finger contracture as measured by the Tubiana scale.

"Validation of a spanish version of the 'Unité Rhumatologique Des Affections De La Main' (URAM) scale".

BACKGROUND: In health care, quality-of-life surveys and questionnaires related to care are becoming increasingly important as a measure of its quality. There is currently no Spanish version of the Unité Rhumatologique des Affections de la Main (URAM) scale, which makes it suitable for hand pathology. The purposes of this study are to develop a Spanish version of the URAM and perform a transcultural adaptation of it, analyzing the result for reliability, validity, and sensitivity to changes. METHODS: The questionnaire was evaluated for patients with Dupuytren's disease and Carpal Tunnel Syndrome. The cohort study subjects were interviewed at three points in time (baseline, three days after intervention, and one month after), administering the QuickDASH, URAM, and SF-12 (CF12 = physical component, CM12 = mental component) questionnaires at baseline and after intervention; and only the URAM at 3 days. Content validity was evaluated using Cronbach's α. The distribution of the factorial loads of the items and the pattern of the answers were checked. Responsiveness was evaluated by the size of the effect and the reliable rate of change. Convergent and divergent validity was performed using Spearman's r between the different questionnaires. RESULTS: The study was conducted with 106 patients. The mean baseline scores were: URAM = 14.8, QuickDASH = 41.6, CF12 = 39.3 and CM12 = 49.4. Ceiling or floor effects were not observed in the Spanish URAM. The Cronbach α = 0.853 explains 49.6% of the variance. The study had a high reproducibility (intraclass correlation coefficient (ICC) = 0.939). Size effect, measured as differences in scores, was moderate for URAM (-0.69) and QuickDASH (-0.51); and low for CF12 and CM12. The correlation of URAM with QuickDASH was high (r = 0.716), and moderate with DD and CTS. CONCLUSION: The Spanish version of the URAM is a valid and reliable tool for use in assessing hand pathology.

Recurrent Dupuytren's disease after fasciectomy and collagenase injection are histologically indistinguishable.

The aim of this study was to determine whether recurrent Dupuytren's disease after collagenase Clostridium histolyticum treatment differs histologically from recurrence in those treated with fasciectomy. We carried out a prospective cohort study of patients with Dupuytren's disease who underwent fasciectomy to treat disease recurrence after previous treatment with collagenase Clostridium histolyticum or fasciectomy. The pathologists and statistician were blinded to the previous treatment. Longitudinal biopsy sections were stained with haematoxylin-eosin and the nodular zones were examined. Fifteen patients were studied: nine previously treated with collagenase Clostridium histolyticum and six previously treated with fasciectomy. There were no histological differences between the samples from the two groups of patients. Dupuytren's disease recurrences after fasciectomy and collagenase Clostridium histolyticum are histologically indistinguishable.

Current role of the collagenase Clostridium histolyticum in Dupuytren's disease treatment.

BACKGROUND: Collagenase Clostridium histolyticum (CCH) is a recent treatment for Dupuytren disease, which is a fibroproliferative disorder that leads to progressive, persistent digital flexion contracture that interferes with basic daily activities. While CCH has changed the treatment of this hand disorder, numerous concerns have to be analyzed. AIMS: Our purpose is to assess the current status of this medical treatment. METHODS: Literary review based on a manual search on PubMed, Web of Science, and Google Academic. RESULTS: Pharmacoeconomic analyses support the use of CCH, but long-term studies showing that it should be favored over conventional surgery or other treatments are lacking. Treatment decisions, therefore, must be guided by current data, which include a 5-year recurrence rate of 47%. Complications following CCH treatment are also a controversial topic, as rates of over 90% have been reported, although most of the complications are mild and self-limiting. A definition and classification of CCH-related complications is sorely needed. If we exclude adverse effects that could be considered inherent to the mechanisms of action of CCH, then the complication rate would be similar to rates reported for other techniques. Although CCH is becoming an increasingly popular treatment for Dupuytren disease, the potential applications of this modality, are much higher than currently believed, for more disorders characterized by excessive fibrosis. CONCLUSION: Currently, the administration of this treatment is promising although long-term studies are necessary to see the real role that this drug can play in both Dupuytren's disease and other fibrotic disorders.

Adverse effects associated with collagenase clostridium histolyticum in Dupuytren disease: A prospective study.

BACKGROUND: Collagenase clostridium histolyticum is now recognized as a viable treatment for Dupuytren disease. The high rate of adverse effects reported in patients continues to spark debate and raise questions about the true frequency of effects and their associated mechanisms of action. HYPOTHESIS: To investigate whether outcomes of CCH treatment are related to the number of adverse effects experienced. To evaluate short-term clinical outcomes in a series of patients. MATERIAL AND METHODS: Prospective single-center cohort study. The Primary End Point for effectiveness at 30 days was deficit of 0°-5°. Adverse effects were evaluated during CCH injection, removal of the dressing prior to finger extension, and finger extension. To investigate the relationship between adverse effects and treatment effectiveness, we analyzed the association between number of effects and clinical outcome at 30 days. RESULTS: A total of 208 injections were evaluated. The mean baseline contracture was 32.11°. Ninety-four patients (45.2%) had a mild contracture. Treatment was effective at 30 days in 194 of the injections (93.3%). The rate of effectiveness per joint was 93.5% for metacarpophalangeal joints (n=129) and 92.9% for proximal-interphalangeal joints (n=65). In total, 734 adverse effects were reported (mean, 3.53). No statistically significant associations were identified between disease severity and secondary effects. Variance analysis showed statistically significant differences in patients with severe contractures (mean, 3.91; 95% CI 3.57-4.25), and in patients with proximal-interphalangeal contractures (mean, 4.17; 95% CI 3.76-4.59). CONCLUSIONS: We found no relationship between number of adverse effects and treatment effectiveness at one month following CCH injection. LEVEL OF PROOF: IV, cohort prospective study.

Anesthesia for collagenase clostridium histolyticum injection in patients with dupuytren disease: A cohort analysis.

Procedural pain is one of the most common adverse effects reported by patients with Dupuytren disease (DD) treated with collagenase clostridium histolyticum (CCH). The aim of this study was to assess the effectiveness of wrist block before CCH injection in reducing procedural pain and to analyze its impact on adverse effects. We performed a prospective, single-center study in which we compared two groups of patients in a consecutive cohort. In the first group (NO-BLOCK), wrist block was only performed before finger extension, whereas in the second group (BLOCK), it was performed before CCH injection and finger extension. Pain was assessed on a 10-item numerical rating scale. Our results show that pain scores were clearlylower in the BLOCK group than in the NO-BLOCK group: 4.72 vs. 0.61 for CCH injection and 3.43 vs. 0.82 for finger extension. Patients who rated CCH injection pain with a score of 4 or higher were 11 times more likely to experience pain during extension. There was a weak correlation between the use of wrist block for CCH injection and the occurrence of skin lacerations (Spearman's rho = -0.222, p < 0.01) and the presence of pruritus (Spearman's rho = 0.183, p < 0.07). In conclusion, wrist block before CCH injection is an effective measure of decreasing perceived pain throughout the different stages of CCH treatment in patients with DD.

Skin Laceration in Collagenase Clostridium histolyticum Treatment for Dupuytren's Contracture.

BACKGROUND: Dupuytren's contracture produces a progressive flexion contracture of the affected fingers. Collagenase Clostridium histolyticum produces breakdown of the cord in the hand and/or finger(s) that tightens as a result of the disease creating a contracture, allowing manual traction and cord rupture. One of the side effects is spontaneous skin laceration when the finger is extended. OBJECTIVES: To evaluate the development of skin lacerations in Dupuytren's contracture treated with collagenase Clostridium histolyticum, to determine predisposing factors, and evaluate the effectiveness of 2 different treatments (antiseptic and non-antiseptic dressings). PARTICIPANTS: Included 157 patients diagnosed with Dupuytren's contracture and treated with collagenase Clostridium histolyticum. METHODS: Analysis of variables and logistic regression model were applied to determine their possible relationship with skin lacerations. The effectiveness of the type of treatment used was evaluated by comparing the amount of time required for healing. RESULTS: Skin lacerations were present in 33.1% (n = 52) of patients, with an average laceration length of 1.12 (SD: 0.70) cm. Characteristics that were significant predisposing factors for lacerations were disease bilateralism (p = .002), previous surgical intervention (p = .003), and initial matacarpophalangeal joint contracture (p < .001). Worse initial contracture (Z = 5.94; p < .001) had a greater risk of laceration as did those who had prior hand surgery, or whose little finger was affected. Average treatment length of healing was 11.24 days (SD: 8.13). All wounds healed successfully. There were no significant differences (p = .511) in healing between different dressings evaluated. CONCLUSIONS: Skin lacerations as a consequence of treating Dupuytren's contracture with collagenase Clostridium histolyticum occur often and are moderately serious. For all cases, evolution is satisfactory in less than 2 weeks, and the type of treatment does not appear to make any difference in healing time.

Effectiveness of Intracameral Phenylephrine in Achieving Mydriasis and Reducing Complications During Phacoemulsification: A Systematic Review and Meta-Analysis.

PURPOSE: To compare the effectiveness of intracameral phenylephrine and topical mydriatics in achieving mydriasis and protecting against complications during phacoemulsification. METHODS: A systematic search of the literature comparing the mydriatic effect and surgical safety profile of intracameral phenylephrine and topical mydriatics in phacoemulsification was conducted in the Medline, Embase, Lilacs, Web of Science, Cochrane, ClinicalTrials.gov , and Teseo databases. The search targeted clinical trials, cohort studies, and case-control studies published between April 20, 2003 and August 14, 2016. Mydriatic effect was assessed by difference in means in pupil of all the patients in the studies [mean difference (MD)] and intraoperative complications were assessed by using inverse-variance weighted odds ratios (ORs), with adjustment for dose. A meta-regression analysis was also conducted, with adjustment for dose, use of epinephrine, tamsulosin use, and type of surgery and type of intraocular lens. RESULTS: We found 7 articles about mydriatic effect and another 7 about complications. Intracameral phenylephrine achieved a similar mydriatic effect to topical mydriatics, with a difference of less than 10% (MD -0.74 mm, 95% CI: -1.67 to 0.18, I2 = 95.8%, P < 0.0001). The pooled OR for complications was OR 0.50, 95% CI: 0.19-1.31, I2 = 0.0%, P = 0.670, and posterior capsular rupture was the most common complication in the different studies analyzed. CONCLUSION: Intracameral phenylephrine achieves a similar mydriatic effect to topical mydriatics (difference <15%) and is associated with a not-significant effect on reducing the odds of intraoperative complications.

Adverse Effects of Collagenase in the Treatment of Dupuytren Disease: A Systematic Review.

BACKGROUND: Collagenase clostridium histolyticum (CCH) has proven to be both safe and effective in the treatment of Dupuytren disease (DD). The medium-term outcomes are similar to those achieved with surgery, and most adverse effects are self-limiting and considered to be mild or moderate. OBJECTIVE: Our objective was to conduct a systematic review of the adverse effects of CCH in DD since the release of the drug to evaluate the incidence, severity, classification, and definitions of these effects. METHODS: We analyzed the literature in terms of modifications to the original treatment protocol and grouped adverse effects according to their pathophysiological origin. RESULTS: We included 28 clinical studies and five case reports or case series analyzing 4456 patients with a mean age of 63.6 years. Mean follow-up was 7.07 months (range 3-24); the mean number of patients per study was 148 (range 5-1082). The studies did not classify the adverse effects they reported into groups. The most common effects were peripheral edema (54.4%), bruising (42.9%), and upper limb pain (28.3%). Significant biases were observed for use of terminology, demarcation of sites of involvement, severity criteria, and assessment methods. CONCLUSION: A simpler and clearer consensus-based classification system would enable better evaluation and comparison of the adverse effects of CCH in the treatment of DD. Consideration of inflammatory phenomena as part of the drug's mechanism of action would significantly reduce overall rates of adverse effects.

Pain Associated With Treatment of Dupuytren Contracture With Collagenase Clostridium histolyticum.

PURPOSE: The primary objective of this study was to quantify the degree of pain associated with collagenase Clostridium histolyticum (CCH) injection and to determine whether it is related to other factors in the intervention. METHODS: A prospective study of 135 patients was performed to evaluate pain at 3 points during treatment: (1) after CCH injection, using a numerical rating scale (NRS), (2) a binary (positive/negative) assessment before manipulation 24 hours after CCH and after removing the bandage, and (3) after joint manipulation performed with wrist block anesthesia. RESULTS: The average NRS for pain during infiltration was 4.7. Pain was present before manipulation in 52.6% of patients. Pain from manipulation showed an average NRS score of 3.6. The amounts of pain at CCH infiltration, pain after 24 hours, and pain from the manipulation were correlated because patients who experienced pain during CCH infiltration were more likely to report experiencing pain during manipulation. CONCLUSIONS: Collagenase Clostridium histolyticum injection for treating Dupuytren contracture can be a painful process. There is a clear relationship between a patient's level of pain during injection of CCH and the likelihood that the patient will experience pain during manipulation, even with the use of local anesthesia. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Intraoperative complications of phacoemulsification in pseudoexfoliation: Metaanalysis.

This review analyzed the effect of pseudoexfoliation (PXF) syndrome on the risk for surgical complications during phacoemulsification. Peer-reviewed literature in Medline, Embase, Lilacs, Web of Science, and Cochrane databases was systematically searched, along with gray literature in the Teseo and National Institutes of Health clinical trials database. Clinical trial, cohort, case-control, and cross-sectional studies comparing phacoemulsification complications in patients with and without PXF were identified, and 22 of 30 studies were selected for analysis. Odds ratios (ORs) for posterior capsule rupture or zonular dialysis were calculated and pooled using random-effects models. A random-effects meta-regression model was also generated. Using the random-effects model, the pooled OR was 2.1363 (95% confidence interval, 1.5394-2.9648), which corresponds to a risk of more than 10%. No significant changes to this risk were observed in the cumulative or stratified analyses. Although advances in surgical technique have been made, PXF syndrome continues to be a risk factor in phacoemulsification. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Use of resources and costs associated with the treatment of Dupuytren's contracture at an orthopedics and traumatology surgery department in Denia (Spain): collagenase clostridium hystolyticum versus subtotal fasciectomy.

BACKGROUND: Our purpose was to analyze and compare the use of direct health resources and costs generated in the treatment of Dupuytren's contracture using two different techniques: subtotal fasciectomy and infiltration with Collagenase Clostridium Histolyticum (CCH) in regular clinical practice at the Orthopedic and Traumatology Surgery (OTS) Department at the Hospital de Denia (Spain). METHODS: Observational, retrospective study based on data from the computerized clinical histories of two groups of patients- those treated surgically using a one or two digit subtotal fasciectomy technique (FSC) and those treated with CCH infiltration, monitored in regular clinical practice from February, 2009 to May, 2012. Demographic (age, sex), clinical (number of digits affected and which ones) and use of resources (hospitalizations, medical visits, tests and drugs) data were collected. Resource use and associated costs, according to the hospital's accounting department, were compared based on the type of treatment from Spain's National Health Service. RESULTS: 91 patients (48 (52.8%) in the FSC group) were identified. The average age and number of digits affected was 65.9 (9.2) years and 1.33 (0.48) digits affected in the FSC group, and 65.1 (9.7) years and 1.16 (0.4) digits in the CCH group.Overall, the costs of treating Dupuytren's disease with subtotal FSC amount to €1,814 for major ambulatory surgery and €1,961 with hospital stay including admission, surgical intervention (€904), examinations, dressings and physiotherapy. As to collagenase infiltration, costs amount to €952 (including minor surgery admission, vial with product, office examination and dressings). Finally, comparing total costs for treatments, a savings of €388 is estimated in favor of CCH treatment in the best-case scenario (patient under MAS system with no need for physiotherapy) and €1,008 in the worst-case scenario (patient admitted to hospital needing subsequent physiotherapy), implying a savings of 29% and 51%, respectively. CONCLUSIONS: This study demonstrates that treating patients with DC by injection with CCH at the OTS department of the Hospital de Denia generates a total savings of 29% and 51% (€388 and €1008) compared with fasciectomy at the time of treatment. Long term evolution of CCH treatment is uncertain and the recurrence rate unknown.