Delayed vascular complication after collagenase injection for Dupuytren disease.

BACKGROUND: Vascular adverse events after collagenase injection for Dupuytren disease are absent in large trials and systematic reviews. The aim of this study is to present a case series of delayed vascular complications after collagenase treatment. METHODS: A prospective evaluation of 1181 consecutively treated patients at one orthopedic department identified three patients reporting symptoms of possible vascular complication. Baseline demographics and description of symptoms were collected, with a physical examination documenting extension deficit and neurovascular status. All patients completed the Cold Intolerance Symptom Severity (CISS) scale (range 4-100, lower is better) and underwent Doppler sonography examination of the digital arteries. RESULTS: All patients were treated in the small finger and two had an isolated proximal interphalangeal joint contracture. All patients had a delayed presentation of a few months, with episodes of white discoloration of the treated finger relieved within 30 min and associated with variable pain, paresthesia, stiffness and weakness. Two of the patients reported cold exposure as an episode trigger and had a pathological CISS score (40 and 36, respectively). Doppler sonography identified a nonpatent ulnar digital artery in one patient. CONCLUSIONS: Delayed vascular complication after collagenase treatment is rare, but surgeons and patients should be aware of the risk, especially when treating the small finger.

Surgically treated adult acquired flatfoot deformity: Register-based study of patient characteristics, health-related quality of life and type of surgery according to severity.

BACKGROUND: Population-level data describing patient characteristics and interventions used in surgical treatment of adult acquired flatfoot deformity (AAFD) is lacking. METHODS: We analyzed baseline patient-reported data including PROMs and surgical interventions for patients with AAFD reported to the Swedish Quality Register for Foot and Ankle Surgery (Swefoot) 2014-2021. RESULTS: 625 feet with primary AAFD surgery were registered. Median age was 60 (range 16-83) years and 64% were women. Mean preoperative EQ-5D index and Self-Reported Foot and Ankle Score (SEFAS) were low. In stage IIa (n = 319) 78% had medial displacement calcaneal osteotomy and 59% had flexor digitorium longus transfer, with some regional variations. Spring ligament reconstruction was less common. In stage IIb (n = 225), 52% had lateral column lengthening, and in stage III (n = 66), 83% had hind-foot arthrodesis. CONCLUSIONS: Patients with AAFD have low health-related quality of life before surgery. Treatment in Sweden follows best-available evidence but regional variations exist. LEVEL OF EVIDENCE: III.

Measuring symptoms severity in carpal tunnel syndrome: score agreement and responsiveness of the Atroshi-Lyrén 6-item symptoms scale and the Boston symptom severity scale.

PURPOSE: To assess score agreement between the Atroshi-Lyrén 6-item symptoms scale and the Boston 11-item symptom severity scale and compare their responsiveness in patients with carpal tunnel syndrome before and after carpal tunnel release surgery. METHODS: This prospective cohort study included 3 cohorts that completed the A-L and Boston scales (conventional score 1-5) on the same occasion: a preoperative and short-term postoperative cohort (212 patients), a mid-term postoperative cohort (101 patients), and a long-term postoperative cohort (124 patients). Agreement was assessed with Lin's concordance correlation coefficient and Passing-Bablok regression analysis. Analyses using item response theory were conducted on responses from the preoperative/short-term postoperative cohort including testing of item infit/outfit. Reliability was assessed with Cronbach alpha. Overall and sex-specific effect sizes were calculated using Cohen's d. RESULTS: Lin's CCCs were high (0.81-0.91). Passing-Bablok analysis showed constant and proportional differences in all cohorts except preoperative to short-term postoperative change. Both scales showed high reliability (alpha, 0.88-0.93). The IRT-based analyses showed infit/outfit values within the desired range. With IRT-based scoring, the A-L scale had significantly higher responsiveness than the Boston scale, overall (d, 2.02 vs 1.59), in women (d, 2.22 vs 1.77) and in men (d, 1.74 vs 1.36). CONCLUSION: The Atroshi-Lyrén 6-item symptoms scale and the Boston 11-item symptom severity scale show good agreement but are not equivalent in measuring CTS-related symptoms severity. When using IRT-based scoring, the Atroshi-Lyrén scale demonstrated significantly higher responsiveness.

Finger Joint Contractures 5 Years After Treatment for Dupuytren Disease: A Comparative Cohort Study of Collagenase Injection Versus Surgical Fasciectomy.

PURPOSE: To compare collagenase injection with surgical fasciectomy in Dupuytren disease (DD) for the prevalence of contracture in treated fingers 5 years after treatment. METHODS: This was a single-center, comparative cohort study comprising 2 cohorts of patients treated for DD in 1 or more of 3 ulnar fingers with collagenase injection (159 patients) or surgical fasciectomy (59 patients). At 5 years after treatment, 13 collagenase-treated and 8 fasciectomy-treated patients had undergone subsequent treatment on the treated fingers and were considered to have current contracture. Of the remaining patients, 112 collagenase-treated patients (128 hands, 180 fingers) and 46 fasciectomy-treated patients (49 hands, 63 fingers) attended follow-up evaluation performed by 2 independent examiners (participation rate 84% and 93%, respectively). We defined current contracture in a treated finger as an active extension deficit of ≥20° in the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint or a total (MCP + PIP) active extension deficit (TAED) of ≥30°. We used linear mixed models to analyze differences between the cohorts over time. RESULTS: In the collagenase cohort, current contracture was present in 45 (25%) MCP and 60 (33%) PIP joints, and in the fasciectomy cohort, current contracture was present in 12 MCP (19%) and 30 PIP (48%) joints; a TAED of ≥30° was present in 79 (44%) of the collagenase-treated and 30 (48%) of the fasciectomy-treated fingers. In MCP and PIP joints with ≥20° pretreatment contracture, complete correction was observed in 82 (56%) MCP and 30 (30%) PIP joints in the collagenase cohort and 23 (70%) MCP and 5 (16%) PIP joints in the fasciectomy cohort. There was no statistically significant difference between the 2 cohorts in the TAED change over time. CONCLUSIONS: In patients with DD, collagenase injection and surgical fasciectomy improved finger joint contracture over the pretreatment status but had a high prevalence of joint contracture in the treated fingers 5 years after treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

What Are the Patient-reported Outcomes of Trapeziectomy and Tendon Suspension at Long-term Follow-up?

BACKGROUND: There are multiple options for the treatment of thumb carpometacarpal joint osteoarthritis (CMC1 OA), with evidence for pain relief and improved function. Although simple trapeziectomy has the lowest complication risk, tendon suspension of the first metacarpal and interposition is still the most commonly used surgical procedure in patients with CMC1 OA. Although there are several reports of good short-term results after trapeziectomy and tendon suspension-interposition arthroplasty, few studies have evaluated long-term outcomes. This study is one of the largest and longest follow-up evaluations of a cohort of patients with CMC1 OA who were treated with trapeziectomy and suspension-interposition arthroplasty, capturing 96% of the original cohort for evaluation. QUESTIONS/PURPOSES: (1) After trapeziectomy and tendon suspension surgery, what are the long-term, patient-reported outcomes and clinical measurements (strength and ROM); and in unilateral procedures, how do these parameters compare with those of the contralateral hand that was not operated on? (2) What is the mean subsidence (unloaded trapezial space), and does pinch strength correlate with the amount of subsidence? METHODS: From 1998 to 2005, 130 patients underwent trapeziectomy and abductor pollicis longus (APL) suspension-interposition arthroplasty for CMC1 OA at one orthopaedic department. During this period, 15 patients were treated with CMC1 arthrodesis and four were treated with implant arthroplasty, for a total of 149 patients. The surgeons used APL suspensionplasty for most patients, based on age and expected postoperative function; they also employed this procedure to avoid hardware or implant failure issues. The 100 living patients were asked to participate in this retrospective study, 96% (96) of whom were enrolled. The mean age at surgery was 58 ± 7 years. The patients completed a two-item thumb pain scale (modified from the SF-36 body pain scale), a hand pain VAS (average level of pain experienced over the week preceding measurement), and the 11-item QuickDASH. Patient-reported outcomes data were obtained from all 96 patients, and 83% (80) of patients underwent bilateral hand radiography and a physical examination at a mean follow-up of 17 ± 2.4 years. We calculated outcome data for each patient, and in 39 patients with unilateral surgery and intact contralateral CMC1 joint, we compared the operated side with the contralateral side. We compared our outcome data with that from the Swedish National Quality Registry for Hand Surgery (HAKIR), noting comparable outcomes for pain and QuickDASH scores. RESULTS: At long-term follow-up after trapeziectomy and APL suspension surgery, the mean thumb pain score was 19 ± 26, hand pain VAS score 23 ± 25, and QuickDASH score 26 ± 21. In the patients with unilateral surgery and intact contralateral CMC1 joint, the thumb pain score for the operated side was lower than the contralateral side, specifically 19 ± 25 compared with 29 ± 30 (mean difference -9.8 [95% CI -19.5 to -0.2]; p = 0.045); hand pain VAS score was 24 ± 23 versus 30 ± 25 (mean difference -6.1 [95% CI -15.2 to 3.1]; p = 0.19), and the QuickDASH score was 27 ± 19. Grip strength showed no differences between the operated and contralateral sides (mean 16.7 ± 7.3 kg versus 16.6 ± 6.9 kg, mean difference 0.1 [95% CI -1.6 to 1.8]; p = 0.90), while pinch was different (4.4 ± 1.4 versus 5.0 ± 1.5 kg, mean difference -0.6 [95% CI -0.9 to -0.3]; p = 0.001). The mean trapezial space was 4.4 ± 2.2 mm, and there was no association between the trapezial space and pinch strength (0.07 kg [95% CI -0.04 to 0.18] per mm of space; p = 0.17). CONCLUSION: The finding of comparable pain and function between operated and unoperated sides at long-term follow-up suggests that trapeziectomy and tendon suspension-interposition arthroplasty provides predictable outcomes, and surgeons can use these data to counsel patients that surgery can potentially return them to comparable use. However, as patients often have asymptomatic radiographic OA on the contralateral side, future studies are needed to examine the impact of asymptomatic disease on function. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Occupational load as a risk factor for clinically relevant base of thumb osteoarthritis.

OBJECTIVE: It is postulated that increased load from pinch and grasp in occupational tasks increases the risk of thumb carpometacarpal (CMC1) osteoarthritis (OA). We sought to characterise the relationship between doctor-diagnosed CMC1 OA and occupation in a large working population. METHODS: We performed a matched case-control study using a Swedish healthcare register. We identified residents aged 30-65 years in 2013 with physician-diagnosed CMC1 OA from 1998 to 2013. We matched four controls per person with CMC1 OA by age, sex, education and postcode. Swedish Standard Classification of Occupations was used to assign occupation. Occupation was categorised as light, light-moderate, moderate and heavy labour. We used conditional logistic regression to estimate ORs with 95% CIs. RESULTS: We identified 3462 patients with CMC1 OA and matched 13 211 controls. The mean age of the CMC1 OA group was 63 (SD 7) years, with 81% women. The ORs for CMC1 OA in men were 1.31 (95% CI 0.96 to 1.79) for light-moderate, 1.76 (95% CI 1.29 to 2.40) for moderate and 2.00 (95% CI 1.59 to 2.51) for heavy compared with light work. Women had ORs for CMC1 OA of 1.46 (95% CI 1.32 to 1.61) for light-moderate, 1.27 (95% CI 1.10 to 1.46) for moderate and 1.31 (95% CI 1.07 to 1.59) for heavy compared with light work. CONCLUSIONS: The association between increased manual load in occupation and risk of CMC1 OA is more pronounced in men than in women, likely due to higher workload in the heavy labour category.

A new finger-preserving procedure as an alternative to amputation in recurrent severe Dupuytren contracture of the small finger.

BACKGROUND: Recurrent severe Dupuytren contracture of the small finger's proximal interphalangeal (PIP) joint is a difficult problem. Further surgery carries high risk of complications and poor outcome. Patients are often offered finger amputation. We have devised a novel surgical procedure consisting of middle phalanx monoblock resection and ligament reconstruction to create a new functioning interphalangeal joint. METHODS: Two patients requesting small-finger amputation because of severe PIP joint contracture after multiple treatments for Dupuytren contracture were offered and accepted this new procedure. Through a dorsal incision the extensor tendon is incised longitudinally exposing the middle phalanx and interphalangeal joints. The collateral ligaments of both interphalangeal joints are detached from the middle phalanx. The middle phalanx is dissected from soft tissues (including the flexor digitorum superficialis tendon) and removed. The distal phalanx is brought proximally and the ends of the collateral ligaments are sutured with non-absorbable sutures with the joint held in full extension and congruency. The two patients were evaluated at 18 months and 15 months after surgery, respectively. RESULTS: Both patients regained good finger posture with almost full extension and had normal sensation and no pain. Active flexion in the new interphalangeal joint was 60 degrees and 35 degrees, respectively. Both patients had full metacarpophalangeal joint flexion and extension, normal 2-point discrimination in the small finger and higher grip strength in the treated than the contralateral hand. Radiographs showed a congruent new interphalangeal joint. Both patients were very satisfied with the outcome. CONCLUSIONS: In patients with Dupuytren disease and severe PIP joint contracture after multiple treatments, this novel procedure consisting of middle-phalanx excision and ligament reconstruction creating a new functioning interphalangeal joint has good short-term outcomes and is a favorable alternative to finger amputation. Longer follow-up will show whether these results are durable.

Collagenase injections for Dupuytren disease: 3-year treatment outcomes and predictors of recurrence in 89 hands.

Background and purpose - Few prospective studies have reported the long-term effect durability of collagenase injections for Dupuytren disease. We assessed the 3-year treatment outcome of collagenase injections and predictors of recurrence.Patients and methods - We conducted a single-center prospective cohort study. Indication for collagenase injection was palpable Dupuytren's cord and active extension deficit (AED) ≥ 20° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint. From November 2012 through June 2013, we treated 86 consecutive patients (92 hands, 126 fingers). A hand therapist measured joint contracture before, 5 weeks, and 3 years after injection. The patients rated their treatment satisfaction. Primary outcome was proportion of treated joints with ≥ 20° AED worsening between the 5-week and 3-year measurements. We analyzed predictors of recurrence.Results - 3-year outcomes were available for 83 of the 86 patients (89 hands, 120 treated fingers). Between the 5-week and 3-year measurements, AED worsened by ≥ 20° in 17 MCP (14%) and 28 PIP (23%) joints. At 3 years, complete correction (passive extension deficit 0-5°) was present in 73% of MCP and 35% of PIP joints. Treatment of small finger PIP joint contracture, greater pretreatment contracture severity, and previous fasciectomy on the treated finger were statistically significant predictors of recurrence. Treatment satisfaction was rated as very satisfied or satisfied in 59 of 87 hands. No long-term treatment-related adverse events were observed.Interpretation - 3 years after collagenase injections for Dupuytren disease, improvement was maintained and treatment satisfaction reported in two-thirds of the treated hands, with no adverse events. Complete contracture correction was achieved in 3 of 4 MCP joints, but in only a third of the PIP joints.

Examiners' influence on the measured active and passive extension deficit in finger joints affected by Dupuytren disease.

BACKGROUND: The most commonly reported outcome measure in Dupuytren disease is the extension deficit in finger joints. This study aimed to investigate the examiners' influence on the measured difference between active and passive extension deficit. METHODS: A prospective cohort study was conducted on 157 consecutive patients (81% men, mean age 70 years) scheduled for collagenase treatment for Dupuytren disease. Before injection, one of three experienced hand therapists measured active extension deficit (AED) and passive extension deficit (PED) in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the affected fingers using a hand-held metal goniometer. We included joints with ≥10° AED, and calculated mean AED and PED in MCP and PIP joints measured by each examiner. For adjusted analysis we used a mixed effects model to determine the relationship between the examiner and the AED-PED difference. RESULTS: For all 291 joints measured, mean AED was 46° (SD 21) and mean PED was 37° (SD 23). Mean difference between AED and PED measured by examiner 1 was 6° (SD 6), by examiner 2 was 9° (SD 9), and by examiner 3 was 12° (SD 9). The mixed effects model analysis showed that the identity of the examining therapist was a significant determinant of the AED-PED difference. CONCLUSIONS: In Dupuytren disease measurement of active and passive extension deficit in finger joint contractures may vary significantly between different examiners. This must be taken into consideration when designing clinical studies and comparing outcomes between studies.

Sick Leave After Surgery for Thumb Carpometacarpal Osteoarthritis: A Population-Based Study.

PURPOSE: Patients undergoing surgery for thumb carpometacarpal (CMC1) osteoarthritis often require sick leave owing to postoperative immobilization, pain, and decreased function. Our goal was to evaluate the amount of sick leave after surgery for 2 common CMC1 arthroplasty procedures. METHODS: Using registry data from the Skåne region of southern Sweden, cross-linked with employment data showing person-specific sick leave, 2 cohorts of CMC1 surgical patients, between ages 40 and 59 years, were examined. These comprised all persons undergoing soft tissue arthroplasty and prosthetic implant arthroplasty from 2004 to 2012 identified using International Classification of Diseases, 10th Revision, and surgical codes. These subjects were analyzed against an age- and sex-matched reference population cohort. RESULTS: Surgical cohorts of 326 and 169 subjects undergoing soft tissue and prosthetic CMC1 arthroplasty, respectively, were compared with reference populations of 1,110 and 574 persons. Surgical subjects had a pronounced increase in sick leave in the first 2 months after surgery, followed by diminishing days of leave over time. Mean sick leave time after soft tissue arthroplasty was 202 days in women and 170 days in men. Following prosthetic arthroplasty, mean sick leave was 177 days in women and 188 in men. When we excluded those with documented sick leave in the month before surgery (owing to preoperative CMC1 disability or other medical issues), the mean postoperative sick leave decreased to 137 days in women and 125 days in men after soft tissue arthroplasty compared with 109 and 94 days in women and men after prosthetic implant arthroplasty, and this difference was significant. There were no differences in the length of sick leave between sexes and no correlation with age. CONCLUSIONS: Soft tissue arthroplasty and implant arthroplasty for patients with CMC1 osteoarthritis are both associated with substantial sick leave time, indicating the impact of surgery on return to work. There were no differences in sick leave by sex or age. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The Spanish version of the Patient-Rated Wrist Evaluation outcome measure: cross-cultural adaptation process, reliability, measurement error and construct validity.

BACKGROUND: The Patient-Rated Wrist Evaluation (PRWE) is a widely used measure of patient-reported disability and pain related to wrist disorders. We performed cross-cultural adaptation of the PRWE into Spanish (Spain) and assessed reliability and construct validity in patients with distal radius fracture. METHODS: Adaptation of the English version to Spanish (Spain) was performed using translation/back translation methodology. The measurement properties of the PRWE-Spanish were assessed in a sample of 40 consecutive patients (31 women), mean age 58 (SD 19) years, with extra-articular distal radius fractures treated with closed reduction and cast. The patients completed the PRWE-Spanish and the standard Spanish versions of the 11-item Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EQ-5D questionnaires at baseline (health status before fracture) and at 8, 9, 12, and 13 weeks after treatment. Internal-consistency reliability was assessed with the Cronbach alpha coefficient and test-retest reliability with the intraclass correlation coefficient (ICC) comparing responses at 8 and 9 weeks and responses at 12 and 13 weeks. Cross-sectional precision was analyzed with the Standard Error of the Measurement (SEM). Longitudinal precision for test-retest reliability coefficient was analyzed with the Standard Error of the Measurement difference (SEMdiff) and the Minimal Detectable Change at 90% (MDC90) and 95% (MDC95) confidence levels. For assessing construct validity we hypothesized that the PRWE-Spanish (lower score indicates less disability and pain) would have strong positive correlation with the QuickDASH (lower score indicates less disability) and moderate negative correlation with the EQ-5D Index (higher score indicates better health); Spearman correlation coefficient (r) was used. RESULTS: For the PRWE total score, Cronbach alpha was 0.98 (SEM = 2.67) at baseline and 0.96 (SEM = 4.37) at 8 weeks. For test-retest reliability ICC was 0.94 (8 and 9 weeks) and 0.96 (12 and 13 weeks) with SEMdiff 7.61 and 6.18 and MDC95 13.74 and 12.11, respectively. The PRWE-Spanish scores had strong positive correlation with the QuickDASH scores at baseline (r = 0.71) and at 8 weeks (r = 0.79) and moderate negative correlation with the EQ-5D Index (r = -0.44 and r = -0.40, respectively). CONCLUSIONS: The PRWE-Spanish showed high internal-consistency and test-retest reliability and good construct validity in patients with distal radius fracture.

Reliability and construct validity of the Spanish version of the 6-item CTS symptoms scale for outcomes assessment in carpal tunnel syndrome.

BACKGROUND: The purpose of this study was to assess the reliability and construct validity of the Spanish version of the 6-item carpal tunnel syndrome (CTS) symptoms scale (CTS-6). METHODS: In this cross-sectional study 40 patients diagnosed with CTS based on clinical and neurophysiologic criteria, completed the standard Spanish versions of the CTS-6 and the disabilities of the arm, shoulder and hand (QuickDASH) scales on two occasions with a 1-week interval. Internal-consistency reliability was assessed with the Cronbach alpha coefficient and test-retest reliability with the intraclass correlation coefficient, two way random effect model and absolute agreement definition (ICC2,1). Cross-sectional precision was analyzed with the Standard Error of the Measurement (SEM). Longitudinal precision for test-retest reliability coefficient was assessed with the Standard Error of the Measurement difference (SEMdiff) and the Minimal Detectable Change at 95 % confidence level (MDC95). For assessing construct validity it was hypothesized that the CTS-6 would have a strong positive correlation with the QuickDASH, analyzed with the Pearson correlation coefficient (r). RESULTS: The standard Spanish version of the CTS-6 presented a Cronbach alpha of 0.81 with a SEM of 0.3. Test-retest reliability showed an ICC of 0.85 with a SRMdiff of 0.36 and a MDC95 of 0.7. The correlation between CTS-6 and the QuickDASH was concordant with the a priori formulated construct hypothesis (r 0.69) CONCLUSIONS: The standard Spanish version of the 6-item CTS symptoms scale showed good internal consistency, test-retest reliability and construct validity for outcomes assessment in CTS. The CTS-6 will be useful to clinicians and researchers in Spanish speaking parts of the world. The use of standardized outcome measures across countries also will facilitate comparison of research results in carpal tunnel syndrome.

Cast-treated distal radius fractures: a prospective cohort study of radiological outcomes and their association with impaired calcaneal bone mineral density.

INTRODUCTION: We hypothesized that treating distal radius fractures with cast only or closed reduction and cast is associated with high malunion risk and that the risk is higher in patients with low bone mineral density (BMD). MATERIALS AND METHODS: We prospectively studied 130 patients aged 40 years or older with distal radius fractures treated with cast only (87 patients) or closed reduction and cast (43 patients). Radiographs were obtained before treatment, after reduction (in the closed reduction group), and at 1 year. We measured calcaneal BMD with DXA scanner and calculated T scores. We calculated radiological changes from baseline (initial radiographs in cast only and post-reduction radiographs in closed reduction patients) to 1 year. We assessed the relationship between BMD status (normal, osteopenia or osteoporosis) and baseline-to-1-year worsening in volar tilt, ulnar variance, and radial inclination with analysis of covariance adjusting for baseline radiological values. We used receiver operating characteristic (ROC) analysis to determine the ability of T scores to distinguish patients with severe malunion (dorsal tilt >25° and/or ulnar variance ≥5 mm) from those with less severe or no malunion. RESULTS: In both treatment groups, baseline radiological variables had deteriorated at 1 year, more in the closed reduction group. Compared to patients with normal BMD, those with osteoporosis had significantly greater worsening in volar tilt and radial inclination but did not differ in ulnar variance worsening. Severe malunion was found in 34 fractures (26 %, 15 in cast only group); T scores had a modest ability in distinguishing severe malunion (area under ROC curve 0.67, 95 % CI 0.56-0.78, p = 0.003). CONCLUSIONS: Closed reduction and cast is not an effective treatment for distal radius fractures if radiological graphic outcomes are considered. There is a higher risk of malunion involving dorsal and radial tilt in patients with osteoporosis. Calcaneal BMD measurement may have some benefit in predicting the risk of severe malunion.

Collagenase treatment of Dupuytren's contracture using a modified injection method: a prospective cohort study of skin tears in 164 hands, including short-term outcome.

BACKGROUND AND PURPOSE: Treatment of Dupuytren's contracture (DC) with collagenase Clostridium histolyticum (CCH) consists of injection followed by finger manipulation. We used a modified method, injecting a higher dose than recommended on the label into several parts of the cord, which allows treatment of multiple joint contractures in 1 session and may increase efficacy. We studied the occurrence of skin tears and short-term outcome with this procedure. PATIENTS AND METHODS: We studied 164 consecutive hands with DC, palpable cord, and extension deficit of ≥ 20º in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint (mean patient age 70 years, 82% men). A hand surgeon injected all the content of 1 CCH vial (approximately 0.80 mg) into multiple spots in the cord and performed finger extension under local anesthesia after 1 or 2 days. A nurse recorded skin tears on a diagram and conducted a standard telephone follow-up within 4 weeks. A hand therapist measured joint contracture before injection and at a median of 23 (IQR: 7-34) days after finger extension. RESULTS: A skin tear occurred in 66 hands (40%). The largest diameter of the tear was ≤ 5 mm in 30 hands and > 10 mm in 14 hands. Hands with skin tear had greater mean pretreatment MCP extension deficit than those without tear: 59º (SD 26) as opposed to 32º (SD 23). Skin tear occurred in 21 of 24 hands with MCP contracture of ≥ 75º. All tears healed with open-wound treatment. No infections occurred. Mean improvement in total (MCP + PIP) extension deficit was 55º (SD 28). INTERPRETATION: Skin tears occurred in 40% of hands treated with collagenase injections, but only a fifth of them were larger than 1 cm. Tears were more likely in hands with severe MCP joint contracture. All tears healed without complications. Short-term contracture reduction was good.

Intervention randomized controlled trials involving wrist and shoulder arthroscopy: a systematic review.

BACKGROUND: Although arthroscopy of upper extremity joints was initially a diagnostic tool, it is increasingly used for therapeutic interventions. Randomized controlled trials (RCTs) are considered the gold standard for assessing treatment efficacy. We aimed to review the literature for intervention RCTs involving wrist and shoulder arthroscopy. METHODS: We performed a systematic review for RCTs in which at least one arm was an intervention performed through wrist arthroscopy or shoulder arthroscopy. PubMed and Cochrane Library databases were searched up to December 2012. Two researchers reviewed each article and recorded the condition treated, randomization method, number of randomized participants, time of randomization, outcomes measures, blinding, and description of dropouts and withdrawals. We used the modified Jadad scale that considers the randomization method, blinding, and dropouts/withdrawals; score 0 (lowest quality) to 5 (highest quality). The scores for the wrist and shoulder RCTs were compared with the Mann-Whitney test. RESULTS: The first references to both wrist and shoulder arthroscopy appeared in the late 1970s. The search found 4 wrist arthroscopy intervention RCTs (Kienböck's disease, dorsal wrist ganglia, volar wrist ganglia, and distal radius fracture; first 3 compared arthroscopic with open surgery). The median number of participants was 45. The search found 50 shoulder arthroscopy intervention RCTs (rotator cuff tears 22, instability 14, impingement 9, and other conditions 5). Of these, 31 compared different arthroscopic treatments, 12 compared arthroscopic with open treatment, and 7 compared arthroscopic with nonoperative treatment. The median number of participants was 60. The median modified Jadad score for the wrist RCTs was 0.5 (range 0-1) and for the shoulder RCTs 3.0 (range 0-5) (p = 0.012). CONCLUSION: Despite the increasing use of wrist arthroscopy in the treatment of various wrist disorders the efficacy of arthroscopically performed wrist interventions has been studied in only 4 randomized studies compared to 50 randomized studies of significantly higher quality assessing interventions performed through shoulder arthroscopy.

Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial.

BACKGROUND: Steroid injections are used in idiopathic carpal tunnel syndrome (CTS), but evidence of efficacy beyond 1 month is lacking. OBJECTIVE: To assess the efficacy of local methylprednisolone injections in CTS. DESIGN: Randomized, placebo-controlled trial. (ClinicalTrials.gov: NCT00806871). SETTING: Regional referral orthopedic department in Sweden. PATIENTS: Patients aged 18 to 70 years with CTS but no previous steroid injections. INTERVENTION: Three groups (37 patients each) received 80 mg of methylprednisolone, 40 mg of methylprednisolone, or placebo. The patients and treating surgeons were blinded. MEASUREMENTS: Primary end points were the change in CTS symptom severity scores at 10 weeks (range, 1 to 5) and rate of surgery at 1 year. Three patients had missing 10-week data. All patients had 1-year data. RESULTS: Improvement in CTS symptom severity scores at 10 weeks was greater in patients who received 80 mg of methylprednisolone and 40 mg of methylprednisolone than in those who received placebo (difference in change from baseline, -0.64 [95% CI, -1.06 to -0.21; P = 0.003] and -0.88 [CI, -1.30 to -0.46; P < 0.001], respectively), but there were no significant differences at 1 year. The 1-year rates of surgery were 73%, 81%, and 92% in the 80-mg methylprednisolone, 40-mg methylprednisolone, and placebo groups, respectively. Compared with patients who received placebo, those who received 80 mg of methylprednisolone were less likely to have surgery (odds ratio, 0.24 [CI, 0.06 to 0.95]; P = 0.042). With time to surgery incorporated, both the 80- and 40-mg methylprednisolone groups had lower likelihood of surgery (hazard ratio, 0.46 [CI, 0.27 to 0.77; P = 0.003] and 0.57 [CI, 0.35 to 0.94; P = 0.026], respectively). LIMITATION: The study was conducted at 1 center, and wrist splinting had previously failed for all patients. CONCLUSION: Methylprednisolone injections for CTS have significant benefits in relieving symptoms at 10 weeks and reducing the rate of surgery 1 year after treatment, but 3 out of 4 patients had surgery within 1 year. PRIMARY FUNDING SOURCE: Region of Scania Research and Development Foundation and Hässleholm Hospital Organization.

A simple visual analog scale for pain is as responsive as the WOMAC, the SF-36, and the EQ-5D in measuring outcomes of revision hip arthroplasty.

BACKGROUND AND PURPOSE: Little is known about the comparative performance of patient-reported outcome measures in revision hip arthroplasty. We compared the performance of the WOMAC, the SF-36, the EQ-5D, and a pain-related visual analog scale (VAS) in revision hip arthroplasty. METHODS: 45 patients with aseptic prosthetic loosening following primary hip arthroplasty completed the WOMAC, the SF-36, the EQ-5D, and a VAS for pain-at baseline and 2 years after revision. Responsiveness of the measures was compared with the effect size (with ≥ 0.8 being considered large). Agreement between scales measuring the same type of outcome (pain or physical function) was assessed with the Bland-Altman method. RESULTS: The mean preoperative scores for the pain and physical function scales of WOMAC and SF-36, EQ-5D index, and VAS for pain improved statistically significantly 2 years after revision. The effect size for the WOMAC pain was 1.7, that for SF-36 pain was 1.4, that for WOMAC physical function was 1.6, that for SF-36 physical function was 0.8, and that for EQ-5D index was 1.2. The VAS for pain had an effect size of 2.1, which was larger than that for SF-36 pain and for the EQ-5D index (p ≤ 0.03) but not for WOMAC pain (p = 0.2). The limits of agreement between WOMAC pain, SF-36 pain, and the VAS scale measuring pain-and between the WOMAC and SF-36 scales measuring physical function-were wide. Internal-consistency reliability was high for the WOMAC and SF-36 scales but low for the EQ-5D. INTERPRETATION: In patients with first-time revision hip arthroplasty done for aseptic loosening, the WOMAC, SF-36, and EQ-5D showed high responsiveness in measuring patient-reported outcomes and the simple VAS for pain performed equally well.

Bias in published randomized trials that compare collagenase injection with percutaneous needle fasciotomy in the treatment of Dupuytren disease: a systematic review.

Purpose: Controversy exists regarding the comparative efficacy of collagenase injection and percutaneous needle fasciotomy in the treatment of Dupuytren contracture. The randomized controlled trials (RCTs) that have compared the two treatment methods have reported results mostly implying similar treatment efficacy, durability, and complications. We aimed to review these RCTs regarding methodical quality and risk of bias. Methods: We searched PubMed and Cochrane Library databases up to May 2023. All RCTs comparing collagenase injection with needle fasciotomy were included. Eligible articles were reviewed by two researchers, of whom one was blinded to each article's title, authors, year of publication, journal, and source of the studies. To assess methodical quality, we used the modified Jadad scale yielding a score of 0 (lowest quality) to 5 (highest quality). We assessed risk of bias with the Cochrane risk-of-bias tool (RoB 2). Results: Five studies were eligible, comprising 204 patients treated with collagenase injection and 209 patients treated with needle fasciotomy. The modified Jadad score ranged from 1 to 2 points in the five studies, and the overall risk of bias was high in all studies. Pretrial protocols could be retrieved for only two studies, revealing important discrepancies with the published articles. Conclusion: The published RCTs that have compared collagenase injection with needle fasciotomy in the treatment of Dupuytren contracture demonstrate a high risk of bias.

Distal radius malunion increases risk of persistent disability 2 years after fracture: a prospective cohort study.

BACKGROUND: Studies concerning the relationship between distal radius fracture malunion and a persistent arm-related disability have produced conflicting results. QUESTIONS/PURPOSES: We investigated (1) how arm-related disability changes during the first 2 years after a fracture and (2) whether fracture malunion causes persistent disability. METHODS: One hundred twenty-three patients with distal radius fractures, treated with closed reduction and casts or external or percutaneous pin fixations, completed the DASH questionnaire at baseline, 3 months, 6 months, 1 year, and 2 years after fracture. Radiographic measurements were made at 1 year. Using a definition of malunion as ulnar variance of 1 mm or more and dorsal tilt greater than 10°, the patients were classified into three groups: no malunion (n = 35), malunion involving either ulnar variance or dorsal tilt (n = 65), and malunion involving ulnar variance and dorsal tilt (n = 23). The changes in the DASH scores with time (baseline to 2 years), in relation to malunion, were analyzed using generalized estimating equations adjusted for age, sex, fracture type (extraarticular or intraarticular), and treatment method. RESULTS: The mean change in DASH scores from baseline to 2 years was worse for patients with malunions involving ulnar variance and dorsal tilt than for patients with no malunions (mean difference, 13; 95% CI, 1.4-25) and for patients with malunions involving either ulnar variance or dorsal tilt (mean difference, 13; 95% CI, 2.2-24). CONCLUSION: After distal radius fracture, arm-related disabilities are more likely to persist at least 2 years in patients with fractures that healed with shortening and dorsal angulation than in patients with only shortening or dorsal angulation or without malunion.