In Vivo Comparison of MONOFIX, A Novel Barbed Suture with a Triangular Stopper, with Pre-existing Products in a Porcine Model.

STUDY OBJECTIVE: MONOFIX, a new absorbable barbed suture device, has a triangular stopper at the end to hold the suture to the tissue without hooking the looped end or knotting. The aim of this study was to compare the biomechanical strength and histologic features of MONOFIX with other barbed suture devices using a porcine model. DESIGN: Well-designed, controlled trial without randomization. SETTING: Animal laboratory in university hospital. SUBJECTS: Sixteen, 60-kg, mature female domestic pigs (skin closure group) and 5, 60-kg, mature female domestic pigs (fascial closure group). INTERVENTIONS: In the skin closure group, 3-0 MONOFIX versus 2 widely used 3-0 absorbable barbed sutures (3-0 V-Loc 180 or Stratafix). In the fascial closure group, 2-0 MONOFIX versus 1 widely used 2-0 absorbable barbed sutures (2-0 Stratafix). MEASUREMENTS AND MAIN RESULTS: In the skin closure group, the biomechanical wound strength of skin sutured with size 3-0 MONOFIX, V-Loc 180, or Stratafix was evaluated by postoperative day assessment (days 0, 3, 7, 14, and 28). In the fascial closure group, pigs underwent 2 paramedian incisions and were sutured with 2-0 MONOFIX or with 2-0 Stratafix to evaluate histologic reaction. At 6 weeks the tissues around the suture line were excised and microscopically evaluated. The biomechanical strength of the MONOFIX had similar tissue tensile strength compared with the control, regardless of postoperative day. In the fascial closure model, there was no significant difference in the average tissue reaction score between MONOFIX and Stratafix (1.2 ± .3 vs 1.3 ± .3, p = .478). CONCLUSION: This study demonstrated that MONOFIX has equivalent tensile strength and histologic reaction when compared with commonly used barbed suture devices. Accordingly, this preclinical study suggests that the use of MONOFIX is a safe alternative to other barbed suture devices.

Comparison of Metzenbaum scissors and Y-shaped fasciotome for deep metatarsal fasciotomy for the treatment of proximal suspensory ligament desmopathy in horses.

OBJECTIVE: To quantitate the iatrogenic injury associated with deep plantar metatarsal fasciotomy performed with Metzenbaum scissors compared with a Y-shaped fasciotome. STUDY DESIGN: Experimental ex vivo surgical study. STUDY POPULATION: Cadaveric hind limbs (n = 20) from 10 sound thoroughbred racehorses. METHODS: A plantar metatarsal fasciotomy was performed, extending from the proximal extent of the deep metatarsal fascia, distally. Hind limbs were randomly assigned to 2 groups, undergoing fasciotomy with straight Metzenbaum scissors (n = 10) or a Y-shaped fasciotome (n = 10). Magnetic resonance imaging was performed before and after surgery to identify the maximal depth of any iatrogenic trauma. Gross examination of the surgical site included measuring the length of the incision in the deep metatarsal fascia and localizing iatrogenic trauma sustained by the plantar aspect of the proximal suspensory ligament (PSL) during the procedure. RESULTS: Iatrogenic injury to the PSL was identified in 6 of 10 and 9 of 10 specimens prepared with the fasciotome and Metzenbaum scissors, respectively (P = .03), and was most commonly located in the distal third of the fascial incision. Differences between the length of incision (P = .02) and the maximal depth of signal (P = .03) for incisions created with Metzenbaum scissors or a fasciotome were identified. CONCLUSION: The use of a fasciotome resulted in longer fascial incisions and less severe iatrogenic trauma to the PSL compared with using Metzenbaum scissors. CLINICAL SIGNIFICANCE: A Y-shaped fasciotome may be the preferred surgical instrument for successful desmopathy of the PSL fasciotomy because a greater release of compartmental pressure is possible through a longer incision with minimal iatrogenic trauma to the underlying PSL.

Percutaneous Plantar Fascia Release With Needle: Anatomic Evaluation with Cadaveric Specimens.

Percutaneous plantar fascia release with needle is a novel procedure for the treatment of plantar fasciitis. The objective of this cadaveric study is to perform an anatomic evaluation of the percutaneous plantar fascia release method using a conventional hypodermic needle. In this study, we used 14 fresh-frozen cadaveric trans-tibial amputation specimens. Percutaneous plantar fasciotomy with a conventional hypodermic needle was performed. After a proper dissection, the width of the plantar fascia, the thickness of the medial border, and the width of the cut segment were measured and recorded. Any muscle damage on the flexor digitorum brevis and damaged area depth were recorded. Any damage on the lateral plantar nerve and the first branch of the lateral plantar nerve, also known as Baxter's nerve, and their distance to fasciotomy were also recorded. Mean width (± standard deviation) of the plantar fascia was measured as 20.34 ± 4.25 mm. The mean thickness of the medial border of the plantar fascia was 3.04 ± 0.54 mm. Partial fasciotomy was performed in all cadavers with 49.47% ± 7.25% relative width of the plantar fascia. No lateral plantar nerve, or its first branch Baxter's nerve, was damaged, and the mean distance from the deepest point of the fasciotomy up to the Baxter's nerve was 8.62 ± 2.62 mm. This cadaveric study demonstrated that partial plantar fasciotomy can be achieved via percutaneous plantar fascia release with a conventional hypodermic needle without any nerve damage.

[Percutaneous needle aponeurotomy for Dupuytren's contracture]. / Perkutane Nadelaponeurotomie bei Dupuytren-Kontraktur.

Dupuytren disease is a benign fibroproliferative disease of the palmar aponeurosis, which can cause considerable functional deficiencies for the person concerned. Partial aponeurectomy is the gold standard in primary surgery. Because it is minimally invasive and has short recovery and low complication rates, the importance of needle aponeurotomy under specific indications has been increasing in the last years. Needle aponeurotomy is a cost-effective treatment with low complication rates. The revision rate compared to partial aponeurectomy is higher. Under consideration of specified indications, needle aponeurotomy is an alternative treatment option.

Paper Clip Localization: Easy Technique for Verification of Portal Placement for Endoscopic Plantar Fasciotomy Procedures.

Surgeons are always searching for useful methods that enhance surgical accuracy. In the case of endoscopic plantar fasciotomy, identifying the optimal location for insertion of the endoscope for precise sectioning of the desired portion of the plantar fascia, without increasing the risk of injury to adjacent anatomic structures and without complicating the surgery in terms of time or costs, would be beneficial to patients and surgeons alike. In the present techniques report, a simple method for accurately determining the optimal location for placement of the endoscope for execution of plantar fasciotomy is described.

Lateral Fasciectomy Sparing the Superficial Peroneal Nerve with Simultaneous Mesh Graft in Non-healing Lateral Leg Ulcers of Diverse Vascular Origins: Surgical Technique, Short- and Long-term Results from 44 Legs.

OBJECTIVES: The technique of lateral fasciectomy (LF) sparing the superficial peroneal nerve with mesh graft coverage is a novel treatment of non-healing lateral leg ulcers of various vascular origin affecting the fascia. We report short- and long-term results of LF for recalcitrant lateral leg ulcers. DESIGN: This study is a single center, retrospective case series of consecutive patients treated by LF. MATERIALS: From 827 ulcers treated at our institution, 44 recalcitrant lateral leg ulcers affecting the fascia (41 patients) underwent lateral fasciectomy between 2006 and 2013. METHODS: Preoperative indications, step-by-step surgical procedures, and perioperative care methodologies are presented. Long-term effects of healing and recurrence were clinically investigated or obtained through telephone interviews with relatives and local practitioners. RESULTS: Three discrete etiologies were identified: venous ulcers (n = 24), arterial-venous/mixed ulcers (n = 11), and arteriolar Martorell hypertensive leg ulcers (n = 9). Complete healing was achieved in 40 legs (91%) after 3 months, and in 43 of the affected legs (98%) in total. The median duration to complete healing was 64 days. There was no difference between the healing times of different etiologies. No local recurrence was observed during the follow-up period, which ranged from 1.8 to 8.7 years (median: 5.11, mean: 5.12). Twelve patients (27%) died within this period due to multimorbidity. CONCLUSIONS: Following lateral fasciectomy and mesh graft coverage, 43 legs (98%) healed in previously treatment resistant lateral leg ulcers.

Comparison of Treatment Outcome After Collagenase and Needle Fasciotomy for Dupuytren Contracture: A Randomized, Single-Blinded, Clinical Trial With a 1-Year Follow-Up.

PURPOSE: This study compared the efficacy of collagenase treatment and needle fasciotomy for contracture of the metacarpophalangeal (MCP) joint in Dupuytren disease. METHODS: This is a prospective, single-blinded, randomized study with follow-up 1 week and 1 year after treatment. One hundred and forty patients with an MCP contracture of 20° or more in a single finger were enrolled, of whom 69 patients were randomized to collagenase treatment and 71 patients to needle fasciotomy. The patients were followed at 1 week and were examined by a physiotherapist after 1 year. Measurements of joint movement and grip strength were recorded as well as patient-perceived outcomes measured by the Unité Rhumatologique des Affections de la Main (URAM) questionnaire and a visual analog scale (VAS) for the estimation of procedural pain and subjective treatment efficacy. RESULTS: Eighty-eight percent of the patients in the collagenase group and 90% of the patients in the needle fasciotomy group had a reduction in their MCP contracture to less than 5° 1 week after treatment, and the median gains in passive MCP movement were 48° and 46°, respectively. The median VAS score for procedural pain was 4.9 of 10 in the collagenase group and 2.7 of 10 in the needle fasciotomy group. After 1 year, 90% of the patients in both groups had full extension of the treated MCP joint. One patient in each group had a recurrence of the contracture. The median improvement in URAM score was 8 units in both groups and the VAS estimation of treatment efficacy by the patients was 8.7 of 10 in both groups. CONCLUSIONS: There was no significant difference between the treatment outcomes after collagenase and needle fasciotomy treatment after 1 year. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Patients' perspectives of collagenase injection or needle fasciotomy and rehabilitation for Dupuytren disease, including hand function and occupational performance.

PURPOSE: To describe patients' perspectives of collagenase injection or needle fasciotomy for Dupuytren disease (DD) including hand therapy, and their view of hand function and occupational performance. MATERIALS AND METHODS: Interviews were performed with twelve patients who had undergone non-surgical treatment and rehabilitation for DD. Data was analysed using a problem-driven content analysis using the model of Patient Evaluation Process as a theoretical framework. RESULTS: The participants' previous experiences influenced their expectations of the upcoming treatment and they needed information to be prepared for treatment. Treatment and rehabilitation had a positive impact on daily life and were regarded as effective and simple with quick recovery. However, there could be remaining issues with tenderness or stiffness. The participants expressed their belief in rehabilitation and how their own efforts could contribute to an improved result. Despite concerns about future recurrence participants described increased knowledge and sense of control regarding future needs. CONCLUSION: Undergoing a non-surgical treatment and rehabilitation process for DD was regarded as quick and easy and can meet the need for improved hand function and occupational performance. Taking responsibility for one's own rehabilitation was considered to influence the outcome positively. The theoretical framework optimally supported the exploration of participants' perspective.Implications for rehabilitationTreatment of Dupuytren Disease (DD) with needle/collagenase combined with hand therapy was experienced as giving fast improvement in hand function and occupational performance.An individualized care process which satisfies the need for knowledge about the disease, prognosis, treatment options and rehabilitation can give individuals suffering from DD a sense of security.The need for active participation in the DD care process can vary and it is crucial to listen to individuals' opinions and needs.Individuals can take considerable responsibility for rehabilitation after non-surgical treatment for DD and regard it as important for the outcome.

A Wearable Augmented Reality Navigation System for Surgical Telementoring Based on Microsoft HoloLens.

This paper reports a new type of augmented reality (AR) system that integrates a Microsoft HoloLens device with a three-dimensional (3D) point tracking module for medical training and telementored surgery. In this system, a stereo camera is used to track the 3D position of a scalpel and transfer its coordinates wirelessly to a HoloLens device. In the scenario of surgical training, a virtual surgical scene with pre-recorded surgical annotations is superimposed with the actual surgical scene so that the surgical trainee is able to operate following virtual instructions. In the scenario of telementored surgery, the virtual surgical scene is co-registered with the actual surgical scene so that the virtual scalpel remotely mentored by an experienced surgeon provides the AR guidance for the inexperienced on-site operator. The performance characteristics of the proposed AR telementoring system are verified by benchtop experiments. The clinical applicability of the proposed system in telementored skin grafting surgery and fasciotomy is validated in a New Zealand rabbit model. Our benchtop and in vivo experiments demonstrate the potential to improve surgical performance and reduce healthcare disparities in remote areas with limited resources.

Return to Work and Associated Costs after Treatment for Dupuytren's Disease.

BACKGROUND: Return to work is potentially an important factor in assessing the success of treatment. However, little is known about the return to work after treatment for Dupuytren's contracture. Therefore, the primary aim of this study was to assess return to work after limited fasciectomy and percutaneous needle fasciotomy. METHODS: Patients who underwent either a limited fasciectomy or percutaneous needle fasciotomy were invited to complete a return-to-work questionnaire at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Median time to return to work was assessed using inverted Kaplan-Meier curves, and hazard ratios were calculated with Cox regression models. Finally, a cost analysis was carried out using the human capital method to determine indirect costs associated with loss of productivity. RESULTS: The authors included 2698 patients in the study, of which 53 percent were employed at intake and included in the follow-up. After 1 year of follow-up, 90 percent of the patients had returned to work. Median time to return to work was 2 weeks after limited fasciectomy and within days after percutaneous needle fasciotomy. Furthermore, physically strenuous work, female sex, and higher age were associated with a longer time to return to work. Lost productivity per patient was estimated at €2614.43. CONCLUSIONS: The majority of patients returned to work after treatment for Dupuytren's disease. Return to work is much faster after percutaneous needle fasciotomy compared to limited fasciectomy. These findings can be used for more evidence-based preoperative counseling with patients with Dupuytren's disease.

Clinical Outcomes of Percutaneous Plantar Fasciotomy Using Microdebrider Coblation Wand.

BACKGROUND: Plantar fasciitis is the most common cause of heel pain in adults. Multiple conservative treatment plans exist; however, some cases do not obtain significant clinical improvement with conservative treatment and require further intervention. This retrospective case study evaluated the success rate of percutaneous plantar fasciotomy and confounding comorbidities that negatively affect outcomes. METHODS: A series of 41 patients treated with percutaneous plantar fasciotomy using the Topaz EZ microdebrider coblation wand were invited to participate in this retrospective follow-up study, and 88% (N = 36) participated. A limited chart review was completed and the patients answered a survey with the visual analog scale (VAS) for pain and the Foot and Ankle Ability Measure (FAAM) questionnaire. Average outcomes were calculated and 45 variables were analyzed to determine if they were statistically significant confounders. Patients had symptoms for an average of 3 years before the procedure and were contacted for follow-up at an average of 14 months after the procedure. RESULTS: The average VAS for pain score was 1.3 ± 1.8 and the average FAAM score was 92 ± 15. Eighty-nine percent of patients had a successful outcome, defined as FAAM greater than 75. In addition, patients at 18 months postprocedure reported complete or near-complete resolution of symptoms with an FAAM score greater than 97. Concurrent foot pathologies (eg, tarsal tunnel syndrome), oral steroid treatment prior to the procedure, and immobilization with a boot prior to the procedure were statistically significant negative confounders (P < .05). Being an athlete was a positive confounder (P = .02). CONCLUSION: Percutaneous plantar fasciotomy using a microdebrider coblation was an effective treatment for plantar fasciitis, particularly without concurrent foot pathology, with a low risk of complications. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Comparison of Treatment Outcomes after Collagenase Injection and Percutaneous Needle Fasciotomy for Dupuytren's Contracture: Objective and Subjective Comparisons with a 3-Year Follow-Up.

BACKGROUND: This study compared the effectiveness of injectable collagenase clostridium histolyticum and percutaneous needle fasciotomy in the treatment of Dupuytren's contracture. METHODS: Patients with a total passive extension deficit of 30 degrees or more in a single digital ray were enrolled and assigned randomly to receive either collagenase clostridium histolyticum injections or percutaneous needle fasciotomy. Preoperative severity of proximal interphalangeal joint contracture for Dupuytren's disease was classified according to the British Society for Surgery of the Hand as less than 30 degrees (stage I) or 30 degrees or more (stage II). RESULTS: Of the 70 patients enrolled, 36 patients with 46 joints received collagenase clostridium histolyticum injections and 34 patients with 48 joints received percutaneous needle fasciotomy. At day 30, successful corrections were obtained in only 50 percent of the injection group and 67 percent of the fasciotomy group for stage II proximal interphalangeal joints. Recurrences were frequent among patients with stage II joint contractures. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score at day 30 was significantly higher in the injection group compared with the fasciotomy group (7.5 versus 4.2, respectively). In the injection group, adverse events were reported for all patients. In the fasciotomy group, complications were reported for 15 percent of patients. CONCLUSIONS: The collagenase clostridium histolyticum and percutaneous needle fasciotomy groups had similar outcomes for Dupuytren's contracture with 3 years' follow-up. Recurrences were frequent among patients with stage II proximal interphalangeal joint contractures. The Unité Rhumatologique des Affections de la Main scale and Quick Disabilities of the Arm, Shoulder and Hand questionnaire score decreased significantly for both groups at final follow-up. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Dermoid Inclusion Cyst Following Percutaneous Needle Fasciotomy: A Novel Complication.

We present the case of a fit and well 62-year-old male with Dupuytren's disease in the right hand who underwent percutaneous needle fasciotomy (PNF) for a moderate flexion contracture of the right little finger. 18 months later he developed a pain-free soft tissue swelling at the distal previous needling site. A fasciectomy procedure identified a cyst within the pre-tendinous cord, which was confirmed as a dermoid inclusion cyst on histological analysis. Dermoid inclusion cysts may occur in the hands at the site of penetrating trauma but we are unaware of any report of an inclusion cyst at the site of PNF surgery. We present this unique case of a dermoid inclusion cyst following percutaneous needle fasciotomy as a novel complication.

Percutaneous needle aponeurotomy for the treatment of Dupuytren's contracture.

OBJECTIVES: This study aims to present the early-period outcomes of patients with Dupuytren's contracture (DC) treated with percutaneous needle aponeurotomy technique. PATIENTS AND METHODS: This retrospective study included 28 patients (20 males, 8 females; mean age 63 years; range, 44 to 88 years) (75 fingers) treated with percutaneous aponeurotomy due to DC between November 2011 and December 2015. Patients were evaluated according to their demographic characteristics, presence of additional disease, family history, history of drug use, complication rate, recurrence development, postoperative patient satisfaction, reoperational request, postoperative Disability of Arm Shoulder and Hand Questionnaire and visual analog scale scores. RESULTS: Mean follow-up duration was 29 months (range, 12 to 60 months). In the postoperative satisfaction questionnaire, 92.9% (n=26) of patients stated that they were satisfied. In the questionnaire of reoperation request, 82.1% (n=23) of patients accepted the reoperation. While the complication rate was 39.3%, recurrence rate was 35.7%. CONCLUSION: Percutaneous needle aponeurotomy technique may be an effective, simple, and safe method for the treatment of DC.

Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture: A Randomized Controlled Trial with a Two-Year Follow-up.

BACKGROUND: Local disruption of the cord that causes contracture of the finger in Dupuytren disease can be achieved either through mechanical division by percutaneous needle fasciotomy (PNF) or through enzymatic digestion by injectable collagenase Clostridium histolyticum (CCH). This study was designed to compare clinical and patient-reported outcomes between patients who had been treated with each method. METHODS: A prospective, randomized, single-blinded, controlled trial was designed and included 156 patients with a contracture of the metacarpophalangeal (MCP) joint of ≥20°. The patients were allocated to treatment with either PNF or CCH. The primary outcome was a reduction of the MCP contracture to <5°. Secondary outcomes included the reduction of any concomitant contracture of the proximal interphalangeal (PIP) joint, the presence of Dupuytren cords, and changes in patient-reported outcomes as measured with the URAM (Unité Rhumatologique des Affections de Main) and QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]) questionnaires and visual analog scales for patient satisfaction. All treatments were performed by a single surgeon and all blinded follow-up measurements were made by a single physiotherapist. The participants were assessed at 1 week, 6 months, and 1 and 2 years after the interventions. RESULTS: A total of 152 patients (97%) were examined at 2 years, at which time 58 patients (76%) treated with CCH and 60 (79%) treated with PNF retained a straight MCP joint. No cords were detectable in >50% of the patients at 2 years. There were no significant differences in the reduction of PIP contracture, range of motion, or patient-reported outcomes between the 2 treatments. CONCLUSIONS: This trial demonstrated no advantage of CCH treatment compared with PNF in terms of clinical outcome at any time during the 2-year follow-up. The significant decrease in the number of pathological cords (p < 0.0001, Wilcoxon signed-rank test) after disruption regardless of the method used may indicate that resorption of pathological collagen occurs when the tension in the Dupuytren cord is diminished. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

[The Extended Percutaneous Needle Fasciotomy Technique (PNF+) For Dupuytren's Contracture]. / Die Technik der erweiterten perkutanen Nadelfasziotomie (PNF+) bei der Dupuytren'schen Kontraktur.

The extended percutaneous needle fasciotomy (PNF+) is a minimal invasive technique especially suitable for treating severe Dupuytren's contractures and recurrences. The familiar needle fasciotomy is complemented by a spontaneous tearing of the skin and a full-thickness graft to cover the defect. Skin tears in fingers and palm are not a complication, but an integral part of the PNF+. The neurovascular bundles remain intact. This surgical procedure may be repeated as often as required.

"Hills, Plains, and Valleys": A Topographical Concept in the Treatment of Dupuytren's Contracture With Needle Aponeurotomy.

Needle aponeurotomy is emerging as a preferred choice of treatment for patients with Dupuytren's contracture keen on a quick, minimally invasive procedure that enables a rapid return of hand function. This article describes a unique topographical concept in the treatment of Dupuytren's contracture with needle aponeurotomy. This concept guides portal placement in a planned manner to achieve better correction and avoid potential complications.

A feasibility study investigating the acceptability and design of a multicentre randomised controlled trial of needle fasciotomy versus limited fasciectomy for the treatment of Dupuytren's contractures of the fingers (HAND-1): study protocol for a randomised controlled trial.

BACKGROUND: Dupuytren's contractures are fibrous cords under the skin of the palm of the hand. The contractures are painless but cause one or more fingers to curl into the palm, resulting in loss of function. Standard treatment within the NHS is surgery to remove (fasciectomy) or divide (fasciotomy) the contractures, and the treatment offered is frequently determined by surgeon preference. This study aims to determine the feasibility of conducting a large, multicentre randomised controlled trial to assess the clinical and cost-effectiveness of needle fasciotomy versus limited fasciectomy for the treatment of Dupuytren's contracture. METHODS/DESIGN: HAND-1 is a parallel, two-arm, multicentre, randomised feasibility trial. Eligible patients aged 18 years or over who have one or more fingers with a Dupuytren's contracture of more than 30° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joints, well-defined cord(s) causing contracture, and have not undergone previous surgery for Dupuytren's on the same hand will be randomised (1:1) to treatment with either needle fasciotomy or limited fasciectomy. Participants will be followed-up for up to 6 months post surgery. Feasibility outcomes include number of patients screened, consented and randomised, adherence with treatment, completion of follow-up and identification of an appropriate patient-reported outcome measure (PROM) to use as primary outcome for a main trial. Embedded qualitative research, incorporating a QuinteT Recruitment Intervention, will focus on understanding and optimising the recruitment process, and exploring patients' experiences of trial participation and the interventions. DISCUSSION: This study will assess whether a large multicentre trial comparing the clinical and cost-effectiveness of needle fasciotomy and limited fasciectomy for the treatment of Dupuytren's contractures is feasible, and if so will provide data to inform its design and successful conduct. TRIAL REGISTRATION: International Standard Registered Clinical/soCial sTudy Number: ISRCTN11164292 . Registered on 28 August 2015.