Evaluation of botulinum toxin A injections for the treatment of refractory chronic digital ulcers in patients with systemic sclerosis.

OBJECTIVES: To evaluate the therapeutic benefit of botulinum toxin A (BTX-A) injections for digital ulcers (DU) in patients with systemic sclerosis (SSc). METHODS: A systematic literature review was performed and the identified articles were selected by two reviewers and analysed with respect to date of publication, inclusion and exclusion criteria, number and age of participants, volume of BTX-A, injection sites, outcomes, and adverse events. In addition, in the Zurich cohort, 7 SSc patients were eligible for the study and were assessed for the duration of DU to heal, duration of DU-free periods, changes in frequency and numbers of prescribed vasodilators, pain and blood flow. RESULTS: In five articles from the systematic review, at least 48% of DU had healed and up to 100% reduction in VAS for pain was reported. Our 7 patients (median age of 53 (47-82) years) had in median 2.5 (2-4) DU and were injected with a median BTX-A volume of 90 (50-100) units per hand. Of the 31 DU in all patients, 77% (n=24) healed. Time to wound closure was in median 8 (4-12) weeks and the DU-free duration was in median 8 (3-10) months. In 80% of the cases, at least one vasodilator was stopped or could be administered less frequently. An improvement of blood flow and pain was reported in 60% of the cases. CONCLUSIONS: BTX-A injections might be of benefit for the treatment of chronic, refractory DU in selected SSc patients, yet a sufficiently powered prospective study will be needed as ultimate proof.

Reasons for scaphoid non-union: Analysis of behavior of health care providers and patients.

To assess factors related to health-system and patient behavior in scaphoid fracture non-union, a retrospective analysis of 134 patients treated by scaphoid reconstruction was performed. Mean age at the accident was 26 years (range, 9-75 years), and the mean age at surgery was 28 years (range, 13-75 years). Mean time to first consultation was 233 days (range, 0-12,136 days), and time to surgery 740 days (range, 19-12,362 days). The physician was mainly a general practitioner (52.2%), or an orthopedist/traumatologist (17.9%), general surgeon (12.7%), or hand surgeon (17.2%). The initial diagnostic procedure was X-ray in 76.9% of cases, computed tomography (CT) in 20.9%, magnetic resonance imaging (MRI) in 13.4%, and none in 11.2%. A fracture was diagnosed in 32.8% of cases, and non-union in 14.9%. Patients mainly presented late: 63% within 3 weeks, and a minority on the day of the accident (39%). In 11% of cases, healthcare providers performed either no or inadequate imaging (77%) and missed correct diagnosis in 52% of cases. 128 patients had a second consultation, and 77 a third, with the same or different physicians, before surgery, leading to increased healthcare costs due to delayed diagnosis and treatment. Delayed presentation and lack of suspicion by attending physicians were the main reasons. Speeding up diagnosis and improving physician training are vital and could significantly reduce health care costs. CT or MRI should be performed if scaphoid fracture is suspected.

Six-Strand Flexor Pollicis Longus Tendon Repairs With and Without Circumferential Sutures: A Multicenter Study.

BACKGROUND: The purpose of this study is to assess outcomes in flexor pollicis longus tendon repairs with 6-strand core sutures with and without circumferential sutures. METHODS: A 6-strand core suture technique with and without circumferential sutures was used. Thirty-three patients were summarized in the C group (circumferential group) and 16 patients in the NC group (non-circumferential group). After the surgery, the wrist was stabilized with a dorsal blocking splint and a controlled early active motion protocol was applied. At weeks 6, 13, and 26 data on demographics, type of injury, surgery, postoperative rehabilitation, complications such as re-rupture and the following outcome measurements were collected: range of motion and its recovery according to the Tang criteria, Kapandji score, thumb and hand strengths, Disabilities of the Arm, Shoulder and Hand score, and satisfaction. RESULTS: There were no significant differences in range of motion and strength between the 2 treatment groups. In both groups, the outcome measurements increased over time and they expressed similar satisfaction with the surgical treatment. In 4 patients of the C group tendon repair ruptured and in 1 patient of the NC group. CONCLUSIONS: Six-strand repair technique is an effective procedure to assure early active motion after flexor pollicis longus tendon injuries and good results can also be achieved by omitting the circumferential suture.