Dupuytren's Contracture: An Evidence Based Review.

Dupuytren's contracture, a benign condition characterized by fibrosis of the palmar and digital fascia, may be a debilitating condition that limits daily function. Several techniques exist for managing symptomatic contractures of the hand related to Dupuytren's. These techniques include the more invasive open fasciotomy or fasciectomy. More recently, less invasive techniques including administration of collagenase Clostridium histolyticum (CCH) or percutaneous needle aponeurotomy (PNA) have become part of the treatment armamentarium. A comprehensive review of the literature is performed and an algorithm for management of Dupuytren's contracture is proposed.

Prevention of ulceration, amputation, and reduction of hospitalization: outcomes of a prospective multicenter trial of tibial neurolysis in patients with diabetic neuropathy.

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy.

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.

Reconstruction of a 4-cm human median nerve gap by including an autogenous nerve slice in a bioabsorbable nerve conduit: case report.

Nerve gaps up to 3 cm in length can be reconstructed in the human with a bioabsorbable nerve conduit; however, nerve gaps greater than 3 cm have not been reconstructible in animal models unless a neurotrophic factor, like cultured Schwann cells, was added to the nerve conduit. It is the purpose of this article to present the result of human nerve regeneration across a 4-cm nerve gap in the median nerve at the wrist when a slice of autogenous normal nerve was placed into the middle of a bioabsorbable nerve conduit.

Innervated free flaps for foot reconstruction: a review.

Whether to provide a sensate plantar weight-bearing flap to reconstruct the foot remains an unanswered, but frequently asked, question. It has been more than a decade since Graham and Dellon reviewed this subject. Increasing emphasis on outcome analysis of microsurgical reconstruction has prompted this new review. All published peer-reviewed literature related to reconstruction of the plantar surface of the foot was reviewed to identify whether the flaps were 1) local, regional or distant; 2) innervated or non-innervated and, if innervated, then 3) identified as to the donor and the recipient peripheral nerves. Outcome measures included direct measurement of sensibility, development of ulceration, and activities of daily living. It was concluded that it is still not possible to determine that innervated flap reconstruction of the weight-bearing portion of the foot is critical for either durability or ambulation. It is recommended that the original nerves that innervate the flap be blocked prior to harvest to improve flap design, i.e., that the flap actually contains the intended nerve. It is recommended that appropriate donor nerves are selected to innervate the flaps, e.g., the calcaneal nerve should be used to reinnervate heel reconstructions (rather than the sural nerve), and medial/lateral plantar branches be used to reinnervate the arch and the forefoot. Reinnervating a muscle flap with a sensory nerve will permit reinnervation of the muscle and the overlying skin, but whether this provides a superior result in durability and gait remains to be seen.