Dupuytren Disease Management Trends: A Survey of Hand Surgeons.

Background: Indication for intervention in Dupuytren disease is influenced by many factors, including location and extent of disease, surgeon preference, and comfort level with different treatment techniques. The aim of this study was to determine current Dupuytren disease management trends. Methods: A questionnaire was sent through the American Society for Surgery of the Hand to all members. In addition to demographic data, questions focused on indications for different procedural interventions based on location of disease, age, and activity level of the patient. Results: Approximately 24% of respondents completed the survey. Respondents were mostly orthopedic surgeons in private practice who do not work with residents or fellows. Respondents preferred collagenase over needle aponeurotomy and limited fasciectomy for primary Dupuytren disease involving only the metacarpophalangeal (MCP) joint. Limited fasciectomy was the preferred treatment for primary Dupuytren disease involving the MCP and proximal interphalangeal joints. For a patient amenable to any treatment option, the majority would use collagenase, although 87.1% felt that fasciectomy offered the longest disease-free interval. Furthermore, given the option of a young, working patient, 42.7% would use collagenase, while plastic and general surgeons were more likely to treat this patient with limited fasciectomy. More plastic surgeons (vs orthopedic) believe that limited fasciectomy yields the longest disease-free interval. For a patient amenable to any surgical option, orthopedic surgeons prefer collagenase, whereas plastic hand surgeons prefer a limited fasciectomy. Conclusion: There are several procedural options for the treatment of Dupuytren disease. This study details current practice patterns among hand surgeons and reveals the increasingly prevalent use of collagenase.

Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database.

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms "orthopaedic or orthopedic" and "malpractice." Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260-e267.].

Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds.

Acute compartment syndrome (CS) is a frequent and potentially devastating complication of blunt and penetrating extremity injuries. Extremity war injuries are particularly susceptible to CS due to associated vascular injuries; high Injury Severity Score; extensive bone and soft tissue injury; and frequent transportation that may limit close monitoring of the injured extremity. Treatment consists of prompt fasciotomy of all compartments in the involved segment, over their full length. Delayed or incomplete fasciotomy is associated with worse outcomes, including muscle necrosis, infection, and amputation. Enhanced pre-deployment training of surgeons decreases the need for revision fasciotomy at higher echelons of care and should be continued in future conflicts. We recommend the liberal use of prophylactic fasciotomy prior to aeromedical evacuation and after limb reperfusion. For leg fasciotomy, we recommend a two-incision approach as it is more reproducible and allows easy vascular exposure when necessary.

Personal Evolution in Thighplasty Techniques for Patients Following Massive Weight Loss.

BACKGROUND: Lockwood described the importance of Colles' fascia anchoring in medial thighplasty to reduce morbidity associated with the procedure. However, this maneuver may still have complications including traumatic dissection, prolonged edema, and potential wound healing ramifications form increased tension. Alternatively, we suggest orienting tension in medial thighplasty for massive weight loss (MWL) patients in the horizontal vector rather than a vertical direction, negating the need for Colles' fascia anchoring. OBJECTIVES: To compare the morbidities, complications, and outcomes between Colles' fascia suture fixation (CFSF) and horizontal vector fixation (HVF) in medial thighplasties in MWL patients. METHODS: A retrospective chart review was conducted on an Institutional Review Board approved database of MWL patients who had medial thighplasty between October 2004 and March 2014. Patient demographics and surgical outcomes were reviewed between those MWL patients with CFSF and HVF. RESULTS: Of 65 post-MWL patients, 26 (40.0%) patients were in the CFSF group, and 39 (60.0%) patients were in the HVF group. The 2 groups had statistically equivocal preoperative characteristics and comorbidities. Intraoperatively, the HVF group had increased use of barbed suture (92.3% vs 30.6%, P < 0.0001) and liposuction (71.8% vs 26.9%, P < 0.0001). Postoperatively, the HVF group had decreased incidence of infection (5.1% vs 23.0%, P = 0.051) and lymphocele/seroma (10.3% vs 34.6%, P = 0.0257). No statistical differences were observed for dehiscence, necrosis, or hematoma. CONCLUSIONS: HVF for medial thighplasty in MWL patients is a safe and effective procedure, with a lower complication profile than CFSF. Furthermore, the incorporation of barbed sutures and/or liposuction may help to achieve optimal results. LEVEL OF EVIDENCE: 3.

Trends in the Treatment of Dupuytren Disease in the United States Between 2007 and 2014.

Background: Dupuytren disease is a common fibroproliferative disorder. Multiple procedural treatment options are available, with Collagenase Clostridium Histolyticum (CCH) injection being introduced in 2010. The purpose of this study was to investigate trends in the treatment of Dupuytren disease in the United States between 2007 and 2014. Methods: The PearlDiver Humana database was queried using International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes for patients with Dupuytren disease that received percutaneous needle aponeurotomy (PNA), fasciotomy, fasciectomy, and CCH injection. Patients were filtered by age, number of comorbidities, and gender. Change in composition of treatments over time was analyzed for each demographic group between 2007 and 2014. Results: Patients presenting to clinic for Dupuytren disease increased from 1118 to 3280, with unchanging treatment percentage of 41. Percent fasciotomies and fasciectomies decreased from 5% to 3% and 33% to 21%, while CCH injection increased to 11% by 2012 to 2014. Percent fasciotomies decreased (P < .05) in younger healthier (age <65, 0-1 comorbidities) and older less healthy (age 65-74, 4+ comorbidities) populations. Percent fasciectomies decreased significantly in nearly all age and comorbidity groups, but by greater amounts in patients with 2+ comorbidities with increasing age. Percent CCH injections increased in all groups, at rates similar to the losses seen in open procedures. Conclusions: CCH injections have risen to substantial levels, with corresponding decreases in the percentage of patients receiving fasciotomies and fasciectomies. Patient age, comorbidities, and gender appear to have influence on the treatment chosen, likely due to their effects on surgical risk and the importance of timely return to activity.

Evolution of Fascial Closure Optimization in Damage Control Laparotomy.

Management of patients undergoing damage control laparotomy (DCL) involves many surgical, medical, and logistical factors. Ideal patient management optimizing fascial closure with regard to timing and closure techniques remains unclear. A retrospective review of patients undergoing DCL from 2000 to 2012 at an urban Level I trauma center was undertaken. Mortality of DCL decreased over the study period from 62.5 to 34.6 per cent, whereas enterocutaneous fistula rate decreased from 12.5 to 3.8 per cent. Delayed primary fascial closure rate improved from 22.2 to 88.2 per cent. Time to closure (P < 0.001), time to first attempted closure (P < 0.001), and number of explorations (P < 0.001) were associated with ability to achieve delayed primary fascial closure. In subgroup analysis, achievement of delayed primary fascial closure was decreased with time to closure after one week (91.7% vs 52.0%, P = 0.002) and time to first attempted closure after two days (86.5% vs 70.0%, P = 0.042). In multivariate analysis, time to closure (odds ratio: 0.13, 95% confidence interval: 0.04-0.39; P < 0.001) and time to first attempted closure (odds ratio: 0.61, 95% confidence interval: 0.37-0.99; P = 0.046) were the only factors associated with achieving delayed primary fascial closure. Timing of attempted closure plays a significant role in attaining delayed primary fascial closure, highlighting the importance of early re-exploration.