Catherine M. Curtin

Collagenase injection as nonsurgical treatment of Dupuytren's disease: 8-year follow-up.

PURPOSE Collagenase has been investigated in phase II and phase III clinical trials for the treatment of Dupuytrens disease. The purpose of this study is to report 8-year follow-up results in a subset of patients who had collagenase injection for the treatment of Dupuytrens contracture. METHODS Twenty-three patients who participated in the phase II clinical trial of injectable collagenase were contacted by letter and phone. Eight patients were enrolled, completed a Dupuytrens disease questionnaire, and had independent examination of joint motion by a single examiner. RESULTS Eight patients completed the 8-year follow-up study: 6 had been treated for isolated metacarpophalangeal (MCP) joint contracture, and 2 had been treated for isolated proximal interphalangeal (PIP) joint contracture. Average preinjection contracture was 57 degrees in the MCP group. Average contracture was 9 degrees at 1 week, 11 degrees at 1 year, and 23 degrees at 8-year follow-up. Four of 6 patients experienced recurrence, and 2 of 6 had no evidence of disease recurrence at 8-year follow-up. Average preinjection contracture was 45 degrees in the PIP group. Average contracture was 8 degrees at 1 weeks, 15 degrees at 1 year, and 60 degrees at 8-year follow-up. Both patients experienced recurrence at 8-year follow-up. No patients had had further intervention on the treated finger in either the MCP or the PIP group. Patients subjectively rated the overall clinical success at 60%, and 88% of patients stated that they would pursue further injection for the treatment of their recurrent or progressive Dupuytrens disease. CONCLUSIONS Enzymatic fasciotomy is safe and efficacious, with initial response to injection resulting in reduction of joint contracture to within 0 degrees -5 degrees of normal in 72 out of 80 patients. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. In addition, patient satisfaction was high.

Pinch and Elbow Extension Restoration in People With Tetraplegia: A Systematic Review of the Literature

PURPOSE We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia. METHODS English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes. RESULTS Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg. CONCLUSIONS More than 500 patients having these procedures experienced a clinically important improvement for both procedures-one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Breast reconstruction national trends and healthcare implications.

Breast reconstruction improves quality‐of‐life of breast cancer patients. Different reconstructive options exist, yet commentary in the plastic surgery literature suggests that financial constraints are limiting access to autologous reconstruction (AR). This study follows national trends in breast reconstruction and identifies factors associated with reconstructive choices. Data were obtained from the Nationwide Inpatient Sample from 1998 to 2008. Patients were categorized as having either implant or ARs. Bivariate and multivariate regression analysis identified variables associated with receiving implants versus AR. Physician fee schedules were analyzed using national average Medicare physician reimbursement rates. From 1998 to 2008, 324,134 breast reconstructions were performed. Reconstructions increased 4% per year. The proportion of implant reconstructions increased 11% per year, whereasARs decreased 5% per year (p < 0.05). Our model showed that the odds of having implant‐based versus AR were significantly associated with age, disease severity, payer type, hospital teaching status, and year of surgery. Year of surgery was the strongest predictor of implant reconstruction; patients receiving breast reconstructive surgery in 2009 were three times more likely to have implant breast reconstructive surgery compared with similar patients in 2002. Medicare reimbursement steadily declined for AR over a similar time frame. From 1998 to 2008, autologous breast reconstruction has significantly declined, parallel to a decrease in physician reimbursement. Our data found no significant change in patient characteristics supporting the lack of choice of AR. Further research is warranted to better understand this shift to implant reconstruction and to ensure future access of these complex reconstructive procedures.

Flexor Tendon Rupture After Collagenase Injection for Dupuytren Contracture: Case Report

Rupture of both flexor tendons after collagenase injection for Dupuytren contracture is a rare and problematic complication. We performed a 2-stage tendon reconstruction to treat this problem, with an acceptable result.

Changes Resembling Complex Regional Pain Syndrome Following Surgery and Immobilization

UNLABELLED The study of complex regional pain syndrome (CRPS) in humans is complicated by inhomogeneities in available study cohorts. We hoped to characterize early CRPS-like features in patients undergoing hand surgery. Forty-three patients were recruited from a hand surgery clinic that had elective surgeries followed by cast immobilization. On the day of cast removal, patients were assessed for vasomotor, sudomotor, and trophic changes, and edema and pain sensitization using quantitative sensory testing. Pain intensity was assessed at the time of cast removal and after 1 additional month, as was the nature of the pain using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS). Skin biopsies were harvested for the analysis of expression of inflammatory mediators. We identified vascular and trophic changes in the surgical hands of most patients. Increased sensitivity to punctate, pressure, and cold stimuli were observed commonly as well. Moreover, levels of IL-6, TNF-alpha, and the mast cell marker tryptase were elevated in the skin of hands ipsilateral to surgery. Moderate-to-severe pain persisted in the surgical hands for up to 1 month after cast removal. Exploratory analyses suggested interrelationships between the physical, quantitative sensory testing, and gene expression changes and pain-related outcomes. PERSPECTIVE This study has identified CPRS-like features in the limbs of patients undergoing surgery followed by immobilization. Further studies using this population may be useful in refining our understanding of CRPS mechanisms and treatments for this condition.

A National Study on Craniosynostosis Surgical Repair

Objective Our study aimed to use national data to assess the perioperative outcomes of craniosynostosis surgical repair. Design Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids Inpatient Database from 1997, 2000, 2003, and 2006. Setting Community hospitals in the United States. Patients The cohort was identified using the ICD-9-CM procedure codes for craniosynostosis surgical repair (2.01, 2.03, 2.04, 2.06). Main Outcome Measures(s) We determined patient and hospital characteristics. We clustered patients by age group (7 months, 7 to 12 months, 1 to 3 years) and assessed mortality, comorbidities, mean length of stay (LOS), and total charge. We performed logistic regression with our dependent variable being longer average hospital stay: LOS > 4.2 days. Results We found 3426 patients. Average age at the time of surgery was 181 days (SD 84). Average length of stay was 4.2 days. The majority of the patients were boys (66%), white (71%), and insured (93%). Nearly all patients underwent surgery in a teaching hospital (98%) in urban centers (99%). Approximately 10% of patients experienced an acute complication, most commonly hemorrhages or hematomas and airway or respiratory failure. Patients ages 1 to 3 years had the highest rates of comorbidities and a longer LOS. Mortality rate was <1%. Conclusions Craniosynostosis surgery is safe with low rates of mortality and acute complications. LOS >4.2 appears to be associated more with comorbidities than with complications. Higher rates of comorbidities and LOS >4.2 days for patients age 1 to 3 years warrant addition research to assess potential barriers to care.

Use of Eight-hole Titanium Miniplates for Unstable Phalangeal Fractures

The authors present a series of 16 unstable phalangeal fractures (13 patients) treated by open reduction and internal fixation using the eight-hole titanium miniplate system from Synthes (Paoli, PA). Thirteen fractures were finger fractures whereas three were thumb fractures. Most fractures (n = 15) were crush injuries with concomitant soft tissue trauma. Six patients with finger fractures had good to excellent range of motion (total active motion ≥180). Two patients with thumb fractures had moderate range of motion (range of motion 70–97), whereas the remaining patient with thumb fracture had poor motion because the interphalangeal joint was destroyed. Complications included two cases of plate exposure because of insufficient soft tissue cover. Although no malunion occurred in this series, there was one case of delayed union. Three patients had extensor tenolysis to improve motion. The eight-hole miniplate system adds to the versatility of the many options available for fixation of unstable phalangeal fractures. Rigid fixation using this system is particularly helpful in initiating early motion in severely crushed fingers with concomitant soft tissue injury.

The Effect of Moving Carpal Tunnel Releases Out of Hospitals on Reducing United States Health Care Charges.

PURPOSE To better understand how perioperative care affects charges for carpal tunnel release (CTR). METHODS We developed a cohort using ICD9-CM procedure code 04.43 for CTR in the National Survey of Ambulatory Surgery 2006 to test perioperative factors potentially associated with CTR costs. We examined factors that might affect costs, including patient characteristics, payer, surgical time, setting (hospital outpatient department vs. freestanding ambulatory surgery center), anesthesia type, anesthesia provider, discharge status, and adverse events. Records were grouped by facility to reduce the impact of surgeon and patient heterogeneity. Facilities were divided into quintiles based on average total facility charges per CTR. This division allowed comparison of factors associated with the lowest and highest quintile of facilities based on average charge per CTR. RESULTS A total of 160,000 CTRs were performed in 2006. Nearly all patients were discharged home without adverse events. Mean charge across facilities was

Who are the women and men in Veterans Health Administration's current spinal cord injury population?

2,572 (SD,

Readmissions After Treatment of Distal Radius Fractures

2,331-