Gary M. Pess

Results of Needle Aponeurotomy for Dupuytren Contracture in Over 1,000 Fingers

PURPOSE To critically review the efficacy, recurrence rate, and complications of needle aponeurotomy (NA) for the treatment of Dupuytren contracture. METHODS This was a retrospective study of the results of NA for the treatment of Dupuytren contracture. We included in the study all patients who had NA performed for metacarpophalangeal (MP) or proximal interphalangeal (PIP) joint contracture of 20° or greater between March 2005 and May 2008. There were 474 patients with 1,013 fingers treated. The average age was 62 years (range, 33-92 y). Pre-procedure MP joint contracture averaged 35° (range, 15° to 95°), and PIP joint 50° (range, 15° to 110°). Immediately postprocedure and at least 3 years after treatment (range, 3.0-6.2 y), we measured MP and PIP joint contractures and reviewed records for complications. RESULTS MP joint contractures were corrected an average of 99% and PIP contractures an average of 89% immediately postprocedure. At final follow-up, 72% of the correction was maintained for MP joints and 31% for PIP joints. The difference between the final corrections for MP versus PIP joints was statistically significant. When we compared the final results of patients age 55 years and older versus under 55 years, we found a statistically significant difference at both MP and PIP joints, with greater correction maintained in the older group. Gender differences were not statistically significant. Needle aponeurotomy provided successful correction to 5° or less contracture immediately postprocedure in 98% (791) of MP joints and 67% (350) of PIP joints. There was recurrence of 20° or less over the original postprocedure corrected level in 80% (646) of MP joints and 35% (183) of PIP joints. Complications were rare except for skin tears, which occurred in 3.4% (34) of digits. CONCLUSIONS This study shows that NA is a safe procedure that can be performed in an outpatient setting. The complication rate was low, but recurrences were frequent in younger patients and for PIP contractures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study

PURPOSE To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum (CCH) injections to treat 2 joints in the same hand with Dupuytren fixed flexion contractures (FFCs). METHODS Patients with 2 or more contractures in the same hand caused by palpable cords participated in a 60-day, multicenter, open-label, phase 3b study. Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same hand (1 injection per affected joint) during the same visit. Finger extension was performed approximately 24, 48, or 72 or more hours later. Changes in FFC and range of motion, incidence of clinical success (FFC ≤ 5°), and adverse events (AEs) were summarized. RESULTS The study enrolled 715 patients (725 treated joint pairs), and 714 patients (724 joint pairs) were analyzed for efficacy. At day 31, mean total FFC (sum of 2 treated joints) decreased 74%, from 98° to 27°. Mean total range of motion increased from 90° to 156°. The incidence of clinical success was 65% in metacarpophalangeal joints and 29% in proximal interphalangeal joints. Most treatment-related AEs were mild to moderate, resolving without intervention; the most common were swelling of treated extremity, contusion, and pain in extremity. The incidence of skin lacerations was 22% (160 of 715). Efficacy and safety were similar regardless of time to finger extension. CONCLUSIONS Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration. The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint. Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints, and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment.

Results of flexor tendon tenolysis after replantation in the hand

Thirty-seven replanted digital units and four thumb replantations had a flexor tendon tenolysis at an average of 10 months after replantation. The results were assessed by measuring total active motion, potential active motion, and by the formula of Strickland and associates. The total active motion increased from a mean pretenolysis of 72 degrees to 130 degrees. The potential active motion increased from a mean of 43% to 70% after tenolysis. Both of these improvements were statistically significant (p less than 0.001). The formula of Strickland and associates rated 13 excellent, 11 good, 6 fair, and 11 poor. The thumbs had two fair results and two poor results. Poor results were also seen in crush or avulsion amputations, hands with more than two digits amputated, and those requiring a proximal interphangeal joint capsulotomy. Little difference was found related to the number of arteries or tendons repaired. Complications included tendon rupture and infection. No digits were lost. The results of this study would support flexor tendon tenolysis after replantation of fingers but not replanted thumbs.

Macrodactyly and the epidermal nevus syndrome

Macrodactyly is an uncommon congenital anomaly that affects the fingers and toes. Speculation as to cause is focused on the association with connective tissue abnormalities, such as neurofibromatosis. We report a highly unusual case of a patient with epidermal nevus syndrome, a specific connective tissue and skeletal disease, who also exhibited bilateral, four finger macrodactyly. Potential causes of linkage between these two specific and unusual syndromes are discussed. Treatment of the epidermal nevus may be nonoperative, differing from the philosophy of aggressive treatment of the similarly appearing premalignant congenital hairy nevus.

Chronic lymphocytic leukemia presenting as pyogenic arthritis of the proximal interphalangeal joint.

A 66-year-old woman was seen and treated for a chronic lymphocystic leukemic infiltrate of a proximal interphalangeal joint, which presented with clinical and radiologic signs consistent with a pyogenic arthritis.

Effect of Delayed Finger Extension on the Efficacy and Safety of Collagenase Clostridium Histolyticum Treatment for Dupuytren Contracture

Purpose: To evaluate efficacy and safety of delayed finger extension after concurrent administration of two collagenase clostridium histolyticum (CCH) injections to treat two joints with Dupuytren contracture.

Erratum to: 6-week radiographs unsuitable for diagnosis of suspected scaphoid fractures (Arch Orthop Trauma Surg, (2016), 136, (771-778), 10.1007/s00402-016-2438-4)

Wint, John M. Erickson, John McAuliffe, John T. Capo, John Taras, Jose A. Ortiz, Julie Adams, Karl-Josef Prommersberger, Kevin M. Rumball, Kyle D. Bickel, Lior Paz, Lisa Lattanza, Louis Catalano III, M. Jason Palmer, Marc J. Richard, Marco Rizzo, Maurizio Calcagni, Maximillian Soong, Megan M. Wood, Michael Baskies, Michael Behrman, Michael Darowish, Michael Nancollas, Michael W. Grafe, Michael W. Kessler, Miguel A. Pirela-Cruz, M. P. Bekerom, Naquira Escobar Luis Felipe, Nathan Hoekzema, Oleg M. Semenkin, Patrick W. Owens, Philip Blazar, Ralph M Costanzo, Ramon de Bedout, Renato M. Fricker, Richard L. Hutchison, Richard S. Gilbert, Rick Papandrea, Robert R. Slater, Robert R. L. Gray, Ryan Klinefelter, Ryan P. Calfee, Sander Spruijt, Sanjeev Kakar, Saul Kaplan, Seth Dodds, Stephen A. Kennedy, Steven Beldner, T. Apard, Taizoon Baxamusa, Thomas G. Stackhouse, Todd Siff, W. Arnnold Batson, Warren C. Hammert. Erratum to: Arch Orthop Trauma Surg (2016) 136:771–778 DOI 10.1007/s00402-016-2438-4