Leon S. Benson

Injection versus surgery in the treatment of trigger finger

One hundred nine trigger fingers in 102 patients were reviewed with respect to management plan and response to treatment. Thirty-four digits eventually underwent surgical release of the A1 pulley, while the other 75 digits were treated with local steroid injection only. All patients were evaluated with respect to clinical resolution of symptoms, dollar cost of treatment, and general satisfaction as measured with a post-treatment questionnaire. These data suggest that surgical management may be the next best option in patients with trigger finger who continue to be symptomatic after a single injection. Although surgical release of the A1 pulley cost our Medicare patients

Bupivacaine use after knee arthroscopy: Pharmacokinetics and pain control study

250.00 more than a second injection, this additional cost may be offset by the benefit conferred through permanency of relief. Subjective data from the patient questionnaire responses also support surgery as a reasonable choice after one injection failure. The information from this study better delineates differences between injection and surgery as treatment choices and may aid the patient and physician in choosing an individually optimal care plan.

CAMPTODACTYLY : CLASSIFICATION AND RESULTS OF NONOPERATIVE TREATMENT

Bupivacaine (Marcaine) pharmacokinetics were determined in 11 patients receiving the drug intraarticularly after arthroscopic procedures performed on the knee with patients under general anesthesia. Forty milliliters of 0.25% bupivacaine (100 mg) were given as a bolus into the intraarticular space of the knee of each patient. The thigh tourniquet was released 2-3 min after injection and blood samples were obtained 5, 10, 15, 20, 30, 60, 120, 180, 250, and 300 min after tourniquet release. Pharmacokinetic parameters obtained were (mean +/- SD): Vd beta 206 +/- 88 L; Cle 0.816 +/- 0.378 L/min; t 1/2 beta 189 +/- 84 min; ka 9.92 +/- 6.79 x 10/min; Cpmax 0.48 +/- 0.20 micrograms/ml; and tmax 43.4 +/- 23.1 min. Correlations between higher peak plasma concentrations and longer tourniquet times (p = 0.02) and shorter intervals from injection to tourniquet deflation (p = 0.03) were found using multiple linear regression. Our results indicate that injections of 100 mg of bupivacaine intraarticularly after knee arthroscopy will produce peak blood levels within the 1st h after surgery and that these levels will be well below those noted to produce toxic reactions. Peak levels can be minimized with shorter tourniquet inflation times and with longer injection to tourniquet release intervals. Ninety healthy adult outpatient knee arthroscopy patients also were studied to evaluate the effectiveness of bupivacaine in relieving postoperative knee discomfort when injected immediately postoperatively. The subjects were randomized into four groups: (a) intraarticular injection of saline, (b) intraarticular injection of bupivacaine, (c) subcutaneous injection of bupivacaine at the portal sites, and (d) both intraarticular and subcutaneous injection of bupivacaine.(ABSTRACT TRUNCATED AT 250 WORDS)

Dupuytren's contracture.

To assess the relationship between clinical presentation and response to treatment, we reviewed the management of 59 involved proximal interphalangeal (PIP) joints in 22 patients with camptodactyly at a mean follow-up of 33 months. This population represented 24 cases of isolated infantile camptodactyly (type I), five cases of adolescent camptodactyly (type II), and 30 cases of syndromic camptodactyly (type III). Treatment response was assessed through passive range of motion measurements. Splinting and close adherence to an occupational therapy program were particularly effective for type I digits. We also recommend this approach for type II and type III camptodactyly, although severe deformities and well-established contractures are more common in these patients. We reserve operative intervention for only those patients who fail nonoperative management.

Dislocation of the distal phalanx epiphysis in toddlers

&NA; Dupuytren’s contracture is a fibroproliferative disorder of autosomal dominant inheritance that most commonly affects men over age 60 who are of Scandinavian, Irish, or eastern European descent. Local microvessel ischemia in the hand and specific platelet‐derived and fibroblast growth factors act at the cellular level to promote the dense myofibroblast population and altered collagen profiles seen in affected tissue. Surgical treatment depends to some degree on patient preference and a clear understanding of the possible complications and considerable postoperative therapy commitment. Operative management is appropriate when metacarpophalangeal or proximal interphalangeal joint contracture exceeds 30 degrees. A volar zigzag Brunner incision in the digit and palm provides reliable exposure and leads to predictable healing in most cases. The mainstay of postoperative hand therapy is early active‐flexion range‐of‐motion exercises to restore grip strength. A nighttime extension splint is often used for several months postoperatively to maintain the correction achieved in the operating room. Early recurrence of disease is most common in individuals with Dupuytren’s diathesis; use of full‐thickness skin grafts may be helpful for these patients.

Pediatric hand injuries due to home exercycles

Two cases of physeal fracture dislocation of the distal phalanx are reviewed. Each injury occurred in a toddler, was originally undiagnosed, and appeared years later as a dorsal mass in a fore-shortened digit with decreased distal interphalangeal joint motion. In each case x-ray films revealed a dislocated epiphysis, accounting for the enlarging dorsal prominence and the phalangeal growth disturbance. These cases demonstrate that dislocation of the distal phalanx epiphysis can occur with a crush injury and may be difficult to detect before development of the ossification center. Careful physical examination and a high index of suspicion will increase the likelihood of early diagnosis. Early open reduction may prevent the late complications of deformity and stiffness.

A Unified Approach to Outcomes Assessment for Distal Radius Fractures

The clinical presentation and management of 19 children who sustained injuries by stationary exercise bicycles were reviewed retrospectively. These injuries represented 32 traumatized digits with a minimum of 2-year follow-up. The index and long fingers were most commonly involved. Wheel-spoke injuries typically produced repairable nerve and tendon lacerations, and full functional recovery in these cases was common. The chain/sprocket injury involved a crushing mechanism and frequently produced severe injury including amputations that were not salvageable. Stationary exercise bicycles represented a predictable source of severe hand injury in children between the ages of 18 months and 5 years. Adult supervision was not reliable in preventing contact between an operating exercycle and a childs hand. We recommend that children not be allowed access to any stationary exercycle machinery, whether it is in use or not. Safety design considerations should focus on not only shielding the wheel spokes, but also (and perhaps even more important) on enclosing the entire chain axis and gear interface. In addition to these design considerations, public education will be critical in reducing the incidence of injury.

Eponyms in orthopaedics.

Distal radius fractures are one of the most common upper extremity injuries. Currently, outcome assessment after treatment of these injuries varies widely with respect to the measures that are used, timing of assessment, and the end points that are considered. A more consistent approach to outcomes assessment would provide a standard by which to assess treatment options and best practices. In this summary, we review the consensus regarding outcomes assessment after distal radius fractures and propose a systematic approach that integrates performance, patient-reported outcomes, pain, complications, and radiographs.

Commentary on an article by Stavros Thomopoulos, PhD, et al.: “The Effects of Exogenous Basic Fibroblast Growth Factor on Intrasynovial Flexor Tendon Healing in a Canine Model”

Eponym (ep o–nim) [Greek eponymos, named after] The name of a disease, structure, operation, or procedure, derived from the name of the person who discovered or described it first. Argot (är gõ) [French origin “in thieves’ jargon”] The specialized vocabulary and idioms of those in the same work. Eponyms are commonly used in orthopaedics. Yet the individual’s name and history often remain obscure or unknown to the user. The recognition and appropriate use of the eponymic terms become more difficult as the terminology falls into disuse. It is hoped that this report will serve as a reference and a resource and will preserve orthopaedic history.

Complications of Endoscopic and Open Carpal Tunnel Release

The goal of this study was to determine whether or not there is an improvement in the healing of flexor tendon repairs by exposing the repair site to basic fibroblast growth factor (bFGF). The study involved a canine model in which intrasynovial flexor tendons were experimentally transected, exposed to a dose of bFGF, and then repaired with suture. Three tendon groups were studied: a group exposed to a lower dose of bFGF (500 ng), a group exposed to a higher dose of bFGF (1000 ng), and a control group of tendon repairs, which were exposed to no bFGF. The bFGF was delivered by implanting within the tendon repair site a fibrin matrix that contained a heparin-based delivery system capable of delivering bFGF in a controlled manner over a ten-day period. Examination of the flexor tendon repair sites after twenty-one days was performed both with histological and mechanical analysis. The investigators found that the lower …