Marie A. Badalamente

Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture

BACKGROUNDnDupuytrens disease limits hand function, diminishes the quality of life, and may ultimately disable the hand. Surgery followed by hand therapy is standard treatment, but it is associated with serious potential complications. Injection of collagenase clostridium histolyticum, an office-based, nonsurgical option, may reduce joint contractures caused by Dupuytrens disease.nnnMETHODSnWe enrolled 308 patients with joint contractures of 20 degrees or more in this prospective, randomized, double-blind, placebo-controlled, multicenter trial. The primary metacarpophalangeal or proximal interphalangeal joints of these patients were randomly assigned to receive up to three injections of collagenase clostridium histolyticum (at a dose of 0.58 mg per injection) or placebo in the contracted collagen cord at 30-day intervals. One day after injection, the joints were manipulated. The primary end point was a reduction in contracture to 0 to 5 degrees of full extension 30 days after the last injection. Twenty-six secondary end points were evaluated, and data on adverse events were collected.nnnRESULTSnCollagenase treatment significantly improved outcomes. More cords that were injected with collagenase than cords injected with placebo met the primary end point (64.0% vs. 6.8%, P < 0.001), as well as all secondary end points (P < or = 0.002). Overall, the range of motion in the joints was significantly improved after injection with collagenase as compared with placebo (from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees, P < 0.001). The most commonly reported adverse events were localized swelling, pain, bruising, pruritus, and transient regional lymph-node enlargement and tenderness. Three treatment-related serious adverse events were reported: two tendon ruptures and one case of complex regional pain syndrome. No significant changes in flexion or grip strength, no systemic allergic reactions, and no nerve injuries were observed.nnnCONCLUSIONSnCollagenase clostridium histolyticum significantly reduced contractures and improved the range of motion in joints affected by advanced Dupuytrens disease. (ClinicalTrials.gov number, NCT00528606.)

Arthrofibrosis after total knee arthroplasty.

Six total knee arthroplasties in five patients were revised because of persistent limited motion after the primary arthroplasty. All of the revised implants were of an appropriate size and not malpositioned. No cause of stiffness was identified other than soft tissue contracture. Four of the components were posterior cruciate retaining and two were posterior cruciate substituting. Heterotopic bone formation was observed in two knees before the revision surgery and five knees after the revision surgery. Arc of motion was increased from 36 °(range, 20 °–70 °) before revision surgery to 86 °(range, 70 °–110 °) after revision surgery. What triggers the proliferation of extensive scar tissue formation in patients with arthrofibrosis is not clear. Some patients may be predisposed to this condition or may have it develop as a response to the surgical trauma and postoperative rehabilitation. However, when arthrofibrosis does develop after total knee arthroplasty, some improvement in motion and pain can be achieved with revision surgery.

The pathobiology of Dupuytren's contracture: Effects of prostaglandins on myofibroblasts

The in vitro response of myofibroblasts to prostaglandins F2alpha (a vasoconstrictor) and E2 (a vasodilator) were evaluated in specimens obtained from the Dupuytrens nodules of 12 patients. Fibroblasts from four control samples of palmar fascia were similarly tested. This study demonstrated the ability of prostaglandin F2alpha to induce significant contraction of myofibroblasts. Prostaglandin E2 was noted to cause significant relaxation of myofibroblasts. The contractile/relaxation responses of control fibroblasts to these prostaglandins were minimal.

Measurement scales in clinical research of the upper extremity, part 2: outcome measures in studies of the hand/wrist and shoulder/elbow.

Part 1 of this article outlined the basic characteristics of useful clinical measurement instruments and described scales used to measure general health, pain, and patient satisfaction. Part 2 describes the features of some of the scales most commonly used in clinical research in the hand, wrist, elbow, and shoulder.

Infantile (desmoid type) fibromatosis with extensive ossification.

Solitary congenital or infantile (desmoid-type) fibromatosis is a benign, but potentially locally aggressive lesion that is best treated by wide local excision. It has been confused with congenital fibrosarcoma and other soft-tissue malignant tumors. To our knowledge, ossification has not been reported previously in this lesion. A case of ossifying solitary congenital fibromatosis is presented with a discussion of its differential diagnosis and histologic distinction from other soft-tissue lesions, including soft-tissue and parosteal osteosarcoma.

Measurement scales in clinical research of the upper extremity, part 1: General principles, measures of general health, pain, and patient satisfaction

Measurement is a fundamental cornerstone in all aspects of scientific discovery, including clinical research. To be useful, measurement instruments must meet several key criteria, the most important of which are satisfactory reliability, validity, and responsiveness. Part 1 of this article reviews the general concepts of measurement instruments and describes the measurement of general health, pain, and patient satisfaction.

Incorporation of a new radioactive compound, 4+Sn-117m DTPA, into normal and burred rat femurs

The physical characteristics of a new tin radiopharmaceutical, 4+Sn-117m diethylenetriamine-pentaacetic acid (DTPA), may make this compound appropriate for orthopedic therapeutic application. The physical and biologic half-lives of this tracer are 14 and 7.8 days, respectively. The decay scheme consists of short-range tissue destroying beta, conversion, and Auger electrons, and a 159-keV gamma ray. Significantly, this compound has a high degree of affinity for newly calcified bone at the site of experimental burr holes in contrast to the adjacent bone marrow. Radioactive skeletal retention was one-half of whole body retention.