Paul Binhammer

Steroid Injection and Needle Aponeurotomy for Dupuytren Contracture: A Randomized, Controlled Study

PURPOSE To compare flexion deformity at 6 months in patients with Dupuytren contracture who had percutaneous needle aponeurotomy (PNA) combined with a series of triamcinolone acetonide (TA) injections to that of patients who had PNA alone. METHODS Forty-seven patients with Dupuytren disease who were candidates for PNA (at least 1 contracture of at least 20°) participated in the study. Patients were randomized either to receive TA injections immediately following and 6 weeks and 3 months after the procedure or to receive no injections. Injections were administered into cords. The number of injections and the amount of TA per injection was determined based on the number of digits involved and the cord size. All subjects returned for 3 follow-up visits after the procedure, and contractures were measured using a goniometer. Change in total active extension deficit (TAED) was analyzed using a repeated measures analysis of variance to assess for differences between groups, time points, and interaction between group and time point. Descriptive statistics were calculated for all variables of interest. Continuous measures were summarized using means and standard deviations. RESULTS There was no significant difference in TAED between groups before cord aponeurotomy. Correction at 6 months was 87% of preoperative TAED for the TA group versus 64% for the control group. This difference was statistically significant. The amount of TA administered did not correlate with TAED improvement. CONCLUSIONS The study group who received TA in combination with PNA experienced a significantly greater degree of correction of flexion deformity at 6 months than those who had PNA alone.

A New System for Severity Scoring of Facial Fractures: Development and Validation

Facial fractures are often the result of high-velocity trauma, causing skeletal disruption affecting multiple anatomic sites to varying degrees. Although several widely accepted classification systems exist, these are mostly region-specific and differ in the classification criteria used, making it impossible to uniformly and comprehensively document facial fracture patterns. Furthermore, a widely accepted system that is able to provide a final summary measure of fracture severity does not exist, making it difficult to investigate the epidemiologic data surrounding facial fracture severity. In this study, a comprehensive method for panfacial fracture documentation and severity measurement is proposed and validated through a retrospective analysis of 63 patients operated on for acute facial fracture. The severity scale was validated through statistical analysis of correlation with surrogate markers of severity (operating room procedure time and number of implants). Spearman correlation coefficients were calculated, and a statistically significant correlation was found between severity score and both number of implants and operating room procedure time (R = 0.92790 and R = 0.68157, respectively). Intraclass correlation coefficients were calculated to assess intrarater and interrater reliabilities of the severity scale and were found to be high (0.97 and 0.99, respectively). This severity scale provides a valuable, validated research tool for the investigation of facial fracture severity across patient populations, allowing for systematic evaluation of facial fracture outcomes, cost-benefit analysis, and objective analysis of the effect of specific interventions.

Coronal fracture of the body of the trapezium: A case report

An unusual fracture of the trapezium was found on computed tomography examination after plain radiographs failed to demonstrate any bony pathology. This coronal fracture has not been previously mentioned in the literature. Management included open reduction and internal fixation with 2 lag screws.

Primary orbital fracture repair: development and validation of tools for morphologic and functional analysis.

Abstract The purpose of this study was to develop and validate a technique for objective quantitative evaluation of outcomes of orbital reconstruction. Facial three-dimensional images were captured using a Vectra three-dimensional camera. Morphometric analysis was based on interactive anthropometric identification. The analysis was applied to a population of healthy adults (n = 13) and a population of patients following primary repair of unilateral orbital fractures (n = 13). Morphologic results following reconstruction were evaluated by identifying residual asymmetries. All subjects further completed the Derriford Appearance Questionnaire and the Orbital Appearance and Function Questionnaire. Normative reference values for periorbital asymmetry were determined in a reference population. The mean asymmetry was less than 1.6 mm for each measured morphologic feature. In the trauma population, primary orbital reconstruction effectively restored normal periorbital symmetry in 16 of 20 measured parameters. The fracture population showed no significant differences in the degree of asymmetry in globe projection, lower eyelid position, or ciliary margin length. The overall DAS59 scores were significantly higher in the fracture population (P = 0.04). This was due to significantly higher physical distress and dysfunction scores (P = 0.02), as well as a trend toward higher general and social self-consciousness scores (P = 0.06). No significant difference in facial self-consciousness was noted (P = 0.21). Thus, although primary orbital reconstruction was effective in restoring periorbital morphology, patients still experienced a higher level of physical distress and dysfunction than their nontraumatized counterparts. This was in accordance with patient self-report, which indicated that a greater percentage of patients were significantly bothered by functional outcomes postoperatively as opposed to appearance.

Comparison of Third Toe Joint Cartilage Thickness to That of the Finger Proximal Interphalangeal (PIP) Joint to Determine Suitability for Transplantation in PIP Joint Reconstruction

PURPOSE To compare the cartilage thickness of the third toe joints to the finger proximal interphalangeal (PIP) joints to assess the appropriateness of using third toe osteochondral grafts for finger PIP joint reconstruction. METHODS A laser scanner was used to construct 3-dimensional computer models of 6 matched cadaver right third toe PIP joints, condyles of the third toe middle phalanx, and finger PIP joints with and without cartilage. Cartilage distribution patterns were computed and analyzed for each surface. The cartilage thickness of both sides of the third toe PIP joint and the third toe middle phalanx condyles were compared to the PIP joint of the fingers. A total of 18 third toe and 48 finger joint surfaces were analyzed. RESULTS For the third toe middle phalanx condyles, the mean thickness was 0.20 ± 0.09 mm with a maximum of 0.52 ± 0.18 mm, and a coefficient of variation (CV%; a measure of uniformity of cartilage distribution) of 62. For the third toe proximal phalanx condyles, the mean cartilage thickness was 0.26 ± 0.10 mm with a maximum thickness of 0.56 ± 0.14 mm and a CV% of 44. The mean thickness, maximum thickness, and CV% of the finger proximal phalanx condyles was 0.43 ± 0.11 mm, 0.79 ± 0.16 mm, and 31, respectively. For the third toe middle phalanx base, the mean thickness was 0.28 ± 0.06 mm with a maximum of 0.47 ± 0.09 mm and a CV% of 34, compared to the finger middle phalanx base mean of 0.40 ± 0.12 mm with a maximum of 0.67 ± 0.14 mm and a CV% of 27. CONCLUSIONS There were significant differences in cartilage thickness between the third toe and the fingers in this study. However, fewer differences were observed with the third toe middle phalanx base cartilage thickness than with the third toe condyles in comparison to the fingers.

Structural Comparison of the Finger Proximal Interphalangeal Joint Surfaces and Those of the Third Toe: Suitability for Joint Reconstruction

PURPOSE This study compared the degree of surface structural similarity between finger proximal interphalangeal joints and third toe articular surfaces to assess the appropriateness of using partial toe articular osteochondral grafts for finger joint reconstruction. METHODS Computer models were generated from 4 paired cadaver hands and feet and compared the radius of curvature of toe and finger articular surfaces. The angle created by the palmar divergence of adjacent condyles of the same phalanx was also compared and described as the angular difference. The distal articular surfaces of the third toe proximal and middle phalanx were compared to distal articular surfaces of all 4 finger proximal phalanges. The radius of curvature was also compared between the third toe middle phalanx base and those of all 4 fingers. RESULTS The toe middle phalanx medial and lateral condyles were 66% and 60% the size of the respective finger condyles. The mean angular difference between adjacent condyles of the toe middle phalanx compared to the finger was 20°. The toe proximal phalanx medial and lateral condyles were 75% and 70% the size of the respective finger condyles, with a mean angular difference between adjacent condyles of 6°. The toe middle phalanx medial base was closer in size to that of the finger (95% to 178%) compared to the toe middle phalanx lateral base (205% to 254%). CONCLUSIONS This study revealed that the third toe proximal phalanx distal articular surface more closely matched the geometric characteristics of the finger proximal phalanx distal articular surface than did the toe middle phalanx distal articular surface. The medial base of the toe middle phalanx more closely approximated the size of the finger middle phalanx base than did the lateral toe middle phalanx base. CLINICAL RELEVANCE Quantitative data have been provided to help guide third toe osteochondral donor site selection when reconstructing traumatic finger proximal interphalangeal joint defects. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Are We Over Treating Hand Fractures? Current Practice of Single Metacarpal Fractures

Purpose: We conducted a national survey of Canadian plastic surgeons to assess if inconsistencies in management strategies exist for single metacarpal fractures. Methods: A cross-sectional study of Canadian plastic surgeons who perform hand surgeries was conducted. A 15-question survey was distributed to all members of the Canadian Society of Plastic Surgeons. Participants’ demographics, practice settings, and current treatment strategies for patients presenting with single metacarpal fractures were evaluated. Results: A total of 113 Canadian plastic surgeons met inclusion criteria. The majority of respondents were male (76%), with 50% in practice for more than 15 years. Canadian surgeons used a wide variety of surgical techniques for the management of single metacarpal fractures, with close reduction (94%), Kirshner wires (94%), and splinting and immobilization (89%) being the most common. The majority of plastic surgeons stated that rotational deformity (81%) was the most important indication for surgery. Surgeons demonstrated a trend toward immobilization after splinting (48%), instead of early mobilization after splinting (21%). When results were stratified by years in practice, no differences in surgical and non-surgical management were found, although surgeons in practice for less than 15 years were more likely to suggest hand therapy. Conclusion: These findings demonstrate inconsistencies in management of single metacarpal fractures among Canadian plastic surgeons. Surprisingly, surgeons in the survey tended to favor immobilization, as oppose to the literature that favors mobilization. The study highlights the lack of clear guidelines dictating treatment, possibly leading to these inconsistencies.

Comparison of Computed Tomography Articular Surface Geometry of Male Versus Female Thumb Carpometacarpal Joints

Background: Given the predilection of first carpometacarpal (CMC) joint osteoarthritis in women compared with men, we aim to determine the differences in first CMC joint surface geometry and congruence between young healthy males and females. Methods: Wrist computed tomographic scan data of 11 men and 11 women aged 20 to 35 years were imported into 3-dimensional software programs. The first metacarpal and the trapezium were aligned in a standardized position according to landmarks at key points on Gaussian and maximum curvature maps. Measurements of joint congruence and surface geometry were analyzed, including joint space volume, distance between the bones at the articular surface edges, area of the joint space, and radii of curvature in the radial-ulnar and volar-dorsal planes. Results: The mean thumb CMC articular space volume was 104.02 ± 30.96 mm3 for females and 138.63 ± 50.36 mm3 for males. The mean first metacarpal articular surface area was 144.9 ± 10.9 mm2 for females and 175.4 ± 25.3 mm2 for males. After normalizing for size, the mean thumb CMC articular space volume was 119.4 ± 24.6 mm3 for females and 117.86 ± 28.5 mm3 for males. There was also no significant difference for the articular space volume, articular surface distances, articular space, and mean radii of curvatures. Conclusions: This study found that there are sex differences in the first CMC joint articular volume without normalizing for size; however, there are no sex differences in first CMC joint articular volume, curvature characteristics, or joint congruence of young, healthy patients after normalizing for joint size.

Steroid Injection and Needle Aponeurotomy for Dupuytren Disease

Purpose The purpose of this study was to compare the use of a combination treatment of needle aponeurotomy (NA) and injected steroids with NA alone for patients with Dupuytren disease (DD).

Corticosteroid Injections and Needle Aponeurotomy in the Management of Dupuytren’s Contracture

Needle aponeurotomy is an effective, noninvasive surgical option for patients with Dupuytren’s disease. However, the drawback of the procedure is a high recurrence rate. Injections of triamcinolone acetonide have been reported to improve keloids and hypertrophic scars. Triamcinolone has been reported to modify disease progression when injected into Dupuytren’s nodules. By combining these two treatments, it is possible to improve the outcomes for needle aponeurotomy alone. Injection of triamcinolone is a safe, simple addition to the needle aponeurotomy procedure that results in increased joint extension.