Roy A. Meals

Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture

BACKGROUND Dupuytrens 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. METHODS We 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. RESULTS Collagenase 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. CONCLUSIONS Collagenase clostridium histolyticum significantly reduced contractures and improved the range of motion in joints affected by advanced Dupuytrens disease. (ClinicalTrials.gov number, NCT00528606.)

Radioulnar Load-Sharing in the Forearm. A Study in Cadavera*

Custom-designed miniature load-cells were inserted into the distal end of the ulna and the proximal end of the radius in ten fresh-frozen forearms from cadavera. The forces transmitted through the bones at these sites were measured under 134 newtons of constant axial load that was applied through the metacarpals as the forearm was rotated from 60 degrees of supination to 60 degrees of pronation. The simultaneous measurements of these forces allowed the calculation of radioulnar load-sharing at the wrist and the elbow as well as the calculation of the amount of force that was transferred from the radius to the ulna through the interosseous membrane. With the elbow in valgus alignment (that is, with contact between the radial head and the capitellum), the main pathway for load transmission through the forearm was direct axial loading of the radius; measurements from both load-cells were unaffected by the angle of elbow flexion. When the forearm was in neutral rotation, the mean force in the distal end of the ulna averaged 2.8 per cent of the load applied to the wrist and the mean force in the proximal end of the ulna averaged 11.8 per cent; this indicated that only a small amount of tension developed in the interosseous membrane. With the elbow in varus alignment (that is, with no contact between the radial head and the capitellum), load was transmitted through the forearm by a transfer of force from the radius to the ulna through the interosseous membrane. When the forearm was in neutral rotation, the force in the distal end of the ulna averaged 7.0 per cent of the load applied to the wrist and the force in the proximal end of the ulna averaged 93.0 per cent; the force through the interosseous membrane decreased with supination of the forearm. Testing with the elbow in valgus alignment and shortening of the distal end of the radius in two-millimeter increments produced corresponding increases in force in the distal end of the ulna and decreases in force in the radial head. The forces through the interosseous membrane remained low after each amount of radial shortening. CLINICAL RELEVANCE: Transfer of load from the wrist, through the radius and the ulna, to the elbow is a complex event that depends on the position of the forearm, anatomy of the wrist, and soft-tissue linkages between the radius and the ulna. Varus-valgus alignment of the elbow influences the basic mechanism of force transmission through the forearm. The interosseous membrane plays a minimum role in load transmission with the elbow in valgus alignment. Dynamic gripping activities that include varus stress to the elbow would be expected to develop force in the interosseous membrane. Radioulnar load-sharing at the wrist and the elbow changed significantly when the distal end of the radius was shortened by as little as two millimeters (p < 0.05). With the elbow in valgus alignment, four millimeters of shortening was required to approximately balance the radioulnar loads at the wrist.

Publication patterns of papers presented at the Annual Meeting of The American Academy of Orthopaedic Surgeons.

Publication in a peer-reviewed journal is the ultimate lasting acknowledgment of an authors research results. Numerous clinical and basic-science papers are presented at the Annual Meeting of The American Academy of Orthopaedic Surgeons, but not all of these presentations culminate in publication in a peer-reviewed journal. In an effort to determine the percentages and patterns of publication, every presentation from the 1990, 1991, and 1992 meetings (a total of 1465 presentations) was reviewed with use of a Melvyl Medline Plus computer search during the summer of 1996. The presentations were classified on the basis of subspecialty. The over-all rate of publication by August 1996 was 46 per cent (668 of 1465), and the rates were similar for the 1990, 1991, and 1992 meetings. The average time to publication was twenty months, and most publications appeared within three years after presentation, with a plateau thereafter. Basic-science presentations had the highest rate of publication: 64 per cent (eighteen of twenty-eight presentations). The rates of publication by clinical subspecialty ranged from 39 per cent (twenty-eight of seventy-two presentations in the hand subspecialty and eighty-two of 210 presentations in the trauma subspecialty) to 53 per cent (110 of 206 presentations in the spine subspecialty). There was no significant difference among these groups (p = 0.611, chi-square test). The American volume of The Journal of Bone and Joint Surgery published the most papers (24 per cent; 161 of the 668 publications), followed by Clinical Orthopaedics and Related Research (16 per cent; 106 of 668). The over-all rate of publication of presentations at the Annual Meeting of The American Academy of Orthopaedic Surgeons is comparable with reported rates in other medical specialties.

Effects of short-term immobilization versus continuous passive motion on the biomechanical and biochemical properties of the rabbit tendon

Little work has been done on the effect that continuous passive motion (CPM) may have on maintaining the mechanical and biochemical characteristics of tendons deprived of normal load-bearing stimuli. This study compared changes in mechanical properties and collagen concentrations of the tibialis anterior tendon between two groups of rabbits: control animals that received no treatment and experimental animals that received CPM to one ankle and immobilization to the other. Treatment duration was three weeks. Mechanical testing yielded values for elastic modulus, stiffness, stress, strain, and strain energy density at linear and maximum loads. Hydroxyproline concentrations were measured to determine tendon collagen content. Findings indicated that cyclic tensile loading of tendons by CPM lessened the harmful effects of immobilization. Linear load and stress for CPM and control tendons were similar, while the same measures for immobilized tendons were 16% and 25% less than control tendons. Ultimate strength of the control tendons, however, exceeded CPM tendons by 16% and immobilized tendons by 20%. Hydroxyproline levels were comparable for the CPM, control, and immobilized tissues. For a short duration (three weeks), CPM reduced the detrimental effects of immobilization in the tendon, primarily in the linear-load region.

Variations in digital sensory patterns: A study of the ulnar nerve—median nerve palmar communicating branch

Eighty percent of 50 dissected cadaver palms showed a communicating branch between the fourth and third common digital nerves (ulnar and median origins, respectively). The branch commonly crossed the palm with the superficial arterial arch and usually provided sensory fibers from a branch of the superficial ulnar nerve into the ring finger radial digital nerve. Caution should be taken during carpal tunnel release or other surgery along the axis of the fourth ray to avoid injury to this structure.

Publication pattern of papers presented at the American Society for Surgery of the Hand annual meeting.

Publication of research results in peer-reviewed journals represents the consummation of the scientific method. In order to determine the rate of publication of oral presentations at the annual meeting of the American Society for Surgery of the Hand, every presentation (n = 397) from the 1990, 1991, and 1992 annual meetings was subjected to a Medline Plus computer search in January 1995. Meeting abstracts were grouped by program designation to scientific session, research session, and residents and fellows conference categories, and a Kaplan-Meier survivorship curve was formulated for each category. We determined an ultimate publication rate of 52% at 53 months. Subanalysis by year of presentation showed rates of 32%, 48%, and 51% for the respective years 1992, 1991, and 1990, with publication for most research occurring within 3 years of presentation. No statistically significant difference existed between the three categories, although a distinct trend toward higher ultimate publication rate (74%) was found for research abstracts. The ultimate publication rate for hand surgery presentations is comparable to that reported for other disciplines.

Manual demands and consequences of rock climbing

Types of rock climbing, hand-grip techniques, and training practices used by rock climbers are described. A survey was completed by 46 climbers. Three fourths of the climbers reported a climbing-related injury; of these injured climbers, almost one half reported a hand or wrist injury. More than half of the injured climbers had been treated by a physician for their injury. More than half of all climbers reported distal interphalangeal or proximal interphalangeal joint pain while climbing. Case reports of three climbers with acute hand injuries are presented to illustrate the minimal effects of their residual deficits on their climbing abilities. A wider understanding of the manual aspects of rock climbing and an awareness of the patterns and incidence of injuries in this sport will facilitate prevention, treatment, and rehabilitation.

Hand Fractures: A Review of Current Treatment Strategies

Fractures of the tubular bones of the hand are common and potentially debilitating. The majority of these injuries may be treated without an operation. Surgery, however, offers distinct advantages in properly selected cases. We present a review of hand fracture management, with special attention paid to advances since 2008. The history and mechanisms of these fractures are discussed, as are treatment options and common complications. Early mobilization of the fractured hand is emphasized because soft tissue recovery may be more problematic than that of bone.

Severe limb deficiency in Poland's syndrome.

Although Polands syndrome is classically considered to consist of simple syndactyly, limb hypoplasia, and ipsilateral pectoral muscle agenesis, a rate group of patients with pectoral agenesis has more severe limb deficiencies. In ten of these patients and in similar patients reported in the literature, a broad range of limb deformities was observed. The authors classified the patients according to limb anomalies: type 1, five digits present even if hypoplastic; type 2, functional border digits with the absence of central digits; type 3, more severe absence deformities with no functional digits; and type 4, radial ray defects with absent thumb. The understanding that Polands syndrome includes a spectrum of limb anomalies is important in searching for associated birth defects, in genetic counseling, and, possibly, in elucidating the pathogenesis of the syndrome.

The journal club and its role in hand surgery education

Journal clubs are a time-honored method of teaching literature appraisal skills in many residency programs. A questionnaire was completed by 57 hand surgery fellowship directors and 91 hand fellows to define the role of the journal club in hand fellowship training. We sought to identify definitive characteristics of hand surgery journal clubs and assess their strengths and weaknesses. One hundred forty-eight of 164 (90%) directors and fellows responded, yielding information on 57 of 58 accredited hand fellowships. Forty-nine of 57 (86%) responding fellowships have a journal club. The majority of clubs meet monthly for 1 to 2 hours, usually within the hospital. The primary purpose is to familiarize both fellows and attendings with the current literature. Most often, fellows choose the articles, which are most commonly original research and review articles. Usually, faculty presides, and residents and fellows present. Increased faculty participation was the most frequently suggested improvement. The great majority of those surveyed felt that their journal club was successful and was an important part of the fellowship training. We conclude that journal clubs have a high perceived value by participants, and recommend the journal club to all hand surgery communities, with or without fellowship involvement.