Fasciectomy For Dupuytren Research Articles

The Evidence for Perioperative Anesthetic Techniques in the Prevention of New-Onset or Recurrent Complex Regional Pain Syndrome in Hand Surgery.

Complex regional pain syndrome (CRPS) is a multifaceted condition characterized by chronic neuropathic pain, allodynia, and hyperalgesia. The incidence of CRPS postoperatively is alarmingly high, particularly following carpal tunnel surgeries, Dupuytren's fasciectomy, and repairs of wrist and hand fractures, with recurrence rates soaring in individuals with a history of CRPS. Despite extensive research, the management of CRPS remains complicated, highlighting the urgent need for effective prevention strategies. This scoping review aimed to consolidate current evidence surrounding the efficacy of perioperative anesthetic techniques in preventing new-onset or recurrent CRPS, focusing on the application of various anesthetic interventions. Through a comprehensive literature search, eight articles were identified, discussing a spectrum of techniques, including wide awake local anesthesia no tourniquet (WALANT) and various regional blockade methods. This review revealed that the WALANT technique, with its simplicity and lower costs, exhibited promising results in preventing CRPS. Conversely, techniques involving intravenous regional and axillary plexus blocks showed variable efficacy, necessitating further investigation. The scarcity of high-quality evidence underscores the critical need for meticulously designed, large-scale randomized controlled trials to validate these findings and explore the potential of stellate ganglion block in the prevention of recurrent CRPS.

THE EPIGENETIC LANDSCAPE IN SOFT-TISSUE FIBROSIS

Dupuytren's disease (DD) is a fibroproliferative soft tissue disease affecting the palmar fascia of the hand causing permanent and irreversible flexion contracture. Aberrant fibrosis is likely to manifest through a combination of extrinsic, intrinsic, and environmental factors, including genetics and epigenetics. However, the role of epigenetics in soft tissue fibrosis in diseases such as DD is not well established. Therefore, we conducted a comprehensive multi-omic study investigating the epigenetic profiles that influence gene expression in DD pathology. Using control (patients undergoing carpal tunnel release) and diseased fibroblasts (patients undergoing Dupuytren's fasciectomy), we conducted ATAC-seq to assess differential chromatin accessibility between control and diseased fibroblasts. Additionally, ChIP-seq mapped common histone modifications (histone H4; H3K4me3, H3K9me3, H3K27me3, H4K16Ac, H4K20Me3) associated with fibrosis. Furthermore, we extracted RNA from control and DD tissue and performed bulk RNA-seq.ATAC-seq analysis identified 2470 accessible genomic loci significantly more accessible in diseased fibroblasts compared to control. Comparison between diseased and control cells identified numerous significantly different peaks in histone modifications (H4K20me3, H3K27me3, H3K9me3) associated with gene repression in control cells but not in diseased cells. Pathway analysis demonstrated a substantial overlap in genes being de-repressed across these histone modifications (Figure 1). Both, ATAC-seq and ChIP-seq analysis indicated pathways such as cell adhesion, differentiation, and extracellular matrix organisation were dysregulated as a result of epigenetic changes. Moreover, de novo motif enrichment analysis identified transcription factors that possibly contributed to the differential gene expression between control and diseased tissue, including HIC1, NFATC1 and TEAD2. RNA-seq analysis found that these transcription factors were upregulated in DD tissue compared to control tissue.The current epigenetic study provides insights into the aberrant fibrotic processes associated with soft tissue diseases such as DD and indicates that epigenetic-targeted therapies may be an interesting viable treatment option in future.For any figures or tables, please contact the authors directly.

Collagenase clostridium histolyticum injection versus limited fasciectomy for the treatment of Dupuytren's disease: a systematic review and meta-analysis of comparative studies.

The aim of the present study is to systematically review the literature on well-selected comparative studies for meta-analysis on outcome differences between collagenase clostridium histolyticum (CCH) injection and limited fasciectomy (LF) forDupuytren's disease. PubMed/Medline, Embase, and the Cochrane Library were searched for comparative studies assessing differences in outcomes of CCH and LF. Effect estimates were pooled across studies using random effects models and presented as weighted mean difference (MD) and odds ratio (OR) with corresponding 95% confidence interval (CI). A total of 11 studies encompassing 1'051 patients was included (619 patients in the CCH and 432 in the LF group). The residual contracture at a minimal average follow-up of three months was higher in the CCH group than in the LF group (27.8 vs. 16.2°, MD 11.6°, 95% CI [8.7, 14.5°], p < 0.001). The recurrence rate was significantly higher in the CCH group (25.8 vs. 9.3%, OR 5.2, 95% CI [1.5, 18.8], p = 0.01) while the rate of severe complications was significantly higher in the LF group (0.3 vs. 7.3%, OR 0.12, 95% CI [0.03, 0.42], p = 0.001). Evidence of the present study confirms that CCH injection has a higher rate of disease recurrence whereas LF carries a higher risk for severe complications. It's imperative that the trade-off between these aspects is considered, keeping in mind that CCH injections may be repeated in case of disease recurrence without increasing procedure related risks, especially in complex cases.

Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis.

Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use. (1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not? In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use. When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually. Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies. Level III, therapeutic study.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy.

The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy. We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6. The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group. Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

Fasciectomy under local anaesthetic and adrenaline for Dupuytren's contracture in a community setting in the UK with a cost analysis.

In the UK, fasciectomy for Dupuytren's contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354-1358.

Dupuytren's Fasciectomy: Surgical Pearls in Planning and Dissection.

Fasciectomy remains the mainstay of surgical treatment for Dupuytren's disease at many units worldwide, particularly in cases of recurrence after aponeurotomy or enzymatic fasciotomy. In some series, this has been reported as high as 48% in 3 years. The lead author has since abandoned the use of collagenase altogether. In this innovation article, we describe simple maneuvers to aid the planning and dissection of a Dupuytren's fasciectomy. We describe techniques to enable efficient dissection of the cord and minimize problems when designing skin flaps. We also highlight technical points in revision cases.

Predictors of Patient Satisfaction with Hand Function after Fasciectomy for Dupuytren's Contracture.

This study examined patient satisfaction with hand function after fasciectomy for Dupuytren's contracture and determined which preoperative patient- and disease-specific factors predicted this satisfaction. Demographics and disease-specific factors were assessed from a prospective cohort of 194 patients who completed the Michigan Hand Outcomes Questionnaire preoperatively and underwent limited fasciectomy between 2011 and 2014 at six hand surgery practice sites. To evaluate satisfaction with hand function, patients were asked to complete the Michigan Hand Outcomes Questionnaire during the first year after fasciectomy. After patients were classified into a satisfied and an unsatisfied category using the question that specifically pertains to satisfaction with hand function, the authors applied multivariate logistic regression modeling to identify independent predictors of patient satisfaction. At an average of 10 months (range, 6 to 12 months) after fasciectomy, 84 percent (n = 163) of the patients were satisfied with their hand function. In multivariate analyses adjusting for the degree of postoperative residual contracture (p < 0.001) and complications (p < 0.001), a higher preoperative Michigan Hand Outcomes Questionnaire hand appearance subscore and male gender predicted a higher likelihood of becoming satisfied after fasciectomy. Other patient- and disease-specific factors did not show evidence for an association with patient satisfaction. The findings of this study suggest that providers should consider assessing concerns about the appearance of the hand in patients with Dupuytren's contracture. They also highlight the importance of complication prevention and full contracture correction from the patient's perspective. Risk, III.

Variations in Postoperative Immobilization Following Common Hand Surgery Procedures.

The aim was to investigate variations in the duration of postoperative immobilization for common hand surgery procedures and to determine whether there is any correlation between surgeon experience and duration of postoperative immobilization. An anonymous cross-sectional survey was sent to the American Society for Surgery of the Hand asking the following questions: (1) number of years in practice and (2) duration of immobilization for 16 common hand surgery procedures. A Pearson's correlation coefficient was used to determine correlations between surgeon experience and duration of immobilization. Box plots were created to display the distribution and variability in postoperative immobilization per procedure among surgeons. A total of 1126 respondents completed the survey, yielding a response rate of 40%. Procedures with a greater average duration of immobilization demonstrated the greatest variability. The largest variability overall was observed in intercarpal ligament repair with the majority of responses distributed between 4 and 10 weeks of immobilization. The smallest variability was observed following De Quervain's release and Dupuytren's fasciectomy. Only small correlations between surgeon experience and duration of immobilization were observed. Specifically, all Pearson correlation coefficients were less than .20. This study supports the hypothesis that large variations exist in the duration of immobilization following common hand surgery procedures. Only small correlations were found between surgeon experience and average duration of immobilization. The study suggests that there is a lack of evidence to guide postoperative immobilization for common hand surgery procedures and that prolonged immobilization may not be necessary for certain hand procedures.

The quantitative role of flexor sheath incision in correcting Dupuytren proximal interphalangeal joint contractures.

Controversy exists regarding intra-operative treatment of residual proximal interphalangeal joint contractures after Dupuytren's fasciectomy. We test the hypothesis that a simple release of the digital flexor sheath can correct residual fixed flexion contracture after subtotal fasciectomy. We prospectively enrolled 19 patients (22 digits) with Dupuytren's contracture of the proximal interphalangeal joint. The average pre-operative extension deficit of the proximal interphalangeal joints was 58° (range 30-90). The flexion contracture of the joint was corrected to an average of 28° after fasciectomy. In most digits (20 of 21), subsequent incision of the flexor sheath further corrected the contracture by an average of 23°, resulting in correction to an average flexion contracture of 4.7° (range 0-40). Our results support that contracture of the tendon sheath is a contributor to Dupuytren's contracture of the joint and that sheath release is a simple, low morbidity addition to correct Dupuytren's contractures of the proximal interphalangeal joint. Additional release of the proximal interphalangeal joint after fasciectomy, after release of the flexor sheath, is not necessary in many patients. IV (Case Series, Therapeutic).

Hueston Revisited

Various surgical treatment modalities have been advocated for the treatment of Dupuytren's disease. However, recurrence following surgical treatment of Dupuytren's disease remains a common problem. Previous studies have demonstrated lower recurrence rates with use of a full-thickness skin graft. We therefore postulated that use of acellular dermal matrix may be associated with a similar outcome, based on the common inhibitory effect on underlying myofibroblasts. We performed a retrospective cohort study of 43 patients undergoing open fasciectomy for Dupuytren's disease from years 2005 to 2012 at our academic institution. Standard fasciectomies of the affected palmar and digital fascia were performed via Brunner incisions on all patients. Patients in the experimental group had a sheet of acellular dermal matrix (Alloderm; LifeCell, Bridgewater, NJ) sutured into the surgical bed with interrupted absorbable sutures before closure, whereas patients in the control group were not closed with acellular dermal matrix. Patients were then evaluated at follow-up for disease recurrence, defined as presence of Dupuytren's tissue in an area previously operated on with a contracture greater than that recorded following the surgical fasciectomy, or presence of contracture requiring surgery. Among our cohort of 43 patients, 23 (53.5%) were treated with acellular dermal matrix while 20 (46.5%) were not. The median age of our cohort was 66.5 years (range 54-91 years). The median follow-up was 1.8 years. During this follow-up period, recurrence of contracture was observed in 1 of 23 patients in the group receiving acellular dermal matrix, compared to 5 of 20 in the control group (P = 0.045). No differences in the incidence of minor wound complications were observed. Our novel technique of placement of acellular dermal matrix into the wound bed following fasciectomy for Dupuytren's disease may be an important surgical strategy to reduce recurrence rates in patients with Dupuytren's disease.

The incidence of postoperative flare reaction and tissue complications in Dupuytren's disease using tension-free immobilization.

Open fasciectomy represents a standard treatment of Dupuytren's disease. Although patients are commonly immobilized in extension to prevent postoperative contracture formation, immobilizing the extremity under tension may precipitate a flare reaction and scar-related complications. This study explores the incidence of flare reaction and other complications with postoperative tension-free splinting after fasciectomy for Dupuytren's contracture. We retrospectively reviewed patients' charts that consisted of 228 procedures in 191 patients who underwent surgery by the senior author between 2000 and 2010. Postoperative notes were reviewed for wound healing problems, scar appearance, flare reaction, and complications. The grading system defined by Evans et al. was used to standardize flare reaction and scar complications. Using tension-free splinting, the incidence of flare reaction was 3.5% (8/228). The eight patients that had flare reactions had mild involvement, and no severe reaction was observed. Fifteen patients had hypertrophic scars, eight had hypersensitive scars, and six had recurrent contractures. The incidence of flare reaction using tension-free immobilization postoperatively was low in our study. According to our findings, wound healing problems are rare when tensionless splinting is utilized. Type of study/level of evidence Case series, Level IV, Therapeutic study.

Safety and tolerability of collagenase Clostridium histolyticum and fasciectomy for Dupuytren’s contracture

Safety was evaluated for collagenase Clostridium histolyticum (CCH) based on 11 clinical trials (N = 1082) and compared with fasciectomy data in a structured literature review of 48 European studies (N = 7727) for treatment of Dupuytren’s contracture. Incidence of adverse events was numerically lower with CCH vs. equivalent complications from fasciectomy (median [range] incidence), including nerve injury (0% vs. 3.8% [0%−50+%]), neurapraxia (4.4% vs. 9.4% [0%−51.3%]), complex regional pain syndrome (0.1% vs. 4.5% [1.3%−18.5%]) and arterial injury (0% vs. 5.5% [0.8%−16.5%]). Tendon injury (0.3% vs. 0.1% [0%−0.2%]), skin injury (16.2% vs. 2.8% [0%−25.9%]) and haematoma (77.7% vs. 2.0% [0%−25%]) occurred at a numerically higher incidence with CCH than surgery. Adverse events in CCH trials not reported after fasciectomy included peripheral oedema; extremity pain; injection site pain, haemorrhage and swelling; tenderness; pruritus and lymphadenopathy. CCH-related adverse events were reported as predominantly injection-related and transient. These results may support clinical decision-making for treatment of Dupuytren’s contracture.

Angular correction related to excision of specific cords in fasciectomy for Dupuytren’s disease

Named cords were excised sequentially at fasciectomy for Dupuytren's disease and the resultant correction in the joint angle was measured intra-operatively in 99 fingers. Eighty-two metacarpophalangeal and 59 proximal interphalangeal joints were affected. At the metacarpophalangeal joint, excision of the central cord resulted in 82% correction in 69 joints, and spiral/lateral cord excision resulted in an additional 12% correction in 10 joints. At the proximal interphalangeal joint, excision of the central cord resulted in 44% correction in 36 joints, spiral/lateral cord excision resulted in an additional 19% correction in 16 joints, and retrovascular cord excision resulted in a further 23% correction in 27 joints. Subsequent division of the accessory collateral ligament resulted in a further 14% correction in 14 joints. Larger pre-operative angles of the proximal interphalangeal joint were associated with a retrovascular cord, and larger combined angles were associated with an increasing number of pathological structures involved. The data explain the complexity of surgery at the proximal interphalangeal joint, where four structures are implicated in causing flexion deformity.

A rare anatomical variation of the Berrettini anastomosis and third common palmar digital branch of the median nerve

Variations in the origin and distribution of Berrettini anastomosis between the digital branches of the ulnar and median nerves exist and are well described in the literature. During regular dissections by medical students, we encountered a rare variation in the left hand of an approximately 50-year-old male cadaver. Berrettini anastomosis connecting the third common palmar digital branch of the median nerve with the fourth common palmar and proper palmar digital branches of the ulnar nerve presented a plexiform nature. This communicating branch and the third common palmar digital branch of the median nerve were perforated by the superficial palmar arch. Further, the superficial palmar arch was incomplete, and it was solely formed by the superficial branch of the ulnar artery. The unusual relationship of Berrettini anastomosis with the superficial palmar arch is very rare, and knowledge about such a variation is important when performing carpal tunnel release, flexor tendon surgery, and Dupuytren's fasciectomy and when dealing with arterial repairs and vascular graft applications in the hand.

The development of one-stop wide-awake dupuytren's fasciectomy service: a retrospective review

ObjectivesTo detail the transition to a totally one-stop wide-awake (OSWA) Dupuytren's contracture surgical service.DesignRetrospective review of Dupuytren's component of last 1000 OSWA cases.SettingThe UK's first totally one-stop wide-awake orthopaedic service.Participants270 patients with Dupuytren's contracture out of the last 1000 OSWA cases.Main outcome measuresSurgical outcomes, patient satisfaction and cost-effectiveness and efficiency.ResultsThe OSWA Dupuytren's model is safe, efficient and effective; with a low complication rate, extremely high patient satisfaction; and cost-savings to the nhs of £2500 per case treated. The service saved the NHS approximately £675,000 for the 270 cases presented.ConclusionsA totally one-stop wide-awake Dupuytren's Contracture service is practicable and feasible alternative to the conventional treatment pathway, with benefits in terms of efficiency and cost-effectiveness.

Patient Satisfaction with Postoperative Follow‐up by a Hand Therapist

There has been a move to reduce and, indeed, stop postoperative appointments for uncomplicated surgical procedures within the National Health Service. The purpose of this study was to measure patient satisfaction with postoperative follow-up conducted by a hand therapist, with no routine postoperative follow-up by the surgeon. A total of 124 patients were recruited over two years. Fifty patients post-simple trapeziectomy and 74 patients post-single-digit Dupuytren's fasciectomy were prospectively surveyed for their opinion on their postoperative care and whether or not they would have liked to be reviewed by the surgeon in a routine postoperative follow-up appointment. All patients included in this study had their operations performed by one surgeon in one hospital. All patients were reviewed by a hand therapist within two weeks of surgery. A total of 116 patients completed the study, of whom 106 patients (91%) were satisfied with their postoperative management and 99 patients (85%) did not want to be reviewed by the surgeon in a postoperative outpatient follow-up appointment. This study reflects the successful application of postoperative follow-up by a hand therapist.

Re: Howard et al. A prospective randomised trial of absorbable vs. non-absorbable sutures for wound closure after fasciectomy for Dupuytren’s contracture. J Hand Surg Eur. 2009, 34: 618–20.

Re: Howard et al. A prospective randomised trial of absorbable vs. non-absorbable sutures for wound closure after fasciectomy for Dupuytren’s contracture. J Hand Surg Eur. 2009, 34: 618–20.

Use of casting motion to mobilize stiffness to regain digital flexion following Dupuytren's fasciectomy

Background A priority in hand therapy following Dupuytren's fasciectomy is to regain and maintain extension of the proximal interphalangeal joint (PIPJ). Historically this has been achieved through the application of mechanical stress to the affected digit with splinting and exercise. However, loss of a normal pattern of digital flexion in both the operated and non-operated digits is a common complication. Method Four patients who underwent a Dupuytren's fasciectomy presented with persistent digital stiffness and a poor pattern of motion of the operated hand following traditional therapy. The casting motion to mobilize stiffness (CMMS) technique was therefore applied. The type of cast applied, duration of casting, duration of sessions and cast exercises are described. Results All patients regained digital flexion and an improved pattern of motion through the use of the CMMS technique without compromising PIPJ extension. Conclusion This small case series demonstrates the use of the CMMS technique to regain digital flexion and a normal pattern of motion when traditional treatment fails to achieve the desired outcomes following Dupuytren's fasciectomy. The use of the CMMS technique was beneficial in these patients and provides a means to regain digital flexion without the loss of PIPJ extension and is successful even when traditional therapy has failed.

Simultaneous Carpal Tunnel Release and Dupuytren's Fasciectomy

To determine whether members of the American Society for Surgery of the Hand (ASSH) consider it safe to perform concurrent carpal tunnel release (CTR) and Dupuytren fasciectomy, and to report our own experience with simultaneous CTR and fasciectomy. An e-mail survey was sent to all active members of the ASSH regarding their preferences in the concurrent surgical management of carpal tunnel syndrome and Dupuytren's disease. In addition, 70 patients who had had simultaneous CTR and Dupuytren's fasciectomy were identified in a retrospective chart review from a 7-person hand surgery group. Data on the severity of disease and risk factors for intraoperative, early, and late complications were collected for these patients. Comparison groups of 50 patients having fasciectomy alone and 50 patients having CTR alone were also compiled for internal comparison. The survey response rate was 50% (698/1399 respondents). Fifty percent of the responding ASSH members replied that they would not or would only sometimes perform these 2 procedures together because of concern for the development of complex regional pain syndrome and postoperative stiffness. Two of 70 patients experienced a transient pain flare, and 1 of 70 experienced stiffness, which was comparable to internal and literature controls for Dupuytren's fasciectomy alone. Controversy exists among ASSH members in regard to treating carpal tunnel syndrome and Dupuytren's disease simultaneously. Based on our findings, we recommend performing both of these procedures at the same surgical session, thereby dispelling the myth that simultaneous surgery has an increased complication rate.