Extension Deficit Research Articles

The CeCORD-J study on collagenase injection versus aponeurectomy for Dupuytren's contracture compared by hand function and cost effectiveness

This study compared hand function and the cost-effectiveness of treatment between collagenase Clostridium histolyticum (CCH) injection and limited fasciectomy for patients with Dupuytren’s contracture (DC). The CeCORD-J study is a prospective, multicenter, non-randomized controlled, observational study of two parallel groups. Participants were DC patients with multiple affected fingers, including flexion contracture of the proximal interphalangeal (PIP) joint. The primary outcome was the Hand10 score, as a patient-reported outcome measure (PROM). We set secondary outcomes of EQ-5D-5L (QOL) score, degree of extension deficit, and direct cost. Propensity score adjustment was used to balance differences in patient characteristics between groups. Participants comprised 52 patients in the Collagenase group and 26 patients in the Surgery group. There were no significant differences in the Hand10 and QOL scores between the two groups at 26 weeks. Mean direct cost was 248,000 yen higher in the Surgery group than in the Collagenase group. Extension deficit angle of the PIP joint was significantly larger in the Collagenase group at 26 weeks. Although the Collagenase group showed dominance in cost-effectiveness, there was no significant difference between the two groups in hand function at 26 weeks.

Arthroscopic Dorsal Ligamentocapsulodesis in the Treatment of Isolated Lunotriquetral Interosseous Ligamentous Injury: A Retrospective Case Series of 22 Patients.

Background: The literature is scarce regarding isolated tears of lunotriquetral interosseous ligament (LTIL). The purpose of this study was to present mid-term clinical and functional results of arthroscopic dorsal ligamentocapsulodesis in the treatment of isolated LTIL tears. Methods: Twenty-two patients (8 females, 14 males; mean age: 31 years; age range: 18-42) with isolated LTIL tears verified by wrist arthroscopy were retrospectively reviewed and included in the study. The mean follow-up was 55 months (range: 24-84). The modified Mayo wrist score, visual analog scale (VAS), flexion and extension deficits of passive wrist range of motion (ROM), pain-free ROM with forced wrist extension and grip strength were measured in all patients preoperatively and at final follow-up. Results: The mean modified Mayo wrist score significantly improved from 50 ± 10.29 preoperatively (range: 30-65) to 86 ± 11.61 (range: 60-100) at the final follow-up (p < 0.001). The mean VAS score significantly improved from 7.1 ± 0.83 (range: 6-8) preoperatively to 2.2 ± 1.35 (range: 0-6; p < 0.001) at the final follow-up. At the final follow-up examination, the forced wrist extension was painless in all but three patients who developed pain at 70º, 75º and 80º of extension, respectively. The mean strength of hand grip significantly increased from 38.6 ± 9.68 (range: 24-54) kg to 49.5 ± 12.36 (range: 33-66) kg at the final assessment (p < 0.001). No major complications were observed during or after the procedure. Conclusions: With the encouraging mid-term outcomes and a lower complication rate, arthroscopic LTIL dorsal ligamentocapsulodesis seems to be a safe and effective surgical technique in improving functional outcomes and reducing pain in patients with isolated LTIL tears. Level of Evidence: Level IV (Therapeutic).

Two-level fixation with headless compression screws for tibial plateau fractures

PurposeReduction and fixation of tibial plateau fractures associated with small, “floating” intra-articular fragments proposes a challenge. We use fully threaded headless compression screws for (interfragmentary) fixation of such fragments before final plate fixation when standard fixation of intra-articular fragments with k-wires or lag screws is deemed insufficient. Our aim is to describe our technique and clinical experience of this two-level fixation.MethodsBetween 2006 and 2021, 29 patients with a comminuted tibial plateau fracture were treated with this two-level fixation in this retrospective case series. Clinical baseline and surgical variables were collected for all patients. Clinical outcome variables were available for 28 patients with a median follow-up of 16.5 months (IQR 5–24). Functional outcomes were measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and reported by 22 patients at a median of 5.2 years (IQR 3.5–9.8).ResultsReduction was anatomic or good in 82% of cases, fair in 14%, and a malreduction in 4%. Arthrosis was graded as grade 0 in 25% of cases, 1 in 39%, 2 in 21%, and 3 in 14%. Flexion was 110 degrees (IQR 100–130). Five patients had an extension deficit of 5 to 10 degrees. Median KOOS for symptoms and stiffness was 69 points (IQR 45–78), for pain 71 (IQR 45–88), for ADL 85 (IQR 52–95), for sports 30 (IQR 11–55), and for quality of life 34 (IQR 19–56).ConclusionThe use of fully threaded headless compression screws is a simple and helpful addition in the treatment of comminuted tibial plateau fractures.

Arthrogenic Muscle Inhibition Following Knee Injury or Surgery: Pathophysiology, Classification, and Treatment

Background: Arthrogenic muscle inhibition (AMI), a process in which quadriceps activation failure is caused by neural inhibition, is common following knee injury or surgery. No classifications exist to describe the variable presentations of AMI following knee injury. Indications: AMI can result in significant morbidity following knee injury, and it is essential to recognize and treat. It is crucial to identify patients at higher risk of postoperative complications as surgery should be delayed for specific rehabilitation programs. Understanding the pathophysiology of AMI is vital as this can guide therapeutic interventions. Technique Description: AMI following knee injury can present in a variety of ways including inhibition of the vastus medialis obliquus (VMO) muscle, extension deficits due to hamstring contracture, as well as chronic extension deficits. They also respond differently to conventional treatment modalities and often require longer and specific rehabilitation programs. Therefore, we propose a classification to define these different presentations. Results: Grade 0 is a normal VMO contraction. Grade 1a is when VMO contraction is inhibited but activation failure is reversible with simple exercises while Grade 1b requires longer and specific rehabilitation programs. Grade 2a is when VMO contraction is inhibited with an associated extension deficit due to hamstring contracture, but activation failure and loss of range of motion is reversible with simple exercises. However, Grade 2b is refractory to simple exercises, and longer and specific rehabilitation programs are required. Grade 3 is a chronic extension deficit that is irreducible without extensive posterior arthrolysis. Conclusion: In conclusion, AMI is a process in which quadriceps activation failure is caused by neural inhibition and is common following knee injury or surgery. Not taking AMI into account preoperatively can result in a very high risk of stiffness postoperatively. We propose a classification for AMI following knee injury or surgery, which describes different presentations and can be used to guide management.

Transosseous Multiple Finger Flexor Tendon Pulley Reconstruction

Background: Closed finger flexor tendon pulley injuries occur most frequently in rock climbing but also during other heavy finger strength work or exercises. While single pulley injuries receive a conservative therapy, multiple pulley injuries often require a surgical repair, as otherwise they will lead to contracture and loss of range of motion and functionality. While established surgical techniques, which use bone encircling tendon graft techniques, were found to produce osteonecrosis of the phalanx, our new transosseous technique avoids this problem. Indications: All triple pulley injuries (A2,3,4) (grade-4b injuries) and double pulley injuries (A2,3 or A3,4) (grade-4a injuries) are indicated, if the injury is older than 10 days at the point of therapy start or the flexor tendons bowstringing is either not redressable in the ultrasound or extended. Also, grade-4a injuries are indicated, if a secondary contracture starts to build. Technique Description: Standard palmar-sided incision, followed by debridement of the tendon sheath, pulley flap, and, if applicable, scare tissue in between the flexor tendons and the bone is performed. Wire-guided 3.0-mm drill holes at the base phalanx at the level of the former distal portion of the A2 pulley are completed. Passing of the palmaris longus tendon through the drill hole and interlacing it as a “loop and a half” follows. Distal continuation through lacing the transplant through the remaining rims of the former pulleys and the flexor tendon sheath is then performed. Securing the repair after tendon gliding control to itself is completed. Postsurgically, the splint is immobilized for 2 weeks, followed by the use of a thermoplastic pulley support ring for 4 weeks with active mobilization. Results: No complications occurred during or after the surgery. In few cases, a restricted range of motion in the proximal interphalangeal (PIP) joint of the respective finger of up to 3 to 5 grade occurred. One patient, who had a presurgical PIP extension deficit of 30°, which was released during the surgery, developed over time again a 20° extension deficit. The functional outcome score ranged between good and excellent, with one case being only satisfactory. The sport-specific outcome score was either good or excellent for all patients, with one patient with contracture where it was satisfactory. No osteonecrosis of the phalanx was recorded. Discussion: For multiple pulley ruptures, various surgical techniques are described. We favored a modified “loop and a half” technique with a distal continuation to the A3 pulley. This combines the advantages of the “loop and a half” technique, as the strongest, and the Weilby repair, as the most functional repair. We recently noticed some cases with osseous necrosis of the phalanx following this repair, likely due to the high pressure of the circulation of the tendon graft onto the bone and its blood vessels. Therefore, we have modified our procedure into a transosseous repair, which is presented in this article. This approach was first evaluated in a cadaver study to exclude a potential risk of osseous failure (fracture) during stress caused by the drill hole. After ruling out this risk, the transosseous technique became our standard approach, as it combines the advantages of the “loop and a half” technique with those of the Weilby repair and decreases the pressure onto the dorsal cortex of the fingers base phalanx and thus the risk of osteonecrosis.

Anti-tumour necrosis factor therapy for early-stage Dupuytren's disease (RIDD): a phase 2b, randomised, double-blind, placebo-controlled trial.

BackgroundDupuytren’s disease is a common fibrotic condition that causes the fingers to flex irreversibly into the palm. Treatments for late-stage disease all have limitations, and there is no approved treatment for early-stage disease. We identified tumour necrosis factor as a therapeutic target in Dupuytren’s disease, and in a dose ranging trial found 40 mg adalimumab in 0·4 mL to be most efficacious. Here we aimed to assess the effects of intranodular injection of adalimumab in early-stage disease.MethodsIn this phase 2b, randomised, double-blind, placebo-controlled trial adults with early-stage Dupuytren’s disease and an established clinically distinct nodule with a clear history of progression in the preceding 6 months were recruited from two clinical centres in the UK and were randomly assigned 1:1 to receive four injections of adalimumab or saline every 3 months. Participants and assessors were masked. The primary outcome was nodule hardness measured with a durometer at 12 months. Data were analysed by linear mixed effects regression models in the intention-to-treat population with multiple imputation for missing primary outcome data. The trial is registered at the ISRCTN registry, ISRCTN 27786905 and is complete.FindingsBetween Feb 17, 2017, and Jan 11, 2019, 284 participants were screened in the UK and 140 were enrolled. 47 (34%) participants were female and 93 (66%) were male. Mean age of participants was 59·7 years (SD 10·0). Primary outcome data were available from 113 participants. Nodule hardness was lower (−4·6 AU [95% CI −7·1 to −2·2], p=0·0002) in the adalimumab compared with the saline group at 12 months. There were no related serious adverse events; the most common adverse events were minor injection site reactions.InterpretationIntranodular injections of adalimumab in participants with early-stage Dupuytren’s disease resulted in softening and reduction in size of the nodules. Longer follow-up would be required to assess the effect of tumour necrosis factor inhibition on disease progression, extension deficit and hand function.

Disease Course of Primary Dupuytren Disease: 5-Year Results of a Prospective Cohort Study.

Predicting progression of Dupuytren disease becomes relevant in an upcoming era with progression-preventing treatment. This study aimed to determine the course of Dupuytren disease and identify factors associated with progression. Two hundred fifty-eight patients with Dupuytren disease participated in this prospective cohort study, obtaining 17,645 observations in 5 years. Outcomes were disease extent (surface area) and contracture severity (total passive extension deficit). Demographics, lifestyle, health status, exposure to manual work, and genetic risk scores were gathered as potential predictors. Subject-specific, mixed-effects models were used to estimate disease course, and logistic regression with least absolute shrinkage and selection operator was used to evaluate factors associated with the presence of progression. On average, Dupuytren disease was progressive in all finger rays with regard to area [yearly increase, 0.07 cm2 (95% CI, 0.02 to 0.13 cm2) to 0.25 cm2 (95% CI, 0.11 to 0.39 cm2)]. Progression in total passive extension deficit was only present on the small finger side [yearly increase, 1.75 degrees (95% CI, 0.30 to 3.20 degrees) to 6.25 degrees (95% CI, 2.81 to 9.69 degrees)]. Stability or regression in area and total passive extension deficit was observed in 11 and 13 percent and 16 and 15 percent (dominant and nondominant hands), respectively. Smoking, cancer, genetic risk score, and hand injury were univariate associated with progression in area, but after multivariate variable selection, none of these associations remained. No predictors for progression in total passive extension deficit were found. Dupuytren disease is progressive, especially with respect to disease extent. Progression in contracture severity is mainly present on the small finger side of the hand. None of the traditional risk and diathesis factors were associated with progression, indicating that new hypotheses about Dupuytren disease progression might be needed. Risk, III.

Management of hypertrophic anterior cruciate ligament mucoid degeneration by arthroscopy

Introduction: Mucoid degeneration of the anterior cruciate ligament (ACL) is a less common entity. The primary pathology is the damage to the functional synovial lining protecting the ACL with no significant preceding trauma. Two types are described i.e., cystic (synovial and mucoid cysts) and infiltrating (mucoid degeneration). These lesions can be asymptomatic. When symptomatic, the patient complained of posterior knee pain with restriction of flexion in the knee. The diagnosis is confirmed by Magnetic Resonance Imaging of the Knee. Recent trends include arthroscopic procedures, including ACL debridement, i.e. partial resection. Total resection can be required in a few cases with ACL reconstruction. Inclusion Criteria: Diagnosed cases of ACL mucoid degeneration on MRI. Exclusion Criteria: Post-traumatic knee injuries-meniscal or ligamentous or bony, ACL synovial or mucoid cysts. Materials and Methods: A total of 18 patients diagnosed with ACL mucoid degeneration were included in the study. The study was conducted from August 2019-August 2021. The patients were assessed clinically with history and clinical examination. MRI was advised in patients with clinical suspicion of ACL mucoid degeneration. Results: The study sample consisted of 18 patients (7 females and 11 males) with ages ranging from 30 to 55 years (mean age, 43.2 years) in males and 35 to 55 years (mean age, 41.5 years) in females. On clinical assessment, exacerbation of pain was more commonly related with terminal flexion in 10 patients (58.8%) as compared to terminal extension (7 patients, 41%). No motion-related exacerbation of pain was seen in 1 case. 17 patients had an extension deficit. No complaint of instability was seen except for 2 cases. Postoperatively an average improvement of the Visual analogue scale by 4 was seen. No flexion or extension deformity was noted. No patient had any major complication. On follow up Anterior Lachman test was grade 1 in 16 cases and in others it was same as opposite non-affected knee. A complete resection of ACL with reconstruction using hamstring graft was done in 1 patient. The same patient showed a pain improvement of 4 scales on VAS. The patient however had episodes of instability. Conclusion: A clinical suspicion of mucoid degeneration of ACL with confirmatory classical appearance on MRI are key to diagnosis. Symptomatic pain relief is better provided with ACL debridement with mild laxity in upcoming future.

Surgical Treatment of Camptodactyly with Malek Cutaneous Approach and Stepwise Release: A Retrospective Multi-centre Study.

Background: Clinical manifestations of camptodactyly are varied and no official consensus on the etiopathogenesis or best treatment is available. Conservative treatment is generally preferred and, in refractory patients, surgery might be considered. However, reported results of surgery are often unsatisfactory and it is difficult to compare outcomes as different classification systems are adopted. We reported the outcomes of surgical treatment of camptodactyly with the Malek cutaneous approach and stepwise release, assessed using the Siegert classification. Methods: A retrospective analysis of paediatric patients (≥1 and ≤18 years) with congenital camptodactyly refractory to conservative management (flexion contracture >30°), treated with Malek cutaneous approach and stepwise release surgery between June 2009 and June 2019 with at least 1 year of follow-up was performed. Pre- and post-operative clinical and radiographic assessments were evaluated for degrees of flexion contractures and early (<30 days) or late (>30 days) complications were recorded. Results: A total of 59 patients underwent surgery, of whom 38 (64%), including 42 fingers, were enrolled; mean patient age was 8 years (range 1-18). Post-operative mean flexion contracture was significantly improved (p > 0.001) and no infections were recorded. Mean follow-up was 6 years (range 1-10) and proximal interphalangeal joint extension deficits were rated according to Siegert classification as excellent (69%), good (12%), or fair (9.5%) and poor (9.5%). Conclusions: The Malek cutaneous approach and stepwise release of the retracting soft tissues allow prompt evaluation of the anatomical structures involved in the deformity and seem to be an effective surgical correction in the long term. Level of Evidence: Level IV (Therapeutic).

Clinical long-term results of radial head arthroplasty in comminuted radial head fractures.

Modern radial head prostheses have recently become more common in the treatment of comminuted radial head fractures. The goal of this study was to evaluate how well the EVOLVE® modular metallic radial head implant prosthetic restores the functional range of motion and stability of the elbow. 30 patients with comminuted radial head fractures received an arthroplasty with an EVOLVE® prosthesis in our institution. 20 of those patients were available for long-term follow-up (mean > 10years). The outcomes were assessed on the basis of pain, motion, and strength. The overall outcome was scored with functional rating scores. According to the Broberg-Morrey elbow evaluation score, after a mean follow-up period of 10.2years, ten (50.0%) patients were rated as very good, four (20.0%) as good, six (30.0%) as satisfactory, and none as poor. In the long-term results the Broberg-Morrey score increased from 79 (in short-term results) to 89 points. The Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure questionnaire showed an average of 16.2 points. Initially, patients had an extension deficit of 20°, which was reduced to 5° at the latest follow-up. In our long-term results, an improvement in the function of the elbow was observed after arthroplasty using a metallic modular radial head implant. Comminuted radial head fractures with elbow instability can be treated effectively with the EVOLVE® radial head prosthesis, which restores stability in acute treatment. Our long-term results after 10.2years demonstrate good functional outcome and low major complication rate. IV.

SRD5A3-CDG: Twins with an intragenic tandem duplication

Steroid 5α-reductase type 3 congenital disorder of glycosylation (SRD5A3-CDG) is a rare metabolic disease mainly characterized by psychomotor disability, visual impairment, and variable eye malformations caused by bi-allelic pathogenic variants in SRD5A3. So far, only 23 distinct mutations were described. Exome sequencing in 32-year old monozygotic male twins revealed only the heterozygous splice variant c.562+3delG in SRD5A3, but no second variant. The twins presented with psychomotor deficit and a complex eye disease including retinal dystrophy, pallor of the papilla, nystagmus, and strabismus suggestive of SRD5A3-CDG. Only when applying exome-based copy number analysis, we identified as a second compound heterozygous variant a previously not reported tandem duplication of exons 2–4 in SRD5A3. Next to the typical skeletal anomalies of SRD5A3-CDG such as kyphosis and scoliosis, extension deficits of the proximal interphalangeal (PIP) joints IV were observed. Since similar contractures were described once in a patient with SRD5A3-CDG, we suggest that this rare symptom is possibly associated with SRD5A3-CDG. Our findings further expand the mutational and clinical spectrum of SRD5A3-CDG and emphasize the importance of an intragenic copy number analysis in patients with strong clinical suspicion of SRD5A3-CDG and only one detectable sequence variant.

Anterior Neck Resurfacing Using Multiple Free Flaps in Patients With Burn Sequelae of the Anterior Neck and Chest.

It has been established that patients with burn sequelae of the anterior neck and chest have a significant degree of flap descent and deficit in neck extension when resurfaced with a single free flap. A protocol was developed to avoid flap descent in these patients by resurfacing the neck with multiple free flaps. The purpose of this article is to present our protocol for treatment and long-term results of this technique. Twenty-five 25 patients with burn sequelae of the anterior neck and anterior thorax were retrospectively identified. Ten patients were treated with a single free flap (group 1), and 15 patients were treated with multiple free flaps (group 2). Patients were followed up for an average of 7 years after their definitive reconstructive procedure at which time measurements including flap descent from sternal notch, deficit of neck extension, and subjective reports of discomfort were obtained. Patients in group 1 demonstrated 8 cm (interquartile range [IQR], 1.75 cm) of flap descent, whereas patients in group 2 demonstrated 0.5 cm (IQR, 0 cm) of flap descent. Patients in group 1 demonstrated 12.5 degrees (IQR, 10 degrees) of deficit in neck extension, whereas patients in group 2 demonstrated 0 degrees (IQR, 0 degrees) of deficit in neck extension. Analysis demonstrated significantly greater descent and deficit in neck extension in group 1 compared with group 2. Patients with burn sequelae of the neck and anterior chest experience less flap descent and deficits in neck extension when resurfaced with multiple free flaps.

Anatomic Monopolar Press-fit Radial Head Arthroplasty; High Rate of Loosening at Mid-Term Follow Up.

Radial head arthroplasty (RHA) is used for the management of unstable or unreconstructable injuries of the radial head. Our aim was to investigate clinical and radiographic outcomes in patients treated with the Acumed anatomic radial head press-fit system for trauma. Clinical and radiographic assessment of RHAs undertaken for trauma with minimum 2-year follow-up. 16 consecutive patients, mean age 53 (21-82) and 66 month ± 27 (26-122) clinical follow-up were included. There were marked radiographic changes with 11/16 showing periprosthetic lucent lines and 13/16 showing subcollar osteolysis. Radiographic changes occurred early post-surgery. Stem loosening was associated with larger cantilever quotients (0.47 vs 0.38, p = 0.004). Overall survivability was 81.2%, with 3 RHAs removed. Clinical outcomes for the retained RHAs were acceptable with mean flexion 134°, extension deficit of 10°, pronation of 82°, and supination of 73°. Mean VAS scores were 8.5 ± 14.4, QuickDASH 13.8 ± 18.9, Mayo Elbow Performance Scores were 91.5 ± 12.5 with no poor scores. Mid-term clinical functional outcomes following the Acumed anatomic RHA are acceptable in most cases. However, in view of the extensive periprosthetic lucencies and surgical removal due to loosening, patients should be cautioned when consented for implantation of the prosthesis, especially if a large collar is anticipated.

Arthroscopic fixation for tibial eminence fractures: A clinical retrospective study of cannulated screws versus transosseous anchor knot fixation techniques with suture anchors

BackgroundA variety of different techniques or methods for treatment of tibial eminence fracture (TEF) have been reported, but there is still controversy on the optimum choice for treating TEFs. The aim of the current work was to compare the clinical outcomes of arthroscopic cannulated screw fixation and a new arthroscopic anchor fixation technique for tibial eminence fracture. MethodsWe included 69 isolated tibial eminence fracture patients from June 2012 to February 2017; 36 patients received the cannulated screw fixation and 33 received the transosseous anchor knot (TAK) fixation under arthroscopy. The two techniques were performed by two different high-volume surgeons. The clinical efficacies of the two techniques were assessed by radiographs, extension deficit, flexion deficit, anterior drawer test (ADT), Lachman test, Lysholm scores and International Knee Documentation Committee (IKDC) scores in follow ups. ResultsPatients were followed up for 35.8 months on average (range, 24–54 months). There were 40 (58%) males and 29 (42%) females included, and four (6%) patients were ＜18 years old. Asymptomatic grade II laxity was found in two patients in the CS group and three patients in the TAK group from the results of Lachman test. Postoperative radiographs in all patients showed anatomic reductions and bony unions were achieved within 12 weeks. There were no significant differences in extension deficit, flexion deficit, ADT, Lachman test, Lysholm scores and IKDC scores between groups (P > 0.05). ConclusionsThe TAK technique shows satisfactory clinical and radiological outcomes equal to the cannulated screw fixation, which is applicable for TEFs as a reliable effective method.

Quadriceps tendon repair using double row suture anchor fixation: Case reports and review of the literature.

IntroductionTraumatic rupture of the quadricipital tendon is rare and disabling. The traditional repair technique involving transpatellar tunnels is still relevant, but this technique seems to be superseded for the technique using anchors. This study aimed to present the place of the anchors in quadriceps tendon tears, and assess the functional results after a means follow-up of 18.66 months.Case reportsWe report 03 cases of acute rupture of the quadricipital tendon collected in the Trauma Surgery and Orthopaedics Department. The average age was 53.66 years, all patients were male, the rupture occurred after a sporting accident in one case, and in 2 cases concerning minimal trauma from a fall in 2 patients followed for renal failure. The average consultation time was 48 h. The right knee was affected in 2. The clinical presentation was identical in all patients with the deficit of active extension of the leg. All patients were treated surgically with the use of double row anchors. The technique used consisted of insertion of two 5.0 mm anchors at the base of the patella, and the proximal part of the quadricipital tendon was sutured with heavy absorbable sutures using Krakow suture.ResultsAt a mean follow-up of 18.66 months, no infectious complications were noted, no active extension deficit and the active flexion average was 123.33°.ConclusionThe rupture of the quadricipital tendon is a rare injury. Surgical treatment by double row anchors gives excellent results with a satisfactory medium-term functional recovery and allow early rehabilitation.

TRANSFER OF BRACHIALIS MUSCLE TO TRICEPS FOR RESTORATION OF ELBOW EXTENSION IN PATIENTS WITH OBSTETRIC PALSY SEQUELAE

Objective: Elbow extension deficit following brachial plexus injuries can sometimes be overlooked. Elbow flexion deficit is more prominent in the early stages of obstetric paralysis and is used as an indication for early nerve surgery. However, in the future extension deficits may become more numerous. Residual disabilities following obstetric paralyses can be dynamically addressed by tendon transfers. In patients with obstetric paralysis, canonical donor muscles such as the deltoid or biceps may be insufficient for restoration of elbow extension. The brachialis muscle, because of its deep and secluded position, may be considered as one of the more recent options for selection as a donor in these patient groups. In this study, the efficiency of brachialis to triceps transfer both in elbow extension and in shoulder abduction was assessed. Materials and Methods: Seven obstetrical palsy patients with varying degrees of sequelae around the shoulder and elbow underwent a brachialis to triceps transfer procedure. All patients had previously undergone a modified Hoffer procedure. Ranges of motion in shoulder and elbow joints were recorded before&nbsp;and after the transfer. A minimum of M3+ in elbow flexion was set as a prerequisite for the transfer. Results: The elbow extension was improved from a median of -70° (interquertile range, IQR: 20º) to a median of -10° (IQR: 35º) in the follow-up (p&lt;0.05). Shoulder abduction was improved from a median of 140° (IQR: 5º) to a median of 170° (IQR: 15º) (p&lt;0.05). Elbow flexion power was found to be diminished from median M4 (Q1: M3+, Q3: M5) to M3 (Q1: M3, Q3: M3+) (p&lt;0.05). Conclusions: Brachialis to triceps transfer was found to be a suitable alternative in palliative surgery of obstetric palsy patients in terms of elbow extension. Loss of elbow flexion power was within acceptable range.

Modified Pulvertaft on Weave Technique Restores Full Active Knee Extension in Patients With Large Chronic Quadriceps Tendon Rupture: A Case Series

We aimed to investigate the clinical and functional outcomes, including maximal and explosive strength, after chronic quadriceps tendon rupture repair with Modified Pulvertaft on Weave (MPW) technique METHODS: Knee joint range of motion (ROM), patella height, thigh circumference, and Lysholm and International Knee Documentation Committee (IKDC) scores were assessed preoperatively and postoperatively. The knee extensors maximal (isokinetic peak torque and isometric maximal voluntary contraction (MVC) torque) and explosive strength-rate of torque development (RTD) early [RTD50 and RTD100] and late [RTD250]-were performed. We assessed the thigh circumference and vastus lateralis muscle thickness (MT) as indicators of quadriceps muscle mass, and the voluntary quadriceps activation using surface electromyography (EMG50). Nine patients (mean age: 53 ± 11 years) took part in the study. We observed a significant increase in the knee active ROM and a decreased extension deficit (both, P < .001), but not for pain (P= .07), IKDC (P= .07), and Lysholm (P= .21) after the surgery. We did not observe a difference between involved (n= 8) and uninvolved (n= 10) limbs for ROM, thigh circumference, and MT. We observed differences for extensors peak torque, MVC torque, and late RTD (all, P < .05). However, we did not observe differences for early RTD and EMG50. Significant positive correlations were observed for RTD50 (ρ= .80) and RTD100 (ρ= .81) vs EMG50. Both the IKDC and Lysholm were better correlated with the early than with later RTD. The MPW reestablished the active knee extension. The same level of quadriceps muscle mass was observed in both limbs, suggesting a lack of hypotrophy due to the injury. Although the involved limb had demonstrated lower knee extensors maximal strength, they demonstrate an equivalent early RTD when compared to the uninvolved limb. The early RTD seems to be better correlated with the patient's functionality than the later RTD and maximal strength. IV, case series.

Impact of Patient and Tumor Characteristics on Range of Motion and Recurrence Following Treatment of Enchondromas of the Hand

The approach to the treatment of enchondromas of the hand is varied, and there is no clear consensus on graft source, fixation, or need for intraoperative adjuvant therapy. We reviewed a cohort of patients who underwent curettage and bone grafting with cancellous allograft chips without internal fixation or adjuvant therapy and reported on postoperative range of motion (ROM) and recurrence rates. We performed a retrospective review of patients who underwent surgical treatment for hand enchondroma over a 23-year period. We collected information on demographics and presenting enchondroma characteristics, including Takigawa classification and presence of pathologic fracture or associated syndromes. Patients were treated with open biopsy with curettage and grafting with cancellous allograft chips. Postoperative ROM, complications, and recurrences were recorded. Our series included 111 enchondromas in 104 patients. Seventeen of 104 patients (16%) had a diagnosis of Ollier disease. Average length of follow-up was 3.1 years. Eighty-one percent of patients achieved full ROM. Treatment of patients who presented with preoperative pathologic fracture resulted in a greater frequency of reduced postoperative ROM at 28% (9/32) compared to 15% (11/72) of those patients who did not present with preoperative pathologic fracture. Local recurrence developed in 5 of 50 (10%) patients with a minimum of 2 years of follow-up. Local recurrence occurred at higher-than-average rates in patients with giant form Takigawa classification (43%, 3/7) and Ollier disease (23%, 3/13). Treatment of enchondromas with biopsy, curettage, and allograft results in full ROM in 81% of patients. Patients with preoperative pathologic fracture should be advised of a greater risk of postoperative extension deficit. Recurrence remains rare and is associated with syndromic presentation and giant form lesions. Therapeutic IV.

Five-Year Results of a Randomized, Controlled Trial of Collagenase Treatment Compared With Needle Fasciotomy for Dupuytren Contracture

Over the past decade, collagenase treatment and needle fasciotomy (NF) have gained widespread popularity in the treatment of Dupuytren contracture. This prospective study was designed to compare the results of these treatments in terms of clinical and patient-reported outcomes. A prospective, randomized, controlled trial included patients with a contracture of 20° or more in a single metacarpophalangeal joint. Patients were allocated to treatment with either NF or collagenase Clostridium histolyticum. The primary outcome was a reduction in the metacarpophalangeal joint contracture to less than 5°. Secondary outcomes included recurrence, the presence of Dupuytren cords, and changes in patient-reported outcomes. The participants were examined 5 years after the intervention. The study cohort comprised 156 patients divided into 2 equally sized groups. After 5 years, data were collected from 143 (92 %) of the initially enrolled participants. The mean time for the clinical follow-up was 5.1 years. In the remaining cohort without a second procedure, 51% (23 patients) in the collagenase Clostridium histolyticum group and 47% (27 patients) in the NF group still had extension deficits of less than 5°. Among the participants with a successful initial procedure, the recurrence rate was 56% (36 patients) in the collagenase Clostridium histolyticum group and 45% (30 patients) in the NF group. There were no differences between the 2 treatments in regard to passive joint extension, reduction of contracture, range of motion, or patient-reported outcomes. The 5-year outcomes for NF are similar to those for collagenase in terms of sustained correction, recurrence, presence of Dupuytren cords, and patient-reported outcomes for the treatment of metacarpophalangeal joint contractures. Therapeutic I.

Vitamin D status in Dupuytren's disease: Association with clinical status and vitamin D receptor expression

Dupuytren's disease (DD) is a progressive fibroproliferative condition involving contractures of the fascia of the palm. Up to now, there are no relevant investigations on patients with DD in case of serum vitamin D deficiency. We hypothesized that transforming growth factor-β1 (TGF-β1) is increased in patients with DD in consequence of vitamin D deficiency, thereby leading to myofibroblast differentiation and subsequent progression of contractures. The aim of this study was to analyze serum vitamin D levels and explore possible clinical and immunohistochemical correlates with vitamin D concentrations in a group of patients with DD. Vitamin D levels were measured in all patients with DD and healthy controls. In the patient group, clinical characteristics were compared between vitamin D deficient and nondeficient subgroups. Diseased palmar fascia samples were obtained from 14 patients undergoing fasciectomy for DD. Correlations between vitamin D levels and vitamin D receptor(VDR), TGF-β1 expression levels in collected fascia samples were evaluated. Vitamin D concentrations were significantly lower in patients than in healthy controls. In addition, total extension deficit of involved fingers was higher in vitamin D deficient patients. Moreover, a positive correlation was found between vitamin D levels and expression of VDR in pathologic fascia in patients undergoing fasciectomy for contracture. Serum vitamin D levels were found to be low in patients with DD. Expression of VDR was lower in the vitamin D deficient group. The results suggest a potential link between vitamin D status and DD but causation is not yet established. The potential role of vitamin D and its interaction with VDR and the TGF-β1 signaling pathway in the pathogenesis of DD needs to be explored further.