Introduction. Negative pressure wound therapy (NPWT) and vessel loop assisted closure are two common methods used to assist with the closure of fasciotomy wounds. This retrospective review compares these two methods using a primary outcome measurement of skin graft requirement. Methods. A retrospective search was performed to identify patients who underwent fasciotomy at our institution. Patient demographics, location of the fasciotomy, type of assisted closure, injury characteristics, need for skin graft, length of stay and evidence of infection within 90 days were recorded. Results. A total of 56 patients met the inclusion criteria. Of these, 49 underwent vessel loop closure and seven underwent NPWT assisted closure. Patients who underwent NPWT assisted closure were at higher risk for requiring skin grafting than patients who underwent vessel loop closure, with an odds ratio of 5.9 (95% confidence interval 1.11 to 31.24). There was no difference in the rate of infection or length of stay between the two groups. Demographic factors such as age, gender, fracture mechanism, location of fasciotomy and presence of open fracture were not predictive of the need for skin grafting. Conclusion. This retrospective descriptive case series demonstrates an increased risk of skin grafting in patients who underwent fasciotomy and were treated with NPWT assisted wound closure. In our series, vessel loop closure was protective against the need for skin grafting. Due to the small sample size in the NPWT group, caution should be taken when generalising these results. Further research is needed to determine if NPWT assisted closure of fasciotomy wounds truly leads to an increased requirement for skin grafting, or if the vascular injury is the main risk factor

Aims. Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury. Methods. In this trial, 134 patients were randomized into a lateral fasciotomy (n = 67) or a conventional fasciotomy (n = 67) group. This study was a dual-centre, double-blind, prospective randomized controlled two-arm trial with parallel group design and a 1:1 allocation ratio. The primary endpoint was the presence of LFCN injury, which was determined by the presence of numbness, decreased sensation, tingling, jolt-like sensation, or pain over the lateral aspect of the thigh, excluding the surgical scar, using a patient-based questionnaire. The secondary endpoints were patient-reported outcome measures (PROMs) using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS-12). Assessments were obtained three months after surgery. Results. The incidence of LFCN injury tended to be lower in the lateral fasciotomy group (p = 0.089). In the lateral fasciotomy group, there were no significant differences in the mean PROM scores between patients with and without LFCN injury (FJS-12: 54.42 (SD 15.77) vs 65.06 (SD 26.14); p = 0.074; JHEQ: 55.21 (SD 12.10) vs 59.72 (SD 16.50); p = 0.288; WOMAC: 82.45 (SD 6.84) vs 84.40 (SD 17.91); p = 0.728). In the conventional fasciotomy group, there were significant differences in FJS-12 and JHEQ between patients with and without LFCN injury (FJS-12: 43.21 (SD 23.08) vs 67.28 (SD 20.47); p < 0.001; JHEQ: 49.52 (SD 13.97) vs 59.59 (SD 15.18); p = 0.012); however, there was no significant difference in WOMAC (76.63 (SD 16.81) vs 84.16 (SD 15.94); p = 0.107). Conclusion. The incidence of LFCN injury at three months after THA was comparable between the lateral and conventional fasciotomy groups. Further studies are needed to assess the long-term effects of these approaches. Cite this article: Bone Joint J 2023;105-B(12):1252–1258

Aims. The results of surgery for Dupuytren’s disease can be compromised by the potential for disease recurrence and loss of function. Selecting which patients will benefit from repeat surgery, when to operate, and what procedure to undertake requires judgement and an understanding of patient expectations and functional needs. We undertook this study to investigate patient outcomes and satisfaction following repeat limited fasciectomy for recurrent Dupuytren’s disease. Methods. We prospectively identified all patients presenting with recurrence of Dupuytren’s disease who were selected for surgical treatment with repeat limited fasciectomy surgery between January 2013 and February 2015. Patients were assessed preoperatively, and again at a minimum of five years postoperatively. We identified 43 patients who were carefully selected for repeat fasciectomy involving 54 fingers. Patients with severe or aggressive disease with extensive skin involvement were not included; in our practice, these patients are instead counselled and preferentially treated with dermofasciectomy. The primary outcome measured was change in the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were change in finger range of motion, flexion contracture, Semmes-Weinstein monofilament (SWM) values, and overall satisfaction. Results. There was a significant improvement in MHQ scores, across all domains, with a mean overall score increase of 24 points (p < 0.001). The summed flexion contracture across the metacarpophalangeal joint (MCPJ) and the proximal interphalangeal joint (PIPJ) reduced from means of 72.0° (SD 15.9°) to 5.6° (SD 6.8°) (p < 0.001). A significant increase in maximal flexion was seen at the MCPJ (p < 0.001) but not the PIPJ (p = 0.550). The mean overall satisfaction score from the visual analogue scale was 8.9 (7.9 to 10.0). Complications were uncommon although five fingers showed reduced sensibility at final follow-up. Conclusion. Our study shows that repeat limited fasciectomy for selected patients presenting with recurrence of Dupuytren’s disease can be an effective and safe treatment resulting in excellent patient-reported outcomes and levels of satisfaction. Cite this article: Bone Joint J 2021;103-B(5):946–950

Aims. 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. Methods. 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. Results. 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. Conclusion. 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

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy. A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D. There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039). These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced

Compartment syndrome is a devastating complication of limb trauma requiring prompt decompression by means of fasciotomy; however to date little is known about the long term morbidity directly related to the fasciotomy procedure. This is a retrospective study from June 2001 to July 2008 of all patients undergoing fasciotomy in a tertiary referral centre following trauma to a limb. In total this comprised of 66 patients and of these one had since died and five were uncontactable. Therefore 60 patients were surveyed, 48 of whom underwent lower limb fasciotomy and 12 underwent upper limb fasciotomy. Patients were subjected to a phone survey with end points including weakness, parasthaesia and dysasthaesia which had persisted for more than one year post-op. The results were then correlated with time to fasciotomy, site of fasciotomy, initial post-op complications and Methods: of closure. 42 out of 60 patients (70%) reported persistent symptoms. Of these 20 (33%) reported that their symptoms limited them severely either occupationally or socially. Lower morbidity was seen in the upper versus the lower limb fasciotomy group, with decreased incidence of persistent severe symptoms (16.7% versus 35%). Twelve patients had early post-op complications (seven wound infections, 1 cardiac arrest, 2 amputations, 2 haematomas requiring evacuation). Amongst those with post-op complications, 10 out of 12 had persistent symptoms with severe symptoms seen in 80%. In terms of Methods: of closure, 39 patients had delayed primary closure, six were allowed to heal by secondary intention and 15 patients underwent skin grafting. All patients who underwent skin graft were symptomatic at the time of survey with 80% being severely symptomatic. Meanwhile of the patients allowed to heal by seconday intention 83% were asymptomatic. Mean time to closure of fasciotomy was four days. In those patients who were closed in three days or less, 47% were asymptomatic with 23% mildly symptomatic. In the group closed between 8–14 days 37% were symptomatic while all patients closed after 14 days were severely symptomatic. These results demonstrate significant morbidity associated with the fasciotomy procedure. Incidence was highest amongst those undergoing leg or thigh fasciotomy, those who had early post-op complications, those who were closed late and those who were closed with split/ full thickness skin graft. This was most dramatic in those who underwent skin grafting, a vast majority of whom were severely symptomatic. Long term sequelae were lowest in those with upper limb fasciotomies, those undergoing early primary closure and those that were allowed to heal by secondary intention

Dupuytren's contracture is a common condition affecting 25% of men over the age of 65. With less advanced disease or with patients not suitable for a general or regional anaesthetic needle fasciotomy is the surgical option of choice. The aim of this audit is to see whether the Department of Trauma and Orthopaedic surgery at Wirral University Teaching Hospital NHS Foundation Trust comply with the NICE guidelines. All patients who underwent needle fasciotomy for Dupuytren's contracture at Wirral University Teaching Hospital NHS Foundation Trust from December 2008 and November 2010 were identified. The case notes of these patients were reviewed. In a 23 month period 9 patients (13 fingers), underwent needle fasciotomy. There were 6 female and 3 male patients. The mean age at the time of surgery was 70 years (61-84 years). Of the 13 MCPJ contractures 12 had a full correction. At the PIPJ 5 of the 8 had a full correction. Of the one contracture affecting the DIPJ, this was fully corrected. None of the patients undergoing needle fasciotomy had any complications recorded. At a minimum follow up 4 months and a mean follow up of 14 months, none of our patients have returned to the unit with recurrence of disease. In our unit needle fasciotomy is a safe and effective in correcting deformity. To date we have no complications or recurrence. None of these patients have returned for further surgery. We are compliant with the NICE guidelines

Aims: Our purpose was to evaluate þnal results of the fasciotomy of the lower leg in athletes, who were treated surgically for their chronic compartment syndromes. Methods: 339 consecutive patients were operated during years 1985 Ð 2000. A total number of 631 fasciotomies were done. In the retrospective patient series the results were analyzed by athletes´ ability to train and compete maximally. When maximal performances were possible without any pain the result was good, if they had some pain and light difþculties with maximal trainng, the result was moderate, and if they were not able to train normally or had pains during it the result was poor. The adequate end result (from 6 months to 12 years) was obtained from 91% of the patients. Results: The athletes represented following sports:endurance sports (endurance and middle distance running, orienteering, cross country skiing, triathlon, walking) 73%, sprinting, hurdling and jumping 18%, ball sports 4%, power and contact sports 3% and other sports 2%. The overall results of fasciotomy were good in 72%, moderate in 23%, and poor in 5% of the operated cases. Best results were obtained with anterior and posterior compartment syndromes. Complications were seen in 44 fasciotomies. One third of them affected with the end result. Reoperation due to the failure of the þrst fasciotomy or due to recurrent new compartment syndrome at the same compartment was performed in 39 cases. Conclusions: Chronic lower leg pains require sometimes fasciotomy. The operation gives usually good or moderate results. Athletes, who before the surgery were not able to train normally, could increase their training level to maximal or near to it

There has been recent interest in the treatment of Dupuytren's disease by minimally invasive techniques such as needle fasciotomy and collagenase injection, but only few studies have reported the outcomes following open fasciotomy. This study attempts to address this gap, with a retrospective analysis of a large series of patients who underwent an open fasciotomy by a single surgeon over a five-year period. The aim of the study was to determine the requirement for re-operation in the cohort and to analyse the revisionary procedures performed. Theatre coding data was used to identify a consecutive series of patients who underwent open fasciotomy over a five-year period between 2000 and 2005. Within this group medical records were obtained for those patients who underwent a secondary procedure for recurrence. All procedures were carried out by a single surgeon in a regional hand unit using an unmodified open technique. A total of 1077 patients underwent open fasciotomy for Dupuytren's disease. Of these, 865 (80.3%) were male and 212 (19.7%) were female. The mean age at initial surgery was 64.4 years (range 21.7 to 93.7 years) for males and 68.3 (range 43.6 to 89.8 years) for females. Of the 1077 patients who underwent open fasciotomy, 143 patients (13.3%) subsequently underwent a second procedure for recurrence. The medical records were available for 97 patients. The median time to re-operation in this group of patients was 42.0 months (95% CI, 8.3 to 98.0 months). The most common revision procedure being dermofasciectomy (54.2%), followed by fasciectomy (32.6%) and re-do open fasciotomy (13.2%). Mean pre-operative total extension deficit was 88 degrees (range 30–180 degrees) with intra-operative correction to a mean of 9.5 degrees (range 0–45 degrees). There is no standard definition for recurrence after Dupuytren's surgery. We have looked at the rate of revision surgery after open fasciotomy, in a relatively fixed population serviced over a 5-year period by a single hand surgeon. A low re-operation rate has been identified, with good intra-operative correction achieved by secondary surgery

This study aimed to determine if the adoption of collagenase treatment is economically viable. Xiapex collagenase was trialled at Gloucestershire Hospitals NHS Trust in 50 patients suitable for fasciectomy, with a palpable cord and up to two affected joints. Retrospective data for contracture angle pre-injection, immediately post-manipulation and at an average 6 weeks (range 2–17) clinic follow up was collected from medical notes. At follow up the post-procedure number of days required for return to activities of daily living (ADLs) and/or work were recorded, along with overall patient satisfaction rating. Complete data was obtained for 43 patients of average age 67 (range 45–82). At follow up 88% had ≤ 20° residual contracture. Average days return to full ADLs was 9 and work was 11. Overall satisfaction was 8.6 out of 10. Xiapex patients required an average 1 hand physiotherapy appointment post-manipulation compared to 6 for fasciectomy, saving £172.20. Total cost for one treatment course, excluding physiotherapy, was £1166 for Xiapex compared to £2801 for palmar fasciectomy and £5352 for digital fasciectomy. The level of contracture after one Xiapex treatment course permitted return of hand function in the majority of patients whose overall treatment course required less financial and hospital resources

Abstract. Background. Progressive muscle ischaemia results in reduced aerobic respiration and increased anaerobic respiration, as cells attempt to survive in a hypoxic environment. Acute compartment syndrome (ACS) is a progressive form of muscle ischaemia that is a surgical emergency resulting in the production of Lactic acid by cells through anaerobic respiration. Our previous research has shown that it is possible to measure H+ ions concentration (pH) as a measure of progressive muscle ischaemia (in vivo) and hypoxia (in vitro). Our aim was to correlate intramuscular pH readings and cell viability techniques with the intramuscular concentration of key metabolic biomarkers [adenosine triphosphate (ATP), Phosphocreatine (PCr), lactate and pyruvate], to assess overall cell health in a hypoxic tissue model. Methods. Nine euthanised Wistar rats were used in a non-circulatory model. A pH catheter was used to measure real-time pH levels from one of the exposed gluteus medius muscles, while muscle biopsies were taken from the contralateral gluteus medius at the start of the experiment and subsequently at every 0.1 of a pH unit decline. The metabolic biomarkers were extracted from the snap frozen muscle biopsies and analyzed with standard fluorimetric method. Another set of biopsies were stained with Hoechst 33342, Ethidium homodimer-1 and Calcein am and imaged with a Zeiss LSM880 confocal microscope. Results. Our study shows that the direct pH electrode readings decrease with time and took an average of 69 minutes to drop to a pH of 6.0. The concentrations of ATP, pyruvate and PCr declined over time, and the concentration of lactate increased over time. At pH 6.0, both ATP and PCr concentrations had decreased by 20% and pyruvate has decreased by 50%, whereas lactate had increased 6-fold. The majority of cells were still viable at a pH of 6.0, suggesting that skeletal muscle cells are remarkably robust to hypoxic insult, although this was a hypoxic model where reperfusion was not possible. Conclusions. Our research suggests that histologically, skeletal muscle cells are remarkably robust to hypoxic insult despite the reduction in the total adenine nucleotide pool, but this may not reflect the full extent of cell injury and quite possibly irreversible injury. The timely restoration of blood flow in theory should halt the hypoxic insult, but late reperfusion results in cellular dysfunction and cell death due to localised free radical formation. Further research investigating the effects of reperfusion in vivo are warranted, as this may identify an optimal time for using pharmacological agents to limit reperfusion injury, around the time of fasciotomy to treat acute compartment syndrome. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Objectives. Injectable Bromelain Solution (IBS) is a modified investigational derivate of the medical grade bromelain-debriding pharmaceutical agent (NexoBrid) studied and approved for a rapid (four-hour single application), eschar-specific, deep burn debridement. We conducted an ex vivo study to determine the ability of IBS to dissolve-disrupt (enzymatic fasciotomy) Dupuytren’s cords. Materials and Methods. Specially prepared medical grade IBS was injected into fresh Dupuytren’s cords excised from patients undergoing surgical fasciectomy. These cords were tested by tension-loading them to failure with the Zwick 1445 (Zwick GmbH & Co. KG, Ulm, Germany) tension testing system. Results. We completed a pilot concept-validation study that proved the efficacy of IBS to induce enzymatic fasciotomy in ten cords compared with control in ten cords. We then completed a dosing study with an additional 71 cords injected with IBS in descending doses from 150 mg/cc to 0.8 mg/cc. The dosing study demonstrated that the minimal effective dose of 0.5 cc of 6.25 mg/cc to 5 mg/cc could achieve cord rupture in more than 80% of cases. Conclusions. These preliminary results indicate that IBS may be effective in enzymatic fasciotomy in Dupuytren’s contracture. Cite this article: Dr G. Rubin. A new bromelain-based enzyme for the release of Dupuytren’s contracture: Dupuytren’s enzymatic bromelain-based release. Bone Joint Res 2016;5:175–177. DOI: 10.1302/2046-3758.55.BJR-2016-0072

After having had a standard decompression for anterior compartment syndrome, five patients presented with persistent symptoms and pressure values above normal. A repeat procedure combined with fasciectomy relieved their pain; postoperative pressure values were normal

Introduction. “No routine post-operative follow up appointments” policy has been implemented in NHS hospitals in different specialties for uncomplicated surgical procedures. In trauma and orthopaedics few studies to date reviewed this practice and reflected on the patients' opinions. Methods. A total of 121 patients were recruited over 2 years, each patient had post operative follow up by the hand therapist for 3 months. 50 patients post Trapeziectomy and 71 patients post single digit Dupuytren's fasciectomy were prospectively surveyed for their opinion on their post operative care and whether they would have liked to be reviewed by the surgeon in a routine post operative follow up appointment or not. All operations were done by one surgeon in one hospital. All patients were reviewed by a hand therapist within 2 weeks post operatively and treatment protocols were followed with all the patients. During their final appointment with the hand therapist all patients completed a questionnaire. Results. 116 patients completed the study, 5 post Dupuytren's fasciectomy patients were lost for follow up. 106 patients (91%) were satisfied with their post operative management and 99 patients (85%) did not want to be reviewed by the surgeon in a post operative outpatient follow up appointment. Discussion. This study reflects the successful application of “Hand therapy led follow up and discharge” policy with no routine post operative review by the surgeon. We succeeded in reducing the waste in the NHS by avoiding at least 215 un-necessary routine follow up appointments over a 2 year period. By applying this policy we also succeeded in avoiding the inconvenience to patients having multiple trips to the hospital. We advise implementing this practice for other common uncomplicated surgical procedures, with the possibility of giving the patient the option to request an appointment with the surgeon if needed

Reconfiguration of elective orthopaedic surgery presents challenges and opportunities to develop outpatient pathways to reduce surgical waiting times. Dupuytren's disease (DD) is a benign progressive fibroproliferative disorder of the fascia in the hand, which can be disabling. Percutaneous-needle-fasciotomy (PNF) can be performed successfully in the outpatient clinic. The Aberdeen hand-service has over 10 years' experience running dedicated PNF clinics. NHS Grampian covers a vast area of Scotland receiving over 11749 referrals to the orthopaedic unit yearly. 250 patients undergone PNF in the outpatient department annually. 100 patients who underwent PNF in outpatients (Jan2019–Jan2020). 79M, 21F. Average age 66 years range (29–87). 95 patients were right hand dominant. DD risk factors: 6 patients were diabetic, 2 epileptic, 87 patients drank alcohol. 76 patients had a family history of DD. Disease severity, single digit 20 patients, one hand multiple digits in 15 patients, bilateral hands in 65 patients of which 5 suffered form ectopic manifestation suggestive of Dupuytren's diasthesis. Using Tubiana Total flexion deformity score pre and post fasciotomy. Type 1 total flexion deformity (TFD) between 0–45 degrees pre PNF n=60 post N= 85, Type 2 TFD 45–90 degrees pre PNF n=18 post N=9, Type 3 TFD 90–135 pre PNF n=15 post N= 5, Type 4 TFD >135 pre PNF n=1 post PNF N=1. Using Chi-square statistical test, a significant difference was found at the p<0.05 between the pre and post PNF TFD. Complication: 8 recurrence, 1 skin tear. No patients sustained digital nerve injury. Outpatients PNF clinics are a valuable resource

Introduction. An educated public are becoming increasingly aware of percutaneous needle fasciotomy (PNF) for the treatment of Dupuytren's contracture. We believe that it has an important place in the management of this condition and have set up a dedicated one-stop clinic to perform this procedure. Methods. A prospective study of 61 patients with Dupuytren's, who have undergone PNF have been recruited so far. The study population includes 50 men and 11 women. The average age is 65. The senior author has operated on 81 fingers including 69 MCP joints, 62 PIP joints and 6 DIP joints. We recorded contractures prior to PNF and immediately following the procedure, as well as any complications. At follow up we recorded the Patient global impression of change (PGIC), DASH scores, degree of straightness of the operated finger and whether they would have the procedure again or recommend it. Results. For MCP joints the average pre treatment contracture was 43. o. and immediately post operatively it was 3. o. For PIP joints the average pre treatment contracture was 48. o. and immediately post operatively it was 17. o. For DIP joints the average pre treatment contracture was 41. o. and immediately post operatively it was 20. o. 8 patients had small skin tears and 2 found it too uncomfortable to continue. No nerve or tendon injuries. Mean follow up was 9 months (6–24). At follow up the average PGIC was 6 (very good) and the average DASH score was 30.9 (excellent). Subjectively the vast majority of fingers remained straight. All but 4 patients would have the procedure again and would recommend it to others. Discussion. This specialist clinic offers a very effective, safe procedure and our patients are highly satisfied withthe results. It is also cost effective for our Department

Introduction. Evaluating the success of a treatment has changed. Currently, the emphasis is on patient-rated outcome scores rather than surgeon recording of outcome measures. Functional outcome and patient satisfaction following Dupuytren's disease surgery is poorly quantified in the literature. This study aimed to assess subjective patient hand function, disability and satisfaction using a PEM score and its correlation with residual contracture. Methods. Percutaneous Needle Fasciotomy (PNF) is performed in our outpatient clinic to treat Dupuytren's contracture at MCP joints. A validated patient completed questionnaire (PEM) was used to record patient demographics, side of surgery, finger involved, time since surgery, residual symptoms, disability, subjective hand function and satisfaction. The questionnaire was posted to all patients who had PNF over the study period (n=68) along with a stamped addressed envelope and participant information sheet. Results. 68 patients had PNF surgery on 73 hands. Completed questionnaires were returned from 46 patients (51 hands), a response rate of 70%. Mean follow-up was 15 months (SD +/− 10), range 5-36 months. Wilcoxon Signed Ranks Test showed that change in ‘function of hand’ over time was statistically significant (z = 5.82, n-ties = 50, p < 0.001). Spearman's test showed a significant correlation between any residual contracture and total score on the PEM (r. s. = 0.540, N=51, p <0 .001, two tailed). Multiple linear regression revealed that the correction achieved at time of surgery was a significant predictor of subjective hand function (p= 0.001). Most of the patients were satisfied with their surgery and its outcome, a cumulative mean score of 4.80 with SD +- 2.58. Conclusion. Significant improvement in contracture and deformity and good patient satisfaction can be achieved by percutaneous needle fasciotomy. Hand function measured using this tool (PEM Score) was strongly correlated with final deformity at follow-up

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients’ social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome. Cite this article: Bone Joint J 2014;96-B:1370–7

Atraumatic compartment syndrome results from prolonged compression of a limb by an obtunded subject. It is most commonly seen in drug abusers and presentation is frequently late. The key factor in the pathogenesis is the fact that muscle necrosis precedes the development of a compartment syndrome.

We set out to establish if surgical decompression of these compartment syndromes, as recommended in the literature, was justified. We reviewed 16 patients who underwent decompression of 19 limbs within our unit. Patients presented between 5 and 100 hours following their overdose (mean 30.5 hours) and surgery was performed at a mean time of 64.5 hours after admission. Surgical decompression resulted in the requirement for multiple operations, mean 3.7, and an extremely high complication rate. Infection was particularly prevalent, occurring in 10 of the 19 limbs decompressed. Only one of the 16 patients had normal limb function at follow up.

Based on these results and an understanding of the pathogenesis of the condition, we conclude that surgical decompression of atraumatic compartment syndromes is illogical, leads to an increased complication rate and is therefore unjustified.

Full thickness skin grafting has been used following dermo-fasiectomy for Dupuytren’s contracture. We have used a conservative approach following excision of the contracture. Following radical excision through Brunner’s incision, an elliptical full thickness skin graft is harvested from the volar aspect of the wrist. This is applied to the wound on the volar aspect of the proximal phalanx to cover the gap with the finger held in extension. Patients who have undergone primary Dupuytren’s excision between 1990–1998 were recalled and evaluated in special clinic. Clinical notes were reviewed for pre-operative deformity, wound problems if any and recurrence of deformity at annual follow-up. Patients were reviewed for present status of deformity, ROM, sensation, 2-point discrimination, evidence of recurrence and patient satisfaction.

One hundred and six fingers were evaluated in 80 patients. Average duration of follow-up was 52 months. Sixty-five patients had bilateral disease and 29 patients had family history of Dupuytren’s disease. Average pre-operative flexion deformity of the PIP joint was 68.6 degrees and 12 patients had deformity of the DIP joint. Mean flexion deformity at review of the PIP joint was 26.4 degrees. 29 patients reported sensitivity to cold. Two-point discrimination was abnormal in 24 patients. Skin tightness was noted in 8 fingers and 7 cases had recurrence. In 2 fingers the recurrence was away from the graft and in remaining 5 fingers it was proximal to the graft not crossing the grafted area. Thirty-three patients had progressive disease in the adjacent fingers away from the operated area. There was no case of graft loss. Seventy patients were satisfied with the end results of the operation.

Our study has shown a very low incidence of recurrence following radical dissection and similar result as dermo-fasciectomy, and the skin graft acting as a barrier in cases of recurrence. Also graft harvested from the wrist matches the colour of the palm with increased patient satisfaction.