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.
Dupuytrens disease is a fibrosing condition of the palmar aponeurosis and its extensions within the digits. Normal fascial fibres running longitudinally in the subcutaneous tissues of the palm become thickened and form the characteristic nodules and cords pathognomonic of Dupuytrens disease. A wide variety of surgical interventions exist, of these the partial fasciectomy remains the most conventional and widely used technique. Minimally invasive surgical treatments such as needle fasciotomy are, however, becoming increasingly popular. Dupuytrens disease remains a challenging condition to treat as recurrence is universally found with all surgical interventions. Although recurrence may be related to the severity of the disease, there are currently no research tools other than clinical examination to examine changes in the diseased tissue postoperatively and predict likelihood of long-term success. Magnetic Resonance Imaging (MRI) may be of value for the study of Dupuytren disease, at present its use has been greatly underexplored. We wished to carry out a pilot study in order to examine the possibility of using 3.0 Tesla MRI to study Dupuytren tissue and then furthermore to examine the potential changes post-operatively following percutaneous fasciotomy. Five patients set to undergo percutaneous needle fasciotomy were recruited and consented for the study. All patients underwent MRI scanning of the affected hand pre-operatively and at two weeks post-operatively. Scanning was carried out in the 3.0 Tesla research MRI scanner at Aberdeen Royal Infirmary. Patients were placed prone in the MRI scanner with the hand outstretched above the head in the so-called “Superman” position. A specially designed wrist and hand coil was used. Under the expertise of radiographers and physicists, image capture encompassed four novel scanning sequences in order to make a volumetric three-dimensional image sample of the affected hand. MIPAV software (Bethesda, Maryland) was used for image analysis. Scanning revealed well defined anatomy. The Dupuytren cord arose from the palmar aponeurosis tissue which is deep to the palmar skin and subcutaneous tissue. It was distinctly different to deep structures such as the flexor tendons and intrinsic hand muscles which appeared with a uniform low and high signal respectively. The Dupuytren tissue had a heterogeneous signal on both T1 and T2 images. On T1 the tissue signal appeared high to intermediate, similar to that of bone and muscle, but low areas of signal were observed diffusely in an irregular fashion throughout. On T2 the tissue had a low signal throughout with some focal areas of high signal. Dupuytren tissue was mapped using MIPAV software for pre- and post-operative comparisons. Signal intensity, surface area and volume of the cords and fasciotomy sites were explored. Our initial results suggest MRI can be used to study Dupuytren tissue. Such a research tool may be of use to study the natural history of Dupuytren disease and furthermore, the response to medical and surgical interventions.
ARI is a busy trauma unit (catchment: 500 000 people). In September 2010 a day-case Hand Trauma Service (HTS) started. Previously cases were often postponed due to prioritisation of orthopaedic emergencies; therefore increasing inpatient stay and associated costs. We aim to characterise presenting cases, evaluate improvements in service provision and financial costs. Data was collected from the first HTS year (Sept 10–11), and the preceding year (Sept 09–10). Data was collected on patient characteristics, operation, operative time, anaesthetic type and number of inpatient days. The cost of inpatient stay was calculated from the NHS Scotland resource allocation committee data. Pre HTS there were 410 cases (500 operative hours). 141 wound explorations, 22 nail-bed repairs, 34 metacarpal ORIF, 68 phalangeal ORIF, 5 scaphoid fixations, 69 tendon repairs, 30 terminalisations, 5 MUA, 19 nerve repairs, 17 unclassified. Accounting for 510 inpatient nights (mean: 1.25, range: 0–8), costing £204,387.60 (mean: £500.95). 123 cases required image intensification (II). Most patients had GA. During the first HTS year there were 282 operations. Most operations were day-case. 77 cases were performed under LA, 81 regional blocks and 34 under GA. During this year cases requiring II continued to be performed in the main theatre. The HTS has increased time available in main theatres. It has reduced inpatient stay costs, potentially saving £141,267.90. Performing more operations under LA/regional block decreases the risks associated with anaesthesia. Provision of II for the HTS would permit more cases to be performed, improving the service provision and further reducing costs.
The use of roentgen stereophotogrammetric analysis (RSA) in the assessment of total hip arthroplasty is well recognised as an accurate technique in the measurement of small movements of implants. The technique requires the insertion of tantalum beads into a stable location in the bone at the time of surgery. Failure of bead insertion leads to unstable extra-osseous beads that require to be excluded from the analysis. Previous studies have reported an incidence of extra-osseous beads in the proximal femur of between 2% and 13%. In order to further improve the accuracy of the RSA technique, we have developed a test criterion for exclusion of unstable osseous beads in RSA of total joint replacements. Using specifically developed software each bead’s movement was determined relative to the rest of the beads in the bone segment. The bead movement was determined for radiologically identified extra-osseous beads, which were assumed loose, and for the remaining intra-osseous beads which were suitable for analysis. Analyses with a condition number greater than 100 were rejected. The rate of motion was calculated from consecutive examinations. Unstable beads were identified as those having a median rate greater than a given threshold. The sensitivity and specificity for detecting extra-osseous beads was calculated for different thresholds of median bead motion. In 149 RSA hip study patients, 43 extra-osseous beads that could be analysed were identified and a group of 36 osseous beads were selected as a control group. This resulted in an optimum threshold of 0.36mm that gave a sensitivity of 89% and a specificity of 86% for detecting unstable (extra-osseous) beads. The remaining 1428 beads, which were assumed to be osseous, were then tested with this threshold, which gave a sensitivity of 84% and a specificity of 79%. The median extra-osseous bead rate of movement at 6, 12, 18 and 24 months were 2.24, 0.78, 1.03 and 1.31mm respectively and for osseous beads were 0.27, 0.19, 0.18 and 0.19mm. As both groups of beads appear to show a “bedding in” period, with a higher median bead movement in the first 6 months, the test was repeated with the first 6 month period excluded from the criteria. An optimal threshold of 0.37mm was found to have a sensitivity of 73% and a specificity of 87% for identifying an extra-osseous bead. While most radiographically classified osseous beads identified as unstable may be false-positives, it is probable that some are extra-osseous but not visibly so on radiographs. The specificity of this technique is likely to be further improved with the increased precision from digital scanning techniques. Tantalum beads in general appear to be relatively unstable in the first 6 months, consistent with the expected osteo-intergration of the bead. This new criterion for bead instability allows automatic exclusion of unstable beads increasing the reliability of the RSA technique both in future studies and retrospectively to existing data.
