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

Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p < 0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain

We treated post-traumatic contracture of the elbow in 13 consecutive patients (14 elbows) by operative release. Through a single medial approach, the posterior oblique bundle of the medial collateral ligament was resected, followed by posterior and anterior capsulectomies. An additional lateral release through a separate incision was required in only four elbows. The results were assessed at a mean interval of 57 months after operation. Before surgery active extension lacked 43° which improved to 17° after operation. Active flexion before operation was 89°, which improved to 127°. The mean arc of movement increased from 46° to 110°. All 14 elbows showed scarring of the posterior oblique bundle of the medial collateral ligament. Neither the interval from injury to operative release nor the age of the patient affected the results. A medial approach is useful to reveal and excise the pathological changes in the medial collateral ligament. It is a safe and effective route through which to correct post-traumatic contracture of the elbow

There is little published information on the health impact of frozen shoulder. The purpose of this study was to assess the functional and health-related quality of life outcomes following arthroscopic capsular release (ACR) for contracture of the shoulder. Between January 2010 and January 2012 all patients who had failed non-operative treatment including anti-inflammatory medication, physiotherapy and glenohumeral joint injections for contracture of the shoulder and who subsequently underwent an ACR were enrolled in the study. A total of 100 patients were eligible; 68 underwent ACR alone and 32 had ACR with a subacromial decompression (ASD). ACR resulted in a highly significant improvement in the range of movement and functional outcome, as measured by the Oxford shoulder score and EuroQol EQ-5D index. The mean cost of a quality-adjusted life year (QALY) for an ACR and ACR with an ASD was £2563 and £3189, respectively. . ACR is thus a cost-effective procedure that can restore relatively normal function and health-related quality of life in most patients with a contracture of the shoulder within six months after surgery; and the beneficial effects are not related to the duration of the presenting symptoms. Cite this article: Bone Joint J 2013;95-B:942–6

Aims

Rotator cuff muscle atrophy and fatty infiltration affect the clinical outcomes of rotator cuff tear patients. However, there is no effective treatment for fatty infiltration at this time. High-intensity interval training (HIIT) helps to activate beige adipose tissue. The goal of this study was to test the role of HIIT in improving muscle quality in a rotator cuff tear model via the β3 adrenergic receptor (β3AR).

The purpose of this study was to compare the outcome and complications of endoscopic versus open release for the treatment of de Quervain’s tenosynovitis. Patients with this condition were randomised to undergo either endoscopic (n = 27) or open release (n = 25). Visual Analogue Scale (VAS) pain and Disabilities of Arm, Shoulder, and Hand (DASH) scores were measured at 12 and 24 weeks after surgery. Scar satisfaction was measured using a VAS scale. The mean pain and DASH scores improved significantly at 12 weeks and 24 weeks (p <  0.001) in both groups. The scores were marginally lower in the endoscopic group compared to the open group at 12 weeks (p = 0.012 and p = 0.002, respectively); however, only the DASH score showed a clinically important difference. There were no differences between the groups at 24 weeks. The mean VAS scar satisfaction score was higher in the endoscopic group at 24 weeks (p < 0.001). Transient superficial radial nerve injury occurred in three patients in the endoscopic group compared with nine in the open release group (p = 0.033). We conclude that endoscopic release for de Quervain’s tenosynovitis seems to provide earlier improvement after surgery, with fewer superficial radial nerve complications and greater scar satisfaction, when compared with open release. Cite this article: Bone Joint J 2013;95-B:947–51

Aims

Rotator cuff (RC) injuries are characterized by tendon rupture, muscle atrophy, retraction, and fatty infiltration, which increase injury severity and jeopardize adequate tendon repair. Epigenetic drugs, such as histone deacetylase inhibitors (HDACis), possess the capacity to redefine the molecular signature of cells, and they may have the potential to inhibit the transformation of the fibro-adipogenic progenitors (FAPs) within the skeletal muscle into adipocyte-like cells, concurrently enhancing the myogenic potential of the satellite cells.

Latissimus dorsi tendon transfer (LDTT) is technically challenging. In order to clarify the local structural anatomy, we undertook a morphometric study using six complete cadavers (12 shoulders). Measurements were made from the tendon to the nearby neurovascular structures with the arm in two positions: flexed and internally rotated, and adducted in neutral rotation. The tendon was then transferred and measurements were taken from the edge of the tendon to a reference point on the humeral head in order to assess the effect of a novel two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances between the superior tendon edge and the radial nerve, brachial artery, axillary nerve and posterior circumflex artery were 30 mm (26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to 21), respectively. The mean distance between the inferior tendon edge and the radial nerve, brachial artery and profunda brachii artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively. Moving the arm to a neutral position reduced these distances. A mean of 15 mm (8 to 21) was gained from a standard soft-tissue release, and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of this region and the potential for transfer of the latissimus dorsi tendon. Cite this article: Bone Joint J 2013;95-B:517–22

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2° pronation (−70° to 80°) to 95.8° supination (80° to 140°). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6° (60° to 90°) in pronation and 50.4° (0° to 90°) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function

Linburg-Comstock syndrome is characterised by an anomalous tendon slip from the flexor pollicis longus to the flexor digitorum profundus, usually of the index finger. An incidence as high as 60% to 70% has been reported. Post-traumatic inflammation of inter-tendinous connections between the flexor pollicis longus and flexor digitorum profundus, usually of the index finger, may cause unexplained chronic pain in the distal forearm. A total of 11 patients (eight females, three males), mean age 29.1 years (14 to 47) with a clinical diagnosis of Linburg-Comstock syndrome underwent surgical release of the inter-tendinous connection. The mean follow-up was for 27 months (2 to 48). Ten patients reported excellent relief of pain in the forearm, with independent flexion of flexor pollicis longus and flexor digitorum profundus to the index finger. Surgical release was an effective treatment for the Linburg-Comstock syndrome in this series

Residual muscle weakness in obstetric brachial plexus palsy results in soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. We describe the results of surgical treatment in 98 patients (mean age 2.5 years, 0.5 to 9.0) for the correction of active abduction of the shoulder. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). The transferred muscles were sutured to the teres minor muscle, not to a point of bony insertion. The mean pre-operative active abduction was 45° (20° to 90°). At a mean follow-up of 4.8 years (2.0 to 8.7), the mean active abduction was 162° (100° to 180°) while 77 (78.6%) of the patients had active abduction of 160° or more. No decline in abduction was noted among the 29 patients (29.6%) followed up for six years or more. This procedure involving release of the contracted internal rotators of the shoulder combined with decompression and neurolysis of the axillary nerve greatly improves active abduction in young patients with muscle imbalance secondary to obstetric brachial plexus palsy

Operative release for entrapment of the suprascapular nerve was carried out in 35 patients. They were assessed at an average of 30 months (12 to 98) after operation using the functional shoulder score devised by Constant and Murley. The average age at the time of surgery was 40 years (17 to 67). Entrapment was due to injury in ten patients and no cause was found in three; 34 had diffuse posterolateral shoulder pain. The strength of abduction was reduced in all the patients. The average Constant score, unadjusted for age or gender, before operative release was 47% (28 to 53). In 25 of the patients both the supraspinatus and infraspinatus muscles were atrophied and seven had isolated atrophy of the infraspinatus muscle. The average conduction time from Erb’s point to the supraspinatus muscle and to the infraspinatus muscle was 5.7 ms (2.8 to 12.8) and 7.4 ms (3.4 to 13.4), respectively. In two patients MRI revealed a ganglion in the infraspinatus fossa and, in another, a complete rupture of the rotator cuff. The average time from the onset of symptoms to operation was ten months (3 to 36). A posterior approach was advocated. The average Constant score, after operative release, unadjusted for age or gender was 77% (35 to 91). The overall result was excellent in ten of the patients, very good in seven, good in 14, fair in two, and poor in two. The symptomatic and functional outcome in our series confirmed the usefulness and safety of operative decompression for entrapment of the suprascapular nerve

Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular. . This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.

We performed a lateral approach for the release of post-traumatic stiffness of the elbow in 22 patients using a modified technique designed to spare the lateral ligaments. They were reviewed after a mean interval of 26 months. The total humeroulnar joint movement had increased from a mean of 74° to 129° and forearm rotation from a mean of 135° to 159°. Both pain and function in the elbow had improved significantly. This modified lateral approach allows release of post-traumatic contracture without disruption of the lateral collateral ligament or the origins of the extensor tendon at the lateral epicondyle of the humerus. The advantages include a simplified surgical procedure, less operative morbidity, and unrestricted rehabilitation

We conducted a prospective, randomised, controlled trial of 45 patients (47 elbows), with tennis elbow, who underwent either a formal open release or a percutaneous tenotomy. All patients had pre- and post-operative assessment using the Disability of Arm, Shoulder and Hand (DASH) scoring system. Both groups were followed up for a minimum of 12 months. Statistical analyses using the Mann-Whitney U test and repeated measured ANOVA showed significant improvements for patient satisfaction (p = 0.012), time to return to work (p = 0.0001), improvements in DASH score (p = 0.001) and improvement in sporting activities (p = 0.046) in the percutaneous group. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and improved significantly more quickly than those undergoing an open procedure. The percutaneous procedure is a quicker and simpler procedure to undertake and produces significantly better results

We treated 22 patients with a diagnosis of primary frozen shoulder resistant to conservative treatment by manipulation under anaesthetic and arthroscopic release of the rotator interval, at a mean time from onset of 15 months (3 to 36). Biopsies were taken from this site and histological and immunocytochemical analysis was performed to identify the types of cell present. The tissue was characterised by the presence of fibroblasts, proliferating fibroblasts and chronic inflammatory cells. The infiltrate of chronic inflammatory cells was predominantly made up of mast cells, with T cells, B cells and macrophages also present. The pathology of frozen shoulder includes a chronic inflammatory response with fibroblastic proliferation which may be immunomodulated

Injectable collagenase is an alternative to surgical treatment for Dupuytren’s disease. Previous studies have reported on the effectiveness of collagenase in finger contractures. This prospective study reports on the short-term safety and efficacy of collagenase treatment in five thumb and first web space Dupuytren’s contractures. The thumb and first web space contractures were treated with injectable collagenase in four consecutive patients (five hands) with experience of previous surgical digital fasciectomy. The thumb contracture was measured by angle and span in two planes of thumb extension and abduction before injection and after manipulation. Collagenase treatment resulted in release of the contracture with a mean increase in thumb to index angle from 23° (10° to 35°) to 56° (45° to 60°) in extension and from 30° (10° to 50°) to 58° (50° to 65°) in abduction and a mean increase in span from 1.9 cm (1 to 3.5) to 3.9 cm (3 to 5) in extension and from 2.4 cm (1.5 to 3.5) to 3.9 cm (3 to 4.5) in abduction. All patients reported an increased range of movement and function and described collagenase therapy as preferable to surgery. In the short-term collagenase is an effective, well-tolerated and safe alternative to surgery for Dupuytren’s disease of the thumb

Over-zealous release of the first dorsal compartment of the wrist for de Quervain’s disease or other lesions such as ganglia, may result in volar subluxation of the tendons of abductor pollicis longus and extensor pollicis brevis. This is usually asymptomatic, but may occasionally become disabling. We describe an operation using part of the extensor retinaculum to stabilise such a subluxation

We describe an operation to relieve compression of the lateral antebrachial cutaneous nerve at the elbow. Between 1987 and 1997 we operated on seven patients, one with bilateral compression. In two the compression was associated with injury to biceps. A longitudinal or a transverse incision was carried out and the nerve was released from the deep fascia. Partial excision of the biceps aponeurosis was undertaken in the patients who did not have injury to biceps; some additional procedures were required for those patients with injuries. All patients had symptomatic relief

We have treated 22 patients with an elbow contracture using a static progressive turnbuckle splint for a mean of 4.5 ± 1.8 months. All had failed to improve with supervised physiotherapy and splinting. The mean range of flexion before splintage was from 32 ± 10° to 108 ± 19° and afterwards from 26 ± 10° (p = 0.02) to 127 ± 12° (p = 0.0001). A total of 11 patients gained a ‘functional arc of movement,’ defined as at least 30° to 130°. In eight patients movement improved with turnbuckle splinting, but the functional arc was not achieved. Six of these were satisfied and did not wish to proceed with surgical treatment and two had release of the elbow contracture. In three patients movement did not improve with the use of the turnbuckle splint and one subsequently had surgical treatment. Our findings have shown that turnbuckle splinting is a safe and effective treatment which should be considered in patients whose established elbow contractures have failed to respond to conventional physiotherapy