ABSTRACT: Plantar fibromatosis is a rare benign but often locally aggressive tumor of the plantar aponeurosis. Nonsurgical treatment is the first line of treatment for symptomatic lesions. Because of the high recurrence rate associated with surgical treatment, operation is indicated only when the lesions are highly symptomatic and conservative measures fail or the diagnosis is in question. The purpose of this technical note is to report the details of endoscopic subtotal fasciectomy. This may reduce the risks of skin necrosis and dehiscence, infection, and formation of painful hypertrophic scars.
Project description:Introduction Plantar fibromatosis is a rare hyperproliferative disease of plantar aponeurosis and is also called Ledderhose disease. Case properties and treatment are discussed in this report. Case Report A 30-year-old man presented with painful bilateral plantar nodules. He had multiple and bilateral fixed and solid nodules on the plantar and medial side of his feet measuring 1 cm each. Ultrasound was performed and hypoechoic homogeneous nodules were detected. The patient underwent surgery, and the nodes were removed via a plantar incision with 2-cm safety distance. Discussion Ledderhose disease is a rare, hyperproliferative disorder of the plantar aponeurosis. The nodules are slow growing and found in the medial part of the plantar fascia. The precise etiology remains unknown. The treatment options are conservative management, steroid injections, radiotherapy, and surgery. Conclusion The main cause of this disease remains uncertain. Related conditions should be evaluated, and a patient who presents with Dupuytren or Peyronie disease should also be investigated for Ledderhose disease.
Project description:Fasciectomy remains the mainstay of surgical treatment for Dupuytren's disease at many units worldwide, particularly in cases of recurrence after aponeurotomy or enzymatic fasciotomy. In some series, this has been reported as high as 48% in 3 years. The lead author has since abandoned the use of collagenase altogether. In this innovation article, we describe simple maneuvers to aid the planning and dissection of a Dupuytren's fasciectomy. We describe techniques to enable efficient dissection of the cord and minimize problems when designing skin flaps. We also highlight technical points in revision cases.
Project description:To compare collagenase injections and surgery (fasciectomy) for Dupuytren's contracture (DC) regarding actual total direct treatment costs and short-term outcomes.Retrospective cohort study.Orthopaedic department of a regional hospital in Sweden.Patients aged 65 years or older with previously untreated DC of 30° or greater in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joints of the small, ring or middle finger. The collagenase group comprised 16 consecutive patients treated during the first 6 months following the introduction of collagenase as treatment for DC at the study centre. The controls were 16 patients randomly selected among those operated on with fasciectomy at the same centre during the preceding 3 years.Treatment with collagenase was given during two standard outpatient clinic visits (injection of 0.9 mg, distributed at multiple sites in a palpable cord, and next-day finger extension under local anaesthesia) followed by night-time splinting. Fasciectomy was carried out in the operating room (day surgery) under general or regional anaesthesia using standard technique, followed by therapy and splinting.Actual total direct costs (salaries of all medical personnel involved in care, medications, materials and other relevant costs), and total MCP and PIP extension deficit (degrees) measured by hand therapists at 6-12 weeks after the treatment.Collagenase injection required fewer hospital outpatient visits to a therapist and nurse than fasciectomy. Total treatment cost for collagenase injection was US$1418.04 and for fasciectomy US$2102.56. The post-treatment median (IQR) total extension deficit was 10 (0-30) for the collagenase group and 10 (0-34) for the fasciectomy group.Treatment of DC with one collagenase injection costs 33% less than fasciectomy with equivalent efficacy at 6 weeks regarding reduction in contracture.
Project description:Safety was evaluated for collagenase Clostridium histolyticum (CCH) based on 11 clinical trials (N = 1082) and compared with fasciectomy data in a structured literature review of 48 European studies (N = 7727) for treatment of Dupuytren's contracture. Incidence of adverse events was numerically lower with CCH vs. equivalent complications from fasciectomy (median [range] incidence), including nerve injury (0% vs. 3.8% [0%-50+%]), neurapraxia (4.4% vs. 9.4% [0%-51.3%]), complex regional pain syndrome (0.1% vs. 4.5% [1.3%-18.5%]) and arterial injury (0% vs. 5.5% [0.8%-16.5%]). Tendon injury (0.3% vs. 0.1% [0%-0.2%]), skin injury (16.2% vs. 2.8% [0%-25.9%]) and haematoma (77.7% vs. 2.0% [0%-25%]) occurred at a numerically higher incidence with CCH than surgery. Adverse events in CCH trials not reported after fasciectomy included peripheral oedema; extremity pain; injection site pain, haemorrhage and swelling; tenderness; pruritus and lymphadenopathy. CCH-related adverse events were reported as predominantly injection-related and transient. These results may support clinical decision-making for treatment of Dupuytren's contracture.
Project description:Purpose:The purpose of this study is to assess the feasibility of conducting a large, multicentre randomised controlled trial (RCT) comparing needle fasciotomy with limited fasciectomy for treatment of Dupuytren's contractures. Design:The design of this study is a parallel, two-arm, multicentre, randomised feasibility trial with embedded QuinteT Recruitment Intervention. Participants:Patients aged 18?years or over who were referred from primary to secondary care for treatment of a hand with Dupuytren's contractures of one or more fingers of more than 30° at the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joints and well-defined cord(s). Patients were excluded if they had undergone previous Dupuytren's contracture surgery on the same hand. Methods:Potential participants were screened for eligibility. Recruited participants randomised (1:1) to treatment with either needle fasciotomy or limited fasciectomy and followed-up for up to 6?months after treatment. Data on recruitment rates, completion of follow-up, and procedure costs were collected. Four patient reported outcome measures (PROMs) and objective outcome measures were collected before intervention and 6?weeks and 6?months afterwards. Results:One hundred and fifty-three of 267 (57%) primary-care referrals for Dupuytren's contractures met the eligibility criteria for the study. Seventy-one of the 153 (46%) agreed to participate and were randomly allocated to treatment with needle fasciotomy or limited fasciectomy. Sixty-seven of these underwent their allocated treatment, two were crossovers from limited fasciectomy to needle fasciotomy, and two (both allocated limited fasciectomy) received no treatment. Fifty-nine participants (85%) completed 6-month follow-up PROMs. Participants felt the MYMOP, PEM and URAM PROMs allowed them to better describe how their treatment affected their hand function than the DASH PROM. The estimated costs of limited fasciectomy (in an operating theatre) and needle fasciotomy (in a clinic room) were £777 and £111 respectively. Conclusion:A large RCT comparing treatment of Dupuytren's contractures by needle fasciotomy and limited fasciectomy is feasible. Data from this study will help determine the number of sites and duration of recruitment required to complete an adequately powered RCT and will assist the selection of PROMs in future studies on the treatment of Dupuytren's contractures. (Level 1 feasibility study). Trial registration:Trial registered with ISRCTN (registration number: ISRCTN11164292), date assigned - 28/08/2015.
Project description:OBJECTIVES: To compare the effects of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy on sexual wellbeing. DESIGN: Prospective observational study over six months. SETTING: 13 teaching and non-teaching hospitals in the Netherlands. PARTICIPANTS: 413 women who underwent hysterectomy for benign disease other than symptomatic prolapse of the uterus and endometriosis. MAIN OUTCOME MEASURES: Reported sexual pleasure, sexual activity, and bothersome sexual problems. RESULTS: Sexual pleasure significantly improved in all patients, independent of the type of hysterectomy. The prevalence of one or more bothersome sexual problems six months after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy was 43% (38/89), 41% (31/76), and 39% (57/145), respectively (chi2 test, P = 0.88). CONCLUSION: Sexual pleasure improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. The persistence and development of bothersome problems during sexual activity were similar for all three techniques.
Project description:Tuberosity avulsion fractures of the fifth metatarsal are common and the lateral band of the plantar aponeurosis as the structure more likely to cause these fractures. Most tuberosity avulsion fractures heal by 8 weeks with conservative treatment. Symptomatic nonunion can occasionally occur. Internal fixation with or without bone graft is the treatment of choice for painful nonunion if conservative treatment fails. The purpose of this Technical Note is to describe the details of endoscopic management of nonunion of the tuberosity of the fifth metatarsal without diastasis. This includes endoscopic release of the nonunion site, debridement of the fibrous tissue, microfracture of the sclerotic bone surfaces, and percutaneous screw fixation.
Project description:INTRODUCTION:There is no definitive cure for Dupuytren disease (DD), and recurrence of finger contractures after treatment is common. Surgical fasciectomy is considered the standard treatment method for recurrence, although associated with a high incidence of complications. Collagenase injection, a non-surgical treatment option, has been shown to be a safe and effective method; however, most studies regarding collagenase have involved first-time treatment. Collagenase efficacy in patients with recurrent DD beyond the immediate effect has not yet been determined. The aim of our study is to compare surgical fasciectomy and collagenase injection in treating recurrent DD. METHODS AND ANALYSIS:The study is a single-centre randomised controlled trial. Inclusion criteria are recurrence of DD in one or more fingers after previous treatment with fasciectomy or collagenase injection, a passive extension deficit ≥30° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint, and a palpable cord causing the recurrent contracture. A total of 56 patients will be randomised to either surgical fasciectomy or collagenase injection. A hand therapist blinded to patients' group allocation will measure range of motion at baseline, 3 months, 12 months, 24 months and 60 months. The primary outcomes are the total active extension deficit (MCP plus PIP) at 3 months and the proportion of patients with contracture worsening ≥20° in the treated finger joint at 2 years compared with 3 months. The secondary outcomes include changes in total active motion, active and passive extension deficit from baseline up to 5 years, scores on patient-reported outcome measures, adverse events and costs of treatment. ETHICS AND DISSEMINATION:Ethical approval has been obtained from the Regional Ethical Review Board, Lund University, Sweden(2017/623). The trial will be conducted according to the Helsinki Declaration of 1975, revised in 2000. The results of the trial will be disseminated as published articles in peer-reviewed journals. TRIAL REGISTRATION:NCT03406338; Pre-results.
Project description:Entrapment of the first branch of the lateral plantar nerve is a commonly missed cause of recalcitrant plantar heel pain. The diagnosis is made on a clinical ground with maximal tenderness at the site of nerve entrapment. Treatment of the nerve entrapment is similar to that for plantar fasciitis, with rest, activity modification, nonsteroidal anti-inflammatory drugs, stretching exercise, and local steroid injection. Surgical release of the deep abductor hallucis fascia is indicated when conservative treatment failed. Endoscopic release of the nerve through the dorsal and plantar portals, as well as endoscopic plantar aponeurosis release, is a feasible approach.
Project description:67 runners participated in the Trans Europe FootRace 2009 (TEFR09), a 4487 km (2789 mi) multistage ultra-marathon covering the south of Europe (Bari, Italy) to the North Cape. Reports on ultra-marathons are lacking, but the literature reports overuse injuries in athletes, especially to the Achilles tendon (AT), ankle or hind foot. Bone oedema may be related to exposure and is present in fatigue fractures. Therefore, the aim of this study was to determine prospectively if sustained maximal load during an ultra-marathon leads to damage to the foot.In a cohort study, repeated scanning of the 22 athletes participating in the study was performed before and during (approximately every 1000 km) the race. Using the obtained fat saturated inversion recovery sequence, two experienced readers blinded to the clinical data rated the images regarding foot lesions. Statistical analysis included regression analysis and computation of the inter-rater reliability.The TEFR09 course. MRI scanning was performed according to prearranged schedules for every participant, using a mobile 1.5 Tesla MRI unit on a trailer following the race.MRI data such as AT diameter, bone or tendon lesions, subcutaneous, plantar fascia or intraosseous oedema.The 22 study participants did not differ significantly from the total of the 67 TEFR09 runners regarding height, weight and age. The AT diameter increased significantly from 6.8 to 7.8 mm as did intraosseous signal, bone lesions and subcutaneous oedema. However, finishers differed only regarding plantar aponeurosis and subcutaneous oedema from participants aborting the TEFR09. Inter-rater reliability was 0.88-0.98.Under the extreme stress of the TEFR09, an increase of the AT diameter as well as bone signal are thought to be adaptive since only subcutaneous oedema and plantar fascia oedema were related to abortion of the race.University of Ulm, Germany Ethics Committee Number 78/08-UBB/se.