Here's my disclosures. Indications for using the collagen aids are the same as surgical, 20 to 30 degree contracture of the MP, 20 degrees in the PIP that's progressing, typically a positive tabletop test. The procedure is done with an insulin needle, 27 gauge fixed to the hub. It takes about 60 to 20 seconds to inject. You have to have a good understanding of the cord anatomy. This is done by feeling the cords, by visualizing them until you build a mental image, very similar to what Charlie's doing, to understand where the cord is. In post-surgical cases, be sure to understand the difference between a displaced tendon and a recurrent cord. The depths in the palm at the MP joint level, there's about 7 millimeters between the skin and the flexure sheath. In the PIP joint, it's 2 to 4 millimeters. Keep this in mind when you're inserting the needle. The dose is a 0.058 milligrams and it's given in the MP level and a quarter of a CC and the PIP level and a two-tenths of the CC. Needles inserted into the central part of the cord, hold the plunger with one hand while advancing the, hold the barrel, excuse me, with one hand while advancing the plunger so you don't advance the needle inadvertently as you're injecting. It's nice to have someone pull on the finger to keep the cord on tension to make it easier to palpate the cord. The disposition of the aliquots of the dose can be given longitudinally in little cords and big thick cords transverse placement makes sense and helps the cord disrupt. Manipulation is done under local anesthesia. Typically I use lidocaine field block with bicarb, which helps make the injection of the local anesthesia a little less painful. Position the hand in a slight supination with the wrist palmer flexed and the manipulation maneuver is done in four steps. One, hyperextending the MP joint, two, hyperextending the PIP joint with the MP flexed. Both joints are extended and then with both joints extended, you push down on the cord and break any remaining bands. This is typically done 24 hours after the injection. My experience has been about 300 in research studies and since the FDA approval in February 2010, I've now done about 400. My colleagues and I at Stony Brook have done about 600. Nationally the number is now approaching 32,000. The distribution of the patients that I've personally done, you see there, some are on aspirin which I haven't stopped anticoagulation. I usually stop before giving the drug, but I have colleagues around the country who are using this without stopping the anticoagulation. That needs to be studied so we can be sure which way is the safest. The button. Is it frozen? You said go quickly. There we go. MP joints in this study were 85% involved, but isolated only 31%. Most MP joints, MPIP joints are association through a central cord contracting both at once, as you see here. I've done a few DIPs caused by lateral cords. It's a little trickier because of the safety zone between the cord and the flexor tendon is smaller. Y cords, a combination of a central cord and an aditory cord, 18%. Combined central cord and two aditory cords do occur. Thumbs I've done a small number. They're a little harder to manipulate. Complex cords where there's multiple digits involved, they're becoming something we deal with. I've done little thin cords with a single dose, which is split in two fingers. We're now doing a so-called double dose study where we're looking at using two doses and with two doses you can pretty much treat the entire hand regardless of how it presents in terms of how many cords are there. We've also done studies to look at manipulating at different time points, which seems to be safe and the two dose study seems to be working fine. Here's a central cord. Figure out where exactly it is. Palpate it carefully. Get an image in your mind where the cord is located exactly. Define where the aliquots are going to go, where the target is for the dose. Here's the manipulation after 24 hours. And here's this gentleman two weeks after. Several patients admitting that even though I tell them to take a little bit of time off, they're back playing golf in a week or so. Here's a Y cord, combination of a central cord and an auditory cord. Again visualizing exactly where the cord is located, where the dose is going to go. Here you see it on the actual patient. And here's the manipulation after the injection has been done. And here he is three days after that particular manipulation. Another digiminimi cord is going to be dealt with quite easily. Then visualize the cord, figure out where you should put the dose. Some cords are quite soft, the medication goes in easily, others are pretty hard and you have to actually push the plunger down pretty forcefully. So that's why it's important to stabilize the barrel as you're injecting. We think about doing trigger finger injections with cortisone. This is a much more powerful drug, it has to be much more carefully placed. Here's the manipulation of that particular abductor minimi cord the next day. Little residual PIP contracture from the stiff joint. Patients have to be told you can fix the cord, you can't fix the stiff joint. In my personal series, 90% are popping to basically straight, about 8% partial, 1% no change. The MP contractures were minimum of 10, which was when they were combined with something more severe in the PIP. Maximum of 100, average 49, secondary joints are showed. PIP contractures, you see the range there. The MP results, the maximum correction was 90 degrees, average 45. Percentage basis, sometimes 100% improvement. The average was 92. This is a little bit better than in the final phase 3 studies we did, and I think that is primarily because of using local anesthesia. PIP contractures noted here, and the improvement. PIP contractures represented 42%. Many patients have had prior surgery. The one caveat you should take back with treating PIPs in particular, if the skin is shot or there's a big skin graft, then this isn't a proper tool. You get itching and swelling in almost everybody, no severe allergic reactions, no nerve injuries, no vessel injuries. In the large study of 1,082 patients, there were 3 tendon injuries. These all occurred at the PIP joint in the 5th finger. If you stay a little proximal in the distance between the 1st and 2nd finger creases, you can usually avoid this particular complication. Splinting, we use a commercial splint most of the time. Let the patient do their own exercise, nighttime splinting. I've used two cases with severe PIP contractures in combination with cords where I've used the DigitWidget to help stretch out the PIP joint. And a reverse knuckle bender is sometimes useful in the 5th finger PIP contractures. The recurrence happens. I tell all patients you can't cure this disease regardless of the therapy you apply to them. The best follow-up data that we have right now has been recently published, as you see there in the Journal of Hand Surgery. And here's a patient of mine with 13 years follow-up for the ring finger with no recurrence. Thank you.

collagen aids

contractures

joint

injection

complications