Plastic Surgery Research Council

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The Use of Ultrasound Guidance for the treatment of Raynaud's Disease of the Hand with Botulinum Toxin
David C. Lobb, MBChB, Jennifer L. Pierce, MD, Michael Perry, MD, Thomas Gampper, MD, Brent DeGeorge, MD PhD.
University of Virginia, Charlottesville, VA, USA.

PURPOSE
While the use of Botulinum Toxin in the treatment of episodic vasospasm of the hand is established, the possibility of causing objectionable intrinsic muscle weakness exists with delivery of the toxin using a traditional landmark-based surface anatomy approach. The present study sought to examine the feasibility and effectiveness of the use of ultrasound as a clinical adjunct in the delivery of Botulinum Toxin for the treatment of Raynaud's phenomenon of the hand.
METHODS
For the anatomic feasibility study, cadaveric elbow-to fingertip specimens were injected with dye using either a landmark-based surface anatomy approach or using ultrasound guidance to specifically target the common digital arteries. The specimens were dissected and areas of distribution of the dye at the levels of the neurovascular bundles and intrinsic muscles of the hand were objectively analyzed using Image J (National Institutes of Health).
For the clinical efficacy of ultrasound-guided delivery, three patients diagnosed with Raynaud's Disease of the hand who had failed other non-surgical interventions were treated with Botulinum Toxin using ultrasound guidance.
Demographic information, co-morbidities, and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (United States Department of Health and Human Services) were collected.
RESULTS
The cadaver hand injected with dye using the traditional landmark-based approach demonstrated significantly increased infiltration of the intrinsic muscles of the hand compared to the cadaver hand injected using ultrasound guidance.
The area of vasculature that were infiltrated with the dye was not statistically different between the two techniques.
All three patients treated with Botulinum Toxin using ultrasound guidance reported improvement in symptoms and function after injection (PROMIS Upper Extremity T score pre-injection mean 29.2, post-injection mean 37) and zero patients reported intrinsic hand weakness.
CONCLUSION
Ultrasound guided injection of a simulation material dye was significantly more accurate in this anatomical study for targeting the vasculature and avoiding the intrinsic muscles of the hand. Ultrasound guidance was practicable in the clinic setting for the delivery of Botulinum Toxin for treatment of vasospastic disease of the hand with no hand weakness reported in this study. Further studies are required to characterize the apparent risk reduction using ultrasound guidance and to demonstrate cost effectiveness.


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