Update on Upper Limb Neuroma Management.

Painful terminal neuromas in the upper limb due to nerve injury are common. Neuroma symptoms include a sharp and burning sensation, cold intolerance, dysesthesia, pain, numbness, and paresthesia. These symptoms could have a negative impact on the functional ability of the patient and quality of life. In addition, Prostheses use might be abandoned by amputees due to neuroma-induced pain. Many clinicians face challenges while managing neuromas. Contemporary "active" methods like regenerative peripheral nerve interface (RPNI), targeted muscle reinnervation (TMR), and processed nerve allograft repair (PNA) are replacing the conventional "passive" approaches such as excision, transposition, and implantation techniques. RPNI involves inducing axonal sprouting by transplanting the free end of a peripheral nerve into a free muscle graft. TMR includes reassigning the role of the peripheral nerve by the transfer of the distal end of a pure sensory or a mixed peripheral nerve to a motor nerve of a nearby muscle segment. To give the peripheral nerve a pathway to re-innervate its target tissue, PNA entails implanting a sterile extracellular matrix prepared from decellularized and regenerated human nerve tissue with preserved epineurium and fascicles. Of these, RPNI and TMR appear to hold a promising treatment for nerve-ending neuromas and prevent their relapse. In contrast, PNA may reduce neuroma pain and allow meaningful nerve repair. The aim of this article is to provide an overview of the newer approaches of TMR, RPNI, and PNA and discuss their implications, surgical techniques, and reported consequences.

Development of Autologous Platelet-Rich Plasma Mixed-Microfat as an Advanced Therapy Medicinal Product for Intra-Articular Injection of Radio-Carpal Osteoarthritis: From Validation Data to Preliminary Clinical Results.

Wrist osteoarthritis (OA) is one of the most common conditions encountered by hand surgeons with limited efficacy of non-surgical treatments. The purpose of this study is to describe the Platelet-Rich Plasma (PRP) mixed-microfat biological characteristics of an experimental Advanced Therapy Medicinal Product (ATMP) needed for clinical trial authorization and describe the clinical results obtained from our first three patients 12 months after treatment (NCT03164122). Biological characterization of microfat, PRP and mixture were analysed in vitro according to validated methods. Patients with stage four OA according to the Kellgren Lawrence classification, with failure to conservative treatment and a persistent daily painful condition >40 mm according to the visual analog scale (VAS) were treated. Microfat-PRP ATMP is a product with high platelet purity, conserved viability of stromal vascular fraction cells, chondrogenic differentiation capacity in vitro and high secretion of IL-1Ra anti-inflammatory cytokine. For patients, the only side effect was pain at the adipose tissue harvesting sites. Potential efficacy was observed with a pain decrease of over 50% (per VAS score) and the achievement of minimal clinically important differences for DASH and PRWE functional scores at one year in all three patients. Microfat-PRP ATMP presented a good safety profile after an injection in wrist OA. Efficacy trials are necessary to assess whether this innovative strategy could delay the necessity to perform non-conservative surgery.

Sensitivity and specificity of the sensory collapse test for nerve entrapment syndrome in the upper extremity.

OBJECTIVES: Several prospective blinded studies have found poorer sensitivity for the sensory collapse test than reported by Susan E Mackinnon's team. However, the blinded examiner had no knowledge of the patient's clinical presentation, or even of the purpose of the test. In these conditions, it seems difficult to perform the sensory collapse test correctly. The aim of the present study was to evaluate the efficacy of the sensory collapse test in the diagnosis of nerve compression in the upper extremity, using a trained, "partially" blinded examiner, with a minimum of clinical information in order to avoid bias due to poor execution of the test, while still unable to influence the test result. METHODS: Seventy-two patients with diagnosis of nerve entrapment in the upper extremity were included prospectively. The sensory collapse test was performed by two examiners, one of whom was blinded to laterality and to the site of nerve compression, aware only of the affected nerve. Using electrodiagnosis study as reference, the sensitivity and specificity of the sensory collapse test were calculated for each examiner. RESULTS: The unblinded examiner showed 72% sensitivity and 57% specificity, and the blinded 68% sensitivity and 57% specificity. CONCLUSIONS: The sensory collapse test is useful for diagnosis of nerve entrapment in the upper limb, even with a blinded examiner.

Free Fibula Flap in Traumatic Femoral Bone Reconstruction: A 10-year Review.

Introduction: The loss of femoral bone substance represents a major therapeutic issue. When the loss of bone substance is extensive, or the local condition is unfavourable, there are few satisfactory solutions. In this study, we share our experience of large femoral bone reconstruction by free fibula flap. Materials and methods: A retrospective monocentric chart review (2007-2017) was performed for 26 patients after receiving a pure bone-free fibula flap operation. The times of consolidation and hypertrophy of the graft were analysed according to the fixation with a 2-year follow-up. Results: The time to consolidation was 8.7 months (range, 6-15) for double plates, 7.2 months (range, 5-11) for locked plates, 6 months (range, 5-7) for external fixators and plate blades and 8 months (range, 7-9) for intramedullary nails.Full weight-bearing was resumed at an average of 6.5 months (range, 5-10) postoperatively. It was authorised at 7 months (range, 5-10) for patients fixed by double plate, at 6.3 months (range, 5-9) for those fixed by a locked plate, at 5.5 months (range, 5-6) for those fixed by an external fixator or plate blade and at 7 months for those fixed by an intramedullary nail. Conclusion: Free fibula flap remains reliable in the face of a great loss of bone material after trauma, with high consolidation rates. The choice of fixation must be reasoned and should offer a compromise between stability, allowing consolidation and hypertrophy of the graft, and rigidity, exposing the risk of massive osteosynthesis dismantling. Other multicentric studies, including more patients, should be carried out to compare the techniques of fixation. How to cite this article: Viaud-Ambrosino S, Bargemon JBV, Kachouh N, et al. Free Fibula Flap in Traumatic Femoral Bone Reconstruction: A 10-year Review. Strategies Trauma Limb Reconstr 2023;18(1):44-50.

Intra Articular Injection of Autologous Microfat and Platelets-Rich Plasma in the Treatment of Wrist Osteoarthritis: A Pilot Study.

No injection treatment has been proven to be effective in wrist osteoarthritis. When conservative measures fail, its management involves invasive surgery. Emergence of biotherapies based on adipose derived stem cells (ADSC) offers promising treatments for chondral degenerative diseases. Microfat (MF) and platelets-rich plasma (PRP) mixture, rich in growth factors and ADSC could be a minimally invasive injectable option in the treatment of wrist osteoarthritis. The aim of this uncontrolled prospective study was to evaluate the safety of a 4 mL autologous MF-PRP intra-articular injection, performed under local anesthesia. The secondary purpose was to describe the clinical and MRI results at 12 months of follow-up. Patients' data collected were: occurrence of adverse effects, Visual analog scale (VAS), Disabilities of the Arm, Shoulder and Hand score (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, wrist strength, wrist range of motion and 5-level satisfaction scale. No serious adverse event was recorded. A statistically significant decrease in pain, DASH, PRWE and force was observed at each follow-up. Our preliminary results suggest that intra-articular autologous MF and PRP injection may be a new therapeutic strategy for wrist osteoarthritis resistant to medical symptomatic treatment prior to surgical interventions.

A jersey finger diagnostic trap: Rupture of the flexor digitorum profundus tendon and the flexor digitorum superficialis tendon.

Management of a 30-year-old man with a rarely described form of jersey finger: simultaneous rupture of the flexor digitorum profundus and flexor digitorum superficialis on the middle finger. Excision of the superficial tendon and anchoring of the flexor digitorum profundus tendon was performed. After 6 months of follow-up, the patient did not present any complaint and reported a complete return to his daily activities. Although very rare, these lesions could be easily detected upstream by ultrasound to avoid 'surprise' during surgical exploration and allow better operative planning.