Deposition of drugs in the nose and sinuses with an exhalation delivery system vs conventional nasal spray or high-volume irrigation in Draf II/III post-surgical anatomy.

BACKGROUND: Endoscopic sinus surgery is often performed to improve delivery of topical medication into sinus cavities. Intranasal steroids are guideline recommended in post-surgical patients, and experiments with cadavers suggest that surgery improves delivery of drug into sinuses. Exhalation delivery systems (EDS) use a new mechanism for intranasal delivery and have been shown to reach superior/posterior regions of the nasal cavity better than nasal sprays in unoperated patients. METHODS: Silicone casts of the nasal cavity and sinuses from a patient after Draf II, and then Draf III, were made from high-resolution computed tomography (CT) data using 3D printing. Internal surfaces were coated with liquid-sensitive, color-changing gel. Color changes were evaluated following conventional nasal spray delivery (0.1 mL x 2) (Nasonex), EDS delivery (0.1 mL x 2) (XHANCE), and high-volume, low-flow (HVLF) delivery (80 mL) with head tilted either 45° or 90°. RESULTS: Conventional nasal spray deposited liquid only in anterior nasal segments. EDS deposited liquid throughout the nasal cavity, in surgically opened ethmoid and maxillary spaces, at entrances of the frontal sinuses in Draf II geometry, and into frontal sinuses in Draf III. Tilted 45° HVLF delivery enters the maxillary sinuses but not the frontal sinuses or the ethmoid region. At full 90° inclination, HVLF delivery reaches most of the frontal and maxillary sinuses but not the roof and posterior wall of the ethmoid region. CONCLUSIONS: HVLF and EDS produced a deep intranasal/intrasinal deposition in the silicone cast compared with conventional nasal spray delivery; both deposited liquid inside the surgically opened sinuses. HVLF offers the benefit of lavage, whereas EDS may be more efficient and convenient.

EXHANCE-3: a cohort study of the exhalation delivery system with fluticasone for chronic sinusitis with or without nasal polyps.

BACKGROUND: Inhaled nasal corticosteroid sprays (INS) are often inadequate to treat chronic rhinosinusitis (CRS). The exhalation delivery system with fluticasone (EDS-FLU; XHANCE®) may improve outcomes in CRS by increasing medication delivery to target superior/posterior anatomic sites. This study assessed safety and efficacy of EDS-FLU in a large population with moderate-to-severe CRS with or without nasal polyps (CRSwNP, CRSsNP). METHODS: Prospective, multicenter, 12-week, single-arm study of EDS-FLU 372 Â#181;g twice daily (BID) at 38 U.S. sites. Safety was assessed by adverse-event evaluations, nasal endoscopy, and ocular examinations. Efficacy was serially assessed by outcomes including nasal endoscopy (Lund-Kennedy Score, polyp grade), patient- and physician-reported outcomes (22-item Sinonasal Outcome Test [SNOT-22]), study-defined surgical indicator assessment, and Patient Global Impression of Change (PGIC). RESULTS: 705 comparatively refractory subjects were enrolled, 603 CRSsNP and 102 CRSwNP [moderate-to-severely symptomatic; baseline SNOT-22 ~43, high rates of prior INS use (92.3%) and/or prior surgery (27.5%)]. More than 90% reported improvement on treatment by PGIC. SNOT-22 scores improved substantially and similarly in patients with NP (-23.7) and without NP (-24.4). Among patients with baseline Lund-Kennedy edema scores >0, 33.3% (CRSwNP) and 54.8% (CRSsNP) had complete resolution of edema. In CRSwNP patients, 48% had polyp elimination in ?1 nostril, 63% had ?1-point improvement in polyp grade, mean bilateral polyp grade decreased from 2.9 to 1.6, and study-defined surgical eligibility decreased. EDS-FLU was generally well tolerated, with a safety profile similar to conventional INS sprays when used to treat CRS CONCLUSION: EDS-FLU 372 #181;g BID in the treatment of CRS with or without polyps was safe, well-tolerated, and produced substantial improvement across a broad range of both objective and subjective measures.

Autologous chondrocyte transplantation in the treatment of thumb CMC joint osteoarthritis.

Degenerative thumb carpometacarpal (CMC) joint osteoarthritis is a common disease in women starting at 40-50 years of age. Nevertheless, synovitis and initial cartilage damage start earlier, and then degenerative arthritis develops leading to joint narrowing with progressive exposure of subchondral bone, subluxation, osteophyte formation and joint deformity that can impact the surrounding joints. The aim of this study was to evaluate the outcome of patients treated with autologous chondrocyte transplantation at the thumb CMC joint at early stages. A prospective study on 10 cases of thumb CMC osteoarthritis in 8 patients was done. The thumbs were stage Eaton II (2 cases) and III (8 cases) and were treated by CMC arthroplasty with the implant of autologous chondrocytes by an open or arthroscopic technique. Two patients were treated bilaterally. Preoperatively all patients had persistent pain resistant to various kinds of nonoperative treatments for at least 1 year. Mean preoperative pinch strength was 3.7 Kg pain on VAS was 8, DASH was 55. All patients had limited abduction and flexion at the end range. Ethics committee approval was obtained for this study. Fragments of 3-4 mm of cartilage were harvested by arthroscopy or by an open technique from the wrist or elbow joint. Cartilage cells were sent to the laboratory to be grown on a collagenous biphasic matrix (MACI/Novocart®). After 3 weeks, the chondrocyte augmented scaffold was ready to be implanted in the thumb CMC joint, or frozen for a second operation later. All patients were females aged 42-67 years (mean 52 years). The dominant hand was treated in 6 cases. In 7 cases, the patients were operated with an open technique and in three cases by arthroscopy. Partial trapezium resection and dorsoradial ligament reconstruction was added to stabilize the CMC joint in most cases. Patients were seen in person at 1, 3, and 6, months, 1 year, 2 years, and 5 years after the initial surgery. Patients (nine thumbs) were then reviewed at a mean follow up 8 years (range 4.4-11 years); pain on VAS, Mayo, DASH and PRWE scores were evaluated at follow-up. One patient was lost to follow-up after 2 years. Of those nine hands, seven had an excellent result according to Mayo score, one had a good result. One thumb CMC joint was still painful and was reoperated and converted to arthroplasty after 4.4 years. All patients regained full range of motion. Mean pinch strength increased to 6.25 ± 1.3 Kg, mean DASH score was 7.3 ± 6.7; pain on VAS was 1.0 ± 1.5; these data were statistically significant compared to preoperative values (p < 0.01). Grip strength also increased in all cases, but this was not statistically significant. PRWE was 7.7 ± 6.4. No complications occurred postoperatively. The results obtained are encouraging since the implanted cartilage has lasted a mean of 8 years and up to 11 years. Biological tissue engineering techniques are being developed and could be a new solution to restore normal cartilage in young patients to postpone more aggressive surgical procedures until an older age. In cases of CMC joint instability, a ligament stabilization procedure was added to avoid subsequent damage to the implanted neocartilage. A longer follow-up and a greater number of cases are necessary to definitively establish the usefulness of this procedure, which has the advantage of being completely biological but the disadvantage of being costly.

COVID-19: Initial experience of an international group of hand surgeons.

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

The use of skeletal traction in the treatment of severe primary Dupuytren's disease.

In 13 patients (18 fingers) we used two types of external fixator as progressive static splints for the preoperative correction of the deformities of severe Dupuytren's disease before conventional fasciectomy. The duration of treatment was from one to four weeks. At a mean follow-up of 18 months the mean total fixed flexion deficit had been reduced from 138 degrees to 39 degrees and the mean proximal interphalangeal joint contracture from 80 degrees to 29 degrees. The mean total active range of movement had increased from 123 degrees to 175 degrees. These preliminary results are promising, but continued follow-up is needed since recurrence is common.

The direct midlateral approach with lateral enlargement of the pulley system for repair of flexor tendons in fingers.

The direct midlateral approach and the lateral enlarging procedure of the pulley system have been utilized in our service since 1972. The incision runs directly behind the neurovascular pedicle, which is left in the palmar skin flap of the anterior compartment of the finger, in order to ensure its blood supply and sensibility. The transverse digital lamina of Landsmeer's skin anchoring system and Cleland's ligament are preserved and are used to perform a lateral enlargement of the pulleys after tendon repair. The technique allows wide surgical exposure of the digital fibro-osseous tunnel, enlargement and reconstruction of the pulley system and tendon sheath, flexor tendon repair (using the technique of choice) and reduces postoperative impingement in zone 2.

Transposition of the ulnar nerve and its vascular bundle for the entrapment syndrome at the elbow.

Surgical findings show important alterations of the extrinsic and intrinsic vascularity of the ulnar nerve in the epitroclear groove. Current procedures are only able to solve the mechanical aspect of nerve compression. Transposition may cause additional iatrogenic ischaemic damage of endoneural vascularity if the nerve is separated from the ulnar collateral artery to achieve anterior mobilization. Our technique of transposition of the ulnar nerve with its vascular bundle maintains the advantages of anterior transposition currently in use, but is able to preserve the whole vascularity of the nerve, thus solving the biological aspect of nerve compression. This allows quicker recovery of axonal activity that was chronically compromised by the entrapment neuropathy. The technique and the results in 30 patients (90% excellent and good, 10% fair) treated since 1987 are presented.

[Vascularized rotatory transfer of the trapezoid-trapeziometacarpal bi-articular complex for treatment of severe TMC-joint arthritis]. / Le traitement de la rhizarthrose évoluée par transposition rotatoire vascularisée du complexe bi-articulaire trapézoïde-trapézométacarpien.

A new surgical technique to reconstruct the basal joint of the thumb, to treat persistent pain, restore stability and function, due to severe degenerative osteo-arthritis, is here presented. Our research on the anatomo-topographical and bio-mechanical aspect of the Trapezium-Trapezoid-Metacarpal bi-articular complex (TM-TZM) has led us to observe that trapezoid-metacarpal joint (TZM) is a working joint, which has remained inactive for many years, a true joint bank for the TM joint. When it is transposed at the base of the thumb column, it is obliged to move according to the active movements of the intrinsic and the extrinsic muscles. Since January 1998, 34 patients have been operated on, replacing the trapezio-metacarpal (TM) joint with trapezoid-metacarpal (TZM) joint and vice-versa. Rotatory transfer of trapezoid-metacarpal pro-trapezio-metacarpal joint was achieved preserving entirely the intrinsic ligaments and the dorsal branch of the radial artery, which rotates palmarly with the biarticular complex thus ensuring vascular supply. Procedure consists in a wrist dorso-radial approach, metaphyseal osteotomy of first and second metacarpal bases, capsulotomy all around and rotatory transfer of the bi-articular complex, stabilization with K wires of osteotomies and capsulo-ligamentous reconstruction. Follow-up evaluation of the patients ranged between 3 months and 10 years (mean 4 years). Results have been excellent in 24 cases and good in 10. Painless motion, stability due to the first metacarpal ray length reconstruction with a subsequent redistribution of forces along the entire axis, restored thumb opposition, pinch and grip strength of the hand have been obtained. In conclusion, this technique represents now a new surgical opportunity for a surgeon to choose a straightforward and reliable treatment in a wider range of care for degenerative arthritis or severe and destructive trauma of the TMC joint. A greater number of cases and a longer follow-up are necessary for a wider evaluation of the procedure.

Double armed reinsertion suture (DARS) of the profundus flexor tendon with immediate active mobilization of the finger. 63 cases.

Between 1982 and 1994, the authors performed 63 flexor digitorum profundus tendon reinsertions according to the "lost-suture" DARS method (double armed reinsertion suture). This technique consists of 2 Bunnell sutures fixed to the lateral and anterior parts of the cut surface of the tendon. Nylon suture material is passed through a transverse hole made in the base of the distal phalanx. Active flexion without resistance is commenced postoperatively. A similar limit to extension is only applied in the case of an associated lesion if the neurovascular pedicle. Forty tendons were reviewed for this study (patients between the ages of 7 and 75 years, 35 males for 5 females). The lesion involved the thumb in 13 cases and long fingers in 27 cases. According to the authors' criteria, the results were scored as excellent 20% (8 cases); good 70% (28 cases); poor 10% (10 cases). The "lost-suture" DARS technique is a simple method which allows immediate active mobilization of the finger and appears to guarantee satisfactory functional results with no risk of tendon rupture.

Lack of adverse pharmacodynamic drug interactions with rivastigmine and twenty-two classes of medications.

Alzheimer's disease (AD) is often associated with multiple comorbidities and subsequent polypharmacy. Treatment of AD with acetylcholinesterase (AChE) inhibitors can carry a risk of drug interaction with multiple medications often prescribed for other co-existing illnesses. Rivastigmine is an AChE inhibitor that is enzymatically cleaved by AChE, minimally metabolized by cytochrome P450 enzymes, has low protein binding, has a short plasma half-life, and a relatively short duration of action. Such properties make it ideal for use in this patient population. A pharmacodynamic analysis of rivastigmine administered concomitantly with other medications (22 different therapeutic classes) did not reveal any significant pattern of increase in adverse events that would indicate a drug interaction. In summary, rivastigmine was well tolerated and safely administered to a population receiving multiple medications for 'real-world' comorbidities.