Translation of a patient-surgeon relationship assessment instrument (Q-PASREL) into six languages.

The Questionnaire for Patient-Surgeon Relationship (Q-PASREL) is a French "Patient-Reported Experience Measure" for hand surgery patients. It is the only one which considers the impact of the patient-surgeon relationship on time to return to work and cooperation by the surgeon for administrative issues. It has been shown that a good Q-PASREL score is associated with shorter sick leave and faster return to work. To make this instrument available to more countries, we translated the Q-PASREL into six languages (English, Spanish, German, Italian, Arabic and Persian), following a validated "translation and cultural adaptation" process guideline. This process includes multiple forward and backward translations, discussions and reconciliations with final harmonization and cognitive debriefing. For each language, a team was set up, comprising a key in-country hand surgery consultant, native target-language speaker and fluent in French, and several forward and back translators. The final translated versions were reviewed and approved by the project manager. The six versions of Q-PASREL are now available in the appendices of this publication.

Flexor Tendon Adhesion Formation: Current Concepts.

Over the years, various physical and chemical/biological methods of inhibiting adhesion formation have been developed, focusing on how to suppress healing around the tendon and not inhibit healing within the tendon. Unfortunately, however, these methods are accompanied by drawbacks, both large and small, and no absolute antiadhesion method capable of maintaining tendon repair strength has yet been developed. Recent innovations in biomaterials science and tissue engineering have produced new antiadhesion technologies, such as barriers combined with cytokines and cells, which have improved outcomes in animal models, and which may find clinical relevance in the future.

Carbodiimide-Derivatized Synovial Fluid for Tendon Graft Coating Improves Long-Term Functional Outcomes of Flexor Tendon Reconstruction.

BACKGROUND: Flexor digitorum profundus (FDP) tendon injury is common in hand trauma, and flexor tendon reconstruction is one of the most challenging procedures in hand surgery because of severe adhesion that exceeds 25% and hinders hand function. The surface properties of a graft from extrasynovial tendons are inferior to those of the native intrasynovial FDP tendons, which has been reported as one of the major causations. Improved surface gliding ability of the extrasynovial graft is needed. Thus, this study used carbodiimide-derivatized synovial fluid and gelatin (cd-SF-gel) to modify the surface of the graft, thus improving functional outcomes using a dog in vivo model. METHODS: Forty FDP tendons from the second and fifth digits of 20 adult women underwent reconstruction with a peroneus longus (PL) autograft after creation of a tendon repair failure model for 6 weeks. Graft tendons were either coated with cd-SF-gel ( n = 20) or not. Animals were euthanized 24 weeks after reconstruction, and digits were collected after the animals were euthanized for biomechanical and histologic analyses. RESULTS: Adhesion score (cd-SF-gel, 3.15 ± 1.53; control, 5 ± 1.26; P < 0.00017), normalized work of flexion (cd-SF-gel, 0.47 ± 0.28 N-mm/degree; control, 1.4 ± 1.45 N-mm/degree; P < 0.014), and distal interphalangeal joint motion (cd-SF-gel, 17.63 ± 6.77 degrees; control, 7.07 ± 12.99 degrees; P < 0.0015) in treated grafts all showed significant differences compared with nontreated grafts. However, there was no significant difference in repair conjunction strength between the two groups. CONCLUSION: Autograft tendon surface modification with cd-SF-gel improves tendon gliding ability, reduces adhesion formation, and enhances digit function without interfering with graft-host healing. CLINICAL RELEVANCE STATEMENT: The authors demonstrate a clinically relevant and translational technology by using the patient's own synovial fluid to "synovialize" an autologous extrasynovial tendon graft to improve functional outcomes following flexor tendon reconstruction.

The Effect of Flexor Carpi Ulnaris Pulley Design on Tendon Gliding Resistance After Flexor Digitorum Superficialis Tendon Transfer for Opposition Transfer.

PURPOSE: The flexor digitorum superficialis (FDS) tendon transfer can be used to restore opposition of the thumb. Several pulley designs have been proposed for this transfer. Gliding resistance is considered to be an important factor influencing the efficiency of the pulley design. Our purpose was to compare the gliding resistance among 4 commonly used pulleys for the FDS oppositional transfer. METHODS: Ten fresh-frozen cadaver specimens were studied. The ring FDS was used as the donor tendon. An oppositional transfer was created using 4 pulley configurations: FDS passed around the flexor carpi ulnaris (a-FCU), FDS passed through a 2.5-cm circumference distally based FCU loop (2.5-FCU), FDS passed through a 3.5-cm circumference distally based FCU loop (3.5-FCU), and FDS passed through a longitudinal split in the FCU tendon (s-FCU). The gliding resistance was measured with the thumb in radial abduction and maximum opposition. RESULTS: In abduction, the average FDS gliding resistance of a-FCU, 2.5-FCU, 3.5-FCU, and s-FCU was 0.66 N (SD, 0.14 N), 0.70 N (SD, 0.14 N), 0.68 N (SD, 0.16 N), and 0.79 N (SD, 0.15 N), respectively. The peak gliding resistance of a-FCU, 2.5-FCU, 3.5-FCU, and s-FCU was 0.75 N (SD, 0.16 N), 0.74 N (SD, 0.15 N), 0.74 N (SD, 0.15 N), and 0.86 N (SD, 0.15 N), respectively. CONCLUSIONS: The average gliding resistance of the s-FCU was found to be significantly higher than that of the a-FCU and 3.5-FCU pulleys. In opposition, there were no differences in average or peak gliding resistance among the different pulley designs. CLINICAL RELEVANCE: In this in vitro cadaveric study, the FDS split pulley produced higher gliding resistance. Consideration of the pulley configuration may improve the overall thumb function by decreasing forces needed to overcome gliding resistance.

Apoptotic Body-Rich Media from Tenocytes Enhance Proliferation and Migration of Tenocytes and Bone Marrow Stromal Cells.

The intrinsic healing following tendon injury is ideal, in which tendon progenitor cells proliferate and migrate to the injury site to directly bridge or regenerate tendon tissue. However, the mechanism determining why and how those cells are attracted to the injury site for tendon healing is not understood. Since the tenocytes near the injury site go through apoptosis or necrosis following injury, we hypothesized that secretions from injured tenocytes might have biological effects on cell proliferation and migration to enhance tendon healing. Tenocyte apoptosis was induced by 24 h cell starvation. Apoptotic body-rich media (T-ABRM) and apoptotic body-depleted media (T-ABDM) were collected from culture media after centrifuging. Tenocytes and bone marrow-derived stem cells (BMDSCs) were isolated and cultured with the following four media: (1) T-ABRM, (2) T-ABDM, (3) GDF-5, or (4) basal medium with 2% fetal calf serum (FCS). The cell activities and functions were evaluated. Both T-ABRM and T-ABDM treatments significantly stimulated the cell proliferation, migration, and extracellular matrix synthesis for both tenocytes and BMDSCs compared to the control groups (GDF-5 and basal medium). However, cell proliferation, migration, and extracellular matrix production of T-ABRM-treated cells were significantly higher than the T-ABDM, which indicates the apoptotic bodies are critical for cell activities. Our study revealed the possible mechanism of the intrinsic healing of the tendon in which apoptotic bodies, in the process of apoptosis, following tendon injury promote tenocyte and stromal cell proliferation, migration, and production. Future studies should analyze the components of the apoptotic bodies that play this role, and, thus, the targeting of therapeutics can be developed.

Carpal tunnel syndrome treatment and the subsequent alterations in tendon and connective tissue dynamics.

BACKGROUND: Carpal tunnel syndrome patients demonstrate diminished motion of the median nerve and fibrotic changes in the subsynovial connective tissue within the carpal tunnel. Currently, there are few prognostic factors to help predict the outcome of commonly performed treatments including surgical carpal tunnel release and corticosteroid injections. This study aimed to non-invasively assess the changes in the dynamic response of the subsynovial tissue relative to tendon motion after the intervention and to correlate this with disease severity. METHODS: A total of 145 patients with carpal tunnel syndrome were recruited into this study. Clinical and demographic data, electrophysiological severity and dynamic ultrasound images were collected before and after treatment, either by injection or surgery. The relative motion of the subsynovial tissue with the underlying middle finger flexor digitorum superficialis tendon was measured using a speckle tracking algorithm and was expressed as a shear index (SI). Baseline and follow-up data, the association between change in SI and severity, and the role of treatment modality were analyzed and statistically compared. FINDINGS: Overall, there was a significant increase (more relative motion) after treatment in the mean shear index from 79.9% (±15.4% SD) to 82.9% (±14.8% SD) (p = 0.03). Secondary analyses showed that this change was mostly present in those with mild disease severity undergoing surgery (p = 0.01). INTERPRETATION: This study shows that the relative subsynovial tissue movement increases in patients after intervention. The present study lays a foundation for future studies to non-invasively assess the role of carpal tunnel dynamics in response to treatment.

Administration of Purified Exosome Product in a Rat Sciatic Serve Reverse Autograft Model.

BACKGROUND: The nerve autograft remains the gold standard when reconstructing peripheral nerve defects. However, although autograft repair can result in useful functional recovery, poor outcomes are common, and better treatments are needed. The purpose of this study was to evaluate the effect of purified exosome product on functional motor recovery and nerve-related gene expression in a rat sciatic nerve reverse autograft model. METHODS: Ninety-six Sprague-Dawley rats were divided into three experimental groups. In each group, a unilateral 10-mm sciatic nerve defect was created. The excised nerve was reversed and used to reconstruct the defect. Group I animals received the reversed autograft alone, group II animals received the reversed autograft with fibrin glue, and group III animals received the reversed autograft with purified exosome product suspended in the fibrin glue. The animals were killed at 3 and 7 days and 12 and 16 weeks after surgery. Evaluation included compound muscle action potentials, isometric tetanic force, tibialis anterior muscle wet weight, nerve regeneration-related gene expression, and nerve histomorphometry. RESULTS: At 16 weeks, isometric tetanic force was significantly better in group III (p = 0.03). The average axon diameter of the peroneal nerve was significantly larger in group III at both 12 and 16 weeks (p = 0.015 at 12 weeks; p < 0.01 at 16 weeks). GAP43 and S100b gene expression was significantly up-regulated by purified exosome product. CONCLUSIONS: Local administration of purified exosome product demonstrated improved nerve regeneration profiles in the reverse sciatic nerve autograft rat model. Thus, purified exosome product may have beneficial effects on nerve regeneration, gene profiles, and motor outcomes.

Carpal Tunnel Syndrome Treatment and the Subsequent Alterations in Median Nerve Transverse Mobility.

OBJECTIVES: The mobility (transverse movement) of the median nerve (MN) is decreased in patients with carpal tunnel syndrome and can be measured noninvasively by ultrasound. To date, there are few prognostic features to help predict the outcome of 2 commonly performed treatments: surgical carpal tunnel release and corticosteroid injection. This study aimed to assess the changes in nerve mobility after the intervention and to correlate this with treatment and the disease severity. METHODS: A total of 181 patients with carpal tunnel syndrome with different electrophysiologic severities were recruited and assessed by dynamic ultrasound scanning of the MN before and after treatment. The dynamic ultrasound images were collected while the patients performed finger and wrist flexion. RESULTS: For both injection and carpal tunnel release, the nerve displacement increased with wrist flexion, from a mean ± SD of 7.0 ± 2.4 to 7.9 ± 2.7 mm (P < .005). Patients who underwent surgery showed greater improvement (P < .005) in nerve mobility compared to those who underwent injection. We also observed that the increase in nerve mobility was predominantly in patients with more nerve damage at baseline. CONCLUSIONS: This study shows that the dynamic behavior of the MN changes in response to treatment and lays a foundation for future studies to assess the prognostic potential of nerve mobility measurement.

The effect of fibrin formulation on cell migration in an in vitro tendon repair model.

BACKGROUND: The purpose of this study was to determine the effect of fibrinogen concentration on cell viability and migration in a tissue culture tendon healing model. METHODS: Forty-eight canine flexor digitorum profundus tendons were randomly divided into three groups. In each group the tendons were lacerated and repaired augmented with a canine bone marrow stromal cell seeded fibrin interposition patch using either 5 mg/ml fibrinogen and 25 U/ml thrombin (physiological as a control), 40 mg/ml fibrinogen and 250 U/ml thrombin (low adhesive), or 80 mg/ml fibrinogen and 250 U/ml thrombin (high adhesive). The sutured tendons were cultured for two or four weeks. RESULTS: Failure load was not significantly different among the groups. Cell-labeling staining showed that the stromal cells migrated across the gap in the control and low adhesive groups, but there was no cell migration in the high adhesive group at two weeks. CONCLUSION: A high fibrinogen concentration in a fibrin patch or glue may impede early cell migration. LEVEL OF EVIDENCE: Not applicable because this study was a laboratory study.

The Turkey Digit: A New Training Model for Digit Replantation.

PURPOSE: Replant survival rates have reportedly declined over the past decade. Although this problem is multifactorial, 1 potential solution may include the development of a relevant teaching model. The development of an in vivo animal model that can be used for surgical training could enhance surgeon and resident experience and potentially improve outcomes. Here, we present a novel training model for digit replantation using turkey digits. METHODS: Six mature male Bourbon Red turkeys were included in this study. With the animal under general anesthesia, the third digit on either the left or the right foot was randomly selected and amputated. The medial and lateral digital neurovascular bundles were dissected on both sides and the digit was replanted. Perfusion was confirmed prior to skin closure. The foot was casted prior to extubating the turkeys. Turkeys were then placed in a non-weight-bearing sling. Digit status was evaluated twice daily. RESULTS: All 6 replanted digits were viable immediately after surgery and for at least 24 hours after surgery. The average digit survival was 6 days with a maximum survival of 15 days. All digits were eventually lost owing to a variety of reasons including infection and arterial thrombosis. CONCLUSIONS: The turkey digit proved to be a successful short-term animal training model for digit replantation. Future studies are needed to determine optimum standard surgical procedure and postoperative care to maximize the educational benefits of this training model. CLINICAL RELEVANCE: To establish an animal model that can simulate digital replantation.

Lateral slit delivery of bone marrow stromal cells enhances regeneration in the decellularized allograft flexor tendon.

BACKGROUND/OBJECTIVE: Stem cell-based therapy has been applied to accelerate the revitalization of allograft tendon into a viable and functional tendon. Although many authors have proposed different methods to help the seeded stem cell distribution in the decellularized allograft, limited success has been achieved as tendon is a high dense connective tissue. We hypothesized that bone marrow stromal cells (BMSCs), seeded through the lateral slit, can regenerate the decellularized tendon (DCT) graft. The cell proliferation, cell viability, and tendon-specific gene expression are increased with the seeded cell density. METHODS: Eighty-seven flexor digitorum profundus tendons were equally and randomly divided into 6 treatment groups that were seeded with low-density (2 × 107 cells/mL) and high-density (5 × 107 cells/mL) BMSCs through lateral slits cultured for 2 and 4 weeks, DCT without cells, and fresh live tendons. Tendons were evaluated for cell distribution, cell proliferation, cell viability, gene expression of Collagen I and Collagen III, tenogenic markers, and MMPs. RESULTS: Histologic evaluation revealed BMSCs distributed from the lateral slit to the whole DCT. BMSCs were proliferated and kept viable in lateral slit decellularized tendon (LSDCT) in both seeded cell density groups after 2 and 4 weeks of culture. However, no significant differences in the cell proliferation between both cell density groups at 2 and 4 weeks of culture were observed. The lowest cell viability was found in the high-density group after 4 weeks of culture. BMSCs in LSDCT showed a significant tendency of higher gene expression of Collagen I, Collagen III, tenascin C, MMP2, MMP9, and MMP13 compared to normal tendons in both cell density groups at 2 and 4 weeks of culture. CONCLUSION: BMSCs proliferated and remained viable after 2 and 4 weeks of culture with distribution throughout the lateral slits. Lateral slit preparation allows for the effective delivery and maintenance of mesenchymal cells with proliferation and generating a tenogenic behaviour of DCT in both the low and high cell densities in an in vitro model. THE TRANSLATION POTENTIAL OF THIS ARTICLE: Revitalizing the implanted decellularized allograft is important for clinical application. In this study, we demonstrated that the DCT, with lateral slits, could harbour the seeded stem cell and stimulate proliferation with collagen synthesis. This evidence was presented for clinical application of the lateral slit technique, in DCT grafts, which would repopulate the seeded BMSCs during tendon and ligament reconstruction.

The Management of the Healed Scaphoid Malunion: What to Do?

Successful bone union is only a portion of scaphoid fracture management. Malunion is possible and can alter wrist kinematics, potentially causing wrist pain and accelerated degeneration. Evaluation of scaphoid malunion begins with adequate imaging and understanding of deformity. Treatment includes nonoperative management, reconstruction, or salvage options. Correction of malunion can be obtained with an osteotomy and the use of structural graft to recreate anatomy and restore normal carpal motion. Clinical improvement of symptomatic scaphoid malunion can be reliably obtained with reconstruction, although the natural history and role for intervention in asymptomatic malunions remains unclear.

Better Patient-Reported Experiences with Health Care Are Associated with Improved Clinical Outcome after Carpal Tunnel Release Surgery.

BACKGROUND: In hand surgery, and specifically carpal tunnel syndrome, it is currently unknown whether experiences with health care influence surgical outcome. To investigate whether there is an association between patient-reported experience measures and symptom relief, data were gathered using a cohort of patients undergoing surgical treatment for carpal tunnel syndrome. METHODS: Patient-reported experience measures and patient-reported outcome measures were registered in a national database of 16 hand surgery practices. The experience measure data were gathered at 3 months after surgery and included six subscales on different health care delivery aspects (e.g., provided information, communication, facility, operative care). The outcome measure data were acquired before and 3 months after surgery with the Boston Carpal Tunnel Assessment Questionnaire. The association was tested using linear regression analyses. RESULTS: A total of 1607 patients were included in the analysis. The experience measure scores were good to excellent, with a median value between 8.0 and 8.5 on a 10-point scale. Regression analyses showed a significant (p < 0.001) association with the Boston Carpal Tunnel Assessment Questionnaire for all individual patient-reported experience measure subscales. The greatest effects were found in physician communication and treatment information. Patient-reported experience measures accounted for more than 5 percent of the explained variance, with patient characteristics explaining an approximately additional 3 percent. CONCLUSIONS: In this large data set of carpal tunnel syndrome patients who underwent surgical release, a significant impact of health care experiences on self-reported clinical outcome was found. This is relevant information, not only for directing care providers in improving health care experiences as a quality-of-health care measure but now also potentially to achieve better clinical outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Engineered tendon-fibrocartilage-bone composite and bone marrow-derived mesenchymal stem cell sheet augmentation promotes rotator cuff healing in a non-weight-bearing canine model.

Reducing rotator cuff failure after repair remains a challenge due to suboptimal tendon-to-bone healing. In this study we report a novel biomaterial with engineered tendon-fibrocartilage-bone composite (TFBC) and bone marrow-derived mesenchymal stem cell sheet (BMSCS); this construct was tested for augmentation of rotator cuff repair using a canine non-weight-bearing (NWB) model. A total of 42 mixed-breed dogs were randomly allocated to 3 groups (n = 14 each). Unilateral infraspinatus tendon underwent suture repair only (control); augmentation with engineered TFBC alone (TFBC), or augmentation with engineered TFBC and BMSCS (TFBC + BMSCS). Histomorphometric analysis and biomechanical testing were performed at 6 weeks after surgery. The TFBC + BMSCS augmented repairs demonstrated superior histological scores, greater new fibrocartilage formation and collagen fiber organization at the tendon-bone interface compared with the controls. The ultimate failure load and ultimate stress were 286.80 ± 45.02 N and 4.50 ± 1.11 MPa for TFBC + BMSCS group, 163.20 ± 61.21 N and 2.60 ± 0.97 MPa for control group (TFBC + BMSCS vs control, P = 1.12E-04 and 0.003, respectively), 206.10 ± 60.99 N and 3.20 ± 1.31 MPa for TFBC group (TFBC + BMSCS vs TFBC, P = 0.009 and 0.045, respectively). In conclusion, application of an engineered TFBC and BMSCS can enhance rotator cuff healing in terms of anatomic structure, collagen organization and biomechanical strength in a canine NWB model. Combined TFBC and BMSCS augmentation is a promising strategy for rotator cuff tears and has a high potential impact on clinical practice.

Wide Awake Surgery as an Opportunity to Enhance Clinical Research.

Wide Awake surgery under Local Anesthesia with No Tourniquet (WALANT) has revolutionized clinical hand surgery, improving clinical outcomes and reducing postoperative pain and morbidity. It can also be used to deepen scientific knowledge, because the unsedated patient, with sensation intact and without the adverse effects of tourniquet neurapraxia or paralysis, can follow commands and actively move the limb after tendon and nerve surgery. These movements can be correlated with fingertip force, tendon tension, nerve conduction and amplitude, and muscle sarcomere length measurements to develop new insights into the effectiveness of many different tendon and nerve procedures in the hand.

Isolation and characterization of turkey bone marrow-derived mesenchymal stem cells.

Flexor tendon injury is often associated with suboptimal outcomes and results in substantial digit dysfunction. Stem cells have been isolated from several experimental animals for the growing interest and needs of utilizing cell-based therapies. Recently, turkey has been developed as a new large animal model for flexor tendon research. In the present study, we reported the isolation and characterization of bone marrow-derived mesenchymal stem cells (BMSCs) from 8- to 12-month-old heritage-breed turkeys. The isolated cells demonstrated fibroblast-like morphology, clonogenic capacity, and high proliferation rate. These cells were positive for surface antigens CD90, CD105, and CD44, but were negative for CD45. The multipotency of turkey BMSCs was determined by differentiating cells into osteogenic, adipogenic, chondrogenic, and tenogenic lineages. There was upregulated gene expression of tenogenic markers, including mohawk, tenomodulin, and EGR1 as well as increased collagen synthesis in BMP12 induced cells. The successful isolation and verification of bone marrow-derived MSCs from turkey would provide opportunities of studying cell-based therapies and developing new treatments for tendon injuries using this novel preclinical large animal model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1419-1428, 2019.

Hand Surgeons Performing More Open Carpal Tunnel Releases Do Not Show Better Patient Outcomes.

BACKGROUND: Although previous studies have shown that more experienced surgeons have better patient outcomes following a variety of procedures, in hand surgery and carpal tunnel release in particular, this relation remains unproven. The authors assessed whether there is an association between surgeon volume and patient outcomes following open carpal tunnel release. METHODS: Patients who underwent carpal tunnel release between 2011 and 2015 at outpatient hand surgery clinics in The Netherlands were included. Surgeon annual volume was defined as the average number of carpal tunnel releases performed per year per participating surgeon over the study period. Primary outcome measures were the Symptom Severity Scale and Functional Status Scale of the Boston Carpal Tunnel Questionnaire 6 months postoperatively. Multilevel random intercept linear regression analyses were performed to assess whether there was an association between surgeon annual volume and outcome measures, with adjustment for patient characteristics, concomitant procedures, and intake score on the Boston Carpal Tunnel Questionnaire. RESULTS: A total of 1345 patients were included, operated on by 17 surgeons. Median annual surgeon volume was 75 (interquartile range, 50 to 149). Only 0.5 to 0.6 percent of the total variance in patient outcome on the Boston Carpal Tunnel Questionnaire could be explained by random differences between surgeons. The authors did not find an association between annual surgeon volume and outcome measures 6 months postoperatively (Symptom Severity Scale: ß = 0.000; 95 percent CI, -0.001 to 0.001; and Functional Status Scale: ß = 0.000; 95 percent CI, -0.001 to 0.001). CONCLUSION: In the authors' sample of highly specialized hand surgeons operating in high-volume centers, they found no differences in outcome between high- and low-volume surgeons.