Novel artificial nerve transplantation of human iPSC-derived neurite bundles enhanced nerve regeneration after peripheral nerve injury.

BACKGROUND: Severe peripheral nerve damage always requires surgical treatment. Autologous nerve transplantation is a standard treatment, but it is not sufficient due to length limitations and extended surgical time. Even with the available artificial nerves, there is still large room for improvement in their therapeutic effects. Novel treatments for peripheral nerve injury are greatly expected. METHODS: Using a specialized microfluidic device, we generated artificial neurite bundles from human iPSC-derived motor and sensory nerve organoids. We developed a new technology to isolate cell-free neurite bundles from spheroids. Transplantation therapy was carried out for large nerve defects in rat sciatic nerve with novel artificial nerve conduit filled with lineally assembled sets of human neurite bundles. Quantitative comparisons were performed over time to search for the artificial nerve with the therapeutic effect, evaluating the recovery of motor and sensory functions and histological regeneration. In addition, a multidimensional unbiased gene expression profiling was carried out by using next-generation sequencing. RESULT: After transplantation, the neurite bundle-derived artificial nerves exerted significant therapeutic effects, both functionally and histologically. Remarkably, therapeutic efficacy was achieved without immunosuppression, even in xenotransplantation. Transplanted neurite bundles fully dissolved after several weeks, with no tumor formation or cell proliferation, confirming their biosafety. Posttransplant gene expression analysis highlighted the immune system's role in recovery. CONCLUSION: The combination of newly developed microfluidic devices and iPSC technology enables the preparation of artificial nerves from organoid-derived neurite bundles in advance for future treatment of peripheral nerve injury patients. A promising, safe, and effective peripheral nerve treatment is now ready for clinical application.

Point of care ultrasound combined with CTS-6 to diagnose idiopathic carpal tunnel syndrome.

BACKGROUND: This study aimed to demonstrate the effectiveness of our new diagnostic chart using point of care ultrasound combined with CTS-6 for diagnosing idiopathic carpal tunnel syndrome. METHODS: We conducted a retrospective analysis of the data of patients who visited our department and received point of care ultrasound combined with CTS-6 from 2020 to 2023. Data regarding age, sex, initial and final diagnosis, cross-sectional area of the median nerve, CTS-6 score, and electrodiagnostic severity were obtained and statistically analyzed. RESULTS: Of the 177 wrists included in our study, 138 (78 %) were diagnosed with carpal tunnel syndrome, while 39 (22 %) were not (non-carpal tunnel syndrome). With our diagnostic method, 127 wrists (72 %) were diagnosed initially with carpal tunnel syndrome, 23 wrists (13 %) with non-carpal tunnel syndrome, and the rest 27 wrists (15 %) as borderline. Our initial diagnoses of carpal tunnel syndrome and non-carpal tunnel syndrome were maintained in all cases except for two. Cross-sectional area, CTS-6 score, and electrodiagnostic severity showed a positive correlation. A post hoc analysis showed that the new scoring system (CTS-6 score + 2 × cross-sectional area) with a cutoff value of 31.25 points showed a sensitivity as high as 95 % and a specificity of 100 %. CONCLUSIONS: Our findings suggest that most suspected idiopathic carpal tunnel syndrome cases can be diagnosed correctly using the diagnostic chart. Although additional tools, including electrodiagnostic studies, may be needed for borderline cases, the use of point of care ultrasound combined with CTS-6 may be a recommendable first-line confirmatory test because point of care ultrasound and CTS-6 could be complementary tools, and this chart may be especially beneficial for atypical or outlier cases. LEVEL OF EVIDENCE: Diagnostic III.

Painful snapping of the middle finger caused by hyperplasia of the ulnar lateral band: A case report.

Snapping of fingers can be caused by pathologies such as stenosing flexor tenosynovitis. However, snapping symptoms in the metacarpophalangeal (MP) joint caused by hypertension and hyperplasia of the lateral band are rare. We present a 26-year-old female with symptoms of painful snapping of the middle finger. When the finger was actively flexed from the hyperextension of the MP joint, the ulnar lateral band was prominent, and a snapping phenomenon occurred. The cause of the snapping finger was considered to be tightness of the ulnar lateral band, and surgery was planned. Intraoperatively, the ulnar lateral band was tense and hyperplastic. The snapping phenomenon disappeared immediately after the resection of the lateral band. It is important to consider this condition as one of the differential diagnoses of snapping finger when the patient complains of an atypical snapping phenomenon.

Long-standing Ulnar Wrist Pain Caused by an Anatomic Variant of the Ulnar Nerve: A Case Report.

CASE: We present a 28-year-old woman with long-standing left ulnar wrist pain. Physical examination revealed severe tenderness over the pisiform; imaging findings were normal. Surgical exploration revealed compression of an aberrant branch, likely Kaplan's accessory branch, around the pisiform. Complete symptom relief was achieved after nerve decompression. CONCLUSION: Clinical symptoms associated with Kaplan's accessory branch are rare, indicating that many branches may be asymptomatic or overlooked despite the presence of symptoms. Kaplan's accessory branch should be considered as a potential differential diagnosis for refractory ulnar wrist pain.

Persistent Ulnar Nerve Palsy with Cubitus Valgus Deformity Following a Surgically Treated Flexion-type Supracondylar Humeral Fracture - A Case Report.

Introduction: Supracondylar humeral fractures (SHFs) in children are mostly extension-type. SHFs have a high risk of cubitus varus deformity, while valgus deformity is rarely described. Nerve palsy can also occur during or after the injury, with most cases recovering spontaneously. Here, we present a rare case of cubitus valgus deformity after a flexion-type SHF with ulnar nerve (UN) palsy, which was successfully treated by corrective osteotomy and anterior transposition of the UN. Case Report: A 10-year-old girl had left-sided cubitus valgus deformity with persistent UN palsy 4 months after open reduction and internal fixation (ORIF) at another hospital. Half a year after the initial operation, corrective osteotomy of the distal humerus with neurolysis and subcutaneous anterior transposition of the UN were performed. She showed excellent recovery 14-month postoperatively and reported restored motor and sensory function with symmetrical elbow appearance. Conclusion: Surgeons usually observe the elbow angle carefully to avoid cubitus varus deformity. However, when treating a case of flexion-type SHFs, ORIF should be conducted to avoid cubitus valgus deformity, which could potentially cause UN traction as well as cosmetic dissatisfaction.

Influence of Electrodiagnostic Studies on Surgery for Carpal Tunnel Syndrome: A Retrospective Analysis of Data from a Single Urban Institution.

Background: This study aimed to clarify the influence of preoperative electrodiagnostic (EDX) utilisation and its severity on surgically treated patients with carpal tunnel syndrome (CTS). Methods: This retrospective study analysed the data of patients who underwent CTS surgery at our facility from 2012 to 2022. Data regarding age, sex, affected side, diabetes mellitus, rheumatoid arthritis, haemodialysis and insurance type were collected, along with the following clinical information: utilisation of EDX, steroid injection, number of items of preoperative physical examination and history taking, intervals between symptom onset and the initial visit and between the initial visit and surgery, type of surgical procedure and surgery categorisation (primary or revision). EDX data (EDX severity, interval between EDX and surgery and concomitant nerve lesions) were also investigated. Univariate and multivariate analyses were conducted to assess the influence of EDX utilisation and severity on clinical parameters. Results: Of the 343 hands enrolled in our study, 304 (89%) underwent preoperative EDX assessment. EDX severity was classified as normal, mild, moderate or severe in 6 (2%), 18 (6%), 102 (34%) and 178 hands (58%), respectively. After the univariate and multivariable analyses, more items of preoperative physical examination and history taking were associated with non-EDX utilisation, whereas younger age, female sex and steroid injection were associated with milder EDX. Conclusions: Increased number of items of preoperative physical examination and history taking or steroid injection were independently associated with non-EDX utilisation or milder EDX, respectively, suggesting that when thorough clinical evaluation is conducted, hand surgeons may be less likely to request for EDX before surgery. Moreover, their treatment recommendation may be influenced by EDX severity. Level of Evidence: Level III (Diagnostic).

Press-Fit Hemihamate Arthroplasty for the Proximal Interphalangeal Joint.

Background Chronic proximal interphalangeal joint fracture-dislocations with articular malunion are complex injuries. Hemihamate arthroplasty is an established technique for the management of both acute and chronic cases but is associated with several complications. We present the clinical experience of modified press-fit hemihamate arthroplasty. Description of Technique The base of the middle phalanx was exposed from the volar side, and the cartilage defect of the proximal interphalangeal joint (PIPJ) was evaluated in the hyperextended position. A bone hole was created slightly toward the volar side to recreate the curvature of the PIPJ. The hemihamate osteochondral graft was harvested and fixed into the bone hole in a press-fit manner without using a screw. The volar plate and flexor tendon sheath were then reattached. Patients and Methods The study included three patients with chronic dorsal fracture-dislocations of the PIPJ. All patients were treated for >6 weeks after the injury (average 11 weeks). Results The average total arc of motion of the affected joint improved from 38 degrees before surgery to 80 degrees after surgery. Radiographically, bone union and congruity of the joint surface were achieved in all the patients. None of the treated patients complained of resting pain and reported minimal pain during activity (average visual analog scale 0.5; range 0-1.4). Conclusions Press-fit hemihamate arthroplasty is a safe and effective procedure for treating chronic PIPJ fracture-dislocations without the risk of screw protrusion.

Schwann cell-encapsulated chitosan-collagen hydrogel nerve conduit promotes peripheral nerve regeneration in rodent sciatic nerve defect models.

Chitosan has various tissue regeneration effects. This study was designed to investigate the nerve regeneration effect of Schwann cell (SC)-encapsulated chitosan-collagen hydrogel nerve conduit (CCN) transplanted into a rat model of sciatic nerve defect. We prepared a CCN consisting of an outer layer of chitosan hydrogel and an inner layer of collagen hydrogel to encapsulate the intended cells. Rats with a 10-mm sciatic nerve defect were treated with SCs encapsulated in CCN (CCN+), CCN without SCs (CCN-), SC-encapsulated silicone tube (silicone+), and autologous nerve transplanting (auto). Behavioral and histological analyses indicated that motor functional recovery, axonal regrowth, and myelination of the CCN+ group were superior to those of the CCN- and silicone+ groups. Meanwhile, the CCN- and silicone+ groups showed no significant differences in the recovery of motor function and nerve histological restoration. In conclusion, SC-encapsulated CCN has a synergistic effect on peripheral nerve regeneration, especially axonal regrowth and remyelination of host SCs. In the early phase after transplantation, SC-encapsulated CCNs have a positive effect on recovery. Therefore, using SC-encapsulated CCNs may be a promising approach for massive peripheral nerve defects.

Surgical Approaches for Thoracic Outlet Syndrome: A Review of the Literature.

Thoracic outlet syndrome (TOS) is caused by entrapment of the neurovascular bundle in the interscalene, costoclavicular, or subpectoral minor space. Compression in the interscalene or costoclavicular space with the first rib and scalene muscle leads to vascular and neurogenic TOS, whereas compression in the subpectoral minor space leads to pectoralis minor syndrome. Various surgical approaches exist for the treatment of TOS. The introduction and development of surgical approaches have minimized surgical invasiveness and complications. The reported approaches include transaxillary, supraclavicular, infraclavicular, posterior, combined transaxillary and supraclavicular, combined supraclavicular and infraclavicular (paraclavicular), endoscopic-assisted transaxillary, and video-assisted thoracoscopic approaches. In this review, we summarize the reported surgical approaches for TOS treatment, in terms of the history of the approach, surgical procedure, advantages and disadvantages, clinical outcomes, and complications. An adequate excision of compression structures, including the first rib and scalene muscles, provides satisfactory outcomes regardless of the approach selected, whereas an inadequate release of compression structures leads to failed or recurrent outcomes. Reducing the risk of complications is the most important aspect of TOS management. Surgery should be performed safely, with sufficient resection of compression structures. Additionally, the approach should be selected based on the surgeon's skill, surgeon's preferences, surgical invasiveness, cosmetic appearance, and the presence of special equipment, as well as other advantages and disadvantages of each approach.

Artificial Lunate Arthroplasty for Kienböck Disease With Multiple Extensor Tendon Ruptures: A Case Report.

CASE: A 73-year-old woman presented with wrist pain and loss of extension in the middle and ring fingers. Radiography revealed a dorsally displaced lunate fragment, resulting in a diagnosis of Kienböck disease with extensor tendon rupture. Artificial lunate replacement and tendon transfer were performed as treatment. Two years postoperatively, the pain was relieved, and the extension lag was 0°. The wrist motion and carpal height had also improved. CONCLUSION: Lunate excision, partial wrist arthrodesis, or proximal row carpectomy are known treatments for Kienböck disease with extensor tendon rupture. Lunate arthroplasty is a novel, useful treatment option for this condition.

Distal Radioulnar Joint Locking with Bipolar Injury.

Background Locking of the distal radioulnar joint (DRUJ) induces restriction of the active and passive motion of pronation or supination of the forearm. Diagnosis of DRUJ locking due to a triangular fibrocartilage complex (TFCC) tear is sometimes difficult. Case Description A 15-year-old female suffered from restriction of forearm supination after cast immobilization for the treatment of an elbow injury. The active and passive range of motion (ROM) of supination was 30 degrees, while the active ROM of pronation was normal. Radiographs of the elbow showed a fracture of the medial epicondyle and a fracture around the radial head. Radiographs of the wrist showed a subluxation of the ulnar head. Accurate diagnosis of supination restriction was difficult before surgery, so an operation was performed for the diagnosis and treatment. DRUJ locking was reduced manually and arthroscopic findings showed central perforation of the TFCC. Forearm supination improved to 90 degrees postoperatively. Literature Review DRUJ locking due to a TFCC injury is rare and this condition with bipolar injury has not been reported. Clinical Relevance DRUJ locking due to an injured TFCC should be considered as one of the differential diagnoses of supination contracture.

Factors Associated with Change in Diagnosis of Carpal Tunnel Syndrome after Electrodiagnostic Studies.

Background: Hand surgeons sometimes place more weight on clinical findings and may not always consider the results of electrodiagnostic studies (EDX) in the diagnosis of carpal tunnel syndrome (CTS). The aim of this study is to determine factors associated with a change in diagnosis of CTS after EDX. Methods: This is a retrospective study of all patients with an initial clinical diagnosis of CTS who underwent EDX at our hospital. We identified patients whose diagnosis changed from CTS to non-CTS after EDX and used univariate and multivariate analysis to determine if age, sex, hand dominance, unilateral symptoms, history of diabetes mellitus, rheumatoid arthritis, haemodialysis, cerebral lesion, cervical lesion, mental disorder, initial diagnosis by a non-hand surgeon, the number of examined items in CTS-6 and a CTS-negative EDX result were associated with a change in diagnosis after EDX. Results: A total of 479 hands with a clinical diagnosis of CTS underwent EDX. The diagnosis was changed to non-CTS in 61 hands (13%) after EDX. Univariate analysis demonstrated that unilateral symptoms, cervical lesion, mental disorder, initial diagnosis by a non-hand surgeon, the number of examined items and a CTS-negative EDX result were significantly associated with a change in diagnosis. In the multivariate analysis, only the number of examined items was significantly associated with a change in diagnosis. Conclusions: EDX results were particularly valued in hands where the initial diagnosis was uncertain for CTS. In hands with an initial diagnosis of CTS, the performance of sufficient history-taking and physical examination was more valued at the final diagnosis than EDX results or other aspects of the patient's background. The process of confirming a clear initial clinical diagnosis of CTS using EDX may be of little value for decision-making at the final diagnosis. Level of Evidence: Level III (Therapeutic).

Endoscopic-assisted Infraclavicular Approach for First-Rib Resection in Neurologic Thoracic Outlet Syndrome: A Report of Two Cases.

Various reported surgical approaches for the treatment of thoracic outlet syndrome (TOS) exist and no firm evidence exists for any approach. A 16-year-old and a 29-year-old male presented with numbness in the upper limb. Neurologic TOS was diagnosed, and surgery was planned for the resection of the first rib and scalene muscles. Through an infraclavicular incision, open resection of the anterior scalene muscle and the anterior aspect of the first rib was performed. With the assistance of endoscopy, the middle scalene muscles and the posterior aspect of the first rib were resected. Preoperative symptoms improved after surgery without any complications. The endoscopic-assisted infraclavicular approach enabled resection of the first rib and scalene muscles, leading to satisfactory outcomes. Level of Evidence: Level V (Therapeutic).

Hybrid Tension Band Wiring for Olecranon Fractures.

Tension band wiring (TBW) is a standard surgical technique for treating olecranon fractures (OFs). We devised a hybrid TBW (HTBW) combining TBW using wires with eyelets and cerclage wiring. Twenty-six patients with isolated OFs with Colton classification groups 1-2C were subjected to HTBW, and the data was compared with those treated with conventional TBW (38 patients). The mean operation time and hardware removal rate were 51 versus 67 minutes (p < 0.001) and 42% versus 74% (p < 0.012), respectively. The HTBW group had one patient (4%) with surgical wire breakage. The conventional TBW group had 14 patients (37%) with symptomatic backout of Kirschner wires, three patients (8%) with loss of reduction, two patients (5%) with surgical site infection and one patient (3%) with ulnar nerve palsy. The motion and functional score ranges of the elbow were not significantly different. Therefore, this procedure may be a feasible alternative. Level of Evidence: Level V (Therapeutic).

Modified Thompson-Littler Method for Chronic Instability of the Proximal Interphalangeal Joint: A Report of Two Cases.

A 40-year-old patient and a 45-year-old patient presented with chronic dorsal and lateral subluxation of the proximal interphalangeal (PIP) joint of the little finger and underwent surgeries. Through a dorsal approach, the ulnar lateral band was transected and transferred to the radial side through the volar side of the PIP joint. The transferred lateral band and the remnant of the radial collateral ligament were secured with an anchor on the radial side of the proximal phalanx. Satisfactory results were obtained without the loss of flexion and recurrence of subluxation of the finger. This method enabled the correction of both dorsal and lateral instability of the PIP joint through a dorsal incision. The modified Thompson-Littler technique was useful for chronic instability of the PIP joint.- Level of Evidence: Level V (Therapeutic).

Excision of the hook of hamate in athletes using the carpal tunnel approach.

BACKGROUND: Hook of the hamate fractures can be managed conservatively or fixed using a screw, but excision is recommended for prompt return to activities. Although various approaches have been described, there is no gold standard. Herein, the authors have described their clinical experiences in excising the hook of the hamate using the carpal tunnel approach, in athletes. METHODS: A total of 36 athletes underwent excision of the hamate hook using the carpal tunnel approach. The mean age of the patients was 23 years, and most of them were baseball players (n = 31). RESULTS: The mean operation time was 33 min. None of the patients presented with any complications aside from transient pillar pain in five cases. All of them returned to their sports activities within an average of 27 days. CONCLUSIONS: In our study, excision of the hook of the hamate was performed safely via the carpal tunnel. The carpal tunnel approach reportedly provides superior benefits over other approaches.

A case of neuropathic arthropathy of the elbow with early loosening after total elbow arthroplasty.

We reported the case of a 65-year-old woman who presented with neuropathic arthropathy of the elbow and had undergone cervical spinal cord tumour resection at 32 years of age. Open synovectomy with free-body resection was performed; however, the instability of the elbow joint rapidly progressed. Therefore, we performed total elbow arthroplasty (TEA) using a linked-type prosthesis. However, the humeral stem became severely loosened 1 year after arthroplasty. Furthermore, a periprosthetic humeral fracture developed due to a minor trauma. A revision TEA using a long-stem prosthesis was performed 4 years after the primary TEA. Radiographs taken 2 years after the revision surgery showed no evidence of implant loosening. In this case, early postoperative loosening occurred despite the use of a linked-type prosthesis and an appropriate cementing technique, suggesting that normal implants may not provide sufficient fixation for neuropathic arthropathy of the elbow. Since surgery for neuropathic arthropathy generally has a poor prognosis, surgical interventions including TEA should be carefully considered.

Comparative study on the effectiveness of bone grafting for arthrodesis of the thumb carpometacarpal arthritis.

The aim of this retrospective study was to assess the effectiveness of autogenous bone grafting for arthrodesis of the thumb carpometacarpal joint by comparing the bone union rates with and without bone grafting. We included 36 patients who underwent arthrodesis of the thumb carpometacarpal joint for arthritis (20 patients with bone grafts and 16 without bone grafts). Implants used for internal fixation were K-wire, tension band wiring, headless compression screw and locking plate. The presence of bone union and the time from surgery to bone union were evaluated. The bone union rate was 20/20 (100%) in the bone grafting group and 12/16 (75%) in the non-bone grafting group (p = 0.03). There were no significant differences between the two groups in the time from surgery to bone union and patient characteristics. In conclusion, autogenous bone grafting may contribute to the bone union in the arthrodesis of thumb carpometacarpal arthritis.Level of evidence: III.

Rupture of the Flexor Pollicis Longus Tendon Involved between the Radial Shaft and the Volar Locking Plate.

We report the case of a 61-year-old woman with right-sided flexor pollicis longus (FPL) tendon ruptured a month after volar locking plate fixation. Five months after the initial operation, hardware removal and reconstruction of the FPL tendon with the ipsilateral palmaris longus were performed. The proximal stump of the ruptured FPL tendon was found in the space between the distal radius and plate.