New generation of superior single plating vs. low-profile dual minifragment plating in diaphyseal clavicle fractures: a biomechanical comparative study.

BACKGROUND: Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and a less prominent and optimized plate-to-bone fit design. On the other hand, minifragment plates in dual plating mode have demonstrated promising clinical results. The aim of the current study was to compare the biomechanical competence of single superior plating using the new-generation plate vs. dual plating using low-profile minifragment plates. METHODS: Sixteen paired human cadaveric clavicles were pairwise assigned to 2 groups for instrumentation with either a superior 2.7-mm variable-angle locking compression plate (group 1), or with one 2.5-mm anterior combined with one 2.0-mm superior matrix mandible plate (group 2). An unstable clavicle shaft fracture (AO/OTA 15.2C) was simulated by means of a 5-mm osteotomy gap. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis, and monitored via motion tracking. RESULTS: Initial construct stiffness was significantly higher in group 2 (9.28 ± 4.40 N/mm) compared to group 1 (3.68 ± 1.08 N/mm), P = .003. The amplitudes of interfragmentary motions in terms of axial and shear displacement, fracture gap opening and torsion, over the course of 12,500 cycles were significantly higher in group 1 compared to group 2, P ≤ .038. Cycles to 2 mm shear displacement were significantly lower in group 1 (22,792 ± 4346) compared to group 2 (27,437 ± 1877), P = .047. CONCLUSION: From a biomechanical perspective, low-profile 2.5/2.0-mm dual plates could be considered as a useful alternative for diaphyseal clavicle fracture fixation, especially in less common unstable fracture configurations.

Collagenase clostridium histolyticum injection versus limited fasciectomy for the treatment of Dupuytren's disease: a systematic review and meta-analysis of comparative studies.

INTRODUCTION: The aim of the present study is to systematically review the literature on well-selected comparative studies for meta-analysis on outcome differences between collagenase clostridium histolyticum (CCH) injection and limited fasciectomy (LF) for Dupuytren's disease. MATERIALS AND METHODS: PubMed/Medline, Embase, and the Cochrane Library were searched for comparative studies assessing differences in outcomes of CCH and LF. Effect estimates were pooled across studies using random effects models and presented as weighted mean difference (MD) and odds ratio (OR) with corresponding 95% confidence interval (CI). RESULTS: A total of 11 studies encompassing 1'051 patients was included (619 patients in the CCH and 432 in the LF group). The residual contracture at a minimal average follow-up of three months was higher in the CCH group than in the LF group (27.8 vs. 16.2°, MD 11.6°, 95% CI [8.7, 14.5°], p < 0.001). The recurrence rate was significantly higher in the CCH group (25.8 vs. 9.3%, OR 5.2, 95% CI [1.5, 18.8], p = 0.01) while the rate of severe complications was significantly higher in the LF group (0.3 vs. 7.3%, OR 0.12, 95% CI [0.03, 0.42], p = 0.001). CONCLUSIONS: Evidence of the present study confirms that CCH injection has a higher rate of disease recurrence whereas LF carries a higher risk for severe complications. It's imperative that the trade-off between these aspects is considered, keeping in mind that CCH injections may be repeated in case of disease recurrence without increasing procedure related risks, especially in complex cases.

Mid-term Clinical Outcome of Microvascular Gracilis Muscle Flaps for Defects of the Hand.

PURPOSE: Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand. AIM: To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity. METHODS: 16 patients aged 44.3 (range 20-70) years were re-examined after a mean follow-up of 23.6 (range 2-77) months. Mean defect size was 124 (range 52-300) cm2 located palmar (n = 9), dorsal (n = 6), or radial (n = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft. RESULTS: Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss (n = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap (n = 1) with renewed split thickness skin cover. A surplus of the flap (n = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3-96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1-3) (1 = excellent; 4 = poor). CONCLUSIONS: Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure. LEVEL OF EVIDENCE: IV observational.

Cat bite injuries to the hand and forearm: the impact of antibiotic treatment on microbiological findings and clinical outcome.

INTRODUCTION: Patients and physicians often underestimate cat bite injuries. The deep and narrow wound seals quickly and provides an environment for the inoculated saliva and bacteria. Interestingly, the literature reports no bacterial growth in the microbiological workup of wound swaps in up to 43%. The time between bite injury and the first clinical presentation, the start of antibiotic treatment and surgical debridement might affect these findings. Therefore, the current project examines if (1) these factors impact the outcome of microbiological results following cat bite injuries and (2) the detection of bacterial growth leads to higher complication rates, longer hospital stays, longer total treatment time, or higher total treatment costs. MATERIALS AND METHODS: This single-center retrospective study analyzed data from 102 adult patients. All patients received antibiotic and surgical treatment following a cat bite injury. Microbiological samples were collected during surgery in all cases. The time from the bite incident to the first presentation, beginning of antibiotic administration, and surgical debridement was calculated. Demographic data, complication rate, length of hospital stay, total treatment time, and total treatment costs were recorded. (1) A generalized linear model was fitted using the microbiological outcome as the dependent variable. (2) Two groups (negative or positive microbiological results) were formed and statistically compared. RESULTS: The median age was 50 (SD 16), and 72% were female. (1) The time from the bite incident to the first clinical presentation, antibiotic administration, or surgical treatment was not associated with the outcome of the microbiological result. (2) No significant differences were observed between the two groups. CONCLUSIONS: Our data do not suggest that early antibiotic administration or delayed surgical treatment affects the outcome of the microbiological workup following cat bite injuries to the hand and forearm. The microbiological outcome did not affect the complication rate, treatment time, and total treatment costs.

New dynamic suture material for tendon transfer surgeries in the upper extremity - a biomechanical comparative analysis.

BACKGROUND: Early mobilization after tendon surgery is crucial to avoid commonly observed postoperative soft tissue adhesions. Recently, a new suture was introduced (DYNACORD; DC) with a salt-infused silicone core designed to minimize laxity and preserve consistent tissue approximation in order to avoid gap formation and allow early mobilization. AIMS: To compare the biomechanical competence of DC against a conventional high strength suture (FiberWire; FW) in a human cadaveric tendon transfer model with an early rehabilitation protocol. METHODS: Sixteen tendon transfers (flexor digitorum superficialis (FDS) IV to flexor pollicis longus (FPL)) were performed in 8 pairs human cadaveric forearms using either DC or FW. Markings were set 0.8 cm proximally and 0.7 cm distally to the level of the interweaving zone of the transfer. All specimens underwent repetitive thumb flexion against resistance in 9 intermittent series of 300 cycles each, simulating an aggressive postoperative rehabilitation protocol. After each series, the distance of the proximal marker to the interweaving zone (proximal), the length of the interweaving zone (intermediate) and the distance of the distal marker to the interweaving zone (distal) were measured. RESULTS: Pooled data over all nine series, normalized to the immediate postoperative status, demonstrated no significant differences between FW and DC (p ≥ 0.355) for the proximal and distal markers. However, at the intermediate zone, DC was associated with significant length shortening (p < 0.001) compared to FW without significant length changes (p = 0.351). Load to catastrophic failure demonstrated significant higher forces in FW (p = 0.011). Nevertheless, due to failure mainly proximal or distal of the transfer zone, these loads are not informative. CONCLUSION: From a biomechanical perspective, DC preserved tissue approximation and might be considered as a valid alternative to conventional high-strength sutures in tendon transfer surgery. DC might allow for a shorter interweaving zone and a more aggressive early postoperative rehabilitation program, possibly avoiding commonly observed postoperative soft tissue adhesions and stiffness.

Sonographically controlled minimally-invasive A1 pulley release using a new guide instrument - a case series of 106 procedures in 64 patients.

BACKGROUND: With percutaneous and minimally-invasive pulley release becoming more popular, safety and reliability of such minimally-invasive procedures remain a concern. Visualization of the technical steps by ultrasound suggests increased safety but shows the potential for harm to tendons, nerves and vessels without proper instrumentation. We present the results of implementing a sonographically guided minimally-invasive procedure in 106 trigger digits of 64 patients between 2018-2021. METHODS: A guide instrument for use with a commercially available hook knife was developed and tested in 16 cadaver hands. Due to complication early in our clinical series this guide was modified in due course. A revised design of the guide has been in use since November 2019 with improved performance and safety. RESULTS: One hundred six procedures in 64 patients were performed. After guide revision, we report a success rate of 97.3%. Complications after instrument revision include two cases of incomplete pulley release and one case of inadvertent skin laceration. The majority of patients report returning to all strenuous activities within two weeks at most apart from four individuals with prolonged postoperative discomfort. CONCLUSION: We present the results of the development and implementation of a novel guide instrument for use with a hook knife to treat trigger finger. Despite several limitations of this study, we show that sonographically controlled, minimally-invasive A1 pulley release can be performed safely and effectively with appropriate surgical instruments and practice.

Comparing treatment of proximal phalangeal fractures with intramedullary screws versus plating.

PURPOSE: Phalangeal fractures are the most common injuries in humans and account for approximately 10% of all fractures. With plate fixation, anatomic reduction is achievable in most cases, but extension lag is seen in up to 67%. Intramedullary headless screw offers treatment of unstable proximal phalangeal fractures using a minimally invasive procedure with very few complications. One of the major disadvantages of this technique is the transarticular screw position, damaging the articular surface and thus preventing very proximal fractures from being treated with a distally inserted screw. In this study, we present a modified approach to the fixation of the proximal phalangeal fractures and compare outcomes with plate osteosynthesis. MATERIALS AND METHODS: Twenty-nine patients with 31 comparable fractures of the proximal phalanx were treated either with a plate (14) or with minimal invasive cannulated compression screw (17). Pain, strength, range of motion (ROM), work disability and QuickDASH score were assessed. RESULTS: TAM was significantly better in the screw group. The extension lag was worse in the plate group. Plate removal had to be performed in 13 of 14 the cases, while the screw had to be removed in only 3 cases. The average duration of work disability was 9.9 weeks in the plate group, compared to 5.6 weeks in the screw group. CONCLUSION: Minimally invasive screw osteosynthesis not only has the advantage of significantly shorter work disabilities, but also shows remarkably improved postoperative range of motion. In contrast to plate osteosynthesis, removal of the screw is only necessary in exceptional cases. With the antegrade screws position, even difficult fractures close to the base can be treated without destroying any articular surface. In proximal phalanx fractures with both options of plate or single-screw osteosynthesis, we recommend minimal invasive cannulated screw osteosynthesis.

A prospective study to analyse the concentration of octenidine in hand wounds after disinfection by LC-MS/MS.

Toxic reactions can appear after pressurised flushing of soft tissue with octenidine (OCT) containing disinfectants. Their use for surgical disinfection could complicate the diagnosis of possible contamination. In patients with open lacerations of their hand's subcutaneous tissue samples were taken before and after surgical disinfection with Octenisept® and analysed by ultra-high-performance liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). In 16 out of 20 tissue samples, OCT was detected after disinfection (lower limit of quantification (LLOQ)=10 pg/mL/mg). The concentration of OCT was below the LLOQ, estimation of mean of 0.6 pg/mL/mg (0.22-0.98 pg/mL/mg, 95%-CI) before disinfection and mean of 179.4 pg/mL/mg (13.35-432.0 pg/mL/mg, 95%-CI) after disinfection. This study shows that the disinfection of open wounds with Octenisept® leads to a quantifiable concentration of OCT in open wounds. In cases of suspected OCT-mediated toxic reaction, the use of antiseptics containing OCT should be avoided.

Quality of Life and Working Conditions of Hand Surgeons-A National Survey.

Background and Objectives: Providing high-quality care for patients in hand surgery is an everyday endeavor. However, the quality of life (QoL) and working conditions of hand surgeons ensuring these high-quality services need to be investigated. The aim of this study was to evaluate the QoL and working conditions of Swiss hand surgeons. Materials and Methods: A national survey with Swiss hand surgeons was conducted. Standardized questionnaires were completed anonymously online. Core topics included working conditions, QoL, satisfaction with the profession, and aspects of private life. Results: A total of 250 hand surgeons were invited to participate, of which 110 (44.0%) completed the questionnaire. Among all participants, 43.6% stated that they are on call 4-7 days per month, versus 8.2% never being on call. Overall, 84.0% of the residents, 50.0% of the senior physicians, 27.6% of the physicians in leading positions, and 40.6% of the senior consultants/practice owners, as well as 55.1% of the female and 44.3% of the male respondents, felt stressed by their job, even during holidays and leisure time. Out of all participants, 85.4% felt that work affects private relationships negatively. Despite the reported stress, 89.1% would choose hand surgery as a profession again. Less on-call duty (29.1%) and better pay (26.4%) are the most prioritized factors for attractiveness of a position at a hospital. Conclusions: The QoL of Swiss hand surgeons is negatively affected by their workload and working hours. Residents, senior physicians and female surgeons suffer significantly more often from depression, burnout or chronic fatigue in comparison to leading positions, senior consultants/practice owners and male surgeons. Better pay or less on-call duty would make the work more attractive in acute care hospitals.

Atypical Pleomorphic Lipomatous Tumor of the Right Hand Mimicing Venous Malformation.

We present the case of a 31-year-old woman who was referred with a 12-month history of a tumor on the ulnar side of her dominant right hand. The eventual histopathologic diagnosis was an atypical pleomorphous lipomatous tumor, an entity that has only been recently classified in the World Health Organization Classification of Soft Tissue and Bone Tumors.

Non-vascularized partial joint transfer for Finger Proximal Interphalangeal joint reconstruction: a series of 9 patients.

INTRODUCTION: Finger proximal interphalangeal joint (PIP) reconstruction after the destruction of parts of the joint remains challenging. Surgical techniques include implant arthroplasty, arthrodesis, free vascularized joint transfer, and non-vascularized bone and joint transfer. This study analyzes our experience after non-vascularized transfer in terms of range of motion, postoperative rehabilitation, and patient satisfaction. MATERIALS AND METHODS: Between 2009 and 2014, ten patients underwent non-vascularized partial joint transfer for PIP joint reconstruction. One of them was lost to follow-up. Included patients had osteochondral partial joint transplants of 25-50% of the toes (n = 4) and the hand (n = 5). Range of motion (ROM), grip-, and pinch-strength were measured at the last follow-up control and compared to the healthy side. Patients were asked to score the pain at rest/ on load on a visual scale (VAS: 0 = no pain; 10 = excruciating pain). Satisfaction self-assessment was evaluated by asking the patients to grade their postoperative result as excellent, very good, good or poor. RESULTS: Mean follow-up period was 4.0 years (range 1.2-7.9 years). Mean PIP joint flexion was 93 ± 26° at the last follow-up control. Mean grip- and pinch-strength of the operated side at the last control were, respectively, 43 ± 18 kg and 8 ± 5 kg, close to the healthy side values (45 ± 15 kg and 9 ± 4 kg). Mean pain at rest/on load measured on a visual scale was, respectively, 0.3 ± 1 and 1.8 ± 2. Eight patients (89%) rated their operation as excellent, and one as poor. CONCLUSION: In this study, non-vascularized partial joint transfer provides a mobile and stable PIP joint 4 years after reconstruction. The surgical technique presented herein is complex depending on additional injuries but results in great patient satisfaction.

[Treatment of acute injuries of the hand]. / Tipps und Tricks in der Behandlung offener Handverletzungen in der Notfallpraxis.

Treatment of acute injuries of the hand Abstract. Injuries to the hand are a common presentation in primary care units. When accurately assessed, many open injuries may be handled in the emergency department without referral to a hand surgery specialist. We would like to give some recommendations on how to treat the most frequent injuries like lesions to the nail and nailbed, fingertip amputation as well as burns, infections and bites. But first, we highlight the different methods of local anesthesia and discuss the use of a tourniquet or vasoconstriction with adrenalin - WALANT - instead.

[Pain assessment of CRPS in Hand Therapy]. / Assessments des neurogenen Schmerzes in der Handtherapie am Beispiel des Complex Regional Pain Syndrome (CRPS).

Pain assessment of CRPS in Hand Therapy Abstract. Pain massively controls everyday life of affected persons. In case of a nerve being damaged, pain becomes more complex, as the trophism of the affected skin area may significantly be altered in addition to loss of sensibility and / or motor function. Quantifying pain is, therefore, difficult. Nevertheless, there exists a broad variety of pain assessments in hand therapy. A comprehensive documentation of pain and its effects on the patients' life are therefore pivotal for the individual design of therapy. Guidelines recommend an early start of therapy, a multimodal approach and a mixture of drug and non-drug interventions. However, specific recommendations are difficult to make, as the course of therapy is often complex and varies from person to person. Therefore, open and transparent communication, a stable therapeutic relationship, professional knowledge and active involvement of those affected are a prerequisite for successful therapy. In this article, the most frequently used assessments for pain in hand therapy are presented, as they are applied, for example, in complex regional pain syndromes. The clinical examination of allodynia is described in more detail by means of a patient example. Potential therapy goals and contents are illustrated. Despite all launched therapy interventions, treatment of pain remains a challenge that is best approached in an interdisciplinary setting and with the support of those affected.

Acquired Constriction Ring: A Case of Rubber Band Syndrome.

Rubber band syndrome is a rare entity seen in younger children mainly in communities where rubber bands are worn around the wrist for decorative purposes. When the band is worn for a long duration, it burrows through the skin and soft tissues resulting in distal edema, loss of function, and even damage to the neurovascular structures. These symptoms are difficult to relate to this rare but typical condition. We report a case of a 2¾-year-old girl with the history of a linear circumferential scar at the right wrist combined with the limited use of a swollen hand for several weeks. The child was taken to surgery with the purpose to release the red, indurated scar and eliminate the lymphatic congestion. A rubber band was found lying in a plane superficial to the flexor tendons but had cut through the superficial branch of the radial nerve and partially through the abductor pollicis longus tendon. The band was removed and the lacerated structures were repaired. The child had excellent recovery postoperatively. The cardinal features of a linear constricting scar around the wrist in the presence of a swollen hand should always alert the clinician to the possibility of a forgotten band around the wrist, which might have burrowed into the soft tissues for a period. Early recognition may be important to prevent further damage of essential structures.

The Role of Health Locus of Control in Pain Intensity Outcome of Conservatively and Operatively Treated Hand Surgery Patients.

PURPOSE: Psychological factors have shown to be associated with treatment outcomes in hand injury patients. This study aimed to investigate the role of health locus of control (HLOC) and its dimensions internal, social-external, and fatalistic-external HLOC in treatment outcomes of hand injury patients. METHOD: One hundred thirty-two consecutive patients of a tertiary center for hand surgery undergoing treatment for acute hand injury or degenerative hand problems were included in this study. Pretreatment levels of depression, anxiety, HLOC, and pain intensity were measured, along with pain intensity levels at 4-month follow-up. Hierarchical regression analyses were calculated to test for moderation effects of the HLOC dimensions on the relationship between pretreatment and follow-up pain intensity. RESULTS: Controlling for age, gender, treatment modality, source of hand pain, and depressive symptoms, a moderation effect emerged (ß = - 0.16, p < 0.05), such that among patients higher in initial pain intensity, those lower in social-external HLOC experienced higher pain intensity at follow-up compared to those with high social-external HLOC. Internal HLOC and fatalistic-external HLOC did not moderate the effect of initial pain intensity on pain intensity at follow-up. CONCLUSION: Hand injury patients suffering greater initial pain intensity who also had lower versus higher social-external HLOC experienced less favorable treatment outcome. This finding suggests that if patients with high initial pain succeed in transferring perceived health control to professionals and to gain confidence in treatment and clinicians, treatment outcome could be improved in hand surgery.

Range of motion, postoperative rehabilitation and patient satisfaction in MCP and PIP joints affected by Dupuytren Tubiana stage 1-3: collagenase enzymatic fasciotomy or limited fasciectomy? A clinical study in 52 patients.

INTRODUCTION: In Switzerland, collagenase Clostridium histolyticum therapy (CCH) for Dupuytren's disease was introduced in 2011. This study analyzes possible differences between CCH and limited fasciectomy (LF) in terms of range of motion, patient satisfaction and postoperative rehabilitation. MATERIALS AND METHODS: This retrospective study included 52 patients with Dupuytren's disease stage 1-3 according to Tubiana, treated with CCH or LF between January 2012 and December 2013. Complications were analyzed for each patient. The contracture of each treated joint measured on average at the 3 months and up to 2 years follow-up was compared with the preoperative values. The Michigan Hand score was evaluated at 2 years and the patients were asked to subjectively evaluate the outcome of the treatment and whether they would repeat it if necessary. Postoperative rehabilitation was also precisely quantified. RESULTS: 11 minor complications were reported for a complication rate of 29% in the CCH group. No major complications were reported in both groups. In the CCH group, mean MCP joint contracture was, respectively, 44° ± 20°, 9° ± 2° (gain of mobility compared to the preoperative situation 35°, P < 0.001), and 10° ± 3° (gain 34°, P < 0.001), respectively, before, at the 3 months' control and at the 2-year clinical control. In the LF group, mean MCP joint contracture was, respectively, 30° ± 21°, 2° ± 0.5° (gain 28°, P < 0.001), and 1° ± 0.5° (gain 29°, P < 0.001) for the same control periods. In the CCH group, mean PIP joint contracture was, respectively, 51° ± 21°, 18° ± 3° (gain of mobility compared to the preoperative situation 33°, P < 0.001), and 32° ± 4° (gain 19°, P < 0.001), respectively, before, at the 3 months' control and at the 2-year clinical control. In the LF group, mean PIP joint contracture was, respectively, 30° ± 20°, 2° ± 0.5° (gain of mobility compared to the preoperative situation 28°, P < 0.001), and 11° ± 4° (gain 19°, P < 0.001) for the same control periods. Outcomes were compared across the LF and CCH groups: surgery performed better than collagenase for PIP joint treatment at early (P < 0.001) and 2-year follow-up (P = 0.004) controls. However, patient satisfaction was higher in the CCH group: 92% were satisfied or very satisfied of the treatment compared to 71% in the LF group. All patients would reiterate the treatment in the CCH group if necessary compared to only 71% in the LF group. Rehabilitation was highly reduced in the CCH group compared to the LF group. CONCLUSION: In this study, surgery performed better than collagenase at early and 2-year follow-up in PIP joints and similar in MCP joints. While surgery seems to achieve better results, collagenase is considered in Switzerland as an off-the-shelf therapy that provides consistent results without scars, with shorter rehabilitation time, minor hand therapy, shorter splinting time, and applicability. LEVEL OF EVIDENCE AND STUDY TYPE: Level III.

Perilunate fracture-dislocations: clinical and radiological results of 21 cases.

BACKGROUND: Perilunate dislocations and fracture-dislocations are a subcategory of the carpal instability complex. Herein, we report our university hospital experience with this complex injury. The goal of our study was to find predictive factors and quantify the development of arthritis and lunate necrosis. We tried to measure the impact of arthritis on hand function. METHODS: Between January 2000 and December 2014, 21 patients underwent surgery for perilunate dislocations and perilunate fracture-dislocations of the wrist in our tertiary university center. Mean patient age was 29.3 ± 10.0 years (range 18-49 years). All displacements were posterior. They were reviewed both clinically and radiologically. RESULTS: Complications included misdiagnosed Essex-Lopresti-like lesion in one case, insufficient reposition of the carpus in two cases (LT in one case, SL in one case), and iatrogenic injury to the radial artery immediately sutured in one case. All 3 cases underwent a second procedure with satisfactory outcome. After a mean follow-up of 112 ± 60 months (range 12-210 months), the average Cooney score was 80 ± 19 (range 50-125). The mean PRWE score was 10 ± 8 (range 0-25). The mean DASH score was 40 ± 13 (range 30-75 months). Mean pain on load, measured with VAS was 1.1 ± 1.6; Clinical examination assessed a mean wrist extension/flexion of 42.4° ± 17.2°/48.4° ± 15.2°. Mean wrist ulnar/radial deviation was, respectively, 22.9° ± 11.3°/15.3° ± 7.0°. Mean pro/supination was, respectively, 75.2° ± 11.5°/76.3° ± 8.1°. Mean pinch strength was 9.4 ± 2.2 kg (87.4 ± 17.7% of the contralateral side). Mean power strength was 41.9 ± 9.9 kg (76.2 ± 19.2% of the contralateral side). Two patients had a scaphoid non-union identified on their most recent imaging. The mean carpal height ratio was 0.53 ± 0.05 (range 0.44-0.65). All except one patient developed arthritis: Grade 1 in 11 patients, Grade 2 in 3 patients, and Grade 3 in the remaining 6 patients. Age, length of follow-up, and loss of reduction were significantly associated with wrist arthritis (p < 0.001). Lunate avascular necrosis assessed by magnetic resonance imaging was present in 6 patients: Stage 2 in 4 patients, Stage 3a in 1 patient, and Stage 3b in the remaining patient. All these patients' intraoperative findings showed lesion of the cartilage of the radial side of the lunate. However, the small number of patients who developed lunate necrosis did not allow satisfactory statistical analysis. CONCLUSIONS: This retrospective study demonstrates good functional results despite the high rate of radiological wrist arthritis. Age, length of follow-up, and loss of reduction were significantly associated with wrist arthritis in our series.

Novel targeted drug delivery systems to minimize systemic immunosuppression in vascularized composite allotransplantation.

PURPOSE OF REVIEW: The long-term adverse effects of immunosuppressive treatment, the high rate of acute rejection and the development of chronic rejection are the main factors preventing a wider clinical application of vascularized composite allotransplantation (VCA). Targeted immunosuppression using innovative drug delivery systems (DDS) may help to overcome these hurdles, increasing therapeutic efficacy while reducing systemic toxicity. This review provides a summary of the recently developed strategies for targeted delivery of immunosuppressive drugs in VCA. RECENT FINDINGS: Currently, several innovative strategies for targeted immunosuppression have been designed based on the anatomy and function of the target organ. Site-specific DDS have been developed both for directly accessible organs (i.e. skin, eye and lung) and internal organs (i.e. lymph nodes, liver, nervous system, etc.). In preclinical models, DDS designed for sustained, 'on demand,' or 'on cue' drug release has been shown to promote VCA survival while reducing systemic toxicity. These findings suggest that targeted delivery could increase patient compliance and potentially decrease toxicity in VCA recipients. SUMMARY: Targeted immunosuppression in VCA represents a promising approach for improving patient compliance and graft survival while reducing off-target toxicity, intensity and frequency of acute rejection episodes and risk of chronic rejection. VIDEO ABSTRACT.

Bioengineering a Human Face Graft: The Matrix of Identity.

OBJECTIVE: During the last decade, face allotransplantation has been shown to be a revolutionary reconstructive procedure for severe disfigurements. However, offer to patients remains limited due to lifelong immunosuppression. To move forward in the field, a new pathway in tissue engineering is proposed. BACKGROUND: Our previously reported technique of matrix production of a porcine auricular subunit graft has been translated to a human face model. METHODS: 5 partial and 1 total face grafts were procured from human fresh cadavers. After arterial cannulation, the specimens were perfused using a combined detergent/polar solvent decellularization protocol. Preservation of vascular patency was assessed by imaging, cell and antigen removal by DNA quantification and histology. The main extracellular matrix proteins and associated cytokines were evaluated. Lip scaffolds were cultivated with dermal, muscle progenitor and endothelial cells, either on discs or in a bioreactor. RESULTS: Decellularization was successful in all facial grafts within 12 days revealing acellular scaffolds with full preservation of innate morphology. Imaging demonstrated a preservation of the entire vascular tree patency. Removal of cells and antigens was confirmed by reduction of DNA and antigen markers negativation. Microscopic evaluation revealed preservation of tissue structures as well as of major proteins. Seeded cells were viable and well distributed within all scaffolds. CONCLUSIONS: Complex acellular facial scaffolds were obtained, preserving simultaneously a cell-friendly extracellular matrix and a perfusable vascular tree. This step will enable further engineering of postmortem facial grafts, thereby offering new perspectives in composite tissue allotransplantation.

Intra-graft injection of tacrolimus promotes survival of vascularized composite allotransplantation.

BACKGROUND: Immunosuppressive therapies derived from solid organ transplantation are effective in promoting survival of vascularized composite allotransplantation (VCA), but they cause serious side effects that are difficult to justify for this non-life-saving procedure. Unlike solid organ transplantation, hand and face transplants offer the possibility of site-specific immunosuppression for reducing systemic exposure while increasing intra-graft concentrations of the drug. Therefore, in this study, we tested whether a single intra-graft injection tacrolimus could promote VCA survival. METHODS: Brown Norway-to-Lewis hind limb transplantations were performed, and animals were left untreated (group I), treated with a daily injection of 1-mg/kg tacrolimus for 21 days (group 2) or injected with 7-mg tacrolimus directly into the transplanted limb on day 1 (group III). Graft rejection was monitored, and animals were sacrificed at grade 3 rejection or 200 days after transplantation. RESULTS: Intra-graft injection of tacrolimus significantly prolonged allograft survival as compared to untreated animals or animals treated with systemic tacrolimus. Half of the intra-graft-treated rats rejected their graft on average at day 70.5. Interestingly, the other half remained rejection-free for more than 200 days without signs of kidney or liver toxicity. In these animals, tacrolimus was detected in the VCA skin but not in the blood until day 200. Long-term survival was not linked to induction of donor-specific tolerance but to a higher level of lymphocyte chimerism. CONCLUSIONS: Intra-graft delivery of tacrolimus may promote VCA survival by increasing tissue drug availability and promoting the establishment of transient chimerism and thus long-term graft acceptance.