Surgery, Needle Fasciotomy, or Collagenase Injection for Dupuytren Contracture : A Randomized Controlled Trial.

BACKGROUND: Surgery, needle fasciotomy, and collagenase injection are used to treat Dupuytren contracture. The treatment decision requires balancing initial morbidity and costs of surgery against its potential long-term benefits over needle fasciotomy and collagenase. OBJECTIVE: To compare the effectiveness of surgery, needle fasciotomy, and collagenase injection at 3 months and 2 years (secondary time points of the trial). DESIGN: A multicenter, randomized, outcome assessor-blinded, superiority trial. (ClinicalTrials.gov: NCT03192020). SETTING: 6 public hospitals in Finland. PARTICIPANTS: 302 persons with treatment-naive Dupuytren contracture (contracture angle <135°). INTERVENTION: Surgery (n = 101), needle fasciotomy (n = 101), or collagenase (n = 100). MEASUREMENTS: The primary outcome was the success rate, defined as greater than 50% contracture release and patients reaching the patient acceptable symptom state. Secondary outcomes included hand function, pain, quality of life, patient satisfaction, residual contracture angle, finger flexion, risk for retreatment, and serious adverse events. RESULTS: A total of 292 (97%) and 284 (94%) participants completed the 3-month and 2-year follow-ups. Success rates were similar at 3 months: 71% (95% CI, 62% to 80%) for surgery, 73% (CI, 64% to 82%) for needle fasciotomy, and 73% (CI, 64% to 82%) for collagenase. At 2 years, surgery had superior success rates compared with both needle fasciotomy (78% vs. 50%; adjusted risk difference [aRD], 0.30 [CI, 0.17 to 0.43]) and collagenase (78% vs. 65%; aRD, 0.13 [CI, 0.01 to 0.26]). Secondary analyses paralleled with the primary analysis. LIMITATION: Participants were not blinded. CONCLUSION: Initial outcomes are similar between the treatments, but at 2 years success rates were maintained in the surgery group but were lower with both needle fasciotomy and collagenase despite retreatments. PRIMARY FUNDING SOURCE: Research Council of Finland.

The Learning Curves of Adelaide- and Gan-Modified Lim-Tsai Flexor Tendon Repair Techniques.

PURPOSE: Surgical performance that improves with experience is often depicted as representing a "learning curve." Although numerous studies examine the tensile properties of various flexor tendon repairs, few compare the associated learning curves. This study aims to address this gap by comparing the learning curves of Adelaide- and Gan-modified Lim-Tsai repairs. Emphasizing the difference in learning curves is crucial because it highlights the tension between achieving biomechanically superior repairs, which may be challenging to many surgeons, and opting for possibly incrementally less strong but more feasible techniques. METHODS: We organized a workshop attended by 20 medical students whose experience in surgery was limited to a few suturing exercises. Each participant repaired five porcine tendons in situ either with Adelaide- or Gan-modified Lim-Tsai, followed by a peripheral suture. We tested all tendons with linear static testing to measure ultimate and yield loads. In addition, repair times were recorded for each repair. We used a linear mixed model to compare learning between the techniques. RESULTS: Ultimate loads increased with experience and were higher in Adelaide technique during the first two repairs, compared with Gan-modified Lim-Tsai (80 N vs 63 N and 79 N vs 66 N, respectively). Yield loads also increased with experience but did not differ between the repair techniques at any time point. Mean repair times decreased from 44 to 28 minutes and from 46 to 25 minutes with Adelaide- and Gan-modified Lim-Tsai repairs, respectively. CONCLUSIONS: The Adelaide core suture had a higher initial ultimate load capacity despite fewer suture strands, possibly indicating better tension consistency. The ultimate load of the Gan-modified Lim-Tsai repair increased between the first and fifth repair, and repeats were needed to achieve comparable results with the Adelaide repair. CLINICAL RELEVANCE: The results of this study suggest that both repair methods are suitable for novice surgeons, but Adelaide tends to result in higher strength from the first repair. Generalizability to other repairs should be made with caution.

Is Replantation Associated With Better Hand Function After Traumatic Hand Amputation Than After Revision Amputation?

BACKGROUND: Replantation is an established treatment for traumatic upper extremity amputation. Only a few studies, however, have assessed the patient-reported outcomes of replantation, and the findings of these studies have been conflicting. QUESTIONS/PURPOSES: (1) Is replantation associated with better hand function than revision amputation? (2) Is replantation associated with better health-related quality of life, less painful cold intolerance, and more pleasing hand esthetics than revision amputation after a traumatic hand amputation? METHODS: In this retrospective, comparative study, we collected the details of all patients who sustained a traumatic upper extremity amputation and were treated at the study hospital. Between 2009 and 2019, we treated 2250 patients, and we considered all patients who sustained a traumatic amputation of two or more digital rays or a thumb as potentially eligible. Based on that, 15% (334 of 2250) were eligible; a further 2% (8 of 334) were excluded because of a subsequent new traumatic amputation or bilateral amputation, and another 22% (72 of 334) refused participation, leaving 76% (254 of 334) for analysis here. The primary outcome was the DASH score. Secondary outcomes included health-related quality of life (EuroQOL-5D [EQ-5D-5L] Index), painful cold intolerance (the Cold Intolerance Symptom Severity score), and hand esthetics (the Michigan Hand Questionnaire aesthetic domain score). The minimum follow-up time for inclusion was 18 months. Patients were classified into two treatment groups: replantation (67% [171 of 254], including successful replantation in 84% [144 of 171] and partially successful replantation in 16% [27 of 171], in which some but not all of the replanted tissue survived), and revision (complete) amputation (33% [83 of 254], including primary revision amputation in 70% [58 of 83] and unsuccessful replantation followed by secondary amputation in 30% [25 of 83]). In this cohort, replantation was performed if possible, and the reason for choosing primary revision amputation over replantation was usually an amputated part that was too severely damaged (15% [39 of 254]) or was unattainable (2% [4 of 254]). Some patients (3% [8 of 254]) refused to undergo replantation, or their health status did not allow replantation surgery and postoperative rehabilitation (3% [7 of 254]). Gender, age (mean 48 ± 17 years in the replantation group versus 50 ± 23 years in the revision amputation group; p = 0.41), follow-up time (8 ± 4 years in the replantation group versus 7 ± 4 years in the revision amputation group; p = 0.18), amputation of the dominant hand, smoking, extent of tissue loss, or presence of arterial hypertension did not differ between the groups. Patients in the replantation group less frequently had diabetes mellitus (5% [8 of 171] versus 12% [10 of 83]; p = 0.03) and dyslipidemia (4% [7 of 171] versus 11% [9 of 83]; p = 0.04) than those in the revision group and more often had cut-type injuries (75% [129 of 171] versus 60% [50 of 83]; p = 0.02). RESULTS: After controlling for potential confounding variables such as age, injury type, extent of tissue loss before treatment, and accident of the dominant hand, replantation was not associated with better DASH scores than revision amputation (OR 0.82 [95% confidence interval (CI) 0.50 to 1.33]; p = 0.42). After controlling for potential cofounding variables, replantation was not associated with better EQ-5D-5L Index scores (OR 0.93 [95% CI 0.56 to 1.55]; p = 0.55), differences in Cold Intolerance Symptom Severity scores (OR 0.85 [95% CI 0.51 to 1.44]; p = 0.79), or superior Michigan Hand Questionnaire esthetic domain scores (OR 0.73 [95% CI 0.43 to 1.26]; p = 0.26) compared with revision amputation. CONCLUSION: Replantation surgery was conducted, if feasible, in a homogenous cohort of patients who underwent amputation. If the amputated tissue was too severely damaged or replantation surgery was unsuccessful, the treatment resulted in revision (complete) amputation, which was not associated with worse patient-reported outcomes than successful replantation. These results contradict the assumed benefits of replantation surgery and indicate the need for credible evidence to better guide the care of these patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

Platelet-rich Plasma or Autologous Blood Do Not Reduce Pain or Improve Function in Patients with Lateral Epicondylitis: A Randomized Controlled Trial.

BACKGROUND: Platelet-rich plasma (PRP) and autologous blood are commonly used therapies for lateral epicondylitis, but the evidence from randomized, placebo-controlled trials is conflicting. Thus, it is still unclear if patients benefit from these treatments. QUESTIONS/PURPOSES: In the setting of a randomized, placebo-controlled trial, we compared PRP, autologous blood, and saline injections in the treatment of lateral epicondylitis with respect to: (1) VAS pain scores, and (2) functional outcomes (DASH score and grip strength) 1 year after treatment. METHODS: We performed a parallel-group, randomized, controlled participant- and assessor-blinded study including adults with clinically diagnosed lateral epicondylitis. We defined lateral epicondylitis as pain in the lateral humeral epicondyle area exacerbated during resisted wrist extension and epicondyle compression. The participants were recruited from a secondary referral center, after not responding to initial nonoperative treatment. Patients with other concomitant upper-limb symptoms and surgical treatment of the elbow were excluded. Randomization sequence was generated with computer software and concealed from the investigators. We randomized 119 participants to receive an injection of PRP, autologous blood, or saline (1:1:1) in the proximal insertion of the extensor carpi radialis brevis muscle; 40 participants received PRP, 40 received autologous blood, and 39 received a saline injection. To prepare the PRP, we collected venous blood with a syringe kit followed by centrifugation, whereas autologous blood group received unprepared blood injection. Two unblinded investigators gave injections while the participant was unable to see the injection. There was no formal postinjection rehabilitation protocol and the use of NSAIDs was similar between different treatment arms. Follow-up visits were at 4, 8, 12, 26, and 52 weeks after the injection. The primary outcome measure was improvement in pain, measured with VAS scale (without specification as to whether the pain was activity related or at rest; range 0-10; a higher score indicates worse pain; the minimum clinically important difference [MCID] on the 10-cm scale was 1.5 cm), from baseline to 52 weeks. The secondary outcomes were the DASH score (range 0-100; a higher indicates a poorer outcome, and the MCID was 10.2 points) and grip strength. All patients were included in the analyses, and analyses were performed using the intention-to-treat principle. There was no crossover between treatment groups. At 52 weeks, nearly all (95% [38 of 40]) participants in autologous blood group were available for analysis whereas 78% (31 of 40) and 82% (32 of 39) were available in PRP and saline groups. This study was registered at ClinicalTrials.gov and funded by the local hospital district. With 40 patients in each group, we had 80% power to detect a clinically important improvement in pain (1.5 cm on the 10-cm VAS pain scale). RESULTS: There were no clinically important differences in the mean VAS pain or DASH scores among the groups at any timepoint. At 52 weeks, the mean difference in the VAS score for pain was -0.2 (95% CI -1.5 to 1.1; p = 0.75) for PRP versus saline and 0.5 (95% CI -0.7 to 1.7; p = 0.40) for autologous blood versus saline. The corresponding mean differences in the DASH score were 0.0 (95% CI -9.2 to 9.2; p > 0.99) and 7.7 (95% CI -1.3 to 16.7; p = 0.09) and those for grip strength were 1.4 kg (95% CI -3.3 to 6.1; p = 0.56) and -0.2 kg (95% CI -5.0 to 4.5; p = 0.92). No complications occurred because of the injections. CONCLUSIONS: PRP or autologous blood injections did not improve pain or function at 1 year of follow-up in people with lateral epicondylitis compared with those who were given a saline injection. However, because the 95% CIs did not exclude the MCID in VAS scores for autologous blood versus saline at 52 weeks, it is possible that a larger study could identify a between-group difference that we missed, but the effect size of that difference (based on our findings), even if present, is likely still to be small. Until or unless future randomized trials convincingly show a benefit either to PRP or autologous blood injections, we recommend against their use in patients with lateral epicondylitis. LEVEL OF EVIDENCE: Level II, therapeutic study.

Local adventitial anti-angiogenic gene therapy reduces growth of vasa-vasorum and in-stent restenosis in WHHL rabbits.

BACKGROUND: Antiproliferative drugs in drug eluting stents (DES) are associated with complications due to impaired re-endothelialization. Additionally, adventitial neovascularization has been suggested to contribute to in-stent restenosis (ISR). Since Vascular Endothelial Growth Factors (VEGFs) are the key mediators of angiogenesis, we investigated feasibility and efficacy of local gene therapy for ISR utilizing soluble decoy VEGF receptors to reduce biological activity of adventitial VEGFs. METHOD: Sixty-nine adult WHHL rabbit aortas were subjected to endothelial denudation. Six weeks later catheter-mediated local intramural infusion of 1.5x10e10 pfu adenoviruses encoding soluble VEGF Receptor-1 (sVEGFR1), sVEGFR2, sVEGFR3 or control LacZ and bare metal stent implantation were performed in the same aortic segment. Marker protein expression was assessed at 6d in LacZ cohort. Immunohistochemistry, morphometrical analyses and angiography were performed at d14, d42 and d90. RESULTS: Transgene expression was localized to adventitia. All decoy receptors reduced the size of vasa-vasorum at 14d, AdsVEGFR2 animals also had reduced density of adventitial vasa-vasorum, whereas AdsVEGFR3 increased the density of vasa-vasorum. At d42, AdsVEGFR1 and AdsVEGFR2 reduced ISR (15.7 ±â€¯6.9% stenosis, P < 0.01 and 16.5 ±â€¯2.7%, P < 0.05, respectively) vs. controls (28.3 ±â€¯7.6%). Moreover, AdsVEGFR-3 treatment led to a non-significant trend in the reduction of adventitial lymphatics at all time points and these animals had significantly more advanced neointimal atherosclerosis at 14d and 42d vs. control animals. CONCLUSIONS: Targeting adventitial neovascularization using sVEGFR1 and sVEGFR2 is a novel strategy to reduce ISR. The therapeutic effects dissipate at late follow up following short expression profile of adenoviral vectors. However, inhibition of VEGFR3 signaling accelerates neoatherosclerosis.

Factors Accounting for Variation in the Biomechanical Properties of Flexor Tendon Repairs.

PURPOSE: To investigate factors that cause variation in the mechanical properties of flexor tendon repairs. METHODS: One surgeon repaired 50 homogeneous absorbent sticks and 40 porcine flexor tendons with a simple loop, an Adelaide repair, a peripheral over-and-over repair, or a combination of the latter 2 repairs. Ten hand surgeons repaired 1 porcine flexor tendon with the combined Adelaide core and over-and-over peripheral repair. We loaded the samples statically until failure and calculated the variations caused by the testing process, tendon substance, and surgical performance in terms of yield and ultimate load. RESULTS: Tendon material and surgical performance both caused about half of the variation in the yield load of the combined repair. Surgical performance caused all variations observed in the ultimate load of the combined, peripheral-only, and core repairs. The effect of the tendon material was negligible in ultimate load. The intersurgeon variation was present only in yield load, and it represented one-tenth of the total variation. CONCLUSIONS: The effect of tendon substance on variation of the ultimate load is minimal. In yield load, both tendon and surgical performance are responsible for the variation. CLINICAL RELEVANCE: In clinical realm, variation caused by testing is not present, but intersurgeon variation may cause additional variation in yield load. A hand surgeon cannot change the variation due to tendon properties, but with a more meticulous surgical technique, the variation related to the surgical performance can probably be diminished.

Gap Formation During Cyclic Testing of Flexor Tendon Repair.

PURPOSE: Substantial gap formation of a repaired finger flexor tendon is assumed to be harmful for tendon healing. The purpose of this study was to investigate the relationship between gap formation and the failure of the repair during cyclic loading. METHODS: Thirty-five porcine flexor tendons were repaired and tested cyclically using variable forces until failure or a maximum of 500 cycles. Depending on the biomechanical behavior during cyclic testing, specimens were divided into 3 groups: Sustained (no failure), Fatigued (failure after 50 cycles), and Disrupted (failure before 50 cycles). The relationships between the gap formations, time-extension curves, and group assignments of the samples were investigated. RESULTS: The time-extension curves of the Fatigued specimens showed a sudden onset of repair elongation-a fatigue point-which preluded the subsequent failure of the repair. This point coincides with the start of plastic deformation and, thereafter, cumulative injury of the repair consistently led to failure of the repair during subsequent cycles. None of the sustained repairs showed a fatigue point or substantial gapping during loading. CONCLUSIONS: We conclude that the emergence of a fatigue point and subsequent gap formation during loading will lead to failure of the repair if loading is continued. CLINICAL RELEVANCE: The results of this experimental study imply that an inadequate flexor tendon repair that is susceptible to gap formation is under risk of failure.

Activation of Peroxisome Proliferator-Activated Receptor-δ as Novel Therapeutic Strategy to Prevent In-Stent Restenosis and Stent Thrombosis.

OBJECTIVE: Drug-eluting coronary stents reduce restenosis rate and late lumen loss compared with bare-metal stents; however, drug-eluting coronary stents may delay vascular healing and increase late stent thrombosis. The peroxisome proliferator-activated receptor-delta (PPARδ) exhibits actions that could favorably influence outcomes after drug-eluting coronary stents placement. APPROACH AND RESULTS: Here, we report that PPARδ ligand-coated stents strongly reduce the development of neointima and luminal narrowing in a rabbit model of experimental atherosclerosis. Inhibition of inflammatory gene expression and vascular smooth muscle cell (VSMC) proliferation and migration, prevention of thrombocyte activation and aggregation, and proproliferative effects on endothelial cells were identified as key mechanisms for the prevention of restenosis. Using normal and PPARδ-depleted VSMCs, we show that the observed effects of PPARδ ligand GW0742 on VSMCs and thrombocytes are PPARδ receptor dependent. PPARδ ligand treatment induces expression of pyruvate dehydrogenase kinase isozyme 4 and downregulates the glucose transporter 1 in VSMCs, thus impairing the ability of VSMCs to provide the increased energy demands required for growth factor-stimulated proliferation and migration. CONCLUSIONS: In contrast to commonly used drugs for stent coating, PPARδ ligands not only inhibit inflammatory response and proliferation of VSMCs but also prevent thrombocyte activation and support vessel re-endothelialization. Thus, pharmacological PPARδ activation could be a promising novel strategy to improve drug-eluting coronary stents outcomes.

Outcomes After Flexor Tendon Repair Combined With the Application of Human Amniotic Membrane Allograft.

PURPOSE: Clinically proven methods to prevent adhesion formation after flexor tendon repair have not yet been established. The aim of this pilot study was to assess the feasibility of amniotic membrane allograft as a mechanical barrier to decrease adhesion formation. METHODS: Ten patients having flexor tendon injuries were planned to be recruited to the pilot study. The operative treatment consisted of tendon repair and fixation of amniotic membrane allograft around the repaired tendon. The primary outcome variable was the range of motion of the operated finger 6 months after the operation. Patients were monitored for infections and repair failures. RESULTS: The study was terminated owing to unfavorable results after treatment of 5 patients. One patient had extensive stiffness and was subjected to tenolysis and joint release. Histopathological analysis of the tendon sheath revealed focal fibrosis. Another patient had a repair failure. The other 3 patients had fair to good results. CONCLUSIONS: It seems improbable that the use of amniotic membrane allograft would yield clinically relevant improvement compared with the existing techniques. However, it remains unclear whether the unfavorable results are associated with technical factors, amniotic membrane allograft itself, or an irregular distribution of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Class IA Phosphatidylinositol 3-Kinase Isoform p110α Mediates Vascular Remodeling.

OBJECTIVE: Neointima formation after vascular injury remains a significant problem in clinical cardiology, and current preventive strategies are suboptimal. Phosphatidylinositol 3'-kinase is a central downstream mediator of growth factor signaling, but the role of phosphatidylinositol 3'-kinase isoforms in vascular remodeling remains elusive. We sought to systematically characterize the precise role of catalytic class IA phosphatidylinositol 3'-kinase isoforms (p110α, p110ß, p110δ), which signal downstream of receptor tyrosine kinases, for vascular remodeling in vivo. APPROACH AND RESULTS: Western blot analyses revealed that all 3 isoforms are abundantly expressed in smooth muscle cells. To analyze their significance for receptor tyrosine kinases-dependent cellular responses, we used targeted gene knockdown and isoform-specific small molecule inhibitors of p110α (PIK-75), p110ß (TGX-221), and p110δ (IC-87114), respectively. We identified p110α to be crucial for receptor tyrosine kinases signaling, thus affecting proliferation, migration, and survival of rat, murine, and human smooth muscle cells, whereas p110ß and p110δ activities were dispensable. Surprisingly, p110δ exerted noncatalytic functions in smooth muscle cell proliferation, but had no effect on migration. Based on these results, we generated a mouse model of smooth muscle cell-specific p110α deficiency (sm-p110α(-/-)). Targeted deletion of p110α in sm-p110α(-/-) mice blunted growth factor-induced cellular responses and abolished neointima formation after balloon injury of the carotid artery in mice. In contrast, p110δ deficiency did not affect vascular remodeling in vivo. CONCLUSIONS: Receptor tyrosine kinases-induced phosphatidylinositol 3'-kinase signaling via the p110α isoform plays a central role for vascular remodeling in vivo. Thus, p110α represents a selective target for the prevention of neointima formation after vascular injury, whereas p110ß and p110δ expression and activity do not play a significant role.

Global DNA methylation analysis of human atherosclerotic plaques reveals extensive genomic hypomethylation and reactivation at imprinted locus 14q32 involving induction of a miRNA cluster.

AIMS: We conducted a genome-wide analysis to identify differentially methylated genes in atherosclerotic lesions. METHODS: DNA methylation at promoters, exons and introns was identified by massive parallel sequencing. Gene expression was analysed by microarrays, qPCR, immunohistochemistry and western blots. RESULTS: Globally, hypomethylation of chromosomal DNA predominates in atherosclerotic plaques and two-thirds of genes showing over 2.5-fold differential in DNA methylation are up-regulated in comparison to healthy mammary arteries. The imprinted chromatin locus 14q32 was identified for the first time as an extensively hypomethylated area in atherosclerosis with highly induced expression of miR127, -136, -410, -431, -432, -433 and capillary formation-associated gene RTL1. The top 100 list of hypomethylated promoters exhibited over 1000-fold enrichment for miRNAs, many of which mapped to locus 14q32. Unexpectedly, also gene body hypermethylation was found to correlate with stimulated mRNA expression. CONCLUSION: Significant changes in genomic methylation were identified in atherosclerotic lesions. The most prominent gene cluster activated via hypomethylation was detected at imprinted chromosomal locus 14q32 with several clustered miRNAs that were up-regulated. These results suggest that epigenetic changes are involved in atherogenesis and may offer new potential therapeutic targets for vascular diseases.

Keyhole Revascularization for Treatment of Coronal Plane Fracture of the Lunate in Kienböck Disease.

Coronal plane fracture of lunate in Kienböck disease is a challenging problem with no proven treatment. We present a technique for the treatment. A vascularized bone graft from the distal radius employing the fourth and fifth extracompartmental artery pedicles is used as a mechanical support in order to enable fracture union. The technical pearls and pitfalls are described and a clinical case is presented.

The bottleneck stent model for chronic myocardial ischemia and heart failure in pigs.

A large animal model of chronic myocardial ischemia and heart failure is crucial for the development of novel therapeutic approaches. In this study we developed a novel percutaneous one- and two-vessel model for chronic myocardial ischemia using a stent coated with a polytetrafluoroethylene tube formed in a bottleneck shape. The bottleneck stent was implanted in the proximal left anterior descending (LAD) or proximal circumflex artery (LCX), or in both proximal LCX and mid LAD 1 wk later (2-vessel model), and pigs were followed for 4-5 wk. Ejection fraction (EF), infarct size, collateral growth, and myocardial perfusion were assessed. Pigs were given antiarrhythmic medication to prevent sudden death. The occlusion time of the bottleneck stent and the timing of myocardial infarction could be modulated by the duration of antiplatelet medication. Fractional flow reserve measurements and positron emission tomography imaging showed severe ischemia after bottleneck stenting covering over 50% of the left ventricle in the proximal LAD model. Complete coronary occlusion was necessary for significant collateral growth, which mostly had occurred already during the first wk after the stent occlusion. Dynamic and competitive collateral growth patterns were observed. EF declined from 64 to 41% in the LCX model and to 44% in the LAD model 4 wk after stenting with 12 and 21% infarcted left ventricle in the LCX and LAD models, respectively. The mortality was 32 and 37% in the LCX and LAD models but very (71%) high in the two-vessel disease model. The implantation of a novel bottleneck stent in the proximal LAD or LCX is a novel porcine model of reversible myocardial ischemia (open stent) and ischemic heart failure (occluded stent) and is feasible for the development of new therapeutic approaches.

[Treatment of the scaphoid fracture]. / Veneluun murtuma.

The scaphoid fracture is a typical consequence of a young person falling on an outstretched arm. The diagnosis is based on clinical examination and conventional radiography as well as computed tomography or MR imaging, when necessary. More detailed investigations should be directed to patients having a high likelihood of fracture. Nondisplaced scaphoid waist fractures are treated with a dorsal plaster splint. A scaphoid fracture with good position will usually unite within 5 to 8 weeks. Fractures within the proximal part of the bone as well as displaced fractures are recommended to be treated operatively.

Long-term donor site outcome after second toe transfer for congenital hand differences.

This study evaluates the long-term donor site outcomes after second toe transfers for congenital hand differences performed during childhood. In total, 25 toe transfers in 18 patients were followed up for a mean period of 17.4 years. We examined the patients clinically, radiologically and with a gait analysis system. Patient-reported outcome measures were collected. The patients were asymptomatic and there were no problematic clinical or radiological findings. Patients expressed high levels of satisfaction. The results were consistent, regardless of the resection level in the toe transfer or whether the operation was unilateral or bilateral. No postoperative complications or late reoperations on the foot were observed.Level of evidence IV.

The effects of immobilization on vascular canal orientation in rat cortical bone.

It is well established that bone is capable of adapting to changes in loading; however, little is known regarding how loading specifically affects the internal 3D microarchitecture of cortical bone. The aim of this study was to experimentally test the hypothesis that loading is a determinant of the 3D orientation of primary vascular canals in the rat tibial diaphysis. Left tibiae from 10 rats (30 weeks old) that had been immobilized (sciatic neurectomy) for 27 weeks, right SHAM-operated tibiae from these same rats (internal control) and right tibiae from 10 normal age-matched rats (external control) were scanned by micro-CT. Mean canal orientation (for the whole bone segment and by region), percent porosity, canal diameter and canal separation were quantitatively assessed in 3D. Canal orientation in the immobilized tibiae was significantly (P < 0.001) more radial (by 9.9°) compared to the external controls but did not differ from the internal controls (P = 0.310). Comparing the external and internal controls, orientation was significantly (P < 0.05) more radial in the internal control group (by 6.8°). No differences were found for percent porosity and canal separation. Canal diameter was significantly greater in the immobilized vs. internal (P < 0.001) and external control (P < 0.001) tibiae. The differences in orientation relative to the external controls indicated that the organization of cortical bone in the rat is affected by loading. Although the predicted difference in canal orientation was not detected between immobilized and internal control groups, the distributions of individual canal orientations, from which the mean values were derived, revealed distinctive patterns for all three groups. The internal controls exhibited an intermediate position between the immobilized and external controls, suggesting that paralysis on the contralateral side resulted in altered loading relative to the normal state represented by the external control. This was also evident in a regional analysis by quadrant. The loaded bones had the same cross-sectional shape; however, their internal structure differed. These results provide novel insights into the impact of loading on the 3D organization of primary cortical bone and have implications for understanding the relation between cortical bone adaptation, disease and mechanical properties.

The consistency and reliability of six-strand and four-strand flexor tendon repairs: a comparative porcine cadaveric study.

The aim of this study was to compare the consistency and reliability of the six-strand Gan modification of the Lim-Tsai flexor tendon repair with the four-strand Adelaide repair, both with 3-0 sutures and with eight to ten runs of simple 5-0 running peripheral suture as well as the influence of the surgeons' level of experience on the strength of the repair in a cadaveric animal setup. Thirty-nine surgeons repaired 78 porcine flexor digitorum profundus tendons with either the Adelaide technique (39 tendons) or the modified Lim-Tsai technique (39 tendons). Each repaired tendon was tested in a material testing machine under a single cycle load-to-failure test. The forces were recorded when the gap between the two tendon stumps reached 1 and 2 mm and when irreversible elongation or total rupture occurred. We found no significant differences in gap formation force and yielding strength of the tendons between the two methods. The surgeon's previous experience in tendon repairs did not improve the consistency, reliability or tensile strength of the repairs. We conclude that if a strong peripheral suture is added, the modified Lim-Tsai repair has the same technical reliability and consistency as the Adelaide repair in term of ultimate loading strength in this test setup.

The effect of digital sensory loss on hand dexterity.

The purpose of this study is to determine how loss of sensation affect hand dexterity. In this study, digital nerve block anaesthesia was performed in different stages of timing for thumb, index and middle fingers of 12 volunteers. The Moberg pick-up test was conducted in the assessment of hand dexterity. Grip and pinch forces were also measured. Loss of thumb sensation had the greatest effect on dexterity, increasing average timing by at least 10.5 seconds (range 3.4 to 32.4). Loss of sensation to the index and middle fingers has a lesser impact, but decreased hand grip and chuck pinch forces (grip -25% or -33%, chuck pinch -31% or -32% depending on the timing of injections). We concluded that loss of thumb sensation has the greatest impact on hand dexterity. Index and middle finger sensory loss had less of an impact on hand dexterity but decreased grip and chuck pinch forces.Level of evidence: IV.

Factors Influencing Bone Union in Finger Distal Interphalangeal and Thumb Interphalangeal Joint Arthrodesis.

Background: Finger joint arthrodesis is a common operation which has many indications including acute trauma, post traumatic condition, osteoarthritis, and rheumatoid joint deformity. The objective of this study was to evaluate factors which may influence bone union in arthrodesis of the distal interphalangeal (DIP) joint of the fingers and interphalangeal (IP) joint of the thumb. Methods: A total of 310 arthrodesis (221 finger DIP and 89 thumb IP joint) were analysed retrospectively. We used variables related to the patient and to the operative technique in univariable and multivariable regression analysis. Outcome events were bone union within 90 days, established non-union, infection and re-operation. Results: Of the 310 operations 280 resulted in a favourable outcome while 30 resulted in bone non-union. In the univariable analysis the most important negative predictor variable for bone non-union was an operation done by other than hand surgery specialist (OR = 3.75, 95% CI = 1.727-8.140, p = 0.001), which also predicted the indication for re-operation (OR = 4.705, 95% CI = 1.563-14.163, p = 0.006). Because of insufficient event rate of bone non-union multivariable analysis was not possible for bone non-union. In the multivariable analysis rheumatoid arthritis had negative influence on bone union within 90 days (OR = 0.45, 95% CI = 0.219-0.925, p = 0.03) and none of the variables predicted infection. Conclusions: In our cohort finger DIP and thumb IP joint arthrodesis generally resulted in favourable outcome in terms of bony union regardless of the underlying medical condition or technical details of the surgical operation. Overall the results emphasize the importance of adequate surgical skill and practice even with a simple surgical operation.

Long-term outcomes after pollicization: a mean 11-year follow-up study.

This study evaluates the long-term results of pollicization for a congenitally absent or severely hypoplastic thumb. Twenty-nine patients with 34 pollicizations were divided to two groups: those with simple thumb hypoplasia (22 pollicizations) and those with radial longitudinal dysplasia (12 pollicizations). The patients were followed from 1.3 to 32 years, with a mean follow-up time of 11 years. The patients were examined clinically and radiologically, and they completed a questionnaire concerning satisfaction with appearance, function, and social interaction. The Percival score was also calculated. In both groups, grip and pinch strengths of the operated hands were inferior to the normative age-related values. Radiologically, flattening of the original metacarpal head was found in 20 out of the 34 operated hands. We found better patient satisfaction in the simple hypoplasia group than in the radial longitudinal dysplasia group. The functional outcomes and patients' satisfaction did not correlate with the age of patients at operation. Level of evidence: IV.