Spontaneous Midsubstance Rupture of the Flexor Digitorum Profundus Tendon of the Long Finger.

Closed flexor tendon injuries can often result from trauma that causes sudden forceful extension of an actively flexed digit. These closed tendon injuries commonly occur as avulsions in flexor zone I. Spontaneous midsubstance flexor tendon ruptures are rare, especially in the absence of an underlying pathology. Diagnosing such injuries accurately is challenging and critical. We present a case of a zone III spontaneous flexor tendon rupture of the long finger after forceful eccentric loading. Surgical exploration was performed, and the level of the rupture was identified during surgery. A side-to-side tendon repair technique was performed using a palmaris longus tendon graft. No underlying pathology to explain the rupture was found in this case. This report emphasizes the importance of considering spontaneous midsubstance ruptures, identifying the level of ruptures, and preoperative planning for such cases. It reviews the possible causes and treatment of spontaneous flexor tendon rupture.

Impact of the COVID-19 Pandemic on the Practice of Hand and Upper Extremity Surgeons.

Objective The purpose of this study was to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on the practice of hand and upper extremity surgeons. Methods We assessed how the pandemic affected the practice on multiple fronts including professional, personal, and practice aspects. The survey was conducted through an online questionnaire that had six sections: demographics, clinic, elective surgery, emergency surgery, urgent surgery, and human resources. The survey was sent to 586 Kleinert Society members who are all practicing hand and upper extremity surgeons. Results We received 35 responses from the United States and 53 from the rest of the world. Based on our findings, the clinic volume was reduced by >50% in the early stages, subsequently returning to a level that was 25-50% lower than pre-COVID-19 times in later stages. A corresponding decrease in elective surgeries was also noted. The need for preoperative COVID-19 tests added to the logistics of surgery, causing delays of three to six hours for emergency cases and >24 hours for urgent cases. The hand surgeons witnessed multiple furloughs, layoffs, and even COVID-19 infections among nursing and support staff. Most hand surgeons continued to perform urgent and emergency surgeries during the pandemic. The application of telemedicine was not popular and had multiple drawbacks. Hand surgeons are modifying their practice by adopting measures such as social distancing, reducing the clinic volume, and using personal protective equipment (PPE). Conclusions As COVID-19 is likely to prevail for the foreseeable future, these measures are here to stay. The initial reduction in the clinic and elective volume has improved but has not reached pre-COVID-19 levels, suggesting a slow recovery. As reopening measures will lead to more people rejoining employment, subsequently, more patients with hand-related conditions are likely to present to the clinics. Rapid COVID-19 testing and supply of PPEs will play a crucial role in the near future to enable hand surgeons to continue their service while taking care of their personal health.

Current Status of Vascularized Composite Allotransplantation.

The field of vascularized composite allotransplantation (VCA) has moved from a highly experimental procedure to, at least for some patients, one of the best treatment alternatives for catastrophic tissue loss or dysfunction. Although the worldwide experience is still limited, progress has been made in translation to the clinic, and hand transplantation was recently designated standard of care and is now covered in full by the British Health System. This progress is tempered by the long-term challenges of systemic immunosuppression, and the rapidly evolving indications for VCA such as urogenital transplantation. This update will cover the state of and recent changes in the field, and an update of the Louisville VCA program as our initial recipient, the first person to receive a hand transplant in the United States celebrates the 20th anniversary of his transplant. The achievements and complications encountered over the last two decades will be reviewed. In addition, potential directions for research and collaboration as well as practical issues of how third party payers and funding are affecting growth of the field are presented.

The role of B cell immunity in VCA graft rejection and acceptance.

Vascularized composite allotransplantation (VCA) has emerged as the most recent field of transplantation to offer an alternative treatment for those patients that have failed or are not suitable candidates for conventional therapy. Most of the current clinical experience in this field is with recipients of skin containing grafts such as the face, upper extremity and abdominal wall transplants. Like solid organ recipients, VCA recipients require lifelong systematic immunosuppression to maintain their grafts. To date, the most successful immunosuppressant regimens are calcineurin inhibitor based and have been targeted to the control of T cells. While these regimens have resulted in excellent short term graft survival in solid organ transplantation, achieving significant improvements in long term survival has been more challenging. The reasons are multi-factorial, but a role for B cells and humoral immunity has been proposed. Antibody mediated rejection leading to chronic rejection has been cited as the leading cause of renal graft loss. While the number of VCA transplants performed is still small, evidence to date suggests that antibody mediated rejection may occur less frequently than seen in solid organ transplants. Here we will discuss the role of B cell immunity in solid organ transplantation as it pertains and contrasts to the field of VCA and present some examples of possible sequela of B cell immunity in a series of hand transplant recipients.

Flexor carpi ulnaris herniation after cubital tunnel release: A case report.

Muscle herniation in the upper extremity is a rare but recognized phenomenon with a paucity of reports in the current literature. In the majority of cases, the herniation is secondary to trauma, with some of the cases due to muscle hypertrophy and increased intra-compartmental pressure from the forced exertion. Treatment for this condition ranges from nonsurgical, repair, or reconstruction to fasciotomy of the flexor carpi ulnaris fascia. Here, we present a case of flexor carpi ulnaris herniation after an open in situ cubital tunnel release in a 57-year-old male 6 years after initial surgery. The patient's symptoms did not improve with conservative management, and the patient subsequently underwent endoscopic fasciotomy with resolution of his symptoms and maintenance of his wrist and grip strength. The rationale for the treatment chosen is discussed.

Outcomes and cost of care for patients with distal radius fractures.

This study was designed to evaluate treatment patterns in open treatment and percutaneous fixation of distal radius fractures, compare morbidity rates for the 2 types of treatment, and compare costs associated with the procedure and treatment of complications up to 1 year after surgery. From a 5% sample of nationwide Medicare claims records (1997-2009), patients with distal radius fractures were identified with International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), codes. Patients who underwent percutaneous fixation and open treatment were tracked with appropriate Current Procedural Terminology codes. Complications were identified at 3 and 12 months. Medicare charges and payments associated with the treatment groups were compiled from the claims data. The rate of surgical treatment increased from 44.7 to 82.0 surgeries per 100,000 persons (+83.0%) over the study period. A total of 9343 procedures met the inclusion criteria between 1998 and 2008. The proportion of open treatment procedures increased from 25.5% in 1998 to 73.4% in 2008. Percutaneous fixation was associated with lower adjusted risk of carpal tunnel syndrome and release and mononeuritis at 3 and 12 months. The percutaneous fixation group had lower adjusted risk of malunion/nonunion at 3 months and tendon rupture at 12 months. Average charges were lower in the percutaneous fixation group for the index operation as well as for treatment of morbidities at 3 and 12 months. The operative fixation rate for distal radius fractures in the Medicare population continues to rise, with a significant trend toward open fixation. Charges and payments associated with open treatment are significantly higher than those for percutaneous fixation.

A 178-kb BAC transgene imprints the mouse Gtl2 gene and localizes tissue-specific regulatory elements.

The regulation of genomic imprinting, the allele-specific expression of an autosomal gene, is complex and poorly understood. Imprinted genes are organized in clusters, where cis-acting regulatory elements are believed to interact to control multiple genes. We have used BAC transgenesis in the mouse to begin to delineate the region of DNA required for proper expression and imprinting of the mouse Delta-like1 (Dlk1) and Gene-trap locus2 (Gtl2) imprinted genes. We demonstrate that the Gtl2 gene is expressed from a BAC transgene in mouse embryo and placenta only upon maternal inheritance, as is the endogenous Gtl2 gene. Gtl2 is therefore properly imprinted on the BAC in an ectopic chromosomal location and must carry with it all necessary imprinting regulatory elements. Furthermore, we show that the BAC Gtl2 gene is expressed at levels approaching those of the endogenous gene only in the brain of adult animals, not in other sites of endogenous expression such as the pituitary, adrenal, and skeletal muscle. These data localize the enhancer(s) for brain Gtl2 expression, but not those for other tissues, to the DNA contained within the BAC clone. As the Dlk1 gene is not expressed from the BAC in any tissues, it must require additional elements that are different from those necessary for Gtl2 expression. Our data refine the interval for future investigation of Gtl2 imprinting and provide evidence for distinct regulation of the linked Dlk1 and Gtl2 genes.