Outcomes and Complications of Tendon Transfers to Address Pinch and Grasp Weakness: A Systematic Review of the Operative Management of Ulnar Nerve Paralysis.

BACKGROUND: Patients with ulnar nerve paralysis note difficulties performing activities of daily living because of weakness of pinch and altered grasp mechanism. This review investigates outcomes of tendon transfers for ulnar nerve paralysis to assist in shared decision-making with patients during preoperative counseling and to inform operative choices. METHODS: A systematic review was conducted to identify studies reporting outcomes following tendon transfer for ulnar nerve palsy. Studies were screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and inclusion and exclusion criteria were applied. Primary outcome measures included postoperative pinch strength and mechanism of grasp. RESULTS: A total of 26 studies (687 patients) met criteria for inclusion. After pooled analysis, the flexor digitorum superficialis lasso procedure yielded the highest rate of complete correction of claw deformity (60.6 percent), followed by flexor digitorum superficialis four-tail operation (31.4 percent). The extensor carpi radialis longus four-tail operation yielded the greatest improvement in grip strength (3.8 kg). The extensor carpi radialis brevis four-tail operation resulted in the best open hand assessment and mechanism of closing scores; however, these studies did not objectively evaluate grip strength. The greatest increase in pinch strength was following tendon transfer to adductor pollicis alone. CONCLUSIONS: Despite the heterogeneous data, if the primary goal is improvement in the appearance of claw deformity, the evidence supports flexor digitorum superficialis lasso transfer. However, if the primary concern is grip strength, the data favor extensor carpi radialis longus four-tail transfer. When pinch strength is functionally limiting, adductorplasty alone is most effective. These data will assist providers in appropriately informing patients of common risks and complications and setting realistic expectations following tendon transfer procedures.

Management of Gustilo Type IIIC Injuries in the Lower Extremity.

Gustilo IIIC injuries of the lower extremity pose a significant challenge to the reconstructive surgeon. Key principles include early vascular repair and serial debridement followed by definitive coverage within 10 days. Primary reconstructive options following vascular repair include the anterolateral thigh flap or the latissimus dorsi muscle flap. Complications include elevated rates of microvascular thrombosis requiring return to the operating room, partial and complete flap loss, and infection. There is also an elevated rate of secondary amputation. However, in spite of higher complication rates, when approached thoughtfully and with an experienced multidisciplinary team, patients can achieve reasonable functional outcomes.

Patient-Generated Actigraphy Data as a Novel Outcomes Instrument in Carpal Tunnel Syndrome.

BACKGROUND: Currently, we lack objective measures to quantify outcomes in carpal tunnel syndrome. Instead, surgeons rely on patient-reported outcomes measures (PROMs) to assess the effect of carpal tunnel release (CTR). We assessed the validity and reliability of wearable activity monitors to objectively characterize the functional and sleep impact of CTR. We hypothesized that actigraphy could detect changes in sleep and activity and would demonstrate short-term impairment due the operative procedure. METHODS: This pilot, prospective, cohort study compared validated PROMS with actigraphy data obtained via wearable activity monitors (ActiGraph Link; ActiGraph Corp, Pensacola, Fla). Subjects completed baseline questionnaires and wore their device for 1 week preoperatively as a baseline. Subjects then underwent open CTR, wearing actigraphy devices for 4 weeks and completing questionnaires at 2 and 4 weeks postoperatively. Preintervention and postintervention data were compared using paired-sample t test. The Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire data were analyzed in accordance with published PROMIS scoring manuals and raw scores were converted to standardized T scores. RESULTS: Twenty subjects (5 males, 15 females) with moderate or severe carpal tunnel syndrome were enrolled. The mean age was 57.7 years. The PROMIS 29 average cumulative T score was 42.9 with average change of -0.072 preoperatively versus postoperatively. Average sleep disturbance T score was 38.9 preoperatively and 41.4 postoperatively. There was no statistically significant difference in T score in any domain. The mean actigraphy activity data demonstrated near immediate return to baseline activity. Actigraphy sleep data demonstrate improvement in sleep fragmentation and decreased duration of awakenings. CONCLUSIONS: Overall, patient-generated data detected differences in sleep and activity preoperatively versus postoperatively and demonstrated only a short period of activity disruption after CTR, which may be used when counseling patients. These data support actigraphy as a viable adjunct to traditional PROMS to evaluate the impact of surgical intervention and therefore may be useful in the study of other diseases affecting the upper extremity.

Quantifying Burn Injury-Related Disability and Quality of Life in the Developing World: A Primer for Patient-Centered Resource Allocation.

BACKGROUND: Untreated or undertreated burns are commonly encountered by plastic surgeons on medical trips in India and represent a major cause of disability. We sought to utilize validated patient-reported outcomes instruments to identify the patient population with the greatest burn-related disability in order to appropriately allocate plastic surgery resources to those in greatest need. METHODS: The Quick Disability of the Arm, Shoulder, and Hand, RAND 36-Item Short Form Health Survey, and Burn-Specific Health Scale-Revised, Brief, and Adapted questionnaires were administered via an interpreter during a plastic surgery trip to Jharkhand, India, in January 2018. Demographics, comorbidities, and burn-specific history were recorded. RESULTS: Twenty-eight postburn patients were surveyed (mean age, 17.0 ± 9.2 years; male:female ratio, 1:2.5). Mean time from injury was 4.74 years. No patient had received formal, primary burn care. Mechanism of injury: flame (39%), oil (32%), scalding water (14%), and other (14%). Fifty-four percent were extremity burns; 25%, facial; and 18%, neck burns. The Burn-Specific Health Scale-Revised, Brief, and Adapted demonstrated that the most significantly impacted domains for all patients were body image and skin sensitivity, with more than 80% of patients complaining of issues with skin sensitivity. In addition, children (aged <18 years) had diminished body image domain scores. RAND SF-36 scores were lowest in the energy (73.1 ± 25.0) and general health (76.5 ± 13.8) domains, and females with extremity burns demonstrated statistically significant decreases in their physical limitation domain scores (85.9 ± 17.3, P < 0.05). Females with extremity burns also had statistically significant lower scores in the energy domain (64.09 ± 25.75) as compared with their male counterparts with extremity burns (100 ± 0, P = 0.045). In general, females scored lower than did males in multiple domains, and those results reached statistical significance in the energy (65.9 ± 24.6 vs 93.6 ± 10.9), emotional (77.2 ± 21.5 vs 95.4 ± 11.2), and general health domains (71.1 ± 11.9 vs 90.0 ± 7.5) with P < 0.05. Children demonstrated significantly diminished scores in the emotional (75.5 ± 24.6) and general health (79.1 ± 11.8) domains. CONCLUSION: These data demonstrate the significant impact on quality of life that untreated burns have in this population. Male and female children with extremity burns and adult women with extremity burns were most significantly affected in multiple domains. Consequently, children and adult women with extremity burns appear to be the patient cohort with the greatest opportunity to impact their quality of life. These data may be utilized to improve patient triage and resource allocation for future surgical trips but could also be of significant benefit to internal health agencies and ministries for the same purpose.

Specific aromatic foldamers potently inhibit spontaneous and seeded Aß42 and Aß43 fibril assembly.

Amyloid fibrils are self-propagating entities that spread pathology in several devastating disorders including Alzheimer's disease (AD). In AD, amyloid-ß (Aß) peptides form extracellular plaques that contribute to cognitive decline. One potential therapeutic strategy is to develop inhibitors that prevent Aß misfolding into proteotoxic conformers. Here, we design specific aromatic foldamers, synthetic polymers with an aromatic salicylamide (Sal) or 3-amino benzoic acid (Benz) backbone, short length (four repetitive units), basic arginine (Arg), lysine (Lys) or citrulline (Cit) side chains, and various N- and C-terminal groups that prevent spontaneous and seeded Aß fibrillization. Ac-Sal-(Lys-Sal)3-CONH2 and Sal-(Lys-Sal)3-CONH2 selectively inhibited Aß42 fibrillization, but were ineffective against Aß43, an overlooked species that is highly neurotoxic and frequently deposited in AD brains. By contrast, (Arg-Benz)4-CONH2 and (Arg-Sal)3-(Cit-Sal)-CONH2 prevented spontaneous and seeded Aß42 and Aß43 fibrillization. Importantly, (Arg-Sal)3-(Cit-Sal)-CONH2 inhibited formation of toxic Aß42 and Aß43 oligomers and proteotoxicity. None of these foldamers inhibited Sup35 prionogenesis, but Sal-(Lys-Sal)3-CONH2 delayed aggregation of fused in sarcoma (FUS), an RNA-binding protein with a prion-like domain connected with amyotrophic lateral sclerosis and frontotemporal dementia. We establish that inhibitors of Aß42 fibrillization do not necessarily inhibit Aß43 fibrillization. Moreover, (Arg-Sal)3-(Cit-Sal)-CONH2 inhibits formation of toxic Aß conformers and seeding activity, properties that could have therapeutic utility.

Examining the efficacy and maintenance of contracture correction after collagenase clostridium histolyticum treatment for Dupuytren's disease.

BACKGROUND: This study examined the efficacy, complications, and contracture recurrence in patients who received injectable collagenase clostridium histolyticum (CCH) for Dupuytren's-induced metacarpophalangeal (MP) and proximal interphalangeal (PIP) joint contractures. METHODS: A retrospective chart review at one center compared the degree of MP and PIP joint contracture pre-injection, post-cord rupture, and at final follow-up after a minimum duration of 6 months. Recurrence was defined as a 20 ° or greater increase in contracture above the minimum value achieved. RESULTS: Of 102 eligible patients, 48 patients (47 %) (31 males, 17 females) were available for review. 53 digits and 64 joints (46 MP joints and 18 PIP joints) were studied. The mean patient age was 66 years (range, 48-87 years) and mean follow-up duration was 15 months (range, 6 to 25 months). The mean MP joint contracture was 51 ± 20 ° at baseline, 4 ± 8 ° post-cord rupture, and 9 ± 15 ° at latest follow-up. The mean PIP joint contracture was 39 ± 23 ° at baseline, 14 ± 14 ° at cord rupture, and 29 ± 20 ° at latest follow-up. Of the 46 MP joints and 18 PIP joints, 11 MP (24 %) and 7 (39 %) PIP joints met the recurrence criteria. Of 102 patients, 1 patient had a small finger flexor tendon rupture. CONCLUSIONS: Despite the dramatic initial reduction in contracture, recurrence developed in a high proportion of patients over the study period. While initially effective, CCH may not provide durable contracture reduction. However, CCH remains a viable nonsurgical treatment for Dupuytren's disease.

Cyanylated Cysteine: A Covalently Attached Vibrational Probe of Protein-Lipid Contacts.

Cyanylated cysteine, or beta-thiocyanatoalanine, is an artificial amino acid that can be introduced into peptides and proteins by post-translational chemical modification of solvent-exposed cysteine side chains, and thus it can be used in any protein with a suitable expression and mutagenesis system. In this study, cyanylated cysteine is introduced at selected sites in two model peptides that have been shown to bind to membrane interfaces: a membrane-binding sequence of the human myelin basic protein and the antimicrobial peptide CM15. Far-UV circular dichroism indicates that the secondary structures of the bound peptides are not influenced by introduction of the artificial side chain. Infrared spectra of both systems in buffer and exposed to dodecylphosphocholine micelles indicate that the CN stretching absorption band of cyanylated cysteine can clearly distinguish between membrane burial and solvent exposure of the artificial side chain. Since infrared spectroscopy can be applied in a wide variety of lipid systems, and since cyanylated cysteine can be introduced into proteins of arbitrary size via mutagenesis and post-translational modification, this new probe could see wide use in characterizing the protein-lipid interactions of membrane proteins.

The effects of alpha-helical structure and cyanylated cysteine on each other.

Beta-thiocyanatoalanine, or cyanylated cysteine, is an artificial amino acid that can be introduced at solvent-exposed cysteine residues in proteins via chemical modification. Its facile post-translational synthesis means that it may find broad use in large protein systems as a probe of site-specific structure and dynamics. The C[triple bond]N stretching vibration of this artificial side chain provides an isolated infrared chromophore. To test both the perturbative effect of this side chain on local secondary structure and its sensitivity to structural changes, three variants of a model water-soluble alanine-repeat helix were synthesized containing cyanylated cysteine at different sites. The cyanylated cysteine side chain is shown to destabilize, but not completely disrupt, the helical structure of the folded peptide when substituted for alanine. In addition, the [triple bond]N stretching bandwidth of the artificial side chain is sensitive to the helix-coil structural transition. These model system results indicate that cyanylated cysteine can be placed into protein sequences with a native helical propensity without destroying the helix, and further that the CN probe may be able to report local helix formation events even when it is water-exposed in both the ordered and disordered conformational states. These results indicate that cyanylated cysteine could be a widely useful probe of structure-forming events in proteins with large in vitro structural distributions.