A Cadaver Study of the Feasibility of Multidigit Allotransplantation for Reconstruction of the Metacarpal Hand.

BACKGROUND: Amputation of all fingers (metacarpal hand) can be functionally equivalent to hand amputation. Multidigit allotransplantation can benefit patients who require a full complement of fingers to return to their preinjury activities. The authors investigated the feasibility of the transfer of four fingers and thumb as a single allograft. METHODS: Four fingers and the thumb were harvested from 16 hands as an allograft based on the radial and ulnar arteries. Dorsal digital veins were dissected until confluent in the major veins. The common digital nerves were divided at the origin. The flexor and extensor tendons were transected, respectively, in zones V and VI. The fingers were disarticulated at the metacarpophalangeal joint. After harvest, ulnar and radial arteries were injected with red and blue India ink, respectively, followed by injection of lead gel in the ulnar artery to study the perfusion of the fingers. Digital radiographs and computed tomographic scans were obtained. A bilateral mock transplantation was performed. RESULTS: The ulnar artery perfused the small, ring, long, and ulnar half of the index finger, whereas the radial artery vascularized the thumb. The index finger represented a watershed area. The presence of contrast in the four fingers, decreasing toward the radial fingers, was confirmed by computed tomography. The mock transplantation procedure was performed successfully. CONCLUSIONS: Multidigit transplantation is an anatomically feasible procedure. Although the ulnar artery can supply the entire allograft, the variable anatomy of the palmar arches should be considered and the flap based on both ulnar and radial arteries.

The follow-up of trapeziometacarpal arthrodesis using V-shaped osteotomy for osteoarthritis of the first carpometacarpal joint.

INTRODUCTION: Osteoarthritis of the trapeziometacarpal joint, also known as the thumb carpometacarpal joint, is one of the most common anatomic sites of arthritis in the human body. Many surgical techniques to address this problem have been developed; including, trapeziectomy with or without ligament reconstruction tendon interposition, implant arthroplasty, and arthrodesis. No methods have yet proven superior to the others, and each has associated limitations and complications. The primary complication found in the literature after arthrodesis of the trapeziometacarpal joint is nonunion; with a reported incidence in the literature as 13% (8% to 39%). METHODS: In 2010, a new surgical technique for this procedure was published by Wolff and Duerinckx in Techniques in Hand Surgery. In summary, a V-shaped osteotomy is made at the base of the first metacarpal and, together with a matching osteotomy of the trapezium, creates a more stable fusion site. Our current research looks at a minimum of 2-year follow-up of patients treated with this technique between 2004 and 2012. RESULTS: Twenty-one patients, including 3 who had bilateral procedures, have participated in the study. The average age is 62.6 years (range, 51 to 76 y) with an average follow-up of 4.6 years (range, 2 to 8 y). Sixteen are female and 5 are male, with a variety of occupations. In these patients, the Quick DASH score improved 51% (49.8 to 24.2; P=0.0006), and the Quick DASH Work score improved 56% (52.8 to 23.2; P=0.0035). Nineteen of 21 patients said that they wound have the procedure again. Range of motion and strength of the operated versus nonoperated thumbs were compared and showed very similar capabilities. Seventy-five percent (18 of 24) were able to lay their hand flat. There were 4 fibrous unions, resulting in an 83% complete fusion rate. There were no infections or reoperations for nonunion. CONCLUSION: The data suggest that this procedure is a highly successful, pain-relieving, strength-preserving, reproducible arthrodesis with a nonunion rate similar to that of the published literature.

Gamekeeper's thumb--a treatment-oriented magnetic resonance imaging classification.

PURPOSE: To investigate by magnetic resonance imaging the degree of ulnar collateral ligament (UCL) displacement in order to create a simple classification to aid in determining which UCL injuries require surgery. METHODS: We evaluated 43 cases of UCL injury with a dedicated extremity magnetic resonance imaging and measured the degree of ligament displacement. This was correlated to clinical outcome with planned surgical intervention reserved for patients with a Stener lesion. By collating results we could generate 4 types of injury based on the appearances of the UCL. RESULTS: Partial and minimally displaced UCL tears (type 1) and tears displaced less than 3 mm (type 2) typically healed by immobilization alone, whereas 90% of tears displaced more than 3 mm (type 3) failed immobilization and required surgery as did all of those with a Stener lesion (type 4). CONCLUSIONS: Our 4-stage, treatment-oriented classification of thumb UCL injury is based on the degree of UCL displacement in, with correlation with the likelihood of success with either immobilization or operative intervention. Tears of the UCL with more than 3 mm of displacement are likely to require operative repair even in the absence of a true Stener lesion.

Intraosseous xanthoma of the distal radius - a case report.

An intraosseous xanthoma is a very rare condition. It has an aggressive appearance on radiographs mimicking primary or metastatic malignant bone tumors. We report a case of intraosseous xanthoma of the distal radius in a 51-year-old male with no history of hyperlipidaemia. To the best of our knowledge, this condition has not been reported so far in the wrist and forearm region. The lesion was successfully excised and at last follow-up, there were no signs of recurrence and patient has been symptom-free.

Monitoring and long-term outcomes in vascularized composite allotransplantation.

PURPOSE OF REVIEW: The field of vascularized composite allotransplantation (VCA) is young, with less than 150 transplants worldwide. However, we now possess as much as 14 years of clinical follow-up. There are similarities and distinct differences between solid-organ transplantation (SOT) and VCA. This review will summarize how VCA recipients are monitored, outcomes observed, and what aspects are unique to VCA. RECENT FINDINGS: Of about 90 documented cases, 10% of VCA recipients are out more than 10 years and 14% are out 5 or more years. There have been both graft losses and patient mortality. In most cases, these losses have been acute, most within the first year, and all within 3 years. Unlike SOT, VCA grafts function well during severe rejection. Chronic rejection-like sequelae are less frequent than in SOT, but do appear. Immunosuppression ranges from standard protocols to novel trials aimed at immunosuppression minimization. Patient selection greatly affects the outcome. Graft loss after year 1 is associated with compliance issues. SUMMARY: Functional outcomes have exceeded expectations. VCA recipients enjoy a quality of life not achievable with conventional reconstruction. Outstanding long-term results of more than a decade have been achieved. Monitoring of VCA patients will require new strategies to incorporate external visualization and effects of environment on rejection. Graft loss has occurred early, suggesting we focus improvement on this time period. More follow-up is needed to determine the rates and targets of chronic rejection, and the characteristics of VCA unique to face vs. hand transplantation.

Retiform hemangioendothelioma of the finger: a case report.

Retiform hemangioendothelioma is a rare, intermediate-grade, locally aggressive vascular tumour that involves the skin and soft tissues of the trunk and extremities (1-10). Macroscopically it appears as a plaque or an exophytic lesion. Involvement of the hand or upper extremity is rare, with only Three cases reported in the literature (2, 3, 9). Treatment usually involves surgical excision or amputation (2). We present the case of a middle-aged woman with a retiform hemangioendothelioma of the small finger, successfully treated with surgical excision with no signs of recurrence at 4 years of follow-up.

Combined common extensor and supinator aponeurotomy for the treatment of lateral epicondylitis.

Pain at the lateral epicondyle and the extensor origin that is attributable to lateral epicondylitis can be successfully treated with a combined aponeurotomy of the supinator and the extensor muscles. This technique has been used at our institution for over 3 decades with good results. Aponeurotomy of the supinator decompresses the posterior interosseous nerve, whereas the extensor aponeurotomy relieves the stresses on the extensor carpi radialis brevis origin. We retrospectively reviewed a series of 56 patients clinically diagnosed with resistant lateral epicondylitis who underwent surgery by a single surgeon with our technique between 2002 and 2010. Patients experienced a subjective improvement in symptoms, visual analog pain score, and grip strength (Jamar II). Only 3% of patients experienced recurrence requiring further treatment.

Elastofibroma dorsi: clinicopathologic review of 6 cases.

Elastofibroma dorsi is a rare, benign lesion arising from connective tissue and usually found at the angle of the scapula. Surgical resection is often indicated in the presence of an enlarging mass or when malignancy can not be excluded. Herein we report our most recent case of elastofibroma dorsi and our review of 6 cases from the past 16 years.