Provision of a Home-Based Video-Assisted Therapy Program Is Noninferior to In-Person Hand Therapy After Thumb Carpometacarpal Arthroplasty.

BACKGROUND: In-person hand therapy is commonly prescribed for rehabilitation after thumb carpometacarpal (CMC) arthroplasty but may be burdensome to patients because of the need to travel to appointments. Asynchronous, video-assisted home therapy is a method of care in which videos containing instructions and exercises are provided to the patient, without the need for in-person or telemedicine visits. The purpose of the present study was to evaluate the effectiveness of providing video-only therapy (VOT) as compared with scheduled in-person therapy (IPT) after thumb CMC arthroplasty. METHODS: We performed a single-site, prospective, randomized controlled trial of patients undergoing primary thumb CMC arthroplasty without an implant. The study included 50 women and 8 men, with a mean age of 61 years (range, 41 to 83 years). Of these, 96.6% were White, 3.4% were Black, and 13.8% were of Hispanic ethnicity. The primary outcome measure was the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) score. Subjects in the VOT group were provided with 3 videos of home exercises to perform. Subjects in the control group received standardized IPT with a hand therapist. Improvements in the PROMIS UE score from preoperatively to 12 weeks and 1 year postoperatively were compared. RESULTS: Fifty-eight subjects (29 control, 29 experimental) were included in the analysis at the 12-week time point, and 54 (27 control, 27 experimental) were included in the analysis at the 1-year time point. VOT was noninferior to IPT for the PROMIS UE score at 12 weeks and 1 year postoperatively, with a difference of mean improvement (VOT - IPT) of 1.5 (95% confidence interval [CI], -3.6 to 6.6) and 2.2 (95% CI, -3.0 to 7.3), respectively, both of which were below the minimal clinically important difference (4.1). Patients in the VOT group potentially saved on average 201.3 miles in travel. CONCLUSIONS: VOT was noninferior to IPT for upper extremity function after thumb CMC arthroplasty. Time saved in commutes was considerable for those who did not attend IPT. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

What Factors Influence Variability in Thumb Carpometacarpal Arthroplasty Care? A Survey of ASSH Members.

BACKGROUND: The purpose of this study was to gather information regarding current practices in the care of carpometacarpal (CMC) arthroplasty including the use of hand therapy, immobilization, and surgical technique, and to determine which factors influence these patterns. METHODS: We conducted a survey from February 24, 2022, through March 26, 2022, of 3648 currently practicing members of the American Society for Surgery of the Hand. We developed an 11-item questionnaire that contained questions about surgical technique, immobilization, and postoperative therapy utilization. Results were analyzed using chi-square analysis and a Bonferroni correction was applied to account for multiple comparisons. Statistical significance was set at a P-value of less than .05. RESULTS: A total of 811 hand surgeons completed the survey (22% response rate). Surgeons who are employed by the same medical center as their hand therapist use more in-person hand therapy than surgeons with other types of business relationships. Surgeons with more than 25 years of experience are less likely to recommend therapy routinely, more likely to use ligament reconstruction and tendon interposition, and less likely to be an employee of the same medical center as their hand therapist. The length of immobilization and the time at which hand therapy began were related to surgical technique. CONCLUSIONS: Variability in hand therapy usage after CMC arthroplasty is at least partially explained by business relationships with hand therapists and surgeon experience. Variability in the length of immobilization and the beginning of hand therapy postoperatively was more associated with surgical technique.

Antibiotic Prophylaxis for Distal Interphalangeal Joint Arthrodesis.

Prior evidence is clear that in clean, elective soft-tissue hand procedures less than 2 hours, antibiotic prophylaxis is not indicated. However, there is a lack of consensus regarding the boney procedures of the hand involving implanted hardware. Previous studies reviewing complications after distal interphalangeal (DIP) joint arthrodesis did not analyze whether patients receiving antibiotics before surgery had a significant difference in the infection rate. Methods: A retrospective review of clean, elective DIP arthrodesis was conducted between September 2018 and September 2021. The subjects were aged 18 years and older and underwent elective DIP arthrodesis for the treatment of osteoarthritis or deformity of the DIP joint. All the procedures were performed using an intramedullary headless compression screw. The rates of postoperative infections and treatments required for infections were recorded and analyzed. Results: Overall, 37 unique patients had at least one case of DIP arthrodesis that met the criteria for inclusion in our analysis. Twenty of the 37 patients did not receive antibiotic prophylaxis, and 17 of the 37 patients received antibiotic prophylaxis. Five of the 20 patients who did not receive antibiotics prophylactically developed infections, and none of the 17 patients who received antibiotics prophylactically developed an infection. Fisher exact test revealed a significant difference in the infection rates between the two groups (P < 0.05). There was no significant difference in infections with respect to smoking or diabetes status. Conclusion: Antibiotic prophylaxis should be administered for clean, elective DIP arthrodesis, using an intramedullary screw.

Immobilization and Hand Therapy After Carpometacarpal Arthroplasty: A Systematic Review.

Purpose: We provide a systematic review of the current literature regarding best practices in postoperative care following carpometacarpal arthroplasty, and compare these findings to current practices via reported survey data. Methods: The PubMed, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Science Direct, and Google Scholar databases were searched for relevant studies. English-language articles were included that assessed any aspect of postoperative care, including the immobilization time or rehabilitation strategy. In addition, studies were included that surveyed surgeons and hand therapists on current practices regarding this topic. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. Results: The initial search yielded 3,899 hits. Two systematic reviews were found, along with 5 studies that specifically tested the desired variables of the immobilization duration and type following carpometacarpal arthroplasty. Three relevant surveys were also found. Using the Oxford Centre for Evidence-Based Medicine Level of Evidence guidelines, we found moderate-quality evidence that (1) there is no additional benefit for extended cast immobilization (>6 weeks); and (2) a semirigid orthosis performs as well as a rigid orthosis. We found a lack of evidence regarding formal therapy versus no therapy, and a lack of evidence comparing therapy regimens. When analyzing the survey data, we found wide variation in practices among surgeons and therapists. Conclusions: Longer immobilization times (>6 weeks) and rigid orthotic devices provide no additional benefit over earlier immobilization and semirigid orthotic devices. There is a lack of evidence for the use of formal hand therapy or any specific rehabilitation protocol. Current practices in these areas vary widely among hand surgeons. Clinical relevance: Practices following carpometacarpal arthroplasty are widely variable, and guidance has previously been lacking. This review compiles the most recent data, as well as identifies gaps in the literature for future studies.

Intraligand Excited States Turn a Ruthenium Oligothiophene Complex into a Light-Triggered Ubertoxin with Anticancer Effects in Extreme Hypoxia.

Ru(II) complexes that undergo photosubstitution reactions from triplet metal-centered (3MC) excited states are of interest in photochemotherapy (PCT) due to their potential to produce cytotoxic effects in hypoxia. Dual-action systems that incorporate this stoichiometric mode to complement the oxygen-dependent photosensitization pathways that define photodynamic therapy (PDT) are poised to maintain antitumor activity regardless of the oxygenation status. Herein, we examine the way in which these two pathways influence photocytotoxicity in normoxia and in hypoxia using the [Ru(dmp)2(IP-nT)]2+ series (where dmp = 2,9-dimethyl-1,10-phenanthroline and IP-nT = imidazo[4,5-f][1,10]phenanthroline tethered to n = 0-4 thiophene rings) to switch the dominant excited state from the metal-based 3MC state in the case of Ru-phen-Ru-1T to the ligand-based 3ILCT state for Ru-3T and Ru-4T. Ru-phen-Ru-1T, having dominant 3MC states and the largest photosubstitution quantum yields, are inactive in both normoxia and hypoxia. Ru-3T and Ru-4T, with dominant 3IL/3ILCT states and long triplet lifetimes (τTA = 20-25 µs), have the poorest photosubstitution quantum yields, yet are extremely active. In the best instances, Ru-4T exhibit attomolar phototoxicity toward SKMEL28 cells in normoxia and picomolar in hypoxia, with phototherapeutic index values in normoxia of 105-1012 and 103-106 in hypoxia. While maximizing excited-state deactivation through photodissociative 3MC states did not result in bonafide dual-action PDT/PCT agents, the study has produced the most potent photosensitizer we know of to date. The extraordinary photosensitizing capacity of Ru-3T and Ru-4T may stem from a combination of very efficient 1O2 production and possibly complementary type I pathways via 3ILCT excited states.

Fine-Feature Modifications to Strained Ruthenium Complexes Radically Alter Their Hypoxic Anticancer Activity†.

In an earlier study of π-expansive ruthenium complexes for photodynamic and photochemo-therapies, it was shown that a pair of structural isomers differing only in the connection point of a naphthalene residue exhibited vastly different biological activity. These isomers are further explored in this paper through the activity of their functionalized derivatives. In normoxia, the inactive 2-NIP isomer (5) can be made as photocytotoxic as the active 1-NIP isomer (1) by functionalizing with methyl or methoxy groups, while methoxy variants of the 1-NIP isomer became inactive. In all cases, the singlet oxygen sensitization quantum yield was below 1%. Hypoxic photocytotoxicity was attenuated, with only three of the series showing any activity, notwithstanding the photodissociative ligands. The results here are consistent with the earlier findings in that seemingly minor structural modifications on the non-strained ligand can dramatically modulate the normoxic and hypoxic activity of these strained compounds and that these changes appear to exert a greater influence on photocytotoxicity than singlet oxygen sensitization or rates of photosubstitution in cell-free conditions would suggest.

Anticancer Agent with Inexplicable Potency in Extreme Hypoxia: Characterizing a Light-Triggered Ruthenium Ubertoxin.

Tumor hypoxia renders treatments ineffective that are directly (e.g., radiotherapy and photodynamic therapy) or indirectly (e.g., chemotherapy) dependent on tumor oxygenation. This study introduces a ruthenium compound as a light-responsive anticancer agent that is water-soluble, has minimal dark cytotoxicity, is active at concentrations as low as 170 pM in ∼18.5% O2 normoxia and near 10 nM in 1% O2 hypoxia, and exhibits phototherapeutic indices as large as >500,000 in normoxia and >5,800 in 1% O2 hypoxia using broadband visible and monochromatic blue light treatments. These are the largest values reported to date for any compound class. We highlight the response in four different cell lines to improve rigor and reproducibility in the identification of promising clinical candidates.

Os(II) Oligothienyl Complexes as a Hypoxia-Active Photosensitizer Class for Photodynamic Therapy.

Hypoxia presents a challenge to anticancer therapy, reducing the efficacy of many available treatments. Photodynamic therapy is particularly susceptible to hypoxia, given that its mechanism relies on oxygen. Herein, we introduce two new osmium-based polypyridyl photosensitizers that are active in hypoxia. The lead compounds emerged from a systematic study of two Os(II) polypyridyl families derived from 2,2'-bipyridine (bpy) or 4,4'-dimethyl-2,2'-bipyridine (dmb) as coligands combined with imidazo[4,5-f][1,10]phenanthroline ligands tethered to n = 0-4 thiophenes (IP-nT). The compounds were characterized and investigated for their spectroscopic and (photo)biological activities. The two hypoxia-active Os(II) photosensitizers had n = 4 thiophenes, with the bpy analogue 1-4T being the most potent. In normoxia, 1-4T had low nanomolar activity (half-maximal effective concentration (EC50) = 1-13 nM) with phototherapeutic indices (PI) ranging from 5500 to 55 000 with red and visible light, respectively. A sub-micromolar potency was maintained even in hypoxia (1% O2), with light EC50 and PI values of 732-812 nM and 68-76, respectively -currently among the largest PIs for hypoxic photoactivity. This high degree of activity coincided with a low-energy, long-lived (0.98-3.6 µs) mixed-character intraligand charge-transfer (3ILCT)/ligand-to-ligand charge-transfer (3LLCT) state only accessible in quaterthiophene complexes 1-4T and 2-4T. The coligand identity strongly influenced the photophysical and photobiological results in this study, whereby the bpy coligand led to longer lifetimes (3.6 µs) and more potent photo-cytotoxicity relative to those of dmb. The unactivated compounds were relatively nontoxic both in vitro and in vivo. The maximum tolerated dose for 1-4T and 2-4T in mice was greater than or equal to 200 mg kg-1, an excellent starting point for future in vivo validation.

Breaking the barrier: an osmium photosensitizer with unprecedented hypoxic phototoxicity for real world photodynamic therapy.

Hypoxia presents a two-fold challenge in the treatment of cancer, as low oxygen conditions induce biological changes that make malignant tissues simultaneously more aggressive and less susceptible to standard chemotherapy. This paper reports the first metal-based photosensitizer that approaches the ideal properties for a phototherapy agent. The Os(phen)2-based scaffold was combined with a series of IP-nT ligands, where phen = 1,10-phenanthroline and IP-nT = imidazo[4,5-f][1,10]phenanthroline tethered to n = 0-4 thiophene rings. Os-4T (n = 4) emerged as the most promising complex in the series, with picomolar activity and a phototherapeutic index (PI) exceeding 106 in normoxia. The photosensitizer exhibited an unprecedented PI > 90 (EC50 = 0.651 µM) in hypoxia (1% O2) with visible and green light, and a PI > 70 with red light. Os-4T was also active with 733 nm near-infrared light (EC50 = 0.803 µM, PI = 77) under normoxia. Both computation and spectroscopic studies confirmed a switch in the nature of the lowest-lying triplet excited state from triplet metal-to-ligand charge transfer (3MLCT) to intraligand charge transfer (3ILCT) at n = 3, with a lower energy and longer lifetime for n = 4. All compounds in the series were relatively nontoxic in the dark but became increasingly phototoxic with additional thiophenes. These normoxic and hypoxic activities are the largest reported to date, demonstrating the utility of osmium for phototherapy applications. Moreover, Os-4T had a maximum tolerated dose (MTD) in mice that was >200 mg kg-1, which positions this photosensitizer as an excellent candidate for in vivo applications.

Strained, Photoejecting Ru(II) Complexes that are Cytotoxic Under Hypoxic Conditions.

A series of strained Ru(II) complexes were studied for potential anticancer activity in hypoxic tissues. The complexes were constructed with methylated ligands that were photolabile and an imidizo[4,5-f][1,10]phenanthroline ligand that contained an appended aromatic group to potentially allow for contributions of ligand-centered excited states. A systematic variation of the size and energy of the aromatic group was performed using systems containing 1-4 fused rings, and the photochemical and photobiological behaviors of all complexes were assessed. The structure and nature of the aromatic group had a subtle impact on photochemistry, altering environmental sensitivity, and had a significant impact on cellular cytotoxicity and photobiology. Up to 5-fold differences in cytotoxicity were observed in the absence of light activation; this rose to 50-fold differences upon exposure to 453 nm light. Most significantly, one complex retained activity under conditions with 1% O2 , which is used to induce hypoxic changes. This system exhibited a photocytotoxicity index (PI) of 15, which is in marked contrast to most other Ru(II) complexes, including those designed for O2 -independent mechanisms of action.

Photophysical Properties and Photobiological Activities of Ruthenium(II) Complexes Bearing π-Expansive Cyclometalating Ligands with Thienyl Groups.

A new family of cyclometalated ruthenium(II) complexes [Ru(N^N)2(C^N)]+ derived from the π-extended benzo[h]imidazo[4,5-f]quinolone ligand appended with thienyl groups (n = 1-4, compounds 1-4) was prepared and its members were characterized for their chemical, photophysical, and photobiological properties. The lipophilicities of 1-4, determined as octanol-water partition coefficients (log Po/w), were positive and increased with the number of thienyl units. The absorption and emission bands of the C^N compounds were red-shifted by up to 200 nm relative to the analogous Ru(II) diimine systems. All of the complexes exhibited dual emission with the intraligand fluorescence (1IL, C^N-based) shifting to lower energies with increasing n and the metal-to-ligand charge transfer phosphorescence (3MLCT, N^N-based) remaining unchanged. Compounds 1-3 exhibited excited state absorption (ESA) profiles consistent with lowest-lying 3MLCT states when probed by nanosecond transient absorption (TA) spectroscopy with 532 nm excitation and had contributions from 1IL(C^N) states with 355 nm excitation. These assignments were supported by the lifetimes observed (<10 ns for the 1IL states and around 20 ns for the 3MLCT states) as well as a noticeable ESA for 3 with 355 nm excitation that did not occur with 532 nm excitation. Compound 4 was the only member of the family with two 3MLCT emissive lifetimes (15, 110 ns), and the TA spectra collected with both 355 and 532 nm excitation was assigned to the 3IL state, which was corroborated by its 4-6 µs lifetime. The ESA for 4 had a rise time of approximately 10 ns and an initial decay of 110 ns, which suggests a possible 3MLCT-3IL excited state equilibrium that results in delayed emission from the 3MLCT state. Compound 4 was nontoxic toward human skin melanoma cells (SKMEL28) in the dark (EC50 = >300 µM); 1-3 were cytotoxic and yielded EC50 values between 1 and 20 µM. The photocytotoxicites with visible light ranged from 87 nM with a phototherapeutic index (PI) of 13 for 1 to approximately 1 µM (PI = >267) for 4. With red light, EC50 values varied from 270 nM (PI = 21) for 3 to 12 µM for 4 (PI = >25). The larger PIs for 4, especially with visible light, were attributed to the much lower dark cytotoxicity for this compound. Because the dark cytotoxicity contributes substantially to the observed photocytotoxicity for 1-3, it was not possible to assess whether the 3IL state of 4 led to a much more potent phototoxic mechanism in the absence of dark toxicity. There was no stark contrast in cellular uptake and accumulation by laser scanning confocal and differential interference contrast microscopy to explain the large differences in dark toxicities between 1-3 and 4. Nevertheless, the study highlights a new family of Ru(II) C^N complexes where π-conjugation beyond a certain point results in low dark cytotoxicity with high photocytotoxicity, opposing the notion that cyclometalated Ru(II) systems are too toxic to be phototherapeutic agents.