Topographical Analysis of Pacinian Corpuscle in the Pulp of Human Cadaver Finger Tip Pulp: A Pilot Cadaver Study.

Background: The human hand is a specialised organ for fine motion and sensation and has a relatively large representation in the homunculus. The pathway of sensation starts from information sent by mechanoreceptors in the hand. This study reports the topography of the Pacinian corpuscle in the fingertips of a human cadaver. Methods: All 10 digits from both hands of a fresh-frozen cadaver were examined. Glabrous skin distal to the distal interphalangeal joint was harvested superficial to the periosteum including fat and subcutaneous tissue. The glabrous skin were divided into 10 sections that included five distal and five proximal sections. Modified gold chloride staining was performed. Sectioned specimens were observed under a light microscope and the density of Pacinian corpuscles was determined in each segment. The density of the corpuscles was compared between the radial/ulnar and proximal/distal segments and also between digits from the right hand versus those from the left hand. Results: Pacinian corpuscles were observed only in the subcutaneous tissue. There was no significant difference in density of the corpuscles between the distal and proximal segments or between the right and left hands. There was a statistically significant greater density of Pacinian corpuscles on the radial segments of all digits except the thumb. Conclusions: There is a greater density of Pacinian corpuscles on the radial side of the human fingertip in all digits except the thumb.

Radius palmar plate removal without carpal tunnel release: Correlation between plate position and median nerve symptoms.

We aimed to report the clinical results of volar plate removal without carpal tunnel release in patients with late-onset median neuropathy and to evaluate the relationship between plate position and median nerve symptoms. Part I. Twelve consecutive patients with late-onset median neuropathy treated with volar plate removal without carpal tunnel release were enrolled for analysis. Pre- and post-operative Tinel sign, Phalen and Ten test, subjective rating of tingling sensation, Mayo wrist score and Disabilities of the Arm, Shoulder and Hand (DASH) score were collected. Part II. 232 consecutive patients underwent volar plating for distal radius fracture. The relationships between median nerve symptoms and volar plate prominence on the Soong classification, fracture classification, gender and age were investigated. All cases except one showed complete symptom resolution at final follow-up, with negative Tinel sign and Ten test score of 10/10. Tingling was rated 0 at final follow-up. Mean Mayo wrist and DASH scores improved to 86.7 and 23.1, respectively. The incidence of the median nerve symptoms in our cohort was 5.6%. Even though the odds ratio in Soong grade 2 was 4.0957 (95% CI, 0.93-16.9) compared to the combination of grades 0 and 1, no statistically significant relationship was found between the median nerve symptoms and volar plate prominence (p > 0.05). Plate removal without carpal tunnel release adequately relieved symptoms of late-onset median neuropathy after volar plating in patients with distal radius fracture. LEVEL OF EVIDENCE: IV; Therapeutic.

A Systematic Review of Scoring System Based on Magnetic Resonance Imaging Parameters to Predict Outcome in Cervical Spinal Cord Injury.

Background: Magnetic resonance imaging (MRI) is a potential tool for the objective assessment of spinal cord injury (SCI) because it correlates well with the spatial and temporal extension of spinal cord pathology. This study aimed to systematically identify currently available scoring system based on MRI parameters, including measurement of the spinal cord lesion length in sagittal view (intramedullary lesion length (IMLL)) and morphology of the lesion in axial view (Brain and Spinal Injury Center (BASIC) score). Methods: A systematic search was conducted using the PubMed/MEDLINE database for English-language studies with the keywords "cervical," "spinal cord injury," "scoring system," "scoring," "classification," and "magnetic resonance imaging" to systematically identify the scoring system based on MRI parameters. The main outcomes of interest are the scoring system's inter- and intraobserver reliabilities and its predictive accuracy of neurological outcome. Results: After assessing the full text and applying the inclusion and exclusion criteria, 13 articles were found to be eligible. The inter- and intraobserver reliabilities were rated as good until perfect for increased signal intensity (ISI), maximum canal compromise (MCC), maximum spinal cord compression (MSCC), BASIC score, cord-canal-area ratio, space available for the cord, and the compression ratio. The weighted mean difference of IML between the group with converted ASIA Impairment Scale (AIS) grade and the group without conversion is 31.79 (I2 =93%, P=0.008). The percentage of agreement between the initial BASIC score of 4 with AIS grade of A at follow-up is 100%. Conclusions: Certain MRI parameters, including IML and BASIC score, have good reliability and correlate well with neurological outcome, making them candidates for building simple and objective scoring system for cervical SCI. Level of Evidence: 2A.

Outcomes of the Management of Distal Radius Fractures in the Last 5 Years: A Meta-analysis of Randomized Controlled Trials.

Objective Over the last decades, volar locking plates (VLPs) have been the mainstay treatment for distal radius fractures (DRFs). With the growing body of evidence, we systematically reviewed studies on recent VLP modifications. Methods A systematic search was performed in the PubMed/MEDLINE database for studies published in English in the past five years. The inclusion criteria were randomized controlled trials (RCTs) on the operative treatment of DRFs. We excluded ongoing trials and studies not directly addressing DRF. The primary outcomes assessed were subjective (such as the scores on the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire, the Patient-rated Wrist Evaluation [PRWE], the European Quality of Life-5 Dimensions [EQ-5D], the 36-item Short Form Health Survey [SF-36], and the Visual Analog Scale [VAS]) and objective clinical outcomes (the complication rate). Results We identified 29 articles published from 2016 to 2020 with high quality of evidence, except for one, which had evidence of moderate quality. In total, 3,079 DRFs were analyzed in the present study. All studies except one had a greater proportion of female participants, and only in 1 study the mean age of the sample was < 40 years old. There were no significant differences between the VLP and external fixation (EF) in terms of the scores on the DASH ( p = 0.18) and PRWE ( p = 0.77). The VLP alone without pronator quadratus (PQ) repair yielded significantly better outcomes. Conclusion In unstable fractures, the VLP and EF yielded comparable long-term results. There is no clear benefit of adding PQ repair to current the VLP surgical technique. Level of Evidence Level I.

Outcomes of the Management of Distal Radius Fractures in the Last 5 Years: A Meta-analysis of Randomized Controlled Trials / Resultados do manejo de fraturas do rádio distal nos últimos 5 anos: metanálise de ensaios clínicos controlados e randomizados

Abstract Objective Over the last decades, volar locking plates (VLPs) have been the mainstay treatment for distal radius fractures (DRFs). With the growing body of evidence, we systematically reviewed studies on recent VLP modifications. Methods A systematic search was performed in the PubMed/MEDLINE database for studies published in English in the past five years. The inclusion criteria were randomized controlled trials (RCTs) on the operative treatment of DRFs. We excluded ongoing trials and studies not directly addressing DRF. The primary outcomes assessed were subjective (such as the scores on the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire, the Patient-rated Wrist Evaluation [PRWE], the European Quality of Life-5 Dimensions [EQ-5D], the 36-item Short Form Health Survey [SF-36], and the Visual Analog Scale [VAS]) and objective clinical outcomes (the complication rate). Results We identified 29 articles published from 2016 to 2020 with high quality of evidence, except for one, which had evidence of moderate quality. In total, 3,079 DRFs were analyzed in the present study. All studies except one had a greater proportion of female participants, and only in 1 study the mean age of the sample was < 40 years old. There were no significant differences between the VLP and external fixation (EF) in terms of the scores on the DASH (p= 0.18) and PRWE (p= 0.77). The VLP alone without pronator quadratus (PQ) repair yielded significantly better outcomes. Conclusion In unstable fractures, the VLP and EF yielded comparable long-term results. There is no clear benefit of adding PQ repair to current the VLP surgical technique. Level of EvidenceLevel I

Resumo Objetivo Nas últimas décadas, a placa volar bloqueada (PVB) tem sido o tratamento principal para fraturas do rádio distal (FRDs). Com o crescente conjunto de evidências, revisamos sistematicamente estudos sobre modificações recentes na PVB. Métodos Uma pesquisa sistemática foi realizada utilizando o banco de dados PubMed/MEDLINE por estudos publicados em inglês nos últimos cinco anos. Os critérios de inclusão foram ensaios clínicos controlados e randomizados (ECCRs) sobre o tratamento cirúrgico de FRDs. Excluímos ensaios e estudos em andamento que não abordavam diretamente a FRD. Os desfechos primários avaliados foram desfechos clínicos subjetivos (como as pontuações no questionário de Deficiências do Braço, Ombro e Mão [Disabilities of the Arm, Shoulder and Hand, DASH, em inglês], na Avaliação do Punho Classificada pelo Paciente [Patient-rated Wrist Evaluation, PRWE, em inglês], no questionário Qualidade de Vida Europeia - 5 Dimensões [European Quality of Life-5 Dimensions, EQ-5D, em inglês], na Pesquisa de Saúde por Formulário Curto de 36 Itens [36-item Short Form Health Survey, SF-36, em inglês], e na Escala Visual Analógica [EVA]) e objetivos (taxa de complicações). Resultados Identificamos 29 artigos publicados entre 2016 e 2020 com alta qualidade de evidência, exceto por um, de qualidade moderada. Ao todo, foram analisadas 3.079 FRDs neste estudo, Todos os estudos analisados, exceto por um, tinham maior proporção de participantes do gênero feminino, e somente em 1 estudo a idade média da amostra foi < 40 anos. Não houve diferença significativa entre a PVB e fixação externa (FE) em termos das pontuações no DASH (p= 0,18) e na PRWE (p= 0,77). Os resultados da PVB isolada, sem qualquer reparo do pronador quadrado (PQ), foram significativamente melhores. Conclusão Em fraturas instáveis, a PVB e a FE produziram resultados comparáveis no longo prazo. Não há um benefício claro em se adicionar reparo do PQ à técnica cirúrgica atual da PVB. Nível de EvidênciaNível I

Thorough Comparative Analysis of Stand-Alone Cage and Anterior Cervical Plate for Anterior Cervical Discectomy and Fusion in the Treatment of Cervical Degenerative Disease: A Systematic Review and Meta-analysis.

In this systematic review and meta-analysis, we aim to thoroughly describe and objectively compare the efficacy of anterior cervical plate (ACP) and stand-alone cage (SAC). Although recognized as an effective procedure for cervical degenerative disease (CDD), a debate between the methods of anterior cervical discectomy and fusion exists. ACP provides stability to the fusion construct; however, some complications have been reported, such as dysphagia, adjacent disc disease, and soft tissue injury. To overcome these complications, a SAC was later introduced. A systematic search was conducted on the basis of PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines to identify relevant studies through PubMed, Google Scholar, and Cochrane database. A total of 14 studies (960 patients) were included in the meta-analysis. Twenty outcomes were clinically and radiologically compared between the two procedures. ACP and SAC were comparable in terms of dysphasia rate, loss of segmental angle, loss of disc height, the Odom criteria, Robinson's criteria, hospital stay, Japanese Orthopaedic Association score, Neck Disability Index, Visual Analog Scale, and fusion time. However, SAC was superior in terms of shorter operation time, less blood loss, lower dysphagia rate, and lower rate of adjacent level disease, whereas ACP was advantageous in terms of lower subsidence rate, better maintenance of the cervical global and segmental angles and disc height, and higher fusion rate. Both procedures can be used in patients with CDD, although it might be more beneficial to choose ACP in patients with multi-level pathologies, wherein better mechanical stability is provided. However, SAC may be more beneficial to use in patients with comorbidities, anemia, or swelling problems because it offers lower complication rates.

Functional Outcome of Lateral Extraarticular Tenodesis (LET) Procedure in Addition to Anterior Cruciate Ligament Reconstruction: A Metaanalysis.

Objectives The aim of the present study is to systematically review and analyze the functional outcome of lateral extraarticular tenodesis (LET) procedure in addition to anterior cruciate ligament reconstruction (ACLR) in studies with a high level of evidence. Methods We performed a literature search for clinical studies comparing the LET method as an augmentation to ACL reconstruction with ACL reconstruction alone. The primary outcomes were the International Knee Documentation Committee (IKDC) score, the Lysholm score, and graft failures. Continuous variables were reported as means and 95% confidence intervals (CIs). Results Six clinical studies with 1,049 patients were included in the metaanalysis. The follow-up period was, in average, 24 months (range, 6-63 months). The addition of the LET procedure to ACLR results in better functional outcome based on the IKDC score ( p < 0.05). Graft failure was found to be lower in the ACLR plus LET group (16 of 342 patients) compared with the ACLR-only group (46 of 341 patients) ( p < 0.05). Conclusion There is high-level evidence that LET procedure in addition to ACLR is preferable in terms of functional outcome and graft failure.

Functional Outcome of Lateral Extraarticular Tenodesis (LET) Procedure in Addition to Anterior Cruciate Ligament Reconstruction: A Metaanalysis / Resultado funcional do procedimento de tenodese extra-articular lateral (TEL) como complemento à reconstrução do ligamento cruzado anterior: Uma metanálise

Abstract Objectives The aim of the present study is to systematically review and analyze the functional outcome of lateral extraarticular tenodesis (LET) procedure in addition to anterior cruciate ligament reconstruction (ACLR) in studies with a high level of evidence. Methods We performed a literature search for clinical studies comparing the LET method as an augmentation to ACL reconstruction with ACL reconstruction alone. The primary outcomes were the International Knee Documentation Committee (IKDC) score, the Lysholm score, and graft failures. Continuous variables were reported as means and 95% confidence intervals (CIs). Results Six clinical studies with 1,049 patients were included in the metaanalysis. The follow-up period was, in average, 24 months (range, 6-63 months). The addition of the LET procedure to ACLR results in better functional outcome based on the IKDC score (p< 0.05). Graft failure was found to be lower in the ACLR plus LET group (16 of 342 patients) compared with the ACLR-only group (46 of 341 patients) (p< 0.05). Conclusion There is high-level evidence that LET procedure in addition to ACLR is preferable in terms of functional outcome and graft failure.

Resumo Objetivos O objetivo deste estudo é revisar e analisar sistematicamente o desfecho funcional do procedimento de tenodese extra-articular lateral (TEL) em complemento à reconstrução do ligamento cruzado anterior (RLCA) em de estudos com alto nível de evidências. Métodos Realizamos a pesquisa bibliográfica para estudos clínicos comparando o método TEL como complemento à RCLA com a RLCA isolada. Os resultados principais foram a pontuação no Comitê Internacional de Documentação de Joelho (IKDC, na sigla em inglês), pontuação de Lysholm, e falhas no enxerto. Variáveis contínuas foram relatadas, como médias e intervalos de confiança (ICs) de 95%. Resultados Seis estudos clínicos com 1,049 pacientes foram incluídos na metanálise. O período de seguimento foi de, em média, 24 meses (intervalo de 6-63 meses). A adição do procedimento TEL à reconstrução do LCA resultou em melhor resultado funcional com base no escore IKDC (p< 0,05). A falha do enxerto foi menor no grupo RLCA mais TEL (16 dos 342 pacientes) em comparação com o grupo apenas RLCA (46 dos 341 pacientes) (p< 0,05). Conclusão Há evidências de alto nível de que o procedimento TEL como complemento à RLCA é preferível em termos de resultado funcional e falha do enxerto.

Applicative Factors of Helmet Molding Therapy in Late-diagnosed Positional Plagiocephaly.

BACKGROUND: Although the benefits of helmet therapy for positional plagiocephaly are strongly correlated with age, the effective period remains controversial. However, most physicians agree that effective results can be obtained in patients within the age of 6 months. Owing to the characteristics of positional plagiocephaly in Koreans, many Korean patients have delayed diagnosis, and because this results in delayed onset of the helmet therapy, the outcomes remain largely underevaluated. In the management of late-diagnosed positional plagiocephaly, we aimed to determine the factors affecting the effective application of helmet therapy. METHODS: We recruited 39 consecutive patients with positional plagiocephaly who received helmet therapy and completed the treatment between December 2008 and June 2016. The ages at initiation and completion of treatment, duration of daily use, initial and final absolute diagonal differences, cephalic index, and cranial vault asymmetry index (CVAI) were analysed using data retrospectively collected from the patients' medical records. RESULTS: We identified 12 patients with late-diagnosed positional plagiocephaly, of whom 83.33% were effectively treated. The effective change in CVAI (%) was affected by age at treatment initiation (P = 0.001), initial absolute diagonal distance differences (P < 0.001), and initial CVAI (P < 0.001). Up to 9 months, a gradual change of at least 1% CVAI was attained. Treatment initiation at ages < 5.5 months was beneficial. Even at a later age, patients with an initial absolute diagonal distance difference of > 13.50 mm and initial CVAI of > 11.03% could receive effective helmet therapy. CONCLUSION: The efficacy of helmet therapy in late-diagnosed patients can be predicted on the basis of not only age at treatment initiation, but also initial absolute diagonal distance differences and initial CVAI. We anticipate that even patients with late-diagnosed positional plagiocephaly can expect better helmet therapy outcomes.

Curved skin incision for Ulnar nerve transposition in Cubital Tunnel Syndrome: Cadaveric and clinical study to avoid injury of medial cutaneous nerve.

INTRODUCTION: Medial skin incision is obligatory for ulnar nerve transposition in cubital tunnel syndrome. However, inadvertent surgical damage to the terminal branches of both the medial antebrachial cutaneous nerve (MACN) and the medial brachial cutaneous nerve (MBCN) has been a concern in the current surgical approach. HYPOTHESIS: We hypothesized a modified curved skin incision to avoid the damage to the medial cutaneous nerve. MATERIALS AND METHODS: The numbers and locations of MACN and MBCN terminal branches were investigated; also, the location of the posterior branch of MACN in ten fresh frozen cadaveric upper extremities. Using modified incision which is more anterior than classic approach and includes antegrade dissection of the cutaneous branches, same measurement was performed in clinical cases. We described the techniques. RESULTS: The average number of MACN posterior terminal branches was 2.6±1.6 and 4.4±2.4 branches in the cadaveric specimens and clinical cases, respectively. The average number of MBCN terminal branches was 2.1±0.87 branches. The MACN posterior terminal branches were located at an average of 19mm proximal and 45mm distal from the medial epicondyle. In clinical cases, we could preserve all MBCN terminal branches and posterior terminal branches of MACN using the indexed skin incision. DISCUSSION: Our modified medial skin incision technique with antegrade subcutaneous dissection exposed all the terminal branches of MACN and thus, could reduce the risk of inadvertent injury. The medial epicondyle and the basilic vein are reliable anatomical landmarks to identify the posterior branch of the MACN. LEVEL OF PROOF: IV, Cadaveric and Therapeutic study.

Efficacy of Minimally Invasive Surgery on Giant Cell Tumour of the Bone: A Systematic Review.

BACKGROUND: Although major reconstructive surgeries in the form of excision and reconstruction have been the mainstay treatment for Giant Cell Tumour (GCT) of the bone, its recurrence rate remains high and poses various morbidities such as implant failure or skin breakdown. Minimal invasive surgery (MIS) techniques, which has gained popularity mostly in other fields in orthopaedic surgery, are being introduced as an alternative to limit the surgical complications while achieving the best possible outcome. Until now, there has been no literature summarising the evidence of MIS outcome in treating GCT of the bone. AIM: The purpose of this systematic review was to investigate the efficacy of this relatively new treatment. METHODS: We comprehensively searched PubMed, EMBASE, and Cochrane Library to search for studies about MIS for GCT of the bone treatment up to March 1, 2019. The selection of appropriate studies was performed by two independent investigators based on PRISMA guideline. Given the limited number of studies, there was no restriction in terms of patient's demographics, the specific minimally invasive surgical method, and publication status. RESULTS: We found 120 articles from the database. After evaluating full text, 5 articles (16 patients) were found to be eligible. The minimally invasive methods were curettage, cryosurgery, and argon beam coagulator. The visualisation methods include a computer-assisted navigation system, endoscope, otoscope, CT, and MRI. Location of tumours includes axial and long bones. The follow-up period ranges from 7 to 126 months. The functional and oncological outcome was found to be satisfying with no recurrence or complications. CONCLUSION: In conclusion, MIS is a familiar method in orthopaedic surgery with potential expansion in tumour field. The current evidence shows that this approach for GCT results in good functional outcome, with low risk of recurrence.

The Effect of Split Nerve on Electromyography Signal Pattern in a Rat Model.

BACKGROUND: Recent developments of prosthetic arm are based on the use of electromyography (EMG) signals. To provide improvements, such as coordinated movement of multiple joints and greater control intuitiveness, higher variability of EMG signals is needed. By splitting a nerve lengthwise, connecting each half to new target muscles, and employing a program to assign each biosignal pattern to a specific movement, we hope to enrich the number of biosignal sites on amputees' stump. METHODS: We split the gastrocnemius muscle of 12 Sprague-Dawley rats into two muscle heads, searched for the peroneal nerve, divided them lengthwise, and connected one half of the nerve to the tibial nerve innervating both muscle heads (SN_50, n = 8). In another group, we connected the undivided peroneal nerve to the nerve of a single muscle head (non-SN_100, n = 6), while the other muscle head received different innervation (non-SN_0, n = 6). After 10 weeks, we stimulated the peroneal nerve and measured the EMG amplitude. RESULTS: Mean EMG amplitude of the muscle head innervated by one half of the nerve (SN_50; 1.77 [range: 0.71-3.24] mV) and by the undivided nerve (non-SN_100; 3.45 mV [range: 1.13-5.34]) was not significantly different. However, the mean EMG amplitude produced by SN_50 was significantly different from that of the other innervation (i.e., non-SN_0; 0.76 mV [range: 0.41-1.35]), indicating the presence of noise. CONCLUSION: Split nerve in combination with split-muscle procedure can yield a meaningful EMG signal that might be used to convey the intention of living organism to a machine.

Reinnervated Split-Muscle Technique for Creating Additional Myoelectric Sites in an Animal Model.

BACKGROUND: This study proposes a novel reinnervated split-muscle operation to create additional myoelectric sites as sources of command signals of myoelectric prostheses for enhanced dexterous hand-to-wrist motions. The aim of this study was to investigate the postprocedure electromyographic properties of the muscles as distinct myoelectric sites in a rat model. METHODS: The reinnervated split-muscle group (n = 6) had the gastrocnemius muscle separated along its longitudinal axis and nerves transferred to each new muscle (peroneal nerve to lateral muscle head and tibial to medial one); the non-split-muscle group (n = 6) only had nerve transfers with its muscle intact. Functional testing was conducted after 10 weeks. The main parameter is the difference in mean electromyographic amplitude between the new muscles, with greater values indicating better separability. RESULTS: After the reinnervated split-muscle procedure, there is a significant increase of the average ratio between two muscles compared with the control group, from 0.44 (range, 0.02 to 0.86) to 0.77 (range, 0.35 to 0.98) (p = 0.011). In addition, compared with the non-split muscle group, nerve transfer in the split-muscle group is more successful in reaching its intended target muscle. CONCLUSION: A reinnervated split-muscle procedure could be beneficial for acquiring a more precise and discrete command signal in upper limb amputees, thus enabling the creation of more dexterous prosthetic arm.

Results of Abductor Pollicis Longus Suspension Ligamentoplasty for Treatment of Advanced First Carpometacarpal Arthritis.

BACKGROUND: Suspension ligamentoplasty using abductor pollicis longus (APL) tendon without bone tunneling, was introduced as one of the techniques for treatment of advanced first carpometacarpal (CMC) arthritis. The purpose of this study was to evaluate the radiologic and clinical results of APL suspension ligamentoplasty. METHODS: The medical records of 19 patients who underwent APL suspension ligamentoplasty for advanced first CMC arthritis between January 2008 and May 2012 were reviewed retrospectively. The study included 13 female and 6 male patients, whose mean age was 62 years (range, 43 to 82 years). For clinical evaluation, we assessed the grip and pinch power, radial and volar abduction angle, thumb adduction (modified Kapandji index), including visual analogue scale (VAS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Radiologic evaluation was performed using simple radiographs. RESULTS: The mean follow-up was 36 months (range, 19 to 73.7 months). Mean power improved from 18.3 to 27 kg for grip power, from 2.8 to 3.5 kg for tip pinch, and from 4.3 to 5.4 kg for power pinch. All patients showed decreased VAS from 7.2 to 1.7. Radial abduction improved from 71° preoperatively to 82° postoperatively. The modified Kapandji index showed improvement from 6 to 7.3, and mean DASH was improved from 41 to 17.8. The height of the space decreased from 10.8 to 7.1 mm. Only one case had a complication involving temporary sensory loss of the first dorsal web space, which resolved spontaneously. CONCLUSIONS: The APL suspension ligamentoplasty for treatment of advanced first CMC arthritis yielded satisfactory functional results.

Decellularized Nerves for Upper Limb Nerve Reconstruction: A Systematic Review of Functional Outcomes.

BACKGROUND: This is a systematic review for evaluating the evidence for functional outcomes after decellularized nerve use in clinical setting. Decellularized nerves are allografts whose antigenic components have been removed, leaving only a scaffold that promotes the full regeneration of axons. METHODS: Literature research was performed using the PubMed/MEDLINE database for English language studies with the keywords "decellularized nerve" and "processed nerve allograft." Inclusion criteria were prospective and retrospective case reviews in clinical settings. Exclusion criteria were case reports and case series. RESULTS: We retrieved six level VIII studies and one level VI study (classified according to the Jovell and Navarro-Rubio scale) with a total of 131 reconstructions. The basic data ranges of the studies were as follows: patient age, 18 to 86 years; duration between initial injury and nerve reconstruction procedure, 8 hours to 4 years; and follow-up period, 40 days to 2 years. The maximum lengths of the nerve gap for chemically washed decellularized nerves and cryopreserved decellularized nerves were 50 and 100 mm, respectively. Quantitatively, the functional outcome ranges were as follows: static two-point discrimination, 3 to 5 mm; and moving two-point discrimination, 2 to 15 mm. For motor assessment, all patients had a > M3 Medical Research Council score. It is also important to notice that a large variability occurs in almost every factor in the reviewed studies. CONCLUSION: Our study is the first to summarize the clinical results of decellularized nerves. Decellularized nerves have been used to bridge nerve gaps ranging from 5 to 100 mm with associated satisfactory outcomes in static and moving two-point discriminations.

Transtendinous wiring of mallet finger fractures presenting late.

PURPOSE: To determine if transtendinous wiring was an effective late treatment for bony mallet injuries. METHODS: Between 2005 and 2011, 19 consecutive patients (13 men, 6 women) with a mean age of 29 years (range, 13-52 y) were treated late for mallet finger fractures. The mean interval from injury to initial operation was 57 days (range, 28-141 d). RESULTS: Fifteen of 18 mallet fractures demonstrated evidence of radiographic healing after an average of 6 weeks (range, 5-10 wk). One patient developed ankylosis, and 3 patients failed to achieve bone union at the final follow-up. The mean motion of the distal interphalangeal joint was 73° (range, 35°-95°), and the mean extension lag was 7° (range, 0°-25°). CONCLUSIONS: Transtendinous wiring was an effective late treatment for mallet fractures, demonstrating satisfactory fixation, allowing early mobilization, and showing good functional results while avoiding salvage operations. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vortical flow in human elbow joints: a three-dimensional computed tomography modeling study.

The human elbow joint has been regarded as a loose hinge joint, with a unique helical motion of the axis during extension-flexion. This study was designed to identify the helical axis in the ulnohumeral joint during elbow extension-flexion by tracking the midpoint between the coronoid tip and the olecranon tip of the proximal ulna in a three-dimensional (3D) computed tomography (CT) image model. The elbows of four volunteers were CT-scanned at four flexion angles (0°, 45°, 90°, and 130°) at neutral rotation with a custom-made holding device to control any motion during scanning. Three-dimensional models of each elbow were reconstructed and a 3D ulnohumeral joint at 45°, 90°, and 130° was superimposed onto a fully extended joint (0°) by rotating and translating each 3D ulnohumeral joint along the axes. The midpoints of the olecranon and coronoid tips were interpolated using cubic spline technique and the dynamic elbow motion was plotted to determine the motion of the helical axis. The means and standard deviations were subsequently calculated. The average midpoint pattern of joint motion from extension to flexion was elliptical-orbit-like when projected onto a sagittal plane and continuously translated a mean 2.14 ± 0.34 mm (range, 1.83-2.52 mm) to the lateral side during elbow extension-flexion. In 3D space, the average midpoint pattern of the ulnohumeral joint resembles a vortical flow, spinning along an imaginary axis, with an inconsistent radius from 0° to 130° flexion. The ulnohumeral joint axis both rotates and translates during elbow extension-flexion, with a vortex-flow motion occurring during flexion in 3D model analysis. This motion should be considered when performing hinged external fixation, total elbow replacement and medial collateral ligament reconstruction surgery.