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Introduction: The standard treatment for preventing rejection in vascularized composite allotransplantation (VCA) currently relies on systemic immunosuppression, which exposes the host to well-known side effects. Locally administered immunosuppression strategies have shown promising results to bypass this hurdle. Nevertheless, their progress has been slow, partially attributed to a limited understanding of the essential mechanisms underlying graft rejection. Recent discoveries highlight the crucial involvement of innate immune components, such as neutrophil extracellular traps (NETs), in organ transplantation. Here we aimed to prolong graft survival through a tacrolimus-based drug delivery system and to understand the role of NETs in VCA graft rejection. Methods: To prevent off-target toxicity and promote graft survival, we tested a locally administered tacrolimus-loaded on-demand drug delivery system (TGMS-TAC) in a multiple MHC-mismatched porcine VCA model. Off-target toxicity was assessed in tissue and blood. Graft rejection was evaluated macroscopically while the complement system, T cells, neutrophils and NETs were analyzed in graft tissues by immunofluorescence and/or western blot. Plasmatic levels of inflammatory cytokines were measured using a Luminex magnetic-bead porcine panel, and NETs were measured in plasma and tissue using DNA-MPO ELISA. Lastly, to evaluate the effect of tacrolimus on NET formation, NETs were induced in-vitro in porcine and human peripheral neutrophils following incubation with tacrolimus. Results: Repeated intra-graft administrations of TGMS-TAC minimized systemic toxicity and prolonged graft survival. Nevertheless, signs of rejection were observed at endpoint. Systemically, there were no increases in cytokine levels, complement anaphylatoxins, T-cell subpopulations, or neutrophils during rejection. Yet, tissue analysis showed local infiltration of T cells and neutrophils, together with neutrophil extracellular traps (NETs) in rejected grafts. Interestingly, intra-graft administration of tacrolimus contributed to a reduction in both T-cellular infiltration and NETs. In fact, in-vitro NETosis assessment showed a 62-84% reduction in NETs after stimulated neutrophils were treated with tacrolimus. Conclusion: Our data indicate that the proposed local delivery of immunosuppression avoids off-target toxicity while prolonging graft survival in a multiple MHC-mismatch VCA model. Furthermore, NETs are found to play a role in graft rejection and could therefore be a potential innovative therapeutic target.
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Sistemas de Liberação de Medicamentos , Armadilhas Extracelulares , Rejeição de Enxerto , Sobrevivência de Enxerto , Neutrófilos , Tacrolimo , Alotransplante de Tecidos Compostos Vascularizados , Armadilhas Extracelulares/imunologia , Armadilhas Extracelulares/efeitos dos fármacos , Animais , Sobrevivência de Enxerto/efeitos dos fármacos , Suínos , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Tacrolimo/administração & dosagem , Neutrófilos/imunologia , Neutrófilos/efeitos dos fármacos , Alotransplante de Tecidos Compostos Vascularizados/métodos , Imunossupressores/administração & dosagem , Linfócitos T/imunologia , Humanos , Aloenxertos Compostos/imunologia , FemininoRESUMO
The introduction of the new generation of thumb carpometacarpal (CMC I) joint implants for the treatment of CMC I osteoarthritis has significantly broadened the scope of hand surgery in recent years. However, the technical demands of the procedure and the many details that need to be considered require appropriate training and a learning curve. To share experiences with the Touch CMC I prosthesis, we held the first German-speaking CMC I joint prosthetics user meeting in Zurich. After some basic introductory lectures on biomechanics and the principles of prosthetic fitting of the CMC I joint, the various challenges associated with CMC I joint prosthetics were discussed in interactive expert panels. Subsequently, cases were discussed in small groups under expert guidance and the respective conclusions were discussed in plenary. The main results of this symposium are summarised in this manuscript.
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Articulações Carpometacarpais , Prótese Articular , Osteoartrite , Desenho de Prótese , Polegar , Humanos , Masculino , Fenômenos Biomecânicos , Articulações Carpometacarpais/cirurgia , Osteoartrite/cirurgia , Ajuste de Prótese , Polegar/cirurgiaRESUMO
Long-term systemic immunosuppression is needed for vascularized composite allotransplantation (VCA). The high rate of acute rejection episodes in the first posttransplant year, the development of chronic rejection, and the adverse effects that come along with this treatment, currently prevent a wider clinical application of VCA. Opportunistic infections and metabolic disturbances are among the most observed side effects in VCA recipients. To overcome these challenges, local immunosuppression using biomaterial-based drug delivery systems (DDS) have been developed. The aim of these systems is to provide high local concentrations of immunosuppressive drugs while reducing their systemic load. This review provides a summary of recently investigated local DDS with different mechanisms of action such as on-demand, ultrasound-sensitive, or continuous drug delivery. In preclinical models, ranging from rodent to porcine and nonhuman primate models, this approach has been shown to reduce systemic tacrolimus (TAC) load and adverse effects, while prolonging graft survival. Localized immunosuppression using biomaterial-based DDS represents an encouraging approach to enhance graft survival and reduce toxic side effects of immunosuppressive drugs in VCA patients. Preclinical models using TAC-releasing DDS have demonstrated high local immunosuppressive effects with a low systemic burden. However, to reduce acute rejection events in translational animal models or in the clinical reality, the use of additional low-dose systemic TAC treatment may be envisaged. Patients may benefit through efficient graft immunosuppression and survival with negligible systemic adverse effects, resulting in better compliance and quality of life.
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BACKGROUND: Early mobilization after tendon surgery is crucial to avoid commonly observed postoperative soft tissue adhesions. Recently, a new suture was introduced (DYNACORD; DC) with a salt-infused silicone core designed to minimize laxity and preserve consistent tissue approximation in order to avoid gap formation and allow early mobilization. AIMS: To compare the biomechanical competence of DC against a conventional high strength suture (FiberWire; FW) in a human cadaveric tendon transfer model with an early rehabilitation protocol. METHODS: Sixteen tendon transfers (flexor digitorum superficialis (FDS) IV to flexor pollicis longus (FPL)) were performed in 8 pairs human cadaveric forearms using either DC or FW. Markings were set 0.8 cm proximally and 0.7 cm distally to the level of the interweaving zone of the transfer. All specimens underwent repetitive thumb flexion against resistance in 9 intermittent series of 300 cycles each, simulating an aggressive postoperative rehabilitation protocol. After each series, the distance of the proximal marker to the interweaving zone (proximal), the length of the interweaving zone (intermediate) and the distance of the distal marker to the interweaving zone (distal) were measured. RESULTS: Pooled data over all nine series, normalized to the immediate postoperative status, demonstrated no significant differences between FW and DC (p ≥ 0.355) for the proximal and distal markers. However, at the intermediate zone, DC was associated with significant length shortening (p < 0.001) compared to FW without significant length changes (p = 0.351). Load to catastrophic failure demonstrated significant higher forces in FW (p = 0.011). Nevertheless, due to failure mainly proximal or distal of the transfer zone, these loads are not informative. CONCLUSION: From a biomechanical perspective, DC preserved tissue approximation and might be considered as a valid alternative to conventional high-strength sutures in tendon transfer surgery. DC might allow for a shorter interweaving zone and a more aggressive early postoperative rehabilitation program, possibly avoiding commonly observed postoperative soft tissue adhesions and stiffness.
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Cadáver , Suturas , Transferência Tendinosa , Humanos , Transferência Tendinosa/métodos , Fenômenos Biomecânicos , Extremidade Superior/cirurgia , Masculino , Técnicas de Sutura , Idoso , FemininoRESUMO
INTRODUCTION: Patients and physicians often underestimate cat bite injuries. The deep and narrow wound seals quickly and provides an environment for the inoculated saliva and bacteria. Interestingly, the literature reports no bacterial growth in the microbiological workup of wound swaps in up to 43%. The time between bite injury and the first clinical presentation, the start of antibiotic treatment and surgical debridement might affect these findings. Therefore, the current project examines if (1) these factors impact the outcome of microbiological results following cat bite injuries and (2) the detection of bacterial growth leads to higher complication rates, longer hospital stays, longer total treatment time, or higher total treatment costs. MATERIALS AND METHODS: This single-center retrospective study analyzed data from 102 adult patients. All patients received antibiotic and surgical treatment following a cat bite injury. Microbiological samples were collected during surgery in all cases. The time from the bite incident to the first presentation, beginning of antibiotic administration, and surgical debridement was calculated. Demographic data, complication rate, length of hospital stay, total treatment time, and total treatment costs were recorded. (1) A generalized linear model was fitted using the microbiological outcome as the dependent variable. (2) Two groups (negative or positive microbiological results) were formed and statistically compared. RESULTS: The median age was 50 (SD 16), and 72% were female. (1) The time from the bite incident to the first clinical presentation, antibiotic administration, or surgical treatment was not associated with the outcome of the microbiological result. (2) No significant differences were observed between the two groups. CONCLUSIONS: Our data do not suggest that early antibiotic administration or delayed surgical treatment affects the outcome of the microbiological workup following cat bite injuries to the hand and forearm. The microbiological outcome did not affect the complication rate, treatment time, and total treatment costs.
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Antibacterianos , Mordeduras e Picadas , Traumatismos da Mão , Mordeduras e Picadas/complicações , Mordeduras e Picadas/microbiologia , Mordeduras e Picadas/cirurgia , Feminino , Animais , Humanos , Masculino , Gatos , Estudos Retrospectivos , Pessoa de Meia-Idade , Antibacterianos/uso terapêutico , Adulto , Traumatismos da Mão/cirurgia , Traumatismos da Mão/microbiologia , Desbridamento , Traumatismos do Antebraço/cirurgia , Resultado do Tratamento , Idoso , Tempo de Internação/estatística & dados numéricosRESUMO
BACKGROUND: Several surgical techniques have been reported for flexor tendon zone 1a-b lacerations without a clear consensus on the gold standard treatment. The purpose of this multicentre study was to measure the outcomes of zone 1a-b flexor tendon injuries treated with a pull-out suture (POS) versus direct suture (DS) technique. PATIENTS AND METHODS: Fifteen patients were treated with the pull-out technique and 22 patients with a direct suture technique between 2014 and 2020. The controlled active motion (CAM) regimen protocol and a standardised follow-up schedule were used in both groups. Data on the demographics, surgery, and treatment characteristics were collected at baseline as well as at week 6 and 13 post-operatively. The primary outcome measurement was the complication rate. Secondary outcome measurements were reoperation rate, finger range of motion (ROM), strength as well as patient satisfaction. RESULTS: The patient age ranged from 18 to 75 years in both groups with all patients having a complete FDP lesion after a clean-cut injury. The complication rate was 41% in the POS group and 16% in the DS group. The reoperation rate was 29% in the POS group and 8% in the DS group. Significant between-group differences in favour of the DS group were found in the passive DIP and passive PIP+DIP ROM at week 6 and week 13. Mean hand strength was 28.7 (11.6) kg in the POS group at week 13 and 21.3 (7.9) kg in the DS group. This difference was statistically significant (p=0.012) with a medium effect size (r=-0.41). Average patient satisfaction at week 13 was 7.5 (2.2) points in the POS and 7.7 (1.3) points in the DS group. The difference between groups was not significant (p=0.839). CONCLUSION: This register-based study demonstrates lower complication and reoperation rates with the direct suture approach compared with a pull-out button technique. Although clinical results were similar between the two surgery techniques at week 13 post-surgery, a direct suture approach should always be attempted whenever possible. If necessary, other local structures should be included to increase suture strength and allow for early active motion rehabilitation regimens.
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PURPOSE: Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand. AIM: To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity. METHODS: 16 patients aged 44.3 (range 20-70) years were re-examined after a mean follow-up of 23.6 (range 2-77) months. Mean defect size was 124 (range 52-300) cm2 located palmar (n = 9), dorsal (n = 6), or radial (n = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft. RESULTS: Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss (n = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap (n = 1) with renewed split thickness skin cover. A surplus of the flap (n = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3-96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1-3) (1 = excellent; 4 = poor). CONCLUSIONS: Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure. LEVEL OF EVIDENCE: IV observational.
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Retalhos de Tecido Biológico , Músculo Grácil , Procedimentos de Cirurgia Plástica , Lesões dos Tecidos Moles , Humanos , Músculo Grácil/cirurgia , Mãos/cirurgia , Transplante de Pele , Lesões dos Tecidos Moles/cirurgia , Resultado do Tratamento , Adulto Jovem , Adulto , Pessoa de Meia-Idade , IdosoRESUMO
BACKGROUND: Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and a less prominent and optimized plate-to-bone fit design. On the other hand, minifragment plates in dual plating mode have demonstrated promising clinical results. The aim of the current study was to compare the biomechanical competence of single superior plating using the new-generation plate vs. dual plating using low-profile minifragment plates. METHODS: Sixteen paired human cadaveric clavicles were pairwise assigned to 2 groups for instrumentation with either a superior 2.7-mm variable-angle locking compression plate (group 1), or with one 2.5-mm anterior combined with one 2.0-mm superior matrix mandible plate (group 2). An unstable clavicle shaft fracture (AO/OTA 15.2C) was simulated by means of a 5-mm osteotomy gap. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis, and monitored via motion tracking. RESULTS: Initial construct stiffness was significantly higher in group 2 (9.28 ± 4.40 N/mm) compared to group 1 (3.68 ± 1.08 N/mm), P = .003. The amplitudes of interfragmentary motions in terms of axial and shear displacement, fracture gap opening and torsion, over the course of 12,500 cycles were significantly higher in group 1 compared to group 2, P ≤ .038. Cycles to 2 mm shear displacement were significantly lower in group 1 (22,792 ± 4346) compared to group 2 (27,437 ± 1877), P = .047. CONCLUSION: From a biomechanical perspective, low-profile 2.5/2.0-mm dual plates could be considered as a useful alternative for diaphyseal clavicle fracture fixation, especially in less common unstable fracture configurations.
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Clavícula , Fraturas Ósseas , Humanos , Clavícula/cirurgia , Fenômenos Biomecânicos , Fraturas Ósseas/cirurgia , Fixação Interna de Fraturas/métodos , Parafusos Ósseos , Placas ÓsseasRESUMO
INTRODUCTION: The aim of the present study is to systematically review the literature on well-selected comparative studies for meta-analysis on outcome differences between collagenase clostridium histolyticum (CCH) injection and limited fasciectomy (LF) for Dupuytren's disease. MATERIALS AND METHODS: PubMed/Medline, Embase, and the Cochrane Library were searched for comparative studies assessing differences in outcomes of CCH and LF. Effect estimates were pooled across studies using random effects models and presented as weighted mean difference (MD) and odds ratio (OR) with corresponding 95% confidence interval (CI). RESULTS: A total of 11 studies encompassing 1'051 patients was included (619 patients in the CCH and 432 in the LF group). The residual contracture at a minimal average follow-up of three months was higher in the CCH group than in the LF group (27.8 vs. 16.2°, MD 11.6°, 95% CI [8.7, 14.5°], p < 0.001). The recurrence rate was significantly higher in the CCH group (25.8 vs. 9.3%, OR 5.2, 95% CI [1.5, 18.8], p = 0.01) while the rate of severe complications was significantly higher in the LF group (0.3 vs. 7.3%, OR 0.12, 95% CI [0.03, 0.42], p = 0.001). CONCLUSIONS: Evidence of the present study confirms that CCH injection has a higher rate of disease recurrence whereas LF carries a higher risk for severe complications. It's imperative that the trade-off between these aspects is considered, keeping in mind that CCH injections may be repeated in case of disease recurrence without increasing procedure related risks, especially in complex cases.
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Contratura de Dupuytren , Colagenase Microbiana , Humanos , Colagenase Microbiana/uso terapêutico , Contratura de Dupuytren/tratamento farmacológico , Contratura de Dupuytren/cirurgia , Fasciotomia/métodos , Resultado do Tratamento , Recidiva Local de NeoplasiaRESUMO
BACKGROUND: With percutaneous and minimally-invasive pulley release becoming more popular, safety and reliability of such minimally-invasive procedures remain a concern. Visualization of the technical steps by ultrasound suggests increased safety but shows the potential for harm to tendons, nerves and vessels without proper instrumentation. We present the results of implementing a sonographically guided minimally-invasive procedure in 106 trigger digits of 64 patients between 2018-2021. METHODS: A guide instrument for use with a commercially available hook knife was developed and tested in 16 cadaver hands. Due to complication early in our clinical series this guide was modified in due course. A revised design of the guide has been in use since November 2019 with improved performance and safety. RESULTS: One hundred six procedures in 64 patients were performed. After guide revision, we report a success rate of 97.3%. Complications after instrument revision include two cases of incomplete pulley release and one case of inadvertent skin laceration. The majority of patients report returning to all strenuous activities within two weeks at most apart from four individuals with prolonged postoperative discomfort. CONCLUSION: We present the results of the development and implementation of a novel guide instrument for use with a hook knife to treat trigger finger. Despite several limitations of this study, we show that sonographically controlled, minimally-invasive A1 pulley release can be performed safely and effectively with appropriate surgical instruments and practice.
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Mãos , Dedo em Gatilho , Humanos , Reprodutibilidade dos Testes , Dedo em Gatilho/cirurgia , Tendões/cirurgia , UltrassonografiaRESUMO
Toxic reactions can appear after pressurised flushing of soft tissue with octenidine (OCT) containing disinfectants. Their use for surgical disinfection could complicate the diagnosis of possible contamination. In patients with open lacerations of their hand's subcutaneous tissue samples were taken before and after surgical disinfection with Octenisept® and analysed by ultra-high-performance liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). In 16 out of 20 tissue samples, OCT was detected after disinfection (lower limit of quantification (LLOQ)=10 pg/mL/mg). The concentration of OCT was below the LLOQ, estimation of mean of 0.6 pg/mL/mg (0.22-0.98 pg/mL/mg, 95%-CI) before disinfection and mean of 179.4 pg/mL/mg (13.35-432.0 pg/mL/mg, 95%-CI) after disinfection. This study shows that the disinfection of open wounds with Octenisept® leads to a quantifiable concentration of OCT in open wounds. In cases of suspected OCT-mediated toxic reaction, the use of antiseptics containing OCT should be avoided.
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Introduction: The influence of pain and a concomitant digital nerve injury on the course of rehabilitation after flexor tendon injury remains ambiguous. The objectives of the study were to: i) analyse the evolution of pain spanning one year after a primary flexor tendon repair in zones 1-3; ii) examine the differences in pain levels in patients with and without digital nerve injury; and iii) evaluate the relationship between pain, digital nerve injury and pain medication, total active motion (TAM), DASH scores and patient satisfaction. Methods: Data from 189 patients were retrieved from a flexor tendon registry between 2014 and 2020. Differences in pain, TAM, DASH and patient satisfaction were analysed. Multiple linear and binary logistic regression analyses were performed to determine the relationship between clinical outcomes. Results: Pain significantly decreased in the course of rehabilitation (p < 0.001 to 0.006). No relationship could be identified between nerve injury and pain (p = 0.21-0.97). In week 6, the presence of pain and a nerve injury were significantly associated with lower TAM scores (p = 0.001). In week 13, pain during motion (p < 0.001) and the presence of a nerve injury (p = 0.036) were significantly associated with worse DASH scores. Patient satisfaction was significantly inversely correlated to pain during motion in weeks 13 and 26 (p < 0.001). Conclusion: We found a significant relationship between pain during motion and pain medication intake, TAM, DASH scores and patient satisfaction. It is therefore advisable to closely monitor this parameter after flexor tendon injuries. Study registration: This multi-center cohort study is registered under https://clinicaltrials.gov: NCT04312412.
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Background and Objectives: Providing high-quality care for patients in hand surgery is an everyday endeavor. However, the quality of life (QoL) and working conditions of hand surgeons ensuring these high-quality services need to be investigated. The aim of this study was to evaluate the QoL and working conditions of Swiss hand surgeons. Materials and Methods: A national survey with Swiss hand surgeons was conducted. Standardized questionnaires were completed anonymously online. Core topics included working conditions, QoL, satisfaction with the profession, and aspects of private life. Results: A total of 250 hand surgeons were invited to participate, of which 110 (44.0%) completed the questionnaire. Among all participants, 43.6% stated that they are on call 4-7 days per month, versus 8.2% never being on call. Overall, 84.0% of the residents, 50.0% of the senior physicians, 27.6% of the physicians in leading positions, and 40.6% of the senior consultants/practice owners, as well as 55.1% of the female and 44.3% of the male respondents, felt stressed by their job, even during holidays and leisure time. Out of all participants, 85.4% felt that work affects private relationships negatively. Despite the reported stress, 89.1% would choose hand surgery as a profession again. Less on-call duty (29.1%) and better pay (26.4%) are the most prioritized factors for attractiveness of a position at a hospital. Conclusions: The QoL of Swiss hand surgeons is negatively affected by their workload and working hours. Residents, senior physicians and female surgeons suffer significantly more often from depression, burnout or chronic fatigue in comparison to leading positions, senior consultants/practice owners and male surgeons. Better pay or less on-call duty would make the work more attractive in acute care hospitals.
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Qualidade de Vida , Cirurgiões , Humanos , Feminino , Masculino , Condições de Trabalho , Ansiedade , EmoçõesRESUMO
Purpose: The aims of this retrospective cohort study were to present outcomes of zone 2 and 3 primary flexor tendon repairs and to evaluate how clinical outcomes change over time within and between zones of injury at weeks 6, 13, and 26. Methods: Data were retrieved from a multicenter flexor tendon cohort registry from 2014 to 2021. The inclusion criteria were: (1) adult patients after primary flexor tendon surgery in zone 2 or 3, (2) flexor digitorum profundus laceration of >50%, (3) 4-6 multistrand flexor digitorum profundus core suture, and (4) early active motion protocol. The primary outcome was the range of motion. Secondary outcomes were strength, patient satisfaction on an 11-point Likert scale, and self-reported physical function measured with the Disability of the Arm, Shoulder, and Hand questionnaire 6, 13, and 26 weeks after surgery. Results: We evaluated 33 patients after 39 tendon repairs in zone 3 and 174 repairs in zone 2 of 163 patients. Range of motion significantly improved over time in both zones (P < .001 to .01). Between-group range of motion differences were nonsignificant except for week 26 (P < .001) for the zone 3 group. Hand strength significantly improved in both zones over time (P < .001 to .01), while between-zone strength differences were statistically nonsignificant (P = .37 to .93). Patient satisfaction was generally good to high (mean 6.8 to 8.0 points) with significant within-group changes in both zones (P < .001). There were no relevant between-zone differences in Disability of the Arm, Shoulder, and Hand scores at any time point. Conclusions: Patients had significantly improved clinical outcomes in both zones. The zone of injury significantly affected the total active motion scores at the final assessment after 26 weeks for the zone 3 injuries. For the secondary outcomes hand strength, patient satisfaction, and Disability of the Arm, Shoulder, and Hand scores, we discovered no significant between-group differences. Type of study/level of evidence: Therapeutic IV.
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In this retrospective multicentre cohort study, we present the results of primary single-finger flexor tendon repairs in zones 1 to 3 between 2014 and 2021. Data from 218 patients were retrieved with their demographics, injury and surgery characteristics and therapy outcomes. The data were systematically collected and analysed at predefined time points up to 1 year after surgery. A good to excellent return of motion was achieved by 77% (Tang classification) and 92% (American Association for Surgery of the Hand classification) of patients at 1 year. The tendon rupture rate was 8.7%. Time had a significant impact on the recovery of finger motion and grip strength of up to 1 year, of patient satisfaction and upper extremity function up to 26 weeks, and of pain up to 13 weeks after surgery. Our results demonstrate that it is worthwhile to assess therapy outcomes over various measurement periods, as some outcomes may continue to improve up to 1 year after flexor tendon repair surgery.Level of evidence: III.
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Purpose: This study hypothesized that ratios of sonographic cross-sectional areas (CSAs) throughout the median nerve provide a more reliable tool for diagnosing carpal tunnel syndrome (CTS) than a single CSA value. We first tested this hypothesis in a retrospective cohort and subsequently confirmed it in a prospective blinded case-control series. Methods: Seventy patients were included in the retrospective study, and 50 patients and matched controls were included for the prospective study. We evaluated 4 CSAs, at the forearm, inlet, tunnel, outlet, and their ratios (Rforearm, Rinlet, Routlet, Routlet forearm) to evaluate compression of the median nerve. All patients underwent nerve conduction studies. For the prospective cohort, Disabilities of the Arm, Shoulder, and Hand scores and Boston Carpal Tunnel Questionnaire scores were evaluated, and ultrasound was performed by 2 examiners for each participant. Results: The Boston and Disabilities of the Arm, Shoulder, and Hand scores showed worse subjective function in patients with CTS than in controls. Three ultrasonography parameters (CSAs at the inlet, Rinlet, and Routlet) correlated significantly with subjective function. Age and Rinlet were significantly correlated with severity of CTS in the nerve conduction studies. In both the retrospective and prospective patient groups, the numbers of CSAs at the inlet and outlet were significantly higher than that of CSAs at the tunnel, whereas in the control group, no such compression was found. Of the single measurements, CSAs at the inlet had the best diagnostic performance with an optimized cutoff of 11.75 mm2. The Rinlet and Routlet ratios performed even better and showed the highest adjusted odds ratios for predicting CTS of all parameters (cutoff Rinlet, 1.25; Routlet, 1.45). Inter-observer correlation was generally high, with better values for single CSAs than for ratios. Conclusions: The 3 CSA measurements of the median nerve and the associated ratios improved diagnostic power for ultrasonography in CTS in our study. Type of study/level of evidence: Diagnostic I.
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The inner surface layer of human joints, the synovium, is a source of stem cells for the repair of articular cartilage defects. We investigated the potential of the normal human synovium to form novel cartilage and compared its chondrogenic capacity with that of two patient groups suffering from major joint diseases: young adults with femoro-acetabular impingement syndromes of the hip (FAI), and elderly individuals with osteoarthritic degeneration of the knee (OA). Synovial membrane explants of these three patient groups were induced in vitro to undergo chondrogenesis by growth factors: bone morphogenetic protein-2 (BMP-2) alone, transforming growth factor-ß1 (TGF-ß1) alone, or a combination of these two. Quantitative evaluations of the newly formed cartilages were performed respecting their gene activities, as well as the histochemical, immunhistochemical, morphological and histomorphometrical characteristics. Formation of adult articular-like cartilage was induced by the BMP-2/TGF-ß1 combination within all three groups, and was confirmed by adequate gene-expression levels of the anabolic chondrogenic markers; the levels of the catabolic markers remained low. Our data reveal that the chondrogenic potential of the normal human synovium remains uncompromised, both in FAI and OA. The potential of synovium-based clinical repair of joint cartilage may thus not be impaired by age-related joint pathologies.
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Cartilagem Articular , Artropatias , Adulto Jovem , Humanos , Idoso , Fator de Crescimento Transformador beta1/metabolismo , Membrana Sinovial/metabolismo , Cartilagem Articular/patologia , Artropatias/patologia , Células-Tronco , Condrogênese , Células CultivadasRESUMO
PURPOSE: The objective of this systematic review was to perform epidemiological as well as clinical, radiological and patient-reported outcome analysis of surgically treated perilunate dislocations and fracture dislocations (PLDs and PLFDs) based on the so far largest pooled patient population to date. MATERIAL AND METHODS: This systematic review was written according to the updated guideline for reporting systematic reviews by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. A comprehensive literature search of Pubmed, Embase, CENTRAL, and CINAHL databases was performed. All studies reporting on complications, radiological, functional and/or patient-reported outcomes of surgically treated acute PLDs and PLFDs with a minimum follow-up of 12 months were included. RESULTS: Twenty-six studies encompassing 550 patients with 553 operatively treated acute perilunate injuries (106 PLDs and 447 PLFDs) were included. The overall postoperative complication rate was 15.0% with secondary reduction loss representing the main contributing factor (10.1%). The overall reoperation rate was 10.4% and the incidence of salvage procedures was 2.8%. The risk for secondary reduction loss was higher for PLD than for PLFD injuries (24.2% vs. 7.0%, relative risk [RR] 3.5, 95% confidence interval [CI] 1.6-7.5). There was a higher overall complication rate for the combined dorsopalmar approach when compared to the isolated dorsal approach (17.4% vs. 8.4%, RR 0.5, 95% CI 0.2-1.0, number needed to treat [NNT] 11.2) and for open surgery versus arthroscopic surgery (17.4% vs. 4.8%, RR 0.3, 95% CI 0.1-0.9, NNT 8.0). A significant correlation was found between radiological osteoarthritis (rOA) and follow-up duration of the individual studies, while functional and patient-rated outcomes were comparable. CONCLUSIONS: Regardless of surgical technique, PLFDs appear to be less susceptible to secondary reduction loss than PLDs. Whenever possible, less invasive (e.g. arthroscopic) surgery should be performed to minimize postoperative complications. The rate of rOA is high and increases significantly with follow-up duration. Interestingly, rOA does not seem to correlate with reduced wrist function nor patient dissatisfaction and the need for salvage surgery is surprisingly rare. LEVEL OF EVIDENCE: Systematic review of level IV studies.
Assuntos
Fratura-Luxação , Fraturas Ósseas , Luxações Articulares , Osso Semilunar , Traumatismos do Punho , Humanos , Osso Semilunar/diagnóstico por imagem , Osso Semilunar/cirurgia , Osso Semilunar/lesões , Fraturas Ósseas/cirurgia , Fraturas Ósseas/complicações , Luxações Articulares/cirurgia , Traumatismos do Punho/diagnóstico por imagem , Traumatismos do Punho/cirurgia , Complicações Pós-Operatórias/epidemiologiaRESUMO
BACKGROUND: Surgical exploration of the lumbosacral plexus is challenging. Previously described approaches reach from invasive open techniques with osteotomy of the ilium to laparoscopic techniques. OBJECTIVE: To describe a novel surgical technique to explore lumbosacral plexopathies such as benign nerve tumors or iatrogenic lesions of the lumbosacral plexus in 4 case examples. METHODS: We retrospectively evaluated 4 patients suffering from pathologies or injuries of the lumbosacral plexus between 2017 and 2019. The mean follow-up period after surgery was 23.5 (range 11-52) months. All patients underwent neurolysis of the lumbosacral plexus using the single incision, intrapelvic, extraperitoneal pararectus approach. RESULTS: In all patients, the pathology of the lumbosacral plexus was successfully visualized, proving feasibility of the extraperitoneal pararectus approach for this indication. There were no major complications, and all patients recovered well. CONCLUSION: The pararectus approach allows excellent visualization of the lumbar plexus and intrapelvic lesions of the femoral and sciatic nerves.