Vascularized Composite Allotransplantation of the Hand: A Systematic Review of Eligibility Criteria.

BACKGROUND: Hand transplantation (HT) has emerged as an intervention of last resort for those who endured amputation or irreparable loss of upper extremity function. However, because of the considerable effort required for allograft management and the risks of lifelong immunosuppression, patient eligibility is critical to treatment success. Thus, the objective of this article is to investigate the reported eligibility criteria of HT centers globally. METHODS: A systematic review of the HT literature was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, using PubMed, Cochrane, Ovid/Medline, and Scopus. Program Web sites and clinicaltrials.gov entries were included where available. RESULTS: A total of 354 articles were reviewed, 101 of which met inclusion criteria. Furthermore, 10 patient-facing Web sites and 11 clinical trials were included. The most reported criteria related to the capacity to manage the allograft posttransplantation, including access to follow-up, insurance coverage, psychological stability, and history of medical compliance. Other factors related to the impact of immunosuppression, such as active pregnancy and patient immune status, were less emphasized. CONCLUSIONS: Because of the novelty of the field, eligibility criteria continue to evolve. While there is consensus on certain eligibility factors, other criteria diverge between programs, and very few factors were considered absolute contraindications. As the popularity of the field continues to grow, we encourage the development of consensus evidence-based eligibility criteria.

Advances in Upper Extremity Scleroderma Wound Care.

GENERAL PURPOSE: To provide information about the pathophysiology, diagnosis, and treatment options for systemic sclerosis. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Describe the pathophysiology, signs, symptoms, and diagnosis of systemic sclerosis.2. Outline the evidence-based medical and surgical management of systemic sclerosis. ABSTRACT: OBJECTIVE:: To perform a targeted review of systemic sclerosis, including epidemiology, pathophysiology, diagnosis, signs and symptoms, and medical and surgical management of upper extremity manifestations. DATA SOURCES AND STUDY SELECTION: An electronic literature review was conducted using PubMed for all publication dates through October 2017. Searches were performed using combinations of terms including "systemic sclerosis," "scleroderma," "management," "upper extremity," "hypercalcinosis," "Raynaud's phenomenon," "sympathectomy," and "digital ulcers." Only full-length articles written in English that discussed the management of upper extremity scleroderma were used. DATA EXTRACTION AND SYNTHESIS: The epidemiology, pathophysiology, diagnosis, upper extremity manifestations, and medical and surgical management of systemic sclerosis were reviewed. The case described in this article reports the utility of microsurgical interventions in the treatment of medically refractory upper extremity systemic sclerosis. CONCLUSIONS: Systemic sclerosis is a rare rheumatologic disease that greatly impacts quality of life. Medical management is the mainstay of treatment, propelling an improvement in the dismal 10-year cumulative survival rate from 54% in the 1970s to 66% in the 1990s. However, the pathophysiology of this disease is still poorly understood, and when medical management fails and the disease inevitably progresses, surgical approaches are critical.

Neurovascular compromise due to true brachial artery aneurysm at the site of a previously ligated arteriovenous fistula: Case report and review of literature.

True arterial aneurysms of the upper extremity are rare. The case described is that of a 48-year-old man presenting with median neuropathy and distal vascular compromise 4 years after ligation of a brachiocephalic arteriovenous fistula. We describe our approach and present a review of the relevant literature.

Reconstruction of a functional gliding surface with extensor retinaculum in extensor tendon reconstruction in the digits.

BACKGROUND: Tendon gliding is key to optimal recovery of hand function after complex tendon injuries. Gliding is facilitated by a low-friction gliding surface that is normally provided by the periosteum of the underlying bone. However, significant injuries may damage the periosteum, which must be reconstructed to allow uninterrupted tendon excursion. The absence of the periosteum may compromise a tendon's ability to glide freely, thereby limiting the range of motion. METHODS: Six digits in 4 patients with complex, composite soft tissue defects involving tendon, periosteum, and skin of the hand underwent surgical repair. Each digit had disruption of the bony cortex underlying the tendon injury including periosteal loss. Through an incision on the dorsum of the ipsilateral wrist, an extensor retinaculum graft corresponding to the size of the periosteal defect was harvested. It was then sutured into place over the bare cortex to replace the lost periosteum. RESULTS: All the 6 digits in the 4 patients had complete return to function. Additionally, all patients had near normal strength in the repaired hand along with excellent tendon excursion in both flexion and extension. The average time of follow-up of this series of patients was 1.5 years. CONCLUSIONS: Extensor retinaculum grafting to replace lost periosteum is a technique that is easily used, uses locally available autogenous tissues, and produces excellent tendon function. Additionally, the histologic similarities between extensor retinaculum and periosteum add scientific merit to this novel approach. On the basis of our experience, we recommend the use of extensor retinaculum for periosteal reconstruction to provide an adequate gliding surface for a reconstructed tendon.

Lipoblastoma of the hand and cleft palate: is there a genetic association?

We report a case of lipoblastoma of the hand in a 19-month-old female patient with a history of cleft palate. The incidence of lipoblastoma and cleft palate individually is extremely rare. To the best of our knowledge, only 1 other case of a patient with both cleft palate and lipoblastoma exists in the literature. Lipoblastoma is a rare benign neoplasm in adipose tissue almost exclusively found in children younger than 3 years. Cytogenetic testing has shown that lipoblastomas characteristically share a clonal chromosomal rearrangement affecting the long arm of chromosome 8. Furthermore, recent research has shown that the 8q chromosome is an important genetic risk factor for cleft palate development. We describe the second case linking cleft palate with this rare tumor and provide evidence for a potential genetic association.

Traumatic proximal interphalangeal joint reconstruction with an autologous hemi-toe osteochondral graft: case report.

We report a case of a traumatic proximal interphalangeal joint injury with loss of the middle phalangeal base and articular surface, which was reconstructed with an autologous hemi-toe osteochondral graft. The patient had a 72° improvement in proximal interphalangeal joint motion and excellent functional improvements. Postoperative computed tomography imaging indicated bony union and articular congruence.

The First Successful Combined Full Face and Bilateral Hand Transplant.

BACKGROUND: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant. METHODS: A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS: Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSIONS: Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.

Enhancements to nutrition program in Indian integrated child development services increased growth and energy intake of children.

The Indian Integrated Child Development Services (ICDS) provides supplemental food to children aged 6 mo to 6 y. This study assessed the impact of enhancements to the existing Supplemental Nutrition Program of local production of supplemental food, home fortification with a micronutrient powder, and improved program monitoring. A quasi-experimental longitudinal design was used. Data were collected from 15 Anganwadi centers randomly selected from the enhanced program and 15 from the usual program. Multilevel linear regression was used to examine changes over time between the 2 groups accounting for village-level variation in intent-to-treat analysis. Children in the enhanced program initially aged 12-18 mo gained 0.72 (P = 0.02) greater height-for-age Z-score. Significant differences were observed in gain in weight-for-age Z-score among those initially aged 9-11 (2.48; P = 0.01), 12-18 (0.76; P = 0.01), and 19-24 mo old (0.73; P = 0.01), and gain in weight-for-height Z-score among 9-11 (2.66; P = 0.04) and 19-24 mo old (0.99; P = 0.01). For these age groups, the prevalence of stunting, underweight, or wasting averted ranged from 20.3 to 33.4%. Energy intake in the enhanced program was significantly greater for boys initially aged 12-18 mo (575.1 kJ/d; P = 0.03). Results from a qualitative substudy supported the plausibility of observed outcomes. ICDS would be more effective in improving child nutrition if it included these enhancements. The enhancements studied may be useful in improving program delivery and uptake of other similar programs.

Power-assisted suction lipectomy of fasciocutaneous flaps in the extremities.

BACKGROUND: A bulky appearance is one of the major patient complaints after extremity reconstruction after fasciocutaneous flaps. Serial debulking procedures with staged excision are required to improve aesthetic and functional outcome, but these methods risk injury to the vascular pedicle and often require multiple procedures for adequate thinning of the flap. We suggest the use of power-assisted suction lipectomy for the debulking of fasciocutaneous flaps in the upper and lower extremities as a safe, effective, and efficient procedure. METHODS: From 2006 to 2009, we performed power-assisted suction lipectomy on the upper and lower extremities of 16 flaps in 15 patients who had previously undergone reconstruction with fasciocutaneous flaps after a traumatic injury. RESULTS: There was 100% flap survival without any complications. Only 2 of the 16 (12.5%) flaps required a secondary revision for further contouring. CONCLUSIONS: In our experience power-assisted suction lipectomy is a safe and excellent adjunct in fasciocutaneous flap debulking and reduces the number of secondary revision procedures necessary. We recommend its use as an adjunct in debulking and contouring flaps used in extremity reconstruction.

Preoperative chemotherapy to salvage the hand in a case of giant infantile hemangiopericytoma.

Hemangiopericytoma (HPC) is a rare vascular tumor arising from contractile cells around blood vessels, with the potential for malignant degeneration. Up to 10% of HPC occurs in children. Standard therapy for this tumor is surgical excision. We report the case of a 6-month-old infant with giant HPC involving the hand. Chemotherapy resulted in a decrease in tumor size, allowing for salvage of most of the hand and fingers. Preoperative chemotherapy should be considered in the care of HPC tumors involving the upper extremity in children.

Abdominal Obesity, Adipokines and Non-communicable Diseases.

Abdominal obesity may be defined as excess deposits of fat in the abdominal region. It is a common health condition seen in South Asians and is positively related to non-communicable diseases (NCDs). It is independent of body mass index and measured by raised waist circumference for men≥90 cm and women≥80 cm. The reason for its prevalence being common in Indians finds its root from pregnancy, during fetal period and has emerged as a concept of 'Thin Fat Indian'. Malnutrition in such a critical period of growth has consequences in the form of reduced basal metabolic rate (BMR), reduced blood flow to growing tissues, reduced functional ability of vital organs, endocrine changes and reduced capacity of primary adipose tissue. However, excess of visceral fat facilitates high dosage of adipokines in the portal vein to liver and other body tissues having serious implications seen in the form NCDs like diabetes, hypertension, heart diseases, non-alcoholic fatty liver diseases, kidney disorders, cancer and other health problems. Abdominal obesity should be addressed before it has progressed further to defined health issues by exercise and diet, so that people can live a quality life.

Iodine Deficiency during Preconception Period of Adolescent Girls Residing in a District of Rajasthan, India.

BACKGROUND: In India, iodine deficiency (ID) still remains a serious concern even after five decades of enormous efforts. ID during the preconception period of adolescent girls may negatively affect future neonates, resulting in neonatal hypothyroidism. Hence, the present study was conducted to assess the prevalence of goiter and associated factors among adolescent girls in a poor socioeconomic district of Rajasthan. METHODOLOGY: A cross-sectional study was conducted during January-March 2015 in Tonk district of Rajasthan. A total of 1912 adolescent girls were selected from thirty schools using population proportionate to size sampling. Adolescent girls were clinically examined for thyroid using palpation method. Casual urine (n = 344) and salt samples (n = 370) were collected from a subgroup of girls for the estimation of urinary iodine concentration (UIC) and iodine content in salt, respectively. RESULTS: The overall goiter prevalence was 15.3% (95% confidence interval 13.6%-16.9%) and the median UIC was 266 µg/l (interquartile range: 150-300 µg/l) among 1912 adolescent girls (age, 15.7 ± 1.4 years). Around 16.8% of the families of adolescent girls were consuming salt with inadequate iodine (<15 ppm). Goiter prevalence was statistically significantly different with respect to age groups (P = 0.03). There was no statistically significant difference in goiter prevalence with respect to iodine content of salt (P = 0.98) and UIC (P = 0.41). The median UIC increased with an increase in consumption of iodine content of salt from inadequacy to adequacy (P = 0.15). CONCLUSION: Adolescent girls, residing in an underdeveloped district, are in the transition phase from mild ID (goiter prevalence 15.3%) to iodine sufficiency (median UIC 266 µg/l).

Acellular dermal matrix for temporary coverage of exposed critical neurovascular structures in extremity wounds.

INTRODUCTION: Large-volume soft-tissue defects often leave exposed neurovascular and vital structures not amenable to immediate flap coverage. We describe the use of AlloDerm, an acellular dermis allograft, in providing temporary coverage of these structures in multistage reconstruction of the extremity. METHODS: A prospective study of 25 patients was performed using AlloDerm for temporary coverage of exposed vital structures secondary to trauma and oncologic ablation. A direct examination of neurovascular structures and the wound bed after allograft removal was performed as a monitor of outcome. RESULTS: All allografts successfully covered the neurovascular structures at the time of removal with complete viability of neurovascular structures. Granulation tissue was appreciated in the wound bed with no clinical evidence of infection. The allograft was easily removed without damage to underlying structures. CONCLUSION: AlloDerm offers a safe and reliable alternative to cover critical neurovascular structures temporarily, before the definitive reconstruction of soft-tissue defects.

Submuscular versus subcutaneous anterior ulnar nerve transposition: a rat histologic study.

PURPOSE: The 2 most common methods of ulnar nerve anterior transposition are submuscular and subcutaneous. Controversy exists as to which technique yields superior results. The purpose of this study was to examine the histologic differences between the 2 methods in a rat model. METHODS: Twenty forelimbs in 10 adult Sprague-Dawley rats had bilateral ulnar nerve transpositions; one side with the submuscular method, and the other side with the subcutaneous method. Animals were killed 6 weeks after the index surgery and the forelimbs were examined for histologic evidence of the health of the axons and perineural scar formation. RESULTS: Nerve health was assessed using a 4-part classification in which 4 = normal nerve, 3 = abnormal axons in one-third cross-sectional area (CSA), 2 = abnormal axons in two-thirds CSA, and 1 = abnormal axons in 100% CSA. Perineural scar formation was assessed using a 3-part classification in which 3 = scar completely encasing nerve, 2 = scar formation partially surrounding nerve, and 1 = no scar. The submuscular method displayed healthier ulnar nerve axons. In addition, the submuscular method displayed less perineural scar tissue. CONCLUSIONS: On this basis of this rat model, the submuscular method of ulnar nerve anterior transposition displayed histologically healthier axons and less perineural scar tissue when compared to the subcutaneous method.

Ulnar Nerve Compression due to Anconeus Epitrochlearis: A Case Report and Review of the Literature.

CASE: A 32-year-old right-handed surgeon presented with a history of intermittent pain at the right medial epicondyle, a mild Tinel's sign, and dysesthesia in the ulnar nerve distribution. Dynamic ultrasound demonstrated a hypertrophic anconeus epitrochlearis bilaterally, and chronic irritation of the ulnar nerve. Anterior release with myectomy of the accessory muscle was performed. No compressive symptoms were present at 1-year follow-up. CONCLUSIONS: The anconeus epitrochlearis is an often-underappreciated cause of ulnar nerve compression that can lead to significant functional impairment. Dynamic ultrasound is an excellent diagnostic modality, and anterior release with myectomy provides durable relief with minimal downtime.

A Cost and Efficiency Analysis of the WALANT Technique for the Management of Trigger Finger in a Procedure Room of a Major City Hospital.

The "Wide Awake Local Anesthesia No Tourniquet" (WALANT) technique is gaining popularity in hand surgery owing to its benefits of reduced cost, shorter hospital stay, improved safety, and the ability to perform active intraoperative examinations. The aim of this study is to analyze the cost savings and efficiency of performing A1 pulley release for treatment of trigger finger using the WALANT technique in a major city hospital procedure room (PR) as compared with the standard tourniquet, operating room (OR) approach. METHODS: Patients who underwent trigger finger release between 2012 and 2017 were identified. Demographic and procedural information were obtained. Patients were followed for an average of 82 and 242 days in the PR and OR groups, respectively. RESULTS: Thirty-nine PR and 37 OR patients were identified. Case length and turnover time were shorter in the PR group [21.4 ± 7 versus 23.5 ± 14.3 min (P = 0.942) and 31.1 ± 11.1 and 65.3 ± 17.7 min (P < 0.001), respectively). The cost of the instrument tray utilized was calculated as $3,304.25 in the main OR and $993.79 in the PR. Cost per minute for all personal services in the OR was calculated to be $44/min, a cost that was virtually absent in the PR. Complication rates did not differ between both groups. CONCLUSION: Performing A1 pulley release for treatment of trigger finger using the WALANT technique is both cost effective and time efficient compared to performing the same procedure in the main OR of a major city public hospital.

Prevalence of goiter and associated factors among pregnant mothers residing in a district with poor socioeconomic status in Rajasthan state, India.

BACKGROUND: National survey documented that none of the Indian state is free from iodine deficiency (ID). Hence, the study was conducted with the objective to assess prevalence of goiter and associated factors among pregnant mothers (PMs) in a backward district of Indian state, Rajasthan. METHODS: A cross-sectional survey was conducted during January to March 2015. Multistage random sampling was utilized to select PMs. A total of 1,183 villages were enlisted with their respective population, and 30 villages were selected using population proportionate to size sampling. Subjects were included from a cluster till the numbers reached to 17. PMs were clinically examined for goiter by palpation method. Casual urine (n = 226) and salt samples (n = 220), were collected from a subgroup of subjects, and iodine concentrations were analyzed by using wet digestion and iodometric titration methods, respectively. RESULTS: The prevalence of goiter was found to be 14.2% (95% CI; 11.2-17.2). Goiter prevalence did not significantly differ with respect to trimesters of pregnancy (P = 0.09), iodine content in salt (P = 0.8), and urinary iodine concentrations (UIC, P = 0.69). The median UIC was 174 µg/L (IQR; 116-300 µg/L), which indicated adequate iodine intake. There was higher prevalence of goiter in PMs consuming salt with inadequate iodine than those with adequate, which was not significant (P = 0.8). Goiter prevalence was also insignificantly higher among PMs with UIC <150 µg/L than those with UIC ≥150 µg/L (P = 0.69). CONCLUSION: The study population is in transition phase from mild ID (goiter prevalence 14.1%) to sufficiency (median UIC 174 µg/L).

Surgical anatomy of the first extensor compartment: A systematic review and comparison of normal cadavers vs. De Quervain syndrome patients.

PURPOSE: De Quervain syndrome or tenosynovitis is a common wrist pathology caused by stenosing tenosynovitis of the first dorsal compartment. Multiple studies have demonstrated significant anatomic variation within the first extensor compartment. METHODS: The terms "De Quervain's tenosynovitis" and "first extensor compartment anatomy" were comprehensively searched using the PubMed, MEDLINE, and Cochrane database. The presence of a septum within the first dorsal compartment, the number of APL (abductor pollicis longus), and EPB (extensor pollicis brevis) tendon slips were identified. RESULTS: A total of 574 articles were identified on initial search, of which 21 met inclusion criteria. There were 1901 normal cadaver specimens and 470 surgically treated De Quervain disease patients, whose data were available. A septum was present in 43.7% of normal cadavers versus 62.2% De Quervain patients with 58.5% (327 of 559) of the septi characterized as incomplete. There was a difference in the number of APL tendons with a single APL tendon slip noted in 18.3% of normal cadavers (200/1096) versus 27.2% of De Quervain patients (87/230). There was a difference in the number of EPB tendons between the normal cadavers and De Quervain's wrists with 2 or more EPB tendinous slips observed in 5.9% of normal cadavers compared with 2.9% of De Quervain patients. CONCLUSION: Significant anatomic variability exists within the first extensor compartment. Patients with De Quervain disease were more likely to have a septum dividing the compartment and a single slip of APL. These variations are clinically relevant in the pathophysiology and treatment of De Quervain's tenosynovitis. TYPE OF STUDY: Prognostic studies. LEVEL OF EVIDENCE: Level III.

The dorsal scapular island flap: an alternative for head, neck, and chest reconstruction.

The back has become an increasingly popular donor site for flaps because it can provide thin, pliable tissue, with minimal bulk, and the scar can be easily hidden under clothing. The authors performed a cadaveric and clinical study to evaluate the anatomy of the dorsal scapular vessels and their vascular contribution to the skin, fascia, and muscles of the back. On the basis of anatomical studies in 28 cadavers and clinical experience with 32 cases, it was concluded that the dorsal scapular vessels provide a reliable blood supply to the skin of the medial back, making it a versatile flap to use as an island flap. A flap raised on the dorsal scapular vessels can be harvested with a long pedicle and can be rotated to reach as far as the anterior regions of the head, neck, and chest wall. Delaying and expanding the flap may help to facilitate venous drainage. The authors recommend the use of this versatile island pedicle flap as an alternative to microvascular free-tissue transfer for the reconstruction of defects in the head, neck, and anterior chest.