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PurposeTo describe the principles, process, and results of creating the International Consortium for Health Outcomes Measurement (ICHOM) standard set for hand and wrist conditions.MethodsFollowing the standardized methods of ICHOM, an international working group of hand surgeons, therapists, and researchers was assembled to develop an evidence-based, patient-centered, standard set of outcome measures for patients with hand and wrist conditions. Multiple systematic reviews were performed to support our choices of outcome domains and tools for hand and wrist conditions. Fourteen video conferences were held between March 2018 and March 2020, and a modified Delphi process was used.ResultsA consensus was reached on 5 measurement tracks: the thumb, finger, wrist, nerve, and severe hand trauma tracks, with a distinction between regular and extended tracks for which specific allocation criteria applied. The standard set contains a selection of outcome tools and predefined time points for outcome measurement. Additionally, we developed a hierarchy for using the tracks when there are multiple conditions, and we selected risk-adjustment, case-mix variables.ConclusionsThe global implementation of the ICHOM standard set for hand and wrist conditions may facilitate value-based health care for patients with hand and wrist conditions.Clinical relevanceThe ICHOM standard set for hand and wrist conditions can enable clinical decision making, quality improvement, and comparisons between treatments and health care professionals.

Background aims Cultured patient-specific keratinocyte sheets have been used clinically since the 1970s for the treatment of large severe burns. However, despite significant developments in recent years, successful and sustainable treatment is still a challenge. Reliable, high-quality grafts with faster availability and a flexible time window for transplantation are required to improve clinical outcomes. Methods Keratinocytes are usually grown in vitro at 37°C. Given the large temperature differences in native skin tissue, the aim of the authors’ study was to investigate thermal conditioning of keratinocyte sheet production. Therefore, the influence of 31°C, 33°C and 37°C on cell expansion and differentiation in terms of proliferation and sheet formation efficacy was investigated. In addition, the thermal effect on the biological status and thus the quality of the graft was assessed on the basis of the release of wound healing-related biofactors in various stages of graft development. Results The authors demonstrated that temperature is a decisive factor in the production of human keratinocyte sheets. By using specific temperature ranges, the authors have succeeded in optimizing the individual manufacturing steps. During the cell expansion phase, cultivation at 37°C was most effective. After 6 days of culture at 37°C, three times and six times higher numbers of viable cells were obtained compared with 33°C and 31°C. During the cell differentiation and sheet formation phase, however, the cells benefited from a mildly hypothermic temperature of 33°C. Keratinocytes showed increased differentiation potential and formed better epidermal structures, which led to faster biomechanical sheet stability at day 18. In addition, a cultivation temperature of 33°C resulted in a longer lasting and higher secretion of the investigated immunomodulatory, anti-inflammatory, angiogenic and pro-inflammatory biofactors. Conclusions These results show that by using specific temperature ranges, it is possible to accelerate the large-scale production of cultivated keratinocyte sheets while at the same time improving quality. Cultivated keratinocyte sheets are available as early as 18 days post-biopsy and at any time for 7 days thereafter, which increases the flexibility of the process for surgeons and patients alike. These findings will help to provide better clinical outcomes, with an increased take rate in severe burn patients.

Background Wrist arthrolysis is a viable option in wrist stiffness and can be performed via open or arthroscopic techniques. Purpose The aim of the study is to describe and evaluate the available techniques of open and arthroscopic arthrolysis of the radiocarpal joint and the distal radio ulnar joint (DRUJ) in posttraumatic wrist stiffness. Methods A systematic literature search was performed in PubMed to identify studies reporting on open and arthroscopic wrist arthrolysis. Key words included “open wrist arthrolysis,” “arthroscopic wrist arthrolysis,” “post-traumatic wrist stiffness,” and “DRUJ arthrolysis.” Data were extracted independently by a pair of reviewers. Results Overall, 637 studies were identified; 13 additional articles were found through previous publications (total 650 articles). A total of 612 records resulted after duplicates was removed. Fourteen studies were selected and only eight respected the inclusions criteria. One study focused on volar open arthrolysis and four studies on arthroscopic arthrolysis of the radiocarpal joint; two studies reported on open arthrolysis and two studies on arthroscopic DRUJ arthrolysis. Range of motion following open and arthroscopic wrist arthrolysis improved in all studies. Conclusion Both arthroscopic and open arthrolysis can lead to similar and satisfactory results in radiocarpal joint and DRUJ stiffness.. Level of Evidence This is a level 3a study.

Background The aim of this study was to evaluate the effectiveness and safety of free corticoperiosteal medial femoral condyle (MFC) flap for ankle, hindfoot and midfoot reconstruction in patients with recalcitrant nonunion. Methods Patients who underwent ankle and foot reconstruction using the MFC flap at our clinic were recruited for assessment of the union rate, time to union and functional outcome. Furthermore, a clinical and radiological examination of the donor knee was performed using both computed tomography and magnetic resonance imaging. Results Thirteen patients with a mean follow-up time of 2.5 years were included; 10 of them had a previously failed ankle and foot arthrodesis. Union was achieved in 11 patients in an average time of 10 months after MFC flap surgery. Donor site morbidity was minor with no radiological evidence for soft tissue or bone complication. Conclusion MFC flaps are a useful and safe reconstructive tool and may be considered after failed ankle and foot arthrodesis.

Zusammenfassung. Mit zunehmendem Alter der Bevölkerung steigt die Häufigkeit von Arthrose in der Hand. Dies kann bei Manifestation zu Schmerzen und körperlichen Beeinträchtigungen führen. Die daraus resultierende potenzielle Arbeitsunfähigkeit betrifft die Bevölkerung bei steigendem Rentenalter zunehmend. Dieser Artikel gibt einen Überblick über die häufigsten Formen der Arthrose in der Hand, ihre Diagnosestellung und die aktuellen Behandlungsmöglichkeiten und betont, dass eine multimodale Therapie häufig der effektivste Ansatz ist.

Complete distal ruptures of the biceps brachii tendon are rather rare and surgical reinsertion is the gold standard. Recently, one incision approaches for the refixation of the distal biceps tendon have been popularized with the introduction of a single-incision approach employing a trans-radial cortical button fixation. Since the introduction of this fixation technique we have seen more iatrogenic lesions to the posterior interosseous nerve (PIN) after not having seen any PIN lesions with 2 incision biceps refixation techniques over the last 5 years. Several patients with iatrogenic PIN affections after one incision refixation techniques of the distal biceps tendon were referred to our level 1 department of Plastic surgery and hand surgery from different orthopedic surgeons. Over the course of 6 months we saw 5 patients with a similar history. We decided to analyze this problem and propose a course of action to regain function of the PIN innervated muscles as good and fast as possible. If there is a loss of function in the PIN innervated muscles after distal biceps refixation a neurological evaluation including electrophysiology needs to be conducted. An ultrasound assessment of the nerve itself should guide the clinician in the decision between a conservative and a surgical treatment in the early postoperative phase. If surgical exploration is warranted intraoperative neurography should be the basis on which ground (partial) grafting or solely neurolysis is performed. Postoperatively all patients need to follow a rehabilitation protocol to help with nerve regeneration and regaining of motor function.

The purpose of the study is to present a technical approach for arthroscopic three-corner or lunocapitate arthrodesis with mini-open scaphoid excision and to report about the early clinical and functional results. The median surgery time was 112 min with shorter times achieved once mastering the technique. Radiological and clinical union was observed in 11 out of 12 patients in a median time of five months. For final assessments nine patients were included with a median follow-up of 15 months. Wrist extension and flexion after surgery decreased to 58 and 62% of preoperative measurements and represented 37 and 42% of the unaffected side. Grip strength also decreased to 80% of the preoperative value and 57% of the unaffected side. All patients reported significant pain relief and functional improvement. Arthroscopic three-corner or lunocapitate arthrodesis was a safe, reliable and minimally invasive technique for treating wrist osteoarthritis, while it was technically demanding and time-consuming during learning curve.

Copper is an essential trace metal that has been implicated in angiogenesis, the formation of new blood vessels. As tumor growth relies on establishing a functional capillary network for blood supply, copper chelation therapy may hold promise as an anti-cancer strategy by suppressing angiogenesis. To test the anti-angiogenic effect of PSP-2, a recently developed high affinity Cu(I) chelator with low zeptomolar dissociation constant, we utilized the endothelial cancer cell line EAhy926 and assessed changes in cell migration, proliferation, and tube formation in Matrigel. In addition, sprouting was assessed by the chicken and sheep aortic ring assay, and vascular pattern formation was studied in the chorioallantoic membrane of chicken embryos (CAM assay). While incubation with PSP-2 resulted in selective depletion of cellular copper levels, cell migration was not affected and the proliferating activity was even slightly increased. Moreover, the endothelial tube formation assay revealed significant morphological changes in the presence of PSP-2, with thicker tubular walls and an overall decreased meshes area. Similarly, the aortic ring assay and CAM assay showed that PSP-2 evokes significantly longer sprouts with smaller angles at branching points. Altogether, PSP-2 exhibits significant bioactivity at concentrations as low as 5 μM, rendering it a promising anti-angiogenic agent. As EAhy926 cells exhibit both endothelial and tumorigenic properties, the anti-angiogenic effect of PSP-2 might potentially translate also into anti-cancer activity.

Bone regeneration is a complex process and the clinical translation of tissue engineered constructs (TECs) remains a challenge. The combination of biomaterials and mesenchymal stem cells (MSCs) may enhance the healing process through paracrine effects. Here, we investigated the influence of cell format in combination with a collagen scaffold on key factors in bone healing process, such as mineralization, cell infiltration, vascularization, and ECM production. MSCs as single cells (2D-SCs), assembled into microtissues (3D-MTs) or their corresponding secretomes were combined with a collagen scaffold and incubated on the chicken embryo chorioallantoic membrane (CAM) for 7 days. A comprehensive quantitative analysis was performed on a cellular level by histology and by microcomputed tomography (microCT). In all experimental groups, accumulation of collagen and glycosaminoglycan within the scaffold was observed over time. A pronounced cell infiltration and vascularization from the interface to the surface region of the CAM was detected. The 3D-MT secretome showed a significant mineralization of the biomaterial using microCT compared to all other conditions. Furthermore, it revealed a homogeneous distribution pattern of mineralization deposits in contrast to the cell-based scaffolds, where mineralization was only at the surface. Therefore, the secretome of MSCs assembled into 3D-MTs may represent an interesting therapeutic strategy for a next-generation bone healing concept., Scientific Reports, 11 (1), ISSN:2045-2322

Purpose of the study: To evaluate the results of surgical arthrolysis of the radiocarpal joint and the distal radio ulnar joint (DRUJ) in posttraumatic stiffness of the wrist. Methods: A systematic literature search was performed selecting studies on open and arthroscopic wrist arthrolysis. Key words included: “open wrist arthrolysis,” “arthroscopic wrist arthrolysis,” “arthroscopic wrist capsular release,” “DRUJ arthrolysis.” Results: 637 studies were identified; 14 studies were selected and only 8 respected the inclusions criteria. One study focused on volar open arthrolysis of the radio carpal joint, 2 studies on open arthrolysis of the DRUJ, 4 studies on arthroscopic arthrolysis of the wrist and one study on arthroscopic DRUJ arthrolysis. Range of motion following open and arthroscopic wrist arthrolysis improved in all studies. Conclusions: Arthroscopic and open wrist arthrolysis are both useful techniques for the improvement of wrist stiffness.

Degenerative changes of the distal interphalangeal (DIP) joints can be painful, disabling, and disfiguring. Swanson spacers can be used for DIP arthroplasty. The standard approach for Swanson spacer implantation at the DIP joint involves transecting the extensor tendon close to its insertion, which necessitates a 6-week period of postoperative immobilization. Another DIP approach involves sparing the extensor tendons, as already published. Both techniques lead to a similar range of motion of the replaced DIP joints. We present a novel approach for DIP joint arthroplasty with division of the extensor tendon in zone 2 with only 2 weeks of postoperative immobilization. Optimizing the motion-preserving operative approaches is of value to our high-demand patients. Postoperative results do not differ from the postoperative range of motion published in the literature for both tendon-sparing and standard approaches. But our approach is technically easy and requires a significantly shorter time of immobilization.

Arthroplasty of the distal radioulnar joint (DRUJ) using a semiconstrained DRUJ implant yields good outcomes according to the literature. The aim of this study was to investigate the subjective, clinical and radiographic outcomes with a special focus on complications in nine patients with a mean follow-up of 6years and to compare them with our previously published 3-year follow-up results. No subjective or objective changes were seen between the 3-year and the 6-year follow-up. In the previous study, one implant loosening and two irritations of the superficial branch of the radial nerve occurred. We saw three complications that needed surgery in addition to the three complications already found 3years after surgery. One patient with a large ulna had loosening of the cemented ulnar stem and therefore the prosthesis was explanted. One patient had an allergic reaction to the metal alloy of the prosthesis, which also led to removal. One patient had an ulnar impaction syndrome caused by too-distal placement of the implant that needed revision. Prior studies reported low complication rates. In our study, six complications occurred in four out of nine patients, requiring reoperation including two revisions and two implant removals. A precise surgical technique is mandatory to avoid the otherwise frequent complications and potential implant failures. LEVEL OF EVIDENCE: IV.

Recently, a tumor model based on the chorioallantoic membrane (CAM) was characterized structurally with Magnetic Resonance Imaging (MRI). Yet, capability of MRI to assess vascular functional reserve and potential of oxygenation-sensitive MRI remain largely unexplored in this model. For this purpose, we compared MC-38 colon and A549 lung adenocarcinoma cell grafts grown on the CAM, using quantitative T1 and T2* MRI readouts as imaging markers. These are associated with vascular functionality and oxygenation status when compared between periods of air and carbogen exposure. Our data show that in A549 lung adenocarcinoma cell grafts T2* values increased significantly upon carbogen exposure (p in ovo using MRI in the living chicken embryo.

We recorded the dart-throwing motion and basic motion tasks in patients following radioscapholunate fusion and midcarpal fusion with a three-dimensional motion capture system in vivo, using digital infrared cameras to track the movement of reflective skin markers on the hand and forearm. During the dart-throwing motion, 20 healthy volunteers showed a median range of motion of 107°. As expected, patients had significantly reduced wrist range of motion during basic motion tasks and dart-throwing motion compared with the healthy controls, except for ulnar flexion occurring in the dart-throwing motion in patients treated by midcarpal fusion and radial deviation after midcarpal fusion or radioscapholunate fusion. In addition, patients who had undergone radioscapholunate fusion had significantly reduced range of motion during dart-throwing motion compared with patients after midcarpal fusion.

Cell-based tendon therapies with tenocytes as a cell source need effective tenocyte in vitro expansion before application for tendinopathies and tendon injuries. Supplementation of tenocyte culture with biomolecules that can boost proliferation and matrix synthesis is one viable option for supporting cell expansion. In this in vitro study, the impacts of ascorbic acid or PDGF-BB supplementation on rabbit Achilles tenocyte culture were studied. Namely, cell proliferation, changes in gene expression of several ECM and tendon markers (collagen I, collagen III, fibronectin, aggrecan, biglycan, decorin, ki67, tenascin-C, tenomodulin, Mohawk, α-SMA, MMP-2, MMP-9, TIMP1, and TIMP2) and ECM deposition (collagen I and fibronectin) were assessed. Ascorbic acid and PDGF-BB enhanced tenocyte proliferation, while ascorbic acid significantly accelerated the deposition of collagen I. Both biomolecules led to different changes in the gene expression profile of the cultured tenocytes, where upregulation of collagen I, Mohawk, decorin, MMP-2, and TIMP-2 was observed with ascorbic acid, while these markers were downregulated by PDGF-BB supplementation. Vice versa, there was an upregulation of fibronectin, biglycan and tenascin-C by PDGF-BB supplementation, while ascorbic acid led to a downregulation of these markers. However, both biomolecules are promising candidates for improving and accelerating the in vitro expansion of tenocytes, which is vital for various tendon tissue engineering approaches or cell-based tendon therapy., International Journal of Molecular Sciences, 21 (2), ISSN:1422-0067

Tissue engineering of an osteochondral interface demands for a gradual transition of chondrocyte- to osteoblast-prevailing tissue. If stem cells are used as a single cell source, an appropriate cue to trigger the desired differentiation is the use of composite materials with different amounts of calcium phosphate. Electrospun meshes of poly-lactic-co-glycolic acid and amorphous calcium phosphate nanoparticles (PLGA/aCaP) in weight ratios of 100:0; 90:10, 80:20, and 70:30 were seeded with human adipose-derived stem cells (ASCs) and cultured in DMEM without chemical supplementation. After 2 weeks of static cultivation, they were either further cultivated statically for another 2 weeks (group 1), or placed in a Bose® bioreactor with a flow rate per area of 0.16 mL cm-2 min-1 (group 2). Markers for stem cell criteria, chondrogenesis, osteogenesis, adipogenesis and angiogenesis were analyzed by quantitative real-time PCR. Cell distribution, Sox9 protein expression and proteoglycans were assessed by histology. In group 2 (perfusion culture), chondrogenic Sox9 was upregulated toward the cartilage-mimicking side compared to pure PLGA. On the bone-mimicking side, Sox9 experienced a downregulation, which was confirmed on the protein level. Vice versa, expression of osteocalcin was upregulated on the bone-mimicking side, while it was unchanged on the cartilage-mimicking side. In group 1 (static culture), CD31 was upregulated in the presence of aCaP compared to pure PLGA, whereas Sox9 and osteocalcin expression were not affected. aCaP nanoparticles incorporated in electrospun PLGA drive the differentiation behavior of human ASCs in a dose-dependent manner. Discrete gradients of aCaP may act as promising osteochondral interfaces. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1833-1843, 2019.

We report sonographic findings with clinical outcomes after zone 2 flexor digitorum profundus tendon repairs in ten fingers. The tendons underwent a six-strand M-Tang core repair, no circumferential suture, and partial or complete division of the pulleys. Over 12 months after surgery and using ultrasound, we found no gapping at the repair site during finger motion. When the pulleys were divided, there was sonographic evidence of tendon bowstringing, but the bowstringing was minimal. Clinically, we did not find any fingers that displayed tendon bowstringing or had functional loss. With ultrasound examination, the repaired tendons remained enlarged over 12 months. Two patients developed heterotopic ossifications at the repair site without tendon gliding, and these required tenolysis. We conclude that the tendon repair site does not gap when a strong core suture is used in the repair without adding peripheral sutures. There is no notable tendon bowstringing clinically, though the repaired tendons have sonographic evidence of minor bowstringing. Level of evidence: III

We report outcomes in 29 patients with flexor tendon repairs in 32 digits (five thumbs and 27 fingers) with our modified protocols. We repaired the lacerated flexor digitorum profundus tendons with core suture repairs using the 6-strand M-Tang method and without circumferential sutures. We divided the pulleys as much as needed to allow excursion of the repaired tendons, including complete division of the A4 or A2 pulleys when necessary. In nine fingers, we repaired one slip of the flexor digitorum superficialis tendon and resected the other half. When the flexor digitorum profundus tendon would not glide under the A2 pulley, we excised the remaining slip of the flexor digitorum superficialis tendon. The wrist was splinted in mild extension post-surgery with early commencement of tenodesis exercises. No tendon repair ruptured. By the Strickland criteria, out of 27 fingers, 18 had excellent, six had good, two had fair, and one had poor results. We conclude that a strong core suture (such as the M-Tang repair) without peripheral sutures, and with division of pulleys as necessary is safe for early active motion and yields good outcomes. Level of evidence: IV

Background:Complex regional pain syndrome (CRPS) is a rare painful condition that usually appears after trauma or surgery of the extremities. Symptoms include pain, sensory, sudomotor and vasomotor disturbances, trophic changes and impaired motor function. The course varies from mild to chronic disease with a high impact on daily functioning and quality of life. In skin tissue, sustained inflammatory, fibrotic processes together with reduced epidermal nerve fibers are reported. Neurotrophins and their receptors are mediators in cell-to-cell communication and key mediators of pain signalingObjectives:The aim of this study was to identify differential expression of neurotrophins and their receptors in the skin and skin fibroblasts of patients with CRPSMethods:Healthy controls (HC) and patients with acute CRPS with symptoms for less than 6 months fulfilling the Budapest criteria were recruited. Pain scores were evaluated by numeric rating scale (0=no pain, 100=maximal) and body perception was assessed using the Bath Body Perception Disturbance Scale (BBPDS) (0=no perception disturbance, 57=maximal perception disturbance).Skin biopsies of the affected and/or non-affected side were taken. Immunohistochemistry on formalin-fixed, paraffin-embedded skin tissue slides was used to show NT3 expression in skin tissues. Blinded analysis was done by an experienced dermato-pathologist determined staining graduated by 0= none, 1= sparse, 2=moderate, 3= dense.Skin fibroblast were isolated from skin biopsies by outgrowth cultures (CRPS, affected side, n=6 and HC, n=5). Cells (passage 3-6) were starved and subsequently stimulated with TNFα (10 ng/ml) or TGFβ (10 ng/ml) for 24 h to mimic active disease and total RNA was isolated by miRNeasy kit. Gene expression of neurotrophins (NGF, BDNF, and NT3) and neurotrophin receptors (NGFR, TrkA, TrkB and TrkC) was measured by quantitative real time PCR and quantified using the ΔΔCq method with GAPDH as a reference gene. ELISA was used to analyze NT3 protein expression in cell culture supernatants.Results:In 5 of 9 patients with CRPS immunohistological staining of NT3 showed an higher expression (from low to moderate) in the affected side versus the non-affected side. In 4 of 9 patients the expression of NT3 was high in the non-affected side (moderate/dense) and stayed high in the affected side.Of interest, the patients with increasing expression of NT3 in the affected side showed increased pain scores (max pain 80+/-10.95, n=5 versus 48.16+/-18.16, n=4, p=0.059 and changed body perception 26.8+/-8.68 n=5 versus 6.5+/-3.91, n=4, p=0.016).Isolated skin fibroblasts from the affected side of patients with CRPS compared to healthy skin fibroblasts showed higher basal gene expression of NT3 (log2 fold-change= 1.9 +/- 0.4, p= 0.005) and NGFR (log2 fold-change= 3.6 +/- 2.1, p=0.014). TNFα stimulated CRPS skin fibroblasts showed higher expression for NT3 (log2 fold-change= 2.1 +/- 1.2, p=0.002) compared to HC. TGFb stimulated skin fibroblasts of patients with CRPS showed higher expression of NT3 (log2 fold-change= 1.4+/-0.8, p=0.019), NGFR (log2 fold-change= 2.6 +/- 1.8, p=0.036) and TrkC (log2 fold-change= 2.3 +/- 1.8, p=0.032) compared to HC.On protein level, NT3 showed a tendency of upregulation in unstimulated fibroblasts from CRPS patients comparing to HC (CRPS mean= 8.0 +/- 2.2 pg/ml, HC mean= 6.3 +/- 1.8 pg/ml, p=0.25). After TNFα stimulation, protein level of NT3 was significantly higher in CRPS skin fibroblasts (CRPS mean= 10.6 +/- 2.4 pg/ml, HC mean= 4.8 +/- 1.3 pg/ml, p=0.004).Conclusion:These data indicate a new role of skin fibroblasts in CRPS. Differential basal and stimulated expression of NT3, the receptor for NT3 (TrkC) and NGFR, the common receptor for all neurotrophins, indicates deregulated communication of fibroblasts with the sensory nerve fibers in CRPS. This might contribute to the dysregulated healing process and sustained pain.Disclosure of Interests:Sanne Stroeve: None declared, Stefan Dudli: None declared, Isabel Kolm: None declared, Irina Heggli: None declared, Nick Herger: None declared, Sabrina Catanzaro: None declared, Andreas Schweizer: None declared, Maurizio Calcagni Speakers bureau: Arthrex, Consultant of: Medartis, Arthrex, SilkBiomaterials, Grant/research support from: Medartis, Oliver Distler: None declared, Florian Brunner: None declared, Astrid Juengel: None declared

The protocol for primary flexor tendon repair in zones 1 and 2 of the hand is changing. This article discusses recent changes. Immediate repair within 48 hours is performed whenever possible. A 6-strand core suture is performed using the M modification of Tang's technique. The pulleys are divided to allow free excursion of the repaired tendon within the tendon sheath. To avoid repaired structures within the sheath being too bulky, the authors generally repair only half of the flexor digitorum superficialis. In some cases, the flexor digitorum superficialis is excised completely. Rehabilitation remains based on controlled active motion.

The primary goal of the surgical treatment of upper brachial plexus injuries is to restore active elbow flexion. Accordingly, Oberlin's transfer has been frequently performed since 1994 and has influenced the development of other nerve transfers. However, the window of opportunity for nerve transfers remains a subject of controversy. The objective of this study was to assess magnetic resonance (MR) neurographic, clinical and electrophysiological long-term results after Oberlin's transfer. For this purpose, we performed a retrospective follow-up study. Six patients with upper brachial plexus or musculocutaneous nerve injuries were assessed; 2 were iatrogenic nerve injuries following shoulder arthroscopy or neurofibroma resection. Direct and indirect signs of neuropathy were objectified with MR neurography. Moreover, clinical and electrodiagnostic follow-up was performed and all patients completed the Disabilities of Arm, Shoulder and Hand score. Mean follow-up was 48 ± 21.9 (range, 20-73) months. Mean age was 40 ± 11.3 years and mean delay to surgery was 9 ± 3.2 months. All patients were satisfied with the functional results and the median Disabilities of Arm, Shoulder and Hand score was 21 (range, 1-57). Biceps strength was improved in 5 patients from Medical Research Council grade M0 to M4-5 and in one patient to M2-3. The donor nerve showed normal motor and sensory action potentials. Follow-up MR neurography demonstrated biceps reinnervation. Taken together, this study reports good long-term results after Oberlin's transfer. MR neurography represents an excellent, noninvasive preoperative planning tool and can be of high value in selected postoperative cases. The combined evaluation of nerves and muscles may help to indicate nerve transfers in delayed cases.

The human hand is the most frequently used body part in activities of daily living. With its complex anatomical structure and the small size compared to the body, assessing the functional capability is highly challenging. The aim of this review was to provide a systematic overview on currently available 3D motion analysis based on skin markers for the assessment of hand function during activities of daily living. It is focused on methodology rather than results. A systematic review according to the PRISMA guidelines was performed. The systematic search yielded 1349 discrete articles. Of 147 articles included on basis of title, 123 were excluded after abstract review, and 24 were included in the full-text analysis with 13 key articles. There is still limited knowledge about hand and finger kinematics during activities of daily living. A standardization of the task is required in order to overcome the nonrepetitive nature and high variability of upper limb motion and ensure repeatability of task performance. To yield a progress in the analysis of human hand movements, an assessment of human kinematics including fingers, wrist, and thumb and an identification of relevant parameters that characterize a healthy motion pattern during functional tasks are needed.

Background The measurement of finger and wrist range of motion (ROM) is of great importance to clinicians when assessing functional outcomes of therapeutic interventions and surgical procedures. The purpose of the study was to assess the repeatability of ROM measurements of the hand joints with manual goniometer and 3D motion capture system and to calculate the minimal detectable difference for both methods. Methods Active finger and wrist joints ROM of 20 healthy volunteers were assessed using a manual goniometer and 3D motion capture system. Minimal detectable difference (MDD) and standard error of measurement (SEM) were calculated for both measurement systems and compared within the same task. Maximal ROM of all joints was registered twice on two different days to evaluate the test-retest repeatability. The intraclass correlation coefficients (ICC) was calculated and examined to determine if reliability ≥ 0.70 existed. Results MDD for the 3D motion capture was between 5 and 12° except for the metacarpophalangeal joint (MCP) 1, interphalangeal joint (IP), and MCP5. SEM values lay between 2 and 4° for all joints except for the MCP5, IP, and MCP1. For the goniometric measurements, MDD and SEM were between 12–30° and 4–11°, respectively. The reliability criterion (ICC > 0.7) was achieved for the ROM measurement with the 3D motion capture system for 94% of the joints and in only 65% of the joints with the manual goniometer. Conclusions Joint ROM assessed with 3D motion analysis showed higher test-retest agreement demonstrating overall better repeatability for this method. Because of the smaller measurement error, the 3D motion capture system has a smaller MDD. Only individual test-rest differences bigger than the MDD can be considered as real changes, and therefore, in an experimental situation, the use of a more precise measurement method can greatly reduce the number of subjects needed for a statistical significance. Goniometer measurements of some joints should be carefully interpreted, due to a low repeatability and reliability. Trial registration This study is approved by the Ethical Committee Zurich (Kek-ZH-Nr: 2015-0395)., Journal of Orthopaedic Surgery and Research, 14 (1), ISSN:1749-799X

Background:Traditional preclinical approaches, such as two-dimensional cell culture and animal models, are often inadequate to mimic the pathophysiological features of complex diseases such as systemic sclerosis (SSc). Human specific targets, such as the recently described pro-fibrotic long non coding RNA (lncRNA) H19X1, are becoming increasingly relevant in preclinical research, creating the need of new strategies and tools in translational medicine. The employment of novel three-dimensional (3D) culture systems, where multiple cell types are included, is filling an important gap left by the traditional preclinical methods.Objectives:To develop an easy to produce 3D fibrotic skin microtissues model for translational proof of concept studies.Methods:Two thousand five hundred dermal fibroblasts isolated from skin of SSc patients were seeded in ultra-low attachment 96-well plates. Fibroblast were let to aggregate into spheres for 48h. Two thousand five hundred primary normal human keratinocytes were added to the culture and let to layer onto the fibroblast spheres for 72h. H19X silencing experiments were used as proof of concept studies. H19X silencing with antisense oligonucleotides or transfections with a scrambled control were performed in fibroblasts prior to the sphere formation for 24h. TGFβ (10 ng/ml) was added to microtissue to exacerbate the fibrotic phenotype. Haematoxylin eosin staining as well as immunohistochemistry staining for vimentin and cytokeratin 10 was performed. Skin microtissues were processed for RNA and protein isolation. Pro-collagen Iα1 and fibronectin were quantified in the supernatants with ELISA.Results:The microtissues presented a core of SSc fibroblast as revealed by vimentin staining and an external layer of keratinocytes as revealed by cytokeratin 10 staining, mimicking the human skin architecture. Gene expression analysis following TGFβ stimulation displayed induced expression of extracellular matrix gene COL1A1 (p=0.044) and the myofibroblast marker ACTA2 (p=0.018), indicating that the microtissues were able to develop a fibrotic response. Microtissues, where H19X was silenced, displayed reduced gene expression of COL1A1 and ACTA2 after TGFβ stimulation (COL1A1 p=0.007, ACTA2 p=0.045). Additionally, H19X silencing led to lower levels of αSMA protein expression (p=0.009) and pro-collagen1α1 secretion (p=0.039) in the supernatant of the microtissue cultures as revealed by Western Blot and ELISA, respectively. FN1 expression and fibronectin protein levels were not significantly reduced in the microtissues after H19X silencing.Conclusion:We were able to produce a 3D microtissue resembling skin architecture that can respond to fibrotic stimuli. Knockdown experiments of pro-fibrotic lncRNA H19X confirmed the potential of the model as screening platform for novel pro-fibrotic effectors. A future aim will be to optimize the model for high-throughput automated screening platforms.References:[1]Pachera, E., et al. (2020). “Long noncoding RNA H19X is a key mediator of TGF-β–driven fibrosis.” The Journal of Clinical Investigation 130(9): 4888-4905.Disclosure of Interests:Elena Pachera: None declared, Gabriela Kania: None declared, Astrid Juengel: None declared, Maurizio Calcagni Speakers bureau: Arthrex, Consultant of: Medartis, Arthrex, SilkBiomaterials, Grant/research support from: Medartis, Oliver Distler Speakers bureau: Actelion, Bayer, Boehringer Ingelheim, Medscape, Novartis, Roche, Consultant of: Abbvie, Actelion, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, ChemomAb, Corpuspharma, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, -Kymera, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi, UCB, Grant/research support from: Abbvie, Actelion, Bayer, Boehringer Ingelheim, Kymera Therapeutics, Mitsubishi Tanabe

Fifteen consecutive patients with severely comminuted Rolando fractures were treated by closed reduction and fixation with a modified Suzuki frame without rubber bands, followed by immediate mobilization. All the fractures healed within 5 weeks. At 3 months, no rotational deformity was observed. The Kapandji score was equal that of the contralateral thumb in eight cases. No residual pain was recorded. Grip strength was 78% and pinch strength was 78% of the contralateral hand. One patient needed the frame tension modified. One patient developed a sensory deficit in the area of the superficial branch of the radial nerve that resolved spontaneously in 3 months. One patient healed with a 2-mm articular step-off, but the clinical outcome was good. Our retrospective study suggests that the small modification we made to the Suzuki frame provides a relatively simple and minimally invasive technique for the treatment of comminuted Rolando fractures.

The aim of this study was to quantify the articular cartilage defect created with two different antegrade techniques of intramedullary osteosynthesis with a headless compression screw inserted through the metacarpophalangeal joint. In 12 out of 24 fingers from six cadaveric hands, a trans-articular technique with cannulated headless compression screws (2.2 and 3.0 mm diameter) was used; whereas in the other 12 fingers, an intra-articular fixation technique was used. The areas of the articular surface and the defects created were measured with a digital image software program. All measurements were made twice by two observers. In the intra-articular technique, the average defect in the base of the articular surface of the proximal phalanx was 4.6% with the 2.2 mm headless compression screw and 8.5% with the 3.0 mm screw. In the trans-articular technique, the defect size was slightly smaller; 4.2% with the 2.2 mm screw and 8% with the 3.0 mm screw, but the differences were not statistically significant. The main advantage of the intra-articular technique was that it avoided damage to the articular surface of the metacarpal head.

In this report a case of closed mallet thumb injury is described, which was diagnosed clinically and indication for surgical treatment was confirmed with ultrasound examination. The EPL-tendon was successfully reconstructed with an excellent result. We propose a mandatory ultrasound examination of all closed mallet thumb injuries.

A major problem after tendon laceration is the low mechanical strength of the repaired tissue. One viable strategy for improving the functional and biomechanical properties of ruptured and repaired tendons is the delivery of growth factors at the injury site. Here, bioactive and reversibly expandable double-layered emulsion and coaxially electrospun tubes made from biodegradable DegraPol® (DP) (polyester urethane), delivering platelet-derived growth factor BB (PDGF-BB), are explored as implants to improve tendon healing in a rabbit Achilles tendon full laceration model. In vitro studies showed that both emulsion and coaxially electrospun scaffolds allow sustained delivery of bioactive PDGF-BB with similar release kinetics (150-190 pg PDGF-BB/mg of DP scaffold) over a period of 30 days. In vivo assessment after three weeks showed that PDGF-BB delivery through the bioactive DP tubes increased the tensile strength of the treated tendons 2-fold without additional pro-fibrotic effects, i.e., cell hyperproliferation or increase in α-smooth muscle actin expression at the wound site. While no major differences in ECM composition at the wound site were observed for ± PDGF-BB treated samples, collagen I and III were upregulated and fibronectin was downregulated compared to native tendons. In areas away from the wound, increased fibronectin expression was observed qualitatively in regions with lower collagen I and III expression. Both types of bioactive DP tubes provided surgeon-friendly and stable implants to deliver bioactive molecules and positively affected the strength of the repaired tendons after 3 weeks, thus presenting promising bioactive implants for clinical applications in the tendon repair field.

We aimed to examine if joint procedures in hands and wrists of patients with scleroderma could be performed without major morbidity and conducted a systematic review of the literature to assess this hypothesis. Studies were identified in four different databases; soft tissue procedures in scleroderma patients were excluded, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Seven studies out of an initial total of 203 articles were included. One-hundred and twelve scleroderma patients with a total of 402 joint procedures in the hand and wrist were identified. A low complication incidence, comparable with that of non-sclerodermic population, in terms of infection, wound healing problems, and nonunion was reported in all studies. The application of joint procedures in scleroderma hands and wrists seems to be associated with low morbidity.

Aim To prospectively investigate digital tomosynthesis (DTS) as an alternative to digital radiography (DR) for postoperative imaging of orthopaedic hardware after trauma or arthrodesis in the hand and wrist. Materials and methods Thirty-six consecutive patients (12 female, median age 36 years, range 19–86 years) were included in this institutional review board approved clinical trial. Imaging was performed with DTS in dorso-palmar projection and DR was performed in dorso-palmar, lateral, and oblique views. Images were evaluated by two independent radiologists for qualitative and diagnosis-related imaging parameters using a four-point Likert scale (1=excellent, 4 not diagnostic) and nominal scale. Interobserver agreement between the two readers was assessed with Cohen's kappa (k). Differences between DTS and CR were tested with Wilcoxon's signed-rank test. A p-value Results Regarding image quality, interobserver agreement was higher for DTS compared to DR, especially for fracture-related parameters (delineation osteosynthesis material [OSM]: KDTS 0.96 versus KDR 0.45; delineation fracture margins: KDTS 0.78 versus KDR 0.35). Delineation of fracture margins and delineation of adjacent joint spaces scored significant better for DTS compared to DR (delineation fracture margins: DTS 1.54, DR 2.28, p 0.001; delineation adjacent joint spaces: DTS 1.31, DR 2.24, p 0.001). Regarding diagnosis-related findings, interobserver agreement was almost equal. DTS showed a significant higher sharpness of fracture margins (DTS 1.94, DR 2.33, p 0.04). Mean dose area product (DAP) for DTS was significant higher compared to DR (mean DR 0.219 Gy·cm2, mean DTS 0.903 Gy·cm2, p 0.001). Conclusion Fracture healing is more visible and interobserver agreement is higher for DTS compared to DR in the postoperative assessment of orthopaedic hardware in the hand and wrist.

Metacarpal fractures constitute 7.8% of the upper extremity fractures. The common treatments remain nonsurgical procedure, but high-demanding patients or unstable fractures require fixation with Kirschner wire (K-wires), plate, and screws. However, these approaches may cause scarring and adhesion with poor functional results. From 2014 to 2015, the authors used an intramedullary headless screw to treat 25 patients (24 men, 1 woman) with metacarpal bones fractures (20 V, 3 IV, 1 III, and 1 II). The fractures patterns were 23 fractures of distal third of metacarpal bone (16 oblique, 5 comminute configurations, and 2 transverse), 1 fracture of the base of the II metacarpal bone. One case presented a multiple metacarpal and phalangeal facture associated. The authors used wide-awake anesthesia (bupivacaine-epinephrine 1:100,000) and intramedullary titanium headless screw fixation percutaneously inserted (CCS Medartis and HCS Synthes 3 mm of diameter). No open reduction was needed. Early active mobilization started with a buddy strapping soon after surgery (0–3 days). The authors followed all patients until satisfactory function was achieved (4–6 weeks) and recorded the time till return to work. All fracture healed with less than 5 degrees of rotational or axial deformities. All patients return to work within 2.38 weeks after surgery (0.5–6 weeks). No cases of complex regional pain syndrome (CRPS), tendon lesions, nerve injuries, infection, hardware protruding, or mobilization were reported. Intramedullary screw fixation with wide-awake anesthesia for transverse, oblique, and select comminuted fractures treatment metacarpal fractures represent a reliable option to early active mobilization recovery and a quick return to the work and ordinary activities.

Digital replantation is a well-established and increasingly common procedure in specialized hand surgery units worldwide. Replantation after complex trauma is often challenging due to severely injured, small-diameter vessels, especially at the distal level. Digit salvage by arteriovenous anastomosis has been inadequately described in the literature for such cases. The objective of this study was to evaluate the outcomes and complications of arteriovenous digital replantation in complex amputations. We reviewed five cases of digital replantation using a single palmar afferent arteriovenous anastomosis and drainage via a dorsal vein. The postoperative protocol followed our standard replantation protocol. All digits survived with no revision procedures. No major complications were observed. One digit developed partial epidermolysis and one thumb developed marginal skin necrosis, both treated conservatively. The color of the replanted digits was not a reliable monitoring parameter but capillary refill was consistently visible. Microangiography performed four months after surgery demonstrated good digit perfusion. Our results support palmar arteriovenous anastomosis as a reliable alternative in digital replantation if distal arteries are unavailable for anastomosis. The results also suggest that this digit salvage procedure can be carried out at a more proximal level than previously reported.

Purpose Although the literature is encouraging with regard to the survival rate of arterialized free venous flaps, previously reported difficulty in healing owing to early venous congestion and subsequent epidermolysis continues to prevent their widespread application. We report 14 arterialized free venous flaps for primary reconstruction of the hand, with inflow in the arterialized vein running against the valves. Methods Between February 2010 and May 2012, we performed 14 arterialized free venous flaps, each of which included at least 2 veins running in parallel. The arterialized vein was anastomosed in a retrograde manner, with the inflow running against the valves. All flaps were customized with regard to dimension, shape, quality of skin, pedicle length, vessel size, inclusion of additional anatomical structures, and donor site. The flaps were used to cover small, medium, and large defects; 2 flaps were larger than 100 cm 2 . Three flaps were injected with indocyanine green on the table after harvesting, to visualize the vascular tree of the flap. These 3 flaps were then monitored with systemic indocyanine green injection and an infrared camera for 3 days postoperatively. Results All but 1 flap survived. Venous congestion and epidermolysis were observed in 2 small flaps. The flaps injected with indocyanine green displayed a ramified vascular tree with no arteriovenous flow-through phenomenon. Conclusions Arterialized free venous flaps with retrograde arterial flow offer thin and pliable coverage that fits easily around the contours of the hand. They are easy to harvest, with little donor site morbidity. Tendons or nerves can be incorporated for reconstruction of composite defects. Clinical relevance Our series suggests the possibility of routine use of a free venous flap with retrograde arterial flow for reconstruction of the hand. Type of study/level of evidence Therapeutic IV.

Skin coverage in hand reconstruction is a challenging and vast chapter in hand surgery; covering every aspect of it in a report is simply not feasible. Therefore, this report focuses on a few specific topics. The coverage of anatomical regions like the fingertips is common ground for hand surgeons worldwide, but in the last 10 years, various refinements have been published in order to optimize the reconstruction of this organ. Nevertheless, in many emergency departments, the amputation of badly injured fingertips, including the thumb, remains the preferred treatment. The main focus of this report is to counter this tendency by providing alternatives to surgeons. Large defects in the fingers involving more than one segment, defects in the palm and in the dorsum of the hand are currently debated in international meetings. The use of skin substitutes vs. the use of extremely refined microsurgical procedures vs. classic island flaps has generated animated discussions, which are also influenced by cultural and socioeconomic factors around the world. This report offers the views of six surgeons from four different countries, in the hope of animating discussions and suggesting new approaches.

A severely painful, dysfunctional, or destroyed distal radio-ulnar joint (DRUJ) can be reconstructed by fusion, interposition of soft tissue, or by arthroplasty using prostheses. The objective of this study was to review the literature on implants and evaluate their effectiveness in terms of pain relief, range of motion and longevity. A search was carried out using protocols and well-defined criteria in PubMed, the Cochrane Library and by screening reference lists. The review was conducted according to PRISMA guidelines. Of the 27 publications reporting on nine different implants, we excluded reports with less than five cases and silastic replacements of the ulna head. Eighteen publications describing a total of five implants were selected for analysis. Nine of the publications were useful for the evaluation of implant longevity. Despite methodological shortcomings in many of the source documents, a summary estimate was possible. It seems that DRUJ implants have good potential to improve function through pain reduction; an improvement was observed in 17 series, although it was significant in only seven series. Instability is not uncommon with ulna head-only implants, but they cause fewer clinical problems and re-interventions than might be expected. The risk of deep infection is small with the available implants. Overall implant survival in papers with at least five years’ follow-up is 95%, with a slightly better longevity of 98% for the constrained implants. Periprosthetic osteolysis/radiolucency is frequently reported. Its causes and consequences are not clarified.Cite this article: Calcagni M, Giesen T. Distal radioulnar joint arthroplasty with implants: a systematic review. EFORT Open Rev 2016;1:191-196. DOI: 10.1302/2058-5241.1.160008.

Range of motion and stability are important outcome parameters to assess function of the distal radioulnar joint (DRUJ), in particular pronation, supination, and weight-lifting capacity. The DRUJ semiconstrained implant developed by Scheker et al is intended to reproduce all the functions of the triangular fibrocartilage complex and the DRUJ. The aim of the study was to investigate the subjective, clinical, and radiographic results in 10 patients after primary implantation of the semiconstrained DRUJ arthroplasty following DRUJ derangement and painful instability, with an average follow-up of 3 years with a special focus on the complications. Standardized preoperative and postoperative evaluation included assessment of pain by a visual analog scale, radiographic examination, range of motion measurements, lifting capacity, and grip strength. The patient-perceived function was investigated using clinical score charts. Compared with the preoperative status, range of motion showed little change, while grip strength, lifting capacity, pain score, and patient-perceived functions improved significantly. One patient developed an ulna stem loosening, while two patients had to be reoperated because of an irritation of the extensor tendons and the superficial radial nerve at the first dorsal compartment of the wrist. In this study, arthroplasty of the DRUJ using the semiconstrained DRUJ arthroplasty was found to result in satisfactory outcome. Level of evidence: Level IV

After tendon rupture repair, two main problems may occur: re-rupture and adhesion formation. Suitable non-murine animal models are needed to study the healing tendon in terms of biomechanical properties and extent of adhesion formation. In this study 24 New Zealand White rabbits received a full transection of the Achilles tendon 2 cm above the calcaneus, sutured with a 4-strand Becker suture. Post-surgical analysis was performed at 3, 6 and 12 weeks. In the 6-week group, animals received a cast either in a 180 deg stretched position during 6 weeks (adhesion provoking immobilization), or were re-casted with a 150 deg position after 3 weeks (adhesion inhibiting immobilization), while in the other groups (3 and 12 weeks) a 180 deg position cast was applied for 3 weeks. Adhesion extent was analyzed by histology and ultrasound. Histopathological scoring was performed according to a method by Stoll et al. (2011), and the main biomechanical properties were assessed. Histopathological scores increased as a function of time, but did not reach values of healthy tendons after 12 weeks (only around 15 out of 20 points). Adhesion provoking immobilization led to an adhesion extent of 82.7±9.7%, while adhesion inhibiting immobilization led to 31.9±9.8% after 6 weeks. Biomechanical properties increased over time, however, they did not reach full strength nor elastic modulus at 12 weeks post-operation. Furthermore, the rabbit Achilles tendon model can be modulated in terms of adhesion formation to the surrounding tissue. It clearly shows the different healing stages in terms of histopathology and offers a suitable model regarding biomechanics because it exhibits similar biomechanics as the human flexor tendons of the hand., Biology Open, 5 (9), ISSN:2046-6390

Tendon rupture repair is a surgical field where improvements are still required due to problems such as repeat ruptures, adhesion formation and joint stiffness. In the current study, a reversibly expandable and contractible electrospun tube based on a biocompatible and biodegradable polymer was implanted around a transected and conventionally sutured rabbit Achilles tendon. The material used was DegraPol® (DP), a polyester urethane. To make DP softer, more elastic and surgeon-friendly, the synthesis protocol was slightly modified. Material properties of conventional and new DP film electrospun meshes are presented. At 12 weeks post-surgery, tenocyte and tenoblast density, nuclei and width, collagen fibre structure and inflammation levels were analyzed histomorphometrically. Additionally, a comprehensive histological scoring system by Stoll et al. (2011) was used to compare healing outcomes. Results showed that there were no adverse reactions of the tendon tissue following the implant. No differences were found whether the DP tube was applied or not for both traditional and new DP materials. As a result, the new DP material was shown to be an excellent carrier for delivery of growth factors, stem cells and other agents responsible for tendon healing.

Purpose For nonsurgical treatment of fractures of the proximal phalanges of the triphalangeal fingers, different dynamic casts have been described. The main principle behind these casts is advancement and tightening of the extensor hood, caused by a combination of blocking the metacarpophalangeal joints in flexion and actively flexing the proximal interphalangeal joints. In contrast to established treatment protocols using functional forearm casts, the Lucerne cast allows for free mobilization of the wrist joint. The purpose of the current multicenter study was to compare the results of conservative, functional treatment using 2 different methods, either a forearm cast or a Lucerne cast. Methods Over a 2-year-period, a prospective, randomized, multicenter study was conducted at 4 hospitals in Switzerland. Clinical and radiological results of 66 consecutive patients having 75 extra-articular fractures of the proximal phalanges were recorded through a minimum follow-up of 3 months. Intra-articular and physeal fractures, pathological fractures, open fractures, concomitant injuries of the tendons or collateral ligaments, and accidents more than 7 days before presentation were excluded from the study. Results Radiographically, there were no statistically significant differences between the 2 groups in terms of palmar apex angulation and radial or ulnar angulation. There were no differences in total active range of finger motion. Wrist joint motion at the time of cast removal was statistically superior in patients treated with Lucerne cast. However, there were no significant differences in wrist joint motion at 12 weeks of follow-up. Conclusions The clinical and radiological results achieved with the Lucerne cast are comparable to those of established treatment. Well-reduced, minimally angulated, or nonangulated fractures of the proximal phalanges of the fingers can be effectively treated using functional casts without immobilizing the wrist. Type of study/level of evidence Therapeutic II.

In tendon rupture repair, improvements such as higher primary repair strength, anti-adhesion and accelerated healing are needed. We developed a potential carrier system of an electrospun DegraPol® tube, which was tightly implanted around a transected and conventionally sutured rabbit Achilles tendon. Histomorphometric analysis of the tendon tissue 12 weeks postoperation showed that the tenocyte density, tenocyte morphology and number of inflammation zones were statistically equivalent, whether or not DegraPol tube was implanted; only the collagen fibres were slightly less parallelly orientated in the tube-treated case. Comparison of rabbits that were operated on both hind legs with ones that were operated on only one hind leg showed that there were significantly more inflammation zones in the two-leg cases compared to the one-leg cases, while the implantation of a DegraPol tube had no such adverse effects. These findings are a prerequisite for using DegraPol tube as a carrier system for growth factors, cytokines or stem cells in order to accelerate the healing process of tendon tissue. Copyright © 2012 John Wiley & Sons, Ltd.

Hand reconstructive surgery in systemic sclerosis has long time been considered a taboo due to the frequent global stiffness and menaced wound healing associated with digital ischemia and skin tightness. We assumed that joint procedures to sclerodermic hands or wrists have not a higher rate of infection, wound healing problem or non-union in comparison to non-sclerodermic population. We systematically reviewed the literature assessing these complications after performing joint reconstruction in hands and wrists of sclerodermic patients. Studies were identified through systematic review of the available literature in the Pubmed Medline, Cochrane Central Register of Controlled Trials, Embase, Web of Science database up to May 3rd, 2017. Database was searched using a set of search terms, which described systemic sclerosis, bone and joint surgery, and hand or wrist surgery. Only studies including joint procedures in hands or wrists of sclerodermic patients that were related to the functional outcomes and morbidity after surgery were selected. Reviews were excluded. Studies relevant to soft tissue reconstruction in sclerodermic hands or wrists, such as digital sympathectomy, autologous adipose-derived stromal vascular fraction, vascular reconstruction or management of finger ulcers were also excluded. Results A total of 265 unique articles were identified in PubMed. Thirty-eight titles selected for abstract review. Twenty-nine abstracts did not meet the inclusion criteria or did not evaluate our predefined endpoint and were excluded. Nine articles were fully read and two more articles were considered irrelevant and excluded. Seven studies were deemed eligible for our systematic review. One hundred and sixteen sclerodermic patients were found. A total of 402 joint procedures in sclerodermic hand and wrist were exported. The operations concerned metacarpophalangeal and interphalangeal arthroplasty, joint replacement or fusion, Kapandji procedures, osteotomy of the finger and removal of the hardware. A low complications rate in terms of infection or digital ischemia after surgery was mentioned to all studies. In most of the cases, wound healing was uneventful and only in some cases, it was described slow. In cases of joint fusion, bone healing was successfully achieved. The functional outcome was reliable in all the cases. The wrist and hand joint procedures in systemic sclerosis were found to be reliable and related to low morbidity in terms of infection rate, wound healing and bone union. Results from future studies will unquestionably contribute to further establishment of knowledge about the therapeutic outcome after surgery in these suboptimal conditions of the sclerodermic hand.

Background Assessing nerve traumas in children is challenging. Electrodiagnostic studies are often not tolerated. We tested if ultrasound examination in children with recent supracondylar humerus fracture and ulnar nerve pathology was well tolerated and whether it was helpful in assessing the nerve trauma. Methods This is a retrospective analysis of all pediatric cases with recent supracondylar humerus fracture and persistent ulnar deficits presenting to our neurology outpatients clinic from October 2016 to September 2017. All patients underwent clinical neurological examination. Additional examinations in the form of EMG and nerve ultrasound using a 18 MHz hockey stick probe were proposed as additional investigations. Results Patients were aged 3–10 years (mean age 6.3 years), 4 male and 2 female. All experienced severe extension type supracondylar humerus fractures (Type III and Type IV), treated with closed (3 patients) or open reduction (3 patients) and fixed with crossed pinning (2–4 pins). Ulnar nerve deficits in intrinsic hand muscles ranged from M0 to M3. 3 patients showed complete loss of ulnar sensory motor function. 3 were able to tolerate EMG. All 6 patients tolerated and were able to complete ultrasound examination. In 1 patient with complete loss of function, discontinuity of the nerve with formation of stump neuromas was detected in ultrasound. In the other 5 cases, nerve continuity could be demonstrated, but significant nerve swelling (sulcus to upper arm ratios 1.4–2.7; mean 1.97) was apparent in all. In the 2 most severe cases of nerve swelling, additional nerve compromise with scar tissue was detected. Ultrasound findings led to surgical intervention in 2 cases (in one additional EMG data was available): 1) nerve repair by a sural nerve graft for the case of neuronotmesis and 2) neurolysis followed by anterior displacement in one case with severe nerve swelling and compromising scar tissue. Conclusions Nerve ultrasound is well tolerated in children and proved to be useful and informative for management and counselling. Useful ultrasound indicators of neuronal damage included loss of nerve continuity, neuroma formation, compromising scar tissue and nerve swelling.

OBJECTIVE: To assess the nature and rates of complications and recurrences after completion lymph node dissection (CLND) following positive sentinel lymph node biopsy (SLNB) in melanoma patients. SUMMARY BACKGROUND DATA: In contrast to SLNB, CLND is associated with considerable morbidity. CLND delays nodal recurrence, thereby prolonging disease-free survival (DFS), but not overall melanoma-specific survival. Elaborate studies on morbidity and recurrence rates after CLND are scarce. Therefore, many controversies concerning extent and nature of CLND exist. METHODS: We conducted a retrospective study on 100 melanoma patients, on whom we performed CLND between October 1999 and December 2005. The median observation period was 38.8 months. RESULTS: We performed a total of 102 CLNDs, [46.1% axillary (47/102), 42.2% groin (43/102), 11.8% neck (12/102)]. Groin dissection (GD) and axillary dissection (AD) led to comparable morbidity (47.6% and 46.8%), but complications were more severe in GD, mandating additional surgery in 25.6% (11/43), versus 8.5% (4/47) in AD. Of the GD patients, 18.5% (8/43) were readmitted for complications compared with 10.4% (5/47) of AD patients. Only 8.3% (1/12) of ND patients suffered complications, mandating neither readmittance nor further surgery. During the median observation period, 65 (65%) of these patients showed DFS, and 35 (35%) exhibited recurrences after a median DFS of 12.5 months. Of the recurrences, 31.4% were nodal, 42.9% distant, and 25.7% local/in-transit. Of our AD patients, 28.3% suffered recurrences (13/46), as did 33.3% of the GD (14/42) and 66.7% of the ND patients (8/12). CONCLUSIONS: CLND is fraught with considerable morbidity. Local control of the dissected nodal basins was achieved with a modified radical approach in ADs (levels I + II only) and, to a lesser extent, GDs, but not in NDs. Clinical trials are necessary to establish guidelines on the extent of lymphatic dissection.

Healing of tendon ruptures represents a major challenge in musculoskeletal injuries and combinations of biomaterials with biological factors are suggested as viable option for improved healing. The standard approach of repair by conventional suture leads to incomplete healing or rerupture. Here, a new elastic type of DegraPol® (DP), a polyester urethane, is explored as a delivery device for platelet-derived growth factor-BB (PDGF-BB) to promote tendon healing. Using emulsion electrospinning as an easy method for incorporation of biomolecules within polymers, DegraPol® supports loading and release of PDGF-BB. Morphological, mechanical and delivery device properties of the bioactive DP scaffolds, as well as differences arising due to different electrospinning parameters are studied. Emulsion electrospun DP scaffolds result in thinner fibers than pure DP scaffolds and experience decreased strain at break [%], but high enough for successful surgeon handling. PDGF-BB is released in a sustained manner from emulsion electrospun DP, but not completely, with still large amount of it being inside the polymeric fibers after 30 d. In vitro studies show that the bioactive scaffolds promote tenocyte proliferation in serum free and serum(+) conditions, demonstrating the potential of this surgeon-friendly bioactive delivery device to be used for tendon repair.

One of the great challenges in surgical tendon rupture repair is to minimize peritendinous adhesions. In order to reduce adhesion formation, a physical barrier was applied to a sutured rabbit Achilles tendon, with two different immobilization protocols used postoperatively. Methods. Thirty New Zealand white rabbits received a laceration on the Achilles tendon, sutured with a 4-strand Becker suture, and half of the rabbits got a DegraPol tube at the repair site. While fifteen rabbits had their treated hind leg in a 180° stretched position during 6 weeks (adhesion provoking immobilization), the other fifteen rabbits were recasted with a 150° position after 3 weeks (adhesion inhibiting immobilization). Adhesion extent was analysed macroscopically, via ultrasound and histology. Inflammation was determined histologically. Biomechanical properties were analysed. Results. Application of a DegraPol tube reduced adhesion formation by approximately 20%—independently of the immobilization protocol. Biomechanical properties of extracted specimen were not affected by the tube application. There was no serious inflammatory reaction towards the implant material. Conclusions. Implantation of a DegraPol tube tightly set around a sutured tendon acts as a beneficial physical barrier and prevents adhesion formation significantly—without affecting the tendon healing process., BioMed Research International, 2014, ISSN:2314-6133, ISSN:2314-6141

The aim of this study was to compare image quality and extent of artifacts from scaphoid fracture fixation screws using different computed tomography (CT) modalities and radiation dose protocols.Imaging of 6 cadaveric wrists with artificial scaphoid fractures and different fixation screws was performed in 2 screw positions (45° and 90° orientation in relation to the x/y-axis) using multidetector CT (MDCT) and 2 flat-panel CT modalities, C-arm flat-panel CT (FPCT) and cone-beam CT (CBCT), the latter 2 with low and standard radiation dose protocols. Mean cartilage attenuation and metal artifact-induced absolute Hounsfield unit changes (= artifact extent) were measured. Two independent radiologists evaluated different image quality criteria using a 5-point Likert-scale. Interreader agreements (Cohen κ) were calculated. Mean absolute Hounsfield unit changes and quality ratings were compared using Friedman and Wilcoxon signed-rank tests.Artifact extent was significantly smaller for MDCT and standard-dose FPCT compared with CBCT low- and standard-dose acquisitions (all P0.05). No significant differences in artifact extent among different screw types and scanning positions were noted (P0.05). Both MDCT and FPCT standard-dose protocols showed equal ratings for screw bone interface, fracture line, and trabecular bone evaluation (P = 0.06, 0.2, and 0.2, respectively) and performed significantly better than FPCT low- and CBCT low- and standard-dose acquisitions (all P0.05). Good interreader agreement was found for image quality comparisons (Cohen κ = 0.76-0.78).Both MDCT and FPCT standard-dose acquisition showed comparatively less metal-induced artifacts and better overall image quality compared with FPCT low-dose and both CBCT acquisitions. Flat-panel CT may provide sufficient image quality to serve as a versatile CT alternative for postoperative imaging of internally fixated wrist fractures.

Purpose To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved

Plastic interactions between face and hand cortical tactile circuits occur after severe injuries that affect the hand such as in amputation or spinal cord injury. However, whether loss of facial movements alters the cortical circuits involved in processing tactile inputs from the hand remains unknown. In this prospective observational study we used electroencephalography (EEG) to measure cortical activity evoked by tactile stimulation of the hands before and after botulinum toxin-A-induced facial paralysis. We found a reduction in the tactile event-related potentials (ERPs) 6 weeks after the treatment. This suggests that the limited paralysis of facial muscles induced during cosmetic interventions designed to smooth lines and wrinkles on the face is sufficient to alter the cortical processing of tactile inputs from the hand., Annals of Clinical and Translational Neurology, 1 (1), ISSN:2328-9503

In this study, skin-infiltrating cells were characterized in both the active and remission phases of post-burn hypertrophic scar biopsies. Immunohistochemistry examination of active phase samples showed an abundant presence of Langerhans cells, T cells, macrophages, a low presence of natural killer cells and the lack of B lymphocytes. In active hypertrophic scars T lymphocytes infiltrate deep into the superficial dermis and are also observed in the epidermis: CD3+ cells were present at about 222 +/- 107 per 0.25 mm2. In particular the analysis of lymphocyte subpopulations showed that CD4+ T cells predominate in the dermis as well as in the epidermis of active hypertrophic scars whereas CD8+ cells were less well represented (CD4/CD8 ratio is 2.06). This distribution was also shown in remission phase samples and in normotrophic scar specimens, although the lymphocyte number was significantly lower. Approximately 70 per cent of T lymphocytes present in the tissue involved in active phase hypertrophic scar samples were activated (positive with anti-HLA-DR and IL-2 receptor antibodies) which is significantly higher than remission phase hypertrophic and normotrophic scars, in which positivity was 40 and 38 per cent, respectively. Upon activation, the lesional lymphocytes release several cytokines, locally and transiently, that interact with specific receptors in response to different stimulation. Central to the immune hypothesis of hypertrophic scars is that some of the T-cell lymphokines act on keratinocytes, fibroblasts and other cell types to induce changes characteristic of these scars. The presence and close proximity of activated T lymphocytes and antigen-presenting cells of various phenotypes in both the epidermis and dermis of hypertrophic tissues provides strong circumstantial evidence of a local immune response. However, the manner in which T cells achieve and maintain their activated state in hypertrophic tissues is not yet known, and both antigen-dependent and independent mechanisms may contribute.