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Objective: People in the Netherlands are legally allowed to celebrate New Year's Eve with consumer fireworks. The aim of this study was to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from this tradition., Methods: A multicenter, prospective, observational case series performed in the Southwest Netherlands trauma region, which reflects 15% of the country and includes a level I trauma center, a specialized burn center, a specialized eye hospital, and 13 general hospitals. All patients with any injury caused by consumer fireworks, treated at a Dutch hospital between December 1, 2017 and January 31, 2018, were eligible for inclusion. Exclusion criteria were unknown contact information or insufficient understanding of Dutch or English language. The primary outcome measure was injury characteristics. Secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma., Results: 54 out of 63 eligible patients agreed to participate in this study. The majority were males (N = 50; 93%), 50% were children below 16 years of age, and 46% were bystanders. Injuries were mainly located to the upper extremity or eyes, and were mostly burns (N = 38; 48%) of partial thickness (N = 32; 84%). Fifteen (28%) patients were admitted and 11 (20%) patients needed surgical treatment. The mean total costs per patient were €6,320 (95% CI €3,400 to €9,245). The most important cost category was hospital admission. Only few patients reported complaints in patient-reported quality of life and functional outcome after 12 months follow-up., Conclusion: This study found that young males are most vulnerable for fireworks injuries and that most injuries consist of burns, located to the arm and hand, and eye injuries. On the long-term only few patients experienced reduced quality of life and functional limitations., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Carpal tunnel release (CTR) is typically offered to symptomatic patients with electrophysiological abnormalities when night orthoses no longer prevent waking with numbness and preferably before there is any static numbness, weakness, or atrophy. The ability to predict the amount of symptom relief after CTR could be beneficial for managing patient expectations and, therefore, improve treatment satisfaction. Therefore, the aim of this study was to identify predictors for symptom relief after CTR and to determine their contribution to symptom relief at 6 months after surgery., Methods: A total of 1,049 patients who underwent CTR between 2011 and 2015 at 1 of 11 Xpert Clinics in the Netherlands were asked to complete online questionnaires at intake and 3 and 6 months after surgery. Patient demographics, comorbidities, and baseline scores were considered potential predictors for the amount of symptom relief on the Boston Carpal Tunnel Questionnaire (BCTQ) score, which was the primary outcome measure., Results: A low score on the BCTQ at intake, a codiagnosis of a trigger finger, ulnar nerve neuropathy, trapeziometacarpal joint arthrosis, and instability or arthrosis of the wrist were associated with a smaller improvement in the BCTQ domains after a CTR at 6 months after surgery and accounted for 35% to 42% of the variance on the BCTQ domains in our multivariable regression models., Conclusions: In this study, we showed that clinical severity of carpal tunnel syndrome at intake is the most important factor in estimating symptom relief after surgical treatment. Furthermore, this study contributes to a more precise understanding of the capabilities of CTR in relieving symptoms for different subgroups of patients. Results of our study can be used to manage patient expectation on symptom relief from CTR., Type of Study/level of Evidence: Prognostic II., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: To report the number of patients with firework-related injuries treated in December 2017 and January 2018 in a hospital in the south-west Netherlands trauma region, and to provide details about the types of firework used and the specific injuries., Design: A prospective multicentre cohort study (NTR6793)., Methods: Patients of all ages with firework-related injuries were eligible for inclusion. The injury had to have been sustained between 1 December 2017 and 31 January 2018, and treated at a hospital in the south-west Netherlands trauma region (approximately 2.5 million inhabitants). Data were extracted from patients' medical files and additional information was obtained from patient interviews., Results: Fifty-four patients were included. The majority were male (93%) and the median age was 15 years. Twenty-five (46%) patients were bystanders and 12 (22%) were injured by illegal fireworks. Fifty patients were injured by bangers (n=22) or decorative fireworks (n=28). The patients had a total of 79 injuries, of which 29 (37%) were localised to the upper extremity and 19 (24%) to the eyes. Most upper extremity injuries were burns (69%), primarily partial thickness. Of the eye injuries, 14 were caused by blunt trauma, seven by chemical trauma, and one by penetrating trauma. Three patients sustained indirect firework-related injuries., Conclusion: Between 1 December 2017 and 31 January 2018 in the south-west Netherlands trauma region mainly teenage males and bystanders sustained firework-related injuries. Most injuries were upper extremity burns and eye injuries, mainly due to legal fireworks and bangers or decorative fireworks. The extent of the sample indicates that the study findings can be extrapolated to the rest of the Netherlands.

Background: Although previous studies have shown that more experienced surgeons have better patient outcomes following a variety of procedures, in hand surgery and carpal tunnel release in particular, this relation remains unproven. The authors assessed whether there is an association between surgeon volume and patient outcomes following open carpal tunnel release., Methods: Patients who underwent carpal tunnel release between 2011 and 2015 at outpatient hand surgery clinics in The Netherlands were included. Surgeon annual volume was defined as the average number of carpal tunnel releases performed per year per participating surgeon over the study period. Primary outcome measures were the Symptom Severity Scale and Functional Status Scale of the Boston Carpal Tunnel Questionnaire 6 months postoperatively. Multilevel random intercept linear regression analyses were performed to assess whether there was an association between surgeon annual volume and outcome measures, with adjustment for patient characteristics, concomitant procedures, and intake score on the Boston Carpal Tunnel Questionnaire., Results: A total of 1345 patients were included, operated on by 17 surgeons. Median annual surgeon volume was 75 (interquartile range, 50 to 149). Only 0.5 to 0.6 percent of the total variance in patient outcome on the Boston Carpal Tunnel Questionnaire could be explained by random differences between surgeons. The authors did not find an association between annual surgeon volume and outcome measures 6 months postoperatively (Symptom Severity Scale: β = 0.000; 95 percent CI, -0.001 to 0.001; and Functional Status Scale: β = 0.000; 95 percent CI, -0.001 to 0.001)., Conclusion: In the authors' sample of highly specialized hand surgeons operating in high-volume centers, they found no differences in outcome between high- and low-volume surgeons.

Background: This study examined patient satisfaction with hand function after fasciectomy for Dupuytren's contracture and determined which preoperative patient- and disease-specific factors predicted this satisfaction., Methods: Demographics and disease-specific factors were assessed from a prospective cohort of 194 patients who completed the Michigan Hand Outcomes Questionnaire preoperatively and underwent limited fasciectomy between 2011 and 2014 at six hand surgery practice sites. To evaluate satisfaction with hand function, patients were asked to complete the Michigan Hand Outcomes Questionnaire during the first year after fasciectomy. After patients were classified into a satisfied and an unsatisfied category using the question that specifically pertains to satisfaction with hand function, the authors applied multivariate logistic regression modeling to identify independent predictors of patient satisfaction., Results: At an average of 10 months (range, 6 to 12 months) after fasciectomy, 84 percent (n = 163) of the patients were satisfied with their hand function. In multivariate analyses adjusting for the degree of postoperative residual contracture (p < 0.001) and complications (p < 0.001), a higher preoperative Michigan Hand Outcomes Questionnaire hand appearance subscore and male gender predicted a higher likelihood of becoming satisfied after fasciectomy. Other patient- and disease-specific factors did not show evidence for an association with patient satisfaction., Conclusions: The findings of this study suggest that providers should consider assessing concerns about the appearance of the hand in patients with Dupuytren's contracture. They also highlight the importance of complication prevention and full contracture correction from the patient's perspective., Clinical Question/level of Evidence: Risk, III.

Background: Surgical resection of Dupuytren contracture is fraught with morbidity and prolonged recovery. This article introduces a novel minimally invasive alternative for Dupuytren disease and its outcome., Methods: The procedure consists of an extensive percutaneous aponeurotomy that completely disintegrates the cord and separates it from the dermis. Subsequently, the resultant loosened structure is grafted with autologous lipoaspirate. After 1 week of postoperative extension splinting, patients are allowed normal hand use and are advised to use night splints for 3 to 6 months. The authors treated and report on their experience with 91 patients (99 hands) operated on in Miami and Rotterdam; from 50 patients, the authors report on goniometry (average follow-up, 44 weeks)., Results: The contracture from the proximal interphalangeal joint improved significantly from 61 degrees to 27 degrees, and contracture from the metacarpophalangeal joint improved from 37 degrees to -5 degrees. Ninety-four percent of patients returned to normal use of the hand within 2 to 4 weeks and 95 percent were very satisfied with the result. No new scars were added, and a supple palmar fat pad was mostly restored. Complications were digital nerve injury in one patient, postoperative wound infection in one patient, and complex regional pain syndrome in four patients., Conclusions: This new minimally invasive technique shortens recovery time, adds to the deficient subcutaneous fat, and leads to scarless supple skin. By its ability to treat multiple rays, it addresses the abnormality in the entire hand. The procedure is safe and effective, especially for primary cases. Currently, comparative prospective randomized studies are in process to fully determine its role in the treatment of Dupuytren contracture., Clinical Question/level of Evidence: Therapeutic, IV.(Figure is included in full-text article.).

Object: Extradural and intraneural scar formation after peripheral nerve injury frequently causes tethering and compression of the nerve as well as inhibition of axonal regeneration. Regenerating agents (RGTAs) mimic stabilizing and protective properties of sulphated glycosaminoglycan toward heparin-binding growth factors. The aim of this study was to assess the effect of an RGTA known as OTR4120 on extraneural fibrosis and axonal regeneration after crush injury in a rat sciatic nerve model., Methods: Thirty-two female Wistar rats underwent a standardized crush injury of the sciatic nerve. The animals were randomly allocated to RGTA treatment or sham treatment in a blinded design. To score neural adhesions, the force required to break the adhesions between the nerve and its surrounding tissue was measured 6 weeks after nerve crush injury. To assess axonal regeneration, magnetoneurographic measurements were performed after 5 weeks. Static footprint analysis was performed preoperatively and at Days 1, 7, 14, 17, 21, 24, 28, 35, and 42 postoperatively., Results: The magnetoneurographic data show no significant difference in conduction capacity between the RGTA and the control group. In addition, results of the static footprint analysis demonstrate no improved or accelerated recovery pattern. However, the mean pullout force of the RGTA group (67 +/- 9 g [mean +/- standard error of the mean]) was significantly (p < 0.001) lower than that of the control group (207 +/- 14 g [mean +/- standard error of the mean])., Conclusions: The RGTAs strongly reduce nerve adherence to surrounding tissue after nerve crush injury.

Experimental assessment of peripheral nerve regeneration in rats by electrophysiology is controversial due to low reproducibility of electrophysiological indicators and diminished quantitative evaluation in conventional experimental set-ups. Magnetoneurography (MNG) counteracts these drawbacks by magnetically recording electrophysiological signals ex vivo, thereby providing accurate and quantitative data. In 50 rats, sciatic nerve transection was followed by direct repair. MNG outcome parameters, footprints [static toe spread factor (TSF); function] and muscle weight (MW) were studied for their recovery pattern from 2 to 24 weeks. By using MNG, we showed that the regeneration process still continues when functional recovery (static TSF) becomes stagnant. With regression analysis, MNG parameters amplitude, amplitude area and conduction velocity (CV) demonstrated moderate significant correlation with MW, whereas CV was not significantly associated with static TSF. No significant association exists between MW and static TSF. A Kaplan-Meier survival curve revealed that autotomy/contracture of rat hind paws was not related to decreased MNG outcome values. In conclusion, this study highlights and discusses the dissimilarities between direct (MNG) and indirect (static TSF and MW) assessment techniques of the regeneration process. We emphasise the significance of MNG as a direct derivative of axon regeneration in experimental rat studies. Additionally, we stress the must for right-left ratios, as neurophysiological indicators vary with age, and we confute possible bias in footprint analysis caused by exclusion of autotomy/contracture animals.

Background: The concept of the facial artery perforator flap was developed to gain more freedom for reconstruction of perioral defects. Single perforators of the facial artery should supply a large area of facial skin for a pedicled perforator flap., Methods: Five fresh cadavers yielding 10 facial arteries were dissected after Microfil vascular injection to study distribution, number, length, and diameter of facial artery perforators. Five clinical cases with cancer-related perioral defects were reconstructed with facial artery perforator flaps. In two cases, additional regional flaps were used. Surgical technique was governed by the aesthetic unit principle and Doppler identification of the facial artery, which was used as a guideline for identification of suitable facial artery perforators., Results: Cadaver dissection showed a large number of evenly distributed facial artery perforators (average, 5.7; range, three to nine). The average perforator length was 25.2 mm (range, 13 to 51 mm). The average perforator diameter was 1.2 mm (range, 0.6 to 1.8 mm). In all clinical cases, a suitable facial artery perforator was identified to meet reconstructive demands. Flaps were rotated up to 180 degrees. Four flaps survived completely. One flap showed minor distal necrosis., Conclusions: The facial artery perforator flap offers a versatile tailor-made flap, because of the reliable presence of perforators, with a large arc of rotation and an aesthetically pleasing donor site. The thin pedicle makes it an ideal flap for one-stage reconstruction without secondary revisions.

Object: Adhesion formation is a serious problem in peripheral nerve surgery, frequently causing dysfunction and pain. The authors aimed to develop an objective biomechanical method of quantifying nerve adhesions and to use this technique for the evaluation of the efficacy of an autocrosslinked hyaluronic acid (HA) gel as an antiadhesion therapy., Methods: Thirty-three female Wistar rats underwent dissection, crush injury, or transection plus repair of the sciatic nerve. The nerves were or were not treated with the HA gel. Six weeks after surgery, the adhesions formed were assessed by measuring the peak force required to break the adhesions over a standardized area. Results of biomechanical measurements demonstrated that the peak force significantly increased as the severity of the injury increased. After using the HA gel to treat the nerve, the peak force was significantly reduced in rats with any of the three types of injuries; peak force decreased by 26% in the animals in the dissection group, 29% in the crush injury group, and 38% in the transection and repair group, compared with the untreated animals., Conclusions: The biomechanical method described is an objective, quantitative technique for the assessment of nerve adherence to surrounding tissue. It will be a valuable tool in future studies on antiadhesion therapies. Furthermore, HA gel significantly reduces nerve adhesions after different types of nerve injuries.

Peripheral nerves in the limbs stretch to accommodate changes in length during normal movement. The aim of this study was to determine how stretch is distributed along the nerve relative to local variations in mechanical properties. Deformation (strain) in joint and non-joint regions of rat median and sciatic nerves was measured in situ during limb movement using optical image analysis. In each nerve the strain was significantly greater in the joint rather than the non-joint regions (2-fold in the median nerve, 5- to 10-fold in the sciatic). In addition, this difference in strain was conserved in the median nerve ex vivo, demonstrating an in-built longitudinal heterogeneity of mechanical properties. Tensile testing of isolated samples of joint and non-joint regions of both nerves showed that joint regions were less stiff (more compliant) than their non-joint counterparts with joint: non-joint stiffness ratios of 0.5 +/- 0.07 in the median nerve, and 0.8 +/- 0.02 in the sciatic. However, no structural differences identified at the light microscope level in fascicular/non-fascicular tissue architecture between these two nerve regions could explain the observed tensile heterogeneity. This identification of localized functional heterogeneity in tensile properties is particularly important in understanding normal dynamic nerve physiology, provides clues to why peripheral nerve repair outcomes are variable, and suggests potential novel therapeutic targets.

Walking track analysis is a widely accepted technique for functional evaluation after sciatic nerve repair in rats, but it is labour-intensive. In 2000, Bervar described a time-saving digitised static footprint analysis. In that study there were good correlations between the traditional sciatic function index (SFI) and the newly-developed static sciatic index (SSI) and static toe spread factor (TSF), respectively. Despite promising results, static footprint analysis is still not widely used. The present study was designed to validate it. After transection of the sciatic nerve, end-to-end repair was assessed using video recorded dynamic and static footprints in 45 Wistar rats. We found an even better correlation between the SFI and both the SSI and the static TSF. In conclusion, static footprint analysis is a time-saving and easy technique for accurate functional assessment of peripheral nerve regeneration in rats.

Magnetoneurography (MNG) is a technique to record the biomagnetic action fields of peripheral nerves. The benefits of MNG in contrast to electroneurography include the decreased signal disturbance caused by surrounding biological tissues and the use of a calibration pulse, both of which contribute to high reproducibility. MNG has proven to be a valuable tool to quantitate peripheral nerve regeneration in rabbits. However, the most commonly used model to study the peripheral nervous system is the rat sciatic nerve. Until now, the small size of the nerve impeded accurate MNG measurements in rat. This report describes a custom made recording chamber that allows accurate control of conduction distances and temperature and enables adequate MNG measurements of isolated sciatic nerves of Wistar rats. We applied biphasic stimulation with optimized grounding to reduce the stimulus artefact. A high reproducibility of signals was demonstrated. 'Ex vivo' nerve viability was assured for at least 2 h after dissection. In conclusion, MNG is a powerful tool to quantitatively evaluate the function of rat sciatic nerves and will be used for the early assessment of nerve regeneration.

While an important role for the POU domain transcription factor Oct-6 in the developing peripheral nerve has been well established, studies into its exact role in nerve development and regeneration have been hampered by the high mortality rate of newborn Oct-6 mutant animals. In this study we have generated a Schwann cell-specific Oct-6 allele through deletion of the Schwann cell-specific enhancer element (SCE) in the Oct-6 locus. Analysis of mice homozygous for this allele (deltaSCE allele) reveals that rate-limiting levels of Oct-6 in Schwann cells are dependent on the SCE and that this element does not contribute to Oct-6 regulation in other cell types. We demonstrate a Schwann cell autonomous function for Oct-6 during nerve development as well as in regenerating nerve. Additionally, we show that Krox-20, an important regulatory target of Oct-6 in Schwann cells, is activated, with delayed kinetics, through an Oct-6-independent mechanism in these mice.