The Hand Surgeon Consultation Improves Patient Knowledge in a Hand Surgery Mission to Honduras.

BACKGROUND: The purpose of this study was to assess impact of the surgeon consultation and informed consent process on patient education in an international hand surgery mission compared with a US academic hand surgery practice. These two groups were selected to evaluate communication difficulties in a surgical mission setting compared with standard of care in a high-income country. METHODS: A multi-part survey was administered to patients presenting to a hand surgery mission during March 2012 and new patients of a university hand center in a 3-month period during 2011. Surveys were administered prior to and following surgeon consultation with one fellowship-trained hand surgeon. The survey assessed knowledge of basic hand anatomy, physiology, disease, individual diagnosis, and surgical risks. RESULTS: 71 patients participated in the study (university n=36, mission n=35). Pre-consultation quiz score averaged 58% in the university group versus 27% in the mission group. Post-consultation quiz scores averaged 62% in the university group versus 40% in the mission group. Only the mission group's quiz score increase was statistically significant. 93% of the university group reported learning about their condition and diagnosis, but only 40% demonstrated correct insight into their diagnosis. In the mission group, 73% reported learning about their condition and diagnosis while 53% demonstrated correct insight into their diagnosis. Although all consultations involved discussion of surgical risks, only 62% of the university group and 52% of the mission group recalled discussing surgical risks. CONCLUSIONS: The hand surgeon consultation was more effective in improving hand knowledge in the surgery mission group compared to in a university hand practice. This suggests that the surgeon consultation should be pursued despite communication barriers in surgical missions. However, the discrepancy between patient perception of knowledge gains and correct insight into diagnosis, and the deficit of patient retention of surgical risks need to be improved.

The effects of A1 pulley release after flexor tendon repair in a cadaveric model.

BACKGROUND: Decreasing rupture rates after flexor tendon repair is accomplished by increasing the strength of the repair and by decreasing the forces across tendons during rehabilitation. The authors sought to determine whether A1 pulley release affects work of flexion after a zone 2 flexor tendon repair. METHODS: Four fresh-frozen cadaveric hands were thawed to room temperature. The flexor digitorum profundus and flexor pollicis longus tendons were tested in a tensile testing machine. In hands 1 and 2, work of flexion of uninjured tendons was evaluated through the sequential division of the A1 pulley, starting with either the proximal 50 percent or the distal 50 percent of the pulley. In hands 3 and 4, zone 2 flexor digitorum profundus lacerations were created and repaired using a modified Kessler technique; then, sequential division of the A1 pulley was performed. Force-excursion curves were generated and used to calculate work of flexion. Analysis of variance was performed for multigroup comparisons, and t tests were performed for pairwise comparisons. Values of p < 0.05 were considered statistically significant. RESULTS: In uninjured tendons, work of flexion decreased with sequential division of the A1 pulley. After tendon repair, work of flexion increased significantly from baseline in all digits. A1 pulley release after flexor tendon repair produced significant decreases in work of flexion in all digits. CONCLUSIONS: A1 pulley release effectively decreases work of flexion after flexor tendon repair. Release performed at the time of tendon repair may decrease the forces across tendons in the postoperative period.

Cadaveric allograft for wound closure after resection of squamous cell carcinoma in patients with recessive dystrophic epidermolysis bullosa: a report of 32 resections and repairs in 2 patients.

This is a review of the management of squamous cell carcinoma in 2 adult patients with recessive dystrophic epidermolysis bullosa. The 2 have undergone 32 excisions of squamous cell carcinoma of the skin and soft tissue with subsequent reconstruction. Multiple strategies for wound closure have been described in this population. We highlight the usefulness of full thickness cadaveric allograft alone, to close wounds in situations when primary closure or donor site availability of autograft is limited or suboptimal.

Bridging tendon defects using autologous tenocyte engineered tendon in a hen model.

Tendon defects remain a major concern in plastic surgery because of the limited availability of tendon autografts. Whereas immune rejection prohibits the use of tendon allografts, most prosthetic replacements also fail to achieve a satisfactory long-term result of tendon repair. The tissue engineering technique, however, can generate different tissues using autologous cells and thus may provide an optimal approach to address this concern. The purpose of this study was to test the feasibility of engineering tendon tissues with autologous tenocytes to bridge a tendon defect in either a tendon sheath open model or a partial open model in the hen. In a total of 40 Leghorn hens, flexor tendons were harvested from the left feet and were digested with 0.25% type II collagenase. The isolated tenocytes were expanded in vitro and mixed with unwoven polyglycolic acid fibers to form a cell-scaffold construct in the shape of a tendon. The constructs were wrapped with intestinal submucosa and then cultured in Dulbecco's Modified Eagle Medium plus 10% fetal bovine serum for 1 week before in vivo transplantation. On the feet, a defect of 3 to 4 cm was created at the second flexor digitorum profundus tendon by resecting a tendon fragment. The defects were bridged either with a cell-scaffold construct in the experimental group ( n= 20) or with scaffold material alone in the control group ( n= 20). Specimens were harvested at 8, 12, and 14 weeks postrepair for gross and histologic examination and for biomechanical analysis. In the experimental group, a cordlike tissue bridging the tendon defect was formed at 8 weeks postrepair. At 14 weeks, the engineered tendons resembled the natural tendons grossly in both color and texture. Histologic examination at 8 weeks showed that the neo-tendon contained abundant tenocytes and collagen; most collagen bundles were randomly arranged. The undegraded polyglycolic acid fibers surrounded by inflammatory cells were also observed. At 12 weeks, tenocytes and collagen fibers became longitudinally aligned, with good interface healing to normal tendon. At 14 weeks, the engineered tendons displayed a typical tendon structure hardly distinguishable from that of normal tendons. Biomechanical analysis demonstrated increased breaking strength of the engineered tendons with time, which reached 83 percent of normal tendon strength at 14 weeks. In the control group, polyglycolic acid constructs were mostly degraded at 8 weeks and disappeared at 14 weeks. However, the breaking strength of the scaffold materials accounted for only 9 percent of normal tendon strength. The results of this study indicated that tendon tissue could be engineered in vivo to bridge a tendon defect. The engineered tendons resembled natural tendons not only in gross appearance and histologic structure but also in biomechanical properties.

Repairing large porcine full-thickness defects of articular cartilage using autologous chondrocyte-engineered cartilage.

Large full-thickness defects of articular cartilage remain a major challenge to orthopedic surgeons because of unsatisfactory results of current therapy. Many methods, such as chondrectomy, drilling, cartilage scraping, arthroplasty, transplantation of chondrocytes, periosteum, perichondrium, as well as cartilage and bone, have been tried to repair articular cartilage defects. However, the results are far from satisfactory. In this study, we applied a tissue-engineering approach to the repair of articular cartilage defects of knee joints in a porcine model. Using isolated autologous chondrocytes, polyglycolic acid (PGA), and Pluronic, we have successfully in vivo-engineered hyaline cartilage and repaired articular cartilage defects. The surface of the repaired defects appeared smooth at 24 weeks postrepair. Histological examination demonstrated a typical hyaline cartilage structure with ideal interface healing between the engineered cartilage and the adjacent normal cartilage and underlying cancellous bone. In addition, glycosaminoglycan (GAG) levels in the engineered cartilage reached 80% of that found in native cartilage at 24 weeks postrepair. Biomechanical analysis at 24 weeks demonstrated that the biomechanical properties of the tissue-engineered cartilage were improved compared with those at an earlier stage. Thus, the results of this study may provide insight into the clinical repair of articular cartilage defects.