Antineuropathic Pain Management After Orthopedic Surgery: A Systematic Review.

Background: The opioid crisis has become a present concern in the medical field. In an effort to address these complications, antineuropathic pain medications have been considered as alternatives to prescribed opioids. Objective: This review focuses on the analgesic effects of neuromodulators, such as gabapentin, duloxetine, and pregabalin, that provide room for less dependence on narcotic analgesics following orthopedic surgery. Methods: During the database searches, 1,033 records were identified as a preliminary result. After duplicates were removed, an initial screen of each article was completed which identified records to be removed due to absence of a full-text article. Articles were excluded if they were not either prospective or retrospective, showcased an irrelevant medication (such as tricyclic antidepressants) which are not pertinent to this review, or deemed to be unrelated to the topic. Results: Ultimately, 19 articles were selected. Three different drugs, gabapentin, pregabalin, and duloxetine, were analyzed to compile data on the effectiveness of preventing opioid overuse and addiction following hand surgery. This review identifies potential evidence that peri-operative gabapentin, pregabalin, and duloxetine administration decreases post-operative pain and lowers opioid dependency. Conclusion: Gabapentin, pregabalin, and duloxetine have potential to further decrease post-operative pain and lower opioid dependency. This review creates an opening for further research in hand surgery to assess an updated protocol for pain management to reduce opioid dependency.

Outcomes of Threaded Intramedullary Headless Nail Fixation for Metacarpal Fractures.

Metacarpal fractures are common and may require operative treatment; however, there is no gold standard fixation technique. K-wires are used for simplicity and flexibility but require immobilization and can lead to complications. Dorsal plating provides greater stability than K-wires but is subject to its own limitations. Intramedullary threadless nails have reduced time to union and improved range of motion (ROM) but may not provide the stability of plating. Intramedullary screws allow rapid return to activity and increased stability; however, compression forces may shorten metacarpals, producing non-anatomic reduction. The ExsoMed INnateTM threaded intramedullary nail (ExsoMed, Aliso Viejo, CA, USA) was developed with tall threads, a diameter fitting the metacarpal canal cortical purchase, stability, and no compression to prevent fracture displacement and shortening. We designed a prospective study to evaluate INnateTM nail fixation in metacarpal fractures. Visual analog scale (VAS) pain score, total active motion (TAM), radiographic union, and return to normal activity were recorded at each postoperative visit. Descriptive statistics were performed for endpoints. Fifty-eight patients were included with a median age of 38.7 years. The INnateTM nail was used in 80 fractured metacarpals. The 4th and 5th metacarpals were most frequently involved. The most common mechanisms of injury were blunt trauma and motor vehicle collisions. Approximately 31% of patients had multiple, concurrent fractures (16 patients required two nails; two required three nails). The mean follow-up was 9.9 weeks. The mean time to radiographic union was 9.1 weeks. The final visual analog scale (VAS) pain score was 1.1. The mean time to return to work and/or normal activities was 9.7 weeks, and the mean percentage of normal activity resumed was 89.1%.

Elevated Hemoglobin A1c and the Risk of Postoperative Complications in Elective Hand and Upper Extremity Surgery.

BACKGROUND: Studies addressing the utility of hemoglobin A1c (HbA1c) levels in predicting surgical complications have reported mixed results. In practice, many surgeons use HbA1c cutoffs to determine a patient's eligibility for elective surgery. The literature is especially limited in evaluating HbA1c as a risk factor in elective hand and upper extremity surgery. This study aims to evaluate the association of elevated HbA1c levels with the risk of postoperative complications in elective hand and upper extremity surgeries. METHODS: We performed a chart review of patients who underwent these elective operations performed by a single surgeon at a single institution. The outcomes of 930 surgeries were collected up to three months postoperatively, 334 of which had pre or postoperative HbA1c levels recorded. All 930 surgeries were evaluated for association between diabetes mellitus (DM) and complication rates using Fisher's exact test, absolute risk, odds ratio, and regression analysis. RESULTS: DM alone was not associated with an increased risk of postoperative complications. In diabetic patients with both diagnosed DM and HbA1c > 10%, the absolute risk of complications was significantly higher. None of the other HbA1c categories (between 6.5% and 10%) were associated with significantly higher odds of complications in patients with diagnosed DM. CONCLUSIONS: In the context of elective hand and upper extremity surgery, glycemic control (measured by HbA1c) should be included as an element of the surgical preparedness algorithm, rather than an independent disqualifying factor.

Use and efficacy of porcine urinary bladder matrix for tissue regeneration: a review.

Porcine-derived UBM, a type of acellular ECM, has demonstrated clinical utility for tissue repair and regeneration across various body systems. UBM acts as a full-thickness, exogenic skin substitute and scaffolding for soft tissue reconstruction while mimicking the function and properties of human ECM. This review presents an overview of the current literature evaluating UBM's clinical and preclinical utility across a broad range of applications. A compilation of studies of human and animal patients with a multitude of tissue defects resulting from various pathologic or injurious processes were systematically reviewed. The types of reconstructions included were categorized by the following surgical domains: abdominal wall; cardiothoracic and pulmonary; gastrointestinal; neurosurgery; oral and maxillofacial; otolaryngology or head and neck; ophthalmology; orthopedic or plastic or orthoplastic surgery; burn and wound care; and urology and gynecology. This systematic review illustrates that UBM may perform as well as or better than other ECM mimetics across various parameters, including reduced time to definitive wound closure, recurrence of wound, infection and/or complication rates, and immunogenic transplant rejection; reduction in overall cost burden to the patient, improved patient satisfaction, and ease of use and maintenance for providers; increased cellular recruitment, invasion, differentiation, and proliferation; and increased repair and regeneration of tissue. This tissue regeneration tends to be more functionally, mechanically, and histologically similar to native tissue through tissue-specific functional remodeling and maturation. This clinical outcome can be seen in various tissue types, levels of injury, and/or defect severity. UBM also proves valuable because of its ability to be used off-the-shelf in surgical, nonsurgical, or office and in-the-field treatment settings.

Flexor tenotomies for the treatment of bilateral wrist contracture after traumatic brain injury: A case report.

Traumatic brain injuries have the potential to cause the development of long-term complications. We aim to show that the use of flexor tenotomies in the treatment of flexion contractures following traumatic brain injury is a viable solution.

Novel Nerve-Sparing In Situ Assembly of an Expandable Titanium Cage to Maximize Endplate Coverage After Posterior Corpectomy for Comminuted Lumbar Burst Fractures.

BACKGROUND AND OBJECTIVES: The ability to maximize corpectomy cage endcap size and vertebral endplate coverage after corpectomy for lumbar burst fractures (L1-L5) is limited by the presence of lumbar nerve roots and the larger cross-sectional area of the lumbar endplates relative to the restrictive corridor for cage insertion. This work aims to provide details and clinical examples of a novel operative technique for 3-column reconstruction and stabilization of comminuted lumbar burst fractures. METHODS: Through a standard posterior midline approach and following posterior instrumentation and lateral extracavitary corpectomy, an in-situ assembly of a modular corpectomy cage that respects adjacent neural structures, restores segmental alignment, and maximizes endplate coverage across a lordotic segment is completed. RESULTS: Radiographic evidence of anatomic spinal reconstruction and stabilization with complete or near-complete endplate coverage without incurrence of new clinical deficit after this novel treatment of lumbar burst fractures. CONCLUSION: The fixation approach described in this report may be a valuable modification to a long-standing technique used for treating comminuted lumbar burst fractures (L1-L5) from a posterior-only approach without incurring additional neurological deficits and by improving endplate and apophyseal ring coverage.

Arthrex Mini Tightrope Fixation for Chronic Distal Radioulnar Joint Instability.

Chronic distal radioulnar joint (DRUJ) instability is a complex clinical condition that is difficult to treat. Currently, there is no gold standard treatment. We present a novel technique using Arthrex Mini Tightrope for DRUJ stabilization. In this case series, a 1.6 mm K-wire was passed transversely through the distal ulna and radius. The Mini Tightrope was inserted into the end of the K-wire and pulled through the bone tunnels. Appropriate tension was achieved to stabilize the joint according to individual laxity comparable to the contralateral side. Five patients (3 males and 2 females) comprised this pilot series, with a mean age of 27.1 years. All sustained a traumatic injury at an average of 12.4 months before surgery (range: 5 to 32 mo). In addition, 3 patients had central triangular fibrocartilage complex tears treated with arthroscopy at the time of Mini Tightrope placement. While one patient was lost to follow-up after 7 weeks postoperative due to incarceration, 4 patients demonstrated coronal and sagittal stability in the context of DRUJ motion and a satisfactory range of motion. The mean time for the return to work for the two patients who were laborers or normal activity postoperatively was 5.2 weeks (range: 1 to 16.4 wk). Unrestricted activity was generally allowed 8 weeks postoperatively but varied by patient. The same 4 patients underwent hardware removal at an average of 31 weeks (range: 15 to 44 wk). Although this is only a pilot series, this suggests that temporary Mini Tightrope stabilization of the DRUJ may be a viable solution while upholding the benefits of minimally invasive surgery.

Biomechanical Strength of a Novel Tendon Splicing Open Book Technique Compared to the Pulvertaft Method Using Unembalmed Human Cadaveric Tissue.

Background: Extensor pollicis longus (EPL) tendon rupture is a known complication of distal radius fractures. The Pulvertaft graft technique is currently used for tendon transfer of extensor indicis proprious (EIP) to EPL. This technique can produce unwanted tissue bulkiness and cosmetic concerns as well as hinder tendon gliding. A novel "open book" technique has been proposed, but relevant biomechanical data are limited. We designed a study to examine the biomechanical behaviours of the "open book" versus Pulvertaft techniques. Methods: Twenty matched forearm-wrist-hand samples were harvested from 10 fresh frozen cadavers (2 female, 8 male) with a mean age of 61.7 (±19.25) years. The EIP was transferred to EPL using the Pulvertaft versus "open book" techniques for each matched pair (sides randomly assigned). The repaired tendon segments were mechanically loaded using a Materials Testing System to examine graft biomechanical behaviours. Results: Mann-Whitney U test outcomes demonstrated that there was no significant difference between "open book" versus Pulvertaft techniques for peak load, load at yield, elongation at yield, or repair width. The "open book" technique demonstrated a significantly lower elongation at peak load and repair thickness, as well as significantly higher stiffness when compared with the Pulvertaft technique. Conclusions: Our findings support the use of the "open book" technique, producing comparable biomechanical behaviours compared to the Pulvertaft technique. Incorporating the "open book" technique potentially requires smaller repair volume, producing size and appearance that is more anatomic when compared with the Pulvertaft.

Contexte: La rupture du tendon du long extenseur du pouce (EPL - Extensor pollicis longus) est une complication connue des fractures distales du radius. La technique de greffe de Pulvertaft est actuellement utilisée pour un transfert tendineux de l'extenseur propre de l'index (EIP - extensor indicis proprious) à l'EPL. Cette technique peut produire une masse de tissu volumineuse non désirée et des préoccupations cosmétiques, mais aussi gêner le glissement du tendon. Une nouvelle technique en « livre ouvert ¼ a été proposée, mais les données biomécaniques pertinentes sont limitées. Nous avons conçu une étude visant à examiner les comportements biomécaniques de la technique « en livre ouvert ¼ comparativement à la technique de Pulvertaft. Méthodes: Vingt échantillons appariés avant-bras-poignet-main ont été prélevés sur 10 cadavres récemment congelés (2 femmes, 8 hommes) d'âge moyen 61,7 (± 19,25) ans. Les EIP ont été transférés aux EPL en utilisant la technique de Pulvertaft et la technique en livre ouvert pour chaque paire appariée (l'affectation du côté à chaque technique a été faite de manière aléatoire). Les segments tendineux réparés ont été chargés mécaniquement au moyen d'un système pour tester les matériaux afin d'étudier les comportements biomécaniques des greffes. Résultats: Les résultats du test U de Mann-Whitney ont montré qu'il n'y avait pas de différence significative entre la technique « en livre ouvert ¼ et la technique de Pulvertaft pour la charge maximum, la charge à la limite apparente d'élasticité, l'allongement à la limite apparente d'élasticité ou la largeur de réparation. La technique « en livre ouvert ¼ a démontré un allongement à la charge maximum et une épaisseur de réparation significativement moindres, ainsi qu'une significativement plus grande raideur, comparativement à la technique de Pulvertaft. Conclusions: Nos constatations étayent l'utilisation de la technique « en livre ouvert ¼ qui procure des comportements biomécaniques comparables à ceux de la technique de Pulvertaft. L'incorporation de la technique « en livre ouvert ¼ requiert potentiellement un plus petit volume de réparation, aboutissant à des dimensions et à un aspect plus anatomiques par rapport à la technique de Pulvertaft.

Patient-Reported Outcomes and Provocative Testing in Peripheral Nerve Injury and Recovery.

Background Peripheral nerve function is often difficult to assess given the highly variable presentation and subjective patient experience of nerve injury. If nerve assessment is incomplete or inaccurate, inappropriate diagnosis and subsequent treatment may result in permanent dysfunction. Objective As our understanding of nerve repair and generation evolves, so have tools for evaluating peripheral nerve function, recovery, and nerve-related impact on the quality of life. Provocative testing is often used in the clinic to identify peripheral nerve dysfunction. Patient-reported outcome forms provide insights regarding the effect of nerve dysfunction on daily activities and quality of life. Methods We performed a review of the literature using a comprehensive combination of keywords and search algorithms to determine the clinical utility of different provocative tests and patient-reported outcomes measures in a variety of contexts, both pre- and postoperatively. Results This review may serve as a valuable resource for surgeons determining the appropriate provocative testing tools and patient-reported outcomes forms to monitor nerve function both pre- and postoperatively. Conclusion As treatments for peripheral nerve injury and dysfunction continue to improve, identifying the most appropriate measures of success may ultimately lead to improved patient outcomes.

Radiographic Assessment of Bilateral Asymmetry in the Upper Extremities of Living Humans.

Objective Injuries resulting from trauma or tumor resection may cause length alterations in the bones of the upper extremities (UE) requiring reconstruction. Direct contralateral bone is often used to determine the appropriate length for reconstruction but fails to account for potential asymmetry. Given the paucity of data assessing asymmetry in living populations and the need for accurate length approximation, we developed a study evaluating UE long bone asymmetry using radiographic imaging in living subjects. Methods Bilateral X-ray images previously obtained for traumatic injury or chronic osseous conditions were retrospectively collected for adult subjects (ages 18-81). After screening, 61 patients met the inclusion criteria: 28 radii, 29 ulnae, and 19 humeri. Three serial measurements were taken, and the median was used for subsequent analysis. Wilcoxon signed-rank tests were performed to assess differences in contralateral bone lengths. Bootstrapping was utilized to obtain sample sizes of 200, 500, and 1000 for each bone. Results The difference in mean absolute length was 27.0 mm for the humerus, 8.6 mm for the radius, and 7.5 mm for the ulna. Neither the left side nor the right side was significantly longer for any bone. In 57.9% (11/19) of patients, the right humerus was longer than the left; in 60.7% (17/28), the right radius was longer than the left; and in 48.3% (14/29), the right ulna was longer than the left. All other measurements showed the left was longer than the right. Wilcoxon signed-rank tests did not find significant differences between contralateral pairs in any direct measurement group. In bootstrap samples, significant differences in length (p ≤ 0.05) were seen in all samples (n = 200, 500, and 1000) for both humerus and radius but only the 1000 sample group for the ulna. Conclusions Direct contralateral measure may be an appropriate method of length estimation for the humerus, radius, and ulna in post-industrial humans.

Avive Soft Tissue Membrane Improves Outcomes of Revision Upper-extremity Nerve Decompression Surgery.

Revision nerve decompression remains a challenge for surgeons. Avive Soft Tissue Membrane is processed human umbilical cord membrane that may reduce inflammation and scarring, thereby improving tissue gliding. Although synthetic conduits have been reported in revision nerve decompression, the use of Avive has not. Methods: Prospective study of revision nerve decompression with Avive application. VAS pain, two-point discrimination, Semmes-Weinstein, pinch and grip strength, range of motion, Quick Disability of Arm, Shoulder & Hand (QuickDASH), and satisfaction were recorded. Using a propensity-matched cohort, VAS pain and satisfaction were retrospectively collected to compare with cohort outcomes. Results: In the Avive cohort, 77 patients (97 nerves) were included. Mean follow-up was 9.0 months. Avive was applied to the median nerve in 47.4%, ulnar nerve in 39.2%, and radial nerve in 13.4%. VAS pain was 4.5 preoperatively and 1.3 postoperatively. S4 sensory recovery was achieved in 58% of patients, S3+ in 33%, S3 in 7%, S0 in 2%, and improvement from baseline in 87%. Strength improved in 92%. Mean total active motion was 94.8%. Mean QuickDASH score was 36.1, and 96% reported improved or resolved symptoms. Preoperative pain was not significantly different between Avive cohort and controls (P = 0.618). Postoperative pain was significantly lower in cohort patients (1.3 ± 2.2 versus 2.7 ± 3.0, P = 0.001). In the Avive cohort, more had improved or resolved symptoms (P < 0.0001). Clinically important improvement in pain was reported in 64.9% of Avive group patients versus 40.8% of controls (P = 0.002). Conclusion: Avive contributes to improved outcomes in revision nerve decompression.

Threaded intramedullary headless nail fixation for fractures requiring carpometacarpal stabilization.

Carpometacarpal (CMC) fracture-dislocations are uncommon hand injuries, with few studies available regarding their treatment. The current operative treatment options include fixation with K-wires, mini-screws, or plates, though there is no standardized approach because of varying injury patterns and complications associated with each device. The INnate™ threaded intramedullary nail is a relatively novel treatment option that has shown promise in metacarpal fracture fixation by facilitating faster mobilization and recovery with enhanced rotational stability and no compression to prevent fracture displacement and shortening. This study assesses the efficacy of the INnate™ nail for fixation of CMC fracture-dislocations of the second through fifth joints. Nine patients with fourteen CMC fracture-dislocations treated with the INnate™ nail at the University Medical Center between 2019 and 2021 were enrolled in the study. We evaluated postoperative outcomes in terms of pain, total active range of motion (TAM), and return to normal activities. Of the nine patients, seven returned for follow-up. The average time to radiographic union was 11.5 weeks. At final follow-up, no patient reported pain (n = 6). Four patients had 100% TAM, 1 had 95% TAM, and 1 had 25% TAM. The average percentage of normal activity resumed was 84.0% (n = 5). No significant complications were reported. One patient had a dorsal spanning plate; hence, we were unable to record outcomes measures regarding the CMC injury. An additional patient had diminished ROM of the injured hand, but his last follow-up was only 1 month postop. Our pilot data overall suggest that the INnate™ threaded intramedullary nail has the potential to improve treatment algorithms for CMC fracture-dislocations.

Assessment of Motor Function in Peripheral Nerve Injury and Recovery.

Introduction: Peripheral nerve injuries can be difficult to diagnose, treat, and monitor given their highly variable presentation. When the status of nerves is not accurately assessed, treatment may be delayed or overlooked and can result in lasting functional deficits. As our understanding of nerve repair and generation evolves, so will tools for evaluating both the functional and morphological status of peripheral nerves. Objective: There is currently no single article which provides a detailed, comprehensive view of the literature comparing the clinical utility of various assessment modalities. Furthermore, there is no consensus on the optimal assessment algorithm for peripheral nerve injuries. Methods: We performed a literature review using a comprehensive combination of keywords and search algorithm. The search was focused on clinical data regarding the assessment of peripheral nerves Results: This review may help to determine the appropriate tools that are currently available for monitoring nerve function both pre and postoperatively. Additionally, the review demonstrates possible roles and areas of improvement for each tool used to assess motor function. Conclusion: As surgeons work to improve treatments for peripheral nerve injury and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.

Clinical Assessment of Pain and Sensory Function in Peripheral Nerve Injury and Recovery: A Systematic Review of Literature.

Peripheral nerve injuries (PNIs) often present with variable symptoms, making them difficult to diagnose, treat, and monitor. When neurologic compromise is inadequately assessed, suboptimal treatment decisions can result in lasting functional deficits. There are many available tools for evaluating pain and functional status of peripheral nerves. However, the literature lacks a detailed, comprehensive view of the data comparing the clinical utility of these modalities, and there is no consensus on the optimal algorithm for sensory and pain assessment in PNIs. We performed a systematic review of the literature focused on clinical data, evaluating pain and sensory assessment methods in peripheral nerves. We searched through multiple databases, including PubMed/Medline, Embase, and Google Scholar, to identify studies that assessed assessment tools and explored their advantages and disadvantages. A total of 66 studies were selected that assessed various tools used to assess patient's pain and sensory recovery after a PNI. This review may serve as a guide to select the most appropriate assessment tools for monitoring nerve pain and/or sensory function both pre- and postoperatively. As the surgeons work to improve treatments for PNI and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.

Methicillin-Resistant Staphylococcus aureus Spinal Epidural Abscess: Local and Systemic Case Management.

Spinal epidural abscess (SEA) is a rare condition with complex pathophysiology and highly variable clinical presentation. While it is known to cause focal peripheral nerve symptoms such as muscle weakness, paresthesia, or pain, these are typically accompanied by complaints of back or spine pain and systemic symptoms indicative of infection. In our case, a 53-year-old male initially presented with unilateral pain and swelling in his right hand, with no fever at presentation and no complaints of back pain. Blood culture confirmed methicillin-resistant Staphylococcus aureus (MRSA)for which he was given vancomycin. The patient later endorsed back pain and diagnostic imaging revealed a spinal epidural abscess spanning the T5-T9 vertebrae. The abscess was drained, and vancomycin was placed in the subfascial and epifascial compartments. The hand was debrided in the same operation and showed no gross purulence. Two days after the procedure, intraoperative cultures remained negative, and the patient was subsequently managed with daptomycin.

Traumatic Zone II Flexor Tendon Injury Repair Through a Traumatic Dorsal Approach.

Zone II flexor tendons present unique challenges for repair because of their complex anatomy in a confined space. The approach for zone II injuries is often dictated by preexisting traumatic skin lacerations, with a midaxial or volar approach being most common. In some injuries, this approach is not viable, and alternative approaches must be considered. A 45-year-old man presented with a traumatic crush injury that caused complete disruption of the skin, tendon, capsule, collateral ligament, and volar plate and laceration of the flexor digitorum profundus in zone II near the proximal interphalangeal joint. Given the large, near-circumferential zone of injury, we used the traumatic dorsal wound for the flexor tendon for repair. There are no reports of this approach in the literature. Postoperatively, the proximal interphalangeal joint was immobilized for 6 weeks with a K-wire. The patient was followed in the clinic and prescribed occupational therapy. At the 4-month postoperative visit, the patient had a healed incision, no signs of infection, and intact median/radial sensations. Functional testing showed a loose composite fist, improved range of motion, and 2-cm tip-to-palm deficiency of the index finger. Grip strength was 85 lb in the right hand and 60 lb in the left hand. Although patients are not always expected to regain full function, their postoperative course may be further complicated by adhesion and the need for tenolysis. Given these historical complications of tendon repair and our patient's ability to return to work with satisfactory functional outcomes, this approach may be a viable option for treating this unique injury pattern. [Orthopedics. 2022;45(4):e216-e219.].

Bony hypertrophy of the forearm in bareback rodeo athletes.

OBJECTIVE: Activities that require increased load bearing are known to cause bony hypertrophy. This phenomenon has been documented in the dominant arm of athletes in sports requiring significant utilization of a single limb. The literature addressing this effect in rodeo athletes, however, is minimal. Studies evaluating rodeo athletes are primarily focused on acute injury management rather than chronic symptoms resulting from changes in bone and soft tissue. We designed a study to evaluate bony hypertrophy in athletes without acute injury. METHOD: Rodeo bareback riders presented with frequent pain in their grip arm, no radiographic evidence of injury, and clinical signs of peripheral nerve compression. Anteroposterior and lateral X-rays taken for initial evaluation in 17 bareback rodeo athletes were retrospectively reviewed. The diameter of bilateral ulnas was measured at its longitudinal midpoint. Ratio of Ulnar Diameters (grip arm/free arm) and Percentage Diameter Difference were calculated. An independent samples t-test was used to assess differences in diameters of grip and non-grip arms. RESULT: The mean ulnar diameter was 18.4 ± 3.5 in the grip arm and 16.6 ± 3.5 in the non-grip arm (p < 0.001). The mean ratio of grip to free arm ulnar diameter was 1.42 ± 0.21 (range = 1.05-1.92). The mean diameter percent difference measured 42.3% (range = 4.7%-92.0%), and the grip arm was observed to have a greater ulnar diameter compared to the non-grip arm. CONCLUSION: There are significant anatomic differences in the grip arm of bareback rodeo athletes compared to the contralateral arm. In cases of persistent pain in the grip arm and no evidence of acute injury, these differences may be relevant to pain symptoms and should be considered as part of the assessment and treatment algorithm.

CO2 laser resurfacing for burn and traumatic scars of the hand and upper extremity.

BACKGROUND: Scar formation is a normal part of the proliferative phase in wound healing where collagen is remodelled to better approximate normal skin. When collagen is not effectively redistributed, excessive scarring may occur. Recently, CO2 laser has emerged as an adjunct in improving scar quality via remodelling and redistribution of dermal collagen fibres. Due to the paucity of literature related to its use in the hands and upper extremities, we created a study to examine its effects on hypertrophic scars focused on the hands and upper extremities. METHODS: Patients treated with CO2 laser for hypertrophic scars of the hand and upper extremity were included. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to assess the progression of scar quality. Unpaired t-tests were performed to determine statistical difference between pre- and post-treatment scores on each scale. Pearson correlation coefficients were used to understand the relationship between number of treatments and scar quality. RESULTS: Of the 90 patients enrolled, 54 patients completed serial scar assessment forms. All patient and observer-reported POSAS domains showed improvement (P < 0.05) apart from Itching. All VSS domains showed improvement (P < 0.05). There was moderate correlation between overall patient-reported opinion of scar quality and Discoloration, Stiffness and Thickness, and strong correlation between overall patient opinion and Irregularity (r = 0.715). All observer-reported domains were strongly correlated (r = 7.56-8.74) with overall observer opinion of scar quality. CONCLUSION: The results of this study may further substantiate CO2 laser as a treatment modality for excessive scarring in a variety of surgical subspecialties. LAY SUMMARY: Complex trauma and burns that impact the skin sometimes result in abnormal healing of the skin called, "hypertrophic scarring". In our study we assessed how using focused CO2 laser therapy impacts patients and health care provider assessment of wound progression. Our results were based upon patient reported and healthcare provider observations based upon two standardized forms the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). What we found is that after CO2 Laser Therapy, our 64 patients with 77 treated scars received on average almost 3 treatments and these treatments helped them with physical function and improved aesthetic appearance of their scars. The health care providers also found that the treatments improved functional and aesthetic end points. Overall, our study helps substantiate the body of evidence that using CO2 laser therapy improves aesthetics and function of hypertrophic scars in the upper extremity.

Clinical applications of acellular dermal matrices: A review.

INTRODUCTION: The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications. METHODS: PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data. RESULTS: A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers). CONCLUSION: Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario. LAY SUMMARY: Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.

Alpha-Gal Syndrome: Involvement of Amblyomma americanum α-D-Galactosidase and ß-1,4 Galactosyltransferase Enzymes in α-Gal Metabolism.

Alpha-Gal Syndrome (AGS) is an IgE-mediated delayed-type hypersensitivity reaction to the oligosaccharide galactose-α-1, 3-galactose (α-gal) injected into humans from the lone-star tick (Amblyomma americanum) bite. Indeed, α-gal is discovered in salivary glands of lone-star tick; however, the tick's specific intrinsic factors involved in endogenous α-gal production and presentation to host during hematophagy are poorly understood. This study aimed to investigate the functional role of two tick enzymes, α-D-galactosidase (ADGal) and ß-1,4 galactosyltransferases (ß-1,4GalT), in endogenous α-gal production, carbohydrate metabolism, and N-glycan profile in lone-star tick. The ADGal enzyme cleaves terminal α-galactose moieties from glycoproteins and glycolipids, whereas ß-1,4GalT transfers α-galactose to a ß1,4 terminal linkage acceptor sugars-GlcNAc, Glc, and Xyl-in various processes of glycoconjugate synthesis. An RNA interference approach was utilized to silence ADGal and ß-1,4GalT in Am. americanum to examine their function in α-gal metabolism in tick and AGS onset. Silencing of ADGal led to the significant downregulation of genes involved in galactose metabolism and transport in Am. americanum. Immunoblot and N-glycan analysis of the Am. americanum salivary glands showed a significant reduction in α-gal levels in silenced tissues. However, there was no significant difference in the level of α-gal in ß-1,4GalT-silenced tick salivary glands. A basophil-activation test showed a decrease in the frequency of activated basophil by ADGal-silenced salivary glands. These results provide an insight into the roles of ADGal and ß-1,4GalT in α-gal production and presentation in ticks and the probable involvement in the onset of AGS.