Mesenchymal stromal cell therapy for patients with rheumatoid arthritis.

Management of relapses and refractory rheumatoid arthritis (RA) patients is complex and difficult. Even after the administration of new biological disease-modifying anti-rheumatic drugs (DMARDs), only a few patients achieve the complete remission phase. DMARDs help only in modifying the disease activity, which sooner or later fails. They do not manage the disease at the patho-etiological level. There are some serious side effects as well as drug interaction with DMARDs. There are few subsets of RA patients who do not respond to DMARDs, reasons unknown. Mesenchymal stem cells (MSCs) provide a promising alternative, especially in such cases. This review elaborates on the studies pertaining to the application of MSCs in rheumatoid arthritis over the last two decades. A total of 14 studies (one review article) including 447 patients were included in the study. Most of the studies administered MSCs in refractory RA patients through the intravenous route with varied dosages and frequency of administration. MSCs help in RA treatment via various mechanisms including paracrine effects. All the studies depicted a better clinical outcome with minimal adverse events. The functional scores including the VAS scores improved significantly in all studies irrespective of dosage and source of MSCs. The majority of the studies depicted no complications. Although the use of MSCs in RA is still in the early stages requiring further refinement in the source of MSCs, dosage, and frequency. The role of MSCs in the management of RA has a promising prospect. MSCs target the RA at the molecular level and has the potential to manage refractory RA cases not responding to conventional treatment. Multicentric, large sample populations, and long-term studies are required to ascertain efficacy and safety.

Outcome of human amniotic membrane wrap around neurorrhaphy in high radial nerve injury - a case report following monkey bite.

INTRODUCTION: Peripheral nerve injury due to animal bite is a rare phenomenon. Most animal bites are from dogs. Monkey bites constitute a common risk, second only to dog bites, among travelers. Peripheral nerve injuries may occur due to a combination of monkey's strong jaws and sharp long teeth penetrating deep into the soft tissues. Such injuries are associated with increased perineural fibrosis. Human amniotic membrane (HAM) wrap around the nerve repair site reduces fibrotic response, prevents adhesions and scar formation thereby improving outcome. We report a case of "High Radial nerve palsy due to monkey bite, treated by neurorrhaphy with HAM wrap". METHOD: A 3-year old boy presented with wrist drop, and inability to extend the fingers and thumb of his right dominant hand, following a monkey bite over the distal arm. The diagnosis of high radial nerve injury was corroborated by high frequency ultrasound and electrodiagnostic studies. On exploration the radial nerve was found to be transected. An end to end repair was performed, with HAM wrap around the neurorrhaphy. RESULTS: Wrist dorsiflexion recovered at 2.5 months followed by active finger and thumb extension at 4 months with no infection or immune rejection. CONCLUSION: Nerve regeneration in our patient occurred at a faster rate as compared to the conventional 1 mm/day. This could be attributed to decreased perineural fibrosis, improved neurotropism due to the HAM wrap and neuronal plasticity in young brain in addition, the patient being a small child having better regenerative ability in comparison to an adult.

Is performing joint arthroplasty surgery during the COVID-19 pandemic safe?: A retrospective, cohort analysis from a tertiary centre in NCR, Delhi, India.

PURPOSE: Resuming joint replacement arthroplasty amidst the COVID-19 pandemic and lockdown has come with various challenges that had to be dealt with utmost caution. Patients with severe arthritis experiencing a state of intolerable pain, could not be left unaddressed. Guidelines published by surgical associations, collaborative surgical author groups including public health organisations had to be modified to suit the Indian scenario and obtain optimal functional outcomes in these patients. METHODS: A retrospective cohort analysis of 147 patients who underwent arthroplasty during the pandemic (March 2020 to April 2021), for either primary or secondary arthritis, was performed. We assess the efficacy and safety of the newly established Institutional surgical peri-operative protocol at our tertiary care centre in the National Capital Region, India in response to COVID-19 guidelines. The primary outcome measures appraised was 30-day mortality and the secondary outcome measures included length of stay, peri-operative complications and COVID-19 infection. RESULT: The most common indication for arthroplasty during the pandemic was neglected trauma. One patient died, due to myocardial infarction during the follow-up period. About 67% of patients were discharged to their usual residence within 7 days of admission. Two patients tested positive for COVID-19 postoperatively, but none required Intensive Care Unit admission. CONCLUSION: Joint replacement arthroplasty can be undertaken safely with diligent patient selection, application of a stringent COVID appropriate behaviour and a 'ring-fenced' peri-operative pathway.

Functional Outcome of Early, Selective Surgical Nerve Decompression in Leprous Neuropathy.

Background: Leprous neuropathy is a significant, yet preventable, cause of disability worldwide. Decompressive surgery and oral steroids have been used along with Multi Drug Therapy (MDT) for treating leprous neuropathy with varied success as reported in literature. Methods: We prospectively studied 16 peripheral nerves in 10 patients with leprous neuropathy of less than a year duration and not responding to steroid therapy in 3 weeks. The patients were divided into 2 groups: Group-A (decompressive nerve surgery was done within 12 weeks of onset of neurological deficit), and Group-B (nerve decompression was performed after 12 weeks from onset of neurological deficit). Post-operatively patients were assessed for regression of deformity, sensory, motor, vasomotor recovery and neuropathic pain. Results: Median age of patients was 32 years (range; 18 years to 46 years). Mean motor score and mean grip strength was significantly better for group A patients at 2 years follow-up (p < 0.05). Mean sensory score improved significantly in both the groups (p < 0.05). Similarly, mean VAS score for neuropathic pain improved significantly in both the groups (p < 0.05). Recovery of autonomic function was observed in 3 nerves in group A and 1 in group B. Conclusions: The cases who underwent nerve decompression surgery within 12 weeks had better functional outcomes, especially in terms of motor recovery, than those who were operated after that. Studies involving larger number of patients are required to draw firm conclusions.

Complex, Multidirectional Carpometacarpal Dislocations: A Case Report.

CASE: We present a rare combined convergent-divergent carpometacarpal (CMC) fracture dislocation with median nerve involvement in a young adult after a motorbike accident. Radiographs revealed a volar dislocation of the second and fifth metacarpals and dorsal dislocation of the third and fourth metacarpals with bases of the second and fifth metacarpals found to be converging in the coronal plane. Open reduction and fixation was performed with carpal tunnel release. CONCLUSION: Combined convergent-divergent CMC fracture dislocation should be kept as a differential while evaluating CMC dislocations. Metacarpal cascade line (posteroanterior view) and 2 lateral views (radial side up and ulnar side up) with computed tomography scan (3-dimensional reconstruction) prove to be vital in such high-energy trauma.

Correction to: Flexor tendon repair with amniotic membrane.

The original publication of this paper contain an error in Fig. 3.

Unusual Triad of Bifid Median Nerve, Persistent Median Artery, and Aberrant Muscle Causing Carpal Tunnel Syndrome: A Case Report.

CASE: A 15-year-old boy presented with intermittent pain, in the left nondominant hand, for the past 3 years. He recently developed numbness in the radial 3 and a half digits. Ultrasonography revealed a bifid median nerve (BMN) with a persistent median artery (PMA). An open carpal tunnel release was performed, which revealed an accessory lumbrical muscle in addition to the BMN and a PMA. CONCLUSION: The surgeon should be aware of the possible coexistence of 3 anomalous structures while performing carpal tunnel release in a young patient.

Flexor tendon repair with amniotic membrane.

PURPOSE: Flexor tendon adhesion to tissues is one of the most frequent complications reported after flexor tendon repair. The human amniotic membrane (HAM) was used to wrap the tendon repair site to decrease fibrotic response and tendon adhesion. METHODS: A total of 19 patients with flexor tendon injuries were subjected to surgical repair. The repair site was wrapped with human amniotic membrane (HAM) in nine cases. The remaining ten cases served as controls as no HAM wrap was used. The clinical outcome was assessed by pain, range of motion, and pinch strength. The healing of repair was evaluated with high-frequency ultrasound; the biologic response was assessed with two inflammatory mediators, i.e., interleukin-6 and TGF-beta-1. RESULTS: HAM wrap cases recorded less pain, higher total active range of motion, and better tendon glide on ultrasonography at follow-up (6-18 months). The levels of serum inflammatory biologic markers decreased in majority of HAM cases whereas they increased in controls at two to six weeks post-operatively. No infection/immune rejection phenomenon was seen in HAM wrap cases. CONCLUSIONS: HAM wrap around the tendon repair site resulted in quicker function and qualitatively better tendon healing on ultrasound, with a decrease of the biologic response.

Juncturae Tendinum Transfer for Extensor Tendon Reconstruction: A Case Report.

CASE: A 9-year-old girl, with a history of crush injury to her right hand 2 years ago, presented with inability to extend her index finger. Exploration revealed segmental loss of extensor tendons to the index finger with a pre-existing scar in the route of tendon transfer. The juncturae tendinum (JT) between extensor digitorum communis of the middle and ring fingers (Von Schroeder -3y) was transferred to reconstruct the extensor tendon. At 1-year follow-up, finger extension was restored, with improved grasp and release. CONCLUSION: JT transfer could prove useful in reconstructing zone II extensor tendon injuries with scarring and fibrosis in the route of conventional tendon transfer/graft.

Ventral scapular osteochondroma excision through 'triangle of auscultation': A case series.

INTRODUCTION: Surgical intervention through the 'triangle of auscultation' is less morbid to patients, as it is devoid of muscles and provides an easy access to tumours arising on the ventral aspect of scapula especially near inferior angle. METHOD: Three patients presented to us with pseudo-winging of scapula and an audible thud on abduction of the arm. A bony mass, painful in two and painless in one patient, was palpable along the anterior aspect of the inferior angle of scapula. A clinical diagnosis of osteochondroma was made which was corroborated by X-rays and computed tomography (CT) imaging. Ventral scapular osteochondroma excision is challenging due to multiple muscle attachments, requiring extensive soft tissue dissection and muscular release. Numerous blood vessels and nerves in the vicinity may also add to the degree of difficulty. This necessitates the need of a minimally invasive and muscle-sparing procedure. We hereby describe a novel surgical approach to the ventral aspect of scapula through the triangle of auscultation for excision of scapular osteochondroma. RESULTS: Pseudo-winging disappeared following surgery. Snapping of the scapula resolved with early, full shoulder range of motion. Quick disabilities of arm, shoulder and hand (DASH) score improved from mean 20.2 preoperatively to 0 postoperatively at 3 months in all the patients. CONCLUSION: The approach is simple with minimal blood loss as it does not involve splitting or cutting of trapezius, rhomboid major or subscapularis muscles.