Hand Surgery in Indonesia.

The history of hand surgery in Indonesia began with the growing interest in performing a complicated hand surgery. Since the 1970s, hand surgery in Indonesia has made headway, especially when it comes to science and education. The development of hand surgery in Indonesia is not limited to a microsurgery area, but also covers more modern techniques, including reconstruction, minimal invasive surgery, arthroscopy, and various kinds of innovations and developments to overcome the high cost of health, especially medical devices in Indonesia. Voluntary visitations to help or take surgery procedures in many remote areas in Indonesia, such as Papua and Nusa Tenggara, have also contributed to the development of hand surgery. Currently, hand surgery in Indonesia is improving and growing significantly.

An In Vitro Study of Chitosan-Coated Bovine Pericardium as a Dural Substitute Candidate.

Defects in the dura matter can be caused by head injury, and many cases require neurosurgeons to use artificial dura matter. Bovine pericardium is an option due to its abundant availability, adjustable size and characteristics, and because it has more collagen than porcine or equine pericardia. Nevertheless, the drawback of bovine pericardium is that it has a higher inflammatory effect than other synthetic dura matters. Chitosan has been shown to have a strong anti-inflammatory effect and has good tensile strength; thus, the idea was formulated to use chitosan as a coating for bovine pericardium. This study used decellularized bovine pericardial membranes with 0.5% sodium dodecyl sulphate and coatings containing chitosan at concentrations of 0.25%, 0.5%, 0.75%, and 1%. An FTIR test showed the presence of a C=N functional group as a bovine pericardium-chitosan bond. Morphological tests of the 0.25% and 0.5% chitosan concentrations showed standard pore sizes. The highest tensile strength percentage was shown by the membrane with a chitosan concentration of 1%. The highest degradation rate of the membrane was observed on the 7th and 14th days for 0.75% and 1% concentrations, and the lowest swelling ratio was observed for the 0.25% concentration. The highest level of cell viability was found for 0.75% chitosan. The bovine pericardium membrane with a 0.75% concentration chitosan coating was considered the optimal sample for use as artificial dura matter.

Biodegradable vs nonbiodegradable suture anchors for rotator cuff repair: a systematic review and meta-analysis.

Purpose: The use of non-biodegradable suture anchors (NBSA) in arthroscopic rotator cuff repair (RCR) has increased significantly. However, several complications such as migration, chondral damage, revision, and imaging difficulties have been reported. Meanwhile, the effectiveness of biodegradable suture anchors (BSA) in overcoming such complications and achieving functional outcomes requires further study. Thus, we aim to compare the clinical outcomes and complications of RCR using BSA and NBSA using direct comparison studies. Methods: Two independent reviewers conducted systematic searches in PubMed, Embase, Cochrane Library, and Web of Science from conception to September 2022. Using the RoB 2 and ROBINS-I tools, we assessed the included studies for bias. We applied GRADE to appraise our evidence. Our PROSPERO registration number is CRD42022354347. Results: Six studies (two randomized controlled trials, one retrospective cohort, and three case-control studies) involving 423 patients were included (211 patients received BSA and 212 patients received NBSA). BSA was comparable to NBSA in forward flexion, abduction, external rotation, Constant-Murley score, and perianchor cyst formation (P = 0.97, 0.81, 0.56, 0.29, and 0.56, respectively). Retear rates were slightly higher while tendon healing was reduced in BSA compared to NBSA, but the differences were not significant (P = 0.35 and 0.35, respectively). Conclusion: BSA and NBSA appear to yield similar shoulder functions and complications in rotator cuff repairs.

The effect of preconditioning hypoxia in schwann-like-cells-derived adipose mesenchymal stem cells and rat sciatic nerve-derived stem cells: experimental research.

The preconditioning hypoxia for stem cells is a strategy to achieve effective conditions for cell therapy, indicate increased expression of regenerative genes in stem cell therapy, and enhance the secretion of bioactive factors and therapeutic potential of their cultured secretome. Objectives: This study aims to explore the response of Schwann-like cells derived from adipose-derived mesenchymal stem cells (SLCs) and Schwann cells rat sciatic nerve-derived stem cells (SCs) with their secretomes under normoxic and hypoxic conditions in vitro. Material and methods: SLCs and SCs were isolated from the adipose tissue and the sciatic nerve of the adult white male rat strain Wistar. Cells were incubated in 21% O2 (normoxic group) and 1%, 3%, and 5% O2 (hypoxic group) conditions. Concentration values of transforming growth factor-ß (TGF-ß), basic Fibroblast Growth factor (bFGF), brain-derived neurotrophic factor, glial-derived neurotrophic factor, vascular endothelial growth factor, and nerve growth factor were detected and calculated utilizing an enzyme-linked immunosorbent assay, and the growth curve was described. Results: SLCs and SCs indicated positive expression for mesenchymal markers and negative expression for hematopoietic markers. Normoxic conditions SLCs and SCs showed elongated and flattened morphology. Under hypoxic conditions, SLCs and SCs showed a classic fibroblast-like morphology. Hypoxia 1% gave the highest concentration in TGF-ß and bFGF from the SLCs group and TGF-ß, bFGF, brain-derived neurotrophic factor, and vascular endothelial growth factor from the SCs group. No significant differences in concentration of growth factors between the SLCs group compared to SCs group in all oxygen groups. Conclusions: Preconditioning hypoxia has an effect on the composing of SLCs, SCs, and their secretomes in vitro; no significant differences in concentration of growth factors between the SLCs group compared with the SCs group in all oxygen groups.

Effectivity of puncture method for intervertebral disc degeneration animal models: review article.

Intervertebral disk degeneration (IDD) is a chronic condition brought on by various factors and mechanisms that have been linked to many deaths and illnesses. The causes of IDD involve multiple processes, including genetics, stress, cellular aging, and changes in nutrition due to the limited blood supply. Animal models play a crucial role in biomedical research and the selection of these models is based on many considerations, including the need for similarities in structure and function with humans. This is important because the etiology and pathogenesis of IDD are complex. Finding the right animal model is not an easy task. In addition to having similarities to humans, these models should also be reliable, reproducible, cost-effective, and easy to maintain. One common method of inducing IDD in animal models is needle puncture. This method is less invasive and time-consuming compared to other methods and allows for precise control over the extent and location of the injury.

The optimum oxygen level in hypoxic culture conditions of ligament derived stem cells: experimental research.

The hypoxic condition is a physiological norm for various stem cells. The natural microenvironment contains lower oxygen pressures. Recent studies reported significant increases in the cultured cells' proliferation in the presence of a low oxygen pressure. Objective: This study aimed to investigate the optimum oxygen level for rabbit cruciate ligament fibroblast cells culture and Ligament Derived Conditioned Medium/LD-CM (Secretome) preparation in vitro. Materials and methods: Fibroblasts were isolated from the cruciate ligament of the rabbit's knee. Cultured of rabbit cruciate ligament Fibroblast Cells (fifth passage) were assigned to the slight (5% O2), middle (3% O2), and severe hypoxia (1% O2) groups and the normoxia (21% O2) group. Measurement of growth factors: TGF-ß1, PDGF, FGF, and VEGF in LD-CM (Secretome) used an enzyme-linked immunosorbent assay. Results: The highest number of cultured cells were in the 5% O2 group compared to the normoxia, 1 and 3% groups. The hypoxia 5% group also had increased productions of PDGF, FGF, and VEGF proteins in LD-CM (secretome) compared to the 1, 3%, and normoxia groups. TGF-ß1 production was slightly higher in the 3 group than the 5% group. Conclusion: The hypoxic precondition of 5% oxygen was the optimum condition for ligament culture and ligament derived conditioned medium (secretome) preparation in vitro.

Time to surgery and myo-d expression in biceps muscle of adult brachial plexus injury: a preliminary study.

BACKGROUND: Brachial Plexus Injury (BPI) is one of the peripheral nerve injuries which causes severe functional impairment and disability. Without prompt treatment, prolonged denervation will cause severe muscle atrophy. MyoD, which is expressed by satellite cells, is one of the parameters that relate to the regeneration process in post-injury muscle and it is presumed to determine the clinical outcome following neurotization procedure. This study aims to understand the correlation between time to surgery (TTS) and MyoD expression in satellite cells in the biceps muscle of adult brachial plexus injury patients. METHODS: Analytic observational study with a cross-sectional design was conducted at Dr. Soetomo General Hospital. All patients with BPI who underwent surgery between May 2013 and December 2015 were included. Muscle biopsy was taken and stained using immunohistochemistry for MyoD expression. Pearson correlation test was used to assess the correlation between MyoD expression with TTS and with age. RESULTS: Twenty-two biceps muscle samples were examined. Most patients are males (81.8%) with an average age of 25.5 years. MyoD expression was found to be highest at TTS of 4 months and then dropped significantly (and plateau) from 9 to 36 months. MyoD expression is significantly correlated with TTS (r=-0.895; p = 0.00) but not with age (r=-0.294; p = 0.184). CONCLUSION: Our study found, from the cellular point of view, that treatment of BPI needs to be done as early as possible before the regenerative potential - as indicated by MyoD expression - declined.

Long term functional outcome evaluation in post flexor digitorum profundus tendon zone I rupture repaired by palmaris longus tendon grafting augmented with human amniotic membranes and adipose derived mesenchymal stem cell: A case report.

INTRODUCTION AND IMPORTANCE: The sport climbing has many complex maneuvers of the hand producing many potential injuries in flexor digitorum profundus tendon (FDPT). The late management due to an athlete high demand on competition makes the complication of retracted tendon and adhesion tend to occur. We provide the long terms functional outcome in FDPT zone I rupture repaired by palmaris longus (PL) tendon grafting augmented with human amniotic (hAM) and adipose derived mesenchymal stem cell (ASCs). CASE PRESENTATION: We present a case of a 31-years old male sport climbing athlete with excruciating pain in the right middle finger due to an injury at distal phalangeal area occurred two months earlier. Intraoperatively, Bruner's incision was performed for exploration. A modified Kessler suture technique with running sutures around the sutured stump was used. We slightly overcorrected tension between PL and FDPT distal stumps. We shielded the distal and proximal sutured areas with hAM augmented with ASCs. The result was remarkable as he could return to competitive sport. CLINICAL DISCUSSION: Zones I and II have a high adhesion risk due to their complex structures. In the case of the PL tendon graft, the sutured stump lies in these zones which can affect outcomes. An HAM augmented with ASCs has an anti-adhesive property that allows smooth gliding of the tendon FDPT on two sutured stump junctions, as well as stimulating the tendon to produce tenocytes, which accelerates tendon healing. CONCLUSION: The combination of our technique and regenerative therapy effectively prevents adhesions and modulates tendon healing.

Mechanism of spinal cord injury regeneration and the effect of human neural stem cells-secretome treatment in rat model.

BACKGROUND: Globally, complete neurological recovery of spinal cord injury (SCI) is still less than 1%, and 90% experience permanent disability. The key issue is that a pharmacological neuroprotective-neuroregenerative agent and SCI regeneration mechanism have not been found. The secretomes of stem cell are an emerging neurotrophic agent, but the effect of human neural stem cells (HNSCs) secretome on SCI is still unclear. AIM: To investigate the regeneration mechanism of SCI and neuroprotective-neuroregenerative effects of HNSCs-secretome on subacute SCI post-laminectomy in rats. METHODS: An experimental study was conducted with 45 Rattus norvegicus, divided into 15 normal, 15 control (10 mL physiologic saline), and 15 treatment (30 µL HNSCs-secretome, intrathecal T10, three days post-traumatic). Locomotor function was evaluated weekly by blinded evaluators. Fifty-six days post-injury, specimens were collected, and spinal cord lesion, free radical oxidative stress (F2-Isoprostanes), nuclear factor-kappa B (NF-κB), matrix metallopeptidase 9 (MMP9), tumor necrosis factor-alpha (TNF-α), interleukin-10 (IL-10), transforming growth factor-beta (TGF-ß), vascular endothelial growth factor (VEGF), B cell lymphoma-2 (Bcl-2), nestin, brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF) were analyzed. The SCI regeneration mechanism was analyzed using partial least squares structural equation modeling (PLS SEM). RESULTS: HNSCs-secretome significantly improved locomotor recovery according to Basso, Beattie, Bresnahan (BBB) scores and increased neurogenesis (nestin, BDNF, and GDNF), neuroangiogenesis (VEGF), anti-apoptotic (Bcl-2), anti-inflammatory (IL-10 and TGF-ß), but decreased pro-inflammatory (NF-κB, MMP9, TNF-α), F2-Isoprostanes, and spinal cord lesion size. The SCI regeneration mechanism is valid by analyzed outer model, inner model, and hypothesis testing in PLS SEM, started with pro-inflammation followed by anti-inflammation, anti-apoptotic, neuroangiogenesis, neurogenesis, and locomotor function. CONCLUSION: HNSCs-secretome as a potential neuroprotective-neuroregenerative agent for the treatment of SCI and uncover the SCI regeneration mechanism.

Treatment of chronic mallet finger with swan neck deformity using a modified Spiral Oblique Retinacular Ligament (SORL) reconstruction procedure: A case series and technical note.

INTRODUCTION AND IMPORTANCE: Chronic terminal extensor tendon injury produces mallet deformity and secondary swan neck deformity. It can be found in neglect cases and in a failed cases after conservative treatment or primary surgical repair. Surgery is considered in cases with extensor lag of more than 30° and functional deficit. Reconstruction of the spiral oblique retinacular ligament (SORL) has been reported in literatures to correct swan neck deformity by a dynamic mechanical basis. CASE PRESENTATION: Three cases of chronic mallet finger associated with swan neck deformity were treated by the modified technique of SORL reconstruction. Range of motion (ROM) of distal interphalangeal (DIP) joints and proximal interphalangeal (PIP) joints were measured along with the complications. The clinical outcome was reported using the Crawford's criteria. CLINICAL DISCUSSION: All patients had an average age of 34 years (20-54). Average time to surgery was 16.67 months (2-24) and average of DIP extension lag was 66.67°. All patient gave excellent Crawford criteria at the latest follow up (average 15.3 months). The average PIP joint ROM were -1.60 (00 to -50) of extension and 1100 (1000-1200) of flexion for the PIP joint and -1.60 (00 to -50) of extension and 83.330 (800-850) of flexion for the DIP joint. CONCLUSION: We present our technique to manage chronic mallet injury which only utilized two skin incisions and one button at the distal phalanx to minimize risk of skin necrosis and patient discomfort. This procedure can be considered as one of the options for the treatment of chronic mallet finger deformity associated with swan neck deformity.

Validity and Reliability of Prognosis Brachial Plexus Injury Score for Traumatic Brachial Plexus Injury.

Background: Brachial plexus injury (BPI) is a peripheral nerve injury that results in severe functional impairment and disability. Even after prompt treatment, predicting the prognosis of BPI is not easy as it involves various factors. An objective and valid scoring system would aid clinicians in informing families and anticipating problems related to the recovery of BPI. Prognosis BPI (PRO-BPI) score, a new prognostic score to predict the outcome of traumatic BPI (TBPI), was developed in 2019 by Suroto and Rahman. This study aimed to evaluate its validity and reliability. Methods: Retrospective cohort analysis was conducted for 111 BPI patients. A serial assessment of Disabilities of the Arm, Shoulder and Hand (DASH) score and PRO-BPI score was done. Validity analysis was done by assessing Spearman correlations between PRO-BPI score and other scoring systems (DASH, Michigan hand outcomes, and 36-item short form survey score [SF-36]). Internal structure consistency using Cronbach's alpha and test-retest reliability were measured for reliability analyses. A p-value was considered significant if < 0.05. Results: A total of 96 male and 15 female patients were included in our study with a mean age of 27.9 ± 10.6 years. Most of the patients (56.75%) had a poor prognosis based on the scoring system (average, 14.38 ± 3.98). Major contributors of this low score were the persistent pain (score 1 in 57.7% patients) and initial pain scale score (score 1 in 31.5% patients). Validity test showed that 6 parameters were all valid (p < 0.01). Reliability testing was done using Cronbach's alpha and found acceptable internal consistency (α = 0.767). Test-retest reliability was high. Moderate correlations were observed between the measures. Conclusions: PRO-BPI score is a valid and reliable scoring system in predicting the prognosis of TBPI.

The Role of Human Neural Stem Cell Secretomes on the Repair of Spinal Cord Injury Post-laminectomy in Rattus norvegicus Through the Analysis of Basso-Beattie-Bresnahan Score Locomotors, Interleukin-10, Matrix Metalloproteinase 9, and Transforming Growth Factor-ß.

STUDY DESIGN: Experimental animal study. PURPOSE: This study aims to investigate the effects of treatment with human neural stem cell (HNSC) secretomes on subacute spinal cord injury (SCI) post-laminectomy by analyzing interleukin-10 (IL-10), matrix metalloproteinase 9 (MMP9), transforming growth factor-ß (TGF-ß), and Basso-Beattie-Bresnahan (BBB) score locomotors as expressions of neurological recovery. OVERVIEW OF LITERATURE: In the United States, SCI has a recovery rate of 0.08%, tetraplegia 58.7%, and paraplegia 40.6%. Therapeutic approaches to SCI have focused on modulating the secondary cascade to prevent neurological deterioration and glial scar formation. Increasing evidence has shown that the success of cell-based SCI therapy is attributed to the secretomes rather than the cells themselves, but the effect of treatment with HNSC secretomes in SCI is unclear. METHODS: This experimental study investigated 15 Rattus norvegicus rats that were divided into three groups: (1) normal, (2) SCI+nonsecretome, and (3) SCI+secretome (30 µL, intrathecal Th10). Model subacute SCI post-laminectomy was performed in 60 seconds using an aneurysm Yasargil clip with a closing forceps weighing 65 g (150 kdyn). At 35 days post-injury, the specimens were collected, and the immunohistochemicals of IL-10, MMP9, and TGF-ß were analyzed. Motor recovery was evaluated based on the BBB scores. RESULTS: The SCI post-laminectomy of rats treated with HNSC secretomes showed improvements in their locomotor recovery based on the BBB scores (p =0.000, mean=18.4) and decreased MMP9 (p =0.015) but had increased the levels of IL-10 (p =0.045) and TGF-ß (p =0.01). CONCLUSIONS: These results indicate that the factors associated with the HNSC secretomes can mitigate their pathophysiological processes of secondary damage after SCI and improve the locomotor functional outcomes in rats.

The efficacy of topical adipose mesenchymal stem cell-conditioned medium versus framycetin gauze dressing in chronic plantar ulcer of leprosy: A randomized controlled trial.

Background Wound healing shows a unique interaction of several cells, growth factors and cytokines. The healing of chronic plantar ulcer of leprosy is influenced by various factors, one of which is the concentration of growth factors and cytokines related to the pathogenesis of impaired wound healing. Growth factors and cytokines can be found in the secretome of adipose mesenchymal stem cells. Aim To compare the effectiveness of topical adipose mesenchymal stem cell-conditioned medium and framycetin gauze dressing only on the healing of chronic plantar ulcer of leprosy. Methods In this randomised controlled trial, 32 patients with chronic plantar ulcer of leprosy were recruited. After detailed clinical and initial debridement, patients were randomised to two groups to receive either topical adipose mesenchymal stem cell-conditioned medium (n = 16) or framycetin gauze dressing only (n = 16) applied every three days for up to eight weeks, following which the ulcer size, adverse reactions and complications if any were monitored weekly. Results Healing percentage increased each week in all groups. Statistical differences between groups (P < 0.05) were observed from week 2 onwards for ulcer mean size reduction and from week 3 onwards for ulcer mean depth reduction. There were no adverse reactions or complications. Limitations Off-loading on subjects were not performed. Conclusion Adipose mesenchymal stem cell-conditioned medium is a potential therapeutic agent in the management of chronic plantar ulcer of leprosy.

The mechanism of human neural stem cell secretomes improves neuropathic pain and locomotor function in spinal cord injury rat models: through antioxidant, anti-inflammatory, anti-matrix degradation, and neurotrophic activities.

Background: Globally, spinal cord injury (SCI) results in a big burden, including 90% suffering permanent disability, and 60%-69% experiencing neuropathic pain. The main causes are oxidative stress, inflammation, and degeneration. The efficacy of the stem cell secretome is promising, but the role of human neural stem cell (HNSC)-secretome in neuropathic pain is unclear. This study evaluated how the mechanism of HNSC-secretome improves neuropathic pain and locomotor function in SCI rat models through antioxidant, anti-inflammatory, anti-matrix degradation, and neurotrophic activities. Methods: A proper experimental study investigated 15 Rattus norvegicus divided into normal, control, and treatment groups (30 µL HNSC-secretome, intrathecal in the level of T10, three days post-traumatic SCI). Twenty-eight days post-injury, specimens were collected, and matrix metalloproteinase (MMP)-9, F2-Isoprostanes, tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-ß, and brain derived neurotrophic factor (BDNF) were analyzed. Locomotor recovery was evaluated via Basso, Beattie, and Bresnahan scores. Neuropathic pain was evaluated using the Rat Grimace Scale. Results: The HNSC-secretome could improve locomotor recovery and neuropathic pain, decrease F2-Isoprostane (antioxidant), decrease MMP-9 and TNF-α (anti-inflammatory), as well as modulate TGF-ß and BDNF (neurotrophic factor). Moreover, HNSC-secretomes maintain the extracellular matrix of SCI by reducing the matrix degradation effect of MMP-9 and increasing the collagen formation effect of TGF-ß as a resistor of glial scar formation. Conclusions: The present study demonstrated the mechanism of HNSC-secretome in improving neuropathic pain and locomotor function in SCI through antioxidant, anti-inflammatory, anti-matrix degradation, and neurotrophic activities.

Morphology of Humeral Head and Glenoid in Normal Shoulder of Indonesian Population.

Purpose: Shoulder prostheses designed and used around the world may not fit an Asian shoulder. Normal shoulder morphology in Asian population had been reported, ie, Chinese, Indian, Japanese, and Thai populations, but no data from the Indonesian population. The aim of this study was to evaluate the three-dimensional (3D) morphology of the glenohumeral joint in the normal Indonesian population, identify its normal values, and compare them with those of other populations in the literature. Patients and Methods: Images for analysis were computed tomography (CT) scans of 85 normal shoulders from 71 patients who had CT scans for another diagnosis. Morphometry of the humeral head and glenoid were measured using 3D reconstruction. Gender differences and correlations between age, height, and glenohumeral morphometry were evaluated. Indonesians' glenohumeral morphometry was compared with those of other populations in the literature. Results: In the normal Indonesian population, the mean of humeral head inclination (HHI), height (HHH), diameter in sagittal plane (DS), diameter in frontal plane (DF), radius of curvature in sagittal plane (RS), and radius of curvature in frontal plane (RF) were 134.1°, 15.6mm, 39.3mm, 41.3mm, 20.4mm, and 21.4mm, respectively. The glenoid height (GH), upper width (GUW), lower width (GLW), inclination (GI), and version (GV) mean values were 34.2mm, 18.4mm, 24.5mm, 74.0mm, and 12.3mm, respectively. There was a significant difference in HHH, DS, DF, RS, RF, GH, GUW, GLW between males and females. Except for HHI and GI, glenohumeral morphometry was correlated with patient height. Age was not correlated with any glenohumeral morphometry. Conclusion: In the Indonesian population, males had a larger humeral head and glenoid than females, and the size of the humeral head and glenoid was correlated to body height. Indonesians' humeral head and glenoid sizes were smaller than those of Western populations, but close to those of other Asian populations.

Osteoblastogenesis of adipose-derived mesenchymal stem cells in chronic kidney disease patient with regular hemodialysis.

Background: Chronic kidney disease (CKD) is a health problem associated with high morbidity and mortality. Mineral and bone disorders are complications of CKD with a risk of fractures and cardiovascular disease. Mesenchymal stem cells can differentiate into osteoblasts and regulate their regulation by a network of cytokines and transcription factors. Objective: Analyzing differences in osteoblastogenesis of adipose mesenchymal stem cells in CKD patients and healthy people. Methods: The study sample was adipose mesenchymal stem cells from CKD patient undergoing hemodialysis and healthy people. Osteoblastogenesis was assessed by measuring the concentrations of transforming growth factor-ß1 (TGF-ß1), bone morphogenetic protein-2 (BMP-2), and (DKK-1) in culture media. The Elisa method measured the concentration of these parameters on days 4, 7, 14, and 21. Data were analyzed using an independent t-test and post hoc test with p-value <0.05. Result: There was a significant difference in CKD patients with increasing TGF-ß1 on day 4 (t = 2.821; 95% CI = 30,498-199,727; p = 0.010) and decreased on day 14. In the BMP-2 parameter, there was an increase on day 7 (t = 4.291; 95% CI = 0.289-0.831; p <0.001). Similar conditions were also found in the DKK-1 parameter, increasing on the 7th day, but there was no significant difference (p = 0.583). Conclusion: Osteoblastogenesis in adipose mesenchymal stem cells in CKD patients differs from that in healthy individuals. Osteoblasts fail in maturation and cause failure in matrix mineralization.

Adipose-Derived Stem Cells (ASCs) for Regeneration of Intervertebral Disc Degeneration: Review Article.

The intervertebral disc (IVD) is an important structure in the human body because it functions as a weight-bearing. This structure undergoes a process of degeneration like the rest of the body and this process is known as intervertebral disc degeneration (IDD) which is the most common cause of low back pain (LBP). The current common management, either conservative or surgical, is pain-relieving and has not been able to restore degenerated disc optimally. Changes in the IVD microenvironment in IDD conditions make it difficult for the regeneration process to occur. Research to reverse the degeneration process continues to develop, one of them is the use of adipose-derived stem cells (ASCs). ASCs is superior due to the ability to differentiate into several other cells such as adipocytes, chondrocytes, and osteoblasts, it also has ability to act as immunomodulators by stimulating the migration of immune cells to damaged tissues. ASCs becomes a good choice because it is easy to obtain, low donor site morbidity, high proliferation rate, and excellent differentiation abilities. Research on the optimal preparation process for ASCs and their application to various disorders continues to advanced. This study aims to review the potential use of ASCs for regeneration of intervertebral disc degeneration.

What is the Elbow Flexion Strength After Free Functional Gracilis Muscle Transfer for Adult Traumatic Complete Brachial Plexus Injuries?

BACKGROUND: Traumatic brachial plexus injuries (BPIs) in the nerve roots of C5 to T1 lead to the devastating loss of motor and sensory function in the upper extremity. Free functional gracilis muscle transfer (FFMT) is used to reconstruct elbow and shoulder function in adults with traumatic complete BPIs. The question is whether the gains in ROM and functionality for the patient outweigh the risks of such a large intervention to justify this surgery in these patients. QUESTIONS/PURPOSES: (1) After FFMT for adult traumatic complete BPI, what is the functional recovery in terms of elbow flexion, shoulder abduction, and wrist extension (ROM and muscle grade)? (2) Does the choice of distal insertion affect the functional recovery of the elbow, shoulder, and wrist? (3) Does the choice of nerve source affect elbow flexion and shoulder abduction recovery? (4) What factors are associated with less residual disability? (5) What proportion of flaps have necrosis and do not reinnervate? METHODS: We performed a retrospective observational study at Dr. Soetomo General Hospital in Surabaya, Indonesia. A total of 180 patients with traumatic BPIs were treated with FFMT between 2010 and 2020, performed by a senior orthopaedic hand surgeon with 14 years of experience in FFMT. We included patients with traumatic complete C5 to T1 BPIs who underwent a gracilis FFMT procedure. Indications were total avulsion injuries and delayed presentation (>6 months after trauma) or after failed primary nerve transfers (>12 months). Patients with less than 12 months of follow-up were excluded, leaving 130 patients eligible for this study. The median postoperative follow-up period was 47 months (interquartile range [IQR] 33 to 66 months). Most were men (86%; 112 of 130) who had motorcycle collisions (96%; 125 patients) and a median age of 23 years (IQR 19 to 34 years). Orthopaedic surgeons and residents measured joint function at the elbow (flexion), shoulder (abduction), and wrist (extension) in terms of British Medical Research Council (MRC) muscle strength scores and active ROM. A univariate analysis of variance test was used to evaluate these outcomes in terms of differences in distal attachment to the extensor carpi radialis brevis (ECRB), extensor digitorum communis and extensor pollicis longus (EDC/EPL), the flexor digitorum profundus and flexor pollicis longus (FDP/FPL), and the choice of a phrenic, accessory, or intercostal nerve source. We measured postoperative function with the DASH score and pain at rest with the VAS score. A multivariate linear regression analysis was performed to investigate what patient and injury factors were associated with less disability. Complications such as flap necrosis, innervation problems, infections, and reoperations were evaluated. RESULTS: The median elbow flexion muscle strength was 3 (IQR 3 to 4) and active ROM was 88° ± 46°. The median shoulder abduction grade was 3 (IQR 2 to 4) and active ROM was 62° ± 42°. However, the choice of distal insertion was not associated with differences in the median wrist extension strength (ECRB: 2 [IQR 0 to 3], EDC/EPL: 2 [IQR 0 to 3], FDP/FPL: 1 [IQR 0 to 2]; p = 0.44) or in ROM (ECRB: 21° ± 19°, EDC/EPL: 21° ± 14°, FDP/FPL: 13° ± 15°; p = 0.69). Furthermore, the choice of nerve source did not affect the mean ROM for elbow flexion (phrenic nerve: 87° ± 46°; accessory nerve: 106° ± 49°; intercostal nerves: 103° ± 50°; p = 0.55). No associations were found with less disability (lower DASH scores): young age (coefficient = 0.28; 95% CI -0.22 to 0.79; p = 0.27), being a woman (coefficient = -9.4; 95% CI -24 to 5.3; p = 0.20), and more postoperative months (coefficient = 0.02; 95% CI -0.01 to 0.05]; p = 0.13). The mean postoperative VAS score for pain at rest was 3 ± 2. Flap necrosis occurred in 5% (seven of 130) of all patients, and failed innervation of the gracilis muscle occurred in 4% (five patients). CONCLUSION: FFMT achieves ROM with fair-to-good muscle power of elbow flexion, shoulder abduction, and overall function for the patient, but does not achieve good wrist function. Meticulous microsurgical skills and extensive rehabilitation training are needed to maximize the result of FFMT. Further technical developments in distal attachment and additional nerve procedures will pave the way for reconstructing a functional limb in patients with a flail upper extremity. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Relationship Between Patient Factors and Clinical Outcomes of Free Functional Muscle Transfer in Patients with Complete Traumatic Brachial Plexus Injury.

Purpose: Traumatic brachial plexus injury (TBPI) causes severe disabilities to the patients, affecting not only upper limb function but also the psychosocial and economic aspects. Free functional muscle transfer (FFMT) is one of the reconstruction modalities for the management of TBPI. The aim of this study is to evaluate the functional outcomes and their correlation to patient factors. Patients and Methods: This is a retrospective study of 131 patients who suffered from complete TBPI (C5-T1) and were treated with the FFMT procedure to restore elbow flexion and wrist extension from 2010 to 2018 in our institution. We evaluated the active range of motion (AROM), muscle power with MRC (Medical Research Council) scale, DASH score, and complications, with a minimum of 12-month follow-up. Results: Following FFMT surgery, elbow flexion was significantly and successfully restored (MRC ≥ 3) in 75.5% of patients with an average AROM of 88.17 ± 41.29°. The wrist extension was restored in 42% of the patients with an average AROM of 20.69 ± 18.72°. There was no correlation between age, side of injury, and time to surgery with the functional outcomes. There was a weak correlation between education level, rehabilitation compliance, and elbow functional outcomes. Conclusion: FFMT is a reliable surgical option to restore elbow flexion in TBPI with a high satisfactory result. Our findings suggested that the FFMT indication is potentially expanded regardless of the patient factors.

Hypoxia Effects in Intervertebral Disc-Derived Stem Cells and Discus Secretomes: An in vitro Study.

Background: This study aimed to investigate the effects of hypoxia and normoxia preconditioning in rabbit intervertebral disc-derived stem cells (IVDSCs) and discus-derived conditioned medium (DD-CM)/secretomes in vitro. Transforming growth factor (TGF)-ß1, platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), and vascular endothelial growth factor (VEGF) have a role in the proliferation, development, differentiation, and migration of MSCs. Materials and Methods: Intervertebral discs were isolated from rabbit and incubated in normoxia and hypoxia 1%, 3%, and 5% (hypoxia groups) condition. Cell counting was performed after 24 hours of manipulation, then analyzed using one-way ANOVA. TGF-ß1, PDGF, FGF, and VEGF were measured using the ELISA. Results: The highest number of cells was in the hypoxia 3% preconditioning compared to the normoxia, hypoxia 1%, and hypoxia 5% groups. Hypoxia 3% also had the highest increase in PDGF protein production compared to normoxia, with hypoxia 1% and 5%. Among hypoxia groups, the highest secretions of VEGF and FGF proteins were in the hypoxia 3% group. Based on TGF-ß1 protein measurement, the hypoxia 1% group was the highest increase in this protein compared to other groups. Conclusion: Oxygen level in hypoxia preconditioning has a role in the preparation of IVDSCs and secretome preparation in vitro. The highest cell numbers were found in the treatment group with 3% hypoxia, and 3% hypoxia was significantly related to support IVDSCs preparation. Preconditioning with 3% hypoxia had higher PDGF and VEGF levels than other hypoxia groups.