Nerve regeneration conduit from inverted human umbilical cord vessel in the treatment of proper palmar digital nerve sections.

Treatment of digital nerve injuries, particularly in case of a gap, is challenging. Recovery of finger sensitivity is often incomplete and can impair personal and occupational activity. The need for better nerve regeneration has given rise to alternative treatments such as nerve conduits. This study aimed to evaluate the safety and efficacy of a conduit of freeze-dried inverted human umbilical cord vessel for regeneration in digital nerve section. Twenty-three patients with a mean nerve gap of 6.11 mm (range 2-30 mm and static 2-point discrimination (s2PD) > 15 mm underwent surgical repair of digital nerve section using a nerve regeneration conduit. The primary endpoint was recovery of sensitivity after conduit implantation. Secondary endpoints comprised progression of pain, functional symptoms, pressure threshold, hand-specific symptoms and disabilities, and restored innervation. Mean follow-up was 10.1 ± 4.1 months (range 1-14 months). Sensitivity recovered progressively in the months following implantation. There was a mean decrease of 8.54 mm in s2PD between baseline and last follow-up (p < 0.001). Complete innervation recovered in 83.3% of cases at last follow-up. Pressure threshold and hand-related quality of life improved significantly and symptoms due to nerve sectioning (pain, cold intolerance, hypoesthesia, hyperesthesia) resolved almost completely. There were no safety issues related to the nerve conduit. These results indicate that freeze-dried inverted human umbilical vessels can be a safe and effective option as conduit for digital nerve regeneration.

Spontaneous index finger extensor tendon rupture in a SNAC wrist.

We present two recent cases of spontaneous rupture of both index finger extensor digitorum communis and extensor indices proprius tendons caused by a dorsal carpus osteophyte. Both patients had a history of scaphoid fracture non-union with evolution to scaphoid non-union advanced collapse (SNAC) of the wrist. These two cases were treated surgically with a 3-corner arthrodesis, and an interposition of a fragment of one of both ruptured tendons together with a tendon transfer of a supernumerary extensor digitorum communis of the third finger. The interposed tendon fragment was sutured with a Pulvertaft weave proximally and end-to-end distally. The supernumerary tendon was added as reinforcement to this construction. At 6-month and 14-month follow-up, the patients had a slight decrease in range of motion and functionality without hindering the activities of daily living and a great improvement in strength. Isolated extension of the index finger was possible minimum 6 months postoperatively. Spontaneous tendon ruptures of the finger extensors are not common but were described earlier in literature. Recent literature described that underlying cause of a spontaneous tendon rupture should always be corrected in order to prevent or at least delay future ruptures. To our knowledge, this is a rare type of complication and this kind of treatment has never been reported in literature.

Osteotomies around the thumb base in CMC 1 arthritis.

The trapeziometacarpal joint (TMC) is a saddle joint that is subjected to tremendous repetitive loads through our lifetime. This joint is apparently congruent, but only a small part of the articular surface is loaded during pinch grips. This design implies a perfect bony anatomy, high quality articular cartilage and no ligament laxity. Under certain circumstances, where these different anatomical variables are imperfect, symptoms and pain can start at a very early stage in life. They are mainly acquired, but can be posttraumatic in origin. High quality radiographic views are needed: these radiographs must be done methodically by well-trained radiologists. The symptoms and radiographic changes may not match, such as when radiographic changes are minimal but functional impairment is significant. The primary goal of treatment is conservative. This cannot be stressed enough since conservative treatment can be successful with good follow-up by the hand surgeon: resting splint, good postures at work and if necessary, anti-inflammatory drugs and paracetamol. If this fails after a minimum of 6 months, different osteotomies can be proposed, combined with ligament augmentation in some cases. These osteotomies are mainly extra-articular, can be at the level of the base of the first metacarpal and the trapezium, or can be solely at the base of the first metacarpal. Isolated osteotomies of the trapezium should be avoided since they tend to close the first web space. In certain posttraumatic cases, intra-articular osteotomy of the malunion can be done to restore congruency and provide pain relief.

Radiological measurement of trapezial dysplasia - variation of trapezial tilt and trapezial inclination.

Trapeziometacarpal instability is a well-known condition that could lead to trapeziometacarpal osteoarthritis. With the focus in the literature being on ligament insufficiency, bony deformity has received much less attention. Although trapezial tilt is currently used to measure trapezial dysplasia, we believe trapezial inclination is a more reliable measurement. The purpose of this study is to compare these two methods for evaluating trapezial dysplasia and to define the most reproducible measurement. Fifty patients were identified who had three consecutive radiographs of the trapeziometacarpal joint. Eaton views with little to no signs of osteoarthritis (Eaton stage I or II) were used. Both trapezial tilt and trapezial inclination were measured by two independent observers on three radiographs for every patient. Intra-observer variation, absolute agreement and consistency, and intra-observer variation and consistency were assessed for both measurements. Mean trapezial tilt was 135° and mean trapezial inclination was 10°. For both observers, intra-observer variation of trapezial inclination was significantly less than for trapezial tilt. Our study shows that mean trapezial inclination in a middle-aged adult population is approximately 10°. This measurement is more reproducible than the more frequently used trapezial tilt and may be a better parameter to define trapezial dysplasia and to guide its treatment.

Scaphometacarpal arthrodesis with autologous structural bone graft as a salvage procedure after failed trapeziectomy - Surgical technique and initial results.

Painful instability due to proximal migration of the first metacarpal remains a challenging problem in patients who have undergone multiple surgeries for trapeziometacarpal osteoarthritis. The objective of this study was to investigate whether scaphometacarpal (SMC) arthrodesis with a structural bone graft is an acceptable and definitive salvage procedure for the multioperated patient. Three patients underwent SMC arthrodesis using a structural iliac crest bone graft. All patients had symptomatic instability of the thumb base and had undergone three to four surgeries prior to the arthrodesis. All patients were satisfied with the outcomes. Mean opposition decreased from 8 to 7 and mean retropulsion remained at 1. Mean grip strength increased from 3.5 to 10.5kg and mean precision pinch strength increased from 1.5 to 2.5kg. Fusion was confirmed in all patients. SMC arthrodesis with a structural bone graft is an acceptable procedure that largely preserves thumb opposition and restores stability with increased grip and pinch strength. Although far from ideal, it can be considered as a definitive salvage procedure in patients who have already had multiple surgeries to the trapeziometacarpal joint.

Treatment of Dupuytren's disease using one full dose of Clostridiumhistolyticum collagenase at a lower concentration: Retrospective analysis of clinical outcomes.

Clostridiumhistolyticum collagenase (CHC) is rapidly becoming a mainstream treatment option for Dupuytren's disease for hand surgeons. We performed a retrospective study of the efficacy of this substance at a lower concentration, but a higher total dose than recommended by the manufacturer. Thirty-nine patients with 43 affected hands were treated and analyzed at a mean follow-up of 27 months. Subgroup analysis was done for patients who received treatment in one or two joints (group A), and for patients who received treatment in more than two joints (group B). We found that our CHC solution is safe and effective when simultaneously treating as many as four joints affected by Dupuytren's disease. Patients in group B had a lower (but non-significant) treatment failure rate compared to patients in group A. Also, higher satisfaction rates were observed in group B, again non-significant. No major complications were observed in any group. CHC use is associated with only minor complications. The results are consistent even when up to four joints are treated with one dose. LEVEL OF EVIDENCE: III.

Skin grafting the contaminated wound bed: reassessing the role of the preoperative swab.

OBJECTIVE: To investigate use of the preoperative wound swab to predict graft failure compared with establishing the indication for skin grafting on clinical grounds alone. METHOD: Patients requiring meshed split-thickness skin grafting were prospectively included; the indication for grafting was established on clinical grounds exclusively. A preoperative swab of the wound bed was taken, but its result was concealed to prevent it influencing clinical decision-making. Negative pressure wound therapy (NPWT) was used for both wound bed preparation and graft fixation.After 2 months, graft area take percentage was measured using digital image processing software and the results validated against the result of the preoperative wound swab. RESULTS: Eighty-seven wounds were included in the study. Mean graft area take percentage was 88%,with five grafts considered complete failures(< 25% take).A posteriori analysis of the wound cultures showed that 53% had been contaminated on grafting, but these did not fare any worse than near-sterile wounds. Qualitative analysis of cultures showed that wounds containing either Pseudomonas aeruginosa or Staphylococcus aureus did have inferior outcome (mean take percentage 78.9% vs 91.3%; p=0.038).Diabetes was also a deteriorating factor (mean take percentage 83.0% vs 90.7%; p=0.004). CONCLUSION: Establishing the indication for skin grafting on clinical grounds exclusively does not yield grossly inferior results. In light of recent advances in skin grafting, including use of NPWT as adjuvant therapy, the requirement for routine preoperative wound swabs may be questioned.