Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study.

Background Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

Outcomes After Surgically Managed Oblique Extra-Articular Proximal Phalanx Fractures: A Comparison of Closed-Reduction Percutaneous Pinning and Open-Reduction Internal Fixation With Lag Screws.

BACKGROUND: Long oblique extra-articular proximal phalanx fractures are common orthopedic injuries. When unstable and without substantial comminution, treatment options include closed-reduction percutaneous pinning (CRPP) and open-reduction internal fixation using lag screws (ORIF-screws). The aims of this study are primarily to compare the functional outcomes and complication rates between these techniques and secondarily to assess potential factors affecting outcomes after surgery. METHODS: All patients with long oblique extra-articular proximal phalanx fractures treated surgically within a single orthopedic institution from 2010 to 2017 were identified. Outcome measures and complications were assessed at the final follow-up. RESULTS: Sixty patients were included in the study with a mean time to the final follow-up of 41 weeks (range: 12-164 weeks). Thirty-four patients (57%) were treated with CRPP and 26 patients (43%) with ORIF-screws. The mean Disabilities of the Arm, Shoulder, and Hand score across both fixation types was 8 (range: 0-43) and did not differ significantly between the 2 groups. Mean proximal interphalangeal extension at the final follow-up was 9° short of full extension after CRPP and 13° short of full extension after ORIF-screws. The rates of flexion contracture and extensor lag were 15% and 41% in the CRPP group compared with 12% and 68% in the ORIF-screws group. Reoperation rates and complication rates did not differ significantly between fixation strategies. CONCLUSIONS: Acceptable outcomes can be achieved after surgical fixation of long oblique extra-articular proximal phalanx fractures using both CRPP and ORIF-screws. Extensor lag may be more common after ORIF-screws.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy.

BACKGROUND: The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy. METHODS: We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6. RESULTS: The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group. CONCLUSION: Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

Evaluation of the Incidence and Etiology of Unplanned Return to Operating Room Following Open Reduction Internal Fixation of Distal Radius Fractures.

BACKGROUND: Distal radius fractures (DRF) are the most common upper extremity fractures in adults. The purpose of this study was to determine the incidence, causes, and independent predictors for unplanned return to the operating room (URTO) in a single institution within 90 days following distal radius open reduction internal fixation (ORIF). METHODS: A retrospective study of 2933 consecutive patients from January 2015 to December 2019 who underwent distal radius ORIF was undertaken. Patients who returned to the operating room within 90 days of the index procedure were identified. Patients with planned return to the operating room for staged procedures were excluded, yielding a patient cohort of those with URTO. Demographic data, causes for reoperation, and final Quick Disabilities of the Arm, Shoulder and Hand DASH (QuickDASH) scores were collected. RESULTS: Overall, 45 patients had URTO (1.5%) occurring a mean of 44 (6-89) days from the index procedure. Reasons for reoperation included nerve complications (n = 14), loss of fixation (n = 11), hardware complications (n = 9), wound complications (n = 7), and tendon complications (n = 4). Neurologic reasons for return included carpal tunnel release (n = 13) and ulnar nerve decompression (n = 1). QuickDASH scores were higher for URTO compared with control cohort at the final follow-up (33 [range: 0-91] vs 14 [range: 0-100], P < .01). CONCLUSIONS: Mechanical hardware failure and neurologic symptoms were the most common reasons for URTO after distal fracture ORIF.

"Age Is Just a Number": Distal Radius Fractures in Patients Over 75.

Background: Management of distal radius fractures in patients over 65 is a topic of significant study, but there are variations within this group in terms of independence and activity level. This study compares the outcomes of operative distal radius fracture treatment in patients over 75 with those aged 65 to 74, to evaluate the effects of patient demand and advanced age on outcome. Methods: A retrospective review of a single-institution distal radius fracture database was performed. All patients over age 65 were evaluated for inclusion. Patient factors including activity, independence level, and quick disabilities of the arm, shoulder and hand (QuickDASH) score were recorded. Patients were selected for open reduction and internal fixation (ORIF) based on a discussion between the patient and the treating surgeon. Outcome measures including QuickDASH were recorded at 1-year post-injury. Patients aged 65 to 74 and 75 and over were compared to evaluate for demographic, functional, and outcome differences. Results: In all, 75 patients were included in the study. Fifty-one patients were aged 65 to 74, and 24 patients were aged over 75. The majority of patients rated themselves as "completely independent" and "active," the highest levels of each. There was no difference in QuickDASH scores between those patients who rated themselves as completely partially independent, or active versus moderately active. There was no statistically significant difference in QuickDASH or range of motion parameters at final follow-up. Conclusions: This study demonstrates that, in a group of patients with high levels of independence and activity, outcomes are similar in patients aged 65 to 74 and over 75 at 1 year following distal radius ORIF.

Blocking Screw Technique for Maintaining Reduction during Intramedullary Screw Fixation of Oblique Metacarpal Fractures.

Intramedullary screw fixation provides a less-invasive means of surgically managing metacarpal fractures. While there are advantages to using this technique compared to CRPP and ORIF, disadvantages of intramedullary screw fixation include loss of reduction intraoperatively due to sagittal and coronal plane translation. The blocking screw technique has been previously described as a solution for this problem in intramedullary fixation of long bone fractures. We describe the blocking screw technique as applied to aid intramedullary screw fixation of metacarpals.

Reliability of Routine Radiographs for Conservatively Treated Metacarpal Shaft and Neck Fractures.

Background: To investigate the reliability of orthopedic hand surgeons to evaluate radiographic healing in initial and follow-up radiographs of the conservatively treated metacarpal shaft and neck fractures. The rationale for this study was to reduce the rate of unnecessary, routine radiographs when treating metacarpal fractures. Methods: Forty sets of digital x-rays, twenty at the initial visit and twenty at the 4-week follow-up, were randomly selected and reviewed. Three hand surgeons evaluated the x-rays for (1) fracture location, (2) radiograph timing, (3) healing status, (4) percentage healed, (5) angulation, and (6) confidence in healing status. Observers reviewed studies in random order and evaluated the same set of radiographs one month after the initial review. Intra- and interobserver agreements were analyzed using Fleiss' kappa (κ) for all parameters and all possible observer pairings. Results: Interobserver and intraobserver reliability was highest when evaluating fracture location and lowest when assessing the percentage healed. The interobserver reliability was fair for radiograph timing and healing status and fair-to-moderate for angulation. The intraobserver reliability was moderate for radiograph timing and healing status and moderate-to-substantial for angulation. Observers correctly differentiated initial vs. follow-up images 62% of the time and reported to feel somewhat certain in their evaluation of healing status. Conclusion: When evaluating initial and 4-week follow-up radiographs, hand surgeons were somewhat confident in their assessment of healing but had less than substantial intra- and interobserver reliability following radiographic evaluation. Due to their poor reproducibility, routine radiographs may be unnecessary when evaluating conservatively treated metacarpal fractures. Further studies and guidelines that identify clear indications for the use of routine imaging in metacarpal fracture care are warranted.

Early Retrieval of Spanning Plates Used for Fixation of Complex Fractures of the Distal Radius.

Background Spanning plates are being increasingly used for the treatment of complex fractures of the distal radius. The traditional recommendation is to leave the hardware in place for at least 12 weeks. Questions/Purpose This study assesses the comparative outcomes of spanning plates removed at or before 10 weeks. We hypothesized that acceptable healing and functional outcomes can be achieved with earlier hardware removal to allow for earlier range of motion, rehabilitation, and return to function. Patients and Methods All patients treated for a comminuted, intra-articular distal radius fracture with a temporary spanning plate were identified. Outcomes of bridge plates removed before 10 weeks were compared with plates removed after 12 weeks. Twenty patients in the short duration cohort were compared with 40 patients in the long duration cohort. Results All fractures healed and there were 10 complications (4 short duration, 6 long duration) and 2 reoperations (1 short duration, 1 long duration) in the study population. There were no significant differences in final Quick-DASH scores (27.4 short duration, 20.9 long duration) or radiographic alignment. Mean values for wrist extension and ulnar deviation were significantly worse in the long duration cohort, although these differences are of unclear clinical significance. Conclusion It may be safe to remove spanning bridge plates earlier than what is traditionally recommended. Plate removal at or before 10 weeks did not detract from healing or radiographic alignment. Prospective investigations assessing the optimal duration of fixation for this technique are needed. Level of Evidence This is a Level IV study.

Baseball Injuries of the Hand and Wrist.

Injuries of the hand and wrist are common in baseball. Because of the unique motions and loads encountered in this sport, physicians treating baseball players may encounter hand and wrist injuries ranging from common to rare. An understanding of these baseball-related injuries must include their pathoanatomy, diagnosis, and treatment options. This knowledge is critical for the general orthopaedic surgeon treating baseball players to allow for timely and appropriate treatment. This article reviews the pathophysiology, diagnosis, and treatment of baseball-related hand and wrist injuries, with a target audience of general orthopeadic surgeons.

Reliability of Radiographs and Computed Tomography in Diagnosing Scaphoid Union After Internal Fixation.

PURPOSE: To evaluate the reliability of radiographs (XR) alone versus the combination of XR and computed tomography (CT) in determining scaphoid union following open reduction internal fixation (ORIF) with a headless compression screw. METHODS: We used our imaging database to identify 32 XR and corresponding CTs over a 6-year period (from 2012 to 2018) that were performed to evaluate scaphoid healing following ORIF. Three hand surgeons evaluated the studies to assess (1) healing, (2) if partially healed, the percentage of healing, and (3) the certainty of healing. Initially, XR were reviewed alone. Three weeks later, the same XR were reviewed with the corresponding CTs. Each reviewer performed a similar 2-stage evaluation 4 weeks later. We measured interobserver and intraobserver reliabilities using linearly weighted kappa (κ) coefficients for healing status and the percentage of healing. RESULTS: The interobserver reliability for healing (healed vs partially healed vs not healed) was moderate both with XR alone and with the combination of XR and CT. The intraobserver reliability for healing was substantial with XR alone compared to moderate with the combination of XR and CT. For the percentage of healing, both interobserver and intraobserver reliabilities were fair with XR alone or with the combination of XR and CT. Reviewers reported significantly greater certainty with the combination of XR and CT compared with XR alone. CONCLUSIONS: Following ORIF, surgeons are more certain in their evaluation of scaphoid healing with the combination of CT and XR. However, the reliability of assessing scaphoid union may not be improved by the addition of CT to XR. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Are Plain X-Rays Necessary in the Diagnosis of De Quervain's Tenosynovitis?

Background The routine use of plain radiography represents a significant expenditure and has been proven unnecessary in several orthopedic conditions. The utility of plain radiographs in the diagnosis of De Quervain's tenosynovitis (DeQ) is not clear. Questions/Purpose This study evaluates whether plain radiographic findings routinely predict the need for surgery or alter treatment courses in the initial diagnosis of DeQ. Patients and Methods A total of 200 patients who received wrist X-rays and had a diagnosis of DeQ were retrospectively selected at random. Their images were evaluated for relevant findings, including radial styloid abnormalities, arthritis, and tendon calcification. A chart review was performed to determine whether these X-rays altered the treatment courses. Results Of the 200 patients, 141 (69.1%) cases had at least one positive radiographic finding. Carpometacarpal joint (CMC) arthritis was the most common finding, seen in 63 (30.9%) cases. Of all patients, 141 (69.1%) were treated with corticosteroid injection only, 54 (26.5%) with corticosteroid injection and ultimately surgery, and 9 (4.4%) with surgery alone. There were no significant differences in the rates of surgery with positive X-ray findings. There were no cases in which radiographic findings resulted in a change in management, per the report of the treating physician. Conclusions Despite the high proportion of positive findings on X-ray, no radiographic findings altered the course of treatment in patients with isolated DeQ. Obtaining plain radiographs for isolated DeQ represents a significant cost and should be reserved for cases in which the results are preemptively deemed likely to influence the treatment course. Level of Evidence This is a level IV study.

Carpal Tunnel Syndrome Surgery: What You Should Know.

Carpal tunnel release (CTR) surgery continues to evolve. Carpal tunnel syndrome remains a primarily clinical diagnosis, although ultrasound has supplemented electrodiagnostic testing as a confirmatory tool. Magnetic resonance imaging of the carpal tunnel has also showed some promise as an alternative method for the examination of the median nerve. Open CTR surgery remains the traditional, and most popular, method of CTR. Wide-Awake, with Local Anesthesia only, and No Tourniquet CTR has emerged as a means to decrease cost and improve pain control and convenience for patients. Endoscopic CTR is increasing in popularity due to its more rapid recovery. The safety profile of endoscopic CTR has improved, and recent studies show similar rates of major complications between open and endoscopic techniques. Nonsurgeon operated ultrasound-guided techniques for release of the transverse carpal ligament have emerged. While promising in early studies, the current evidence in their favor is limited in terms of patient numbers and direct comparison with other techniques. The outcomes of CTR continue to be excellent. Recent research has demonstrated that nerve conduction continues to recover postoperatively over a longer period of time than previously believed. Patient psychological factors play a significant role in outcomes after surgery but do not appear to limit the improvement provided by intervention.

Ultrasound Evaluation for Incomplete Carpal Tunnel Release.

Background: Ultrasound can provide evaluation of the anatomy of the carpal tunnel in a convenient, noninvasive office setting. This study is intended to determine the accuracy and diagnostic performance of ultrasound, used by surgeons, for the evaluation of completeness of carpal tunnel release (CTR). Methods: Ten cadaver arms underwent randomized sectioning of 0%, 25%, 50%, 75%, or 100% of the transverse carpal ligament. Following a brief training session, a blinded observer used ultrasound to evaluate the percentage of the transverse carpal ligament release. The release amount was then confirmed with an open exposure of the transverse carpal ligament. Results: Cronbach α and Pearson correlation coefficients were 0.92 and 0.87, demonstrating excellent reliability and validity of the technique. Diagnostic performance including sensitivity, specificity, positive predictive value, and negative predictive value was 100%, 75%, 86%, and 100%, respectively, for the diagnosis of incomplete release of the transverse carpal ligament by a novice sonographer orthopedic surgeon. Conclusions: The ultrasound is a highly accurate tool for the diagnosis of incomplete transverse carpal ligament release and requires a minimal amount of training to use for this purpose. It provides a rapid means of diagnosing incomplete release of the transverse carpal ligament following CTR.

Open Fractures of the Hand: Review of Pathogenesis and Introduction of a New Classification System.

Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture.

Endoscopic Carpal Tunnel Release with and without Sedation.

BACKGROUND: This study evaluated outcomes and complications with endoscopic carpal tunnel release performed with local anesthesia only versus local anesthesia with sedation. The authors hypothesized that patient outcomes and satisfaction would be equivalent in both groups irrespective of anesthesia type. METHODS: One hundred fifty-four consecutive patients undergoing endoscopic carpal tunnel release with local anesthesia either with or without sedation were prospectively enrolled in a study of satisfaction and outcomes. Patients were surveyed preoperatively and at 2 weeks and 3 months postoperatively to evaluate satisfaction, symptoms, complications, and disability using the 11-question Disabilities of the Arm, Shoulder, and Hand questionnaire survey; the Levine-Katz carpal tunnel survey; and a customized Likert scale. RESULTS: The hypothesis was upheld. Patients reported high levels of satisfaction (96 percent in the local anesthesia group and 93 percent in the local anesthesia with sedation group at 3 weeks). Disability, pain, and symptom scores did not differ significantly between groups at either postoperative time point. After surgery, patients in the sedation group recalled more mean preoperative anxiety (four of 10 versus 2.03 of 10 at 3 months). If they were to undergo surgery again, patients in the sedation group were likely to desire either sedation (68 percent) or general anesthesia (29 percent), whereas patients in the local anesthesia-only group were likely to wish for similar local-only anesthesia (78 percent). There were no reoperations or epinephrine-related complications in either group. CONCLUSIONS: Patients undergoing endoscopic carpal tunnel release with the local anesthesia or local anesthesia plus sedation experience similar levels of satisfaction and outcomes. Both methods of anesthesia provide excellent results and allow surgeons and patients to choose freely between the two anesthetic techniques.

Open Carpal Tunnel Release Outcomes: Performed Wide Awake versus with Sedation.

Background Carpal tunnel release (CTR) is the most common surgery of the hand, and interest is growing in performing it under local anesthesia without tourniquet. To better understand differences, we hypothesized that patients undergoing CTR under wide-awake local anesthesia with no tourniquet (WALANT) versus sedation (monitored anesthesia care [MAC]) would not result in a difference in outcome. Methods Consecutive cases of electrodiagnostically confirmed open CTR across multiple surgeons at a single center were prospectively enrolled. Data included demographic data, visual analog scale, Levine-Katz carpal tunnel syndrome scale, QuickDASH questionnaire, customized Likert questionnaire, and complications. Results There were 81 patients enrolled in the WALANT group and 149 patients in the MAC group. There were no reoperations in either group or any epinephrine-related complications in the WALANT group. Disability and symptom scores did not differ significantly between WALANT and sedation groups at 2 weeks or 3 months. Average postoperative QuickDASH, Levine-Katz, and VAS pain scales were the same in both groups. Both groups of patients reported high levels of satisfaction at 91 versus 96% for the WALANT versus MAC groups, respectively ( p > 0.05). Patients in each group were likely to request similar anesthesia if they were to undergo surgery again. Conclusion Patients undergoing open CTR experienced similar levels of satisfaction and outcomes with either the WALANT or MAC techniques. There was no statistically significant difference between either group relative to the tested outcome measures. These data should facilitate surgeons and patients' choosing freely between WALANT and MAC techniques relative to complications and outcomes.

Patient-Reported Disability Measures Do Not Correlate with Electrodiagnostic Severity in Carpal Tunnel Syndrome.

BACKGROUND: Electrophysiologic studies including electromyography and nerve conduction studies play a role in the evaluation of carpal tunnel syndrome (CTS), despite evidence that these studies do not correlate with CTS-specific symptom scores. There is a lack of evidence comparing electrophysiologic data with general measures of function. METHODS: Fifty patients presenting for CTS treatment over an 8-month period were analyzed retrospectively. All patients completed surveys including the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and the Medical Outcomes Study 12-Item Short-Form Survey [(physical component summary 12, mental component summary (MCS-12)]. Electromyography and nerve conduction studies were performed on all patients and compared with outcome scores. RESULTS: Analysis demonstrated no relationship between DASH or MCS-12 and electrodiagnostic severity. No significant correlations were noted between DASH or MCS-12 and median motor or sensory latency. There was a moderate-weak correlation (rho = 0.34) between more severe electrophysiologic grade and better function based on physical component summary 12. CONCLUSIONS: Electrodiagnostic severity grades do not correlate with patient-reported disability, including the DASH and MCS-12 surveys. There is a counterintuitive correlation between more-severe electrodiagnostic findings and decreased physical disability. These findings indicate that disability may not correlate with electrodiagnostic severity of median neuropathy in CTS.

Prospective Evaluation of Sleep Improvement Following Carpal Tunnel Release Surgery.

PURPOSE: Sleep disturbance due to nighttime awakening is a well-documented symptom of carpal tunnel syndrome. While relief of nighttime waking following carpal tunnel release (CTR) has been demonstrated, the effect of CTR on overall sleep quality has not been fully investigated. We hypothesized that CTR would result in significant improvement in overall sleep quality as well as patients' overall satisfaction with their sleep habits. METHODS: Cases of carpal tunnel syndrome with positive nerve studies, and treated with CTR, were prospectively enrolled. Demographic data, electromyography (EMG) severity, Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, and Insomnia Severity Index (ISI) scale data were collected. RESULTS: A total of 398 patients were enrolled, with 99% available at 2 weeks and 64% available at 3-month final follow-up. At final follow-up, average Quick Disabilities of the Arm, Shoulder, and Hand score improved significantly from the preoperative value. Average ISI score on all 7 sleep categories on the survey improved significantly from before surgery to the first postoperative visit. However, the total ISI score did not further improve significantly between the 2-week and the 3-month postoperative visits. The ISI score improvements did not correlate with EMG severity. CONCLUSIONS: Patients undergoing CTR demonstrated significant improvement in mean scores for 7 aspects of sleep quality. Sleep improvement was unrelated to preoperative EMG severity and was experienced within 2 weeks of surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Open Fractures of the Hand: Review of Pathogenesis and Introduction of a New Classification System.

Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture.

Molecular expression of acute phase mediators is attenuated by machine preservation in human liver transplantation: preliminary analysis of effluent, serum, and liver biopsies.

BACKGROUND: Hypothermic machine perfusion (HMP) mitigates the effects of ischemia/reperfusion injury (IRI) in renal transplantation and preclinical work with livers. In liver transplantation, IRI increases the likelihood of primary graft dysfunction and is associated with significant morbidity. We recently completely the first phase 1 clinical trial of liver HMP at our center, and demonstrated improved clinical parameters and shorter duration of stay for patients who received grafts stored by HMP than patients who received grafts preserved in cold storage. Biomarker analysis of venous effluent collected from the hepatic veins during HMP may yield predictive information reflecting the condition of the donor liver, such as graft injury sustained during brain death and graft preservation. The aim of this study was to characterize biomarkers released into the effluent during HMP. METHODS: Effluent was collected every 30 minutes during liver HMP during our phase 1 clinical trial. Serum was extracted from blood samples obtained at incision, before explantation, and at 1, 2, and 3 hours after reperfusion. The effluent and serum samples were assayed in multiplex to determine the concentration of inflammatory cytokines and growth factors. Tissue obtained from liver biopsies was processed for either downstream reverse transcription-polymerase chain reaction or immunofluorescence. Statistical significance was determined by a two-tailed t-test. RESULTS: Growth factors and most cytokines were not readily detectable in levels above baseline with this technique; however, interleukin-1 (IL-1) receptor antagonist and monocyte chemotactic protein-1 were present in significant concentrations in the effluent at all time points. This finding was confirmed with serum samples and mRNA expression obtained from liver biopsies. The concentrations of these proteins decreased from their initial values over the course of HMP, and mRNA expression levels were decreased by the use of HMP. CONCLUSION: IL-1ß and tumor necrosis factor (TNF)-α are key mediators of inflammation in IRI. Although difficult to measure because of short half-lives, their downstream effectors indicate their levels of activity. IL-1 receptor antagonist is secreted in response to IL-1ß, and monocyte chemotactic protein in response to TNF-α. Their decreased production over the course of HMP suggests that interruption of acute-phase inflammation in the graft may attenuate reperfusion-related graft injury. Further cDNA studies and effluent analyses are required to confirm this hypothesis.