Shin, Alexander Y.

The purpose was to determine if smartphone photography is a reliable tool in measuring wrist movement. Smartphones were used to take digital photos of both wrists in 32 normal participants (64 wrists) at extremes of wrist motion. The smartphone measurements were compared with clinical goniometry measurements. There was a very high correlation between the clinical goniometry and smartphone measurements, as the concordance coefficients were high for radial deviation, ulnar deviation, wrist extension and wrist flexion. The Pearson coefficients also demonstrated the high precision of the smartphone measurements. The Bland–Altman plots demonstrated 29–31 of 32 smartphone measurements were within the 95% confidence interval of the clinical measurements for all positions of the wrists. There was high reliability between the photography taken by the volunteer and researcher, as well as high inter-observer reliability. Smartphone digital photography is a reliable and accurate tool for measuring wrist range of motion. Level of evidence: II

BackgroundThe purpose of this study was to identify which triple immunosuppressive protocols, currently used for vascularized composite allotransplantation in the clinic, will have the best effect on motor function recovery following nerve allograft reconstruction.MethodsEighty‐eight Lewis rats underwent a 1‐cm sciatic nerve allograft transplantation and skin graft from 44 Brown‐Norway rats. Group I received 0.9% isotonic saline (control); Group II, 2 mg/kg FK506; Group III, 1 mg/kg FK506 with 15 mg/kg mycophenolate mofetil (MMF); and Group IV, 2 mg/kg FK506 with 30 mg/kg MMF and prednisone. Each group consisted of 11 rats. After 12 weeks, motor function recovery was evaluated with isometric tetanic force, muscle mass, ankle contracture angle, electrophysiology, and nerve histomorphometry. Adequacy of immunosuppression was monitored with the transplanted skin graft. All data are expressed as a percentage of the contralateral side.ResultsIsometric tetanic force showed significantly better functional recovery in all groups treated with immunosuppression compared to control. Within the immunosuppression groups no significant difference was found: 42.1 ± 6.4% (Group I), 56.1 ± 12.4% (Group II), 58.4 ± 10.7% (Group III), and 61.3 ± 11.2% (Group IV). Group IV was superior to all other groups regarding ankle contracture (P < .05) and electrophysiology (P < .001). Skin graft rejection occurred in 41 and 0% (Groups III and IV, respectively).ConclusionsFK506 significantly enhanced motor recovery after allograft reconstruction. This effect was comparable between combination treatment (low‐dose FK506 and MMF) and triple therapy (high‐dose FK506 and MMF plus prednisolone). However, triple therapy was more effective in suppressing skin rejection.

Abstract Quantitative evaluation of passive tension in a muscle is important in tendon transfer surgeries, however, currently appropriate intraoperative measurement techniques are lacking. Objective : Intramuscular pressure (IMP) is explored as an application to access force. Approach : The tibialis anterior (TA) in New Zealand white rabbits ( n = 9) was used to test the hypothesis of a strong correlation between the IMP, muscle force, and length. This study also helped to develop intraoperative techniques for future human studies evaluating various insertion techniques (parallel versus perpendicular). Main results : The Pearson correlation between IMP and force for all trials was 0.74 ± 0.30. Separating out the parallel insertion from the perpendicular insertion revealed a significantly higher correlation for parallel, 0.91 ± 0.13 versus 0.56 ± 0.32. Significance : These data indicate IMP sensors can be used to assess force in a single muscle and the parallel insertion method should be used. New findings • What is the central question of this study? Successful outcomes of tendon and muscle transfers depend on proper muscle tension. A near linear relationship has been seen between muscle force and intramuscular pressure. This study aims to develop an intraoperative technique for assessing passive muscle tension using intramuscular pressure. • What is the main finding and its importance? The findings from this study reveal a high correlation between pressure and passive tension in a single muscle. The techniques developed in this study will allow the translation to a human model. The work will help to improve surgical outcomes and aim to retain muscle strength in the patient following procedures such as tendon and muscle transfers.

➢ Ulnar collateral ligament injuries are best classified according to chronicity of injury and grade of tear, with partial tears and nondisplaced tears being amenable to nonoperative treatment. ➢ In general, acute injuries may be primarily repaired with suture-anchor fixation, most often to the insertion of the ligament on the proximal phalanx, which allows for early joint range of motion. ➢ Symptomatic chronic injuries may be managed surgically with primary repair, reconstruction, or arthrodesis.

OBJECTIVE Commercially available processed nerve allografts have been shown to be inferior to autografts in previous animal studies. The authors hypothesized that combining different processing and storage techniques will result in improved nerve ultrastructure preservation, lower immunogenicity, and minimized cellular debris. Different processing protocols were evaluated using chemical detergents, enzymes, and irradiation, with the addition the of enzyme elastase, were used. Additionally, the difference between cold and frozen storage was investigated. The goal of this study was to create an optimized nerve allograft. METHODS Fifty rat nerves were decellularized with modifications of previous protocols and the addition of elastase. Subsequently, the nerve segments were stored at either 4°C or −80°C. Both processed and fresh control nerves were analyzed with confocal microscopy using immunohistochemical staining on the basal lamina (laminin γ-1), Schwann cells (S100 protein), and immunogenicity using major histocompatibility complex–I (MHCI) staining. Morphology of the ultrastructure and amount of cellular debris were analyzed on cross-sections of the nerves stained with toluidine blue and H & E, and by using electron microscopy. RESULTS Nerve ultrastructure was preserved with all decellularization protocols. Storage at −80°C severely altered nerve ultrastructure after any decellularization method. Elastase was found to significantly reduce the immunogenicity and amount of Schwann cells, while maintaining good structural properties. CONCLUSIONS Reduced immunogenicity, diminished cellular debris, and the elimination of Schwann cells was observed when elastase was added to the nerve processing while maintaining ultrastructure. Storage at −80°C after the decellularization process heavily damaged the nerve ultrastructure as compared with cold storage. Further in vivo studies are needed to prove the nerve regenerative capacity of these optimized allografts.

The topic of wrist or carpal instability has been a source of confusion and miscommunication for decades. The terminology can often be difficult to understand and one surgeon's concept of instability may be completely different from another's. This is by no means a comprehensive review of carpal instability, which has often been the focus of numerous multi-volume textbooks. The purpose of this paper is to detail the basics of carpal instability, the anatomy, pathomechanics, terminology and basic principles of treatment.

AimsFree vascularised fibular grafting has been used for the treatment of large bony defects for more than 40 years. However, there is little information about the risk factors for failure and whether newer locking techniques of fixation improve the rates of union. The purpose of this study was to compare the rates of union of free fibular grafts fixed with locking and traditional techniques, and to quantify the risk factors for nonunion and failure.Patients and MethodsA retrospective review involved 134 consecutive procedures over a period of 20 years. Of these, 25 were excluded leaving 109 patients in the study. There were 66 men and 43 women, with a mean age of 33 years (5 to 78). Most (62) were performed for oncological indications, and the most common site (52) was the lower limb. Rate of union was estimated using the Kaplan-Meier method and risk factors for nonunion were assessed using Cox regression. All patients were followed up for at least one year.ResultsThe rate of union was 82% at two years and 97% at five years. Union was achieved after the initial procedure in 76 patients (70%) at a mean of ten months (3 to 19), and overall union was achieved in 99 patients (91%). No surgical factor, including the use of locked fixation or supplementary corticocancellous bone grafts increased the rate of union. A history of smoking was significantly associated with a risk of nonunion.DiscussionFree vascularised fibular grafting is a successful form of treatment for large bony defects. These results suggest that the use of modern techniques of fixation does not affect the risk of nonunion when compared with traditional forms of fixation, and smoking increases the risk of nonunion following this procedure. Cite this article: Bone Joint J 2017;99-B:134–8.

Background: Soft tissue sarcomas (STS) of the hand are exceedingly rare. The aim of this study was to review our institution’s experience with STS of the hand to identify factors affecting outcomes and survivorship. Methods: We retrospectively reviewed the records of 46 hand STS treated with definitive surgery at our institution between 1992 and 2013. Pertinent demographics as well as information regarding the surgical procedure, and disease status at latest follow-up were reviewed. Mean age at diagnosis was 38 years with a mean follow-up of 5 years. Results: The most common tumor subtypes were epithelioid (n = 10) and synovial sarcoma (n = 8). Sixty-one percent were superficial in location. Thirty-three patients had had a nononcologic resection prior to definitive surgical treatment at our institution. Ultimately, negative margins were obtained in all cases. Local recurrence was observed in 5 patients and distant metastases in 14 patients. Tumor sizes ≥2 cm, American Joint Committee on Cancer (AJCC) grade, and depth of the tumor were found to adversely affect the outcome in terms of disease-free and overall survival. Reexcision of an inadvertently excised tumor at an outside institution did not adversely affect the outcome. The 10-year overall and disease-free survival was 72% and 63%. Conclusions: Local recurrence after a wide excision was observed infrequently; however, distant disease was relatively common. Tumors with a size ≥2 cm were associated with a worse disease-free and overall survival, highlighting the aggressive nature of these tumors.

Objective: Successful repair of segmental peripheral nerve defects remains a clinical challenge. The current clinical gold standard for such injuries is to use an autologous nerve graft, but this creates donor site morbidity with loss of sensation and potential scarring. Processed nerve allografts have been used to bridge segmental nerve gaps experimentally and clinically. However, in large nerve defects, functional outcomes are not comparable with autograft reconstruction yet; the longer the nerve gap, the poorer the outcome. Nerve architecture and the extracellular matrix (ECM) are preserved after processing; however, all cellular material including Schwann cells and axons are removed. The addition of supporting cells has been proposed to improve the decellularized allograft. Adipose-Derived Mesenchymal Stem Cells (AMSC) can potentially provide the necessary support for nerve regeneration due to local production of essential growth factors. While the mechanisms underlying the neurotrophic potential of AMSC remains unknown, it is postulated that the remaining ECM still has biological activity that influences the AMSC and their differentiation. Therefore, the purpose of this study was to quantitate the changes in gene expression profiles of the cells and quantify the actual produced growth factors after seeding the allograft with AMSC in vitro. Method: A total of 35 human nerve allografts were decellularized and seeded with human AMSC. At each time point (1, 3, 14, 21, and 28 days), total RNA was extracted, reverse transcribed into complementary DNA (cDNA), and quantitative reverse transcription–polymerase chain reaction (qRT-PCR) was performed in combination with gene specific assays for genes essential for nerve regeneration including nerve growth factor (NGF), Brain-derived neurotrophic factor (BDNF), pleiotrophin vascular endothelial growth factor (PTN VEGF), and growth associated protein 43 (GAP43).Additional genes were analyzed to map AMSC characteristics including proliferation, apoptosis, myelinization, and ECM molecules. Production of growth factors was evaluated and quantified using enzyme-linked immunosorbent assay (ELISA). All samples were analyzed in triplicates and data were compared with AMSC cultured in media only. Results: Semiquantitative RT-PCR analysis showed that the interaction of the processed allograft and AMSC enhanced the expression of the neurotrophic factors NGF, BDNF, and GAP43. The expression of the angiogenic molecules, vascular endothelial growth factor A (VEGF-A) was also increased and remained significantly elevated at 28 days post seeding. Analysis of ECM-related gene expression showed that laminin subunit beta-2 (LAMB2), collagen type I alpha 1 (COL1A1), collagen type III alpha 1 (COL3A1), fibulin 1 (FBLN1), were significantly elevated until 21 days post seeding while after 28 days, these levels were normalized. Angiogenic factor cluster of differentiation 31 (CD31) and neurotrophic factor PTN expression were down regulated in the seeded cells. Quantitative results of the ELISA analysis are pending. We anticipate differences in growth factor levels released by the seeded allograft compared with the control expression levels. Conclusion: This study demonstrates that the remaining ECM of the decellularized nerve allograft has a stimulating effect on AMSC. Upon the seeding, secretion of neurotrophic and angiogenic factors were triggered; the cells cultured on the allograft showed enhanced levels of neurotrophic genes. This is hypothesized to be a consequence of specific cell-ECM interactions within the allograft. The combination of patient’s own easily accessible, abundant supply of stem cells harvested from adipose tissue and the readily available processed nerve allograft is potentially a promising method for individualized peripheral nerve repair.

Objective: The treatment of segmental bone defects remains challenging as complications frequently occur with the currently available methods, including vascularized autograft, prosthetic replacement, bone transport, and cryopreserved bone allograft (CBA). Although the use of CBA is comparatively simple, it lacks donor site morbidity and provides immediate stability; however, the grafts remain largely necrotic, resulting in high failure rates due to nonunion, infection, and stress fractures. Revitalizing the CBA has the potential to solve these problems. Previous studies in small animal models have shown the use of surgical revascularization to induce neoangiogenesis and improve bone viability in the CBA. The purpose of this study is to investigate if surgical revascularization enhances bone circulation and bone remodeling in a tibial defect orthotopic reconstruction model, placing a cryopreserved allograft in a Yucatan mini pig. Methods: Cryopreserved tibial bone allografts were transplanted in swine leukocyte antigen (SLA)-type-mismatched Yucatan mini pigs after creating a 3.5-cm segmental bone defect in the tibia. The anterior tibial arteriovenous bundle (AV-bundle) was inserted into the intramedullary canal. Eight pigs received a patent AV-bundle (revascularized group), 8 pigs received a proximally ligated AV-bundle (control group), and the contralateral side was used as an untreated control. The graft was fixated with a locking compression plate to provide a weightbearing construction. After 20 weeks, the pigs were killed and the tibia was removed and analyzed. Neoangiogenesis was evaluated by quantifying vascular volumes using the microcomputed tomography. Bone remodeling was measured by quantitative histomorphometry and micro-computed tomography. Results: Seven AV-bundles in the revascularized group were patent and 1 bundle was thrombosed due to partial dislocation of the graft. Total vascular volume was higher in the revascularized allografts (127 mm 3 ) compared with both the control group (40 mm 3 , P = .003) and the contralateral side (29 mm 3 P = .000). All patent bundles showed neovascularization extending into the cortical bone. Revascularized allografts had increased bone remodeling in the inner cortical area of the graft compared with the non-revascularized grafts (bone formation rate: 381 ± 60 µm 3 /µm 3 /year vs 299 ± 143 µm 3 /µm 3 /year, P = .05). In both the revascularized group and the control group, the bone formation rate exceed the contralateral side: In the revascularized grafts, the bone formation was 305% of contralateral side, and in the non-revascularized grafts, the bone formation was 179% of the contralateral side. There was no statistical significant difference in outer cortical bone formation between the revascularized and the non-revascularized allografts. Conclusion: Surgical revascularization of porcine tibial CBAs by implantation of an AV-bundle creates an enhanced autogenous neoangiogenic circulation and accelerates active bone formation.