Frederic Schuind

The International Registry on Hand and Composite Tissue Transplantation.

Background. The International Registry on Hand and Composite Tissue Transplantation was founded in May 2002, and the analysis of all cases with follow-up information up to July 2010 is presented here. Methods. From September 1998 to July 2010, 49 hands (17 unilateral and 16 bilateral hand transplantations, including 1 case of bilateral arm transplantation) have been reported, for a total of 33 patients. They were 31 men and 2 women (median age 32 years). Time since hand loss ranged from 2 months to 34 years, and in 46% of cases, the level of amputation was at wrist. Immunosuppressive therapy included tacrolimus, mycophenolate mofetil, sirolimus, and steroids; polyclonal or monoclonal antibodies were used for induction. Topical immunosuppression was also used in several cases. Follow-up ranges from 1 month to 11 years. Results. One patient died on day 65. Three patients transplanted in the Western countries have lost their graft, whereas until September 2009, seven hand grafts were removed for noncompliance to the immunosuppressive therapy in China. Eighty-five percent of recipients experienced at least one episode of acute rejection within the first year, and they were reversible when promptly treated. Side effects included opportunistic infections, metabolic complications, and malignancies. All patients developed protective sensibility, 90% of them developed tactile sensibility, and 82.3% also developed a discriminative sensibility. Motor recovery enabled patients to perform most daily activities. Conclusions. Hand transplantation is a complex procedure, and its success is based on patients compliance and his or her careful evaluation before and after transplantation.

Glomus tumours of the hand. A retrospective study of 51 cases.

The authors report a series of 51 patients with glomus tumours in the hand. The duration of symptoms before treatment averaged 10 years. No one site or finger was more commonly involved. Objective features were limited to a blue discoloration in 29%, a pulp nodule or a nail deformity in 33%. An osseous defect was seen on plain X-ray films in 36%. Diagnosis depended on clinical suspicion in 90%. Careful dissection and complete excision of the tumour almost always offer permanent relief. A direct transungual approach was used in the subungual tumours with only one cosmetic problem. Recurrence of symptoms occurred in only two cases after a pain-free interval of 2 years.

External fixation of the clavicle for fracture or non-union in adults

A technique of osteosynthesis of the clavicle with Hoffmann external fixation was used to treat twenty patients for selected indications, including an open fracture, inability of a patient to tolerate prolonged conservative treatment, or a painful non-union. No vascular or pleural complication was observed. The average time that the external fixator was retained was fifty-one days. All of the clavicles united well. Mobility of the shoulder returned to normal in all patients.

Idiopathic carpal tunnel syndrome: Histologic study of flexor tendon synovium

The histologic lesions in flexor tendon synovium of 21 patients seen initially with idiopathic carpal tunnel syndrome have been studied. The findings were similar in all biopsy specimens and were typical of a connective tissue undergoing degeneration under repeated mechanical stresses.

Kienböck’s disease

Kienböcks disease is a form of osteonecrosis affecting the lunate. Its aetiology remains unknown. Morphological variations, such as negative ulnar variance, high uncovering of the lunate, abnormal radial inclination and/or a trapezoidal shape of the lunate and the particular pattern of its vascularity may be predisposing factors. A history of trauma is common. The diagnosis is made on plain radiographs, but MRI can be helpful early in the disease. A CT scan is useful to demonstrate fracture or fragmentation of the lunate. Lichtman classified Kienböck disease into five stages. The natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböcks disease and negative ulnar variance. Many other forms of surgical treatment have been described.

Advances in the Biomechanics of the Hand and Wrist

Material Properties: Effect of Repetitive Loading on the Wrist of Young Rabbits H. Kawai, et al. Passive ForceLength Properties of Cadaveric Human Forearm Musculature R. Wells, et al. Biomechanics of Flexor Pulley Reconstruction K.N. An, et al. Force Analysis: On a Model of the Upper Extremity B. Peterson. Contact Pressures within Wrist Joints S.F. Viegas, R.M. Patterson. Force Transmission through the Proximal Carpal Row H.P. Kern. Motion Analysis: Normal and Abnormal Carpal Kinematics M. Garcia-Elias, et al. Kinematic Geometry of the Wrist C.L. Nicodemus, et al. A Computergraphics Model of the Wrist Joint J.G.M. Kooloos, et al. Clinical Applications: Aspects of the Biomechanics of Fracture Fixation F. Burny, et al. Dislocation and Instability of the Distal RadioUlnar Joint A.I. Kapandji. Scaphoid and Periscaphoid Injuries P. Ledoux. 33 additional articles. Index.

Atypical Acute Rejection After Hand Transplantation

Skin rejection after hand transplantation is characterized by a maculopapular erythematous rash that may be diffuse, patchy or focal, and distributed over forearms and dorsum of the hands. This ‘classical’ pattern of rejection usually spares the skin of the palm and does not affect the nails. Herein, we report the experience on four cases presenting with an ‘atypical’ pattern of rejection that is novel in involving the palmar skin and the nails. All patients were young and exposed to repetitive and persistent mechanical stress of the palm. Characteristic features of rejection included a desquamative rash associated with dry skin, red papules, scaling and lichenification localized to the palm. Skin lesions were associated with nail dystrophy, degeneration, deformation or loss. Histology of the skin and nail bed revealed a lymphocytic infiltrate with predominance of T cells (CD3+, CD4+ and CD8+), with small numbers of B cells (CD20+ and CD79a+) and a low number of Forkhead transcription factor 3 (FOXP3)‐positive cells in one patient. The lesions persisted over weeks to months, responded poorly to steroid treatment and were managed with antithymocyte globulin (ATG; Thymoglobulin, Genzyme, Cambridge, MA), alemtuzumab and/or intensified maintenance immunosuppression.

External fixation of fractures of the distal radius: A study of 225 cases

A stable reduction of comminuted or unstable fractures of the distal radius can be maintained by prolonged traction with pins fixed into plaster, as advocated by Boehler,’ or by external fixation. “Ligamentotaxis,” as first defined by Vidal et al.* and Vidal and Paran’ is the common principle of these techniques; it states that in comminuted wrist fractures, prolonged distraction with tension provided by the preserved capsuloligamentous structures allows us to maintain the reduction of the fracture.

Hand Transplantation: The State-of-the-Art

The feasibility of hand transplantation has been demonstrated, both surgically and immunologically. Levels of immunosuppression comparable to regimens used in solid organ transplantation are proving sufficient to prevent graft loss. Many patients have achieved discriminative sensibility and recovery of intrinsic muscle function. In addition to restoration of function, hand transplantation offers considerable psychological benefits. The recipient’s pre-operative psychological status, his motivation and his compliance with the intense rehabilitation programme are key issues. While the induction of graft specific tolerance represents a hope for the future, immunosuppression currently remains necessary and carries significant risks. Hand transplantation should, therefore, only be considered a therapeutic option for a carefully selected group of patients.

A Biomechanical Study of the Ulnar Nerve at the Elbow

The relative elongation with elbow flexion of the ulnar nerve, proximal and distal to the cubital tunnel, and of the cubital tunnel retinaculum, was measured in cadaver specimens by stereophotogrammetry. The proximal part of the ulnar nerve elongated significantly with full elbow flexion. No significant change of length was measured in the distal part of the nerve. The length of the cubital tunnel retinaculum increased by an average of 45% from full elbow extension to full flexion.