Stefano Lucchina

Cytomegalovirus-related complications in human hand transplantation.

Background. Up to date, 24 hands/thumbs have been transplanted in 18 patients. We herein report on cytomegalovirus (CMV) infection, disease, and the adopted treatment. Methods. Immunosuppression consisted of tacrolimus-based triple-drug therapy with antithymocyte globuline or CD25-receptor antagonist induction. Donor/recipient CMV match was negative/negative (n=8), negative/positive (n=3), positive/positive (n=3), positive/negative (n=3) and unknown in one case. Six patients (three +/−, two +/+, and one −/+) received gancyclovir i.v. followed by oral gancyclovir or valgancyclovir for prophylaxis. Results. Patient and graft survival at a mean follow-up of 42.9 months were 100% and 91%, respectively. Of all patients tested for CMV, 45.5% developed CMV infection or disease. Two patients that were given a CMV-positive graft showed very high viral loads (550 and 1200/200000 leukocytes) after transplantation. Gancyclovir treatment failed to permanently control CMV in 80% of the patients experiencing CMV infection. Those patients requiring more toxic second-line therapies (foscarnet/cidofovir) suffered from side effects such as nephrotoxicity, nausea, vomiting, and diarrhea. Conclusions. CMV infection/disease complicated the postoperative course after composite tissue allograft (CTA) transplantation in five of nine recipients challenged with the virus. The close time correlation suggests an association between virus replication and rejection in some cases. CMV represents the major infectious threat in CTA transplantation. Therefore, CMV-mismatch should be avoided and prophylaxis with valgancyclovir and anti-CMV hyperimmunoglobulin should be mandatory.

Arterial Stiffening Influence of Sympathetic Nerve Activity Evidence From Hand Transplantation in Humans

Studies in animals and humans suggest that sympathetic activity exerts a stiffening influence on large and middle-sized artery walls. We sought to obtain further evidence on this issue by measuring radial artery distensibility in an allotransplanted and thus denervated hand using the contralateral artery as control. In 2 men, blood pressure was measured by a semiautomatic device (Dinamap). Diastolic diameter, systo-diastolic diameter excursion (ultrasound Wall Track system), and distensibility (Reneman formula) of both radial arteries were measured at a level corresponding to 4 cm below the suture of the transplanted hand 40 days after surgery and every 4 weeks for the next 6 months. After surgery, systo-diastolic diameter excursion and distensibility were much greater in the transplanted radial artery than in the contralateral vessel, reaching values similar to the contralateral ones after 4 months, when signs of reinnervation of the transplanted hands had appeared. Radial deinnervation was accompanied by an increased arterial distensibility, which provides further evidence of the sympathetic stiffening effect on arterial wall in humans.

False aneurysm of the common digital artery. Is reconstruction with an arterial graft worth the efforts? A case report

False aneurysms in the hand are rare. A false aneurysm of the common digital artery in the palm for the second and third finger is reported, illustrating our experience with arterial graft reconstruction after excision as a valid alternative surgical therapy to a vein graft, when ligation or end‐to‐end anastomosis are not indicated or feasible. The superficial palmar branch of the radial artery was chosen as donor vessel based on the similarity in vessel diameter and wall thickness to the common digital arteries. Ease of harvesting and performing the microvascular anastomosis using an arterial graft allows for a viable reconstruction after false aneurysm excision in the palm.

Should aspirin be stopped before carpal tunnel surgery? A prospective study

AIM To determine whether patients taking aspirin during carpal tunnel release had an increase of complications. METHODS Between January 2008 and January 2010, 150 patients underwent standard open carpal tunnel release (CTR) under intravenous regional anaesthesia. They were divided into three groups: groups 1 and 2 were made of 50 patients each, on aspirin 100 mg/d for at least a year. In group 1 the aspirin was never stopped. In group 2 it was stopped at least 5 d before surgery and resumed 3 d after. Group 3 acted as a control, with 50 patients who did not take aspirin. The incidence of clinically significant per- or post-operative complications was recorded and divided into local and cardio-cerebro-vascular complications. Local complications were then divided into minor and major according to Page and Stern. Local haematomas were assessed at 2 d (before resuming aspirin in group 2) and 14 d (after resuming aspirin in group 2) postoperatively. Patients were reviewed at 2, 14 and 90 d after surgery. RESULTS There was no significant difference in the incidence of complications in the three groups. A total of 3 complications (2 major and 1 minor) and 27 visible haematomas were recorded. Two major complications were observed respectively in group 1 (non stop aspirin) and in group 3 (never antiaggregated). The minor complication, observed in one patient of group 2 (stop aspirin), consisted of a wound dehiscence, which only led to delayed healing. All haematomas were observed in the first 48 h, no haematoma lasted for more than 2 wk and all resolved spontaneously. A major haematoma (score > 20 cm(2)) was observed in 8 patients. A minor haematoma (score < 20 cm(2)) was recorded in 19 patients. All patients at 90 d after surgery were satisfied with the result in terms of relief of their preoperative symptoms. Major and minor haematomas did not impair hand function or require any specific therapy. CONCLUSION Our study demonstrates that continuation of aspirin did not increase the risk of complications. It is unnecessary to stop aspirin before CTR with good surgical techniques.

Post-traumatic combined flexion of the thumb, index and middle finger after intrinsic muscles reconstruction of the hand: a case report.

We report a case in which simultaneous flexion of the thumb, index and middle finger occurred 6 months after the surgical reconstruction of the adductor (AM) and first dorsal interosseous (IO) muscles. An anomalous connection in the form of tendon slip associated to fibrous adhesions between the flexor pollicis longus (FPL) tendon, flexor digitorum profundus indicis (FDPI) and middle finger (FDPM) tendons were found. Either ultrasound (US) examination or magnetic resonance imaging (MRI) were unable to detect the site of adhesion. Excision of the slip and radical tenosynoviectomy led to early functional recovery.

Patient Management and Follow-up

At present, clinical hand transplantation is still considered an experimental procedure, and consequently, carefully monitoring the transplanted patient is required. From our experience with hand transplantation, we stress the importance of preoperative screening [1], including fully informed consent; patient compliance to postoperative medication and physical therapy and, above all, careful follow-up of the recipient.

Skeletal Muscle Metastases to the Flexor Digitorum Superficialis and Profundus from Urothelial Cell Carcinoma and Review of the Literature

Urothelial cell carcinoma (UCC) metastases to skeletal muscle are extremely rare and usually found in patients with advanced stage cancer. The most common sites of bladder cancer metastases are lymph nodes, lung, liver, and bones. Muscle is an unusual site of metastases from a distant primary cancer, due to several protective factors. We present a rare case of 76-year-old patient with metastases in the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) muscles, 2 years after a radical cystectomy for invasive UCC of the bladder. This case is the first description of a forearm lesion, with an extensive infiltration of the volar compartments of the forearm, and the first one with a clear functional impairment.

Hands on Stamps: Brazil 1979—150th Anniversary of the First Publication in Braille Writing

Among the hand’s symbolic meanings, the communicative relevance is the one with greatest importance for certain people. Braille is a tactile writing system formed by raised dots arranged in specific places in a 6-position matrix. It’s used by the blind and the visually impaired for books, menus, signs, elevator buttons, and currency. Louis Braille, a blinded 15year old boy adapted a 12-dot cell system developed by a French captain in Napoleon’s army to allow soldiers to compose and read messages at night without illumination. The basic technique was the first raised-dot reading and writing system. Nearly 300 million people are now visually impaired worldwide: 14% blind and the remaining have low vision. About 90% of the world’s visually impaired live in developing countries. Historically developing countries like Brazil in 1979 (Fig. 1) encouraged Braille reading to provide an essential skill that would allow visually impaired children to better compete

CMV Infection and Reactivation

Herpes virus infections are common causes of morbidity and mortality in solid organ and haematopoietic stem cell transplant recipients. Recent innovations in diagnosis, prophylaxis and treatment have reduced the incidence of herpes virus infections during the early posttransplant period, but they continue to significantly influence the outcome after transplantation [1].

Clinical results of the Harris-Galante cup implanted from 1986 to 1991

Abstract In the period 1986–1991, we performed 370 consecutive total hip arthroplasties (THA) using the Harris-Galante porus coated prosthesis. The characteristics of this component are: a fiber-mesh coating in pure Ti alloy that stimulates osteoinduction, a process of fusion of fiber-mesh to the metal back that reduces potential damage to the microstructure of the fibers with consequently less resistance to fatigue and a better primary stability guaranteed by fixation screws that stimulate osteoconduction. The average follow-up was 11.5 years. The follow-up was performed through a roentgenographic control at 3, 6 and 12 months and then once a year. Mineralometric evaluation with a Hoxologic QDR apparatus [1,2] permitted quantitative examination of the periprosthetic bonestock. A questionnaire was administered to examine the characteristics of pain and the ability to perform daily activities, to go upstairs, to walk distances, to sit the down and to put on socks and shoes. We found no vascular complications because of the use of Ti screws; the cup, after a primary fixation, ran into osteointegration in most cases. We did not find any aseptic loosening due to the inadequate primary press-fit or to screw breaking. We did not find any periprosthetic bone loss due to the migration of Ultra High Molecular Weight Polyethylene (UHMWPE) wear particles from holes of the shell. When aseptic loosening of the femoral stem and UHMWPE wear particle formation did occur, the metal back was perfectiyl osteointegrated and we only had to substitute the insert. The results are clinically interesting considering the long-term follow-up, the large number of patients and, technically, the type of fixation (line-to-line without press-fit), the semplicity of assembly of UHMWPE without any bone loss around the cup, the good fixation of cups even if badly implanted because of other difficulties in impanting them or for a wrong technique. In our opinion, our choice of implanting HG1 cups line-to-line was successful 10–15 years later.