Tessa Drijkoningen

Tolerance induction via mixed chimerism in vascularized composite allotransplantation: is it time for clinical application?

Purpose of reviewThe present review summarizes current data on the induction of immunologic tolerance through mixed hematopoietic chimerism relevant to applying this approach to vascularized composite allotransplantation. Recent findingsClinical allograft tolerance has been achieved recently for kidney transplants, using nonmyeloablative conditioning regimens and bone marrow transplantation from living donors. The mixed chimerism attained in these studies was either transient or durable, and both permitted tolerance of the renal allografts to be achieved across MHC-matched and MHC-mismatched barriers. In order to extend these protocols to deceased donor transplants across full MHC-mismatched combinations, as will be required for vascularized composite allografts (VCA), a delayed tolerance protocol has recently been developed, in which the donor bone marrow is given 4 months posttransplant. Recent primate studies of kidney transplants using this protocol have been successful and have demonstrated that strategies to abrogate memory T cells may be helpful. SummaryInduction of tolerance in renal allograft transplantation has been achieved clinically, via mixed chimerism protocols. Modifications of these protocols for transplants, which require use of deceased donors across full MHC mismatches, have shown promise in preclinical models. It is therefore appropriate to consider evaluation of these protocols in clinical trials for kidney transplants, and if successful, for VCA.

Night Splinting for Idiopathic Trigger Digits

Background: This study assessed nighttime splinting for 6 weeks as treatment for recent onset idiopathic trigger fingers. Methods: Patients over 18 years with a Quinnell grade 1 or 2, idiopathic trigger finger or thumb causing symptoms for less than 3 months were eligible for a custom-made hand-based orthoplast night orthotic. Improvement of symptoms and/or resolution of triggering were recorded. Patients also completed the short version of the Disabilities of the Arm, Shoulder and Hand and a numerical rating scale for pain at the initial visit, after 6 to 8 weeks, and after 3 months. Results: Thirty-four patients wore a night orthotic for at least 6 weeks. At final evaluation, there was a substantial reduction in disability and pain. Symptoms of triggering resolved completely in 18 patients (55%). Sixteen patients did not resolve their triggering after splinting and therefore underwent a steroid injection. Conclusion: Night splinting is a noninvasive treatment option for idiopathic trigger fingers/thumb with symptoms for less than 3 months.

Case Study: Osteosynthesis, Tenodesis Effect, and Side-to-Side Tendon Repair in Hand Transplantation.

Osteosynthesis and tendon repair are essential in upper extremity transplantation to optimally restore function. Transplant surgeons should be aware of all technical issues involved in osteosynthesis, tendon balancing, and tension setting as well as repair in an effort to optimize the function of the transplanted hand. Preoperative planning is vital to achieve good functional results. We present a case of successful osteosynthesis and side-to-side tendon repair, which led to a desirable functional outcome in hand transplantation.

Eptifibatide Salvage of Arterial Anastomotic Thrombosis in Lower Extremity Free Flap Reconstruction: A Case Report.

Free flap reconstruction conforms to three-dimensional wounds and has an important role in complex soft tissue defects in lower extremities.1 Yazar et al showed complete flap survival rates of 93% in free muscle flap reconstructions of distal third open tibial fractures; some debate remains about indications for free muscle versus free fasciocutaneous flaps.2 The most common cause for reexploration and microvascular failure is perianastomotic thrombosis, with arterial thrombosis less common than venous thrombosis.3Urokinase and alteplase are therapeutic options that have been used to successfully salvage free flap reconstruction.4 Eptifibatide (Integrilin, Millennium Pharmaceuticals, Cambridge, MA) is a drug of the glycoprotein IIb/IIIa-inhibitor class. We present a case of successful salvage with a partial superior latissimus dorsi free muscle flap in a patient with thrombocytosis and intraoperative arterial anastomotic thrombosis using intraand postoperative administration of eptifibatide combined with heparin infusion.

Chapter 8 – Classification Systems of Scaphoid Fractures

There is a great variety of classification systems with considerable controversies. In this chapter an overview is provided on different classification systems, all of which are based on radiographs. Thirteen different (sub)classification systems are found in literature based on (1) fracture location, (2) fracture plane orientation, and (3) fracture stability/displacement. Looking at citations numbers, the Herbert classification was most popular, followed by the Russe and Mayo classifications. Based on the controversy and limited reliability of current classification systems, suggested research areas for an updated classification include three-dimensional fracture pattern etiology and fracture fragment mobility assessed by dynamic imaging.

Interobserver Variability of the Diagnosis of Scaphoid Proximal Pole Fractures

Purpose Fractures of the proximal pole of the scaphoid are prone to adverse outcomes such as nonunion and avascular necrosis. Distinction of scaphoid proximal pole fractures from waist fractures is important for management but it is unclear if the distinction is reliable. Methods A consecutive series of 29 scaphoid fractures from one tertiary hospital was collected consisting of 5 scaphoid proximal pole and 24 scaphoid waist fractures. Fifty‐seven members of the Science of Variation Group (SOVG) were randomized to diagnose fracture location and displacement by using radiographs alone or radiographs and a computed tomography (CT) scan. Results Observers reviewing radiographs alone and observers reviewing radiographs and CT scans both had substantial agreement on fracture location (&kgr; = 0.82 and &kgr; = 0.80, respectively; p = 0.54). Both groups had only fair agreement on fracture displacement (&kgr; = 0.28 and &kgr; = 0.35, respectively; p = 0.029). Conclusion Proximal pole fractures are sufficiently distinct from proximal waist fractures that CT does not improve reliability of diagnosis. Level of Evidence Level IV interobserver reliability case‐control study.

Plain radiographs are reliable in distinction of nonunions from acute fractures of the scaphoid waist without computed tomography

After a fall, a patient with an established scaphoid nonunion may relate the problem to the recent event. Clinicians may misinterpret nonunions as acute fractures, with the potential for undertreatment (e.g. percutaneous screw fixation when debridement and bone grafting of the nonunion is needed). Computed tomography (CT) might help distinguish acute fractures from nonunions. Buijze et al. (2012) studied CT scans of 20 healing scaphoid fractures and 10 confirmed nonunions, and they found the interobserver reliability of diagnosing scaphoid union was good (k = 0.66), but the negative predictive value was only 0.41. Their findings suggest that CT is better for ruling in than ruling out union. The hypothesis of this study is that there is no agreement between observers on whether a scaphoid waist fracture is a nonunion or an acute fracture viewing radiographs alone compared with radiographs and CT scans. After approval of our institutional review board, members of the Science of Variation Group with an interest in hand or fracture surgery, were invited to participate in this study. Among the 161 surgeons that felt the study was appropriate for their expertise and interests, 157 completed the questionnaire. Radiographs and CT scans of patients with scaphoid waist fractures made within 30 days (acute fractures) or after 6 months (nonunions) of trauma were obtained from using billing codes via a research database. Inclusion criteria were: patients aged 18 years or older with a fracture of the scaphoid waist who had a plain radiograph and CT scan within 2 weeks of each other. Radiographs included a posteroanterior (PA) view, PA view with ulnar deviation of the wrist, and a lateral view. All scaphoid CT scans had a slice thickness of 1.25 mm or less. Separate movies showed a full series of CT scan images in the coronal plane and sagittal plane. Images were 0.625 mm thickness, shown in bone windows. Radiographs were presented as static images on a web page: posteroanterior, lateral, and scaphoid views. Oblique views were not used because they were not always available. Participants were randomized 1:1 to view either radiographs alone or radiographs and videos of CT scans of 20 patients; 10 patients with acute scaphoid fractures and 10 patients having a nonunion. CT scans were obtained in the routine management of fractures and nonunions based on surgeon practice style. Observers were asked to diagnose if the fracture was acute or nonunited and to indicate the confidence in their answer. The vast majority (147) of the 157 participants were men. Sixty-three (40%) of 157 participants specialized in hand and wrist surgery and 53 (34 %) in traumatology (Table 1). Our findings are as follows. (1) There was substantial agreement on the age of the scaphoid fracture among observers that viewed radiographs alone (k = 0.73) and observers that viewed radiographs and CT scans (k = 0.80). (2) Raters in the United States and Europe (compared with other parts of the world) had substantial agreement with radiographs alone and nearly perfect agreement when they also had a CT scan. (3) Raters with 0–5 years in practice had substantial agreement. Raters who were more than 5 years in practice had an almost perfect agreement (Table 2). The mean confidence of the observers viewing radiograph alone was 7.2 compared with 7.6 among observers that viewed radiographs and CT scans. The limitations of our study include: data of tertiary hospitals, spectrum bias (more nonunions than Table 1. Characteristics of observers.

Does a Comparison View Improve the Reliability of Staging Wrist Osteoarthritis

Background: Radiological grading of wrist osteoarthritis associated with scaphoid nonunion advanced collapse (SNAC) can be difficult. A comparison radiograph of the contralateral healthy wrist and an educational training in the various SNAC stages may improve reliability. Our purposes were to evaluate the difference in the reliability: (1) between observers who rate SNAC wrists with and without a comparison radiograph; and (2) between observers who receive training prior to ratings and those who do not. Methods: In this cross-sectional survey study, 82 fully trained orthopedic or hand surgeons rated anteroposterior radiographs of 19 patient wrists following a scaphoid nonunion based on SNAC stages 0 to 4. Observers were randomized online in 4 groups: one group rated unilateral views without training, a second group unilateral views with training, a third group bilateral views without training, and a fourth group bilateral views with training. Training included a 1-page clarification of the SNAC stages. Interobserver agreement was calculated using kappa statistics. Results: There was no significant difference between agreement between observers who rated unilateral radiographs (κ = 0.55) and who rated bilateral radiographs (κ = 0.58) (P = .14), nor between agreement between observers who received training (κ = 0.59) and who did not (κ = 0.54) (P = .058). Conclusions: The use of an additional comparison view and/or training does not seem to be clinically relevant in SNAC staging. There is room for improvement in the way we assess patients with SNAC wrists.

The Influence of Psychological Factors on the Michigan Hand Questionnaire

Background: Psychosocial factors help account for the gap between impairment and disability. This study examines the relationship between the Michigan Hand Questionnaire (MHQ) and commonly used psychological measures in patients with upper extremity illness. Methods: A cohort of 135 new or follow-up patients presenting to an urban academic hospital–based hand surgeon were invited to complete a web-based version of the MHQ, Abbreviated Pain Catastrophizing Scale (PCS), and two Patient-Reported Outcomes Measurement Information System (PROMIS)-based questionnaires: Pain Interference and Depression. Bivariate and multivariable analyses measured the correlation of these psychological measures with MHQ. Results: Accounting for potential confounding factors in multivariable regression, upper extremity disability as rated by the MHQ was independently associated with PROMIS Depression, PROMIS Pain Interference, visit type, and working status. The model accounted for 37% of the variability in MHQ scores, with PROMIS Pain Interference having the most influence. Conclusion: Among the non-pathophysiological factors that contribute to patient-to-patient variation in MHQ scores, the measure of less effective coping strategies and symptoms of depression were most influential. Our data add to the evidence of the pivotal role of emotional health in upper extremity symptoms and limitations and the importance of psychosocial considerations in the care of hand illness.

Factors Associated with Unplanned Reoperation in Perilunate Dislocations and Fracture Dislocations

Background Perilunate injuries are complex and uncommon injuries that are typically the result of a high-energy injury and are nearly always treated operatively. Little is known about factors associated with unplanned reoperations after surgery for perilunate injuries. Purpose To assess the rate and types of unplanned reoperation after operative treatment of a perilunate dislocation. Patients and Methods We reviewed 115 patients of all ages with unplanned reoperations after operative treatment of perilunate injuries at five hospitals. Planned removal of implants were not considered as unplanned reoperations. Results Sixteen patients had an unplanned reoperation, including four for compartment syndrome (three hand, one forearm); three for deep infection; three for malalignment or an errant screw; two for early salvage procedures; and four for other reasons. We considered seven unplanned reoperations necessary (forearm compartment syndrome, infection, loss of alignment, errant screw) and nine debatable or unnecessary (hand compartment syndrome, early salvage procedures, suspected malunion, etc.). Patients who had an unplanned reoperation were younger (median age 24 versus 34 years; p = 0.0034); had earlier surgery (median days to surgery 0 versus 3; p = 0.0068); and were more likely injured in a motor vehicle collision (50% versus 17%; p = 0.0070). Accounting for interaction among the variables using multivariable analysis, the factors independently associated with unplanned reoperation were young age (odds ratio 0.92) and motor vehicle collision accidents (odds ratio 4.1). Conclusion We conclude that higher-energy injuries may be at greater risk for unplanned reoperation, but more than half of the unplanned reoperations were for debatable indications. Level III Retrospective Cohort Review.