OP0085 ALTERED EXPRESSION OF NEUROTROPHINS AND THEIR RECEPTORS IN THE SKIN OF PATIENT WITH COMPLEX REGIONAL PAIN SYNDROME (CRPS)

Background:

Complex regional pain syndrome (CRPS) is a rare painful condition that usually appears after trauma or surgery of the extremities. Symptoms include pain, sensory, sudomotor and vasomotor disturbances, trophic changes and impaired motor function. The course varies from mild to chronic disease with a high impact on daily functioning and quality of life. In skin tissue, sustained inflammatory, fibrotic processes together with reduced epidermal nerve fibers are reported. Neurotrophins and their receptors are mediators in cell-to-cell communication and key mediators of pain signaling

Objectives:

The aim of this study was to identify differential expression of neurotrophins and their receptors in the skin and skin fibroblasts of patients with CRPS

Methods:

Healthy controls (HC) and patients with acute CRPS with symptoms for less than 6 months fulfilling the Budapest criteria were recruited. Pain scores were evaluated by numeric rating scale (0=no pain, 100=maximal) and body perception was assessed using the Bath Body Perception Disturbance Scale (BBPDS) (0=no perception disturbance, 57=maximal perception disturbance).

Skin biopsies of the affected and/or non-affected side were taken. Immunohistochemistry on formalin-fixed, paraffin-embedded skin tissue slides was used to show NT3 expression in skin tissues. Blinded analysis was done by an experienced dermato-pathologist determined staining graduated by 0= none, 1= sparse, 2=moderate, 3= dense.

Skin fibroblast were isolated from skin biopsies by outgrowth cultures (CRPS, affected side, n=6 and HC, n=5). Cells (passage 3-6) were starved and subsequently stimulated with TNFα (10 ng/ml) or TGFβ (10 ng/ml) for 24 h to mimic active disease and total RNA was isolated by miRNeasy kit. Gene expression of neurotrophins (NGF, BDNF, and NT3) and neurotrophin receptors (NGFR, TrkA, TrkB and TrkC) was measured by quantitative real time PCR and quantified using the ΔΔCq method with GAPDH as a reference gene. ELISA was used to analyze NT3 protein expression in cell culture supernatants.

Results:

In 5 of 9 patients with CRPS immunohistological staining of NT3 showed an higher expression (from low to moderate) in the affected side versus the non-affected side. In 4 of 9 patients the expression of NT3 was high in the non-affected side (moderate/dense) and stayed high in the affected side.

Of interest, the patients with increasing expression of NT3 in the affected side showed increased pain scores (max pain 80+/-10.95, n=5 versus 48.16+/-18.16, n=4, p=0.059 and changed body perception 26.8+/-8.68 n=5 versus 6.5+/-3.91, n=4, p=0.016).

Isolated skin fibroblasts from the affected side of patients with CRPS compared to healthy skin fibroblasts showed higher basal gene expression of NT3 (log2 fold-change= 1.9 +/- 0.4, p= 0.005) and NGFR (log2 fold-change= 3.6 +/- 2.1, p=0.014). TNFα stimulated CRPS skin fibroblasts showed higher expression for NT3 (log2 fold-change= 2.1 +/- 1.2, p=0.002) compared to HC. TGFb stimulated skin fibroblasts of patients with CRPS showed higher expression of NT3 (log2 fold-change= 1.4+/-0.8, p=0.019), NGFR (log2 fold-change= 2.6 +/- 1.8, p=0.036) and TrkC (log2 fold-change= 2.3 +/- 1.8, p=0.032) compared to HC.

On protein level, NT3 showed a tendency of upregulation in unstimulated fibroblasts from CRPS patients comparing to HC (CRPS mean= 8.0 +/- 2.2 pg/ml, HC mean= 6.3 +/- 1.8 pg/ml, p=0.25). After TNFα stimulation, protein level of NT3 was significantly higher in CRPS skin fibroblasts (CRPS mean= 10.6 +/- 2.4 pg/ml, HC mean= 4.8 +/- 1.3 pg/ml, p=0.004).

Conclusion:

These data indicate a new role of skin fibroblasts in CRPS. Differential basal and stimulated expression of NT3, the receptor for NT3 (TrkC) and NGFR, the common receptor for all neurotrophins, indicates deregulated communication of fibroblasts with the sensory nerve fibers in CRPS. This might contribute to the dysregulated healing process and sustained pain.

Disclosure of Interests:

Sanne Stroeve: None declared, Stefan Dudli: None declared, Isabel Kolm: None declared, Irina Heggli: None declared, Nick Herger: None declared, Sabrina Catanzaro: None declared, Andreas Schweizer: None declared, Maurizio Calcagni Speakers bureau: Arthrex, Consultant of: Medartis, Arthrex, SilkBiomaterials, Grant/research support from: Medartis, Oliver Distler: None declared, Florian Brunner: None declared, Astrid Juengel: None declared

OP0248 DEVELOPMENT OF A 3D SKIN MICROTISSUE MODEL FOR FIBROTIC DISEASES

Background:

Traditional preclinical approaches, such as two-dimensional cell culture and animal models, are often inadequate to mimic the pathophysiological features of complex diseases such as systemic sclerosis (SSc). Human specific targets, such as the recently described pro-fibrotic long non coding RNA (lncRNA) H19X1, are becoming increasingly relevant in preclinical research, creating the need of new strategies and tools in translational medicine. The employment of novel three-dimensional (3D) culture systems, where multiple cell types are included, is filling an important gap left by the traditional preclinical methods.

Objectives:

To develop an easy to produce 3D fibrotic skin microtissues model for translational proof of concept studies.

Methods:

Two thousand five hundred dermal fibroblasts isolated from skin of SSc patients were seeded in ultra-low attachment 96-well plates. Fibroblast were let to aggregate into spheres for 48h. Two thousand five hundred primary normal human keratinocytes were added to the culture and let to layer onto the fibroblast spheres for 72h. H19X silencing experiments were used as proof of concept studies. H19X silencing with antisense oligonucleotides or transfections with a scrambled control were performed in fibroblasts prior to the sphere formation for 24h. TGFβ (10 ng/ml) was added to microtissue to exacerbate the fibrotic phenotype. Haematoxylin eosin staining as well as immunohistochemistry staining for vimentin and cytokeratin 10 was performed. Skin microtissues were processed for RNA and protein isolation. Pro-collagen Iα1 and fibronectin were quantified in the supernatants with ELISA.

Results:

The microtissues presented a core of SSc fibroblast as revealed by vimentin staining and an external layer of keratinocytes as revealed by cytokeratin 10 staining, mimicking the human skin architecture. Gene expression analysis following TGFβ stimulation displayed induced expression of extracellular matrix gene COL1A1 (p=0.044) and the myofibroblast marker ACTA2 (p=0.018), indicating that the microtissues were able to develop a fibrotic response. Microtissues, where H19X was silenced, displayed reduced gene expression of COL1A1 and ACTA2 after TGFβ stimulation (COL1A1 p=0.007, ACTA2 p=0.045). Additionally, H19X silencing led to lower levels of αSMA protein expression (p=0.009) and pro-collagen1α1 secretion (p=0.039) in the supernatant of the microtissue cultures as revealed by Western Blot and ELISA, respectively. FN1 expression and fibronectin protein levels were not significantly reduced in the microtissues after H19X silencing.

Conclusion:

We were able to produce a 3D microtissue resembling skin architecture that can respond to fibrotic stimuli. Knockdown experiments of pro-fibrotic lncRNA H19X confirmed the potential of the model as screening platform for novel pro-fibrotic effectors. A future aim will be to optimize the model for high-throughput automated screening platforms.

References:

[1]Pachera, E., et al. (2020). “Long noncoding RNA H19X is a key mediator of TGF-β–driven fibrosis.” The Journal of Clinical Investigation 130(9): 4888-4905.

Disclosure of Interests:

Elena Pachera: None declared, Gabriela Kania: None declared, Astrid Juengel: None declared, Maurizio Calcagni Speakers bureau: Arthrex, Consultant of: Medartis, Arthrex, SilkBiomaterials, Grant/research support from: Medartis, Oliver Distler Speakers bureau: Actelion, Bayer, Boehringer Ingelheim, Medscape, Novartis, Roche, Consultant of: Abbvie, Actelion, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, ChemomAb, Corpuspharma, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, -Kymera, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi, UCB, Grant/research support from: Abbvie, Actelion, Bayer, Boehringer Ingelheim, Kymera Therapeutics, Mitsubishi Tanabe

Examining elevated blood pressure and the effects of diabetes self-management education on blood pressure among a sample of Marshallese with type 2 diabetes in Arkansas

INTRODUCTION

Hypertension is a leading risk factor for heart attack and stroke. Undiagnosed hypertension increases the risk of heart attack and stroke. The risk of hypertension is increased for those with type 2 diabetes mellitus (T2DM). Diabetes self-management education (DSME) has been shown to be effective at improving clinical outcomes, including reducing blood pressure, but few studies have evaluated the effects of DSME for Native Hawaiians and Pacific Islanders.

METHODS

This study examined the baseline prevalence of diagnosed hypertension and undiagnosed high blood pressure and differences in health care access between those with diagnosed hypertension versus undiagnosed high blood pressure. The sample consisted of 221 Marshallese adults with T2DM participating in a DSME randomized controlled trial in northwest Arkansas. The study also examined the effects of DSME interventions on participants' blood pressure, comparing an Adapted-Family DSME with a Standard DSME.

RESULTS

Nearly two-thirds of participants had blood pressure readings indicative of hypertension, and of those, over one-third were previously undiagnosed. The frequency of doctor visits was significantly lower for those with undiagnosed high blood pressure. There were no differences in health insurance coverage or forgone medical care between those with undiagnosed high blood pressure versus diagnosed hypertension. Across all participants, a significant reduction in systolic blood pressure occurred between baseline and post intervention, and a significant reduction in diastolic blood pressure occurred between baseline and post-intervention, 6 months, and 12 months post-intervention. No differences were observed by study arm.

CONCLUSION

This study is the first to document the prevalence of diagnosed hypertension and undiagnosed high blood pressure, as well as the effects of DSME on blood pressure among a sample of Marshallese adults with T2DM.

Undiagnosed Hypertension and Undiagnosed Type 2 Diabetes among Overweight and Obese Marshallese Participants in a Diabetes Prevention Program

Hypertension and type 2 diabetes (T2D) are major public health issues that disproportionately affect minority communities, including Native Hawaiians and Pacific Islanders (NHPI). Minority communities are also more likely to have undiagnosed hypertension and T2D. Marshallese Pacific Islanders have been shown to have high proportions of diagnosed and undiagnosed hypertension and T2D. Using survey and biometric data collected from 378 overweight/obese Marshallese Pacific Islander adults, this study documents the prevalence of hypertension and T2D, as well as the prevalence of undiagnosed hypertension and T2D. The study also examines associations between undiagnosed hypertension and undiagnosed T2D and age group, sex, health care access (defined by foregone care due to cost and health insurance status), and body mass index (BMI). Among participants with blood pressure readings indicative of hypertension, 68.4% were undiagnosed, and among participants with HbA1c indicative of T2D, 31.6% were undiagnosed. A quarter of participants (24.5%) had blood pressure and HbA1c measures indicative of both undiagnosed hypertension and undiagnosed T2D. Undiagnosed hypertension was significantly associated with age group (p's<0.0001) and sex (p=0.028). Undiagnosed T2D was significantly associated with age group (p's<0.05), forgone care due to cost (p=0.018), health insurance status (p=0.035), and BMI (p=0.001). Participants in this study had high proportions of undiagnosed hypertension and undiagnosed T2D. These findings will be immediately useful for those working to address hypertension and T2D disparities among Marshallese and other NHPI populations.

Long-term results after semiconstrained distal radioulnar joint arthroplasty: A focus on complications

Arthroplasty of the distal radioulnar joint (DRUJ) using a semiconstrained DRUJ implant yields good outcomes according to the literature. The aim of this study was to investigate the subjective, clinical and radiographic outcomes with a special focus on complications in nine patients with a mean follow-up of 6years and to compare them with our previously published 3-year follow-up results. No subjective or objective changes were seen between the 3-year and the 6-year follow-up. In the previous study, one implant loosening and two irritations of the superficial branch of the radial nerve occurred. We saw three complications that needed surgery in addition to the three complications already found 3years after surgery. One patient with a large ulna had loosening of the cemented ulnar stem and therefore the prosthesis was explanted. One patient had an allergic reaction to the metal alloy of the prosthesis, which also led to removal. One patient had an ulnar impaction syndrome caused by too-distal placement of the implant that needed revision. Prior studies reported low complication rates. In our study, six complications occurred in four out of nine patients, requiring reoperation including two revisions and two implant removals. A precise surgical technique is mandatory to avoid the otherwise frequent complications and potential implant failures. LEVEL OF EVIDENCE: IV.

The influence of Generalized Anxiety Disorder on Executive Functions in children with ADHD

The present study was aimed at verifying whether the presence of generalized anxiety disorder (GAD) affects executive functions in children with attention-deficit hyperactivity disorder (ADHD). Two groups of children with ADHD were selected for the study according to the presence or absence of GAD. The first group of 28 children with ADHD with GAD (mean age: 9 ± 1.2; males/females: 24/4) was matched for gender, age, IQ, psychiatric comorbidity with a second group of 29 children with ADHD without GAD (mean age: 8.8 ± 0.7; males/females: 26/3). The two groups with ADHD were compared to 28 typically developing children (mean age: 8.3 ± 1.3; males/females: 23/5) on different measures involving processes especially important in inhibitory control such as rule maintenance, stimulus detection, action selection and action execution. Our results indicated that, differently from children with ADHD with GAD, only the group with ADHD without GAD showed a deficit in inhibitory control. Comorbid subgroups should be differentiated, especially, to develop specific and efficient therapeutic interventions in ADHD.

Gene expression in human adipose-derived stem cells: comparison of 2D films, 3D electrospun meshes or co-cultured scaffolds with two-way paracrine effects

Finding the appropriate cues to trigger the desired differentiation is a challenge in tissue engineering when stem cells are involved. In this regard, three-dimensional environments are often compared to cells' two-dimensional culture behaviour (plastic culture dish). Here, we compared the gene expression pattern of human adipose-derived stem cells (ASC) seeded in a three-dimensional (3D) electrospun mesh and on a two-dimensional (2D) film - both of exactly the same material. Additionally, we conducted experiments with a scaffold floating above a film to investigate two-way paracrine effects (co-system). Electrospun meshes (3D scaffolds) and films (2D), consisting either of pristine poly-lactic-co-glycolic acid (PLGA) or of PLGA-containing dispersed amorphous calcium phosphate nanoparticles (PLGA/aCaP), were seeded with ASCs and cultured either in Dulbecco Minimum Essential Medium (DMEM) or in osteogenic medium. After two weeks, minimum stem cell criteria markers as well as typical markers for osteogenesis, endothelial cell differentiation, adipogenesis and chondrogenesis were analysed by quantitative real-time PCR. Interestingly, mostly osteogenic genes of cells seeded on 3D meshes were upregulated compared to those on 2D films, while stem cell markers seemed to be only slightly affected. Runx2 and osteocalcin showed an especially strong upregulation under all conditions, while most other factors analysed for 2D/3D changes were highly dependent on the material composition, the culture medium and on paracrine signalling effects. The beneficial 3D environment for stem cells found in many studies has therefore not to be attributed to the third dimension alone and should carefully be compared to 2D films fabricated of the same material. Furthermore, paracrine interactions triggering differentiation are not negligible.

Complications after treating Dupuytren's disease. A systematic literature review

The objective of this study was to review the incidence of complications associated with different treatment options for patients with Dupuytren's disease. In a systematic literature review, the PubMed, EMBASE, Cochrane and Scopus databases were searched for clinical studies reporting complications after collagenase treatment, percutaneous needle fasciotomy (PNF), fasciectomy and dermofasciectomy. The incidence of complications was extracted from each study and stratified by procedure. From a total of 2251 references, 113 studies were analyzed and included with complication incidences varying from 0% to 100%. The highest number of nerve and vessel lesions were reported after fasciectomy, whereas the highest rate of edema was after collagenase injection. Accidental skin tears were mostly associated with collagenase and PNF treatment. Pooled complication incidences were 17.4% (95% CI: 11.7-23.1) for fasciectomy, 78.0% (95% CI: 59.6-96.4) for collagenase treatment, 18.9% (95% CI: -5.5-43.3) for PNF and 11.6% (95% CI: 0.0-23.2) for dermofasciectomy. Due to inconsistencies in reporting complications as well as the lack of a standardized definition, the literature does not provide evidence in favor of a specific procedure for Dupuytren's disease. A standardized definition of complications is required to improve the comparability of published results.

Midterm Results of Semiconstrained Distal Radioulnar Joint Arthroplasty and Analysis of Complications

Range of motion and stability are important outcome parameters to assess function of the distal radioulnar joint (DRUJ), in particular pronation, supination, and weight-lifting capacity. The DRUJ semiconstrained implant developed by Scheker et al is intended to reproduce all the functions of the triangular fibrocartilage complex and the DRUJ. The aim of the study was to investigate the subjective, clinical, and radiographic results in 10 patients after primary implantation of the semiconstrained DRUJ arthroplasty following DRUJ derangement and painful instability, with an average follow-up of 3 years with a special focus on the complications. Standardized preoperative and postoperative evaluation included assessment of pain by a visual analog scale, radiographic examination, range of motion measurements, lifting capacity, and grip strength. The patient-perceived function was investigated using clinical score charts. Compared with the preoperative status, range of motion showed little change, while grip strength, lifting capacity, pain score, and patient-perceived functions improved significantly. One patient developed an ulna stem loosening, while two patients had to be reoperated because of an irritation of the extensor tendons and the superficial radial nerve at the first dorsal compartment of the wrist. In this study, arthroplasty of the DRUJ using the semiconstrained DRUJ arthroplasty was found to result in satisfactory outcome. Level of evidence: Level IV.

IFSSH scientific committee on skin coverage: 2015 report

Skin coverage in hand reconstruction is a challenging and vast chapter in hand surgery; covering every aspect of it in a report is simply not feasible. Therefore, this report focuses on a few specific topics. The coverage of anatomical regions like the fingertips is common ground for hand surgeons worldwide, but in the last 10 years, various refinements have been published in order to optimize the reconstruction of this organ. Nevertheless, in many emergency departments, the amputation of badly injured fingertips, including the thumb, remains the preferred treatment. The main focus of this report is to counter this tendency by providing alternatives to surgeons. Large defects in the fingers involving more than one segment, defects in the palm and in the dorsum of the hand are currently debated in international meetings. The use of skin substitutes vs. the use of extremely refined microsurgical procedures vs. classic island flaps has generated animated discussions, which are also influenced by cultural and socioeconomic factors around the world. This report offers the views of six surgeons from four different countries, in the hope of animating discussions and suggesting new approaches.

Modified Suzuki frame for the treatment of difficult Rolando fractures

Fifteen consecutive patients with severely comminuted Rolando fractures were treated by closed reduction and fixation with a modified Suzuki frame without rubber bands, followed by immediate mobilization. All the fractures healed within 5 weeks. At 3 months, no rotational deformity was observed. The Kapandji score was equal that of the contralateral thumb in eight cases. No residual pain was recorded. Grip strength was 78% and pinch strength was 78% of the contralateral hand. One patient needed the frame tension modified. One patient developed a sensory deficit in the area of the superficial branch of the radial nerve that resolved spontaneously in 3 months. One patient healed with a 2-mm articular step-off, but the clinical outcome was good. Our retrospective study suggests that the small modification we made to the Suzuki frame provides a relatively simple and minimally invasive technique for the treatment of comminuted Rolando fractures.

Treatment of proximal phalangeal fractures with an antegrade intramedullary screw: a cadaver study

The aim of this study was to quantify the articular cartilage defect created with two different antegrade techniques of intramedullary osteosynthesis with a headless compression screw inserted through the metacarpophalangeal joint. In 12 out of 24 fingers from six cadaveric hands, a trans-articular technique with cannulated headless compression screws (2.2 and 3.0 mm diameter) was used; whereas in the other 12 fingers, an intra-articular fixation technique was used. The areas of the articular surface and the defects created were measured with a digital image software program. All measurements were made twice by two observers. In the intra-articular technique, the average defect in the base of the articular surface of the proximal phalanx was 4.6% with the 2.2 mm headless compression screw and 8.5% with the 3.0 mm screw. In the trans-articular technique, the defect size was slightly smaller; 4.2% with the 2.2 mm screw and 8% with the 3.0 mm screw, but the differences were not statistically significant. The main advantage of the intra-articular technique was that it avoided damage to the articular surface of the metacarpal head.

Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand: a review of 31 consecutive fractures

We present the results of 26 patients with 31 consecutive displaced or unstable extra-articular fractures of the base and shaft of the proximal and middle phalanges of the digits of the hand, treated over a period of 12 months with an intramedullary headless compression screw and early mobilization with no splinting. All fractures healed with no major complications. Only one patient, who had a pathological fracture through an enchondroma, required a tenolysis to improve the mobility of the finger. This technique seems to be technically simple, effective and with few drawbacks.

LEVEL OF EVIDENCE

IV.

Long-term clinical outcome after epineural coaptation of digital nerves

This study evaluates the long-term clinical outcome and complication rate after digital nerve repair in adults and aims to identify possible prognostic factors of sensory recovery. End-to-end epineural coaptation was performed under magnification. A total of 93 coapted digital nerves were clinically evaluated with a mean follow-up of 3.5 years (range 1-6 years). The mean two-point discrimination was 10.6 mm (versus 4.4 mm for the contralateral side). Cutaneous pressure threshold tested with Semmes-Weinstein monofilaments showed a mean value of 2.7 (versus 2.2 for the contralateral side). Only 2% of our patients developed painful neuromas. None of our patients recovered normal functional sensibility, however, recovery of protective sensation contributed to a high reported level of satisfaction. No correlation was observed between the sensory outcome and age, smoking, mechanism of injury, lesion to or anastomosis of a digital artery, or time of immobilization. The only identified predictor of the result was the surgeon's level of experience. This highlights the importance of adequate training and practice in the surgical repair of smaller peripheral nerves.

LEVEL OF EVIDENCE

IV.

Replantation by palmar arteriovenous anastomosis in complex finger amputations

Digital replantation is a well-established and increasingly common procedure in specialized hand surgery units worldwide. Replantation after complex trauma is often challenging due to severely injured, small-diameter vessels, especially at the distal level. Digit salvage by arteriovenous anastomosis has been inadequately described in the literature for such cases. The objective of this study was to evaluate the outcomes and complications of arteriovenous digital replantation in complex amputations. We reviewed five cases of digital replantation using a single palmar afferent arteriovenous anastomosis and drainage via a dorsal vein. The postoperative protocol followed our standard replantation protocol. All digits survived with no revision procedures. No major complications were observed. One digit developed partial epidermolysis and one thumb developed marginal skin necrosis, both treated conservatively. The color of the replanted digits was not a reliable monitoring parameter but capillary refill was consistently visible. Microangiography performed four months after surgery demonstrated good digit perfusion. Our results support palmar arteriovenous anastomosis as a reliable alternative in digital replantation if distal arteries are unavailable for anastomosis. The results also suggest that this digit salvage procedure can be carried out at a more proximal level than previously reported.

The hemi-hamate autograft arthroplasty in proximal interphalangeal joint reconstruction: a systematic review

Palmar lip injuries of the proximal interphalangeal joint with dorsal fracture-dislocation are difficult to treat and often require major reconstruction. A systematic review was performed and yielded 177 articles. Thirteen articles on hemi-hamate autograft were included in full-text analysis. Results of 71 cases were summarized. Mean follow-up was 36 months and mean proximal interphalangeal joint range of motion was 77°. Overall complication rate was around 35%. Up to 50% of the patients showed radiographic signs of osteoarthritis. However, few of those patients complained about pain or impaired finger motion. Based on this systematic analysis and review, hemi-hamate autograft can be considered reliable for the reconstruction of acute and chronic proximal interphalangeal joint fracture-dislocations with joint involvement >50%, but longer-term follow-up studies are required to evaluate its outcome, especially regarding the rate of osteoarthritis.

Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap

Fingertip injuries often result in fingernail defects. Reconstruction of this structure is important for adequate functional and aesthetic results. This study evaluates the eponychial flap reconstruction technique in 45 fingertip amputations with loss of more than half the fingernail. In 33 cases the procedure was performed in combination with a palmar island flap for pulp reconstruction. Average follow up was 5 months. All eponychial flaps healed uneventfully. In 44 cases, the pulp volume was restored without nail growth disturbance. Five complications (9%) were observed (pain, soft nail, and nail deformity). Only one hook nail deformity required reoperation. All patients were satisfied with the aesthetic and functional outcome. We found eponychial flap fingernail reconstruction effective even for injuries proximal to the lunula and have extended the indication for this technique to very proximal fingernail defects. Eponychial flap reconstruction is a simple, safe, and time-effective technique without donor site morbidity. Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip.

[Comparison of functional results with MRI findings after surgical treatment of transscaphoid perilunate fracture dislocations of the wrist: the role of scapholunate ligament lesions]

PURPOSE

The aim of this study was to review the outcome of transscaphoid perilunate fracture dislocations by MRI to use the advantages of MRI to show the post-traumatic degenerative changes, the examination of cartilage, the integrity of the ligaments and the vascularisation of the carpal bones. A second aim of this study is to interpret the findings in correlation to the functional results and the individual perception of hand functionality (PRWE).

PATIENTS AND METHODS

In this retrospective study, 20 patients (1 woman and 19 men), who were treated with open reduction and internal fixation at our institution, were reviewed at a mean of 67 (25-145) months postoperative. The mean age was 30 (12-73) years. The functional results were measured by range of motion (ROM), grip and pinch strength. The Mayo and Krimmer wrist scores were calculated and the SF-36 and the patient-rated wrist evaluation (PRWE) questionnaires were performed. Radiological findings included consolidation of the fracture and the radiological measures (revised carpal height, SL gap, SL and RL angle). An MRI, performed without a contrasting agent, was used to assess the degenerative changes of the joints, the vascularisation of the carpalia and the integrity of the SL ligament. Statistical data was calculated with SPSS.

RESULTS

Range of motion and strength were reduced by 10-20% compared to the uninjured opposite side. Although the majority of the patients (85%) achieved good to very good results in the Mayo and Krimmer wrist scores, the MRI showed osteoarthritis in 95% of the cases in at least in 1 out of 5 patients evaluated intracarpal joints. MRI showed signs of complete SL ligament tears in 5 patients and a partial tear in 2 patients. The same group also showed the strongest degenerative changes. However, there was no correlation between patient satisfaction and imaging results.

CONCLUSION

MRI findings, as well as X-ray findings, do not correlate with the subjective and objective functional outcomes after surgical treatment of transscaphoid perilunate fracture dislocations. It can be assumed that SL ligament lesions seen in MRI play a major role over the long term course.

[Impact of soft tissue injury on results after osteosynthesis of intraarticular fractures of the base of the middle phalanx of the finger]

BACKGROUND

The aim of this study was to investigate retrospectively if soft tissue injuries have an impact on the functional results of surgically treated intra-articular fractures of the base of the middle phalanx.

PATIENTS AND METHODS

From 1/2007 to 4/2010 we operated on 27 patients with intra-articular fractures of the base of the middle phalanx with pins, screws or external fixation analogous to Suzuki. 5 patients were excluded. 13 patients had no significant soft tissue injury (kWTV group), 9 patients had significant soft tissue damage including open fractures, skin lesions or/and severe soft tissue swelling (WTV group). Postoperative function and complications were analysed based on total active range of motion (TAM) and range of motion of the proximal interphalangeal joint (PIP-ROM) with regard to the Larsen score and clinical data.

RESULTS

Fractures with soft tissue injuries had a significantly worse TAM outcome (p=0.04) than fractures without soft tissue injury (kWTV group: TAM 197.1°; WTV group TAM 231.2°) even if the functional results regarding the Larsen classification were excellent or good in both groups (kWTV 100%, WTV 88.9%). There were no significant differences regarding PIP-ROM of both groups.

CONCLUSION

Soft tissue injuries have a negative impact on the functional results of surgical treated intra-articular fractures of the base of the middle phalanx. The influence on PIP-ROM might be less. Other factors might play a considerable role for PIP-ROM. With an adequate operative treatment most intra-articular middle phalanx fractures show good to excellent functional -results.

Proactive and reactive control of movement are differently affected in Attention Deficit Hyperactivity Disorder children

Attention-Deficit/Hyperactivity Disorder children are impaired in the ability to interrupt an ongoing action in relation to a sudden change in the environment (reactive control, measured by stop signal reaction time, SSRT). Less investigated is the ability to control the response when it is known in advance that it will be required to stop (proactive control, measured by change in Reaction time, RT). The study is aimed at exploring both the reactive and the proactive inhibitory control in a group of ADHD children compared to a group of age-matched controls. ADHD children (N=28) and Controls (N=28) performed 4 tasks: 2 tasks required to respond to the appearance of the go-signals (go task and nostop task) and 2 tasks to respond to the go signals in a context in which sometimes a restrain or suppression of the response was required (go-nogo task and stop task). ADHD children showed a longer SSRT compared to controls. Both groups showed an increment in RT by comparing the go-nogo to the go task and an increment in RT and SD by comparing the stop to the nostop task. ADHD children showed higher intra-individual variability (SD) compared to controls only in the stop and nostop task. ADHD children showed impaired reactive control but preserved proactive control, and the physical appearance of the go signal affected their reaction times intra-individual variability. A comparison between the reactive and proactive controls helps in defining neuropsychological profiles of ADHD children and can inspires therapeutic behavioral-cognitive strategies for response control.

THE SURGICAL TREATMENT OF THE FIRST CARPOMETACARPAL JOINT ARTHRITIS: EVALUATION OF 400 CONSECUTIVE PATIENTS TREATED BY SUSPENSION ARTHROPLASTY

Arthritis of the first carpometacarpal joint is a widespread disease in Western countries. It affects predominantly women with marked impairment in daily life activities. Its aetiopathogenesis is well described, while its treatment still controversial. The authors report their experience with 400 consecutive patients with established clinical and radiological findings of carpometacarpal joint arthritis treated by suspension arthroplasty with Ceruso's modified Weilby's technique. At 12 months follow-up, we were able to assess 315 patients using MAYO's score pre- and post-operatively, obtaining 86 excellent results, 134 good, 62 fair and 33 poor. As for complications, there were seven infections, 32 persistent pain and 42 limited range of motion. According to our experience the treatment modality of suspension arthroplasty with Ceruso's modified Weilby's technique represents the procedure of choice in indicated cases of first carpometacarpal joint arthritis in advanced stages according to Eaton-Littler classification.

[Fibrolipohamartoma of the upper extremity: treatment results in six patients over nine years]

BACKGROUND

Fibrolipohamartoma (FLH) is a rare, benign congenital malformation of peripheral nerves, mainly the median nerve, less frequently of the ulnar or other nerves. Early symptom is an initially painless, slowly growing and circumscript swelling. Affections at the wrist level or the foot are occasionally accompanied by macrodactyly. Although FLH is a congenital disorder, because of absent or discreet symptoms, the diagnosis is often made in early adulthood only due to a compression neuropathy. Magnetic resonance image findings are pathognomonic, biopsies are not necessary. In the medical literature, FLH has been described for the past forty years only by means of case reports or small case series. Meanwhile, surgical decompression is considered as therapeutic gold standard, in case of an accompanying macrodactyly in combination with corrective procedures for length, breadth and axis.

AIM OF THE STUDY

To study long term results after surgical compression of FLH und thus an assessment of this therapeutical concept generally accepted as gold standard in this rare entity.

PATIENTS AND METHODS

Between 1994 and 2004 we treated 9 patients (8 women, 1 man) with 11 tumors, average age was 38 years (3-62). 2 of the 9 patients had macrodactyly. In 7 patients, the median nerve was affected, in one patient bilaterally, in 5 patients the ulnar nerve, and in one patient both ipsilateral median and ulnar nerves. Of those 9 patients, we were able to follow up 6 clinically and electroneurographically. In addition, the DASH-score was collected. Average follow-up after initial decompression was 9 years (2-23). We performed surgical decompression in 5 patients, one patient was treated conservatively.

RESULTS

Patients with affections of the median nerve showed tendentially better results after surgical decompression compared to those with FLH of the ulnar nerve, irrespective of the affected anatomical level. Surgical decompression led to a relief of the symptoms in all patients; an improvement of motor function, hypaesthesia and cold sensitivity, however, could not be demonstrated.

CONCLUSION

FLH must be considered in the differential diagnosis of macrodactyly. We recommend surgical decompression, as it leads to relief of the symptoms. It does, however, not have a beneficial effect on already present motor impairments, sensory deficits and cold sensitivity. We strictly advise against tumor resection.

Factor V Leiden Mutation and Thrombotic Occlusion of Microsurgical Anastomosis After Free TRAM Flap

The transverse rectus abdominis muscle flap is widely used in free microvascular tissue transfer for breast reconstruction following mastectomy. Flap survival may be compromised by failure at the microsurgical anastomosis due to both venous and arterial thrombosis. It is unclear, whether hereditary thrombophilia represents a risk factor for early thrombotic occlusion following free flap procedures. We present a case of a patient with previously diagnosed activated protein resistance caused by heterozygous factor V (position 1691 G→A) Leiden mutation in whom a free transverse rectus abdominis muscle flap was performed. The postoperative course was complicated by repeated thrombosis of both the venous and arterial part of the anastomosis. Immediate thrombectomy and repeated arteriography allowed for partial flap salvage. More data are needed to analyze the impact of hereditary thrombophilia on microvascular anastomosis failure.

[Reconstruction of distal fingeramputations using palmar fingerflaps and the dorsal eponychial flap]

Reconstruction of fingertip amputations, especially if they involve more than half of the fingernail require the surgeon to determine whether the fingernail should be removed. However, aside from aesthetic aspects the fingernail has functional purposes - stabilisation of the pulp and enhancement of sensibility - and should therefore be preserved. Since November 2004 we have been using the technique of combining palmar finger flaps with dorsal eponychial plasty in reconstructing complex distal fingertip defects in 12 patients. All flaps had an uneventful healing. One patient with insufficient bone support after a failed operation developed an onychogryphosis. The remaining patients were satisfied with the result. With a simple technique augmenting the palmar reconstruction of complex fingertip defects by the dorsal eponychial flap plasty we can achieve a better support for the pulpa and also a better cosmetic result.

Spinal cord stimulation and cerebral blood flow in stroke: personal experience

Spinal cord stimulation (SCS) can increase cerebral blood flow (CBF) and improve stroke patients. In order to better understand the haemodynamic changes underlining the clinical improvement, we have studied with transcranial Doppler (TCD), SPECT and NIRS 18 patients harbouring a stroke. SPECT Group: An increase of regional CBF during SCS was measured far from the stroke areas in 9 patients, further decrease in CBF was found in 2, no changes in 1. TCD Group: An increase of CBF velocities during SCS was found in 4 patients, no changes in 6, a decrease in 1. NIRS Group: Data consistent with and increase in CBF were obtained during SCS in the only patient undergone such a study. In 6 patients studied with different techniques, data obtained fitted only in 2 patients. In 3 patients no changes in TCD faced with changes in SPECT. In one case an improvement in TCD was evident in the left while an improvement of SPECT was shown in the right site. SCS is a valid therapeutic tool in stroke patient even if, as matter of fact, parallelism between clinical and haemodynamic changes during SCS is not demonstrated in our patients, rising the question on the role of ischemic penumbra in mediating clinical improvement.

Cutaneous innervation in hereditary sensory and autonomic neuropathy type IV

The authors investigated immunocytochemically the innervation of a skin biopsy in a rare case of hereditary sensory and autonomic neuropathy type IV. A few protein gene product 9.5-, growth-associated protein 43-, calcitonin gene-related peptide-, and substance P-immunoreactive nerve fibers were observed in the deeper regions of the dermis. Neuropeptide Y-, nitric oxide-, and vasoactive intestinal polypeptide-immunoreactive fibers were completely absent. Their observations support the hypothesis that the sensory and autonomic defects reported in hereditary sensory and autonomic neuropathy are based on profound developmental alterations of the peripheral nervous system.

Characterization of T-cell subsets infiltrating post-burn hypertrophic scar tissues

In this study, skin-infiltrating cells were characterized in both the active and remission phases of post-burn hypertrophic scar biopsies. Immunohistochemistry examination of active phase samples showed an abundant presence of Langerhans cells, T cells, macrophages, a low presence of natural killer cells and the lack of B lymphocytes. In active hypertrophic scars T lymphocytes infiltrate deep into the superficial dermis and are also observed in the epidermis: CD3+ cells were present at about 222 +/- 107 per 0.25 mm2. In particular the analysis of lymphocyte subpopulations showed that CD4+ T cells predominate in the dermis as well as in the epidermis of active hypertrophic scars whereas CD8+ cells were less well represented (CD4/CD8 ratio is 2.06). This distribution was also shown in remission phase samples and in normotrophic scar specimens, although the lymphocyte number was significantly lower. Approximately 70 per cent of T lymphocytes present in the tissue involved in active phase hypertrophic scar samples were activated (positive with anti-HLA-DR and IL-2 receptor antibodies) which is significantly higher than remission phase hypertrophic and normotrophic scars, in which positivity was 40 and 38 per cent, respectively. Upon activation, the lesional lymphocytes release several cytokines, locally and transiently, that interact with specific receptors in response to different stimulation. Central to the immune hypothesis of hypertrophic scars is that some of the T-cell lymphokines act on keratinocytes, fibroblasts and other cell types to induce changes characteristic of these scars. The presence and close proximity of activated T lymphocytes and antigen-presenting cells of various phenotypes in both the epidermis and dermis of hypertrophic tissues provides strong circumstantial evidence of a local immune response. However, the manner in which T cells achieve and maintain their activated state in hypertrophic tissues is not yet known, and both antigen-dependent and independent mechanisms may contribute.

The influence of progress in the treatment of severe burns on the quality of life

The problems related to burns treatment can be considered among the oldest and most passionating in history of medicine. Since the early forties amazing progresses have been done in the comprehension of the physiopathology of burns. The fast development of resuscitating techniques determined a remarkable reduction of mortality in the first phase; in a similar way through new concepts in the project and construction of intensive care facilities dedicated to burns, where patients can be isolated and a high standard of environmental control can be guaranteed, together with new topical and systemic antibacterial treatment protocols, a significant reduction of infectious complications has been achieved. Concerning surgical treatment early tangential excision and cultured epidermal grafts can be considered the cornerstones of burn therapy. Quality of life of burnt patients have been greatly ameliorated by these technical advances. Burn sequelae however remain the main concern of survivors because of the many controversial aspects of burn scar physiopathology and treatment. Along my career many endeavours I dedicated in this important research field. I will then report the results of most interesting clinical and experimental studies carried out in the last 30 years by our group in collaboration with basic researchers. All the work done in this domain enhance our hope that good results can really improve quality of life in burns: this is the goal for those who dedicated the whole life to relieve the suffering of these badly injured patients.

An immunohistochemical study on cutaneous sensory receptors after chronic median nerve compression in man

Carpal tunnel syndrome represents the most frequent chronic compressive neuropathy in man and hence may be investigated as a spontaneous model of peripheral nerve damage and repair. In the present report the fate of nerve fibers in the digital skin after long-lasting median nerve compression has been investigated immunohistochemically in comparison to normal digital skin, with special consideration to sensory endings and encapsulated receptors. The presence has been documented of the neurospecific marker PGP 9.5, the glia-associated protein S-100, and the neuropeptides CGRP and CPON which are mainly associated with the sensory and sympathetic nerve fibers respectively. The morphology and distribution of nerve fibers and corpuscles appeared comparable to that of normal digital skin; a reduction in the density of sensory receptors has, however, been observed, although not to the degree that was expected to explain the clinical deficits. It has been also demonstrated that at least part of the CGRP-containing sensory and CPON-containing sympathetic axons may survive unaltered even in patients with a long clinical history of profound sensorial impairment. An apparent discrepancy between the maintenance of nerve fibers and the sensory disturbances and the frequent observation of prompt postoperative recovery even after years of compression results from this investigation. The correlation of immunohistochemical observations and functional scores may not be considered conclusive. It must, however, be discussed if the sensorial impairment in this syndrome might have, at least in some cases, not only an anatomical but also an electrophysiological basis.

Sensory endings in skin grafts and scars after extensive burns

Fifteen patients who underwent a split thickness skin graft operation for full thickness burns and six patients with postburn scars were biopsied after a standard aesthesiological examination completed with Weber and Dellon tests. A semiquantitative evaluation was performed on immunohistochemically stained sections to determine the presence or absence of PGP 9.5 immunoreactive intraepithelial fibres, complex sensory receptors, nerve fibres in the dermal papillae, vessel-innervating fibres, gland-innervating fibres, and nerve trunks in the deep dermis. The reinnervation pattern was similar in grafts and scars. With regard to sensory receptors, free nerve endings and Merkel-neurite complexes were observed. Statistical analysis suggested a significant correlation between sensibility and the amount of regenerated nerve structures (particularly in the epidermis and dermal papillae).

Morphology of corpuscular receptors in hairy and nonhairy human skin as visualized by an antiserum to protein gene product 9.5 compared to anti-neuron-specific enolase and anti-S-100 protein

The present study elucidates the morphology of encapsulated receptors in human skin by means of immunohistochemistry for the recently characterized neurospecific marker protein gene product 9.5, in comparison with neuronal specific enolase and S-100 protein. Only two types of corpuscles are identified, Meissner's corpuscles and simple coiled corpuscles. Moreover, this investigation reveals that though regional specialization may exist with regard to the encapsulated receptor density, the comparison of hairy and nonhairy skin does not reveal important differences.

A sexually dimorphic nucleus in the quail preoptic area

The cytoarchitectural analysis of the preoptic-anterior hypothalamic region of the Japanese quail reveals a sexual dimorphism in the total volume of the medial preoptic nucleus (significantly larger in males than in females). Different nuclei of the region (dorsal preopticus, suprachiasmaticus) do not show any statistically significant difference. The sex-related difference is more consistent comparing the distribution of dark volume. This last is due to a larger number of cells containing high amount of Nissl's substance in male than in female. Present findings represent the first example of sexual dimorphism in the avian hypothalamus.