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PURPOSE: The management of infected humeral shaft nonunion (HSN) remains challenging due to the lack of consensus and the potential for occult infection. The aim of this study was to evaluate a surgical strategy based on a two-stage treatment for suspected infection or a one-stage treatment for infection diagnosed retrospectively based on systematic bacteriological sampling. METHODS: We retrospectively reviewed 16 patients with a median age of 36 years who were treated for septic HSN: 9 patients underwent a two-stage procedure using the induced membrane technique, and 7 patients were treated in a single stage. Revision parameters included achieving bone union, its time frame, and a functional assessment based on joint motion and the Quick-DASH score. RESULTS: At a median follow-up of 47.5 months, 12 out of 16 patients were cured with acquired bone union and no septic recurrence. The median time to bone union was 5.5 months. Smoking and previous surgeries were adverse factors for bone healing. Radiological and functional outcomes were comparable between patients treated in a single stage and those treated in two stages. CONCLUSIONS: This study confirms the relevance of one-stage surgery for HSN with occult infection and the value of systematic bacteriological sampling during the revision of humeral diaphyseal osteosynthesis.

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Background: Arm transplantation has been proposed as a valid therapeutic option for arm amputees. A bilateral arm transplantation including reconstruction of the left shoulder was performed on January 13, 2021 in Lyon (France). Methods: The recipient was a 48-year-old man with bilateral amputation at proximal arm level on both sides following an electric shock in 1998. He had received a liver transplant in 2002. The donor was a 35-year-old man. On the right side, the donor humerus was fixed on the remaining 9-cm-long proximal stump, and was reinforced with the donor fibula in an intramedullary fashion. On the left side, the whole donor humerus (including the humeral head) was transplanted with reconstruction of the gleno-humeral joint, including a suspension ligamentoplasty. The immunosuppressive protocol was based on antithymocyte globulins as induction therapy, and tacrolimus, steroids and mycophenolate mofetil as maintenance therapy. Results: Good bone healing and a well-positioned ligamentoplasty on the left side were achieved. At 2 years, the recipient was able to flex both elbows, and wrist extension, finger flexion, and extension were appreciated on both sides. Intrinsic muscle activity was detectable by electromyography during the eighth posttransplant month, and sensitivity was recovered. The patient is satisfied with his autonomy in some daily activities, but his greatest satisfaction is the recovery of his body image. Conclusions: These results confirm that it is possible to propose this transplantation to proximal-level arm amputees. The patients' information about risks and limits as well as their compliance and determination remain important prerequisites.

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OBJECTIVES: Surgery for congenital malformation of the hand is complex and protocols are not available. Simulation could help optimize results. The objective of the present study was to design, produce and assess a 3D-printed anatomical support, to improve success in rare and complex surgeries of the hand. MATERIAL AND METHODS: We acquired MRI imaging of the right hand of a 30 year-old subject, then analyzed and split the various skin layers for segmentation. Thus we created the prototype of a healthy hand, using 3D multi-material and silicone printing devices, and drew up a printing protocol suitable for all patients. We printed a base comprising bones, muscles and tendons, with a multi-material 3D printer, then used a 3D silicone printer for skin and subcutaneous fatty cell tissues in a glove-like shape. To evaluate the characteristics of the prototype, we performed a series of dissections on the synthetic hand and on a cadaveric hand in the anatomy lab, comparing realism, ease of handling and the final result of the two supports, and evaluated their respective advantages in surgical and training contexts. A grading form was given to each surgeon to establish a global score. RESULTS: This evaluation highlighted the positive and negative features of the model. The model avoided intrinsic problems of cadavers, such as muscle rigidity or tissue fragility and atrophy, and enables the anatomy of a specific patient to be rigorously respected. On the other hand, vascular and nervous networks, with their potential anatomical variants, are lacking. This preliminary phase highlighted the advantages and inconveniences of the prototype, to optimize the design and printing of future models. It is an indispensable prerequisite before performing studies in eligible pediatric patients with congenital hand malformation. CONCLUSION: The validation of 3D-printed anatomical model of a human hand opens a large field of applications in the area of preoperative surgical planning. The postoperative esthetic and functional benefit of such pre-intervention supports in complex surgery needs assessing.

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PURPOSE: Soft tissue coverage of the posterior aspect of the elbow requires thin and flexible flaps to adapt to movements without constraining them. The authors report a clinical series of reconstruction by the descending superficial radial artery (DSRA) flap, a proximal forearm perforator flap which use is rarely reported in the literature. METHODS: Seven patients with a mean age of 50 years (range 24-88 years) were treated for a posterior elbow defect using the DSRA flap with an adipofascial pedicle. The flap was tunneled to the defect in the subcutaneous tissue or raised using the racket-like technique to avoid any pedicle compression. RESULTS: The mean follow-up was 3.3 months (range 1-12 months). A partial necrosis of the skin paddle occurred in an 88-year-old patient. In the other cases, the flap evolution was straightforward. At the last follow-up, the appearance of the flaps was satisfactory in terms of color, texture, and thickness. No complications were observed at the donor site. CONCLUSION: The DSRA flap with an adipofascial pedicle is a simple, reliable, and reproducible method for reconstruction of small to moderate-sized defect on the posterior aspect of the elbow. Its use is easier for defects on the posterolateral side, but it can reach the medial olecranon.

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The influence of the anatomy of the proximal articular surface of the trapezium (PAST) and the trapezoidal articular surface of the trapezium (TRAST) on cup placement during trapeziometacarpal arthroplasty was retrospectively evaluated on 56 preoperative anteroposterior radiographs of patients who underwent surgery for trapeziometacarpal osteoarthritis. The percentage coverage of the prosthetic cup by the PAST and the available height of the trapezium were calculated. In 39% of cases, there was a significant difference (up to a mean 4.5 mm, p < 0.001) between the radial height of the trapezium (which is usually considered) and the available height of the trapezium. The anatomy of the PAST and the TRAST has an impact on the placement of the prosthetic cup when trapezium height is low. The results of the present study suggest that these considerations must be known by all operators performing trapeziometacarpal arthroplasty; that lateralization, implant suspension, or surgical alternatives should be considered to prevent several intra- and postoperative surgical complications. Level of evidence: IV.

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A retrospective study of 945 hand patients was conducted to determine the relevance of systematic radiographic assessment. An osteoarticular lesion or a radiopaque foreign body was found in 34% of cases. The indications for radiographic assessment should be related to the mechanism of injury.

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A retrospective study of 41 trapeziometacarpal prostheses showed that the implant survival rate decreased linearly over time with a critical period in the first years; ranging from 83% after 5 years to 50% after 30 years.Level of evidence: IV.

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A retrospective study of patients with symptomatic trapeziometacarpal osteoarthritis was conducted to assess the prevalence of other disorders of the hand. Another disorder of the hand was associated in 49% of cases. A systematic clinical examination of the whole hand must be performed preoperatively.

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We report the long-term patient-reported outcomes and objective outcomes of a homodigital neurovascular island flap for distal phalangeal amputations in the fingers (with the thumb excluded) for 20 patients at a median follow-up of 4.4 years (IQR 2.2 to 12.3). We assessed the global subjective and aesthetic outcomes, range of motion, sensitivity and strength. The patient-reported median subjective global score was 7.5/10 points (IQR 7 to 9) and the aesthetic score was 8/10 points (IQR 8 to 9). Range of motion, sensitivity and strength were similar to the uninjured side. Stiffness was present in more than half of the cases; 14 patients had a hook nail deformity and seven patients reported symptomatic cold intolerance. At a long-term follow-up, the patient-reported outcome measures and objective outcomes of this flap are satisfactory and it is a safe and reliable flap.Level of evidence: IV.

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STUDY DESIGN: A cross sectional cadaveric measurement study. INTRODUCTION: The etiology of entrapment neuropathies, such as carpal tunnel syndromes or thoracic outlet syndromes (TOS), is usually not only linked with the compressive lesion of the nerve but can also be associated with fibrosis and traction neuropathy. PURPOSE OF THE STUDY: This work studies the biomechanics of the ulnar nerve in a cadaveric model of thoracic outlet syndrome (TOS). We explored the biomechanical impact of a restriction of mobility of the ulnar nerve. We measured if it could significantly affect the deformation undergone by the nerve on the rest of its path. METHODS: We studied 14 ulnar nerves from 7 embalmed cadavers. We opened three 6.5cm windows (at the wrist, forearm, and arm), and two optical markers 2cm apart were sutured to the ulnar nerve. We then studied the deformation of the ulnar nerve in three successive tensioning positions inspired by the ULNT3 manoeuvre (Upper Limb Neural Test 3). We then fixed the brachial plexus to the clavicle to mimic a nerve adhesion at the thoracic outlet. RESULTS: Fixing the brachial plexus to the clavicle bone had significant effects on ulnar nerve mobility. In the position of intermediate tension, the nerve deformation increased by +0.68% / +1.43% compared to the control measure. In the position of maximum tension, it increased by +1.16% / +1.94%, pushing the nerve beyond the traumatic threshold of 8% of deformation causing reversible damage to axonal transport and vascularization. CONCLUSIONS: Our nerve adhesion at the thoracic outlet showed significant effects on the mobility of the ulnar nerve compared to the control situation, by significantly increasing the deformation undergone throughout the rest of the nerve's course, and by taking it over the 8% of physiological traumatic deformation.

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Graft vasculopathy (GV) is the most severe pathologic change of chronic rejection in vascularized composite allotransplantation. Since 2012, the intimal media thickness (IMT) of radial and ulnar arteries was annually monitored by high-resolution ultrasonography in seven bilateral upper extremity transplant (UET) patients. We also investigated the IMT of seven matched healthy subjects (controls). No significant difference between IMT values of controls and UET patients was found. The median IMT values of recipient radial and ulnar arteries were 0.23 mm and 0.25 mm, respectively, while the median IMT values of grafted radial and ulnar arteries were 0.27 mm and 0.30 mm, respectively. There was a statistically significant difference in the IMT values of the grafted and recipient ulnar arteries (p = .043), but this difference was no longer significant when patient #2 was excluded. He showed a significant difference between recipient and grafted arteries and significantly higher IMT values (p = .001) of his grafted arteries compared with those of all transplanted patients. This patient developed GV leading to graft loss 11 years after the transplantation. In conclusion, this study showed a significant IMT increase in an UET recipient who developed GV.

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The importance of psychosocial aspects in upper extremity transplantation (UET) has been emphasized since the beginning of the vascularized composite allotransplantation era. Herein a long-term UET failure mainly due to psychiatric disorders is reported. A young woman amputated in 2004 (electrocution) underwent bilateral UET in 2007. At the time of transplantation the patient underwent a psychological evaluation, which did not completely consider some traits of her personality. Indeed, she had an anxious personality and a tendency to idealize. The trauma of amputation, the injuries associated with the accident, and the short delay between the accident and the transplantation elicited vindictiveness, entitlement, and impulsivity. Following transplantation, she had a high anxiety level, panic attacks, depression, and hypomanic episodes. She was poorly compliant to the rehabilitation program and the immunosuppressive treatment. She developed 13 acute rejection episodes (reversed by appropriate treatment) but neither clinical signs of chronic rejection nor donor specific antibiodies. She developed many severe complications due to the treatment and the psychiatric disorders. At her request, after many interviews, the allografts were removed in 2018. Pathological examination and an angiography performed post-amputation revealed signs of graft vasculopathy of varying severity, in the absence of clinically overt chronic rejection. This case highlights the need to detect during the initial patients' assessment even mild traits of personality disorders, which could herald psychiatric complications after the transplantation, compromising UET outcomes. It further confirms that skin and vessels are the main targets of the alloimmune response in the UET setting.

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Upper extremity allotransplantation (UEA) is the more common type of vascularized composite allotransplantation of which more than 80 patients have benefited worldwide. These allografts include - along with the skin - the nail unit, a specialized epithelial appendage which may be the target of graft rejection. We report an UEA recipient who developed, as an initial manifestation of graft rejection, onychomadesis, that is shedding of the nail plate starting from the proximal nail bed. On this occasion, we reviewed the nail changes we have observed in a series of eight patients with UEA who were grafted and followed in our hospital since 1998 (mean follow-up period of 9.75 years). We also reviewed the relevant literature reporting nail changes in UEA recipients. A brief discussion on the significance of these changes in the context of UEA is provided with emphasis on onychomadesis, a finding usually related to graft rejection in this specific setting.

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Risk-to-benefit analysis of upper extremity allotransplantation (UEA) warrants a careful assessment of immunosuppression-related complications. This first systematic report of infectious complications after UEA aimed to compare incidence and pattern of infections to that observed after kidney transplantation (KT). We conducted a matched cohort study among UEA and KT recipients from the International Registry on Hand and Composite Tissue Transplantation and the French transplant database DIVAT. All UEA recipients between 1998 and 2016 were matched with KT recipients (1:5) regarding age, sex, cytomegalovirus (CMV) serostatus and induction treatment. Infections were analyzed at three posttransplant periods (early: 0-6 months, intermediate: 7-12 months, late: >12 months). Sixty-one UEA recipients and 305 KT recipients were included. Incidence of infection was higher after UEA than after KT during the early period (3.27 vs. 1.95 per 1000 transplant-days, P = 0.01), but not statistically different during the intermediate (0.61 vs. 0.45/1000, P = 0.5) nor the late period (0.15 vs. 0.21/1000, P = 0.11). The distribution of infectious syndromes was significantly different, with mucocutaneous infections predominating after UEA, urinary tract infections and pneumonia predominating after KT. Incidence of infection is high during the first 6 months after UEA. After 1 year, the burden of infections is low, with favorable patterns.

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BACKGROUND: The primary objective of this study was to evaluate improvements in external rotation after isolated arthroscopic capsular release in children with shoulder contracture due to brachial plexus birth palsy. MATERIALS AND METHODS: This study included all children older than 2 years with a range of active external rotation limited to 30° or less and/or active anterior elevation (AE) limited to 90° or less secondary to brachial plexus palsy treated between 2011 and 2015. Passive glenohumeral motion, passive global (glenohumeral plus scapulothoracic) motion, active global motion for external rotation with the elbow at the side (ER1), AE, and internal rotation with the elbow at the side were recorded before and 2 years after surgery. Improvement was evaluated by comparing the preoperative and follow-up values. The operation performed was subscapularis-sparing arthroscopic capsular release. RESULTS: Thirty-five patients were included, and 28 completed 2 years of follow-up. The average changes in active global ER1, passive glenohumeral ER1, and passive global ER1 were +35° (range, -20° to +100°; P <.0001), +35° (range, +0° to +75°; P <.0001), and +26° (range, -15° to +60°; P <.0001), respectively. There were no significant changes in internal rotation with the elbow at the side or AE. The mean improvement in the aggregate Mallet score was 3.9 points (range, -3 to +9 points; P <.0001). CONCLUSIONS: For children with shoulder contracture secondary to brachial plexus palsy, subscapularis-sparing isolated capsular release improves external rotation and functional scores and avoids any loss of active internal rotation but does not improve AE.

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We report a case of a young double-hand allotransplant patient who presented with a full-thickness skin necrosis of the dorsum of the left hand after vascular compromise of the allotransplantation. Considering the lack of viable dorsal tissue overlying the extensor tendons and the need for early hand rehabilitation, an ultrathin pedicled groin flap was used for the coverage. This procedure resulted in salvaging the allotransplantation, and the patient was able to successfully return to work after his surgery. To our knowledge, this is the only case of an upper extremity allotransplant salvaged by a pedicled flap.

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Lymphodepletive agents play important role in different clinical applications or experimental transplant studies. In order to facilitate preclinical pediatric transplant studies, we have developed the rabbit anti-pig thymocyte globulin (pATG) and studied its effects in neonatal swines. In vitro assays showed that pATG can bind to lymphocytes and neutrophils in a dose-dependent manner and lyse peripheral blood mononuclear cells by apoptosis and complement-dependent cytotoxicity. In vivo, pATG as a monotherapy was administered at different doses (2.5, 5, 20, 40 and 80mg/kg) in newborn pigs. Results showed that pATG induced a dose-dependent but transient T-cell depletion in peripheral blood. Lymphodepletion was also observed in lymph nodes, spleen and thymus. Pharmacokinetic studies showed dose-related cell-bound pATG on lymphocytes, as well as the presence of free pATG in the serum. Both cell-bound and free pATG levels decreased gradually after administration. Interestingly, adjuvant mycophenolate mofetil (MMF) given at 1g/m2/day for 1week successfully maintained pATG-induced T-cell depletion. In conclusion, pATG administration can cause transient T-cell depletion in neonatal pigs and this effect can be maintained by MMF. Therefore, we have developed an original immunosuppressive regimen that can be used for transplantation studies in swine model.

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