Upper extremity vascular injuries:Etiology,management and outcome

BACKGROUND Vascular injuries of the upper extremities are considered relatively rare injuries affecting mostly the young population.They often are complex injuries accompanied by other musculoskeletal trauma or trauma in other anatomic locations.Their management is challenging since they can lead to disabilities with major socioeconomic effects.AIM To analyze data about the mechanism of injury,the management algorithm and functional outcomes of vascular injuries of the upper extremity.METHODS One hundred and fifteen patients(96 males and 19 females)with arterial injuries of the upper extremity treated in a tertiary trauma center from January 2003 to December 2022 was conducted.Mean patients’age was 33.7 years and the mean follow up time was 7.4 years.Patients with Mangled Extremity Severity Score≥7 and Injury Severity Score≥20,previous upper limb surgery or major trauma and any neuromuscular or psychiatric disease were excluded,from the study.RESULTS A penetrating trauma was the most common cause of injury.The radial artery was the artery injured in most of the cases(37.4%)followed by the ulnar(29.5%),the brachial(12.1%)and the axillary(6%).A simultaneous injury of both of the forearm’s arteries was in 15.6%of the cases.In 93%of the cases there were other concomitant musculoskeletal injuries of the extremity.Tendon lacerations were the most common,followed by nerve injuries.The postoperative functional scores(full Disabilities of the Arm,Shoulder,and Hand and VAS)had very satisfactory values.CONCLUSION Although vascular injuries of the upper extremity are rare,they may occur in the context of major combined musculoskeletal trauma.Although a multidisciplinary approach is essential to optimize outcome,the ability of trained hand surgeons to repair all injuries in combined vascular and musculoskeletal upper extremity trauma,excluding isolated vascular injuries,ensures shorter operative times and better functional outcomes.

Vascular endothelial growth factor for the treatment of femoral head osteonecrosis: An experimental study in canines

AIM To evaluate the treatment of osteonecrosis of the femoral head(ONFH) with the use of vascular endothelial growth factor(VEGF).METHODS In 30 mature beagles(6 groups of 5 beagles) ONFH was induced cryosurgically and one of the following solutions was administered locally in the femoral head(FH) in each group: Single injection of 500 μg VEGF(t-VEGFμ group); single injection of 500 ng VEGF(t-VEGFn group); continuous delivery of 500 μg VEGF through osmotic micropump(t-VEGFpump-μ group); continuous delivery of 500 ng VEGF through osmotic micropump(t-VEGFpump-n group); single injection of 0.9% sodium chloride(t-NS group), while one group that served as control group did not receive any local solution(No-t group). FHs were retrieved 12 wk postoperatively, underwent decalcification and hematoxylin/eosin and toluidine blue staining. In two canines per group, one half of FH was processed without decalcification and stained with modified Masson Trichrome. Histological sections were observed by light microscopy and measured with a semi-automatized bone histomorphometry system and Bone Volume/Total Volume(BV/TV), Marrow Volume/Total Volume(MaV/TV), and Trabecular Thickness(TbT h) were assessed. Standard and robust tests(Welch, Brown Forsythe) of analysis of variance along with multiple comparisons, were carried out among the categories.RESULTS The untreated(No-t) group had signs of osteonecrosis, whereas the VEGF groups revealed reversal of the osteonecrosis. Statistical analysis of the decalcified specimens revealed a significantly better BV/TV ratio and a higher Tb Th between the VEGF treatment groups(except the t-VEGFn group) and the No-t group or the control t-NS group. Single dose 500 μg VEGF group had significantly better BV/TV ratio and higher Tb Th when compared to the No-t group(50.45 ± 6.18 vs 29.50 ± 12.27, P = 0.002 and 151.44 ± 19.07 vs 107.77 ± 35.15, P = 0.161 respectively) and the control t-NS group(50.45 ± 6.18 vs 30.9 ± 6.67, P = 0.004 and 151.44 ± 19.07 vs 107.14 ± 35.71, P = 0.151 respectively). Similar differences were found for the prolonged VEGF delivery/pump groups of 500 μg and 500 ng. Analysis of the totality of specimens(decalcified/non-decalcified) enhanced the aforementioned differences and additionally revealed significant differences in the comparison of the TbT h.CONCLUSION In an experimental model of ONFH in canines it was found that local treatment with VEGF leads to bone tissue remodeling and new bone formation.

Heterotopic ossification after the use of recombinant human bone morphogenetic protein-7

AIM To present the incidence of heterotopic ossification after the use of recombinant human bone morphogenetic protein-7(rhB MP-7) for the treatment of nonunions.METHODS Bone morphogenetic proteins(BMPs) promote bone formation by auto-induction. Recombinant human BMP-7 in combination with bone grafts was used in 84 patients for the treatment of long bone nonunions. All patients were evaluated radiographicaly for the development of heterotopic ossification during the standard assessment for the nonunion healing. In all patients(80.9%) with radiographic signs of heterotopic ossification, a CT scan was performed. Nonunion site palpation and ROM evaluation of the adjacent jointswere also carried out. Factors related to the patient(age, gender), the nonunion(location, size, chronicity, number of previous procedures, infection, surrounding tissues condition) and the surgical procedure(graft and fixation type, amount of rhB MP-7) were correlated with the development of heterotopic ossification and statistical analysis with Pearsons χ~2 test was performed.RESULTS Eighty point nine percent of the nonunions treated with rh BMP-7, healed with no need for further procedures. Heterotopic bone formation occurred in 15 of 84 patients(17.8%) and it was apparent in the routine radiologi-cal evaluation of the nonunion site, in a mean time of 5.5 mo after the rh BMP-7 application(range 3-12). The heterotopic ossification was located at the femur in 8 cases, at the tibia in 6, and at the humerus in οne patient. In 4 patients a palpable mass was present and only in one patient, with a para-articular knee nonunion treated with rhB MP-7, the size of heterotopic ossification affected the knee range of motion. All the patients with heterotopic ossification were male. Statistical analysis proved that patient's gender was the only important factor for the development of heterotopic ossification(P = 0.007). CONCLUSION Heterotopic ossification after the use of rh BMP-7 in nonunions was common but it did not compromise the final clinical outcome in most cases, and affected only male patients.

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily.Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage,duration of limb ischemia,patient’s medical status and presence of associated injuries.The management of these injuries is challenging and requires a specific algorithm of action,because they are usually characterized by increased morbidity,amputation rate,infection,neurological and functional deficits,and they could be life threatening.Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma,the high index of suspicion,imaging control,and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases.Even after a successful initial treatment of a combined trauma pattern,long-term follow-up is crucial to prevent and detect early possible complications.The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities,from an orthopedic point of view.

Medico-legal risks associated to hand and wrist trauma

BACKGROUND Acute hand and wrist injuries are common and may lead to long-term disability if not managed adequately.Claims for negligence have been increasing in medical practice over the past few decades,with hand and wrist injuries and their treatment representing a significant percentage of orthopedic surgery lawsuits.There is no available literature regarding medical malpractice claims in hand and wrist injuries and surgery in Greece.AIM To identify claims related to hand and wrist trauma and surgery and to define the reasons of successful litigations.METHODS We performed a retrospective study of all legal claims of negligence for hand and upper extremity surgery that went to a trial,attributed to all surgical specialties,in Greece for a 20-year period.Data was further analyzed to identify claims related to hand and wrist trauma and surgery.RESULTS There were six malpractice claims related to hand and wrist trauma that ended in a trial.A missed diagnosis,which resulted in failure of initial management of the injury,was the main reason for a claim.Three of the six cases resulted in complete or partial loss of a finger.Two cases are still open,requiring an expert witness’s report,two cases were closed in favor of the defendant,and two cases were closed in favor of the plaintiff with a mean compensation of€2000(€1000-€3000).CONCLUSION Missed diagnosis was the main reason for a malpractice claim.Better understanding of factors leading to successful claims will help surgeons improve their practice to minimize legal implications and litigation.

Genetics of congenital anomalies of the hand

Congenital anomalies of the hand are malformations occurring during the development of the human limb,and present as isolated disorders or as a part of a syndrome.During the last years,molecular analysis techniques have offered increasing knowledge about the molecular basis of hand malformations.Disturbances in the signaling pathways during the development of the upper limb result in malformations of the upper extremity.At present,several genes have been identified as responsible for hand anomalies and other have been recognized as suspect genes related to them.Different and new high throughput methods have been introduced for the identification of the gene mutations.In the current editorial,we summarize concisely the current molecular status of isolated hand genetic disorders and the recent progress in molecular genetics,including the genes related to the disorder.This progress improves the knowledge of these disorders and has implications on genetic counselling and prenatal diagnosis.

Factors predisposing to thrombosis after major joint arthroplasty

BACKGROUND Total joint arthroplasty is one of the most common options for end stage osteoarthritis of major joints.However,we must take into account that thrombosis after hip/knee arthroplasty may be related to mutations in genes encoding for blood coagulation factors and immune reactions to anticoagulants[heparininduced thrombocytopenia(HIT)/thrombosis].Identifying and characterizing genetic risk should help to develop diagnostic strategies or modify anticoagulant options in the search for etiological mechanisms that cause thrombophilia following major orthopedic surgery.AIM To evaluate the impact of patients’coagulation profiles and to study specific pharmacologic factors in the development of post-arthroplasty thrombosis.METHODS In 212(51 male and 161 female)patients that underwent primary total hip arthroplasty(100)or total knee arthroplasty(112)due to osteoarthritis during a period of 1 year,platelet counts and anti-platelet factor 4(PF4)/heparin antibodies were evaluated pre/postoperatively,and antithrombin III,methylenetetrahydrofolate reductase,factor V and prothrombin gene mutations were evaluated preoperatively.In a minimum follow-up of 3 years,196 patients receiving either low-molecular-weight heparins(173)or fondaparinux(23)were monitored for the development of thrombocytopenia,anti-PF4/heparin antibodies,HIT,and thrombosis.RESULTS Of 196 patients,32 developed thrombocytopenia(nonsignificant correlation between anticoagulant type and thrombocytopenia,P=0134.)and 18 developed anti-PF4/heparin antibodies(12/173 for low-molecular-weight heparins and 6/23 for fondaparinux;significant correlation between anticoagulant type and appearance of antibodies,P=0.005).Odds of antibody emergence:8.2%greater in patients receiving fondaparinux than low-molecular-weight heparins.Gene mutations in factor II or V(two heterozygotes for both factor V and II)were identified in 15 of 196 patients.Abnormal low protein C and/or S levels were found in 3 of 196(1.5%)patients,while all patients had normal levels of von Willebrand factor,lupus anticoagulant,and antithrombin III.Four patients developed HIT(insignificant correlation between thrombocytopenia and antibodies)and five developed thrombosis(two had positive antibodies and two were heterozygotes for both factor II&V mutations).Thrombosis was not significantly correlated to platelet counts or HIT.The correlation of thrombosis to antibodies,factor II,factor V was P=0.076,P=0.043,P=0.013,respectively.CONCLUSION Screening of coagulation profile,instead of platelet monitoring,is probably the safest way to minimize the risk of post-arthroplasty thrombosis.In addition,fondaparinux can lead to the formation of anti-PF4/heparin antibodies or HIT.

Polydactyly:Clinical and molecular manifestations

Polydactyly is a malformation during the development of the human limb,which is characterized by the presence of more than the normal number of fingers or toes.It is considered to be one of the most common inherited hand disorders.It can be divided into two major groups:Non-syndromic polydactyly or syndromic polydactyly.According to the anatomical location of the duplicated digits,polydactyly can be generally subdivided into pre-,post-axial,and mesoaxial forms.Non-syndromic polydactyly is often inherited with an autosomal dominant trait and defects during the procedure of anterior-posterior patterning of limb development are incriminated for the final phenotype of the malformation.There are several forms of polydactyly,including hand and foot extra digit manifestations.The deformity affects upper limbs with a higher frequency than the lower,and the left foot is more often involved than the right.The treatment is always surgical.Since the clinical presentation is highly diverse,the treatment combines single or multiple surgical operations,depending on the type of polydactyly.The research attention that congenital limb deformities have recently attracted has resulted in broadening the list of isolated gene mutations associated with the disorders.Next generation sequencing technologies have contributed to the correlation of phenotype and genetic profile of the multiple polydactyly manifestations and have helped in early diagnosis and screening of most nonsyndromic and syndromic disorders.