Allogeneic hand transplantation is now a clinical reality. While results have been encouraging, acute rejection rates are higher than in their solid-organ counterparts. In contrast, chronic rejections, as defined by vasculopathy and/or fibrosis and atrophy of skin and other tissues, as well as antibody mediated rejection, have not been reported in a compliant hand transplant recipient. Monitoring vascularized composite allograft (VCA) hand recipients for rejection has routinely involved punch skin biopsies, vascular imaging and graft appearance. Our program, which has transplanted a total of 6 hand recipients, has experience which challenges these precepts. We present evidence that the vessels, both arteries and veins may also be a primary target of rejection in the hand. Two of our recipients developed severe intimal hyperplasia and vasculopathy early post-transplant. An analysis of events and our four other patients has shown that the standard techniques used for surveillance of rejection (i.e. punch skin biopsies, DSA and conventional vascular imaging studies) are inadequate for detecting the early stages of vasculopathy. In response, we have initiated studies using ultrasound biomicroscopy (UBM) to evaluate the vessel wall thickness. These findings suggest that vasculopathy should be a focus of frequent monitoring in VCA of the hand.
The incidence of long-term pain (between 1 and 48 weeks and at 2 year follow-up) unrelated to the surgical site following either regional brachial plexus or general anaesthesia was determined. In 834 patients with regional anaesthesia, the incidence (11.1%) was significantly higher than in the 86 patients with general anaesthesia (3.6%; P = 0.03). The incidence of pain was not significantly different among four common techniques of positioning the needle tip in the axillary sheath (9.9 to 11.1%). Parascalene blocks had a slightly but not significantly higher rate (16.3%). A regional re-block was not associated with a higher incidence when compared to those blocked only once. A more distal local re-block was associated with a higher incidence of pain (23%). 2 years post-operatively, 0.5% of patients had pain related to the regional block. A significant proportion of patients developed some long-lasting post-operative pain following regional brachial plexus anaesthesia, although ultimate morbidity was minimal.
D entro de las patologías causantes de dolor cubital de muñeca, se encuentran aquellas relacionadas con la articulación radiocubital distal (ARCD), pudiendo afectar al componente osteocartilaginoso, al ligamentoso o a ambos. En cuanto al tratamiento se refiere, si bien estas patologías pueden ser tratadas tanto de forma conservadora como quirúrgica, existen una serie de casos en los que la lesión es tan grave y/o donde han fallado todos los tratamientos quirúrgicos previos, que la única forma de restaurar la función de la extremidad es mediante una artroplastia total radiocubital distal.El radio y el cúbito se articulan tanto proximal como distalmente mediante una articula- La articulación radiocubital distal es un importante eslabón en la transmisión de los movimientos del antebrazo y es la base fundamental para la función en la elevación de objetos. Existen numerosas causas que pueden conducir a una grave lesión de la misma, con importante dolor y limitación funcional. En estos casos la artroplastia total es la única alternativa de tratamiento. En el presente artículo, se discuten las indicaciones y técnica quirúrgica de la prótesis total de la articulación radiocubital distal, la cual constituye un método efectivo de tratamiento en articulaciones gravemente destruidas. Sólo con la sustitución de todos sus elementos articulares mediante una pró-tesis autoestable, se devuelve la movilidad a la extremidad, de manera inmediata, estable e indolora. Palabras claves: articulación radiocubital distal, prótesis, artroplastia.The distal radio-ulnar joint is an important joint that supports the mobility of the forearm and the elevation of objects. There are many causes that lead to severe damage of the joint, in association with severe pain and lost of the function. In these cases of advanced joint destruction, the complete replacement of the joint is the only option of treatment.In this paper we discus the indications and surgical techniques of a distal radio-ulnar joint total prosthesis, which is a very effective treatment of very severe destroyed joints. Only with the replacement of all the structures involved in the distal radio-ulnar joint with a complete self stabilizing prosthesis, the extremity will recover a stable and painless mobility.
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