The field of vascularized composite allotransplantation (VCA) has moved from a highly experimental procedure to, at least for some patients, one of the best treatment alternatives for catastrophic tissue loss or dysfunction. Although the worldwide experience is still limited, progress has been made in translation to the clinic, and hand transplantation was recently designated standard of care and is now covered in full by the British Health System. This progress is tempered by the long-term challenges of systemic immunosuppression, and the rapidly evolving indications for VCA such as urogenital transplantation. This update will cover the state of and recent changes in the field, and an update of the Louisville VCA program as our initial recipient, the first person to receive a hand transplant in the United States celebrates the 20th anniversary of his transplant. The achievements and complications encountered over the last two decades will be reviewed. In addition, potential directions for research and collaboration as well as practical issues of how third party payers and funding are affecting growth of the field are presented.
This study was designed to evaluate treatment patterns in open treatment and percutaneous fixation of distal radius fractures, compare morbidity rates for the 2 types of treatment, and compare costs associated with the procedure and treatment of complications up to 1 year after surgery. From a 5% sample of nationwide Medicare claims records (1997-2009), patients with distal radius fractures were identified with International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), codes. Patients who underwent percutaneous fixation and open treatment were tracked with appropriate Current Procedural Terminology codes. Complications were identified at 3 and 12 months. Medicare charges and payments associated with the treatment groups were compiled from the claims data. The rate of surgical treatment increased from 44.7 to 82.0 surgeries per 100,000 persons (+83.0%) over the study period. A total of 9343 procedures met the inclusion criteria between 1998 and 2008. The proportion of open treatment procedures increased from 25.5% in 1998 to 73.4% in 2008. Percutaneous fixation was associated with lower adjusted risk of carpal tunnel syndrome and release and mononeuritis at 3 and 12 months. The percutaneous fixation group had lower adjusted risk of malunion/nonunion at 3 months and tendon rupture at 12 months. Average charges were lower in the percutaneous fixation group for the index operation as well as for treatment of morbidities at 3 and 12 months. The operative fixation rate for distal radius fractures in the Medicare population continues to rise, with a significant trend toward open fixation. Charges and payments associated with open treatment are significantly higher than those for percutaneous fixation.
Muscle herniation in the upper extremity is a rare but recognized phenomenon with a paucity of reports in the current literature. In the majority of cases, the herniation is secondary to trauma, with some of the cases due to muscle hypertrophy and increased intra-compartmental pressure from the forced exertion. Treatment for this condition ranges from nonsurgical, repair, or reconstruction to fasciotomy of the flexor carpi ulnaris fascia. Here, we present a case of flexor carpi ulnaris herniation after an open in situ cubital tunnel release in a 57-year-old male 6 years after initial surgery. The patient’s symptoms did not improve with conservative management, and the patient subsequently underwent endoscopic fasciotomy with resolution of his symptoms and maintenance of his wrist and grip strength. The rationale for the treatment chosen is discussed.
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