BACKGROUND: On February 2, 2017, the surgical team of ten board-certified hand specialists of W Hospital in Korea successfully performed the nation\'s first hand transplantation at Yeungnam University Medical Center (YUMC). This paper reports on the legal, financial, and cultural hurdles that were overcome to open the way for hand transplantation and its functional outcomes at 36 months after the operation.
METHODS: W Hospital formed a memorandum of understanding with Daegu city and YUMC to comply with government regulations regarding hand transplantation. Campaigns were initiated in the media to increase public awareness and understanding. With the city\'s financial and legal support and the university\'s medical cooperation, a surgical team performed a left distal forearm hand transplantation from a brain-dead 48-year-old man to a 35-year-old left-handed man.
RESULTS: With this successful allotransplantation, the Korean Act on Organ Transplantation has now been amended to include hand transplantation. Korean national health insurance has also begun covering hand transplantation. Functional outcome at 36 months after the operation showed satisfactory progress in both motor and sensory functions. The disabilities of the arm, shoulder, and hand score were 23. The final Hand Transplantation Score was 90 points. Functional brain magnetic resonance imaging shows significant cortical reorganization of the corticospinal tract, and reinnervation of intrinsic muscle is observed.
CONCLUSIONS: Hand transplantation at the distal forearm shows very satisfactory outcomes in functional, aesthetical, and psychological aspects. Legal and financial barriers against hand transplantation have long been the most burdensome issues. Despite this momentous success, there have been no other clinical applications of vascularized composite allotransplantation due to the limited acceptance by Korean doctors and people. Further public education campaigns for vascularized composite allotransplantation are needed to increase awareness and acceptance.

Background: A lack of established opioid-prescribing guidelines has prompted recent studies to propose preliminary guidelines to mitigate inadvertent overprescribing, diversion, and abuse. The purpose of our study was to assess the efficacy of a specific set of opioid-prescribing guidelines by prospective evaluation of patient consumption and satisfaction. Methods: During a consecutive period, all patients undergoing outpatient upper extremity surgical procedures were postoperatively prescribed opioids based on published guidelines that were specific to the anatomical location and procedure being performed. At the first postoperative visit, surgical details, opioid consumption patterns, and prescription efficacy and satisfaction were recorded. Results: A total of 201 patients reported any amount of prescription use, resulting in a mean consumption of 5.5 pills. Patients who underwent soft tissue procedures reported the lowest requirement (4.2 pills) compared with those who underwent fracture repairs (6.7 pills) or arthroscopy and arthroplasty/fusion procedures (8.7 pills). Patients undergoing hand procedures consumed fewer opioids (3.9 pills) compared with those undergoing wrist (6.3 pills) or elbow (8.1 pills) procedures. Of the patients requiring opioids, 82% reported being satisfied or at least neutral to the prescribed quantity (P < .001), and 92% reported being satisfied or at least neutral to the prescribed opioid analgesic efficacy (P < .001). Overall, the study refill request rate was 13%. Conclusions: Although the proposed guidelines tended to exceed patient need, the study confirmed strong patient satisfaction and an overall refill request rate of only 13%. We conclude that following anatomical and procedure-specific opioid-prescribing guidelines is an effective method of prescribing opioids postoperatively after upper extremity.

Cardiovascular disease is the primary cause of mortality and a major cause of disability worldwide. The dysfunction of the vascular endothelium is a pathological condition characterized mainly by a disruption in the balance between vasodilator and vasoconstrictor substances and is proposed to play an important role in the development of atherosclerotic cardiovascular disease. Therefore, a precise evaluation of endothelial function in humans represents an important tool that could help better understand the etiology of multiple cardio-centric pathologies. Over the past twenty-five years, many methodological approaches have been developed to provide an assessment of endothelial function in humans. Introduced in 1989, the FMD test incorporates a forearm occlusion and subsequent reactive hyperemia that promotes nitric oxide production and vasodilation of the brachial artery. The FMD test is now the most widely utilized, non-invasive, ultrasonic assessment of endothelial function in humans and has been associated with future cardiovascular events. Although the FMD test could have clinical utility, it is a physiological assessment that has inherited several confounding factors that need to be considered. This article describes a standardized protocol for determining FMD including the recommended methodology to help minimize the physiological and technical issues and improve the precision and reproducibility of the assessment.

OBJECTIVE: The median nerve is responsible for the motor innervation of most of the muscles usually involved in upper limb spasticity. Selective neurectomy is one of the treatments utilized to reduce spasticity. The purpose of this study was to describe the variations of the motor branches of the median nerve in the forearm and draw recommendations for an appropriate planning of selective neurectomy.
METHODS: The median nerve was dissected in the forearm of 20 fresh cadaver upper limbs. Measurements included number, origin, division, and entry point of each motor branch into the muscles.
RESULTS: One branch for the pronator teres was the most common pattern. In 9/20 cases, it arose as a common trunk with other branches. A single trunk innervated the flexor carpi radialis with a common origin with other branches in 17/20 cases. Two, three or four branches innervated the flexor digitorum superficialis, the first one frequently through a common trunk with other branches. They were very difficult to identify unless insertions of pronator teres and flexor digitorum superficialis were detached. The flexor digitorum profundus received one to five branches and flexor pollicis longus one to two branches from the anterior interosseous nerve.
CONCLUSIONS: There is no regular pattern of the motor branches of the median nerve in the forearm. Our findings differ in many points from the classical literature. Because of the frequency of common trunks for different muscles, we recommend the use of peroperative electrical stimulation. Selective neurotomy of flexor digitorum superficialis is technically difficult, because the entry point of some of their terminal branches occurs just below the arch and deep to the muscle belly.

OBJECTIVE: Precise knowledge of motor nerve branches is critical to plan selective neurectomies for the treatment of spastic limbs. Our objective is to describe the muscular branching pattern of the ulnar nerve in the forearm and suggest an ideal surgical approach for selective neurectomy of the flexor carpi ulnaris.
METHODS: The ulnar nerve was dissected under loop magnification in 20 upper limbs of fresh frozen cadavers and its branches to the flexor carpi ulnaris muscle (FCU) and to the flexor digitorum profundus muscle (FDP) were quantified. We measured their diameter, length and distance between their origin and the medial epicondyle. The point where the ulnar artery joined the nerve was observed. The position in which the ulnar nerve gave off each branch was noted (ulnar, posterior or radial) and the Martin-Gruber connection, when present, had its origin observed and its diameter measured.
RESULTS: The ulnar nerve gave off two to five muscular branches, among which, one to four to the FCU and one or two to the FDP. In all cases, the first branch was to the FCU. It arose on average 1.4 cm distal to the epicondyle, but in four specimens it arose above or at the level of the medial epicondyle (2.0 cm above in one case, 1.5 cm above in two cases, and at the level of the medial epicondyle in one). The first branch to the FDP arose on average 5.0 cm distal to the medial epicondyle. All the branches to FDP but one arose from the radial aspect of the ulnar nerve. A Martin-Gruber connection was present in nine cases. All motor branches arose in the proximal half of the forearm and the ulnar nerve did not give off branches distal to the point where it was joined by the ulnar artery.
CONCLUSIONS: The number of motor branches of the ulnar nerve to the FCU varies from 2 to 4. An ideal approach for selective neurectomy of the FCU should start 4 cm above the medial epicondyle, and extend distally to 50% of the length of the forearm or just to the point where the ulnar artery joins the nerve.

A cadaveric study of the radial head and neck was performed to determine the anterior and posterior limits for safe placement of internal fixation on the surface of the radial head or neck. A \"safe zone\" of approximately 110 degrees of radial head surface was first identified by cross-sectional anatomic dissections. This \"safe zone\" was then reproducibly confirmed relative to forearm position when viewed from a standard lateral approach. Because the proximal radioulnar joint cannot be directly visualized through the standard lateral approach, the zone was indirectly identified by making reference marks along the radial head and neck. To determine the position of the \"safe zone\" reference marks are first made along radial head and neck so as to bisect the bone\'s anteroposterior distance. Three such marks are made with the forearm in neutral rotation, full supination, and full pronation. Next, the posterior limit of the zone is determined by bisecting the reference marks made with the forearm in neutral rotation and full pronation. The anterior limit is determined by going nearly two thirds of the distance from the neutral mark to that mark made in full supination.

The report reviews individual-related variables (age, sex, race, anatomical site), intra- and inter-individual variation (temporal, physical and mental activity, food and drugs), and environment-related variables (air convection, temperature). Technical variation, instrument validation including a standard reactive hyperemia experiment, and a standard operating procedure are discussed and included in the guidelines.