Electrical Stimulation Use in Upper Extremity Peripheral Nerve Injuries

Peripheral nerve injuries can be debilitating and often have a variable course of recovery. Electrical stimulation (ES) has been used as an intervention to attempt to overcome the limits of peripheral nerve surgery and improve patient outcomes after peripheral nerve injury. Little has been written in the orthopaedic literature regarding the use of this technology. The purpose of this review was to provide a focused analysis of past and current literature surrounding the utilization of ES in the treatment of various upper extremity peripheral nerve pathologies including compression neuropathies and nerve transection. We aimed to provide clarity on the clinical benefits, appropriate timing for its employment, risks and limitations, and the need for future studies of ES.

A Case for Acute Proximal Row Carpectomy for Perilunate Injuries

Background

Perilunate injuries are complex injuries typically arising from high-energy injuries to the wrist. Standard treatment involves open reduction and internal fixation with ligamentous reconstruction; however, outcomes are fraught with complications including pain, stiffness, and arthrosis. Several case reports have demonstrated the role of proximal row carpectomy as a salvage procedure for complex carpal trauma in the setting of significant cartilage injury or bone loss. The authors believe that proximal row carpectomy may be an appropriate acute treatment in certain patient populations, with functional results similar to those obtained with ligamentous reconstruction.

Methods

A retrospective review of two cases with perilunate dislocations managed with primary proximal row carpectomy are presented.

Results

At greater than 1-year follow-up, both patients had stable radiocarpal alignment. Quick-DASH scores were 22.7 and 27.3.

Conclusion

Primary proximal row carpectomy is a treatment option in the acute setting for perilunate injuries in elderly, lower-demand patients. Functional results are similar to those obtained with ligamentous reconstruction, with a shorter recovery period. Level of Evidence: IV.

Long-Term Outcomes of Open and Endovascular Axillosubclavian Interventions After Traumatic Injury Reveal High Rates of Limb Dysfunction

BACKGROUND

Arterial axillosubclavian injuries (ASIs) are currently managed with open repair (OR) and endovascular stenting (ES). The long-term prognosis of patients with these and associated brachial plexus injuries is poorly understood. We hypothesize that OR and ES for ASI have similar long-term patency rates and that brachial plexus injuries would confer high long-term morbidity.

METHODS

All patients at a level-1 trauma center who underwent procedures for ASI over a 12-year period (2010 to 2022) were identified. Long-term outcomes of patency rates, types of reintervention, rates of brachial plexus injury, and functional outcomes were then investigated.

RESULTS

Thirty-three patients underwent operations for ASI. OR was performed in 72.7% (n = 24) and ES in 27.3% (n = 9). ES patency was 85.7% (n = 6/7) and OR patency was 75% (n = 12/16), at a median follow-up of 20 and 5.5 months respectively. In subclavian artery injuries, ES patency was 100% (n = 4/4) and OR patency was 50% (n = 4/8) at a median follow-up of 24 and 12 months respectively. Long-term patency rates were similar between OR and ES (P = 1.0). Brachial plexus injuries occurred in 42.9% (n = 12/28) of patients. Ninety percent (n = 9/10) of patients with brachial plexus injuries who were followed postdischarge had persistent motor deficits at median follow-up of 12 months, occurring at significantly higher rates in patients with brachial plexus injuries (90%) compared to those without brachial plexus injuries (14.3%) (P = 0.0005).

CONCLUSIONS

Multiyear follow-up demonstrates similar OR and ES patency rates for ASI. Subclavian ES patency was excellent (100%) and prosthetic subclavian bypass patency was poor (25%). brachial plexus injuries were common (42.9%) and devastating, with a significant portion of patients having persistent limb motor deficits (45.8%) on long-term follow-up. Algorithms to optimize brachial plexus injuries management for patients with ASI are high-yield, and likely to influence long-term outcomes more than the technique of initial revascularization.

Let's Focus on the Fibrosis in Dupuytren Disease: Cell Communication Network Factor 2 as a Novel Target

Dupuytren disease is a progressive, benign fibroproliferative disorder of the hands that can lead to debilitating hand contractures. Once symptomatic, treatment involves either surgical intervention, specifically fasciectomy or percutaneous needle aponeurotomy, or enzymatic degradation with clostridial collagenase. Currently, collagenase is the only pharmacotherapy that has been approved for the treatment of Dupuytren contracture. There is a need for a pharmacotherapeutic that can be administered to limit disease progression and prevent recurrence after treatment. Targeting the underlying fibrotic pathophysiology is critical. We propose a novel target to be considered in Dupuytren disease-cell communication network factor 2/connective tissue growth factor-an established mediator of musculoskeletal tissue fibrosis.

Plating of Proximal Ulna Fractures Using Posterolateral Distal Humerus Plates: Surgical Technique and Case Series

Precontoured olecranon plates are frequently used in the management of proximal ulna fractures. Occasionally, in comminuted proximal ulna fractures or segmental ulna fractures, available precontoured olecranon plates are too short for the management of these fractures. The authors have utilized posterolateral distal humerus plates in these instances. The coronal bend in some posterolateral distal humerus plates anecdotally fits well to the proximal ulna, despite being designed for the distal humerus. We sought to measure the coronal angulation of precontoured posterolateral distal humerus plates from various companies and compare these to established proximal ulna angles. Case examples are also provided.

The Evolution of the Human Hand From an Anthropologic Perspective

Coupled with the developing brain and freed from ambulatory responsibilities, the human hand has experienced osteologic and myologic changes throughout evolutionary time that have permitted manipulative capacities of social, functional, and cultural importance in modern-day human life. Hand cupping, precision gripping, and power gripping are at the root of these evolutionary developments. It is in appreciation of the evolutionary trajectory that we can truly understand how 'form is function.' The structure of the human hand is distinct in many ways from that of even our closest relatives in the primate order (ie, chimpanzees). We present some of the key anatomic changes and evolutionary anatomic remnants of the human hand. The human hand is truly an amazing organ-the product of millions of years of selective changes.

Perioperative Safety of Combined Augmentation-Mastopexy: An Evaluation of National Database

INTRODUCTION

The safety of combined augmentation-mastopexy is controversial. This study evaluates a national database to analyze the perioperative safety of combined augmentation-mastopexy to either augmentation or mastopexy alone.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients undergoing augmentation mammaplasty and mastopexy from 2005 to 2018. The patients were divided into the following groups: group I, augmentation; group II, mastopexy; group III, combined augmentation-mastopexy. Baseline characteristics and outcomes were compared. Outcomes were 30-day complications, reoperation, and readmission.

RESULTS

We found 5868 (74.2%) augmentation only, 1508 (19.1%) mastopexy only and 534 (6.6%) combined augmentation-mastopexy cases. Mean operative time was highest among the combined group at 129 minutes compared with 127 minutes for mastopexy alone and 66 minutes for augmentation alone (P < 0.01). Rates of any complications and readmission were different among groups (0.8% vs 2.5% vs 1.5% respectively, P < 0.01 and 0.7% vs 1.5% vs 1.5% respectively, P = 0.049), whereas reoperation was not statistically different (1.2% vs 1.4% vs 1.5%, P = 0.75). The incidence of dehiscence (0.6%; P < 0.01) was highest in the combined group. Multivariable logistic regression analysis did not reveal an increased odds of complications, reoperation, or readmission with combined augmentation-mastopexy.

CONCLUSIONS

An evaluation of the nationwide cohort suggests that combined augmentation-mastopexy is a safe procedure in the perioperative period.

Unplanned reoperations after microsurgical breast reconstruction: Findings from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

While microsurgical breast reconstruction may require multiple planned operations, unplanned reoperations has not been studied. We sought to investigate unplanned reoperations after microsurgical breast reconstruction.

METHODS

We queried the American College of Surgeons' National Surgical Quality Improvement Program between 2005 and 2018. Current Procedural Terminology code 19364 was used to identify all patients with microsurgical breast reconstruction. Patient demographics, medical comorbidities, preoperative laboratory results, and operative data were analyzed. The primary outcome measure was 30-day unplanned reoperation.

RESULTS

Of 8449 patients meeting inclusion criteria, 1021 required an unplanned reoperation (12.1%). These patients were more likely to be obese, smokers, hypertensive, on steroids preoperatively, needing concomitant mastectomy, and with prolonged operating room time >9 h (p < .05). Multivariable regression model revealed preoperative steroids intake (OR = 1.92, CI 1.09-3.38, p = .03), concomitant mastectomy (OR = 1.45, CI 1.23-1.71, p < .01), and operating room time >9 h (OR = 1.37, CI 1.16-1.62, p < .01) as independent risk factors. Mastectomy was found to be an independent risk factor for early reoperation, that is, ≤2 days (OR = 1.44, CI 1.14-1.82, p < .01), whereas obesity was an independent risk factor for three reoperations (OR = 3.92, CI 1.14-13.46, p = .03).

CONCLUSION

Unplanned reoperations within 30-days after microsurgical breast reconstruction are a significant problem. Mastectomy is an independent risk factor for early reoperation whereas obesity is an independent risk factor for multiple reoperations. Identification of such patients preoperatively may help microsurgeons improve patient safety and quality of care.

Risk Factors for 30-Day Mortality After Head and Neck Microsurgical Reconstruction for Cancer: NSQIP Analysis

Objective

To identify the incidence and risk factors for 30-day postoperative mortality after microsurgical head and neck reconstruction following oncological resection.

Study Design

Retrospective case-control study.

Setting

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

Methods

Microsurgical head and neck reconstructive cases were identified from 2005 to 2018 using Current Procedural Terminology codes and oncologic procedures using the International Classification of Disease 9 and 10 codes. The outcome of interest was 30-day mortality.

Results

The 30-day postoperative mortality rate was 1.2%. Univariate logistic regression analysis identified the following associations: age >80 years, hypertension, poor functional status, preoperative wound infection, renal insufficiency, malnutrition, anemia, and prolonged operating time. Multivariable logistic regression models were used to stratify further by the degree of malnutrition and anemia. Hematocrit <30% was found to be an independent risk factor for 30-day postoperative mortality (odds ratio [OR] = 9.59, confidence interval [CI] 2.32-39.65, P < .1) with albumin <3.5 g/dL. This association was even stronger with albumin <2.5 g/dL (OR = 11.64, CI 3.06-44.25, P < .01). One-third of patients (36.6%) had preoperative anemia, of which less than 1% required preoperative transfusion, although one-quarter (24.6%) required intraoperative or 72 hours postoperative transfusion.

Conclusions

Preoperative anemia is a risk factor for 30-day postoperative mortality. This association seems to get stronger with worsening anemia. Identification and optimization of such patients preoperatively may mitigate the incidence of 30-day postoperative mortality.

Modified Frailty Index (mFI) predicts 30-day complications after microsurgical breast reconstruction

Frailty lacks a universal definition. The modified Frailty Index (mFI) using patient comorbidities can be used to measure frailty. We hypothesized that mFI predicts 30-day complications after microsurgical breast reconstruction. American College of Surgeons' (ACS) National Surgical Quality Improvement Project (NSQIP) was investigated to identify patients undergoing microsurgical breast reconstruction between 2005-2014 using Current Procedure Terminology (CPT) code, 19364. We used mFI as a measure of frailty. The patients were assigned a frailty score based on the number of preoperative comorbid conditions as defined by the mFI. Other risk indices used include age, BMI, wound class, ASA class. Stratification was performed in ascending order for each. The outcome measure was aggregate 30-day complications. Regression analysis was performed followed by Receptor Operating Characteristic (ROC) curve to determine the accuracy of each risk index in predicting 30-day complications. Of the 3237 patients 24% experienced complications. Univariate logistic regression analysis found odds ratio of complications for frailty score 1 = 22.1 (CI = 17.9-27.3, p < 0.01), and 2 = 28 (CI = 18.3-43, p < 0.01) compared to frailty score = 0. ROC curve demonstrated mFI with the highest concordance score (c-score = 0.816). Multivariable logistic regression found frailty as the strongest independent predictor of 30-day aggregate complications adjusted OR = 22.24, CI = 17.77-27.82, p < 0.01 when compared to other risk indices. The modified Frailty Index is a simple, reliable, and objective tool that can be used to predict postoperative complications after microsurgical breast reconstruction. The application of this tool can help microsurgeons preoperatively identify patients who are at high risk.Abbreviations: ACS: American College of Surgeons; ASA: American Society of Anesthesiologists; BMI: body mass index; CHF: congestive heart failure; CPT: current procedural terminology; COPD: chronic obstructive pulmonary disease; CVA: cerebrovascular accident; DM: diabetes mellitus; IRB: institutional review board; mfi: modified frailty index; MI: myocardial infarction; NSQIP: national surgical quality improvement program; PVD: peripheral vascular disease; ROC: receptor operating characteristic; TIA: transient ischemic attach.

A Survey of Burnout Among Members of the American Society for Surgery of the Hand

PURPOSE

Physician burnout affects approximately half of US physicians, significantly higher than the general working population. The aims of this study were to determine the prevalence of burnout specifically among hand surgeons and to identify factors unique to the practice of hand surgery that may contribute to burnout.

METHODS

A Web-based survey, developed in conjunction with the American Medical Association, was administered to all active and lifetime members of the American Society for Surgery of the Hand using the Mini Z Burnout assessment tool. Additional data were collected regarding physician demographics and practice characteristics.

RESULTS

The final cohort included 595 US hand surgeons (American Society for Surgery of the Hand [ASSH] members) and demonstrated that 77% of respondents were satisfied with their job, although 49% regarded themselves as having burnout. Lower burnout rates were correlated with physicians aged older than 65, those who practice in an outpatient setting, practice hand surgery only, visit one facility per week, having a lower commute time, those who performed 10 or fewer surgeries per month, and being considered grandfathered for Maintenance of Certification. It was shown that sex, the use of physician extenders, compensation level, and travel club involvement had no impact on burnout rates.

CONCLUSIONS

The survey demonstrated that nearly half of US hand surgeons experience burnout even though most are satisfied with their jobs. There is a need to increase awareness and promote targeted interventions to reduce burnout, such as creating a strong team culture, improving resiliency, and enhancing leadership.

CLINICAL RELEVANCE

Burnout has been shown to affect physicians, their families, patient care, and the health care system as a whole negatively. The findings should promote awareness among hand surgeons and inform future quality improvement efforts targeted at reducing burnout for hand surgeons.

Tenosynovitis of the Hand and Wrist: A Critical Analysis Review

Trigger FingerTrigger finger is common in patients with diabetes.Corticosteroid injections are effective in about 60% to 92% of cases.Proximal interphalangeal joint contracture may occur in long-standing cases.The outcomes of open and percutaneous releases are similar; however, surgeons are split on preferences. Intersection SyndromeThe classic finding is crepitus with wrist motion at the distal one-third of the radial aspect of the forearm. Extensor Pollicis Longus (EPL) TenosynovitisCorticosteroid injections should be used with caution because of the potential for rupture.EPL tenosynovitis is very rare. de Quervain DisorderThis condition is common in postpartum women.A positive Finkelstein test is considered to be pathognomonic of de Quervain disorder, but care should be taken to differentiate this condition from thumb carpometacarpal arthritis.Corticosteroid injections are effective in about 80% of cases.Patients in whom corticosteroid injections fail to provide relief of symptoms frequently have a separate extensor pollicis brevis (EPB) compartment.The abductor pollicis longus (APL) tendon has multiple slips; care should be taken not to confuse one of these slips as the EPB.Traction on the APL pulls up the thumb metacarpal but not the thumb tip.Traction on the EPB extends the thumb metacarpophalangeal joint.Care should be taken to avoid injury to the sensory branch of the radial nerve. Fourth Compartment TenosynovitisThis uncommon condition is most often seen in patients with rheumatoid arthritis.The condition involves a large diffuse area, as opposed to the compact dorsal ganglion cyst.

Silicone Metacarpophalangeal Arthroplasty for Osteoarthritis: Long-Term Results

PURPOSE

To demonstrate that silicone metacarpophalangeal (MCP) arthroplasty provides excellent long-term outcomes with a low complication rate in osteoarthritis patients.

METHODS

A consecutive cohort of 35 patients with osteoarthritis of 1 or more MCP joints undergoing anatomically neutral silicone MCP arthroplasty was followed over a 15-year period. Functional outcomes including strength and range of motion (ROM), as well as complications, were recorded. All patients were available for long-term assessment including radiographs and outcomes questionnaire.

RESULTS

Average follow-up for the cohort of 35 patients (40 implants) was 8.3 years (range, 2-17 years). Average age was 58 years (range, 42-80 years) with 22 men and 13 women. In 31 patients, a single MCP joint was involved (middle finger, 20; index finger, 10; little finger, 1). The dominant hand was involved in 23 patients. Seven (of 14) patients had a concomitant RCL reconstruction of the index finger MCP joint; no other digit had a collateral ligament reconstruction. Average final visual analog scale pain score was 0.3 of 10. Average final active ROM arc was from 4° (range, 0°-20°) to 73° (range, 50°-90°) of flexion. One patient had a revision MCP arthroplasty for a 97% clinical survivorship. Radiographs demonstrated fractured implants in 5 of 40 (12.5%) implants, but none exhibited instability, pain, or ROM deterioration. Average Michigan Hand Outcomes Questionnaire score was 82 (of 100) at final follow-up.

CONCLUSIONS

Silicone arthroplasty is effective in the treatment of primary MCP osteoarthritis. Implant survivorship is 97% (clinical) and 88% (radiographic) in long-term follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Scapholunate and perilunate injuries in the athlete

PURPOSE OF THE REVIEW

Scapholunate and perilunate injuries can be difficult to diagnose and treat in the athlete. In this review article, we present the mechanism of injury, evaluation, management, and outcomes of treatment for these injuries.

RECENT FINDINGS

Acute repair of dynamic scapholunate ligament injuries remains the gold standard, but judicious use of a wrist splint can be considered for the elite athlete who is in season. The treatment of static scapholunate ligament injury remains controversial. Newer SL reconstructive techniques that aim to restore scapholunate function without compromising wrist mobility as much as tenodesis procedures show promise in athlete patients. Acute injuries to the scapholunate ligament are best treated aggressively in order to prevent the sequelae of wrist arthritis associated with long-standing ligamentous injury. Acute repair is favored. Reconstructive surgical procedures to manage chronic scapholunate injury remain inferior to acute repair. The treatment of lunotriquetral ligament injuries is not well defined.

Treatment of Distal Radial Fractures by Open Reduction and Internal Fixation with a Volar Locking Plate

The volar locking plate is a popular implant for surgical management of unstable distal radial fractures. We routinely utilize this system for all distal radial fractures except for those with entrapped intra-articular fragments and fractures with a displaced dorsomedial facet fracture (which is hard to capture with the volar approach alone). In this video, we describe in detail the necessary steps for successful placement of the volar locking plate, starting with preoperative planning and ending with expected outcomes. The approach that we utilize is through the flexor carpi radialis tendon sheath and avoids the radial artery. In the video, we describe 4 variations on the application of a volar locking plate: (1) the standard technique after appropriate reduction and provisional fixation with Kirschner wires, (2) regaining length through a shortened distal radial fracture, (3) using the volar plate to assist in the reduction and regain volar tilt, and (4) intraoperative management of coronal shift of the distal fragment. Complications reported for the volar locking plate have decreased with newer low-profile plate designs; however, they still include volar tendon irritation and/or rupture and median neuropathy. Postoperatively, we advise a brief 2-week period of immobilization for wound-healing, which is followed by a period during which a removable wrist splint is used and patients are instructed on the performance of a hand therapy regimen.

Erratum: Carpal Tunnel Release: Do We Understand the Biomechanical Consequences?

[This corrects the article DOI: 10.1055/s-0034-1394363.].

Trends in Revision Elbow Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers

PURPOSE

To determine the frequency of revision elbow ulnar collateral ligament (UCL) reconstruction in professional baseball pitchers.

METHODS

Data were collected on 271 professional baseball pitchers who underwent primary UCL reconstruction. Each player was evaluated retrospectively for occurrence of revision UCL reconstructive surgery to treat failed primary reconstruction. Data on players who underwent revision UCL reconstruction were compiled to determine total surgical revision incidence and revision rate by year. The incidence of early revision was analyzed for trends. Average career length after primary UCL reconstruction was calculated and compared with that of players who underwent revision surgery. Logistic regression analysis was performed to assess risk factors for revision including handedness, pitching role, and age at the time of primary reconstruction.

RESULTS

Between 1974 and 2014, the annual incidence of primary UCL reconstructions among professional pitchers increased, while the proportion of cases being revised per year decreased. Of the 271 pitchers included in the study, 40 (15%) required at least 1 revision procedure during their playing career. Three cases required a second UCL revision reconstruction. The average time from primary surgery to revision was 5.2 ± 3.2 years (range, 1-13 years). The average length of career following primary reconstruction for all players was 4.9 ± 4.3 years (range, 0-22 years). The average length of career following revision UCL reconstruction was 2.5 ± 2.4 years (range, 0-8 years). No risk factors for needing revision UCL reconstruction were identified.

CONCLUSIONS

The incidence of primary UCL reconstructions among professional pitchers is increasing; however, the rate of primary reconstructions requiring revision is decreasing. Explanations for the decreased revision rate may include improved surgical technique and improved rehabilitation protocols.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Bone-Retinaculum-Bone Autografts for Scapholunate Interosseous Ligament Reconstruction

Carpal instability arising from an injury to the scapholunate interosseous ligament (SLIL) is commonly seen and treated by hand surgeons. No technique to this date has proved to provide optimal results for primary repair of acute SLIL tear and the treatment of chronic tears of the SLIL. Recently, attention has shifted toward replacement of the dorsal aspect of the SLIL, which is the most structurally and functionally important aspect of the SLIL. This article describes the indications, surgical technique, postoperative treatment and expected results of the use of a bone-retinaculum-bone autograft procedure in the treatment of scapholunate instability.

Accredited hand surgery fellowship Web sites: analysis of content and accessibility

PURPOSE

To assess the accessibility and content of accredited hand surgery fellowship Web sites.

METHODS

A list of all accredited hand surgery fellowships was obtained from the online database of the American Society for Surgery of the Hand (ASSH). Fellowship program information on the ASSH Web site was recorded. All fellowship program Web sites were located via Google search. Fellowship program Web sites were analyzed for accessibility and content in 3 domains: program overview, application information/recruitment, and education.

RESULTS

At the time of this study, there were 81 accredited hand surgery fellowships with 169 available positions. Thirty of 81 programs (37%) had a functional link on the ASSH online hand surgery fellowship directory; however, Google search identified 78 Web sites. Three programs did not have a Web site. Analysis of content revealed that most Web sites contained contact information, whereas information regarding the anticipated clinical, research, and educational experiences during fellowship was less often present. Furthermore, information regarding past and present fellows, salary, application process/requirements, call responsibilities, and case volume was frequently lacking. Overall, 52 of 81 programs (64%) had the minimal online information required for residents to independently complete the fellowship application process.

CONCLUSIONS

Hand fellowship program Web sites could be accessed either via the ASSH online directory or Google search, except for 3 programs that did not have Web sites. Although most fellowship program Web sites contained contact information, other content such as application information/recruitment and education, was less frequently present.

CLINICAL RELEVANCE

This study provides comparative data regarding the clinical and educational experiences outlined on hand fellowship program Web sites that are of relevance to residents, fellows, and academic hand surgeons. This study also draws attention to various ways in which the hand surgery fellowship application process can be made more user-friendly and efficient.

Carpal tunnel release: do we understand the biomechanical consequences?

Carpal tunnel release is a very common procedure performed in the United States. While the procedure is often curative, some patients experience postoperative scar sensitivity, pillar pain, grip weakness, or recurrent median nerve symptoms. Release of the carpal tunnel has an effect on carpal anatomy and biomechanics, including increases in carpal arch width and carpal tunnel volume and changes in muscle and tendon mechanics. Our understanding of how these biomechanical changes contribute to postoperative symptoms is still evolving. We review the relevant morphometric and biomechanical changes that occur following release of the transverse carpal ligament.

Tibial tubercle-trochlear groove distance: defining normal in a pediatric population

BACKGROUND

The tibial tubercle-trochlear groove (TT-TG) distance is a useful tool in guiding surgical management for patients with recurrent lateral patellar instability. Current recommendations for tibial tubercle transfer are based on TT-TG distance thresholds derived from adult populations. Recurrent patellar instability, however, frequently affects children, but normal and pathological TT-TG values have not been established for pediatric patients. The objectives of this study were to (1) confirm that magnetic resonance imaging (MRI) measurements for TT-TG distance in a pediatric population are reliable and reproducible, (2) determine whether the TT-TG distance changes with age, (3) define normal TT-TG distances in a pediatric population, and (4) confirm that a subgroup of pediatric patients with patellar instability have higher TT-TG distances.

METHODS

Six hundred and eighteen MRIs were retrospectively collected for patients who were nine months to sixteen years old. Each MRI was measured twice in a blinded, randomized manner by each reviewer. Patient age, sex, knee laterality, magnet strength, underlying diagnosis, and pertinent previous surgical treatments were all recorded separately from the measurements. MRIs that were unreadable and those of patients who had previous extensor mechanism surgery, preexisting deformity, or destructive neoplasms were excluded.

RESULTS

There was excellent intraobserver and interobserver reliability of TT-TG distance measurements. TT-TG distance was associated with the natural logarithm of age (p < 0.001). A percentile-based growth chart was created to demonstrate this relationship. The median TT-TG distance for patients without patellar instability in this pediatric population was 8.5 mm (mean and 95% confidence interval, 8.6 ± 0.3 mm). Patients with patellar instability had higher TT-TG distances (median, 12.1 mm; p < 0.001). TT-TG distance measured nearly 2 mm less on MRIs performed with a 3-T magnet than on those acquired with a 1.5-T magnet (p < 0.001).

CONCLUSIONS

TT-TG distance changes with chronologic age in the pediatric population. As such, we developed a percentile-based growth chart in order to better depict normal TT-TG distances in the pediatric population. Like many issues in pediatric orthopaedics, an age-based approach for directing surgical treatment may be more appropriate for skeletally immature individuals with recurrent lateral patellar instability.

Trends in the orthopedic job market and the importance of fellowship subspecialty training

Previous studies have examined possible incentives for pursuing orthopedic fellowship training, but we are unaware of previously published studies reporting the trends in the orthopedic job market since the acceptance of certain criteria for fellowship programs by the Accreditation Council for Graduate Medical Education (ACGME) in 1985. We hypothesized that, since the initiation of accredited postresidency fellowship programs, job opportunities for fellowship-trained orthopedic surgeons have increased and job opportunities for nonfellowship-trained orthopedic surgeons have decreased. We reviewed the job advertisements printed in the Journal of Bone and Joint Surgery, American Volume, for the years 1984, 1994, 2004, and 2009. We categorized the job opportunities as available for either a general (nonfellowship-trained) orthopedic surgeon or a fellowship-trained orthopedic surgeon. Based on the advertisements posted in the Journal of Bone and Joint Surgery, American Volume, a trend exists in the orthopedic job market toward seeking fellowship-trained orthopedic surgeons. In the years 1984, 1994, 2004, and 2009, the percentage of job opportunities seeking fellowship-trained orthopedic surgeons was 16.7% (95% confidence interval [CI], 13.1%-20.3%), 40.6% (95% CI, 38.1%-43.1%), 52.2% (95% CI, 48.5%-55.9%), and 68.2% (95% CI, 65.0%-71.4%), respectively. These differences were statistically significant (analysis of variance, P<.05). Fellowship training is thus a worthwhile endeavor.

The course of the distal saphenous nerve: a cadaveric investigation and clinical implications

INTRODUCTION

Injury to the saphenous nerve at the ankle has been described as a complication resulting from incision and dissection over the distal tibia and medial malleolus. However, the exact course and location of the distal saphenous nerve is not well described in the literature. The purpose of this study was to determine the distal limit of the saphenous nerve and its anatomic relationship to commonly identified orthopaedic landmarks and surgical incisions.

METHODS

Sixteen cadaveric ankles were examined at the level of the distal tibia medial malleolus. An incision was made along the medial aspect of the lower extremity from the knee to the hallux to follow the course and branches of the saphenous nerve under direct visualization. We recorded the shortest distance from the most distal visualized portion of the saphenous nerve to the tip of the medial malleolus, to the antero-medial arthroscopic portal site, and to the tibialis anterior tendon.

RESULTS

The saphenous nerve runs posterior to the greater saphenous vein in the leg and divides into an anterior and posterior branch approximately 3 cm proximal to the tip of the medial malleolus. These branches terminate in the integument proximal to the tip of the medial malleolus, while the vein continues into the foot. The anterior branch ends at the anterior aspect of the medial malleolus near the posterior edge of the greater saphenous vein. The posterior branch ends near the posterior aspect of the medial malleolus. The average distance from the distal-most visualized aspect of the saphenous nerve to the tip of the medial malleolus measured 8mm +/-; 5mm; from the nerve to the medial arthroscopic portal measured 14mm +/-2mm; and from the nerve to the tibialis anterior measured 16mm +/-3mm. In only one case (of 16) was there an identifiable branch of the saphenous nerve extending to the foot and in this specimen it extended to the first metatarsophalangeal joint. The first metatarsophalangeal joint was innervated by the superficial peroneal nerve in all cases. Small variations were also noted.

DISCUSSION AND CONCLUSIONS

This study highlights the proximity of the distal saphenous nerve to common landmarks in orthopaedic surgery. This has important clinical implications in ankle arthroscopy, tarsal tunnel syndrome, fixation of distal tibia medial malleolar fractures, and other procedures centered about the medial malleolus. While the distal course of the saphenous nerve is generally predictable, variations exist and thus the orthopaedic surgeon must operate cautiously to prevent iatrogenic injury. To avoid saphenous nerve injury, incisions should stay distal to the tip of the medial malleolus. The medial arthroscopic portal should be more than one centimeter from the anterior aspect of the medial malleolus which will also avoid the greater saphenous vein. Incision over the anterior tibialis tendon should stay within one centimeter of the medial edge of the tendon.

Liposomal packaging generates Wnt protein with in vivo biological activity

Wnt signals exercise strong cell-biological and regenerative effects of considerable therapeutic value. There are, however, no specific Wnt agonists and no method for in vivo delivery of purified Wnt proteins. Wnts contain lipid adducts that are required for activity and we exploited this lipophilicity by packaging purified Wnt3a protein into lipid vesicles. Rather than being encapsulated, Wnts are tethered to the liposomal surface, where they enhance and sustain Wnt signaling in vitro. Molecules that effectively antagonize soluble Wnt3a protein but are ineffective against the Wnt3a signal presented by a cell in a paracrine or autocrine manner are also unable to block liposomal Wnt3a activity, suggesting that liposomal packaging mimics the biological state of active Wnts. When delivered subcutaneously, Wnt3a liposomes induce hair follicle neogenesis, demonstrating their robust biological activity in a regenerative context.