Improved osteogenesis in rat femur segmental defects treated with human allograft and zinc adjuvants.

Bone allograft is widely used to treat large bone defects or complex fractures. However, processing methods can significantly compromise allograft osteogenic activity. Adjuvants that can restore the osteogenic activity of processed allograft should improve clinical outcomes. In this study, zinc was tested as an adjuvant to increase the osteogenic activity of human allograft in a Rag2 null rat femoral defect model. Femoral defects were treated with human demineralized bone matrix (DBM) mixed with carboxy methyl cellulose containing ZnCl2 (0, 75, 150, 300 µg) or Zn stearate (347 µg). Rat femur defects treated with DBM-ZnCl2 (75 µg) and DBM-Zn stearate (347 µg) showed increased calcified tissue in the defect site compared to DBM alone. Radiograph scoring and µCT (microcomputed tomography) analysis showed an increased amount of bone formation at the defects treated with DBM-Zn stearate. Use of zinc as an adjuvant was also tested using human cancellous bone chips. The bone chips were soaked in ZnCl2 solutions before being added to defect sites. Zn adsorbed onto the chips in a time- and concentration-dependent manner. Rat femur defects treated with Zn-bound bone chips had more new bone in the defects based on µCT and histomorphometric analyses. The results indicate that zinc supplementation of human bone allograft improves allograft osteogenic activity in the rat femur defect model.

Iatrogenic Injuries in Percutaneous Pinning Techniques for Fifth Metacarpal Neck Fractures.

BACKGROUND: There is little information regarding anatomic structures at risk during closed percutaneous treatment of fifth metacarpal neck fractures. This study evaluates a variety of common percutaneous techniques with the hypothesis that each approach presents unique risks to tendons and neurovascular structures. METHODS: Seven cadaveric hands were used for this study. The senior author, a board-certified hand surgeon with more than 20 years of experience, used a mini-C arm to pass 1.6-mm Kirschner wires (K-wires). The 4 percutaneous techniques employed were anterograde, retrograde, cross-pinning, and transverse fixations. Meticulous superficial dissection was carried out, with fixation from all 4 techniques left in place, to identify any tendons or neurovascular structures penetrated by the K-wires. RESULTS: All techniques demonstrated penetration of at least 1 adjacent structure. The anterograde technique showed penetration of the extensor carpi ulnaris tendon in 5 out of 7 cadavers. In the retrograde approach, the K-wire impaled either the extensor digitorum communis or the extensor digitorum minimi tendons in 4 out of 7 cadavers. The transverse pinning technique exhibited injury to the dorsal cutaneous ulnar nerve in 2 of the specimens. In the retrograde cross-pin technique, there were 2 penetrations of the digital branch of the dorsal cutaneous ulnar nerve. CONCLUSIONS: None of the described percutaneous techniques for treating fifth metacarpal neck fractures eliminate the potential for damage to surrounding tendons or nerves. Each technique has at risk structures that the treating surgeon should be aware of in order to anticipate potential complications and counsel patients accordingly.

Intracompartmental Versus Extracompartmental Transposition of the Extensor Pollicis Longus for Treating Thumb-in-Palm Deformity: A Biomechanical Comparison.

PURPOSE: Transecting the extensor pollicis longus (EPL) tendon and rerouting it through the first extensor compartment is an established technique for treating thumb-in-palm deformity (TIPD). An alternative technique that approximates the trajectory of the first extensor compartment without violating the compartment or transecting the EPL tendon can be accomplished by creating an artificial sheath from the extensor retinaculum to radialize the tendon glide path. This study compares this extracompartmental (EC) EPL transposition to the established, intracompartmental (IC) transposition by evaluating, in a cadaver model, the extent of thumb extension in both techniques. METHODS: Eighteen fresh-frozen cadaveric hands were each tested under 3 different conditions: EPL in situ (baseline); EPL rerouted above the first extensor compartment (EC); and EPL rerouted through the first extensor compartment (IC). A controlled traction of 10 N was applied to the EPL under each condition. The range of thumb extension with respect to the fixed index finger was recorded utilizing infrared reflective markers and digital video capture. RESULTS: The mean extension of the thumb with the EPL tendon in situ was 16.7°. The mean extension of the thumb was 22.0° with the EC transposition versus 25.0° with the IC technique. The measured thumb extension in both the EC and the IC techniques were found to be similar because both EPL transpositions yielded a significant difference in thumb extension when compared with baseline. CONCLUSIONS: This biomechanical model demonstrates that radial transposition of the EPL tendon enhances extension of the thumb regardless of whether the tendon is routed through, or superficial to, the first extensor compartment. CLINICAL RELEVANCE: A novel technique, the EC EPL transposition, offers a similar enhancement in measured thumb extension as the already-described IC EPL transposition.

The Role of BMI in Hip Fracture Surgery.

INTRODUCTION: Obesity is an oft-cited cause of surgical morbidity and many institutions require extensive supplementary screening for obese patients prior to surgical intervention. However, in the elderly patients, obesity has been described as a protective factor. This article set out to examine the effect of body mass index (BMI) on outcomes and morbidity after hip fracture surgery. METHODS: The National Surgical Quality Improvement Program database was queried for all patients undergoing 1 of 4 surgical procedures to manage hip fracture between 2008 and 2012. Patient demographics, BMI, and known factors that lead to poor surgical outcomes were included as putative predictors for complications that included infectious, cardiac, pulmonary, renal, and neurovascular events. Using χ2 tests, 30-day postoperative complication rates were compared between 4 patient groups stratified by BMI as low weight (BMI < 20), normal (BMI = 20-30), obese (BMI = 30-40), and morbidly obese (BMI > 40). RESULTS: A total of 15 108 patients underwent surgery for hip fracture over the examined 5-year period. Of these, 18% were low weight (BMI < 20), 67% were normal weight (BMI = 20-30), 13% were obese (BMI = 30-40), and 2% were morbidly obese (BMI > 40). The low-weight and morbidly obese patients had both the highest mortality rates and the lowest superficial infection rates. There was a significant increase in blood transfusion rates that decreased linearly with increasing BMI. Deep surgical site infection and renal failure increased linearly with increasing BMI, however, these outcomes were confounded by comorbidities. CONCLUSION: This study demonstrates that patients at either extreme of the BMI spectrum, rather than solely the obese, are at greatest risk of major adverse events following hip fracture surgery. This runs contrary to the notion that obese hip fracture patients automatically require additional preoperative screening and perioperative services, as currently implemented in many institutions.

The Relative Contribution to Small Finger Abduction of the Ulnar Versus Radial Slip of the EDM: Implications for Tendon Transfers.

BACKGROUND: The extensor digiti minimi (EDM) tendon is commonly divided into a radial slip (EDM-R) and an ulnar slip (EDM-U). To our knowledge, the degree to which each EDM slip concomitantly abducts the small finger with active extension has not been formally tested. This study sought to characterize the comparative contributions of finger abduction inherent to each slip of the EDM to observe the sequelae of active small finger extension following transfer of the contralateral slip. METHODS: Eighteen fresh-frozen cadaveric hands were used in this study. Starting with the hand in resting position, a controlled traction of 10 N was applied to each slip of the EDM tendon. The range of small finger abduction with respect to the fixed ring finger was recorded utilizing infrared reflective markers tracked through the range of motion using a digital video camera. RESULTS: The mean abduction of the small finger when the radial slip of the EDM tendon was tested was 13.33° (95% confidence interval [CI]: 10.10°-16.55°), which was significantly different ( P ≤ .001) than small finger abduction produced by the ulnar slip of the EDM, with a mean of 23.72° (95% CI: 19.40°-28.04°). CONCLUSIONS: Given the fact that the ulnar slip of the EDM tendon is shown to be the major contributor of aberrant abduction with active small finger extension, as traction on this slip produces almost twice as much abduction as the radial slip, the EDM-U is the ideal donor graft with respect to tendon transfers of the EDM.

Readability of the Most Commonly Accessed Online Patient Education Materials Pertaining to Pathology of the Hand.

BACKGROUND: The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that patient education materials be written at no higher than a sixth-grade reading level. METHODS: We examined 100 online educational materials for the 10 hand conditions most commonly treated by hand surgeons, as reported by the American Society for Surgery of the Hand. The listed conditions were carpal tunnel syndrome, basal joint arthritis of the thumb, de Quervain syndrome, Dupuytren's contracture, ganglion cysts, hand fractures, trigger finger, extensor tendon injuries, flexor tendon injuries, and mallet finger. Following a Google search for each condition, we analyzed the 10 most visited websites for each disorder utilizing the Flesch-Kincaid formula. RESULTS: The average grade reading level of the 100 websites studied was 9.49 with a reading ease of 53.03 ("fairly difficult high school"). Only 29% of the websites were at or below the national average of an eighth-grade reading level. Carpal tunnel syndrome had the highest average grade reading level at 10.32 (standard deviation: 1.52), whereas hand fractures had the lowest at 8.14 (2.03). Every hand condition in this study had an average readability at or above the ninth-grade reading level. CONCLUSIONS: The most frequently accessed materials for common maladies of the hand exceed both the readability limits recommended by the AMA and NIH, and the average reading ability of most US adults. Therefore, the most commonly accessed websites pertaining to hand pathology may not be comprehended by the audience for which it is intended.

Readability of the Most Commonly Accessed Arthroscopy-Related Online Patient Education Materials.

PURPOSE: To assess the readability and comprehension of written text by the most commonly visited websites containing patient education materials on common conditions that can be treated arthroscopically. METHODS: We examined 50 websites, assessed independently by 2 orthopaedic surgery residents (S.A. and G.G.), with educational materials on 5 common conditions treated by arthroscopic surgeons: anterior cruciate ligament (ACL) tear, meniscus tear, hip labral tear, shoulder labral tear, and rotator cuff tear. Following a Google search for each condition, we analyzed the 10 most visited websites for each disorder using a widely used and validated tool for assessing the reading levels of written materials (Flesch-Kincaid formula). RESULTS: The average grade reading level of the 50 websites studied was 9.90 with a reading ease of 52.14 ("fairly difficult, high school"). Only 26% of the websites were at or below the national average of an eighth-grade reading level. Of the 5 conditions treated by arthroscopic surgery, ACL tear had the highest average grade reading level at 10.73 ± 1.54, whereas meniscus tear had the lowest at 9.31 ± 1.81. Every condition in this study had an average readability at or above the ninth-grade reading level. CONCLUSIONS: The most frequently accessed materials for patients with injuries requiring arthroscopic surgery exceeds the readability recommendations of the American Medical Association and National Institutes of Health, as well as the average reading ability of US adults. Given the fact that these are the most commonly visited websites by the lay public, there needs to be a greater emphasis on tailoring written information to the literacy levels of the patient population. CLINICAL RELEVANCE: This study emphasizes the discrepancy between the recommended versus the measured reading levels of online patient education materials related to conditions treated by arthroscopic surgeons. The subject matter of these conditions is inherently complex; thus, relying solely on text to inform patients increases the likelihood that the reading level of the material exceeds that of the majority of the lay public.

The Need for Clinical Hand Education in Emergency Medicine Residency Programs.

BACKGROUND: Complaints related to the hands, wrists, and fingers comprise approximately 3.7 million emergency department visits annually. The complexity of this subject can confound timely diagnosis and treatment, particularly if the treating physician has not received specialized training. We set out to determine whether emergency medicine training in the USA provides adequate preparation for dealing with the identification, management, and treatment of hand, wrist, and finger injuries. METHODS: The curricula for 160 accredited U.S. emergency medicine programs were obtained. Each of these was examined to see whether a clinical "hand" rotation was included as a required module. Clinical hand rotations were then classified by length of rotation, the postgraduate years in which they were offered, and if they were offered as stand-alone modules or combined with other rotations. RESULTS: Of the 160 programs, 21 (13.1%) require a clinical hand rotation. Sixteen offer a dedicated module, and five are part of another rotation. The mean amount of time dedicated to hand education was 3 weeks. The 16 dedicated hand rotations had a mean duration of 2.69 weeks; combined rotations were 4 weeks. Four incorporated hand education in the first postgraduate year (PGY-1), 13 into the second (PGY-2), and 3 into the third (PGY-3). CONCLUSIONS: Despite the preponderance of hand injuries seen by emergency physicians, the clinical and legal pitfalls that accompany these conditions, and the benefits to be gained from specialized training, very few programs emphasize clinical hand training in an equivalent fashion.

Atypical Tumoral Presentation of Calcium Pyrophosphate Deposition Disease: A Case Report.

CASE: A 55-year-old man presented with a history of forefoot pain and swelling. Radiographs revealed a mass with internal calcifications and osseous erosion of the fifth metatarsophalangeal bone. The mass was isointense to muscle on T1-weighted magnetic resonance imaging (MRI) and hyperintense on T2-weighted MRI. A biopsy was performed, and intraoperatively, the lesion appeared as chalky white material, which under polarized light microscopy was composed of weakly positively birefringent rhomboid crystals, leading to a diagnosis of tophaceous pseudogout. CONCLUSION: Tophaceus pseudogout should be included in the differential diagnosis of neoplastic-appearing lesions in the foot, and polarized light microscopy should be used when examining biopsy specimens.

The negative effect of carpal tunnel syndrome on sleep quality.

Objective. Sleep disturbances are common in patients with carpal tunnel syndrome (CTS). This study investigates the impact of CTS on sleep quality and clarifies the magnitude of this relationship. Methods. This is a prospective investigation of patients with CTS. Patients responded to the Levine-Katz Carpal Tunnel and the Pittsburgh Sleep Quality Index (PSQI) questionnaires to assess symptom severity and quality, respectively. Descriptive and bivariate analyses summarized the findings and assessed the correlations between CTS severity and sleep quality parameters. Results. 66 patients (53F, 13M) were enrolled. Patients reported a sleep latency of 30.0 (±22.5) minutes, with a total sleep time of 5.5 (±1.8) hours nightly. Global PSQI score was 9.0 (±3.8); 80% of patients demonstrated a significant reduction in sleep quality (global PSQI score >5). Increased CTS symptom and functional severity both resulted in a significant reduction in quality and time asleep. Both significantly correlated with subjective sleep latency, sleep disturbance, use of sleep promoting medications, daytime dysfunction, and overall global PSQI score. Conclusions. The findings confirm the correlation of sleep disturbances to CTS, that is, significant reduction of sleep duration and a correlation to sleep quality. Patients sleep 2.5 hours less than recommended and are at risk for comorbid conditions.

Improving accuracy and confidence in distal radius volar plate screw placement through supplemental radiography: examining specialty, education, and experience levels.

BACKGROUND: The purpose of this study was to assess the extent to which a supplemental radiographic view increases accuracy and confidence ratings when determining screw placement in volar plating of distal radius fractures for evaluators of different specialties and experience levels. METHODS: Thirty-four distal radius fractures treated with volar plate fixation were imaged using standard AP and lateral, and supplemental lateral tilt views. Each case was then evaluated for penetration of distal screw tips into the articular space. Sixty-five physicians then completed a two-phase analysis and survey of these cases. In the first phase, presentation consisted only of AP and lateral views; in the second, the lateral tilt view was added. Participants were asked to determine whether distal screws penetrated the joint and rate their confidence in the determination. Assessments were scored for correctness; changes in accuracy and confidence levels between phases were analyzed using paired t tests. Comparisons between groups were performed by ANOVA. RESULTS: Supplementation increased accuracy and confidence in all position, specialty, and experience groups. Confidence scores were significantly higher following evaluation of three views versus two views. Residents exhibited the greatest improvements in accuracy and confidence. For first-phase (standard view) assessments, accuracy scores were significantly better for attendings with less than 10 years post-fellowship experience than those with more. CONCLUSIONS: A supplemental view of the distal radius combined with AP and lateral views significantly improves the ability of all evaluators, regardless of specialty or training level, to correctly assess placement of fixation screws. The greatest improvements are seen for resident trainees.

Graded levels of Pax2a and Pax8 regulate cell differentiation during sensory placode formation.

Pax gene haploinsufficiency causes a variety of congenital defects. Renal-coloboma syndrome, resulting from mutations in Pax2, is characterized by kidney hypoplasia, optic nerve malformation, and hearing loss. Although this underscores the importance of Pax gene dosage in normal development, how differential levels of these transcriptional regulators affect cell differentiation and tissue morphogenesis is still poorly understood. We show that differential levels of zebrafish Pax2a and Pax8 modulate commitment and behavior in cells that eventually contribute to the otic vesicle and epibranchial placodes. Initially, a subset of epibranchial placode precursors lie lateral to otic precursors within a single Pax2a/8-positive domain; these cells subsequently move to segregate into distinct placodes. Using lineage-tracing and ablation analyses, we show that cells in the Pax2a/8+ domain become biased towards certain fates at the beginning of somitogenesis. Experiments involving either Pax2a overexpression or partial, combinatorial Pax2a and Pax8 loss of function reveal that high levels of Pax favor otic differentiation whereas low levels increase cell numbers in epibranchial ganglia. In addition, the Fgf and Wnt signaling pathways control Pax2a expression: Fgf is necessary to induce Pax2a, whereas Wnt instructs the high levels of Pax2a that favor otic differentiation. Our studies reveal the importance of Pax levels during sensory placode formation and provide a mechanism by which these levels are controlled.