Closed Reduction Percutaneous Pinning Versus Open Reduction With Plate and Screw Fixation in Management of Unstable Proximal Phalangeal Fractures: A Systematic Review and Meta-analysis.

BACKGROUND: Proximal phalanx fractures are common, with surgical fixation indicated for unstable fractures. Traditionally, closed reduction percutaneous pinning (CRPP) resulted in decreased stiffness and tendon irritation compared to open reduction internal fixation (ORIF). We hypothesized that more recent studies would have more similar outcomes to CRPP. The purpose of this study was to compare CRPP and ORIF in terms of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and complications. METHODS: Four electronic databases were queried from 2010 to present. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two independent reviewers performed a two-step review process to identify relevant articles. Patient demographics, total active motion (TAM), DASH, and complications were extracted. The methodological quality of each study included was assessed independently. Meta-analysis was performed for comparative trials. RESULTS: Fourteen studies met inclusion criteria including four comparative studies: Thirteen studies included TAM. The weighted average TAM was 228 ± 34° for CRPP and 223 ± 32° for ORIF (P = .07 with 95% confidence interval (CI), -0.5 to 10.5). Seven studies evaluated DASH scores; weighted average was 8.2 ± 8.9 for CRPP and 11.7 ± 6.5 for ORIF (P < .01 with 95% CI, 1.8-5.2). Two studies directly compared CRPP to ORIF, favoring ORIF for both TAM with d = 1.07 and DASH with d = 0.23. Rates of tenolysis or hardware removal were higher for ORIF (P < .01). CONCLUSIONS: New literature suggests more equipoise with regard to treatment of proximal phalanx fracture with CRPP versus ORIF. TYPE OF STUDY/LEVEL OF EVIDENCE: Meta-analysis, Level II.

An Examination of Sexual Victimization, Self-Injurious Behaviors, and Suicidality Among Female College Students.

Many studies have established a relationship between suicidal ideation and sexual victimization, particularly among women; yet, few have looked specifically at samples of college students or at the potentially mediating effects that several risk factors and coping mechanisms related to sexual victimization may have on suicidality. The current study sought to examine the relationship between reported sexual victimization and suicidality, and more specifically the mediating role that depression and nonsuicidal self-injury had on this relationship. Data were collected from a random sample of 732 female college students attending a Midwestern public university. Path analysis results indicate that while sexual victimization did not have a direct effect on suicidality, it did have an observable and significant mediating indirect effect on suicidality. The current study informs both our theoretical understanding of how victimization affects college women's lives and our capacity to develop and implement effective prevention and intervention programs for college students.

Contamination of the Surgical Field with Propionibacterium acnes in Primary Shoulder Arthroplasty.

BACKGROUND: Propionibacterium acnes is a common pathogen identified in postoperative shoulder infection. It has been shown to be present in culture specimens during primary shoulder arthroplasty; however, recent work has suggested that it is most likely to be a contaminant. Our aim was to identify the potential sources of contamination in shoulder arthroplasty. METHODS: Tissue swabs were obtained for microbiological analysis from consecutive patients undergoing primary shoulder arthroplasty. Routine surgical technique was maintained, and 5 specimens were taken from different sites: (1) the subdermal layer, (2) the tip of the surgeon's glove, (3) the inside scalpel blade (used for deeper incision), (4) the forceps, and (5) the outside scalpel blade (used for the skin incision). RESULTS: Forty patients (25 female patients and 15 male patients) were included. Thirteen (33%) of the 40 patients had at least 1 culture specimen positive for P. acnes. Two (8%) of the 25 female patients and 11 (73%) of the 15 male patients had ≥1 culture specimen positive for P. acnes. The most common site of growth of P. acnes was the subdermal layer (12 positive samples), followed by the forceps (7 positive samples), the tip of the surgeon's glove (7 positive samples), the outside scalpel blade (4 positive samples), and the inside scalpel blade (1 positive sample). There were 27 of 75 swabs that were positive on culture for P. acnes in male patients compared with 4 of 125 swabs in female patients. Male patients had 66 times (95% confidence interval, 6 to 680 times) higher odds of having a positive culture indicating subdermal colonization compared with female patients (p < 0.001). CONCLUSIONS: P. acnes is a common contaminant of the surgical field in primary shoulder arthroplasty. The subdermal layer may be the source of this contamination, and the prevalence of P. acnes in the surgical wound may be due to the surgeon's manipulation with gloves and instruments. Our findings are consistent with those regarding the increased rates of P. acnes bacterial load and intraoperative growth in male patients compared with female patients. CLINICAL RELEVANCE: P. acnes is likely to be spread throughout the surgical field from the subdermal layer via soft-tissue handling by the surgeon and instruments. Strategies need to be utilized to minimize this contact and to reduce the chance of colonization.

Clinical outcomes after decompression of the nerve to the teres minor in patients with idiopathic isolated teres minor fatty atrophy.

BACKGROUND: The purpose of this manuscript is to describe what we believe to be the first series of patients surgically treated for idiopathic isolated teres minor atrophy and to present the results of surgical decompression of the nerve to the teres minor. METHODS: This is a retrospective cohort of 22 patients who underwent decompression of the nerve to the teres minor for isolated teres minor atrophy. Clinical data including duration of symptoms, additional diagnoses, concurrent procedures, preoperative physical examination findings, imaging data, and preoperative visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) scores were collected from the medical record. Postoperative patient-based clinical outcome measures including VAS, SST, and ASES scores were obtained during clinical examination or by telephone interview. RESULTS: Average length of follow-up was 26 months. Nine patients had concurrent procedures performed. Preoperatively, 12 of 14 (86%) had external rotation weakness in Hornblower's position. Postoperatively, pain scores decreased an average of 4 points; ASES scores increased 31.7 ± 20.2 points; SST scores increased 3.1 ± 2.3 points. No external rotation weakness was noted postoperatively in any tested patient. Two patients developed adhesive capsulitis. No other complications occurred. CONCLUSIONS: Isolated compression of the nerve to the teres minor is a rare and novel clinical entity. In properly selected cases, open release of the fascial sling enveloping the nerve branches to the teres minor can provide relief of symptoms and clinical improvement.

Outcome of All-Inside Second-Generation Meniscal Repair: Minimum Five-Year Follow-up.

BACKGROUND: Meniscal repair and preservation are the goal, when possible, of the treatment of meniscal injury. Current research on second-generation all-inside repair systems has been limited to a maximum of three years of follow-up. The purpose of this study was to evaluate the mid-term clinical success (at more than five years) of meniscal repair performed with a second-generation all-inside repair device, both as an isolated procedure and with a concomitant anterior cruciate ligament (ACL) reconstruction. METHODS: This is a retrospective review of patients who underwent meniscal repair with use of the all-inside FAST-FIX Meniscal Repair System (Smith & Nephew Arthroscopy, Andover, Massachusetts) from December 1999 to January 2007. Eighty-three meniscal repairs (in eighty-one patients) were identified, and follow-up data were obtained for seventy-five (90%). Twenty-six (35%) of the meniscal repairs were performed as isolated procedures. Clinical failure was defined as repeat surgical intervention involving resection or revision repair. Clinical outcomes were also assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and the Marx activity score. RESULTS: The minimum duration of follow-up was five years (average, seven years). Twelve patients (16%) had failure of the meniscal repair, at an average of forty-seven months (range, fifteen to ninety-five months). The data did not offer enough statistical evidence, at alpha = 0.05, to establish a difference in average patient age, patient sex, or number of sutures utilized between successful repairs and failures. There was no difference in the failure rate between isolated repairs (12%; 95% confidence interval [CI]: -0.76% to 23.76%) and those performed with concurrent ACL reconstruction (18%; 95% CI: 7.47% to 29.13%), and the average time to failure was similar between these two groups (48.1 months versus 46.6 months, p = 0.939). Postoperative KOOS and IKDC outcome scores were also similar between the groups. CONCLUSIONS: This report of mid-term follow-up results of primary second-generation all-inside meniscal repair demonstrates its effectiveness both as an isolated procedure and when it is performed with concurrent ACL reconstruction. After a minimum of five years of follow-up, 84% of the patients continued to demonstrate successful repair. Treatment success was further supported by favorable results on patient-based outcome measures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Polygenic threshold model with sex dimorphism in adolescent idiopathic scoliosis: the Carter effect.

BACKGROUND: Adolescent idiopathic scoliosis occurs between two and ten times more frequently in females than in males. The exact cause of this sex discrepancy is unknown, but it may represent a difference in susceptibility to the deformity. If this difference is attributable to genetic factors, then males with adolescent idiopathic scoliosis would need to inherit a greater number of susceptibility genes compared with females to develop the deformity. Males would also be more likely to transmit the disease to their children and to have siblings with adolescent idiopathic scoliosis. Such a phenomenon is known as the Carter effect, and the presence of such an effect would support a multifactorial threshold model of inheritance. METHODS: One hundred and forty multiplex families in which more than one individual was affected with adolescent idiopathic scoliosis were studied. These families contained 1616 individuals, including 474 individuals with adolescent idiopathic scoliosis and 1142 unaffected relatives. The rates of transmission from the 122 affected mothers and from the twenty-eight affected fathers were calculated, and the prevalence among siblings was determined in the nuclear families of affected individuals. RESULTS: The prevalence of adolescent idiopathic scoliosis in these multiplex families was lowest in sons of affected mothers (36%, thirty-eight of 105) and highest in daughters of affected fathers (85%, twenty-two of twenty-six). Affected fathers transmitted adolescent idiopathic scoliosis to 80% (thirty-seven) of forty-six children, whereas affected mothers transmitted it to 56% (133) of 239 children (p < 0.001). Siblings of affected males also had a significantly higher prevalence of adolescent idiopathic scoliosis (55%, sixty-one of 110) compared with siblings of affected females (45%, 206 of 462) (p = 0.04). CONCLUSIONS: This study demonstrates the presence of the Carter effect in adolescent idiopathic scoliosis. This pattern can be explained by polygenic inheritance of adolescent idiopathic scoliosis, with a greater genetic load required for males to be affected.

Polygenic threshold model with sex dimorphism in clubfoot inheritance: the Carter effect.

BACKGROUND: Idiopathic clubfoot is approximately twice as common in males than in females. The reason for this discrepancy is unclear but may represent an inherent difference in the susceptibility to the deformity. If this difference is due to genetic factors it is predicted that in order to inherit clubfoot, females need to have a greater number of susceptibility genes than males. Females would also be more likely to transmit the disease to their children and have siblings with clubfoot. This phenomenon is known as the Carter effect, and the presence of such an effect supports a multifactorial threshold model of inheritance. METHODS: Ninety-seven multiplex families with more than one individual with idiopathic clubfoot were studied. The study included 1093 individuals: 291 with clubfoot and 802 unaffected relatives. Rates of transmission by the thirty-seven affected fathers and twenty-six affected mothers were calculated, and the prevalence among siblings was determined in the nuclear families of affected persons. RESULTS: Within these multiplex families, the prevalence of clubfoot was lowest in daughters of affected fathers (eight of twenty-four) and highest in sons of affected mothers (eleven of thirteen). Affected mothers transmitted clubfoot to 59% of their children (nineteen of thirty-two children), whereas affected fathers transmitted idiopathic clubfoot to 37% of their children (twenty-six of seventy children) (p = 0.04). Siblings of an affected female also had a significantly higher prevalence of clubfoot than siblings of an affected male (46% [fifty-four of 117] compared with 34% [sixty-seven of 197]; p = 0.03). CONCLUSIONS: This study demonstrates the presence of the Carter effect in idiopathic clubfoot. This effect can be explained by a polygenic inheritance of clubfoot, with females requiring a greater genetic load to be affected.

Asymmetric lower-limb malformations in individuals with homeobox PITX1 gene mutation.

Clubfoot is one of the most common severe musculoskeletal birth defects, with a worldwide incidence of 1 in 1000 live births. In the present study, we describe a five-generation family with asymmetric right-sided predominant idiopathic clubfoot segregating as an autosomal-dominant condition with incomplete penetrance. Other lower-limb malformations, including patellar hypoplasia, oblique talus, tibial hemimelia, developmental hip dysplasia, and preaxial polydactyly, were also present in some family members. Genome-wide linkage analysis with Affymetrix GeneChip Mapping 10K mapping data from 13 members of this family revealed a multipoint LOD(max) of 3.31 on chromosome 5q31. A single missense mutation (c.388G-->A) was identified in PITX1, a bicoid-related homeodomain transcription factor critical for hindlimb development, and segregated with disease in this family. The PITX1 E130K mutation is located in the highly conserved homeodomain and reduces the ability of PITX1 to transactivate a luciferase reporter. The PITX1 E130K mutation also suppresses wild-type PITX1 activity in a dose-dependent manner, suggesting dominant-negative effects on transcription. The propensity for right-sided involvement in tibial hemimelia and clubfoot suggests that PITX1, or pathways involving PITX1, may be involved in their etiology. Implication of a gene involved in early limb development in clubfoot pathogenesis also suggests additional pathways for future investigations of idiopathic clubfoot etiology in humans.