The Risk of Lymphedema After Breast Cancer Surgery Should Not Restrict Necessary Hand Surgery Interventions.

BACKGROUND: The purpose of this study was to evaluate the incidence of lymphedema onset or exacerbation in patients undergoing upper extremity interventions, both nonoperative and operative, after breast cancer surgery. METHODS: The study inclusion criteria were the following: (1) prior history of breast cancer surgery or lymphedema from the cancer; (2) upper extremity intervention, ipsilateral to the breast cancer side; and (3) follow-up of at least 1 month. Patients were evaluated for demographic information, type of breast cancer procedure and hand intervention, number of lymph nodes dissected, preexisting lymphedema, exacerbation of lymphedema, and new-onset lymphedema. RESULTS: A total of 161 patients undergoing 385 hand interventions (300 injections, 85 surgeries) were reviewed. Median follow-up was 31 months (range: 1-110). Nineteen patients had preexisting lymphedema ipsilateral to the hand procedure and none experienced an exacerbation of their lymphedema. Three patients developed new-onset lymphedema ipsilateral to their hand intervention at an average follow-up of 30 months (range: 4-67). One patient had a single injection and developed lymphedema over 5 years later. One had 2 injections in the same hand on the same date and developed lymphedema 3 months later. The third patient had 2 injections in the right hand, 1 injection and 1 surgery in the left hand, and developed either lymphedema or swelling due to rheumatoid arthritis in the right hand 1 year after the injections. CONCLUSIONS: Patients who have undergone breast cancer surgery can safely undergo upper extremity intervention with low risk of lymphedema exacerbation or onset.

Effects of Premixing Betamethasone and Lidocaine on Chondrocyte Inflammation in an In Vitro Model.

BACKGROUND: It is common practice for hand surgeons to premix corticosteroids with a local anesthetic and store the mixture in pre-loaded syringes for rapid use during clinic. However, any possible loss of efficacy with this practice has never been studied. The purpose of this study, therefore, is to determine whether premixing betamethasone sodium phosphate/betamethasone acetate (BSP) and lidocaine (L) at different time intervals from injection has diminishing anti-inflammatory effects on chondrocytes in vitro. METHODS: Human articular chondrocytes were partitioned into six groups: two controls and four experimental conditions. The negative control had growth media only. The positive control had growth media and inflammatory cytokines (interleukin-1ß and oncostatin M). Experimental conditions were additionally treated with BSP alone or BSP mixed with lidocaine (BSP + L) at the time of treatment (0 hours), or at 4 or 24 hours prior. Relative expressions of inflammatory genes were measured. RESULTS: Relative to the positive control, chondrocytes in all experimental conditions decreased expression of TNF-α, MMP-3, and ADAMTS-4. Chondrocytes exposed to BSP only or BSP + L at 4 hours or 24 hours prior to treatment decreased expression of IL-8. Chondrocytes exposed to BSP only or BSP + L at 0 hours or 4 hours prior to treatment decreased expression of MMP-1. There were no significant differences in expression of IL-6 or MMP-13. CONCLUSIONS: Treatment with BSP + L prepared in pre-loaded syringes at varying time intervals up to 24 hours prior to injection does not significantly impact the ability of the mixture to reduce expression of certain key inflammatory mediators in vitro.

The Effects of Autologous Fat Transfer in an In Vitro Model of Basal Joint Osteoarthritis.

PURPOSE: Basal joint osteoarthritis (OA) is a highly prevalent and debilitating condition. Recent clinical evidence suggests that autologous fat transfer (AFT) may be a promising, minimally invasive treatment for this condition. However, the mechanism of action is not fully understood. It is theorized that AFT reduces inflammation in the joint, functions to regenerate cartilage, or acts as a mechanical buffer. The purpose of this study was to better understand the underlying mechanism of AFT using an in vitro model. We hypothesize that the addition of stromal vascular fraction (SVF) cells will cause a reduction in markers of inflammation. METHODS: Articular chondrocytes were expanded in culture. Liposuction samples were collected from human subjects and processed similarly to AFT protocols to isolate SVF rich in adipose-derived stem cells. A control group was treated with standard growth media, and a positive control group (OA group) was treated with inflammatory cytokines. To mimic AFT, experimental groups received inflammatory cytokines and either a low or high dose of SVF. Expression of relevant genes was measured, including interleukin (IL)-1ß, IL-1 receptor antagonist, and matrix metalloproteinases (MMP). RESULTS: Compared to the OA group, significant decreases in IL-1ß, MMP3, and MMP13 expression on treatment day 3 were found in the high-dose SVF group, while MMP13 expression was also significantly decreased in the low-dose SVF group on day 3. CONCLUSIONS: In this study, we found that SVF treatment reduced expression of IL-1ß, MMP3, and MMP13 in an in vitro model of OA. These results suggest that an anti-inflammatory mechanism may be responsible for the clinical effects seen with AFT in the treatment of basal joint OA. CLINICAL RELEVANCE: An anti-inflammatory mechanism may be responsible for the clinical benefits seen with AFT for basal joint arthritis.

Management of de Quervain Tenosynovitis: A Critical Analysis Review.

¼: Most cases of de Quervain tenosynovitis can be managed with nonoperative measures, and the mainstay of treatment is corticosteroid injection (CSI). The use of ultrasound may improve the accuracy of injections and can help to identify and localize injections to separate subcompartments. ¼: For patients who are in the third trimester of pregnancy or breastfeeding, there is no contraindication to CSI as studies have shown that it can provide optimal symptomatic relief to the mother without impacting the baby. ¼: When nonoperative treatment is unsuccessful, surgical release of the first dorsal compartment (FDC) can provide excellent symptom relief. Open release performed through a longitudinal incision allows for better visualization of the underlying anatomy, resulting in fewer injuries to underlying structures and a lower incidence of hypertrophic scarring compared with a transverse incision. ¼: For surgeons who are comfortable performing endoscopic techniques, endoscopic FDC release can result in quicker symptom improvement, superior scar cosmesis, and a lower incidence of radial sensory nerve injury. ¼: Studies have shown that FDC release can safely and effectively be performed using the WALANT (wide-awake local anesthesia no tourniquet) technique, which has the potential for cost savings without compromising quality or patient comfort.

Current Trends in Sex, Race, and Ethnic Diversity in Orthopaedic Surgery Residency.

BACKGROUND: The representation of minorities among medical students has increased over the past two decades, but diversity among orthopaedic residents lags behind. This phenomenon has occurred despite a recent focus by the American Academy of Orthopaedic Surgeons on the recruitment of minorities and women. OBJECTIVE: To analyze the impact of recent efforts on diversity in orthopaedic residents in comparison with other surgical specialties from 2006 to 2015. METHODS: Data from the American Association of Medical Colleges on residents in surgical specialty programs in the years 2006 to 2015 were analyzed. Linear regression models were used to estimate trends in diversity among orthopaedic residents and residents in other surgical specialties. A mixed model analysis of variance was used to compare rates of diversification among different specialties over time. RESULTS: Female representation in orthopaedic programs increased from 10.9% to 14.4% between 2006 and 2015. However, the rate of increase was significantly lower compared with other specialties (all P < 0.05) studied, except for urology (P = 0.64). Minority representation in orthopaedics averaged 25.6% over the 10-year period. Residents of Hispanic origin in orthopaedic programs increased (P = 0.0003) but decreased for Native Hawaiian/Pacific Islander (P < 0.0001). During the same period, white representation increased (P = 0.004). No significant changes were found in African Americans or Asian American representation. Diversity decreased among orthopaedic residents over the period studied (P = 0.004). CONCLUSIONS: Recruitment efforts have not reversed the sex, racial, and ethnic disparities in orthopaedic residents. Orthopaedics has the lowest representation of women and minorities among residencies studied. The rate of increase in women lags behind all surgical subspecialties, except for urology.

Evaluation of Sex, Ethnic, and Racial Diversity Across US ACGME-Accredited Orthopedic Subspecialty Fellowship Programs.

In recent years, there has been an increasing trend toward subspecialization in orthopedic surgery via fellowships. This study sought to characterize sex, ethnic, and racial representation within each fellowship program and to examine their changes over time to identify trends and/or gaps. Demographic data were obtained from the National Graduate Medical Education Census. Diversity was assessed using proportions of minority and female trainees. The trends in racial, ethnic, and sex diversity from 2006 to 2015 for orthopedics as a whole and within each subspecialty were analyzed. Of 3722 orthopedic fellows, 2551 identified as white (68.5%), 648 as Asian (17.4%), 175 as Hispanic (4.7%), 161 as black (4.3%), 8 as Native Hawaiian/Pacific Islander (0.21%), and 3 as American Indian/Alaskan Native (0.08%). Further, 479 identified as female (12.9%). Racial and ethnic minority representation among orthopedic fellows did not increase over time. Female representation did increase proportionally with female residents. Asian fellows preferred reconstructive adult and spine, whereas white fellows preferred sports medicine, hand surgery, and trauma. Female fellows preferred pediatrics, hand surgery, and musculoskeletal oncology. Although sex diversity among orthopedic fellows has increased in the past 10 years, racial and ethnic minority representation lacked similar growth. Asian and female fellows preferred specific subspecialties over others. These data are presented as an initial step in determining factors that attract minority groups to different orthopedic subspecialties. Further research should define specific factors and identify ways to increase minority distribution among fellowship programs. [Orthopedics. 2018; 41(5):282-288.].

Use of a Fascial Flap to Stabilize an Unstable Ulnar Nerve in Its Bed During In Situ Decompression.

This case report involves a man with ulnar neuropathy at the elbow, who was to undergo an in situ decompression of the ulnar nerve. When the nerve was noted intraoperatively to sublux partially over the posterior portion of the medial epicondyle, the surgeon stabilized the nerve in situ by using a fascial flap that was secured to the anterior rim of the cubital tunnel and loosely sutured posteriorly to the medial side of the olecranon, rather than performing an anterior transposition or medial epicondylectomy. This method could be considered a middle-ground surgical technique because it allowed the nerve to remain in its bed, did not disturb its blood supply, dealt with the problem of a slightly unstable ulnar nerve with a fascial flap, and avoided methods that could be considered as having greater surgical magnitude.

Carpal tunnel syndrome diagnosis and treatment: a survey of members of the American Society For Surgery of the Hand.

PURPOSE: In 2007 and 2009, the American Academy of Orthopaedic Surgeons released Clinical Practice Guidelines (CPG) for diagnosis and treatment of carpal tunnel syndrome (CTS) based upon review of the literature. The lack of consistently high-level evidence resulted in several recommendations, some strongly supported, some weakly supported, and others controversial. We postulated that a survey of American Society for Surgery of the Hand (ASSH) members would provide insight into practice patterns among hand surgeons treating CTS and demonstrate the extent to which the CPG influenced practice behavior. METHODS: A multiple-choice questionnaire including detailed commonly observed clinical scenarios was developed, pre-tested, and approved by our institutional review board and the ASSH Web site committee chair. An anonymous electronic survey was emailed to ASSH members. RESULTS: Surveys were sent to 2,650 eligible ASSH members, and 27% responded. Seventy-two percent would advise a patient to have carpal tunnel release (CTR) if the patient had both classic history/examination of CTS and complete relief following cortisone injection. Forty-seven percent responded that in this scenario electrodiagnostic testing (EDX) is rarely or never necessary to recommend CTR. Seventy-nine percent of respondents were at least slightly more likely to order EDX based on CPG recommendations. Of these respondents, 57% replied that this was because of potential medicolegal ramifications. CONCLUSIONS: Although the CPG recommended EDX before surgery, and although most responding ASSH members use EDX to advise CTR, a majority answered that a supporting history and physical examination alone can be sufficient to recommend surgery, that a positive response to a cortisone injection can be sufficient indication for CTR, that EDX is not necessary in all cases of CTS, and that they would perform CTR in face of normal EDX if cortisone temporarily resolved symptoms. Among respondents more likely to order EDX based on the CPG, 57% answered that it was in some circumstances due to potential medicolegal ramifications. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis III.

A preliminary report on the initiation of a clinical research program in an orthopaedic surgery department: roadmaps and tool kits.

OBJECTIVE: A formal research program enhances resident training experience, productivity and hones critical appraisal skills. This initiative sought to investigate if an academic orthopaedic surgery department could implement a clinical research program, with the goal of increasing resident scholarly activity, a requirement of the Resident Review Committee, and achieve a parallel aim of enhancing the research focus of faculty. DESIGN: A multifaceted intervention including a needs assessment, appropriation of dedicated research staffing, development of tracking tools and policies, and a formalized research curriculum, followed by additional research time for residents was planned and implemented. The impact of all of these efforts is measured with specific outcomes, pre and post implementation. SETTING: The North Shore-LIJ Orthopaedic Surgery Department is a high volume clinical and education program with 17 fulltime core faculty and 18 residents at 2 tertiary hospitals. PARTICIPANTS: Residents were the focus of the intervention. The participation of faculty as principal investigators and sponsors was a key component to ensure success. RESULTS: The following outcomes were observed post intervention: increases in institutionally-required research training for faculty/residents, number of IRB protocols submitted, abstracts submitted to national meetings, percentage of time faculty report they spend on research activities, additional hours allocated to the new Department sponsored research curriculum and an additional research rotation for trainees. CONCLUSIONS: The official inception of a formalized program (2012) with a structured research process, invigorated faculty and trainees to formulate clinical research inquiries, generate hypotheses, create protocols and design and implement protocols. Structured tools, an experienced clinical research "champion" and commitment from departmental leadership were demonstrated as effective in transforming the focus of a clinical department into one with a nascent clinical research program, with demonstrable outcomes.

Enhancement of Achilles tendon repair mediated by matrix metalloproteinase inhibition via systemic administration of doxycycline.

Collagenases or matrix metalloproteinases (MMPs) have been shown to play an important role in the matrix degradation cascade associated with Achilles tendon rupture and disease. The goal of this study was to examine the effects of daily administration of doxycycline (Doxy) through oral gavage on MMP activity and on the repair quality of Achilles tendons in vivo. Our findings indicate that Achilles tendon transection resulted in increasing MMP-8 activity from 2 to 6 weeks post-injury, with peak increases in activity occurring at 4 weeks post-injury. Doxy adiministration at clinically relevant serum concentrations was found to significantly inhibit MMP activity after continuous treatment for 4 weeks, but not for continuous administration for shorter durations (96 h or 2 weeks). Extended doxy administration was also associated with improved collagen fibril organization, and enhanced biomechanical properties (stiffness, ultimate tensile strength, maximum load to failure, and elastic toughness). Our findings indicate that a temporal delay exists between Achilles tendon transection and associated increases in MMP-8 activity in situ. Our findings suggest that inhibition of MMP-8 at its peak activity levels ameliorates fibrosis development and improves biomechanical properties of the Achilles tendon.

Ultrasonic assessment of extracellular matrix content in healing Achilles tendon.

Although several imaging modalities have been utilized to observe tendons, assessing injured tendons by tracking the healing response over time with ultrasound is a desirable method which is yet to be realized. This study examines the use of ultrasound for non-invasive monitoring of the healing process of Achilles tendons after surgical transection. The overall extracellular matrix content of the transection site is monitored and quantified as a function of time. B-mode images (built from successive A-scan signatures) of the injury site were obtained and compared to biomechanical properties. A quantitative measure of tendon healing using the extracellular matrix (ECM) content of the injury site was analyzed using linear regression with all biomechanical measures. Contralateral tendons were used as controls. The trend in the degree of ECM regrowth in the 4 weeks following complete transection of excised tendons was found to be most closely paralleled with that of linear stiffness (R(2) = 0.987, p < .05) obtained with post-ultrasound biomechanical tests. Results suggest that ultrasound can be an effective imaging technique in assessing the degree of tendon healing, and can be used to correlate structural properties of Achilles tendons.

Tendon phenotype should dictate tissue engineering modality in tendon repair: a review.

Advancements in the technical aspects of tendon repair have significantly improved the treatment of tendon injuries. Arthroscopic techniques, suture material, and improved rehabilitation have all been contributing factors. Biological augmentation and tissue engineering appear to have the potential to improve clinical outcomes as well. After review of the physiology of tendon repair, three critical components of tissue engineering can be discerned: the cellular component, the carrier vehicle (matrix or scaffold), and the bioactive component (growth factors, platelet rich plasma). These three components are discussed with regard to each of three tendon types: Intra-synovial (flexor tendon), extra-synovial (Achilles tendon), and extra-synovial tendon under compression (rotator cuff). Scaffolds, biologically enhanced scaffolds, growth factors, platelet rich plasma, gene therapy, mesenchymal stem cells, and local environment factors in combination or alone may contribute to tendon healing. In the future it may be beneficial to differentiate these modes of healing augmentation with regard to tendon subtype.

Scapholunate dissociation with radiolunate arthritis without radioscaphoid arthritis.

PURPOSE: Watson and Ballet introduced the concept of a direct association between scapholunate (SL) dissociation and radioscaphoid (RS) arthritis with preservation of the radiolunate (RL) articulation in 1984. This principle has served as the anatomic, biomechanical, and pathophysiological basis for reconstructive surgery in the carpus. Recently, we have noted cases of concurrent SL dissociation and RL arthritis without RS arthritis, which is contrary to the accepted concept of wrist arthritis due to SL advanced collapse. The purpose of this study was to determine whether Watson and Ballet's thesis that SL dissociation results in RS joint degeneration with sparing of the RL joint can be confirmed, or whether another joint degeneration pattern can be associated with SL dissociation. METHODS: The 3 authors independently reviewed 897 radiographs of the wrist in 691 male patients (206 bilateral and 485 unilateral) with diagnosis codes of wrist osteoarthritis (715.13), wrist instability (718.83), and wrist sprain (842.00). Posterior-anterior, oblique, and lateral views were available for all wrists. Elements assessed were RS joint, RL joint, SL joint, midcarpal joint, ulnar variance, ulnolunate joint, SL angle, and lunocapitate angle. RESULTS: There were 146 wrists with radiographic SL dissociation. Nine wrists in 6 patients had radiographic SL dissociation and RL arthritis but no RS arthritis. An additional 6 wrists in 6 patients had radiographic RL arthritis but no SL dissociation or RS arthritis; however, 5 of these did have an SL angle of 60 degrees or greater. CONCLUSIONS: Our results show that RL arthritis can occur in association with SL dissociation, and that the generally held view that the RL articulation is spared in SL advance collapse is not universally true. Consequently, it is our recommendation that both the RL and RS joints should be carefully evaluated for degenerative changes when planning treatment for patients with SL dissociation, because it should not be assumed that the RL joint has been spared.

Treatment of chronic, traumatic hyperextension deformities of the proximal interphalangeal joint with flexor digitorum superficialis tenodesis.

PURPOSE: To our knowledge, there are no reports in the literature regarding treatment of chronic, posttraumatic proximal interphalangeal (PIP) joint hyperextension deformities with flexor digitorum superficialis tenodesis. The purpose of this study was to describe the surgical treatment and results of flexor digitorum superficialis tenodesis for the treatment of chronic, posttraumatic PIP joint hyperextension deformities. METHODS: Twelve patients were reviewed retrospectively and re-examined at a mean follow-up period of 35 months (range, 6-108 mo). Evaluation included completion of a Disabilities of the Arm, Shoulder, and Hand questionnaire and range of motion (ROM) measurements. RESULTS: There were 5 excellent, 5 good, and 2 fair results. Five patients had a residual flexion contracture at the PIP joint of 5 degrees to 15 degrees, although this did not create any functional impairment as determined by responses to the Disabilities of the Arm, Shoulder, and Hand questionnaire at follow-up evaluation. The 2 patients with fair results had postoperative PIP flexion contractures of 30 degrees and 60 degrees. All 12 patients returned to their previous occupations and recreational activities. CONCLUSIONS: Flexor digitorum superficialis tenodesis is an effective method with predictable results for the treatment of chronic, traumatic hyperextension deformities of the PIP joint.