The Impact of Wrist Fractures on Long-Term Basketball Performance.

Background: Wrist joint fractures may present challenging obstacles for the rehabilitating athlete upon return to play. Although current literature has examined the effects of specific injuries to the upper extremity for basketball athletes, little is known about long-term performance outcomes following wrist joint fractures. Methods: Review of all National Basketball Association players who sustained wrist joint fractures was conducted. Player characteristics, preinjury and postinjury performance, and overall efficiency were analyzed. Results: A total of 31 players were deemed appropriate for inclusion, with an average age of 26.2 ± 4.3 years and a mean of 5.2 ± 3.6 years played before injury and 4.1 ± 3.1 years played upon return. Operative management was pursued in 48.4% of players. Players demonstrated a significant decrease in win shares before injury (mean: 24.3 ± 31.5) compared to after return from injury (mean: 9.6 ± 19.6) (p < 0.032). Multivariate regression demonstrated that increased points per game before injury (standardized ß: 0.71; 95% confidence interval [CI]: 1.2-8.5, p < 0.011) and increased win shares before injury (ß: 1.0; 95% CI: 1.4-9.5, p < 0.001) were both independently predictive with increased win shares after return to play. Player position, age, management type, and all other statistics were not significantly associated with any other findings upon return. Conclusion: Overall efficiency following return to play in the setting of basketball-associated wrist joint fractures appears to be decreased in athletes. However, preinjury performance as captured through win share efficiency and points per game appears to be predictive of increased productivity after successful return.

Office-Based Carpal Tunnel Release With Ultrasound Guidance: 6-month Outcomes From the Multicenter ROBUST Trial.

Purpose: The purpose of this study was to determine the safety and effectiveness of office-based carpal tunnel release with ultrasound guidance (CTR-US). Methods: In this prospective multicenter observational study, patients were treated with CTR-US in an office setting. Outcomes were time to resume normal daily activities, time to return to work, Boston Carpal Tunnel Questionnaire Symptom Severity Scale and Functional Status Scale scores, Michigan Hand Questionnaire, Numeric Pain Scale, EuroQoL-5 Dimension 5-Level score, procedure satisfaction, and adverse events over 6 months. Results: A total of 149 participants (226 hands) from seven centers underwent office-based CTR-US. The mean age was 58 years, 52% were women, and 68% were employed. The mean incision length was 5 mm, 52% had simultaneous bilateral procedures, and wide-awake local anesthesia no tourniquet was used in all cases. All procedures were completed as planned, with no conversions to open repair and mean intraoperative pain severity of 1.6 ± 1.5. The median time to resume normal activities was 2 days (interquartile range: 1-4 days) and return to work was 4 days (interquartile range: 1-5 days). Over 6 months, Boston Carpal Tunnel Questionnaire Symptom Severity Scale decreased by a mean of 1.7 points, Boston Carpal Tunnel Questionnaire Functional Status Scale decreased by 1.1 points, Michigan Hand Questionnaire Global score increased by 35 points, Numeric Pain Scale decreased by 3.7 points, and EuroQoL-5 Dimension 5-Level score increased by 0.11 points. At 6 months, 94% reported procedure satisfaction. Unilateral and simultaneous bilateral procedures were similarly effective. There was one (0.4%) adverse event, a nerve contusion treated with neurolysis and nerve wrap where the patient fully regained normal function within 7 weeks. There were no revisions for persistent or recurrent carpal tunnel syndrome symptoms. Conclusions: Office-based CTR-US, performed either unilaterally or as simultaneous bilateral procedures, is well tolerated with a low complication rate and associated with rapid recovery, sustained improvement in symptoms and function, and high procedure satisfaction. Type of study/level of evidence: Therapeutic III.

Protocol of a Multicenter Prospective Trial of Office-Based Carpal Tunnel Release With Ultrasound Guidance (ROBUST).

Background Carpal tunnel release (CTR) is a common surgical procedure for patients with severe or refractory carpal tunnel syndrome (CTS) symptoms. Historically, CTR procedures have been performed in a hospital or an ambulatory surgery center (ASC). However, due to advancements in techniques, greater patient demand, and concerns about growing healthcare costs, there is a distinct trend toward performing CTR procedures in an office-based setting. Several small studies with limited follow-up duration have demonstrated the feasibility of CTR with ultrasound guidance (CTR-US) when performed in an office-based setting. The objective of this study is to evaluate the safety and effectiveness of office-based CTR-US in a large cohort of patients (n=140) with symptomatic CTS followed for two years post-treatment. Design and methods ROBUST is a prospective multicenter observational study in which 140 subjects at up to 12 sites in the United States will be treated with CTR-US in an office-based setting. The primary endpoint of the study is the change in the Boston Carpal Tunnel Questionnaire Symptom Severity Scale score. Secondary endpoints include time to return to normal daily activities, time to return to work among employed subjects, change in the Boston Carpal Tunnel Questionnaire Functional Status Scale score, change in the Michigan Hand Questionnaire overall and domain scores, change in the Numeric Pain Scale score, change in the EuroQoL-5 Dimension 5-Level score, global satisfaction scores, and the incidence of device or procedure-related adverse events. The primary analysis of study endpoints will occur three months post-treatment. Patient follow-up in this study will continue for two years. Conclusions A central institutional review board approved the study protocol, and a data safety monitoring board will provide study oversight. The authors plan to report study results at medical conferences and in peer-reviewed medical journals. The outcomes of ROBUST will provide physicians, patients, and payors with important safety and effectiveness data regarding the clinical utility of CTR-US when performed in an office setting.

Role of Hashtags in Educating and Promoting the Field of Hand Surgery on Social Media.

Purpose: This study identifies the hand surgery content being posted on Instagram, how hashtags are being used, and those posting to determine what is reaching the public. Methods: Top hand surgery-related hashtags on Instagram from June 2020 to August 2020 were identified by searching "hand surgery" and sorting by relevance. Hashtags were quantified by number and qualitatively assessed. Posts without a clear relationship were excluded. Hashtags relevant to hand surgery were analyzed by educational merit, medical specialty, patient or nonpatient, and demographics. Results: The top 25 hashtags contained 325,400 posts. The 3 hashtags with the highest number of posts were #carpaltunnel (64,700), #handsurgery (50,500), and #handtherapy (48,300). Most posts were educational (53.2%). Nonsurgical fields (66.5%) posted the most, followed by orthopedic (25.9%), and plastic hand surgeons (7.7%). Nonpatients (68.8%) posted more than patients. The top 3 languages of the posts were English (67.7%), Russian (9.4%), and Spanish (7.1%). However, when looking at the hashtags with more than half of the posts being made by hand surgeons, we observed that most (62.9%) of the posts were noneducational in content. Conclusions: Instagram posts on hand surgery topics are largely posted by nonexperts and are educational in content. There is a major opportunity for hand surgeons to educate and market effectively using hand surgery-related hashtags. Given the number of hand surgeries performed annually, one would hope to see more representation by hand surgeons on social media. More active participation and provision of educational content by specialists is warranted. Clinical relevance: There is an opportunity for hand surgeons to educate those searching upper extremity conditions and seeking out expertise in a domain where information is largely driven by nonsurgeons and the quality of information is not vetted. This study identifies the need for more hand surgeon involvement to expand knowledge and communication efforts within the specialty and with the public through the evolving world of social media.

Lessons Learned: Trapeziectomy and Suture Suspension Arthroplasty for Thumb Carpometacarpal Osteoarthritis.

In this study, we describe refinements of an accepted technique made by a single surgeon for trapeziectomy and suture suspension arthroplasty for thumb carpometacarpal (CMC) osteoarthritis after 220 cases over 4 years. Results are derived from 77 patients who underwent treatment using this technique comparing postoperative results with preoperative assessment and had sufficient data for inclusion. The surgical technique is described, including tips and modifications to avoid known possible complications. All patients in this study had advanced Eaton stage III or IV osteoarthritis. Grip strength and key pinch showed statistically significant improvement, and the improvement in palmar pinch approached significance. Pain scores were significantly decreased with over 50% of the patients rating their pain at 0 postoperatively. The overall complication rate was very low, and improvements in technique were made to mitigate future occurrence. This surgical technique for the treatment of thumb CMC arthritis achieved pain relief and recreated ligamentous support of the base of the first metacarpal to resist proximal migration after trapeziectomy, providing an increase in grip strength and key pinch with return of range of motion early in the postoperative period. Refinements on this technique through a large volume single surgeon experience provide technical tips for optimizing outcomes.

Novel insights into negative pressure wound healing from an in situ porcine perspective.

Negative pressure wound therapy (NPWT) is used clinically to promote tissue formation and wound closure. In this study, a porcine wound model was used to further investigate the mechanisms as to how NPWT modulates wound healing via utilization of a form of NPWT called the vacuum-assisted closure. To observe the effect of NPWT more accurately, non-NPWT control wounds containing GranuFoam™ dressings, without vacuum exposure, were utilized. In situ histological analysis revealed that NPWT enhanced plasma protein adsorption throughout the GranuFoam™, resulting in increased cellular colonization and tissue ingrowth. Gram staining revealed that NPWT decreased bacterial dissemination to adjacent tissue with greater bacterial localization within the GranuFoam™. Genomic analysis demonstrated the significant changes in gene expression across a number of genes between wounds treated with non-NPWT and NPWT when compared against baseline tissue. However, minimal differences were noted between non-NPWT and NPWT wounds, including no significant differences in expression of collagen, angiogenic, or key inflammatory genes. Similarly, significant increases in immune cell populations were observed from day 0 to day 9 for both non-NPWT and NPWT wounds, though no differences were noted between non-NPWT and NPWT wounds. Furthermore, histological analysis demonstrated the presence of a foreign body response (FBR), with giant cell formation and encapsulation of GranuFoam™ particles. The unique in situ histological evaluation and genomic comparison of non-NPWT and NPWT wounds in this pilot study provided a never-before-shown perspective, offering novel insights into the physiological processes of NPWT and the potential role of a FBR in NPWT clinical outcomes.

Optimizing Tourniquet Pressure in Upper Extremity Surgery.

Background: Pneumatic tourniquet is an effective tool to achieve hemostatic control of the surgical field in upper extremity (UE) operations. Elevated pressures have been associated with adverse effects despite various methods of pressure determination. We aim to demonstrate the usage of reduced tourniquet pressures and examine factors associated with achieving reduced pressures. Methods: A prospective study was conducted (2016-2018) at a Level 1 Trauma Center and an Outpatient Surgical Center, totaling 226 operations, involving a reduction of cuff pressures over time from a standard baseline of limb occlusion pressure for UE operations. Results: A gradual reduction of pressures was successfully achieved with a mean pressure of 187 mmHg and average time of tourniquet application being 25 minutes. We found chronological surgical number and patient BMI to be significantly associated with tourniquet pressure (p < 0.05). 4.5% of cases resulted in breakthrough bleeding, but did not reliably occur with any pressure thresholds, patient demographics, or operative factors (p > 0.05, for all). Conclusions: Reduced tourniquet pressures can mitigate complications associated with tourniquet use. Our research shows reduced pressures are successful in maintaining field visibility and we encourage an adoption of pressures below 200 mm Hg in most procedures that require a tourniquet.

Promoting Gender Equity in the #MeToo Era.

The recent #MeToo movement in social media has brought the important issue of gender-based violence and harassment in the workplace to the forefront of public attention. As in other fields, gender-based discrimination and sexual harassment continue to be a problem in medicine, and gender inequalities are particularly apparent in surgical specialties. Whereas the #MeToo movement has successfully raised awareness and held some perpetrators accountable, there have been unintended backlashes, including reluctance from some male surgeons to mentor female surgeons for fear of false accusations of sexual misconduct at both the trainee and the faculty levels. Gender-based neglect is harmful to the career advancement of female surgeons and threatens to continue to promote gender inequalities in surgery. We propose systems-level strategies to promote gender equity at the academic-training level and within the field of hand surgery.

Modulatory effects of connexin-43 expression on gap junction intercellular communications with mast cells and fibroblasts.

The influence of mast cells upon aberrant wound repair and excessive fibrosis has supportive evidence, but the mechanism for these mast cell activities is unclear. It is proposed that heterocellular gap junction intercellular communication (GJIC) between fibroblasts and mast cells directs some fibroblast activities. An in vitro model was used employing a rodent derived peritoneal mast cell line (RMC-1) and human dermal derived fibroblasts. The influence of the expression of the gap junction channel structural protein, connexin 43 (Cx-43) on heterocellular GJIC, the expression of microtubule ß-tubulin and microfilament α smooth muscle actin (SMA) were investigated. The knockdown of Cx-43 by siRNA in RMC-1 cells completely blocked GJIC between RMC-1 cells. SiRNA knockdown of Cx-43 within fibroblasts only dampened GJIC between fibroblasts. It appears Cx-43 is the only expressed connexin (Cx) in RMC-1 cells. Fibroblasts express other Cxs that participate in GJIC between fibroblasts in the absence of Cx-43 expression. Heterocellular GJIC between RMC-1 cells and fibroblasts transformed fibroblasts into myofibroblasts, expressing α SMA within cytoplasmic stress fibers. The knockdown of Cx-43 in RMC-1 cells increased ß-tubulin expression, but its knockdown in fibroblasts reduced ß-tubulin expression. Knocking down the expression of Cx-43 in fibroblasts limited αSMA expression. Cx-43 participation is critical for heterocellular GJIC between mast cells and fibroblasts, which may herald a novel direction for controlling fibrosis.

Acoustic analysis of vocal development in a New World primate, the common marmoset (Callithrix jacchus).

In contrast to humans and songbirds, there is limited evidence of vocal learning in nonhuman primates. While previous studies suggested that primate vocalizations exhibit developmental changes, detailed analyses of the extent and time course of such changes across a species' vocal repertoire remain limited. In a highly vocal primate, the common marmoset (Callithrix jacchus), we studied developmental changes in the acoustic structure of species-specific communication sounds produced in a social setting. We performed detailed acoustic analyses of the spectral and temporal characteristics of marmoset vocalizations during development, comparing differences between genders and twin pairs, as well as with vocalizations from adult marmosets residing in the same colony. Our analyses revealed significant changes in spectral and temporal features as well as variability of particular call types over time. Infant and juvenile vocalizations changed progressively toward the vocalizations produced by adult marmosets. Call types observed early in development that were unique to infants disappeared gradually with age, while vocal exchanges with conspecifics emerged. Our observations clearly indicate that marmoset vocalizations undergo both qualitative and quantitative postnatal changes, establishing the basis for further studies to delineate contributions from maturation of the vocal apparatus and behavioral experience.

Calcinosis circumscripta in a common marmoset (Callithrix jacchus jacchus).

A 2.5-y-old, male common marmoset (Callithrix jacchus jacchus) developed a 2-cm, interscapular, subcutaneous mass with variably firm and cystic areas. Radiographs demonstrated a radiodense mass in close proximity to a previously implanted microchip. Fine-needle aspiration yielded a chalky liquid that, on cytologic examination, contained amorphous debris. Aerobic and anaerobic cultures were negative. Surgical excision required extensive dissection, with the mass infiltrating deep to the scapula and extending to the mammary gland. The mass weighed 30 g and comprised 10% of the animal's body weight. Microscopic examination demonstrated multifocal, variably sized, amorphous aggregates of granular, basophilic material (mineral) in the subcutis and extending to skeletal muscle. Mineral deposits were surrounded by macrophages, giant cells, and fibrous connective tissue. A focal area of ectopic bone production was present. Crystallographic analysis and x-ray diffractometry determined the material to be comprised of 100% hydroxyapatite. These findings were consistent with a diagnosis of calcinosis circumscripta. Systemic metabolic abnormalities were excluded based on examination of complete blood count, serum chemistry, and ionized calcium. Calcinosis circumscripta in the common marmoset has not previously been reported, although the lesion has been reported to occur in rhesus macaques and is well described in man and dogs. Accumulation of calcium deposits and production of ectopic bone in a marmoset is interesting in light of this species's unique calcium and vitamin D metabolism.

A modified technique for high-resolution staining of myelin.

This report describes a new modification of the Gallyas method for staining myelin in fixed brain tissue and compares results of multiple myelin-visualizing techniques in normal common marmoset (Callithrix jacchus), normal macaque monkey (Macaca mulatta), and a human with multiple sclerosis. The new modification involves immersion in 10% formalin following impregnation in ammoniacal silver nitrate, and the use of a low concentration of 4% paraformaldehyde in the developer. This improved technique is less sensitive to post-mortem tissue handling, temperature, and minor contaminants, allowing a more straightforward implementation in the laboratory setting. It permits simple user-controlled development of the reaction product to maximize contrast in the area of interest, resulting in high contrast staining not only of large axonal bundles, but also thin fascicles throughout tissue sections. Myelin staining in visual cortex of an Old World monkey and a New World monkey reveals similar patterns in the new myelin silver stain, the Gallyas stain, and myelin basic protein immunohistochemistry. The most heavily myelinated areas occupy the edges of blobs, but neither the most lightly stained nor the most darkly stained areas are always in our outside a blob. This indicates a more complex pattern between myelinated axons and blobs than previously suggested. While the new myelin silver stain, darkfield microscopy, the Luxol Fast Blue stain, the Gallyas stain, and myelin basic protein immunohistochemistry all permit visualization of myelin in the CNS, each technique has its own merits and pitfalls; careful evaluation of individual study requirements would best determine which methods are the most useful.

Septicemia and peritonitis in a colony of common marmosets (Callithrix jacchus) secondary to Klebsiella pneumoniae infection.

Six common marmosets from a colony of 50 died over a period of 3 weeks, with the predominant finding of gram-negative bacterial septicemia. Four of these animals died peracutely; the other two were found when they were moribund, and they subsequently died despite clinical intervention. Gram-negative bacterial rods were present in the blood vessels of stained tissues from five of the six marmosets. Three marmosets also had severe fibrinopurulent peritonitis. In addition, one of the marmosets with peritonitis also had purulent mesenteric lymphadenitis with large colonies of gram-negative bacterial rods within dialated colonic crypts. Klebsiella pneumoniae was isolated from multiple organs in three of the marmosets. Clinical evaluation of the entire colony identified four marmosets with anorexia, nasopharyngeal discharge and diarrhea. These marmosets were treated with enrofloxacin immediately, and they responded well. K. pneumonia could not be cultured from nasal or fecal samples obtained from the colony animals. Because of the peracute nature of the disease, animals often die before exhibiting clinical symptoms, and antibiotics are seldom helpful. In this outbreak we saw both of the major forms of Klebsiella infection in common marmosets: the peracute form with bacteremia and minimal inflammatory reaction around blood vessels, and the chronic form with bacteremia, fibrinopurulent peritonitis, and mesenteric lymphadenitis.