Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play.

PURPOSE: This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes. METHODS: NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded. RESULTS: There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position. CONCLUSIONS: Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Neuropeptide Y modulates excitatory synaptic transmission and promotes social behavior in the mouse nucleus accumbens.

Social interactions define the human experience, but these integral behaviors are disrupted in many psychiatric disorders. Social behaviors have evolved over millennia, and neuromodulatory systems that promote social behavior in invertebrates are also present in mammalian brains. One such conserved neuromodulator, neuropeptide Y (NPY), acts through several receptors including the Y1r, Y2r, and Y5r. These receptors are present in brain regions that control social behavior, including the nucleus accumbens (NAc). However, whether NPY modulates NAc neurotransmission is unknown. Using whole-cell patch-clamp electrophysiology of NAc neurons, we find that multiple NPY receptors regulate excitatory synaptic transmission in a cell-type specific manner. At excitatory synapses onto D1+ MSNs, Y1r activity enhances transmission while Y2r suppresses transmission. At excitatory synapses onto D1- MSNs, Y5r activity enhances transmission while Y2r suppresses transmission. Directly infusing NPY or the Y1r agonist [Leu31, Pro34]-NPY into the NAc significantly increases social interaction with an unfamiliar conspecific. Inhibition of an enzyme that breaks down NPY, dipeptidyl peptidase IV (DPP-IV), shifts the effect of NPY on D1+ MSNs to a Y1r dominated phenotype. Together, these results increase our understanding of how NPY regulates neurotransmission in the NAc and identify a novel mechanism underlying the control of social behavior. Further, they reveal a potential strategy to shift NPY signaling for therapeutic gain.

Preoperative and Postoperative Imaging of Scapholunate Ligament Primary Repair and Modified Brunelli Reconstruction.

Injury of the scapholunate ligament (SLL) complex can lead to scapholunate dissociation, characterized by scapholunate interval widening and volar rotary subluxation of the scaphoid. Loss of the mechanical linkage between the scaphoid and lunate results in carpal instability and eventual scapholunate advanced collapse (SLAC) arthropathy. SLL complex injuries vary from acute and traumatic to chronic and degenerative. A staging system can be used to guide treatment options for these injuries on the basis of the reparability of the SLL dorsal band, carpal alignment and malalignment reducibility, and cartilage damage. Preoperative imaging with radiography and MRI is a component of injury staging and aids in planning surgical procedures. If the SLL dorsal band is reparable, then direct primary ligament repair with dorsal capsulodesis or dorsal intercarpal (DIC) ligament transfer can be performed. If the SLL dorsal band is irreparable with normal alignment or reducible malalignment, then reconstruction can be performed. In the setting of irreducible malalignment or SLAC arthropathy, a salvage procedure can be performed. Knowledge of SLL primary repair and various reconstruction techniques is important not only when evaluating postoperative images but also for accurate description of SLL injuries and aiding the surgeon in treatment planning. The authors present the normal anatomy of the SLL complex, a staging classification of SLL injury with radiographic and MRI findings, and common surgical procedures. Special attention is given to the operative techniques and postoperative imaging appearances of primary SLL repair with DIC ligament transfer and modified Brunelli reconstruction. ©RSNA, 2021.

The orthopedic characterization of Goltz syndrome.

Focal dermal hypoplasia (FDH), also known as Goltz syndrome, is a rare condition in which congenital anomalies result in a multitude of defects that affect many systems of the body. These defects can involve the eyes, skin, teeth, and cardiovascular, skeletal, and gastrointestinal systems. There have been many associated abnormalities reported in the literature. An appreciation of the clinical presentation of Goltz syndrome is important because physicians rely heavily on recognition of key physical characteristics in order to help make a diagnosis. In this report, we summarize the clinical findings observed when we were afforded the unique opportunity to interview and physically examine 19 patients, the largest group of individuals with Goltz syndrome brought together in one place to date. The findings are intended to characterize the orthopedic phenotypic manifestations of Goltz syndrome. This collection of data revealed that the most common orthopedic findings were syndactyly (68%), ectrodactyly (68%), leg length discrepancy (57%), and reduction defects of long bones (52%). Nail irregularities were present in 89% of the patients seen.

Biomechanical Comparison of Volar Fixed-Angle Locking Plates for AO C3 Distal Radius Fractures: Titanium Versus Stainless Steel With Compression.

PURPOSE: To determine biomechanical differences between a fixed-angle locking volar titanium plate (VariAx; Stryker, Kalamazoo, MI) and a fixed-angle compression locking volar stainless steel plate (CoverLoc Volar Plate; Tornier, Amsterdam, Netherlands) in the fixation of simulated AO C3 distal radius fractures. METHODS: Eighteen cadaveric upper extremities (9 matched pairs) with an average age of 54 years were tested. A 4-part AO C3 fracture pattern was created in each specimen. The fractures were reduced under direct vision and fixed with either the fixed-angle locking volar titanium plate or the fixed-angle compression locking volar stainless steel plate. Motion tracking analysis was then performed while the specimens underwent cyclic loading. Changes in displacement, rotation, load to failure, and mode of failure were recorded. RESULTS: The fragments, when secured with the fixed-angle compression locking stainless steel construct, demonstrated less displacement and rotation than the fragments secured with the fixed-angle locking titanium plate under physiological loading conditions. In the fixed-angle compression locking stainless steel group, aggregate displacement and rotation of fracture fragments were 5 mm and 3° less, respectively, than those for the fixed-angle locking titanium group. The differences between axial loads at mechanical failure and stiffness were not statistically significant. The compression locking stainless steel group showed no trend in mode of failure, and the locking titanium plate group failed most often by articular fixation failure (5 of 9 specimens). CONCLUSIONS: The fixed-angle compression locking stainless steel volar plate may result in less displacement and rotation of fracture fragments in the fixation of AO C3 distal radius fractures than fixation by the fixed-angle locking volar titanium plate. However, there were no differences between the plates in mechanical load to failure and stiffness. CLINICAL RELEVANCE: Fixation of distal radius AO C3 fracture patterns with the fixed-angle compression locking stainless steel plate may provide improved stability of fracture fragments.

The Perioperative Surgical Home: how can it make the case so everyone wins?

BACKGROUND: Varied and fragmented care plans undertaken by different practitioners currently expose surgical patients to lapses in expected care, increase the chance for operational mistakes and accidents, and often result in unnecessary care. The Perioperative Surgical Home has thus been proposed by the American Society of Anesthesiologists and other stakeholders as an innovative, patient-centered, surgical continuity of care model that incorporates shared decision making. Topics central to the debate about an anesthesiology-based Perioperative Surgical Home include: holding the gains made in anesthesia-related patient safety; impacting surgical morbidity and mortality, including failure-to-rescue; achieving healthcare outcome metrics; assimilating comparative effectiveness research into the model; establishing necessary audit and data collection; a comparison with the hospitalist model of perioperative care; the perspective of the surgeon; the benefits of the Perioperative Surgical Home to the specialty of anesthesiology; and its associated healthcare economic advantages. DISCUSSION: Improving surgical morbidity and mortality mandates a more comprehensive and integrated approach to the management of surgical patients. In their expanded capacity as the surgical patient's "perioperativist," anesthesiologists can play a key role in compliance with broader set of process measures, thus becoming a more vital and valuable provider from the patient, administrator, and payer perspective. The robust perioperative databases created within the Perioperative Surgical Home present new opportunities for health services and population-level research. The Perioperative Surgical Home is not intended to replace the surgeon's patient care responsibility, but rather leverage the abilities of the entire perioperative care team in the service of the patient. To achieve this goal, it will be necessary to expand the core knowledge, skills, and experience of anesthesiologists. Anesthesiologists will need to view becoming perioperative physicians as an expansion of the specialty, rather than an abdication of their traditional intraoperative role. The Perioperative Surgical Home will need to create strategic added value for a health system and payers. This added value will strengthen the position of anesthesiologists as they navigate and negotiate in the face of finite, if not decreasing fiscal resources. SUMMARY: Broadening the anesthesiologist's scope of practice via the Perioperative Surgical Home may promote standardization and improve clinical outcomes and decrease resource utilization by providing greater patient-centered continuity of care throughout the preoperative, intraoperative, and postoperative periods.

A simple technique for augmentation of axonal ingrowth into chondroitinase-treated acellular nerve grafts using nerve growth factor.

BACKGROUND AND PURPOSE: Improvement in axonal regeneration may lead to the development of longer nerve grafts and improved outcomes for patients with peripheral nerve injury. Although the use of acellular nerve grafts has been well documented (Groves et al, Exp Neurol. 2005;195:278-292; Krekoski et al, J Neurosci. 2001;21:6206-6213; Massey et al, Exp Neurol. 2008;209:426-445; Neubauer et al, Exp Neurol. 2007;207:163-170; Zuo et al, Exp Neurol. 2002;176:221-228), less is known about the ability of neurotrophic factors to enhance axonal regeneration. This study evaluates axonal ingrowth augmentation using acellular, chondroitinase-treated nerve grafts doped with nerve growth factor (NGF). METHODS: Acellular chondroitinase-treated murine nerve grafts were placed in experimental (NGF-treated grafts) and control (carrier-only grafts) rats. Five days after implantation, axonal regeneration was assessed by immunocytochemistry along with digital image analysis. RESULTS: Higher axon count was observed throughout the length of the nerve in the NGF group (P < 0.0001), peaking at 3 mm from proximal repair (P = 0.02). Although the NGF group displayed a higher axon count per slice, the mean diameter of individual NGF axons was smaller (P < 0.0001), potentially consistent with induction of sensory axons (Rich et al, J Neurocytol. 1987;16:261-268; Sofroniew et al, Annu Rev Neurosci. 2001;24:1217-1128; Yip et al, J Neurosci. 1984;4:2986-2992). CONCLUSION: The simple technique of doping acellular, chondroitinase-treated nerve grafts with NGF can augment axonal ingrowth and possibly preferentially induce sensory axons.

Evaluation of FiberLoop sutures in locking and nonlocking tendon repair.

UNLABELLED: The FiberLoop suture has been developed as a double stranded, double-armed suture of FiberWire, but has not been previously studied. This is a comparison study of FiberLoop, FiberWire, and Ethibond. METHODS: Six groups of bovine tendons were randomly sorted for testing. They were cut and repaired using FiberWire, FiberLoop, and Ethibond with modified Kessler and modified Krackow repair techniques. A 4-0 core suture was used and tested to failure. RESULTS: Both FiberLoop and FiberWire were significantly stronger than Ethibond regardless of the repair technique used. There was no difference between the nonlocking and locking repair technique in any of the suture groups. However, the nonlocking technique failed by tissue pull through while the locking technique failed by suture breakage. CONCLUSIONS: The FiberLoop suture and the FiberWire suture were significantly stronger than the Ethibond suture. Additionally, this study shows that the 4-0 suture is of adequate strength to repair a tendon injury. The double-armed Fiberloop may translate into quicker tendon repairs without sacrificing strength.

Medical errors in orthopaedics. Results of an AAOS member survey.

BACKGROUND: There has been widespread interest in medical errors since the publication of To Err Is Human: Building a Safer Health System by the Institute of Medicine in 2000. The Patient Safety Committee of the American Academy of Orthopaedic Surgeons has compiled the results of a member survey to identify trends in orthopaedic errors that would help to direct quality assurance efforts. METHODS: Surveys were sent to 5540 Academy fellows, and 917 were returned (a response rate of 16.6%), with 53% (483) reporting an observed medical error in the previous six months. RESULTS: A general classification of errors showed equipment (29%) and communication (24.7%) errors with the highest frequency. Medication errors (9.7%) and wrong-site surgery (5.6%) represented serious potential patient harm. Two deaths were reported, and both involved narcotic administration errors. By location, 78% of errors occurred in the hospital (54% in the surgery suite and 10% in the patient room or floor). The reporting orthopaedic surgeon was involved in 60% of the errors; a nurse, in 37%; another orthopaedic surgeon, in 19%; other physicians, in 16%; and house staff, in 13%. Wrong-site surgeries involved the wrong side (59%); another wrong site, e.g., the wrong digit on the correct side (23%); the wrong procedure (14%); or the wrong patient (5% of the time). The most frequent anatomic locations were the knee and the fingers and/or hand (35% for each), the foot and/or ankle (15%), followed by the distal end of the femur (10%) and the spine (5%). CONCLUSIONS: Medical errors continue to occur and therefore represent a threat to patient safety. Quality assurance efforts and more refined research can be addressed toward areas with higher error occurrence (equipment and communication) and high risk (medication and wrong-site surgery).

Treating trigger finger in diabetics using excision of the ulnar slip of the flexor digitorum superficialis with or without A1 pulley release.

The purpose of this study was to evaluate the results of excision of the ulnar slip of the flexor digitorum superficialis tendon, with or without A1 pulley release, for the treatment of trigger finger in diabetic patients. We performed a retrospective review with long-term follow-up examinations. Short-term data was obtained on 18 consecutive patients (37 fingers). Long-term information was collected on 14 of these patients (24 fingers) at an average of 48 months after surgery. Short-term follow-up revealed average proximal interphalangeal joint (PIP) flexion of 81 degrees . One patient had slight residual triggering. At long-term follow-up, 93% of patients were completely or very satisfied with the procedure. Total active finger motion averaged 218 degrees , and PIP extension deficit averaged less than 5 degrees . Pinch strength was equal to the contralateral corresponding finger. There were no significant complications. One finger had minimal residual triggering. In conclusion, this procedure is a safe and effective treatment for the often-difficult problem of stenosing flexor tenosynovitis in the diabetic patient.

Degenerative and post-traumatic arthritis affecting the carpometacarpal joints of the fingers.

Symptomatic post-traumatic arthritis affecting the finger CMC joints is less common than might otherwise be expected based on the frequency of injury, especially to the fifth CMC joint. For the fifth CMC joint, the shallow concavoconvex articulation combined with the typical fracture location may provide a protective effect. Non-operative measures are typically successful, except in cases of missed fracture/dislocations and symptomatic joint instability. In these instances, re-construction emphasizes stability first, with an eye toward mobility for the ulnar column. It is common to detect a bony prominence in the region of the dorsal second and third CMC joints during examination of the hand. In most instances, the projection is asymptomatic and likely represents an os styloideum [18]. When painful and unresponsive to nonoperative treatments, this carpometacarpal boss can be excised surgically.

Comparing and contrasting methods for tenodesis of the ruptured distal biceps tendon.

The evidence is clear that anatomic reinsertion is the best treatment for an active, compliant patient with an acute distal biceps rupture or a subacute rupture without significant proximal retraction of the tendon. Patients with partial tears and chronic ruptures require surgical attention when persistently symptomatic. Biceps tenodesis through dual incisions or a single anterior incision is a safe, highly reliable, and effective operation. The posterior interosseous nerve is potentially at risk with either approach. This risk is minimized by avoiding exposure and retraction of the nerve. Heterotopic ossification and subsequent proximal radio-ulnar synostosis are reported complications of the two-incision technique. The incidence of this devastating complication has been reduced, but not eliminated, by using a limited posterior forearm muscle-splitting incision and by not exposing the ulna. It is the authors' belief that a single anterior incision with suture anchor fixation of the distal biceps (in the manner described herein) is the surgical treatment of choice for most distal biceps ruptures. Compared with the two-incision method, the posterior interosseous nerve is at no more risk and the chance of heterotopic ossification is diminished. The secure fixation obtained and the limited surgical exposure required allow for early mobilization and rapid return of function.

Effect of rofecoxib on the pharmacokinetics of chronically administered oral contraceptives in healthy female volunteers.

The effect of rofecoxib, a highly selective cyclooxygenase (COX)-2 inhibitor, on the pharmacokinetics of ethinyl estradiol (EE) and norethindrone (NET), two common components of a combination oral contraceptive product, was examined. A double-blind, two-period crossover study was conducted in 18 healthy women who received ORTHO-NOVUM 1/35, a combination of EE (35 microg) and NET (1 mg), concurrently for 14 days with either 175 mg rofecoxib or matching placebo during two consecutive menstrual cycles. Plasma was sampled for EE, NET, sex hormone binding globulin (SHBG), and albumin. The AUC(0-24 h) geometric mean ratio (GMR: rofecoxib/placebo) with corresponding 90% confidence interval (CI) of EE and NET was 1.13 (1.06, 1.19) and 1.18 (1.13, 1.24), respectively. The Cmax GMR of EE and NET was 1.06 (0.98, 1.16) and 1.04 (0.99, 1.09), respectively. In each case, the 90% CIs satisfied the predefined bioequivalence limits of (0.80, 1.25). Measures of SHBG and albumin and routine clinical and laboratory safety parameters showed no clinically meaningful changes. The addition of rofecoxib to the oral contraceptive was not associated with any clinically important changes in EE or NET pharmacokinetics and thus would not be anticipated to influence the efficacy of this contraceptive regimen.