Publications by authors named "Amin Mohamadi"

38 Publications

The effect of surgeon-controlled variables on construct stiffness in lateral locked plating of distal femoral fractures.

BMC Musculoskelet Disord 2021 Jun 4;22(1):512. Epub 2021 Jun 4.

Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Isreal Deconess Medical Center, 330 Brookline Ave, MA, 02215, Boston, USA.

Background: Nonunion following treatment of supracondylar femur fractures with lateral locked plates (LLP) has been reported to be as high as 21 %. Implant related and surgeon-controlled variables have been postulated to contribute to nonunion by modulating fracture-fixation construct stiffness. The purpose of this study is to evaluate the effect of surgeon-controlled factors on stiffness when treating supracondylar femur fractures with LLPs: 1. Does plate length affect construct stiffness given the same plate material, fracture working length and type of screws? 2. Does screw type (bicortical locking versus bicortical nonlocking or unicortical locking) and number of screws affect construct stiffness given the same material, fracture working length, and plate length? 3. Does fracture working length affect construct stiffness given the same plate material, length and type of screws? 4. Does plate material (titanium versus stainless steel) affect construct stiffness given the same fracture working length, plate length, type and number of screws?

Methods: Mechanical study of simulated supracondylar femur fractures treated with LLPs of varying lengths, screw types, fractureworking lenghts, and plate/screw material. Overall construct stiffness was evaluated using an Instron hydraulic testing apparatus.

Results: Stiffness was 15 % higher comparing 13-hole to the 5-hole plates (995 N/mm849N vs. /mm, p = 0.003). The use of bicortical nonlocking screws decreased overall construct stiffness by 18 % compared to bicortical locking screws (808 N/mm vs. 995 N/mm, p = 0.0001). The type of screw (unicortical locking vs. bicortical locking) and the number of screws in the diaphysis (3 vs. 10) did not appear to significantly influence construct stiffness (p = 0.76, p = 0.24). Similarly, fracture working length (5.4 cm vs. 9.4 cm, p = 0.24), and implant type (titanium vs. stainless steel, p = 0.12) did also not appear to effect stiffness.

Discussion: Using shorter plates and using bicortical nonlocking screws (vs. bicortical locking screws) reduced overall construct stiffness. Using more screws, using unicortical locking screws, increasing fracture working length and varying plate material (titanium vs. stainless steel) does not appear to significantly alter construct stiffness. Surgeons can adjust plate length and screw types to affect overall fracture-fixation construct stiffness; however, the optimal stiffness to promote healing remains unknown.
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http://dx.doi.org/10.1186/s12891-021-04341-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176588PMC
June 2021

Treatment modalities and outcomes following acetabular fractures in the elderly: a systematic review.

Eur J Orthop Surg Traumatol 2021 Jun 2. Epub 2021 Jun 2.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Purpose: The treatment of geriatric acetabular fractures remains controversial. Treatment options include nonoperative management, open reduction and internal fixation (ORIF), total hip arthroplasty (THA) with or without internal fixation, and closed reduction with percutaneous pinning (CRPP). There is currently no consensus on the optimal treatment strategy for geriatric patients with acetabular fractures. The purpose of this study is to compare adverse event rates, functional and radiographic outcomes, and intraoperative results between the various treatment modalities in order to help guide surgical decision making.

Methods: We performed a systematic review (registration number CRD42019124624) of observational and comparative studies including patients aged ≥ 55 with acetabular fractures.

Results: Thirty-eight studies including 3,928 patients with a mean age of 72.6 years (range 55-99 years) and a mean follow-up duration of 29.4 months met our eligibility criteria. The pooled mortality rate of all patients was 21.6% (95% confidence interval [CI] 20.9-22.4%) with a mean time to mortality of 12.6 months, and the pooled non-fatal complication rate was 24.7% (95% CI 23.9-25.5%). Patients treated with ORIF had a significantly higher non-fatal complication rate than those treated with ORIF + THA, THA alone, CRPP, or nonoperative management (odds ratios [ORs] 1.87, 2.24, 2.15, and 4.48, respectively; p < 0.01). Patients that underwent ORIF were significantly less likely to undergo subsequent THA than these treated with CRPP (OR 0.49, 95% CI 0.32-0.77) but were more likely to require THA than patients treated nonoperatively (OR 6.81, 95% CI 4.63-10.02).

Conclusion: Elderly patients with acetabular fractures tend to have favorable functional outcomes but suffer from high rates of mortality and complications. In patients treated with internal or percutaneous fixation, there was a high rate of conversion to THA. When determining surgical treatment in this population, THA alone or concurrent with ORIF should be considered given the significantly lower rate of non-fatal complications and similar mortality rate. Nonoperative management remains a viable option and was associated with the lowest non-fatal complication rate.

Level Of Evidence: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00590-021-03002-3DOI Listing
June 2021

Modifiable lifestyle factors associated with fragility hip fracture: a systematic review and meta-analysis.

J Bone Miner Metab 2021 May 15. Epub 2021 May 15.

Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, RN115, Boston, MA, 02215, USA.

Introduction: Among the various hip fracture predictors explored to date, modifiable risk factors warrant special consideration, since they present promising targets for preventative measures. This systematic review and meta-analysis aims to assess various modifiable risk factors.

Material And Methods: We searched four online databases in September 2017. We included studies that reported on modifiable lifestyle risk factors for sustaining fragility hip fractures. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). The inclusion criteria consisted of (1) adult patients with osteoporotic hip fracture, (2) original study, (3) availability of full text articles in English, and (4) report of a modifiable lifestyle risk factor.

Results: Thirty-five studies, containing 1,508,366 subjects in total, were included in this study. The modifiable risk factors that were significantly associated with an increased risk of hip fracture were the following: weight < 58 kg (128 lbs) (pooled OR 4.01, 95% CI 1.62-9.90), underweight body mass index (BMI) (< 18.5) (pooled OR 2.83, 95% CI 1.82-4.39), consumption of ≥ 3 cups of coffee daily (pooled OR 2.27, 95% CI 1.04-4.97), inactivity (pooled OR 2.14, 95% CI 1.21-3.77), weight loss (pooled OR 1.88, 95% CI 1.32-2.68), consumption of ≥ 27 g (approx. > 2 standard drinks) alcohol per day (pooled OR 1.54, 95% CI 1.12-2.13), and being a current smoker (pooled OR 1.50, 95% CI 1.22-1.85). Conversely, two factors were significantly associated with a decreased risk of hip fracture: obese BMI (> 30) (pooled OR 0.58, 95% CI 0.34-0.99) and habitual tea drinking (pooled OR 0.72, 95% CI 0.66-0.80).

Conclusion: Modifiable factors may be utilized clinically to provide more effective lifestyle interventions for at risk populations. We found that low weight and underweight BMI carried the highest risk, followed by high coffee consumption, inactivity, weight loss, and high daily alcohol consumption.
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http://dx.doi.org/10.1007/s00774-021-01230-5DOI Listing
May 2021

Does a Patient's Approach to Achieving Goals Influence His or Her Recovery Trajectory After Musculoskeletal Illness?

Clin Orthop Relat Res 2020 Sep;478(9):2067-2076

A.-M. Vranceanu, M. Reichman, R. A. Mace, Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

Background: The regulatory focus theory posits that, in general, people tend to be predominantly "promotion focused" or "prevention focused", and each individual's values and motivations influence which approach he or she may use when pursuing personal goals. People who are primarily promotion focused mostly see goals as opportunities to gain or advance (that is, play to win); people who are prevention focused mostly see goals as opportunities to stay safe (that is, play not to lose). Understanding the role of regulatory focus in the recovery of patients with orthopaedic conditions could provide novel insight into how surgeons can best communicate with patients to improve how they recover from illness or injury.

Question/purpose: Are improvements in pain intensity and disability over 6 months associated with a patient's levels of promotion focus or prevention focus?

Methods: In this longitudinal observational study, we enrolled 144 patients with an upper extremity orthopaedic illness at a tertiary teaching hospital and followed them for 6 months. At baseline, patients completed validated self-reported measures of regulatory focus (Regulatory Focus Questionnaire), pain (Numerical Rating Scale), disability (the QuickDASH), and demographics. Assessments were repeated 6 months later, with 76% (110 of 144) of patients completing follow-up assessments. We examined whether regulatory focus was associated with recovery outcomes (level of pain and disability at 6 months). The patient's regulatory focus was graded as two numerical scores on separate promotion-focus and prevention-focus continuums. Each individual received a score on promotion focus and one on prevention focus..

Results: An individual's level of promotion (ΔR = 0.021; p = 0.03; small effect size), but not his or her level of prevention (ΔR = 0.003; p = 0.35; negligible effect size), was associated with improvement in disability over a 6-month period (R = 0.61; p < 0.001). Patients with high promotion (n = 20, b = 0.284; p = 0.001) had the greatest improvements in disability after 6 months compared with patients with moderate (n = 73, b = 0.422; p < 0.001) or low (n = 17, b = 0.561; p < 0.001) promotion. The levels of promotion (b = -0.22; p = 0.09) and prevention (b = -0.04; p = 0.65) were not associated with pain over time.

Conclusions: To support improvements in disability for patients with upper extremity orthopaedic conditions, surgeons' communication strategies, including explanations of diagnoses and recovery trajectories, should focus on increasing patients' level of promotion (for example, by emphasizing gains and promoting positive thinking), rather than prevention (for example, by providing reassurance and problem-solving what might go wrong).

Level Of Evidence: Level II, prognostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431226PMC
September 2020

Comparison of surgical and non-surgical treatments for 3- and 4-part proximal humerus fractures: A network meta-analysis.

Shoulder Elbow 2020 Apr 28;12(2):99-108. Epub 2019 Feb 28.

Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital; Harvard Medical School, Boston, USA.

Introduction: Common treatment strategies for proximal humerus fractures include non-surgical treatment, open reduction internal fixation, hemiarthroplasty, and reverse total shoulder arthroplasty. There is currently no consensus regarding the superiority of any one surgical strategy. We used network meta-analysis of randomized controlled trials to determine the most successful treatment for proximal humerus fractures.

Methods: MEDLINE, EMBASE, Web of Science, and Cochrane Central electronic databases were searched for randomized controlled trials comparing 3- and 4-part proximal humerus fracture treatments. Data extraction included the mean and standard deviation of clinical outcomes (Constant, DASH), adverse events, and additional surgery rates. Standard Mean Difference was used to compare clinical outcome scores, and pooled risk ratios were used to compare adverse events and additional surgeries.

Results: Eight randomized controlled trials were included for network meta-analysis. Non-surgical treatment was associated with a lower rate of additional surgery and adverse events compared to open reduction internal fixation. Reverse total shoulder arthroplasty resulted in fewer adverse events and a better clinical outcome score than hemiarthroplasty. Non-surgical treatment produced similar clinical scores, adverse event rates, and additional surgery rates to hemiarthroplasty and reverse total shoulder arthroplasty.

Conclusion: Non-surgical treatment results in fewer complications and additional surgeries compared to open reduction internal fixation. Preliminary data supports reverse total shoulder arthroplasty over hemiarthroplasty, but more evidence is needed to strengthen this conclusion.
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http://dx.doi.org/10.1177/1758573219831506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7153210PMC
April 2020

Medications as a Risk Factor for Fragility Hip Fractures: A Systematic Review and Meta-analysis.

Calcif Tissue Int 2020 07 7;107(1):1-9. Epub 2020 Apr 7.

Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Fragility hip fractures and their associated morbidity and mortality pose a global healthcare problem. Several pharmaceutical products have been postulated to alter bone architecture and contribute to fragility hip fractures. We searched four electronic databases from inception to September 2017. Inclusion criteria were the following: (1) adult patients with fragility hip fractures, (2) full text in English, (3) minimum one-year follow-up, and (4) reporting of at least one risk factor. To minimize heterogeneity among the studies, we performed subgroup analyses. Whenever heterogeneity remained significant, we employed random effect meta-analysis for data pooling. Thirty-eight studies were included, containing 1,244,155 subjects and 188,966 cases of fragility hip fractures. Following medications were significantly associated with fragility hip fractures: Antidepressants (OR 2.07, 95% CI 1.98-2.17), antiparkinsonian drugs (OR 2.21, 95% CI 1.15-4.24), antipsychotic drugs (OR 2.0, 95% CI 1.50-2.66), anxiolytic drugs (OR 1.44, 95% CI 1.19-1.75), benzodiazepines (OR 1.84, 95% CI 1.26-2.69), sedatives (OR 1.33, 95% CI 1.14-1.54), systemic corticosteroids (OR 1.65, 95% CI 1.37-1.99), H antagonists (OR 1.21, 95% CI 1.18-1.24), proton pump inhibitors (OR 1.41, 95% CI 1.16-1.71), and thyroid hormone (OR 1.29, 95% CI 1.13-1.47). Hormone replacement therapy with estrogen (HRT) was associated with decreased risk of hip fracture (OR 0.80, 95% CI 0.65-0.98). There are several medications associated with sustaining a fragility hip fracture. Medical interventions should be considered for patients on these medications, including information about osteoporosis and fracture prevention.
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http://dx.doi.org/10.1007/s00223-020-00688-1DOI Listing
July 2020

Risk factors for developing acute compartment syndrome in the pediatric population: a systematic review and meta-analysis.

Eur J Orthop Surg Traumatol 2020 Jul 27;30(5):839-844. Epub 2020 Feb 27.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Purpose: Acute compartment syndrome (ACS) is often difficult to diagnose in pediatric patients due to their erratic symptomatology. Therefore, it is of paramount importance to identify at-risk patients to facilitate a prompt diagnosis. This study aims to identify risk factors for the development of ACS in the pediatric population.

Methods: We included studies comprised of pediatric patients with traumatic ACS. We excluded studies evaluating compartment syndrome secondary to exertion, vascular insult, abdominal processes, burns, and snake bites. Heterogeneity was addressed by subgroup analysis, and whenever it remained significant, we utilized a random-effects meta-analysis for data pooling. The protocol has been registered at PROSPERO (ID = CRD42019126603).

Results: We included nine studies with 380,411 patients, of which 1144 patients were diagnosed with traumatic ACS. The average age was 10 years old, and 67% of patients were male. Factors that were significantly associated with ACS were: open radius/ulna fractures (OR 3.56 CI 1.52-8.33, p = 0.003), high-energy trauma (OR 3.51 CI 1.71-7.21, p = 0.001), humerus fractures occurring concurrently with forearm fractures (OR 3.49 CI 1.87-6.52, p < 0.001), open tibia fractures (OR 2.29 CI 1.47-3.55, p < 0.001), and male gender (OR 2.06 CI 1.70-2.51, p < 0.001).

Conclusion: In the present study, open fractures, high-energy trauma, concurrent humerus and forearm fractures, and male gender significantly increased the risk of developing ACS in the pediatric population. Clinicians should raise their suspicion for ACS when one or multiple of these factors are present in the right clinical context.

Type Of Study: Systematic review and meta-analysis.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00590-020-02643-0DOI Listing
July 2020

Biomechanical properties of an intramedullary suture anchor fixation compared to tension band wiring in osteoporotic olecranon fractures- A cadaveric study.

J Orthop 2020 Jan-Feb;17:144-149. Epub 2019 Aug 7.

Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Introduction: The aim of the study is to compare three different fixation techniques for transverse olecranon repair in cadaveric osteoporotic bone: (1) current recommended AO tension band technique with K-wire fixation; (2) Suture anchor fixation and (3) Polyester suture fixation.

Methods: Evaluated with bone densitometry, 7 osteoporotic human elbow specimens were included in the study. A transverse olecranon fracture was reduced anatomically and were fixated first using a K-wire tension band technique, second using two suture anchors, and third using polyester suture. Static simulations of the kinetics associated with active range of motion (AROM) and push up from a chair exercises were performed with cyclic loading using Instron hydraulic testing apparatus. Fracture displacement was measured using videographic analysis. Failure was defined as 2 mm fracture displacement.

Results: The biomechanical analysis found no statistical difference in displacements between the three fixation methods when testing AROM. In simulated push-up exercises, polyester suture fixation failed after 17 cycles and had significantly higher displacement compared to the other two methods. No difference between the K-Wire fixation versus Suture anchor fixation was observed, p = 0.162.

Conclusion: Suture anchor fixation might be a viable surgical treatment option for osteoporotic transverse elbow fractures in geriatric patients.
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http://dx.doi.org/10.1016/j.jor.2019.08.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919365PMC
August 2019

Scaphoid Fracture Patterns-Part Two: Reproducibility and Demographics of a Simplified Scaphoid Fracture Classification.

J Wrist Surg 2019 Dec 12;8(6):446-451. Epub 2019 Jul 12.

Hand and Upper Extremity Surgery Unit, Lapeyronie University Hospital, Montpellier, France.

 To analyze the reproducibility, reliability, and demographics of a simplified anatomical scaphoid fracture classification based on posteroanterior radiographs using a large database of scaphoid fractures.  The study consisted of a retrospective review of electronic medical records of 871 consecutive patients. All patients presented between 2003 and 2014 at two centers. Patient- and surgeon-related factors were analyzed. Additionally, interobserver reliability of the Herbert and simplified scaphoid fracture classifications were tested.  Proximal pole fractures were defined as fractures in which the center of the fracture line was proximal to the distal scapholunate interval (n = 30), waist fractures (n = 802) were defined as fractures involving the scaphocapitate interval, and distal tubercle fractures (n = 39) were defined as fractures involving the scaphotrapeziotrapezoid (STT) interval. The interobserver reliability of the simplified classification was fair (κ = 0.37) as for the Herbert classification (κ = 0.31). The average doubt of the answers of the observers was 2.1 on a scale from 0 to 10 for the simplified classification and 3.6 for the Herbert classification (  < 0.05).  All complete fractures across the entire scaphoid distal to the scapholunate articulation and proximal to the STT joint can be classified as waist fractures; nonwaist scaphoid fractures are uncommon (6%) and have somewhat different presentations compared to waist fractures. Simplifying the fracture classification slightly improves interobserver reliability, although remaining fair, and significantly reduces doubt.  This is a Level III, prognostic study.
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http://dx.doi.org/10.1055/s-0039-1692470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892654PMC
December 2019

Scaphoid Fracture Patterns-Part One: Three-Dimensional Computed Tomography Analysis.

J Wrist Surg 2019 Dec 8;8(6):441-445. Epub 2019 Jul 8.

Department of Orthopedic Surgery, Academic Medical Center, Amsterdam, The Netherlands.

 Using three-dimensional (3D) computed tomography models of acute scaphoid fractures, we looked for differences between volumetric size of the fracture fragments, recognizable groups, or a shared common fracture area.  We studied 51 patients with an adequate computed tomography scan of an acute scaphoid fracture using 3D modeling. Fracture surfaces were identified and fragment volumetric size of the fracture fragments was measured. A principal component analysis was used to find groups. Density mapping was used to image probable common fracture areas in the scaphoid.  Forty-nine of 51 fractures had a similar pattern. It was not possible to identify subgroups based on fracture pattern. The mean volumetric size of the fracture fragments of the proximal (1.45 cm  ± 0.49 cm standard deviation [SD]) and distal fracture fragments (1.53 cm  ± 0.48 cm SD) was similar. There was a single common fracture area in the middle third of the bone. In the distal third, there were no horizontal fractures through-but only directly proximal to-the tubercle suggesting that these would be best classified as distal waist fractures.  Acute scaphoid fractures mainly occur in the middle third of the bone and tend to divide the scaphoid in half by volumetric size of the fracture fragments. There were two distinct grouping patterns: fractures through the proximal and middle third were horizontal oblique, whereas fractures of the distal third were vertical oblique. It seems that scaphoid fractures might be classified into proximal pole fractures, a range of waist fractures, and tubercle avulsion fractures.  This is a Level IV study.
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http://dx.doi.org/10.1055/s-0039-1693050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892660PMC
December 2019

Predicting factors of muscle necrosis in acute compartment syndrome of the lower extremity.

Injury 2020 Feb 16;51(2):522-526. Epub 2019 Nov 16.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States.

Background: Acute physiologic compartment syndrome (ACS) is a disorder of increased intra-compartmental pressure leading to decreased tissue perfusion and muscle necrosis. Tissue ischemia can result in irreversible muscle and nerve injury and requires urgent fasciotomy. The aim of this study was to determine the factors associated with the presence of necrotic muscle in patients undergoing leg fasciotomy.

Methods: This is a retrospective cohort study of all patients undergoing fasciotomies for ACS of the leg at two level 1 trauma centers from 2000 to 2015. We found 1,028 patients who underwent leg fasciotomies. We excluded ACS at other sites than the leg, the index fasciotomy performed at an outside institution, prophylactic fasciotomy with no clinical signs of ACS, and patients with inadequate medical records. A total of 357 patients were included in the final analysis. We used bivariate analysis to assess which explanatory variables are associated with the main outcome measure, the presence of necrotic muscle at fasciotomy. We used multivariable regression analysis to determine association accounting for any confounding.

Results: Of 357 cases of ACS of the leg, 14.6% of patients presented with an open fracture and 21.3% of patients were multiply injured. Overall, 14.3% of cases had muscle necrosis at the time of fasciotomy. Fifty-nine percent of patients with necrotic muscle required more than 3 debridements. Open fracture was the only statistically significant predictor of muscle necrosis (OR=2.8). Crush injury (OR=3.1) and soft tissue injuries (OR=2.8) were at an increased odds of necrotic muscle, but only marginally significant.

Conclusion: ACS is a potentially limb threatening condition often associated with poor outcomes, particularly when the diagnosis is delayed. Patients with open fracture have a three-fold increase in odds of necrotic muscle at the time of fasciotomy.
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http://dx.doi.org/10.1016/j.injury.2019.11.022DOI Listing
February 2020

Factors Associated with Requesting Magnetic Resonance Imaging during the Management of Glomus Tumors.

Arch Bone Jt Surg 2019 Sep;7(5):422-428

Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: The characteristic clinical presentation of glomus tumors and the low negative predictive value of the magnetic resonance imaging (MRI) raise the question whether MRI improves their management. Therefore, this study aimed to investigate whether MRI improved the management of glomus tumors.

Methods: In total, 87 patients with a histologically confirmed glomus tumor were treated over a 25-year period and analyzed retrospectively. Multivariable logistic regression analysis was used to evaluate the independent predictors of an MRI request during the management of glomus tumors.

Results: ccording to the results, the patients who were treated by orthopaedic surgeons were more likely to have an MRI during the management of a glomus tumor.

Conclusion: The role of an MRI during the management of a glomus tumor is unclear. Orthopaedic surgeons are more likely to request an MRI. Furthermore, visible lesions with characteristic symptoms probably do not benefit from MRI. However, it may help to be sure that the highest-quality MRI is used with the best possible coil for the finger.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802551PMC
September 2019

Long-Duration Tracking of Cervical-Spine Kinematics With Ultrasound.

IEEE Trans Ultrason Ferroelectr Freq Control 2019 11 30;66(11):1699-1707. Epub 2019 Aug 30.

Cervical-spine (C-spine) pathoanatomy is commonly evaluated by plane radiographs, computed tomography (CT), or magnetic resonance imaging (MRI); however, these modalities are unable to directly measure the dynamic mechanical properties of the functional spinal units (FSU) comprising the C-spine that account for its functional performance. We have developed an ultrasound-based technique that provides a non-invasive, real-time, quantitative, in vivo assessment of C-spine kinematics and FSU viscoelastic properties. The fidelity of the derived measurements is predicated on accurate tracking of vertebral motion over a prolonged time duration. The purpose of this work was to present a bundle adjustment method that enables accurate tracking of the relative motion of contiguous cervical vertebrae from ultrasound radio-frequency data. The tracking method was validated using both a plastic anatomical model of a cervical vertebra undergoing prescribed displacements and also human cadaveric C-spine specimens subjected to physiologically relevant loading configurations. While the velocity of motion and thickness of the surrounding soft tissue envelope affected accuracy, using the bundle adjustment method, B-mode ultrasound was capable of accurately tracking vertebral motion under clinically relevant physiologic conditions. Therefore, B-mode ultrasound can be used to evaluate in vivo real-time C-spine kinematics and FSU mechanical properties in environments where radiographs, CT, or MRI cannot be used.
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http://dx.doi.org/10.1109/TUFFC.2019.2928184DOI Listing
November 2019

What Are the Indications and Contraindications for Irrigation and Debridement and Retention of Prosthesis (DAIR) in Patients With Infected Total Ankle Arthroplasty (TAA)?

Foot Ankle Int 2019 Jul;40(1_suppl):52S-53S

1 Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Recommendation: Debridement, antibiotics, and implant retention (DAIR) with polyethylene exchange may be indicated in early postoperative infection (<4 weeks) or acute hematogenous infection (<4 weeks of symptoms) in patients with infected total ankle arthroplasty (TAA), although recurrent infection has been seen. Suffcient clinical evidence is lacking.

Level Of Evidence: Consensus.

Delegate Vote: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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http://dx.doi.org/10.1177/1071100719861099DOI Listing
July 2019

Factors influencing treatment recommendations for base of 5th metatarsal fractures in orthopaedic residency programs.

Foot Ankle Surg 2020 Jun 30;26(4):464-468. Epub 2019 May 30.

Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States. Electronic address:

Background: Management of proximal 5th metatarsal fractures remains a controversial topic in orthopaedic surgery. Both operative and non-operative approaches have been described in the clinical setting. This confusion has led to non-standardized treatment recommendations for proximal 5th metatarsal fractures. This study was designed to analyze concordance rate of treatment recommendations between orthopaedic trainees and orthopaedic foot and ankle experts.

Methods: An online survey containing 14 cases of proximal 5th metatarsal fractures were distributed to 92 orthopaedic residents in two ACGME-accredited programs. Relevant weight-bearing radiographs, patient's age and gender were provided, and two questions regarding treatment recommendations were surveyed. Resident's recommended treatment was then matched against ultimate treatment by orthopaedic foot and ankle experts. ANOVA and T-test are used for associations between the rate of concordant treatment with PGY and trainee foot and ankle experience. Fleiss' kappa was used to assess the inter-observer agreement.

Results: Seventy-two residents returned the survey. The overall concordance rate was 43.98% with no correlation between agreement rate and PGY-years. No difference in agreement rate was observed between residents who had completed their foot and ankle rotation versus those who had not. There was a slight inter-observer agreement in recommending treatment among all residents (κ=0.117, 95% CI: 0.071-0.184).

Conclusions: Our data demonstrated no significant concordance between resident level in training regarding proximal 5th metatarsal fracture treatment decisions, nor between residents and subspecialty-trained foot and ankle surgeons. Increased rotations with foot and ankle fellowship-trained surgeons throughout residency may be desirable to improve the quality of residency training.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.fas.2019.05.015DOI Listing
June 2020

Diagnostic Modalities for Acute Compartment Syndrome of the Extremities: A Systematic Review.

JAMA Surg 2019 Jul;154(7):655-665

Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.

Importance: Acute compartment syndrome (ACS) can cause catastrophic tissue damage leading to permanent muscle and nerve loss. Acute compartment syndrome is a clinical diagnosis, with intracompartmental pressure (ICP) used in equivocal cases. There are no reliable diagnostic methods. The clinical evaluation is impossible to standardize, and the threshold for ICP has been known to be unreliable; thus, guidelines for diagnosis can result in overtreatment or delayed diagnosis.

Objective: To present and review the advantages and disadvantages of each diagnostic modality and identify gaps that need to be addressed in the future and to review the most used and appropriate animal and human ACS models.

Evidence Review: We included clinical studies and animal models investigating diagnostic modalities for ACS of the extremities. A MEDLINE and Web of Science search was performed. The protocol for the study was registered on PROSPERO (CRD42017079266). We assessed the quality of the clinical studies with Newcastle-Ottawa scale and reported level of evidence for each article.

Findings: Fifty-one articles were included in this study, reporting on 38 noninvasive and 35 invasive modalities. Near-infrared spectroscopy and direct ICP measurement using a Stryker device were the most common, respectively. Cadaveric studies used saline infusions to create an ACS model. Most studies with human participants included injured patients with acquired ACS or at risk of developing ACS. In healthy human participants, tourniquets formed the most commonly used ACS model. Application of tourniquets and infusion of saline or albumin were the most used ACS models among animal studies.

Conclusions And Relevance: This article reports on the most common as well as many new and modified diagnostic modalities, which can serve as inspiration for future investigations to develop more effective and efficient diagnostic techniques for ACS. Future studies on diagnostic modalities should include the development of tools for continuous assessment of ICP to better identify the earliest alterations suggestive of impending ACS. With the advent of such technologies, it may be possible to develop far less aggressive and more effective approaches for early detection of ACS.
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http://dx.doi.org/10.1001/jamasurg.2019.1050DOI Listing
July 2019

Shoulder biomechanics of RC repair and Instability: A systematic review of cadaveric methodology.

J Biomech 2019 01 14;82:280-290. Epub 2018 Nov 14.

Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia. Electronic address:

Background: Numerous biomechanical studies have addressed normal shoulder function and the factors that affect it. While these investigations include a mix of in-vivo clinical reports, ex-vivo cadaveric studies, and computer-based simulations, each has its own strengths and limitations. A robust methodology is essential in cadaveric work but does not always come easily. Precise quantitative measurements are difficult in in-vivo studies, and simulation studies require validation steps. This review focuses on ex-vivo cadaveric studies to emphasize the best research methodologies available to simulate physiologically and clinically relevant shoulder motion.

Methods: A PubMed and Web of Science search was conducted in March 2017 (and updated in May 2018) to identify the cadaveric studies focused on the shoulder and its function. The key words for this search included rotator cuff (RC) injuries, RC surgery, and their synonyms. The protocol of the study was registered on PROSPERO and is accessible at CRD42017068873.

Results: Thirty one studies consisting of 167 specimens with various biomechanical methods met our inclusion criteria. All studies were level V cadaveric studies. Cadaveric biomechanical models are widely used to study shoulder instability and RC repair. These models are commonly limited to the glenohumeral joint by a fixed scapula, passively and discretely move the humerus, and statically load the RC without regard for the integrity of the glenohumeral capsule.

Conclusion: All studies captured in this review evaluated shoulder biomechanics. Recent studies in patients suggest that some assumptions made in this space may not fully characterize motion of the human shoulder. With reproducible scapular positioning, dynamic RC activation, and preservation of glenohumeral capsule integrity, cadaveric studies can facilitate proper validation for simulation models and broaden our understanding of the shoulder environment during motion in healthy and disease states.
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http://dx.doi.org/10.1016/j.jbiomech.2018.11.005DOI Listing
January 2019

Comparative Efficacy and Safety of Nonsurgical Treatment Options for Enthesopathy of the Extensor Carpi Radialis Brevis: A Systematic Review and Meta-analysis of Randomized Placebo-Controlled Trials.

Am J Sports Med 2019 10 31;47(12):3019-3029. Epub 2018 Oct 31.

Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Background: Numerous treatment options have been proposed for enthesopathy of the extensor carpi radialis brevis (eECRB).

Purpose: To (1) compare the efficacy and safety of nonsurgical treatment options for eECRB described in randomized placebo-controlled trials at short-term, midterm, and long-term follow-up and (2) evaluate outcomes in patients receiving placebo.

Study Design: Systematic review and meta-analysis.

Methods: Following PRISMA guidelines, 4 electronic databases were searched for randomized placebo-controlled trials for eECRB. Studies reporting visual analog scale (VAS) for pain scores and/or grip strength were included. Random- or fixed-effects meta-analysis was employed to compare treatments with at least 2 eligible studies using the standardized mean difference and odds ratio. The study protocol was registered at PROSPERO (ID: CRD42018075009).

Results: Thirty-six randomized placebo-controlled trials, evaluating 11 different treatment modalities, with a total of 2746 patients were included. At short-term follow-up, only local corticosteroid injection improved pain; however, it was associated with pain worse than placebo at long-term follow-up. At midterm follow-up, laser therapy and local botulinum toxin injection improved pain. At long-term follow-up, extracorporeal shock wave therapy provided pain relief. With regard to grip strength, only laser therapy showed better outcomes in comparison with placebo. While there was no difference among various treatments in the odds ratio of an adverse event, they all increased adverse events compared with placebo. In placebo-receiving patients, a sharp increase in the percentage of patients reporting mild pain or less was observed from 2% at short-term follow-up to 92% at midterm follow-up.

Conclusion: Most patients experienced pain resolution after receiving placebo within 4 weeks of follow-up. At best, all treatments provided only small pain relief while increasing the odds of adverse events. Therefore, if clinicians are inclined to provide a treatment for particular patients, they may consider a pain relief regimen for the first 4 weeks of symptom duration. Patient-specific factors should be considered when deciding on treatment or watchful waiting.
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http://dx.doi.org/10.1177/0363546518801914DOI Listing
October 2019

Meta-analysis and Systematic Review of Skin Graft Donor-site Dressings with Future Guidelines.

Plast Reconstr Surg Glob Open 2018 Sep 24;6(9):e1928. Epub 2018 Sep 24.

Department of Surgery, Division of Plastic Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass.

Background: Many types of split-thickness skin graft (STSG) donor-site dressings are available with little consensus from the literature on the optimal dressing type. The purpose of this systematic review was to analyze the most recent outcomes regarding moist and nonmoist dressings for STSG donor sites.

Methods: A comprehensive systematic review was conducted across PubMed/MEDLINE, EMBASE, and Cochrane Library databases to search for comparative studies evaluating different STSG donor-site dressings in adult subjects published between 2008 and 2017. The quality of randomized controlled trials was assessed using the Jadad scale. Data were collected on donor-site pain, rate of epithelialization, infection rate, cosmetic appearance, and cost. Meta-analysis was performed for reported pain scores.

Results: A total of 41 articles were included comparing 44 dressings. Selected studies included analysis of donor-site pain (36 of 41 articles), rate of epithelialization (38 of 41), infection rate (25 of 41), cosmetic appearance (20 of 41), and cost (10 of 41). Meta-analysis revealed moist dressings result in lower pain (pooled effect size = 1.44). A majority of articles (73%) reported better reepithelialization rates with moist dressings.

Conclusion: The literature on STSG donor-site dressings has not yet identified an ideal dressing. Although moist dressings provide superior outcomes with regard to pain control and wound healing, there continues to be a lack of standardization. The increasing commercial availability and marketing of novel dressings necessitates the development of standardized research protocols to design better comparison studies and assess true efficacy.
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http://dx.doi.org/10.1097/GOX.0000000000001928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6191241PMC
September 2018

Clinical Outcomes and Complications of the Surgical Implant Generation Network (SIGN) Intramedullary Nail: A Systematic Review and Meta-Analysis.

J Orthop Trauma 2019 Jan;33(1):42-48

Department of Orthopedics, Massachusetts General Hospital, Boston, MA.

Objectives: This study is a systematic review and meta-analysis of the clinical outcomes and pooled complication rate of femoral, tibial, and humeral fracture fixation using SIGN nails. We aimed at comparing the pooled rate of adverse events based on the country of study origin, acute versus delayed fracture fixation, and length of follow-up.

Methods: We searched PubMed/MEDLINE/Cochrane databases from 2000 to 2016 for English language studies. There was substantial heterogeneity among included studies. Therefore, we used subgroup analysis of varying adverse events and removal of potential outlier studies based on the "remove one" sensitivity analysis to address the heterogeneity across studies. A funnel plot was drawn and inspected visually to assess publication bias. We reported pooled complication rates for each adverse event with 95% prediction interval.

Results: There were 14 studies with 47,169 cases across 58 different low- and middle-income countries. The average age was 33 ± 14 years, with 83% men and 17% women. Sixty percent of SIGN nails used in these 14 studies were used in femur fracture fixation, 38% in tibial shaft fractures, and the remaining 2% for humeral shaft fractures. Approximately 23% of patients had follow-up data recorded. All studies that measured clinical outcome indicated that >90% achieved full weight-bearing status, favorable range of motion (knee range of motion >90 degrees according to the SIGN database), and radiographic or clinical union depending on the specific variable(s) measured in each study. The overall complication rate was 5.2% (4.4%-6.4%). Malalignment (>5 degrees of angulation in any plane) was the most common complication (7.6%), followed by delayed/nonunion (6.9%), infection (5.9%), and hardware failure, (3.2%).

Conclusions: Overall, the use of SIGN nails in fixing femoral, tibial, and humeral shaft fractures demonstrates good results with a high rate of return to full weight-bearing and radiographic/clinical union. The most common complications when using the SIGN nail are malalignment, delayed/nonunion, infection, and hardware failure.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001328DOI Listing
January 2019

Effects of dietary omega-3 fatty acids on bones of healthy mice.

Clin Nutr 2019 10 1;38(5):2145-2154. Epub 2018 Sep 1.

Vascular Biology Program and the Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA. Electronic address:

Background & Aims: Altering the lipid component in diets may affect the incidence of metabolic bone disease in patients dependent on parenteral nutrition. Consumption of polyunsaturated fatty acids (PUFA) can impact bone health by modulating calcium metabolism, prostaglandin synthesis, lipid oxidation, osteoblast formation, and osteoclastogenesis. The aim of this study was to evaluate the dietary effects of PUFA on murine bone health.

Methods: Three-weeks-old male (n = 30) and female (n = 30) C57BL/6J mice were randomized into one of three dietary groups. The diets differed only in fat composition: soybean oil (SOY), rich in ω-6 PUFA; docosahexaenoic acid alone (DHA), an ω-3 PUFA; and DHA with arachidonic acid, an ω-6 PUFA, at a 20:1 ratio (DHA/ARA). After 9 weeks of dietary treatment, femurs were harvested for micro-computed tomographic analysis and mechanical testing via 3-point bending. Separate mice from each group were used solely for serial blood draws for measurement of biomarkers of bone formation and resorption.

Results: At the microstructural level, although some parameters in cortical bone reached differences that were statistically significant in female mice, these were too small to be considered biologically relevant. Similarly, trabecular bone parameters in male mice were statistically different in some dietary groups, although the biological interpretation of such subtle changes translate into a lack of effect in favor of any of the experimental diets. No differences were noted at the mechanical level and in blood-based biomarkers of bone metabolism across dietary groups within gender.

Conclusions: Subtle differences were noted at the bones' microstructural level, however these are likely the result of random effects that do not translate into changes that are biologically relevant. Similarly, differences were not seen at the mechanical level, nor were they reflected in blood-based biomarkers of bone metabolism. Altogether, dietary consumption of PUFA do not seem to affect bone structure or metabolism in a healthy model of growing mice.
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http://dx.doi.org/10.1016/j.clnu.2018.08.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465171PMC
October 2019

Different References for Valgus Cut Angle in Total Knee Arthroplasty.

Arch Bone Jt Surg 2018 Jul;6(4):289-293

Department of knee Surgery, Firoozgar Hospital, Neuromusculoskeletal Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: The valgus cut angle (VCA) of the distal femur in Total Knee Arthroplasty (TKA) is measured preoperatively on three-joint alignment radiographs. The anatomical axis of the femur can be described as the anatomical axis of the full length of the femur or as the anatomical axis of the distal half of the femur, which may result in different angles in some cases. During TKA, the anatomical axis of the femur is determined by intramedullary femoral guides, which may follow the distal half or near full anatomical axis, based on the length of the femoral guide. The aim of this study was to compare using the anatomical axis of the full length of the femur versus the anatomical axis of the distal half of the femur for measuring VCA, in normal and varus aligned femurs. We hypothesized that the VCA would be different based upon these two definitions of the anatomical axis of the femur.

Methods: Full-length weight bearing radiographs were used to determine three-joint alignment in normal aligned (Lateral Distal Femoral Angle; LDFA = 87º ± 2º) and varus aligned (LDFA >89º) femurs. Full-length anatomical axis-mechanical axis angle (angle 1) and distal half anatomical axis-mechanical axis angle (angle 2) were measured in all subjects by two independent orthopedic surgeons using a DICOM viewer software (PACS). Angles 1 and 2 were compared in normal and varus aligned subjects to determine whether there was a significant difference.

Results: Ninety-seven consecutive subjects with normally aligned femurs and 97 consecutive subjects with varus aligned femurs were included in this study. In normally aligned femurs, the mean value of angle 1 was 5.05° ± 0.76° and for angle 2 was 3.62° ± 1.19°, which were statistically different (). In varus aligned femurs, the mean value of angle 1 was 5.42° ± 0.85° and for angle 2 was 4.23° ± 1.27°, which were also statistically different ().

Conclusion: The two different methods of outlining the anatomical axis of the femur lead to different results in both normal and varus-aligned femurs. This should be considered in determination of the valgus cut angle on pre-operative radiographs and be adjusted according to the length of the intramedullary guide.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110428PMC
July 2018

Risk Factors and Pooled Rate of Prolonged Opioid Use Following Trauma or Surgery: A Systematic Review and Meta-(Regression) Analysis.

J Bone Joint Surg Am 2018 Aug;100(15):1332-1340

Center for Advanced Orthopaedic Studies (A.M., C.L.W., A.M.M., E.K.R., A.v.K., and A.N.) and Department of Orthopaedic Surgery (A.M., E.K.R., and A.v.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background: Prolonged use of opioids initiated for surgical or trauma-related pain management has become a global problem. While several factors have been reported to increase the risk of prolonged opioid use, there is considerable inconsistency regarding their significance or effect size. Therefore, we aimed to pool the effects of risk factors for prolonged opioid use following trauma or surgery and to assess the rate and temporal trend of prolonged opioid use in different settings.

Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched Embase, PubMed, Web of Science, EBM (Evidence-Based Medicine) Reviews - Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from inception to August 28, 2017, without language restriction. Observational studies reporting risk factors for, or the rate of, prolonged opioid use among adult patients following surgery or trauma with a minimum of 1 month of follow-up were included. Study and patient characteristics, risk factors, and the rate of prolonged opioid use were synthesized.

Results: Thirty-seven studies with 1,969,953 patients were included; 4.3% (95% confidence interval [CI] = 2.3% to 8.2%) of patients continued opioid use after trauma or surgery. Prior opioid use (number needed to harm [NNH] = 3, odds ratio [OR] = 11.04 [95% CI = 9.39 to 12.97]), history of back pain (NNH = 23, OR = 2.10 [95% CI = 2.00 to 2.20]), longer hospital stay (NNH = 25, OR = 2.03 [95% CI = 1.03 to 4.02]), and depression (NNH = 40, OR = 1.62 [95% CI = 1.49 to 1.77]) showed some of the largest effects on prolonged opioid use (p < 0.001 for all but hospital stay [p = 0.042]). The rate of prolonged opioid use was higher in trauma (16.3% [95% CI = 13.6% to 22.5%]; p < 0.001) and in the Workers' Compensation setting (24.6% [95% CI = 2.0% to 84.5%]; p = 0.003) than in other subject enrollment settings. The temporal trend was not significant for studies performed in the U.S. (p = 0.07) while a significant temporal trend was observed for studies performed outside of the U.S. (p = 0.014).

Conclusions: To our knowledge, this is the first meta-analysis reporting the pooled effect of risk factors that place patients at an increased chance for prolonged opioid use. Understanding the pooled effect of risk factors and their respective NNH values can aid patients and physicians in developing effective and individualized pain-management strategies with a lower risk of prolonged opioid use.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.17.01239DOI Listing
August 2018

Chronic Scapholunate Interosseous Ligament Disruption: A Systematic Review and Meta-Analysis of Surgical Treatments.

Hand (N Y) 2020 01 20;15(1):27-34. Epub 2018 Jul 20.

Harvard Medical School, Boston, MA, USA.

Although many techniques have been described, there is no clear optimal surgical treatment for chronic scapholunate interosseous ligament (SLIL) disruption. We identified 255 articles reporting outcomes of SLIL reconstruction. Of these, 40 studies (978 wrists) met eligibility requirements and reported sufficient data on radiographic outcomes to be included in the study. The mean and standard deviation of preoperative and follow-up assessments including scapholunate gap (SLG) and scapholunate angle (SLA) were used to calculate pooled standardized mean differences (SMD) with 95% confidence intervals (CIs). For other radiographic or clinical outcomes, there were not enough reported data to calculate a pooled effect size, and pooled nonstandardized comparisons were made. The SMD between preoperative and postoperative SLA in tenodesis reconstruction was 0.7 (CI, 0.29 to 1.11, = .001) and 0.04 (CI, -0.27 to 0.38, = .8) for capsulodesis reconstruction. For SLG, tenodesis demonstrated an SMD of 1.1 (CI, 0.6 to 1.55, < .001) compared with 0.1 (CI, -0.36 to 0.59, = .6) for capsulodesis reconstruction. Tenodesis had a significant improvement compared with capsulodesis in SLA ( = .01) and SLG ( = .005). Tenodesis also showed improvement in grip strength and Disabilities of the Arm, Shoulder and Hand scores. Comparing preoperative and postoperative radiographic measurements, tenodesis reconstruction demonstrated significantly improved SLG and SLA relative to capsulodesis. Interpreted in the context of the limitations, existing data demonstrates some benefit of tenodesis reconstruction.
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http://dx.doi.org/10.1177/1558944718787289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6966285PMC
January 2020

Rehabilitation following meniscal repair: a systematic review.

BMJ Open Sport Exerc Med 2018 9;4(1):e000212. Epub 2018 Apr 9.

Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To review existing biomechanical and clinical evidence regarding postoperative weight-bearing and range of motion restrictions for patients following meniscal repair surgery.

Methods And Data Sources: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, we searched MEDLINE using following search strategy: (((("Weight-Bearing/physiology"[Mesh]) OR "Range of Motion, Articular"[Mesh]) OR "Rehabilitation"[Mesh])) AND ("Menisci, Tibial"[Mesh]). Additional articles were derived from previous reviews. Eligible studies were published in English and reported a rehabilitation protocol following meniscal repair on human. We summarised rehabilitation protocols and patients' outcome among original studies.

Results: Seventeen clinical studies were included in this systematic review. There was wide variation in rehabilitation protocols among clinical studies. Biomechanical evidence from small cadaveric studies suggests that higher degrees of knee flexion and weight-bearing may be safe following meniscal repair and may not compromise the repair. An accelerated protocol with immediate weight-bearing at tolerance and early motion to non-weight-bearing with immobilising up to 6 weeks postoperatively is reported. Accelerated rehabilitation protocols are not associated with higher failure rates following meniscal repair.

Conclusions: There is a lack of consensus regarding the optimal postoperative protocol following meniscal repair. Small clinical studies support rehabilitation protocols that allow early motion. Additional studies are needed to better clarify the interplay between tear type, repair method and optimal rehabilitation protocol.
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http://dx.doi.org/10.1136/bmjsem-2016-000212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905745PMC
April 2018

A systematic review and meta-analysis of arthroscopic assisted techniques for thumb carpometacarpal joint osteoarthritis.

J Hand Surg Eur Vol 2018 Dec 16;43(10):1098-1105. Epub 2018 Feb 16.

2 Department Plastic Surgery and Hand Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.

Arthroscopic management of thumb carpometacarpal (CMC) osteoarthrosis (OA) is an approach that has unclear results. We performed a systematic review encompassing three electronic databases up to May 2016 for studies describing arthroscopic-assisted techniques for thumb CMC OA. Meta-analyses of visual analogue scores (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) scores, grip strength and pinch strength before and after arthroscopy were performed for ten included non-randomized cohort studies comprising 294 patients. Based on Hedges' g measure, we found a large effect on VAS and DASH scores, a small effect on grip strength and no effect on pinch strength. On average, VAS improved by 4.1 cm, DASH by 22 points and grip strength by 2.8 kg. Complications were reported in 4% of patients. The use of arthroscopic-assisted techniques for thumb CMC OA is still limited; however, it may be a reasonable option for patients with thumb CMC OA who do not respond to non-operative treatment.
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http://dx.doi.org/10.1177/1753193418757122DOI Listing
December 2018

Comparison of adverse events and postoperative mobilization following knee extensor mechanism rupture repair: A systematic review and network meta-analysis.

Injury 2017 Dec 16;48(12):2793-2799. Epub 2017 Oct 16.

Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Harvard Medical School, United States.

Background: Extensor mechanism rupture (EMR) of the knee is a rare but potentially debilitating injury that often occurs due to trauma. While a wide variety of surgical treatments have been reported, there is currently no consensus on the most successful treatment method. The timing of post-operative joint mobilization is also critical for successful recovery after EMR repair. Despite the traditional method of complete immobilization for 6 weeks, there is an increasing trend towards early post-operative knee mobilization. The purpose of this network meta-analysis was to compare adverse event rates and function outcomes between repair methods and between post-operative mobilization protocols.

Methods: MEDLINE, EMBASE, Web of Science, and Cochrane Central electronic databases were searched in August 2016 for observational studies involving repair of acute, traumatic EMRs. Data extraction included functional outcomes, adverse events, and additional surgeries. Cohort studies that were used in functional outcome analysis were assessed for risk of bias by the Newcastle-Ottawa Quality Assessment Scale (NOS).

Results: Twenty-three studies (709 patients) were included for adverse event analysis. There were no significant differences in adverse event or additional surgery rates between EMR repair methods However, early mobilization produced significantly higher adverse event rates (p=0.02) and total event rates (p<0.001) than late mobilization, but the difference in additional surgery rates was not significant (p=0.06). Six studies (85 patients) were included for functional outcome analysis. There were no significant differences in thigh girth atrophy or muscle strength compared to the contralateral leg between patients treated with transosseous drill holes and simple end-to-end sutures.

Conclusions: We performed the first network meta-analysis to date comparing treatment of EMRs. Our results support the current body of knowledge that there is no single superior repair method. Although there is an increasing trend towards early or immediate post-operative knee mobilization, we found that early mobilization is associated with significantly higher adverse event and total event rates compared to fixed immobilization for a minimum of 6 weeks, implicating an increased financial burden and decreased quality of life associated with early post-operative mobilization.
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http://dx.doi.org/10.1016/j.injury.2017.10.013DOI Listing
December 2017

Type D personality in patients with upper extremity musculoskeletal illness: Internal consistency, structural validity and relationship to pain interference.

Gen Hosp Psychiatry 2018 Jan - Feb;50:38-44. Epub 2017 Sep 27.

Department of Psychiatry, Behavioral Medicine Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. Electronic address:

Objective: Type D personality - the joint tendency toward negative affectivity (NA) and social inhibition (SI) - is associated with greater symptom perception and negative health outcomes among various patient populations. We investigated Type D personality among patients with upper extremity musculoskeletal illness.

Method: In cross-sectional design, we estimated the prevalence of Type D personality in this population and explored the associations of two different Type D conceptualizations (i.e., categorical and dimensional as the NA×SI interaction) and the individual NA and SI traits with pain interference as well as structural-internal validity of DS14.

Results: The categorical Type D personality and greater NA and SI were associated with pain interference above and beyond descriptive variables, but the interaction term between NA and SI was not. NA explained a larger proportion of the variance in pain interference than SI. DS14 showed a two-factor structure and high internal consistency in this sample.

Conclusions: The categorical Type D allows for identifying individuals who struggle with recovery from musculoskeletal injury. Although the dimensional conceptualization didn't prove to be associated with pain interference, NA and SI appear to have individual effects on pain interference, with most variance being accounted for by NA. Implications for clinical care are discussed.
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http://dx.doi.org/10.1016/j.genhosppsych.2017.09.005DOI Listing
October 2018

Open Reduction and Internal Fixation for Lateral Unicondylar Distal Humeral Fractures.

JBJS Essent Surg Tech 2017 Jun 26;7(2):e12. Epub 2017 Apr 26.

Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Introduction: Unicondylar distal humeral fractures are uncommon, partially intra-articular fractures (OTA/AO type B1) that are among the most complex fractures to treat; however, most displaced distal humeral fractures, including lateral unicondylar distal humeral fractures, can be effectively managed with open reduction and internal fixation.

Indications & Contraindications:

Step 1 Preparation Of The Operating Room And The Patient: Perform sterile preparation, have the patient brought into the operating room, induce anesthesia, and place the patient in the lateral decubitus or supine position before sterile draping.

Step 2 Approach To The Fracture: Make a lateral incision, expose the lateral distal part of the humerus, identify the ulnar nerve if necessary, visualize the fracture fragments, and debride the fracture site.

Step 3 Reduction Of The Fracture: Reduce the fracture and fix it temporarily.

Step 4 Plate Fixation Of The Fracture: Determine the plate length; position the plate posterolaterally, posteriorly, or laterally; insert screws; remove provisional Kirschner wires; and obtain intraoperative images.

Step 5 Final Radiographic Imaging: Make anteroposterior and lateral radiographic images to confirm reduction and adequate anatomic alignment of the elbow and the position of the hardware.

Step 6 Closure Of The Wound: Deflate the tourniquet, irrigate the wound, and apply postoperative dressings.

Results: The detailed outcome for a cohort of 24 patients who underwent this procedure has been reported elsewhere.

Pitfalls & Challenges:
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http://dx.doi.org/10.2106/JBJS.ST.16.00084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6132604PMC
June 2017

Diagnostic Wrist Arthroscopy for Nonspecific Wrist Pain.

Hand (N Y) 2017 03 29;12(2):193-196. Epub 2016 Jul 29.

Massachusetts General Hospital, Boston, USA.

This study addresses the prevalence of discrete pathophysiology accounting for patients' symptoms during diagnostic wrist arthroscopy in individuals with wrist pain without a specific preoperative diagnosis. Secondarily, we determined the number and type of surgeries subsequent to diagnostic wrist arthroscopy. Between January 2000 and January 2015, 135 diagnostic wrist arthroscopies were performed by 12 surgeons in 3 urban academic hospitals. We recorded the diagnostic findings of diagnostic wrist arthroscopy and any subsequent surgeries. One hundred and five patients had synovitis or a normal wrist (78%), 17 had likely age-appropriate changes (eg, central triangular fibrocartilage complex defects scapholunate changes) (13%), 8 (6%) were given uncommon diagnoses, and 5 (4%) had osteochondral defects. Sixteen patients (12%) had subsequent wrist surgery: 2 were for adverse events, 2 were carpal tunnel releases, and 12 were other surgeries. Diagnostic arthroscopy performed in the setting of an unclear preoperative diagnosis yielded limited diagnostic benefit.
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http://dx.doi.org/10.1177/1558944716661993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349414PMC
March 2017