Publications by authors named "Daluiski Aaron"

64 Publications

Combined clinic and home-based therapeutic approach for the treatment of bilateral radial deficiency for a young child with Holt-Oram syndrome: A case report.

J Hand Ther 2021 Mar 6. Epub 2021 Mar 6.

NYU Langone Health Rusk Rehabilitation, New York, NY, USA. Electronic address:

Background: Holt-Oram syndrome (HOS) is a rare, genetic condition characterized by the combination of congenital heart defect and hypoplasia in one or both upper extremities. Children with HOS commonly present with varied joint and limb involvement including radial longitudinal deficiency impacting hand function. Evidence-based guidelines regarding orthotic wear and therapeutic techniques are lacking.

Purpose: The aim of this case report was to present the results of a long-term occupational therapy program for a patient with HOS pre and postpollicization.

Study Design: Case report.

Methods: A 4-month-old patient with bilateral radial longitudinal deficiencies began outpatient occupational therapy for custom orthosis fabrication and treatment which included long term clinic and home-based intervention. Techniques included passive range of motion, orthosis wear, therapeutic taping, and modified constraint induced movement therapy. Longitudinal assessment of musculoskeletal alignment and functional hand use was performed using goniometry for passive and active range of motion, the Assisting Hand Assessment (AHA), and The Thumb Grasp and Pinch Assessment (T-GAP).

Results: Improvement in passive and active range of motion was achieved as well as improved activity level function as measured by the AHA and T-GAP postpollicization and intervention.

Conclusions: A combined clinic and home-based therapeutic approach can be effective for children with HOS to improve alignment and function pre and postpollicization to further enhance hand function. Comprehensive, long-term assessment is necessary to fully evaluate and communicate improvement.
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http://dx.doi.org/10.1016/j.jht.2021.03.003DOI Listing
March 2021

Reliability and agreement between two wearable inertial sensor devices for measurement of arm activity during walking and running gait.

J Hand Ther 2020 Aug 20. Epub 2020 Aug 20.

Leon Root, MD Motion Analysis Laboratory, Hospital for Special Surgery, New York City, NY, USA.

Study Design: This is a validation study.

Background: Tracking limb movement with body worn sensors allows clinicians to measure limb dynamics to guide treatment for patients with movement disorders. The current gold standard, 3-dimensional optical motion capture, is costly, time-consuming, requires specific training, and is conducted in specialized laboratories.

Purpose: The purpose of our study was to a compare consumer-grade inertial sensor to a laboratory-grade sensor to provide additional methods for capturing limb dynamics.

Methods: The participants wore an Apple Watch and a laboratory-grade Xsens sensor on each wrist during 3 conditions: walk, fast-walk, and run. Acceleration data were collected simultaneously on each device per wrist for all conditions. Intraclass correlation coefficients and Bland-Altman plots were calculated to measure intra-/interdevice reliability, evaluate bias, and limits of agreement.

Results: Intradevice ICCs showed good reliability during walk and fast-walk (0.79-0.87) and excellent reliability during run (0.94-0.97) conditions. Inter-device ICCs yielded moderate reliability during walk (0.52 ± 0.22) and excellent reliability in fast-walk and run (0.93 ± 0.02, 1.00 ± 0.01) conditions. Bland-Altman plots showed small biases with 90% or more of the data contained within the limits of agreement.

Discussion: Our study demonstrates reliability and agreement between the two devices, suggesting that both can reliably capture upper extremity motion data during gait trials.

Conclusion: Our findings support further study of consumer-grade motion trackers to measure arm activity for clinical use. These devices are inexpensive, user-friendly, and allow for data collection outside of the laboratory.
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http://dx.doi.org/10.1016/j.jht.2020.08.001DOI Listing
August 2020

Assessment of a deep-learning system for fracture detection in musculoskeletal radiographs.

NPJ Digit Med 2020 30;3:144. Epub 2020 Oct 30.

Imagen Technologies, Inc., 151 West 26th Street, Suite 1001, New York, NY 10001 USA.

Missed fractures are the most common diagnostic error in emergency departments and can lead to treatment delays and long-term disability. Here we show through a multi-site study that a deep-learning system can accurately identify fractures throughout the adult musculoskeletal system. This approach may have the potential to reduce future diagnostic errors in radiograph interpretation.
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http://dx.doi.org/10.1038/s41746-020-00352-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599208PMC
October 2020

The use of wearable inertial sensors effectively quantify arm asymmetry during gait in children with unilateral spastic cerebral palsy.

J Hand Ther 2020 Jun 19. Epub 2020 Jun 19.

Leon Root, MD Motion Analysis Laboratory, Department of Rehabilitation, Hospital for Special Surgery, New York, NY, USA.

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http://dx.doi.org/10.1016/j.jht.2020.03.026DOI Listing
June 2020

Polydactyly a review and update of a common congenital hand difference.

Curr Opin Pediatr 2020 02;32(1):120-124

Department of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York, USA.

Purpose Of Review: The purpose of this review is to describe various forms of hand polydactyly and their different treatment approaches. Hand polydactyly is commonly classified as ulnar (small finger) or radial (thumb). Polydactyly can be sporadic, genetic, and/or associated with syndromic conditions.

Recent Findings: Both ulnar and radial polydactyly can be surgically treated to optimize hand aesthetics and function. Timing of surgery is based on multiple factors, most notably including safety of anesthesia and socialization of the affected child. The pediatrician should be aware of potential associated conditions, such as chondroectodermal dysplasia or Ellis-van Creveld syndrome for ulnar polydactyly.

Summary: Polydactyly is a common congenital hand difference and can be broadly be classified by radial or ulnar involvement. Polydactyly warrants hand surgical referral, as surgical treatment is often indicated. Pediatricians should be aware of treatment options, as well as of commonly associated anomalies and syndromes.
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http://dx.doi.org/10.1097/MOP.0000000000000871DOI Listing
February 2020

Epidemiology of syndactyly in New York State.

World J Orthop 2019 Nov 18;10(11):387-393. Epub 2019 Nov 18.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, United States.

Background: There is paucity of literature focusing on the incidence and surgical management of syndactyly. In this study, we describe the incidence and rates of surgical management of patients with syndactyly in New York State.

Aim: To describe the incidence and surgical management of patients with syndactyly using an America's population-based database.

Methods: We conducted a retrospective study using the New York State Statewide Planning and Research Cooperative System. All patients with a diagnosis of syndactyly at birth were identified and followed longitudinally to determine yearly incidence as well as demographic and surgical factors. Descriptive statistics and univariate analyses were used.

Results: There were 3306 newborns with a syndactyly diagnosis between 1997 and 2014 in New York State. The overall incidence was 0.074% or 7 cases per 10000 live births. A small number of patients underwent surgical correction in New York State (178 patients, 5.4%). Among the surgical patients, most of the operations were performed before the age of two (79%). Approximately 87% of surgeries were performed at teaching hospitals, and 52% of procedures were performed by plastic surgeons. Skin grafting was performed in 15% of cases. Patients having surgery in New York State were more likely to have Medicaid insurance compared to patients not having surgery ( = 0.02).

Conclusion: Syndactyly occurs in approximately 7 per 10000 live births, and the majority of patients undergo surgical correction before age two. There may be several barriers to care including the availability of specialized hand surgeons, access to teaching hospitals, and insurance status.
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http://dx.doi.org/10.5312/wjo.v10.i11.387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908446PMC
November 2019

Incidence of Nerve Repair Following Endoscopic Carpal Tunnel Release Is Higher Compared to Open Release in New York State.

HSS J 2019 Jul 27;15(2):143-146. Epub 2018 Nov 27.

1Department of Hand & Upper Extremity Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: Carpal tunnel release (CTR) has traditionally been performed through an open approach, although in recent years endoscopic CTR has gained in popularity.

Questions/purposes: We sought to assess whether a difference exists between the rates of nerve repair surgery following open versus endoscopic CTR in New York State (NYS).

Methods: Patients undergoing endoscopic and open CTR from 1997 to 2013 were identified from the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health using Current Procedural Terminology, 4th Revision (CPT-4) codes 29848 and 64721, respectively. The primary outcome measure was subsequent nerve repair surgery (as identified using CPT-4 codes 64831-64837, 64856, 64857, 64859, 64872, 64874, and 64876). Other variables analyzed included patient age, sex, payer, and surgery year.

Results: There were 294,616 CTRs performed in NYS from 1997 to 2013. While the incidence of open CTR remained higher than endoscopic CTR, the proportion of endoscopic CTR steadily increased, from 16% (2984/19,089) in 2007 to 25% (5594/22,271) in 2013. For the 134,143 patients having a single CTR, the rate of subsequent nerve repair was significantly higher following endoscopic CTR (0.09%) compared to open CTR (0.04%). The Cox model showed that factors significantly associated with a higher risk of subsequent nerve repair surgery were endoscopic CTR and younger age.

Conclusions: Endoscopic CTR has been increasingly performed in NYS and associated with a higher rate of subsequent nerve repair. This rate likely underestimates the incidence of nerve injuries because it only captures those patients who had subsequent surgery. While this catastrophic complication remains rare, further investigation is warranted, given the rise of endoscopic CTR in the setting of equivalent outcomes, but favorable reimbursement, versus open CTR.
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http://dx.doi.org/10.1007/s11420-018-9637-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609660PMC
July 2019

Reliability of the Modified Clavien-Dindo-Sink Complication Classification System in Pediatric Orthopaedic Surgery.

JB JS Open Access 2018 Dec 23;3(4):e0020. Epub 2018 Oct 23.

Hospital for Special Surgery, New York, NY.

Background: There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as and are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases.

Methods: The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively.

Results: The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group.

Conclusions: The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.
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http://dx.doi.org/10.2106/JBJS.OA.18.00020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6400510PMC
December 2018

The Fragility Index in Hand Surgery Randomized Controlled Trials.

J Hand Surg Am 2019 Aug 9;44(8):698.e1-698.e7. Epub 2018 Nov 9.

Department of Orthopaedics, Hospital for Special Surgery, New York, NY.

Purpose: Randomized controlled trials (RCTs) are the gold standard for comparing clinical interventions. Statistical significance as reported via a P value has been used to determine if a difference between clinical interventions exists in an RCT. However, P values do not clearly convey information about the robustness of a study's conclusions. An emerging metric, called the fragility index (the number of subjects who would need to change outcome category to raise the P value above the .05 threshold), is an indirect measure of how likely a repeat of the trial would reach the same conclusions. This study addressed the fragility of RCTs using dichotomous outcomes in hand surgery.

Methods: Using systematic searching of the MEDLINE database, we identified hand surgery RCTs published in 11 high-impact journals published in the last decade (2007-2017). Studies were identified that involved 2 parallel arms, allocated patients to treatment and control in a 1:1 ratio, and reported statistical significance for a dichotomous variable. The fragility index was calculated using Fisher's exact test, using previously published methods.

Results: Five hand surgery RCTs were identified for inclusion reporting a range of fragility indices from 0 to 26. Two of the trials (40%) had a fragility index of 2 or less. Two of the trials (40%) reported that the number of patients lost to follow-up exceeded the fragility index, meaning that results of the patients lost to follow-up could theoretically completely reverse the study conclusions.

Conclusions: The range of fragility indices reported in the recent hand surgery literature is consistent with previous reporting within orthopedic surgery.

Clinical Relevance: The fragility index is a useful metric to analyze the robustness of the study conclusions that should complement other methods of critical evaluation including the P value or effect sizes. Our results emphasize the need for future efforts to strengthen the robustness of RCT conclusions.
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http://dx.doi.org/10.1016/j.jhsa.2018.10.005DOI Listing
August 2019

Deep neural network improves fracture detection by clinicians.

Proc Natl Acad Sci U S A 2018 11 22;115(45):11591-11596. Epub 2018 Oct 22.

Imagen Technologies, New York, NY 10012.

Suspected fractures are among the most common reasons for patients to visit emergency departments (EDs), and X-ray imaging is the primary diagnostic tool used by clinicians to assess patients for fractures. Missing a fracture in a radiograph often has severe consequences for patients, resulting in delayed treatment and poor recovery of function. Nevertheless, radiographs in emergency settings are often read out of necessity by emergency medicine clinicians who lack subspecialized expertise in orthopedics, and misdiagnosed fractures account for upward of four of every five reported diagnostic errors in certain EDs. In this work, we developed a deep neural network to detect and localize fractures in radiographs. We trained it to accurately emulate the expertise of 18 senior subspecialized orthopedic surgeons by having them annotate 135,409 radiographs. We then ran a controlled experiment with emergency medicine clinicians to evaluate their ability to detect fractures in wrist radiographs with and without the assistance of the deep learning model. The average clinician's sensitivity was 80.8% (95% CI, 76.7-84.1%) unaided and 91.5% (95% CI, 89.3-92.9%) aided, and specificity was 87.5% (95 CI, 85.3-89.5%) unaided and 93.9% (95% CI, 92.9-94.9%) aided. The average clinician experienced a relative reduction in misinterpretation rate of 47.0% (95% CI, 37.4-53.9%). The significant improvements in diagnostic accuracy that we observed in this study show that deep learning methods are a mechanism by which senior medical specialists can deliver their expertise to generalists on the front lines of medicine, thereby providing substantial improvements to patient care.
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http://dx.doi.org/10.1073/pnas.1806905115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233134PMC
November 2018

Management of Joint Contractures in the Spastic Upper Extremity.

Hand Clin 2018 Nov;34(4):517-528

Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, 5th Floor, New York, NY 10021, USA; Department of Hand and Upper Extremity, Hospital for Special Surgery, 523 East 72nd Street, 4th Floor, New York, NY 10021, USA. Electronic address:

Upper extremity contractures in the spastic patient may result from muscle spasticity, secondary muscle contracture, or joint contracture. Knowledge of the underlying cause is critical in planning successful treatment. Initial management consists of physical therapy and splinting. Botulinum toxin can be helpful, as a therapeutic treatment in relieving spasticity and as a diagnostic tool in determining the underlying cause of the contracture. Surgical management options include release or lengthening of the causative muscle/tendon unit and joint capsular release, as required. Postoperative splinting is important to maintain the improved range of motion and protect any associated tendon lengthening or transfer.
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http://dx.doi.org/10.1016/j.hcl.2018.06.011DOI Listing
November 2018

Online Patient Ratings Are Not Correlated with Total Knee Replacement Surgeon-Specific Outcomes.

HSS J 2018 Jul 10;14(2):177-180. Epub 2018 Jan 10.

2Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: Despite potential concerns regarding their validity, physician-rating websites continue to grow in number and utilization and feature prominently on major search engines, potentially affecting patient decision-making regarding physician selection.

Questions/purposes: We sought to determine whether patient ratings on public physician-rating websites correlate with surgeon-specific outcomes for high-volume total knee replacement (TKR) surgeons in New York State (NYS) from 2010 to 2012.

Methods: Online patient ratings were compared to surgeon-specific outcomes from the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health. For each surgeon, we determined the infection rate, re-admission rate, and revision surgery rate within the study period, as well as the mean inpatient length of stay, for TKR from the SPARCS database. Online ratings were collected from two physician-rating websites (Vitals.com and HealthGrades.com).

Results: One hundred seventy-four high-volume TKR surgeons were identified in NYS from 2010 to 2012. The mean rates of in-hospital infection, 90-day infection, 30-day re-admission, 90-day re-admission, and revision surgery were 0.25, 1.00, 4.89, 8.43, and 1.31%, respectively. The mean number of ratings for individual surgeons on HealthGrades.com and Vitals.com were 24.0 (range: 0 to 109) and 19.3 (range: 0 to 114), respectively, and mean overall ratings were 4.2 and 4.1 (out of 5) stars, respectively. As with online patient ratings of individual surgeons, variability was observed in the total adverse event rate distribution for individual surgeons. Despite sufficient variability in both online patient rating and surgeon-specific outcomes for high-volume TKR surgeons in NYS, no correlation was observed.

Conclusion: There was no correlation between surgeon-specific TKR outcome measures and online patient ratings. We therefore advise that patients exert caution when interpreting ratings on these websites.
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http://dx.doi.org/10.1007/s11420-017-9600-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6031536PMC
July 2018

A matched quantitative computed tomography analysis of 3 surgical approaches for osteochondral reconstruction of the capitellum.

J Shoulder Elbow Surg 2018 Oct 22;27(10):1762-1769. Epub 2018 Jun 22.

Hospital for Special Surgery, New York, NY, USA. Electronic address:

Background: The location of capitellar osteochondritis dissecans (OCD) lesions in the sagittal plane guides the surgical approach used for autologous osteochondral transplantation. We sought to compare the capitellar region accessible for orthogonal graft placement through 3 approaches: (1) posterior anconeus-split approach; (2) lateral approach with lateral collateral ligament (LCL) preservation (LCL-preserving lateral approach); and (3) lateral approach with LCL release (LCL-sacrificing lateral approach).

Methods: The 3 approaches were sequentially performed on 9 cadaveric elbows: posterior anconeus-split approach, LCL-preserving lateral approach, and LCL-releasing lateral approach. The extent of perpendicular access was delineated with Kirschner wires. Each specimen underwent computed tomography. The accessible region was quantified as degrees on the capitellum and converted into time on a clock, where 0° corresponds to the 12-o'clock position. Generalized estimating equation modeling was used to investigate for significant within-specimen, between-approach differences.

Results: The LCL-preserving and LCL-sacrificing lateral approaches provided more anterior perpendicular access than the posterior anconeus-split approach (mean, 0° vs 83°; P < .001). The posterior anconeus-split approach provided more posterior perpendicular access (mean, 215.0°; P < .001) than the LCL-preserving (mean, 117°; P < .001) and LCL-sacrificing (mean, 145°; P < .001) lateral approaches. The LCL-sacrificing lateral approach provided more posterior exposure than the LCL-preserving lateral approach (mean, 145° vs 117°; P < .001). The mean arc of visualization was greater for the LCL-sacrificing lateral approach than for the LCL-preserving lateral approach (145° vs 117°, P < .001).

Conclusions: A capitellar OCD lesion can be perpendicularly accessed from a posterior anconeus-split approach if it is posterior to 83° (2:46 clock-face position). A laterally based approach may be required for lesions anterior to this threshold. These data inform clinical decisions regarding the appropriate surgical approach for any OCD lesion.
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http://dx.doi.org/10.1016/j.jse.2018.03.029DOI Listing
October 2018

Location of Osteochondritis Dissecans Lesions of the Capitellum.

J Hand Surg Am 2018 Nov 17;43(11):1039.e1-1039.e7. Epub 2018 Apr 17.

Hospital for Special Surgery, New York, NY. Electronic address:

Purpose: The location of capitellar osteochondritis dissecans (OCD) lesions in the sagittal plane guides the surgical approach, and lesion location in the coronal plane influences surgical management. Although most lesions have been reported to occur between 4 o'clock and 4:30 (120° to 135° anterior to the humerus), some lesions are located elsewhere in the capitellum. The primary aim was to define the region of the capitellum affected by OCD lesions using a novel clock-face localization system.

Methods: We reviewed 104 magnetic resonance imaging examinations diagnosing a nontraumatic capitellar OCD lesion. In the sagittal plane, lesion margins were recorded as degrees on the capitellum and converted into a clock-face format in which 0° corresponds to 12:00 with the forearm facing to the right. The 0° axis (12-o'clock axis) was defined as a line parallel to the anterior humeral line that intersects the capitellum center. The following coronal measurements were recorded: lesion width, capitellar width, and distance between the lateral capitellum and lateral lesion. Two independent observers took measurements.

Results: In the sagittal plane, average lesion location was 92° to 150° (3:04-5:00, clock face) and ranged from 52.1° to 249.5° (1:44-8:19, clock face). Average lesion dimensions were 10.7 mm (mediolateral width) and 5.2 mm (anteroposterior depth). Interrater reliability was high (intraclass correlation coefficient = 0.98).

Conclusions: Using a magnetic resonance imaging-based clock-face localization system, we found that capitellar OCD lesions affect a broad region of the capitellum in the sagittal plane.

Clinical Relevance: The clock-face localization system allows for precise description of capitellar OCD lesion location, which may facilitate intraoperative decision and longitudinal monitoring.
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http://dx.doi.org/10.1016/j.jhsa.2018.03.017DOI Listing
November 2018

Update on operative treatment of scapholunate (SL) instability for radiologists: part 1-SL ligament repair, dorsal capsulodesis and SL ligament reconstruction.

Skeletal Radiol 2017 Dec 3;46(12):1615-1623. Epub 2017 Jun 3.

University of Washington Radiology, 4245 Roosevelt Way NE Box 354755, Seattle, WA, 98105, USA.

Scapholunate instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management and post-operative follow-up of scapholunate (SL) instability. The goals of this article are to review the pre-operative staging of SL instability, the surgical options for repair and reconstruction of the SL ligament, along with the normal postoperative imaging findings as well as complications associated with these surgical options.
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http://dx.doi.org/10.1007/s00256-017-2676-8DOI Listing
December 2017

Update on the operative treatment of scapholunate instability for radiologists. II. Salvage procedures, total wrist arthrodesis, and total wrist arthroplasty.

Skeletal Radiol 2017 Aug 26;46(8):1031-1040. Epub 2017 May 26.

University of Washington Radiology, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA.

Scapholunate (SL) instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management, and postoperative follow-up of SL instability. In the final stage of SL instability, known as scapholunate advanced collapse, progressive degenerative changes occur at the carpal level. The goals of this article are to review the surgical options available for addressing the different stages of scapholunate advanced collapse, along with an emphasis on normal postoperative imaging and complications associated with each surgical option.
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http://dx.doi.org/10.1007/s00256-017-2671-0DOI Listing
August 2017

The electrodiagnostic natural history of parsonage-turner syndrome.

Muscle Nerve 2017 Oct 13;56(4):737-743. Epub 2017 Apr 13.

Hand and Upper Extremity Surgery, Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.

Introduction: Recovery from Parsonage-Turner syndrome (PTS) is generally favorable, although recovery times have been shown to vary, in part because there are no universally accepted outcome measures. In this study, we describe the electrodiagnostic natural history of this condition based on objective electrodiagnostic testing, and propose that complete electrodiagnostic recovery can be seen as early as 1 year.

Methods: Twenty-six subjects with 29 affected nerves confirmed as PTS were followed every 3 months for electrodiagnostic testing, or until full reinnervation was confirmed.

Results: Twenty-three cases (79.3%) demonstrated electrodiagnostic evidence of initial recovery at a mean of 5.8 months. Nine cases (31%) showed complete electrodiagnostic recovery at a mean of 1 year. When excluding cases with <1 year of follow-up, 52.9% achieved complete electrodiagnostic recovery.

Conclusions: In contrast to previous reports, full electrodiagnostic recovery of PTS was demonstrated at a mean of 1 year in > 50% of patients with longer term follow-up. Muscle Nerve 56: 737-743, 2017.
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http://dx.doi.org/10.1002/mus.25558DOI Listing
October 2017

Risk Factors for 30-Day Postoperative Complications Following Open Reduction Internal Fixation of Proximal Ulna Fractures.

J Hand Surg Am 2016 Dec 23;41(12):1122-1127. Epub 2016 Sep 23.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY. Electronic address:

Purpose: Fractures of the proximal ulna are common injuries in the elderly population. These fractures can be managed nonsurgically or with open reduction internal fixation (ORIF). Whereas nonsurgical management may lead to a relative loss of elbow extension and to nonunion, ORIF carries a risk of complications. Although complications specific to the orthopedic intervention have been reported, few studies have identified postoperative systemic complications in this higher-risk group. The purposes of this study were to determine the rate of systemic complications in patients undergoing surgical fixation of proximal ulna fractures and to determine risk factors for complications.

Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program database for all cases of proximal ulna fracture ORIF between 2005 and 2013. Demographic, historical, and preoperative laboratory data and 30-day postoperative complications were recorded. Univariate and multivariable analyses were performed to identify independent risk factors for complications.

Results: A total of 650 patients met inclusion criteria. Within the 30-day postoperative period, 61 complications occurred in 45 patients (6.9%). Return to the operating room, which occurred in 19 patients (2.9%), was the most common major morbidity. American Society of Anesthesiologists class III or IV and dialysis dependence were independent risk factors for any complication.

Conclusions: Proximal ulna fracture ORIF has a low rate of systemic complications. The most common morbidities are return to the operating room, blood transfusion, and urinary tract infections. Dialysis and American Society of Anesthesiologists class III or IV are independent risk factors for complications. These complications may be nonspecific and related more to the patient population than procedure. We believe that the relatively low risk of short-term complications makes operative treatment a suitable option even in elderly patients with multiple morbidities.

Type Of Study/level Of Evidence: Prognostic II.
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http://dx.doi.org/10.1016/j.jhsa.2016.08.020DOI Listing
December 2016

Elbow Kinematics During Gait Improve With Age in Children With Hemiplegic Cerebral Palsy.

J Pediatr Orthop 2018 Sep;38(8):436-439

Departments of Hand & Upper Extremity Surgery.

Background: Children with hemiplegic cerebral palsy (hCP) exhibit a typical posture of elbow flexion during gait. However, the change in elbow kinematics and symmetry during gait across age span in both hCP and typically developing (TD) children is not well described. The aim of this study was to quantify the change in elbow kinematics and symmetry across age span in hCP children compared with TD children.

Methods: Upper extremity kinematic data were extracted and analyzed from a database for gait studies performed between 2009 and 2015. A total of 35 hCP and 51 TD children between the ages of 4 and 18 (mean age: TD=11.2±0.6, hCP=9.8±0.5) met inclusionary criteria. The groups were further subdivided into 3 age categories: 4 to 7, 8 to 11, 12+ years old. Elbow angles were extracted and peak elbow flexion, overall range of motion during gait, and asymmetry indices were calculated. A 1-way analysis of variance was performed on each group with post hoc Tukey honestly significant difference pairwise comparisons.

Results: Peak elbow flexion during gait increased with age in TD children (P<0.05) and decreased with age in hCP children on the affected side (P<0.05). There was no change on the less affected side of hCP children. TD children demonstrated significantly less elbow flexion (mean=51.9±2.1 deg.) compared with the affected side in hCP (mean=82.1±3.8 deg.) across all age categories (P<0.05). There was no change in elbow asymmetry index (0=perfect symmetry) across age in either controls or hCP children; however, there were differences between hCP and TD groups in younger age groups (TD=28, hCP=62, P<0.05) that resolved by adolescence (TD=32, hCP=40).

Conclusions: During gait, hCP children have greater peak elbow flexion on the affected side than do TD children. Peak elbow flexion angle converged between the 2 groups with age, decreasing in hCP children and increasing in TD children. Furthermore, elbow symmetry during gait improves with age in hCP children, approximating symmetry of TD children by adolescence. These findings have implications for both consideration and optimal timing of surgical intervention to improve elbow flexion in children with hCP.

Level Of Evidence: Level III-retrospective case-control study.
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http://dx.doi.org/10.1097/BPO.0000000000000842DOI Listing
September 2018

Blunt Force May be an Effective Treatment for Ganglion Cysts.

HSS J 2016 Jul 24;12(2):100-4. Epub 2016 Feb 24.

Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: Ganglion cysts are the most common soft tissue tumors of the hand and wrist. There is currently no data available for the recurrence or complication rate of patients that self treat ganglion cysts by using an extrinsic force. Despite this absence of evidence, patients are still using this mode of treatment.

Questions/purposes: The purpose of the study is to evaluate the efficacy of blunt force as a treatment modality for disrupting ganglion cysts.

Methods: We analyzed videos of patients attempting to disrupt their ganglion cysts of the wrist by blunt force on Youtube.com and surveyed them anonymously. Candidates were contacted through YouTube's email server and given a link to an online questionnaire.

Results: Two hundred fourteen individuals were reviewed with a total of 1,008,913 views. Eighty three percent of videos were effective in treating the cyst. All 38 individuals that responded to the survey reported that the blunt force was effective in immediate elimination of the cyst in an average of 1.6 attempts (range 1-5). A majority (N = 21, 55%) reported no recurrence since the initial disruption of the cyst at a follow-up of 24 months.

Conclusions: YouTube.com was found to be an effective outlet to study a treatment modality that would otherwise be limited by practical considerations. The study showed that a subset of patients is utilizing blunt force trauma to successfully treat wrist ganglion cysts.
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http://dx.doi.org/10.1007/s11420-016-9493-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4916095PMC
July 2016

A Thematic Analysis of Online Discussion Boards for Brachial Plexus Injury.

J Hand Surg Am 2016 Aug 14;41(8):813-8. Epub 2016 Jun 14.

Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, St. Louis, MO; Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO. Electronic address:

Purpose: Patients with brachial plexus injury (BPI) and their family members contribute to Internet discussion groups dedicated to BPI. We hypothesized that a thematic analysis of posts from BPI Internet discussion groups would reveal common themes related to the BPI patient experience, providing topics for patient education and counseling.

Methods: Internet discussion boards were identified using the search term "brachial plexus injury support group" in Google, Bing, and Yahoo! search engines. Two discussion boards had substantially more posts than other Web sites and were chosen for analyses. Posts from January 1, 2015, through January 1, 2016, were examined. Using an iterative and established process, 2 investigators (M.T.M. and C.J.D) independently analyzed each post using thematic analysis in 3 steps (open coding, axial coding, and selective coding) to determine common themes. In this process, each post was reviewed 3 times.

Results: A total of 328 posts from the 2 leading discussion boards were analyzed. Investigators reached a consensus on themes for all posts. One central theme focused on emotional aspects of BPI. Four other central themes regarding information support were identified: BPI disease, BPI treatment, recovery after BPI treatment, and process of seeking care for BPI.

Conclusions: Examination of posts on Internet support groups for BPI revealed recurring concerns, questions, and opinions of patients and their family members. The most common themes related to disease information, treatment, recovery, and the emotional element of BPI.

Clinical Relevance: These findings provide a helpful starting point in refining topics for patient education and support that are targeted on patients' interests and concerns.
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http://dx.doi.org/10.1016/j.jhsa.2016.05.007DOI Listing
August 2016

Evaluation of Patient Information Posters Directing Patients to Access a Health Information Website.

JAMA Surg 2016 09;151(9):880-1

Divisions of Hand and Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.

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http://dx.doi.org/10.1001/jamasurg.2016.1235DOI Listing
September 2016

The Evaluation of Therapeutic Efficacy and Safety Profile of Simvastatin Prodrug Micelles in a Closed Fracture Mouse Model.

Pharm Res 2016 08 10;33(8):1959-71. Epub 2016 May 10.

The Departments of Pharmaceutical Sciences, University of Nebraska Medical Center, 986025 Nebraska Medical Center, COP 3026, Omaha, Nebraska, 68198-6025, USA.

Purpose: To evaluate the therapeutic efficiency of a micellar prodrug formulation of simvastatin (SIM/SIM-mPEG) and explore its safety in a closed femoral fracture mouse model.

Methods: The amphiphilic macromolecular prodrug of simvastatin (SIM-mPEG) was synthesized and formulated together with free simvastatin into micelles. It was also labeled with a near infrared dye for in vivo imaging purpose. A closed femoral fracture mouse model was established using a three-points bending device. The mice with established closed femoral fractures were treated with SIM/SIM-mPEG micelles, using free simvastatin and saline as controls. The therapeutic efficacy of the micelles was evaluated using a high-resolution micro-CT. Serum biochemistry and histology analyses were performed to explore the potential toxicity of the micelle formulation.

Results: Near Infrared Fluorescence (NIRF) imaging confirmed the passive targeting of SIM/SIM-mPEG micelles to the bone lesion of the mice with closed femoral fractures. The micelle was found to promote fracture healing with an excellent safety profile. In addition, the accelerated healing of the femoral fracture also helped to prevent disuse-associated ipsilateral tibia bone loss.

Conclusion: SIM/SIM-mPEG micelles were found to be an effective and safe treatment for closed femoral fracture repair in mice. The evidence obtained in this study suggests that it may have the potential to be translated into a novel therapy for clinical management of skeletal fractures and non-union.
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http://dx.doi.org/10.1007/s11095-016-1932-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4945391PMC
August 2016

Capitellum Fracture Fragment Excision: a Case Series.

HSS J 2015 Oct 1;11(3):204-8. Epub 2015 Aug 1.

Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ; Weill Cornell Medical College, New York, NY 10065 USA.

Background: Fractures of the capitellum are rare injuries, and few studies have reported the results of fragment excision.

Questions/purposes: The purpose of this study was to determine range of motion and short-term clinical outcomes for patients treated with capitellum excision.

Methods: A retrospective review was performed to identify all patients with an isolated capitellum fracture who underwent excision as definitive treatment at our institutions. Mechanism of injury, associated elbow injuries, type of capitellum fracture, complications, and postoperative outcomes including final elbow range of motion (ROM), elbow instability, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded.

Results: Four patients met the inclusion and exclusion criteria of this study. All patients were female with an average age of 69 years (range 42-85). Based on the Bryan and Morrey classification system, three (75%) fractures were classified as type I and one (25%) fracture as type III. The average clinical follow-up was 11 months. Final examination demonstrated a mean elbow range of motion from 14° (range 0-30) of extension to 143° (range 130-160) of flexion. All patients had full forearm rotation, and there was no clinical evidence of elbow instability. The average DASH score was 18.3 (12.5-24.2) at final follow-up.

Conclusion: Excision of the capitellum, much like excision of the radial head, results in acceptable short-term outcome scores and elbow range of motion in patients with fractures that are not amenable to open reduction and internal fixation.
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http://dx.doi.org/10.1007/s11420-015-9452-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773682PMC
October 2015

Online Patient Ratings: Why They Matter and What They Mean.

J Hand Surg Am 2016 Feb 1;41(2):316-9. Epub 2016 Jan 1.

Department of Hand & Upper Extremity Surgery, Hospital for Special Surgery, New York, NY. Electronic address:

The increasing focus on patient satisfaction and consumer-driven health care, combined with the recent rise in online social media, have resulted in the growing trend of patients rating physicians on publicly accessible Web sites. The number and use of such Web sites continue to grow despite potential concerns about the validity of these ratings and negative physician perception. These Web sites can influence patient decision making regarding physician selection. In this article, we review the literature regarding the use of such Web sites by patients, the validity of these ratings, potential implications for hand surgical practice, and methods to minimize or challenge inaccurate reviews.
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http://dx.doi.org/10.1016/j.jhsa.2015.04.018DOI Listing
February 2016

Online Patient Ratings of Hand Surgeons.

J Hand Surg Am 2016 Jan;41(1):98-103

Department of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY. Electronic address:

Purpose: To evaluate factors associated with positive online patient ratings and written comments regarding hand surgeons.

Methods: We randomly selected 250 hand surgeons from the American Society for Surgery of the Hand member directory. Surgeon demographic and rating data were collected from 3 physician review Web sites (www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com). Written comments were categorized as being related to professional competence, communication, cost, overall recommendation, staff, and office practice. Online presence was defined by 5 criteria: professional Web site, Facebook page, Twitter page, and personal profiles on www.Healthgrades.com and/or www.Vitals.com.

Results: A total of 245 hand surgeons (98%) had at least one rating among the 3 Web sites. Mean number of ratings for each surgeon was 13.4, 8.3, and 1.9, respectively, and mean overall ratings were 4.0 out of 5, 3.3 out of 4, and 3.8 out of 5 stars on www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com, respectively. Positive overall ratings were associated with a higher number of ratings, Castle Connolly status, and increased online presence. No consistent correlations were observed among online ratings and surgeon age, sex, years in practice, practice type (ie, private practice vs academics), and/or geographic region. Finally, positive written comments were more often related to factors dependent on perceived surgeon competence, whereas negative comments were related to factors independent of perceived competence.

Conclusions: Physician review Web sites featured prominently on Google, and 98% of hand surgeons were rated online. This study characterized hand surgeon online patient ratings as well as identified factors associated with positive ratings and comments. In addition, these findings highlight how patients assess care quality.

Clinical Relevance: Understanding hand surgeon online ratings and identifying factors associated with positive ratings are important for both patients and surgeons because of the recent growth in physician-rating Web sites.
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http://dx.doi.org/10.1016/j.jhsa.2015.10.006DOI Listing
January 2016

TMEM107 Is a Critical Regulator of Ciliary Protein Composition and Is Mutated in Orofaciodigital Syndrome.

Hum Mutat 2016 Feb 23;37(2):155-9. Epub 2015 Nov 23.

Department of Genetics, Yale University, School of Medicine, P.O. Box 208005, SHM I-142D, 333 Cedar Street, New Haven, CT, 06520.

The proximate causes of multiple human genetic syndromes (ciliopathies) are disruptions in the formation or function of the cilium, an organelle required for a multitude of developmental processes. We previously identified Tmem107 as a critical regulator of cilia formation and embryonic organ development in the mouse. Here, we describe a patient with a mutation in TMEM107 that developed atypical Orofaciodigital syndrome (OFD), and show that the OFD patient shares several morphological features with the Tmem107 mutant mouse including polydactyly and reduced numbers of ciliated cells. We show that TMEM107 appears to function within cilia to regulate protein content, as key ciliary proteins do not localize normally in cilia derived from the Tmem107 mouse mutant and the human patient. These data indicate that TMEM107 plays a key, conserved role in regulating ciliary protein composition, and is a novel candidate for ciliopathies of unknown etiology.
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http://dx.doi.org/10.1002/humu.22925DOI Listing
February 2016

The effect of simulated elbow contracture on temporal and distance gait parameters.

Gait Posture 2015 Mar 28;41(3):791-4. Epub 2015 Feb 28.

Department of Hand & Upper Extremity Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. Electronic address:

Background: Elbow contractures can be functionally debilitating. Extensive research has been published on treatments to restore elbow motion, but few have discussed clinical implications beyond the affected extremity. Reciprocal arm swing in normal gait has been shown to increase stability and reduce energy expenditure. The importance of arm swing has been clinically demonstrated in patients with cerebral palsy, stroke and Parkinson's disease. We hypothesized that elbow contractures would result in an abnormal spatio-temporal gait parameters.

Methods: Forty volunteer subjects walked on the Gaitmat II which provided real-time analysis of temporal and distance gait parameters. Five conditions were tested: no brace (control 1), elbow brace unlocked (control 2) and brace locked in 30°, 90° or 120° flexion (simulating fixed elbow contractures). Condition order was randomized for each subject. Each condition consisted of five walking trials.

Results: All three fixed elbow conditions (120°, 90° and 30°) demonstrated significantly decreased gait velocity (1.37, 1.39 and 1.39m/s) and stride length (1.45, 1.46 and 1.46m) compared to the control condition (1.42m/s and 1.48m, respectively). Single limb stance and double support times were decreased and increased, respectively, compared to control. There was no significant difference in cadence or limb asymmetry in the three fixed elbow conditions.

Conclusions: Despite well-established functional limitations in elbow contracture patients and importance of arm swing in normal gait, the impact of elbow contractures on gait is unknown. This study demonstrates that simulated elbow contracture results in significant differences in spatio-temporal gait parameters suggesting that elbow contractures have a broader functional impact beyond the affected extremity.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.gaitpost.2015.02.010DOI Listing
March 2015

Characteristics of glomus tumors in the hand not diagnosed on magnetic resonance imaging.

J Hand Surg Am 2015 Mar 30;40(3):542-5. Epub 2015 Jan 30.

Department of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY; Department of Pathology, Hospital for Special Surgery, New York, NY; Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY. Electronic address:

Purpose: To determine whether the diagnosis of hand glomus tumors by magnetic resonance imaging (MRI) is associated with tumor size, tumor pathology, tumor location, and/or clinical suspicion.

Methods: We reviewed our pathology database for patients with hand glomus tumors diagnosed between 2006 and 2013 and included those patients who had preoperative MRI at our institution. We excluded patients with recurrent and persistent tumors. Magnetic resonance imaging reports were reviewed for clinical history, tumor location, and associated bone erosion. Pathology reports were reviewed for diagnosis and tumor size. We classified MRI studies as positive (glomus tumor diagnosis), negative (no mention of glomus tumor as possible diagnosis), or indeterminate (glomus tumor mentioned as possible differential diagnosis). Fisher exact test was used to compare positive studies and those that were nondiagnostic (ie, either negative or indeterminate).

Results: Of the 46 patients who had pathologically confirmed hand glomus tumors, 38 had preoperative MRI studies. A total of 24 MRI studies were positive, 5 were indeterminate, and 7 were negative. Five patients had atypical pathology, 1 had a multifocal tumor, and 2 had extra-digital hand glomus tumors. Failure to diagnose glomus tumors on MRI was associated with atypical pathology, atypical location (ie, not located in the subungual region), absence of bone erosion, and lack of clinical suspicion. Tumor size was not associated with MRI diagnosis.

Conclusions: In this series of 36 hand glomus tumors, one-third of MRI studies were nondiagnostic. Occurrence of nondiagnostic MRIs was more likely when glomus tumors were pathologically and/or anatomically atypical, without bone erosion, and with no or unrelated clinical history provided. These findings highlight the continued importance of clinical suspicion in glomus tumor diagnosis.

Type Of Study/level Of Evidence: Diagnostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2014.12.002DOI Listing
March 2015

Conservative management of elbow dislocations with an overhead motion protocol.

J Hand Surg Am 2015 Mar 21;40(3):515-9. Epub 2015 Jan 21.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY. Electronic address:

Purpose: To report the results of using an overhead motion protocol in 27 patients and to assess final range of motion and incidence of persistent instability in this cohort.

Methods: A total of 27 patients were included who sustained a simple elbow dislocation and were treated nonsurgically with an overhead motion protocol designed to convert gravity from a distracting to a stabilizing force. Motion was initiated within 1 week of injury and average follow-up was 29 months. Final arc of motion and prevalence of instability were the primary outcomes measures.

Results: Final mean arc of extension to flexion was from 6° to 137°, and of pronation to supination was from 87° to 86°. No recurrent instability was observed in this cohort and all patients were fully functional and without limitations at latest follow-up.

Conclusions: The overhead motion protocol was a reliable rehabilitation program after elbow dislocation that allowed for controlled early motion by placing the elbow in an inherently stable position. Prompt initiation of motion in a protected position can optimize final motion and satisfaction outcomes, and when done in a mechanically advantageous position it can potentially limit the risk of recurrent instability.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2014.11.016DOI Listing
March 2015
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