Publications by authors named "Eliana B Saltzman"

16 Publications

  • Page 1 of 1

The Value Added of Advanced Imaging in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Pathology.

J Hand Surg Am 2021 Sep 1. Epub 2021 Sep 1.

Department of Orthopaedic Surgery, Duke University, Durham, NC.

Purpose: Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality.

Methods: A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand-adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed.

Results: All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand-adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand-adjusted life year), inclusion of MRA became the most favorable strategy.

Conclusions: Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics.

Type Of Study/level Of Evidence: Economic/Decision Analysis IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.06.027DOI Listing
September 2021

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcomes.

J Shoulder Elbow Surg 2021 Apr 2. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA. Electronic address:

Background: Malnutrition is associated with poor postoperative outcomes after knee, hip, and spine surgery. However, whether albumin labs should be part of the routine preoperative workup for shoulder arthroplasty remains understudied. This study investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty.

Methods: All shoulder arthroplasty cases performed at 2 tertiary referral centers between July 2013 and May 2019 (institution 1) and between June 2007 and Feb 2020 (institution 2) were reviewed. A total of 421 primary and 71 revision elective shoulder arthroplasty cases had preoperative albumin levels recorded. Common demographic variables and relevant Elixhauser comorbidities were pulled. Outcomes gathered included extended (>3 days) postoperative inpatient length of stay (eLOS), 90-day readmission, and discharge to rehab or skilled nursing facility (SNF).

Results: The prevalence of malnutrition (albumin <3.5 g/dL) was higher in the revision group compared with the primary group (36.6% vs. 19.5%, P = .001). Reverse shoulder arthroplasty (P = .013) and increasing American Society of Anesthesiologists score (P = .016) were identified as independent risk factors for malnutrition in the primary group. In the revision group, liver disease was associated with malnutrition (P = .046). Malnourished primary shoulder arthroplasty patients had an increased incidence of eLOS (26.8% vs. 13.6%, P = .003) and discharge to rehab/SNF (18.3% vs. 10.3%, P = .045). On univariable analysis, low albumin had an odds ratio (OR) of 2.34 for eLOS (P = .004), which retained significance in a multivariable model including age, American Society of Anesthesiologists score, sex, and body mass index (OR 2.11, P = .03). On univariable analysis, low albumin had an OR of 1.94 for discharge to SNF/rehab (P = .048), but this did not reach significance in the multivariable model. Among revisions, malnourished patients had an increased incidence of eLOS (30.8% vs. 6.7%, P = .014) and discharge to rehab/SNF (26.9% vs. 4.4%, P = .010). In both the primary and revision groups, there was no difference in 90-day readmission rate between patients with low or normal albumin.

Conclusion: Malnutrition is more prevalent among revision shoulder arthroplasty patients compared with those undergoing a primary procedure. Primary shoulder arthroplasty patients with low preoperative albumin levels have an increased risk of eLOS and may have an increased need for postacute care. Low albumin was not associated with a risk of 90-day readmissions. Albumin level merits further investigation in large, prospective cohorts to clearly define its role in preoperative risk stratification.
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http://dx.doi.org/10.1016/j.jse.2021.03.143DOI Listing
April 2021

Overuse Elbow Injuries in Youth Gymnasts.

Am J Sports Med 2021 Mar 29:3635465211000776. Epub 2021 Mar 29.

OrthoCarolina, Charlotte, North Carolina, USA.

Background: Gymnastics is a unique sport that places significant loads across the growing elbow, resulting in unique overuse injuries, some of which are poorly described in the current literature.

Purpose: To provide a comprehensive review of the unique overuse elbow injuries seen in youth gymnasts and to provide an up-to-date synthesis of the available literature and clinical expertise guiding treatment decisions in this population.

Study Design: Narrative review.

Methods: A review of the PubMed database was performed to include all studies describing elbow biomechanics during gymnastics, clinical entities of the elbow in gymnasts, and outcomes of operative and/or nonoperative treatment of elbow pathology in gymnasts.

Results: Participation in gymnastics among youth athletes is high, being the sixth most common sport in children. Early specialization is the norm in this sport, and gymnastics also has the highest number of participation hours of all youth sports. As a result, unique overuse elbow injuries are common, primarily on the lateral side of the elbow. Beyond common diagnoses of radiocapitellar plica and osteochondritis dissecans of the capitellum, we describe a pathology unique to gymnasts involving stress fracture of the radial head. Additionally, we synthesized our clinical experience and expertise in gymnastics to provide a sport-specific rehabilitation program that can be used by providers treating surgical and nonsurgical conditions of the elbow and wishing to provide detailed activity instructions to their athletes.

Conclusion: Overuse injuries of the elbow are common in gymnastics and include osteochondritis dissecans of the capitellum, radiocapitellar plica syndrome, and newly described radial head stress fractures. A thorough understanding of the psychological, cultural, and biomechanical aspects of gymnastics are necessary to care for these athletes.
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http://dx.doi.org/10.1177/03635465211000776DOI Listing
March 2021

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures.

JSES Int 2021 Mar 16;5(2):212-219. Epub 2020 Dec 16.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA.

Hypothesis: We hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture.

Methods: We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time.

Results: We identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (-value < .001), and rates of any complication increased from 6.5% to 13.9% (-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (-value = .042 and -value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, -value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, -value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time.

Conclusion: An increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.
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http://dx.doi.org/10.1016/j.jseint.2020.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910730PMC
March 2021

A Cadaveric Study on the Utility of the Levator Scapulae Motor Nerve as a Donor for Brachial Plexus Reconstruction.

J Hand Surg Am 2021 Sep 21;46(9):812.e1-812.e5. Epub 2021 Jan 21.

Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY. Electronic address:

Purpose: The purpose of the study was to evaluate the utility of the levator scapulae motor nerve (LSN) as a donor nerve for brachial plexus nerve transfer. We hypothesized that the LSN could be transferred to the suprascapular nerve (SSN) or long thoracic nerve (LTN) with a reliable tension-free coaptation and appropriate donor-to-recipient axon count ratio.

Methods: Twelve brachial plexus dissections were performed on 6 adult cadavers, bilaterally. We identified the LSN, spinal accessory nerve (SAN), SSN, and LTN. Each nerve was prepared for transfer and nerve redundancies were calculated. Cross-sections of each nerve were examined histologically, and axons counted. We transferred the LSN to target first the SSN and then the LTN, in a tension-free coaptation. For reference, we transferred the distal SAN to target the SSN and LTN and compared transfer parameters.

Results: Three cadavers demonstrated 2 LSN branches supplying the levator scapulae. The axon count ratio of donor-to-recipient nerve was 1:4.0 (LSN:SSN) and 1:2.1 (LSN:LTN) for a single LSN branch and 1:3.0 (LSN:SSN) and 1:1.6 (LSN:LTN) when 2 LSN branches were available. Comparatively, the axon count ratio of donor-to-recipient nerve was 1:2.5 and 1:1.3 for the SAN to the SSN and the LTN, respectively. The mean redundancy from the LSN to the SSN and the LTN was 1.7 cm (SD, 3.1 cm) and 2.9 cm (SD, 2.8 cm), and the redundancy from the SAN to the SSN and the LTN was 4.5 (SD, 0.7 cm) and 0.75 cm (SD, 1.0 cm).

Conclusions: These data support the use of the LSN as a potential donor for direct nerve transfer to the SSN and LTN, given its adequate redundancy and size match.

Clinical Relevance: The LSN should be considered as an alternative nerve donor source for brachial plexus reconstruction, especially in 5-level injuries with scarce donor nerves. If used in lieu of the SAN during primary nerve reconstruction, trapezius tendon transfer for improved external rotation would be enabled.
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http://dx.doi.org/10.1016/j.jhsa.2020.11.022DOI Listing
September 2021

Association of Claustrophobia and Anxiety with Cast Intolerance in Patients with Extremity Injuries.

HSS J 2020 Dec 28;16(Suppl 2):383-393. Epub 2020 Jul 28.

Hospital for Special Surgery, New York, NY USA.

Background: Patients undergoing casting for upper or lower extremity injuries may present with recalcitrant pain without an identifiable physiologic etiology, which increases the likelihood of more frequent or unscheduled office visits, insomnia, decreased patient satisfaction, unnecessary investigative procedures or treatments, and-in some cases-cast intolerance. The exact causes of cast intolerance are not well studied, although claustrophobia and associated fears of suffocation and restriction may be underlying causes.

Questions/purposes: We sought to explore the association between claustrophobic tendencies and cast intolerance. We hypothesized that patients with claustrophobia or claustrophobic tendencies would have a higher rate of cast intolerance.

Methods: Patients requiring circumferential casting of an upper or lower extremity were prospectively enrolled at the time of cast application. Data were collected at each office visit until cast removal. Pre- and post-casting anxiety were quantified using the Beck Anxiety Inventory (BAI). Pain was assessed at each visit using the visual analog scale (VAS). Claustrophobic tendencies were evaluated after cast removal using the Claustrophobia Questionnaire (CLQ). At the completion of the study, patients were assigned to either the cast-tolerant or the cast-intolerance cohort according to predetermined criteria. CLQ, BAI, and VAS scores were compared between cohorts.

Results: Out of 199 patients enrolled, 4% ( = 8) met the criteria for cast intolerance. There was no difference in BAI (anxiety) scores between groups at casting, but cast-intolerant patients had significantly lower post-casting BAI scores than the cast-tolerant controls, indicating a decrease in anxiety after cast removal. Taken together, both groups demonstrated significant reduction in VAS scores from casting to cast removal. The tolerant group had a significant reduction in VAS scores, whereas the intolerant group did not. The intolerant group had a significant negative correlation between initial VAS scores and final BAI scores. The tolerant group had a significant positive correlation between initial VAS scores and final BAI scores, as well as between final VAS scores and final BAI scores. Interestingly, no difference in CLQ scores was seen between groups, although there were positive correlations between CLQ scores and pre- and post-casting anxiety scores and between CLQ and final VAS scores.

Conclusions: Our hypothesis was not supported. Although we did not find a relationship between claustrophobia and cast intolerance, we did find significant correlations between anxiety and pain. The tolerant group's initial and final pain scores had significantly positive correlations to final anxiety, suggesting that pain is likely to cause or increase anxiety; indeed, as pain decreased, so did anxiety. The intolerant group, however, had a significant negative correlation between initial pain and final anxiety scores. It would not be expected that lower pain scores would increase anxiety. This may suggest that cast-intolerant patients experience or report their anxiety as pain. These findings may explain why some patients suffer from pain that cannot be explained by an underlying physiologic process and is resistant to traditional pain management. A multidisciplinary approach, including psychological and psychosocial assessments, may help identify nonphysiologic components to pain. An accurate diagnosis for the cause of pain may lead to nonpharmacological interventions and therefore reduce opioid use and overall costs and improve patient outcomes.
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http://dx.doi.org/10.1007/s11420-020-09763-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749881PMC
December 2020

Opioid Prescription After Carpal Tunnel Release Is Declining Independent of State Laws.

J Am Acad Orthop Surg 2021 Jun;29(11):486-497

From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

Background: The opioid misuse crisis focused attention on opioid overprescribing prompting legislation, limiting prescribing. The purpose of this study was to evaluate of opioid filling surrounding carpal tunnel release (CTR) with the hypothesis that filling has decreased in response to state legislation.

Methods: This is a retrospective, observational study of initial discharge, 30-day, 90-day, and 1-year cumulative opioid filling after CTR in a commercial insurance database between 2010 and 2018. All patients aged 18 and older undergoing CTR and with active insurance status for 6 months preoperative through 30 days, 90 days, and 1 year postoperative were considered for inclusion. Patients undergoing same-day distal radius fracture fixation were excluded. Initial and cumulative perioperative patient, state, and year-level opioid filling rates and volumes in oxycodone 5 mg equivalents (oxycodone 5-mg pills) were evaluated.

Results: Patients filled mean volumes of 33, 72, and 144 oxycodone 5-mg pills in the initial prescription, by 90 days post-op and by 1 year post-op, respectively. First prescription opioid filling volume (35 oxycodone 5-mg pills 2010 and 27 oxycodone 5-mg pills 2018, P < 0.001) and cumulative 90-day filling (96 oxycodone 5-mg pills 2010 and 56 oxycodone 5-mg pills 2018, P < 0.001) have decreased significantly from 2010 to 2018. Ten of 24 (41.7%) of states with opioid-limiting legislation had large (>5 oxycodone 5-mg pills), significant reductions in initial opioid filling volume after legislation. Five of 13 (38.5%) states without opioid-limiting legislation had similar reductions during the study period. Thirteen of 24 (54.2%) states with opioid-limiting legislation had large, notable reductions in 90-day opioid filling volume after legislation. Six of 13 (46.2%) states without opioid-limiting legislation had similar reductions during the study period.

Conclusion: Initial and cumulative opioid filling surrounding CTR has decreased significantly since 2010. However, opioid legislation did not result in substantial changes in rates of large, significant reductions in state-specific opioid prescribing.
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http://dx.doi.org/10.5435/JAAOS-D-20-00955DOI Listing
June 2021

Humeral intramedullary nail placement through the rotator interval: an anatomic and radiographic analysis.

J Shoulder Elbow Surg 2021 Apr 19;30(4):747-755. Epub 2020 Aug 19.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Antegrade humeral intramedullary nails are an effective fixation method for certain proximal humeral fractures and humeral shaft fractures. However, owing to potential rotator cuff damage during nail insertion, shoulder pain remains a common postoperative complaint. The purpose of this study was to provide quantitative data characterizing the anatomic and radiographic location of the rotator interval (RI) for an antegrade humeral intramedullary nail using a mini-deltopectoral approach.

Methods: Six consecutive fresh-frozen intact cadaveric specimens (mean age, 69 ± 12.8 years) were obtained for our study. Demographic data were collected on each specimen. A mini-deltopectoral approach was used, followed by placement of a guidewire in the RI. Quantitative anatomic relationships were calculated using a fractional carbon fiber digital caliper. Radiographic measurements were performed by 2 orthopedic residents and 1 practicing fellowship-trained orthopedic surgeon. In addition to re-measurement of similar anatomic relationships on radiographs, the ratio of the distance from the lateral humeral edge to the starting point relative to the width of the humeral head on the anteroposterior (AP) view was calculated. Similarly, on the lateral view, the ratio of the distance from the anterior humeral edge to the starting point relative to the humeral head width was calculated.

Results: In all cases, the described approach allowed for preservation of the biceps tendon and access to the RI for guidewire insertion, with no subsequent rotator cuff or humeral articular cartilage damage identified following nail insertion. The ratio of the distance from the lateral humeral edge to the starting point relative to the humeral head width on the AP view was 0.4 ± 0.0. The ratio of the distance from the anterior humeral edge to the starting point relative to the humeral head width on the lateral view was 0.3 ± 0.0.

Conclusion: This study demonstrates the clinical feasibility of a mini-deltopectoral approach and shows that the ideal starting point through the RI radiographically lies along the medial aspect of the lateral third of the humeral head on the AP view and along the posterior aspect of the anterior third of the humeral head on the lateral view.
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http://dx.doi.org/10.1016/j.jse.2020.07.044DOI Listing
April 2021

A Reliability Study of Multiplanar Radiographs for the Evaluation of SNAC Wrist Arthritis.

Hand (N Y) 2020 Jul 16:1558944720937359. Epub 2020 Jul 16.

Duke University Medical Center, Durham, NC, USA.

Scaphoid nonunion advanced collapse (SNAC) is a common form of wrist arthritis, the treatment of which depends on the arthritic stage. The Vender classification serves to describe SNAC arthritis based on a single posteroanterior (PA) radiograph. The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Vender classification, comparing multi versus single radiographic views. A retrospective review of patients with SNAC arthritis who underwent a proximal row carpectomy or a 4-corner fusion was performed. The included patients had 3 radiographic views of the pathologic wrist. Fifteen patients were analyzed by 5 blinded reviewers. Wrists were graded using the Vender classification first on the PA view and then using multiview radiographs. The intraobserver and interobserver agreement was determined using weighted kappa analysis. χ tests were calculated comparing the evaluation between single- versus multiview radiographs and determining a higher Vender stage. Multiview radiographs demonstrated a higher intraobserver κ compared with single-view radiographs (0.72 vs 0.66), both representing substantial agreement. The average interobserver agreement was moderate (κ of 0.48) for single view and slight (κ of 0.30) for multiview evaluation. Evaluating multiview radiographs was 6.37 times more likely to demonstrate Vender stage 3 arthritis compared with single view (odds ratio = 6.37 [confidence interval, 3.81-10.64], < .0001). Reviewing multiview radiographs more commonly yielded Vender stage 3 osteoarthritis classification. The decreased interrater reliability in the multiview analysis is likely related to the increased number of articular surfaces evaluated. Using a single PA view may underestimate the severity of arthritis present.
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http://dx.doi.org/10.1177/1558944720937359DOI Listing
July 2020

Role of high-resolution peripheral nerve magnetic resonance imaging in diagnosing median nerve tethering in a case of both-bone forearm fracture in a child.

Pediatr Radiol 2021 01 3;51(1):148-151. Epub 2020 Jul 3.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Forearm fractures are common injuries in pediatric patients. We present a case of median nerve tethering as a complication of both-bone forearm fracture in a child, with an emphasis on MRI as an appropriate and important complement to clinical and electrodiagnostic examination. Early intervention is essential because delayed surgical management of median nerve tethering can result in poor clinical outcomes as a result of irreversible muscle denervation. In this case, we highlight the importance of MRI to facilitate management, including early surgical intervention when appropriate, in median neuropathy following forearm fractures.
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http://dx.doi.org/10.1007/s00247-020-04732-yDOI Listing
January 2021

Trends in reimbursement for primary and revision total elbow arthroplasty.

J Shoulder Elbow Surg 2021 Jan 28;30(1):146-150. Epub 2020 Jun 28.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Relative value units (RVUs) are an essential component of reimbursement calculations from the Centers for Medicare & Medicaid Services. RVUs are calculated based on physician work, practice expense, and professional liability insurance. Procedures that are more complex, such as revision arthroplasty, require greater levels of physician work and should therefore be assigned a greater RVU. The purpose of this study is to compare RVUs assigned for primary and revision total elbow arthroplasty (TEA).

Methods: The National Surgical Quality Improvement Program database was used to collect all primary and revision total elbow arthroplasties performed between January 2015 and December 2017. Variables collected included age at time of surgery, RVUs assigned for the procedure, and operative time.

Results: A total of 359 cases (282 primary TEA, 77 revision TEA) were included in this study. Mean RVUs for primary TEA was 21.4 (2.0 standard deviation [SD]) vs. 24.4 (1.7 SD) for revision arthroplasty (P < .001). Mean operative time for primary TEA was 137.9 minutes (24.4 SD) vs. 185.5 minutes (99.7 SD) for revision TEA (P < .001). The RVU per minute for primary TEA was 0.16 and revision TEA was 0.13 (P < .001). This amounts to a yearly reimbursement difference of $71,024 in favor of primary TEA over revision TEA.

Conclusion: The current reimbursement model does not adequately account for increased operative time, technical demand, and pre- and postoperative care associated with revision elbow arthroplasty compared with primary TEA. This leads to a financial advantage on performing primary TEA.
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http://dx.doi.org/10.1016/j.jse.2020.06.004DOI Listing
January 2021

A Comparison Between Two Collagen Nerve Conduits and Nerve Autograft: A Rat Model of Motor Nerve Regeneration.

J Hand Surg Am 2019 Aug 27;44(8):700.e1-700.e9. Epub 2018 Nov 27.

Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, NY; Weill Medical College of Cornell University, New York, NY. Electronic address:

Purpose: To compare recovery in a rat model of sciatic nerve injury using a novel polyglycolic acid (PGA) conduit, which contains collagen fibers within the tube, as compared with both a hollow collagen conduit and nerve autograft. We hypothesize that a conduit with a scaffold will provide improved nerve regeneration over hollow conduits and demonstrate no significant differences when compared with autograft.

Methods: A total of 72 Sprague-Dawley rats were randomized into 3 experimental groups, in which a unilateral 10-mm sciatic defect was repaired using either nerve autograft, a hollow collagen conduit, or a PGA collagen-filled conduit. Outcomes were measured at 12 and 16 weeks after surgery, and included bilateral tibialis anterior muscle weight, voltage and force maximal contractility, assessment of ankle contracture, and nerve histology.

Results: In all groups, outcomes improved between 12 and 16 weeks. On average, the autograft group outperformed both conduit groups, and the hollow conduit demonstrated improved outcomes when compared with the PGA collagen-filled conduit. Differences in contractile force, however, were significant only at 12 weeks (autograft > hollow collagen conduit > PGA collagen-filled conduit). At 16 weeks, contractile force demonstrated no significant difference but corroborated the same absolute results (autograft > hollow collagen conduit > PGA collagen-filled conduit).

Conclusions: Nerve repair using autograft provided superior motor nerve recovery over the 2 conduits for a 10-mm nerve gap in a murine acute transection injury model. The hollow collagen conduit demonstrated superior results when compared with the PGA collagen-filled conduit.

Clinical Relevance: The use of a hollow collagen conduit provides superior motor nerve recovery as compared with a PGA collagen-filled conduit.
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http://dx.doi.org/10.1016/j.jhsa.2018.10.008DOI Listing
August 2019

Nerve Transfers for Enterovirus D68-Associated Acute Flaccid Myelitis: A Case Series.

Pediatr Neurol 2018 11 20;88:25-30. Epub 2018 Aug 20.

Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, New York; Weill Medical College of Cornell University, New York, New York; New York-Presbyterian Hospital, New York, New York. Electronic address:

Background: Acute flaccid myelitis is associated with enterovirus D68 -induced inflammation and destruction of cervical anterior horn cells. To date, no medical intervention has altered the disease course.

Methods: We report two pediatric patients who were treated with nerve transfer in three limbs with sustained upper extremity neuropathy. Postoperative outcomes included muscle strength, graded on the British Medical Research Council (BMRC) scale, range of motion, and electromyography.

Results: Two years postoperatively, Patient 1 had improved elbow flexion to BMRC grade 4+, 125° of flexion, and discrete to decreased motor unit recruitment in targeted muscles. Twenty-one months postoperatively, Patient 2 demonstrated right brachialis flexion to BMRC grade 4+/5 and deltoid firing with simultaneous pectoralis major recruitment, and limited but active flexor digitorum profundus flexion.

Conclusions: Both patients continue to demonstrate functional recovery two years postoperatively. These outcomes suggest a promising reconstructive technique for this emerging and devastating viral endemic.
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http://dx.doi.org/10.1016/j.pediatrneurol.2018.07.018DOI Listing
November 2018

Evaluation of two collagen conduits and autograft in rabbit sciatic nerve regeneration with quantitative magnetic resonance DTI, electrophysiology, and histology.

Eur Radiol Exp 2018 Dec 8;2:19. Epub 2018 Aug 8.

1Department of Radiology and Imaging, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10021 USA.

Background: We compared different surgical techniques for nerve regeneration in a rabbit sciatic nerve gap model using magnetic resonance diffusion tensor imaging (DTI), electrophysiology, limb function, and histology.

Methods: A total of 24 male New Zealand white rabbits were randomized into three groups: autograft ( = 8), hollow conduit ( = 8), and collagen-filled conduit ( = 8). A 10-mm segment of the rabbit proximal sciatic nerve was cut, and autograft or collagen conduit was used to bridge the gap. DTI on a 3-T system was performed preoperatively and 13 weeks after surgery using the contralateral, nonoperated nerve as a control.

Results: Overall, autograft performed better compared with both conduit groups. Differences in axonal diameter were significant (autograft > hollow conduit > collagen-filled conduit) at 13 weeks (autograft vs. hollow conduit,  = 0.001, and hollow conduit vs. collagen-filled conduit,  < 0.001). Significant group differences were found for axial diffusivity but not for any of the other DTI metrics (autograft > hollow conduit > collagen-filled conduit) (autograft vs. hollow conduit,  = 0.001 and hollow conduit vs. collagen-filled conduit,  = 0.021). As compared with hollow conduit (autograft > collagen-filled conduit > hollow conduit), collagen-filled conduit animals demonstrated a nonsignificant increased maximum tetanic force.

Conclusions: Autograft-treated rabbits demonstrated improved sciatic nerve regeneration compared with collagen-filled and hollow conduits as assessed by histologic, functional, and DTI parameters at 13 weeks.
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http://dx.doi.org/10.1186/s41747-018-0049-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6091702PMC
December 2018

Development of a Questionnaire to Measure Impact and Outcomes of Brachial Plexus Injury.

J Bone Joint Surg Am 2018 Feb;100(3):e14

Hospital for Special Surgery, New York, NY.

Background: The physical and psychological impact of brachial plexus injury (BPI) has not been comprehensively measured with BPI-specific scales. Our objective was to develop and test a patient-derived questionnaire to measure the impact and outcomes of BPI.

Methods: We developed a questionnaire in 3 phases with preoperative and postoperative patients. Phase 1 included interviews of patients using open-ended questions addressing the impact of BPI and improvement expected (preoperative patients) or received (postoperative patients). Phase 2 involved assembling a draft questionnaire and administering the questionnaire twice to establish test-retest reliability. Phase 3 involved selecting final items, developing a scoring system, and assessing validity. Patient scores using the questionnaire were assessed in comparison with scores of the Disabilities of the Arm, Shoulder and Hand (DASH) and RAND-36 measures.

Results: Patients with partial or complete plexopathy participated. In Phase 1 (23 patients), discrete categories were discerned from open-ended responses and became items for the preoperative and postoperative versions of the questionnaire. In Phase 2 (50 patients [14 from Phase 1]), test-retest reliability was established, with weighted kappa values of ≥0.50 for all items. In Phase 3, 43 items were retained and grouped into 4 subscales: symptoms, limitations, emotion, and improvement expected (preoperative) or improvement received (postoperative). A score for each subscale, ranging from 0 to 100, can be calculated, with higher scores indicating more symptoms, limitations, and emotional distress, and greater improvement expected (or received). Preoperative scores were worse than postoperative scores for the symptoms, limitations, and emotion subscales (composite score of 48 compared with 38; p = 0.05), and more improvement was expected than was received (69 compared with 53; p = 0.01). Correlations with the DASH (0.44 to 0.74) and RAND-36 (0.23 to 0.80) for related scales were consistent and moderate, indicating that the new questionnaire is valid and distinct.

Conclusions: We developed a patient-derived questionnaire that measures the physical and psychological impact of BPI on preoperative and postoperative patients and the amount of improvement expected or received from surgery. This BPI-specific questionnaire enhances the comprehensive assessment of this population.
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February 2018

MRI bullseye sign: An indicator of peripheral nerve constriction in parsonage-turner syndrome.

Muscle Nerve 2017 07 2;56(1):99-106. Epub 2017 Mar 2.

Weill Medical College of Cornell University, New York, New York, USA.

Introduction: The role of MRI in identifying hourglass constrictions (HGCs) of nerves in Parsonage-Turner syndrome (PTS) is largely unknown.

Methods: Six patients with PTS and absent or minimal recovery underwent MRI. Surgical exploration was performed at identified pathologic sites.

Results: The time between symptom onset and surgery was 12.4 ± 6.9 months; the time between MRI and surgery was 1.3 ± 0.6 months. Involved nerves included suprascapular, axillary, radial, and median nerve anterior interosseous and pronator teres fascicles. Twenty-three constriction sites in 10 nerves were identified on MRI. A "bullseye sign" of the nerve, identified immediately proximal to 21 of 23 sites, manifested as peripheral signal hyperintensity and central hypointensity orthogonal to the long axis of the nerve. All constrictions were confirmed operatively.

Conclusions: In PTS, a bullseye sign on MRI can accurately localize HGCs, a previously unreported finding. Causes of HGCs and the bullseye sign are unknown. Muscle Nerve 56: 99-106, 2017.
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July 2017
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