Publications by authors named "Robert J Strauch"

102 Publications

Isolated Radial Nerve Palsy After Glenohumeral Dislocation in a Collegiate Athlete: A Review of the Literature.

J Hand Surg Glob Online 2021 Nov 11;3(6):360-362. Epub 2021 Aug 11.

Department of Orthopedic Surgery, Columbia University Medical Center, New York City, NY.

Isolated mononeuropathies are uncommon complications after shoulder dislocations. Of these, injuries to the radial nerve are the rarest. Here, we present a case of an isolated radial nerve palsy after a collegiate athlete was hit during a football game and sustained a glenohumeral dislocation. After reduction of the shoulder, he went on to full recovery of motor and sensory function of the radial nerve 1 year after the injury. This case report is further unique given the long-term follow-up in a young, active patient. We review the sparse literature behind the epidemiology and management of these complications.
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http://dx.doi.org/10.1016/j.jhsg.2021.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8991745PMC
November 2021

Resorbable Nerve Wraps: Can They Be Overtightened?

J Reconstr Microsurg 2022 Mar 15. Epub 2022 Mar 15.

Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York.

Background:  Nerve wrapping has been advocated to minimize scarring and adhesion following neurorrhaphy or neurolysis. A wrap should provide an enclosure that is snug enough to protect and support the affected nerve without strangulating the nerve. The degree to which resorbable wraps should be ": tightened" around the nerve is largely subjective with scant literature on the subject. The purpose of this study was to evaluate the effects of tightly fitting resorbable nerve wraps around intact rat sciatic nerves.

Methods:  Twenty-four Sprague-Dawley rats underwent exposure and circumferential measurement of the right sciatic nerve. Porcine-derived extracellular matrix (ECM) wraps were trimmed and sutured to enclose the nerve with a tight (same as that of the nerve,   8) or loose (2.5x that of the nerve,   8) circumference. Sham-surgery control animals ( = 8) had no wrap treatment. Functional outcome was recorded biweekly by sciatic functional index (SFI) with walking track analysis and electrical stimulation. Animals were sacrificed at 12 weeks for histologic analyses.

Results:  No withdrawal response could be evoked in the tight-wrap group until week 9, while significant improvement in SFI first occurred between weeks 5 and 7. By week 12, the tight-wrap group required 60% more current compared with baseline stimulation to produce a withdrawal response. They recovered 81% of SFI baseline values but also demonstrated significantly greater intraneural collagen content ( < 0.001) and lower axon density ( < 0.05) than in the loose-wrap and sham groups. The loose-wrap group had comparable functional and histologic outcomes to the sham control group.

Conclusion:  Resorbable ECM nerve wraps applied tightly around intact rat sciatic nerves caused significant functional impairment and histological changes characteristic of acute nerve compression. Significant but incomplete functional recovery was achieved by the tight-wrap group after 12 weeks, but such recovery may not apply in humans.
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http://dx.doi.org/10.1055/s-0042-1744274DOI Listing
March 2022

Extensor Tendon Injury After Volar Locking Plating for Distal Radius Fractures: A Systematic Review.

Hand (N Y) 2022 Feb 15:15589447211068186. Epub 2022 Feb 15.

Columbia University Medical Center, New York, NY, USA.

Distal radius fractures are common orthopedic injuries. Treatment has varied historically, but volar locking plating currently predominates. Although flexor tendon injury is a well-studied complication of this operation, extensor tendon injury is less well studied. The purpose of this review is to search the literature and present the epidemiology, presentation, and treatment of this complication. The Cochrane, EMBASE, PubMed, and SCOPUS databases were searched for the terms "volar" + "radius" + ("plate" OR "plating") + "extensor." Ninety final studies were included for analysis in this review. The incidence of extensor tendon rupture varies from 0% to 12.5%; the extensor pollicis longus is most commonly ruptured. The presentation and management of extensor tendon injury after injury, intraoperatively, and postoperatively are summarized. Radiographic views are described to detect screw prominence and minimize intraoperative risk. Extensor tendon injury after volar locking plate for distal radius fractures is an uncommon injury with several risk factors including dorsal screw prominence and fracture fragments. Removal of hardware and tendon transfers or reconstruction may be necessary to prevent loss of extensor mechanism.
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http://dx.doi.org/10.1177/15589447211068186DOI Listing
February 2022

Flexor tenosynovectomy in carpal tunnel syndrome as a screening tool for early diagnosis of amyloidosis.

Ir J Med Sci 2021 Oct 28. Epub 2021 Oct 28.

Department of Orthopaedic Surgery, Columbia University Medical Center, New York, USA.

Introduction: Amyloidosis is a heterogeneous group of diseases that most often presents with advanced cardiac pathology. Another presentation of the disease can include symptoms consistent with carpal tunnel syndrome; however, the true incidence of amyloidosis in patients with carpal tunnel syndrome remains unclear.

Methods: We performed a retrospective chart review on all patients who underwent an open carpal tunnel release, with tenosynovium biopsy by a single surgeon between 01/2000 and 12/2018. Samples were stored in formalin following hematoxylin-eosin or congo red staining. A total of 199 patients were excluded for incomplete records, and carpal tunnel release performed for traumatic or infectious etiologies. Histologic findings of the attending pathologist were examined and categorized as follows: amyloidosis, fibrous tissue, tenosynovitis/inflammation edematous, benign tenosynovium, and gout.

Results: Exactly 898 open carpal tunnel releases were performed, and 699 patients were included for final analysis. In all patients, biopsies for histology with hematoxylin-eosin (HE) staining were taken; in those HE stains where amylogenic proteins were suspected (73 or 10.4%), a subsequent congo red staining was additionally performed which confirmed the diagnosis of amyloidosis in 10 patients (1.4% of the carpal tunnel procedures). Overall, 10 patients were identified and constituted 1.4% of all HE stains (n = 10/699) and 13.7% of all congo red stains (n = 10/73).

Conclusion: Our results suggest that the incidence of amyloidosis in the general CTS patient population may be as high as 1.4% with routine screening by synovial biopsy and the diagnosis should be considered as a potential cause. Level of Evidence: III, retrospective study.
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http://dx.doi.org/10.1007/s11845-021-02832-8DOI Listing
October 2021

Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels.

Clin Orthop Relat Res 2021 12;479(12):2576-2586

Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA.

Background: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables.

Questions/purposes: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians?

Methods: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized β coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics.

Results: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did.

Conclusion: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases.

Clinical Relevance: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic.
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http://dx.doi.org/10.1097/CORR.0000000000001987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8726546PMC
December 2021

Percutaneous Fixation of Unstable Proximal Phalanx Fractures: A Biomechanical Study.

Hand (N Y) 2021 Jun 9:15589447211017224. Epub 2021 Jun 9.

Columbia University Irving Medical Center, New York, NY, USA.

Background: Unstable extra-articular proximal phalanx fractures are common injuries to the hand that are often treated by closed reduction and percutaneous pinning. Fracture-induced shortening of the proximal phalanx leads to an extensor lag at the proximal interphalangeal joint. We describe a biomechanical study in cadaver hands to compare the ability of each of three different pin configurations to resist shortening in unstable fractures.

Methods: Seventeen fresh frozen hands were disarticulated at the proximal ends of the metacarpals. The second, third, and fourth proximal phalanges were tested. A 5-mm section of bone was resected from the mid-shaft of proximal phalanx to simulate an unstable fracture. Three techniques were employed and randomized for each finger: transmetacarpophalangeal joint pinning using 1 or 2 Kirschner wires (K-wires) and periarticular cross pinning using 2 K-wires. Compressive axial loads and energy at 1 mm, 2 mm, 3 mm, 4 mm, and 5 mm of subsidence were examined.

Results: The forces and energy required to shorten the finger for each amount of subsidence were similar for all 3 pinning techniques and for all 3 finger types. Greater amounts of shortening were found to require larger forces.

Conclusion: Closed reduction and percutaneous pinning using any of the presented techniques is an adequate method of treatment for unstable proximal phalanx fractures. All of the techniques were equivalent in their ability to resist axial loading, regardless of the complexity of technique, the number of pins used, or finger that was pinned.
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http://dx.doi.org/10.1177/15589447211017224DOI Listing
June 2021

Recurrence Rates of Dorsal Wrist Ganglion Cysts After Arthroscopic Versus Open Surgical Excision: A Retrospective Comparison.

Hand (N Y) 2021 Apr 1:15589447211003184. Epub 2021 Apr 1.

Columbia University Irving Medical Center, New York City, NY, USA.

Background: This study directly compares the recurrence rates of dorsal wrist ganglion cysts in patients treated via open surgical excision versus arthroscopic surgical excision. We hypothesized that there would be no difference between recurrence rates with these 2 surgical options.

Methods: We retrospectively reviewed the charts of all patients with a dorsal ganglion cyst undergoing either open or arthroscopic surgical excision at a single academic center with 3 fellowship-trained attending hand surgeons from 2012 to 2017. Charts were identified using codes and were reviewed using postoperative office notes for preoperative and postoperative symptoms, episodes of recurrence, time at which recurrence occurred, subsequent operations, and outcome at final follow-up.

Results: The charts of 172 patients undergoing either arthroscopic or open dorsal ganglion excision were reviewed. Nine of 54 (16.7%) arthroscopic excisions resulted in cyst recurrence, while 8 of 118 (6.8%) open excisions resulted in cyst recurrence ( = .044). Two of 9 (22%) recurrences after arthroscopic ganglion excision versus 2 of 8 (25%) recurrences after open ganglion excision underwent repeat surgical intervention. Time to recurrence, as well as final follow-up, was not statistically different between groups.

Conclusions: Dorsal wrist ganglion cysts are the most common benign soft tissue mass of the upper extremity, but it remains unknown whether arthroscopic or open surgical excision leads to lower recurrence rate. Scant literature exists directly comparing these 2 methods of surgical excision. This study suggests that open excision of dorsal wrist ganglia leads to a lower recurrence rate than does arthroscopic excision.
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http://dx.doi.org/10.1177/15589447211003184DOI Listing
April 2021

Non-operative Management of Adult Both Bone Forearm Fractures - A Case Report and Literature Review.

J Orthop Case Rep 2020 Oct;10(7):53-56

Department of Orthopaedics, Columbia University Medical Center, 622 West 168th Street PH 11-1119, New York, NY 10032, USA.

Introduction: Adult both bone forearm fractures (BBFF) are common injuries that are typically treated with operative fixation given their instability. Non-displaced fractures can be theoretically treated non-operatively, but there is no literature demonstrating treatment outcomes of such fractures.

Case Report: We present a case of non-displaced BBFF in a 23-year-old Caucasian male adult who was treated with cast immobilization and concomitant ultrasound stimulator use; this patient went on to have solid fracture healing without complication.

Conclusion: Based on this case, we demonstrate that non-operative management of non-displaced BBFF in adult patients is an option if close follow-up is available. This is significant for the fields of both orthopedic and plastic surgery, as there is little concrete evidence of outcomes of such non-displaced fractures in hand surgery literature.
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http://dx.doi.org/10.13107/jocr.2020.v10.i07.1916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857656PMC
October 2020

Top Tips for an Orthopaedic Surgeon's Practice.

Instr Course Lect 2021 ;70:577-586

As orthopaedic surgeons become more specialized, it is important that they remain up to date in the diagnosis and management of common orthopaedic problems. These can include conditions encountered in the clinic and/or on call. It is important that practicing surgeons stay abreast of recognition and management of problems, not only for the patients, but also to avoid commonly missed conditions or less-than-optimal treatment. The orthopaedic surgeon should be aware of the top tips in multiple disciplines, including orthopaedic oncology, hand, and trauma.
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January 2021

Ring finger metacarpal fracture iatrogenic rotation using an ulnar gutter splint: A cadaveric study.

J Hand Ther 2022 Jan-Mar;35(1):80-85. Epub 2020 Oct 24.

Columbia University Medical Center, New York City, NY, USA.

Study Design: Cohort cadaveric study.

Introduction: Ring finger metacarpal fractures are often treated with ulnar gutter orthoses incorporating the ring and small fingers. Iatrogenic pronation of the distal metacarpal fragment may occur from overzealous orthotic "molding", resulting in a crossover deformity of the ring finger over the small finger.

Purpose Of The Study: The goal of this cadaveric study is to determine whether including the middle finger in an ulnar gutter orthotic could lessen the chances of iatrogenic ring finger metacarpal fracture rotation.

Methods: Transverse ring finger metacarpal shaft fractures were created in 24 cadaver hands. The ring and small fingers were then placed into an intrinsic plus position, simulating the application of an ulnar gutter orthotic. Weights of 2.5, 5, and 10 pounds were applied to the ring and small fingers to simulate iatrogenic-induced fracture pronation. The amount of rotational displacement at the fracture was measured, and the protocol was repeated, including the middle finger in the intrinsic plus position. Mann-Whitney-Wilcoxon test was used for statistical analysis.

Results: There was an increase in distal fragment rotation with increasing weight. Fracture displacement was greater with the 2-finger position than the 3-finger at all weight levels; this reached statistical significance at 10 lbs (2.8 vs 1.8 mm).

Conclusions: Application of an ulnar gutter orthotic including only ring and small fingers can rotate the distal fragment of a ring finger metacarpal shaft fracture such that overlap could occur with the small finger. Including the middle finger in ulnar gutter splints will mitigate against the rotation of the ring finger metacarpal shaft fracture.
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http://dx.doi.org/10.1016/j.jht.2020.10.018DOI Listing
May 2022

The Benefits of Expert Instruction in Microsurgery Courses.

J Reconstr Microsurg 2021 Feb 8;37(2):143-153. Epub 2020 Sep 8.

Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York.

Background:  Microsurgery requires repeated practice and training to achieve proficiency, and there are a variety of curriculums available. This study aims to determine the importance of an expert instructor to guide students through procedures. We compared student proficiency across two microsurgery courses: one with (Columbia University, United States [CU] cohort) and one without a dedicated microsurgery instructor (University of Thessaloniki, Greece [UT] cohort).

Methods:  Students were divided into two cohorts of 22 students (UT cohort) and 25 students (CU cohort). Student progress was evaluated by examining patency (lift-up and milking tests), anastomotic timing, and quality (Anastomosis Lapse Index [ALI]) of end-to-end arterial and venous anastomoses on day 1 and again on day 5. Chi-squared tests evaluated patency immediately and 30 minutes postoperation. -Tests evaluated anastomotic timing and ALI scores. -Values < 0.05 were considered significant.

Results:  We evaluated progress within and between each cohort. Within the CU cohort, the quality of the arterial and venous anastomosis improved, respectively (by 54%,  = 0.0059 and by 43%,  = 0.0027), the patency of both the arterial and venous anastomosis improved, respectively (by 44%,  = 0.0002 and by 40%,  = 0.0019), and timing of arterial and venous anastomosis reduced respectively (by 36%,  = 0.0002 and by 33%,  = 0.0010). The UT cohort improved the quality of their arterial anastomoses (by 29%,  = 0.0312). The UT cohort did not demonstrate significant improvement in the other above-mentioned parameters. The CU cohort improved materially over the UT cohort across categories of quality, patency, and timing.

Conclusion:  There are clear benefits of an expert instructor when examining the rate of progress and proficiency level attained at the conclusion of the course. We suggest students who are seeking to maximize proficiency in microsurgical procedures enroll in courses with an expert instructor.
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http://dx.doi.org/10.1055/s-0040-1715910DOI Listing
February 2021

Thumb Disability Examination (TDX) as a New Reliable Tool for Basal Joint Arthritis.

J Wrist Surg 2020 Jun 19;9(3):209-213. Epub 2020 Feb 19.

Department of Orthopaedics, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York.

 The general assessment of basal joint arthritis (BJA) is limited using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. This has been shown to be insensitive to pain and disability levels, leading to the development and validation of the thumb disability examination (TDX) as a specific tool for BJA in 2014.  The goal of this study was to evaluate the reliability, sensitivity, and specificity of the TDX score for BJA.  A multicenter BJA database was established in 2007 to collect prospective data. We evaluated the correlation between the TDX score, visual analog pain scale with activity (A-VAS), Eaton-Littler score, and grip strength using a Pearson test. Additionally, we evaluated the pre- and postintervention scores to assess their predictive values.  A total of 109 thumbs of 74 patients with TDX scores were evaluated. Females were more commonly affected (75.2%), and the mean age was 65.39 years (standard deviation: 10.04). The majority of participants were white (90.8%). A high correlation between TDX and A-VAS score (Pearson's correlation = 0.520;  < 0.001) and between grip strength (Pearson's correlation = -0.336;  < 0.005) and Eaton-Littler score (Pearson's correlation = 0.353'  < 0.01) was identified. Additionally, when comparing pre- and post-intervention for all treatment groups and for operative intervention, significant differences in TDX scores were observed (both ≤ 0.01). No significant differences could be identified for DASH score or A-VAS when assessing these same groups.  The TDX score correlates to high Pearson's correlation values and -values, especially in grip strength, Eaton-Littler score, A-VAS score, and pre-/postintervention for all treatment groups combined and when specifically assessing the surgical intervention group. As a result, it can be concluded that the TDX score is a specific tool for the assessment of BJA.  This is a Level II, prospective comparative study.
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http://dx.doi.org/10.1055/s-0040-1701510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263863PMC
June 2020

Large and Uneven Bites in End-to-End Anastomosis of the Rat Femoral Artery.

J Reconstr Microsurg 2020 Sep 17;36(7):486-493. Epub 2020 Apr 17.

Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York.

Background:  Successful microvascular anastomosis depends on sutures that adequately oppose both cut vessel edges. Trainees tend to take oversized or uneven bite. To improve early microsurgical skill acquisition using the rat, this study tests the belief that such bites compromise early patency by applying exaggerated bites to end-to-end arterial anastomoses.

Methods:  Twelve Sprague-Dawley rats were randomly assigned to one of the four bite techniques to be applied to both femoral arteries (mean diameter, 0.8 mm). Large (L) and standard (S) bites measured 1.0 and 0.2 mm from the edge, respectively. Eight simple interrupted anastomoses were performed per bite technique, each labeled according to every proximal end bite size, followed by every distal end bite size: LL, LS, SL, and SS. Anastomosis time and blood flow rates were recorded and analyzed statistically. After sacrifice 5 days postoperation, anastomosis sections of each technique were examined histologically.

Results:  All 24 anastomoses (100%) maintained patency for 5 days. There was no statistical difference between all postoperative blood flow measurements at any given time. Anastomosis times using LL, LS, SL, and SS bite techniques were 41.6, 33.2, 34.8, and 25.5 minutes, respectively. Anastomosis time for the traditional bite technique (SS) was significantly shorter than all other bite techniques ( < 0.05). Histological examination of the harvested segments from each group revealed similar pathophysiological features.

Conclusion:  Oversized bites (1 mm), placed symmetrically and asymmetrically across the anastomosis, do not affect early patency in the rat femoral artery. A reduced reliance on conventional guidelines for suture bites appears acceptable during microarterial anastomoses if the goal is vessel patency. However, we believe clinical competence involves the ability to place small, even bites consistently and uniformly. During microsurgical training, the occasional large bite need not be replaced; however, the trainee should be encouraged to take standard bites.
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http://dx.doi.org/10.1055/s-0040-1709453DOI Listing
September 2020

Torsion is Tolerated in Arterial End to Venous Side Anastomoses in the Rat Model.

J Reconstr Microsurg 2020 Sep 17;36(7):501-506. Epub 2020 Apr 17.

Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York.

Background:  End-to-side (ETS) anastomoses are necessary for many procedures in microvascular surgery, such as free flap transfers. In training courses that use the rat model, the arterial end to venous side (AEVS) anastomosis is a common training exercise for ETS anastomoses. Surgeons-in-training often inadvertently twist the artery when completing the AEVS anastomosis; however, in the clinical setting, torsion is a reported risk factor for ETS anastomosis failure. The purpose of this study was to determine if torsion in an AEVS anastomosis would have a negative effect on patency in the rat model, accurately simulating the clinical scenario.

Methods:  All AEVS anastomoses were completed in 15 Sprague-Dawley rats divided into three torsion cohorts: 0, 90, and 180 degrees. Torsion was created in the AEVS anastomosis by mismatching the first two sutures placed between the free femoral artery end and the venotomy. Patency was verified at 0, 2, and 4 hours postoperation via the oxygenated-deoxygenated test and transit-time ultrasound blood flow measurements.

Results:  All AEVS anastomoses were patent 0, 2, and 4 hours postoperation according to both the oxygenated-deoxygenated test and transit-time ultrasound blood flow measurements. For the average blood flow measurements at 4 hours postoperation, the proximal measurements for 0, 90, and 180 degrees were -34.3, -18.7, and -13.8 mL/min respectively, and the distal measurements were 4.48, 3.46, and 2.90 mL/min, respectively.

Conclusion:  Torsion of 180 degrees does not affect early AEVS anastomosis patency in the rat model. This contrasts with the clinical setting, where torsion is reported to cause ETS anastomosis failure. Since AEVS anastomosis torsion is often difficult to appreciate visually, we suggested that microvascular surgery training instructors include a method to both detect and prevent AEVS anastomosis torsion, such as by marking the free femoral artery end with a marking pen or suture before beginning the anastomosis.
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http://dx.doi.org/10.1055/s-0040-1709478DOI Listing
September 2020

Topical Treatment for Cutaneous Mucormycosis of the Upper Extremity.

J Hand Surg Am 2020 Dec 23;45(12):1189.e1-1189.e5. Epub 2020 Mar 23.

Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY.

Mucormycosis is a relatively rare but extremely aggressive fungal infection that commonly affects patients who are compromised hosts. These infections typically come in various patterns: pulmonary, sinus, rhinocerebral, cerebral, cutaneous, or disseminated forms. Treatment usually consists of a combination of antifungal agents and surgical debridement, although morbidity and mortality are high. In this case report, we describe the course of a patient with a disseminated Mucor infection, primarily involving the upper extremities, who was successfully treated with topical and systemic antifungal agents without the need for surgical intervention.
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http://dx.doi.org/10.1016/j.jhsa.2020.01.015DOI Listing
December 2020

How Close Are the Volar Wrist Ligaments to the Distal Edge of the Pronator Quadratus? An Anatomical Study.

Hand (N Y) 2022 01 26;17(1):35-37. Epub 2020 Feb 26.

Columbia University Medical Center, Presbyterian Hospital, New York, NY, USA.

This cadaveric study defines the interval distance between the proximal insertion of the volar wrist ligaments and the distal edge of the pronator quadratus on the distal radius. It is important to be aware of this distance during surgical dissection for placement of volar locking plates for wrist fractures. Disruption of the volar wrist ligament insertion may have adverse biomechanical consequences such as carpal instability, which can lead to pain and eventually wrist arthritis. Thirteen cadaveric wrists were dissected using the trans-flexor carpi radialis volar approach to identify relevant anatomy. The distance between the distal border of the pronator quadratus and the most proximal insertion of the volar wrist ligaments was measured. The average distance between the pronator quadratus and the proximal insertion of the volar wrist ligaments was 5 mm, with a standard deviation of 2 mm. The volar wrist ligaments insert quite near the distal end of the pronator quadratus. Surgeons should be cognizant of the proximity of the volar wrist ligaments and be judicious with subperiosteal stripping of the distal fragment during volar plating procedures.
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http://dx.doi.org/10.1177/1558944720906496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8721788PMC
January 2022

Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures.

J Wrist Surg 2020 Feb 21;9(1):81-89. Epub 2019 Jul 21.

Department of Orthopaedic Surgery, Columbia University Medical Center-Presbyterian Hospital, New York City, New York.

 Scaphoid fracture accounts for approximately 15% of acute wrist fractures. Clinical examination and plain X-rays are commonly used to diagnose the fracture, but this approach may miss up to 16% of fractures in the absence of clear-cut lucent lines on plain radiographs. As such, additional imaging may be required. It is not clear which imaging modality is the best. The goal of this study is to summarize the current literature on scaphoid fractures to evaluate the sensitivity, specificity, and accuracy of four different imaging modalities.  A systematic-review and meta-analysis was performed. The search term "scaphoid fracture" was used and all prospective articles investigating magnetic resonance imaging (MRI), computed tomography (CT), bone scintigraphy, and ultrasound were included. In total, 2,808 abstracts were reviewed. Of these, 42 articles investigating 51 different diagnostic tools in 2,507 patients were included.  The mean age was 34.1 ± 5.7 years, and the overall incidence of scaphoid fractures missed on X-ray and diagnosed on advanced imaging was 21.8%. MRI had the highest sensitivity and specificity for diagnosing scaphoid fractures, which were 94.2 and 97.7%, respectively, followed by CT scan with a sensitivity and specificity at 81.5 and 96.0%, respectively. The sensitivity and specificity of ultrasound were 81.5 and 77.4%, respectively. Significant differences between MRI, bone scintigraphy, CT, and ultrasound were identified.  MRI has higher sensitivity and specificity than CT scan, bone scintigraphy, or ultrasound.  This is a Level II systematic review.
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http://dx.doi.org/10.1055/s-0039-1693147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000269PMC
February 2020

Sequential Radiographic Evaluation During Closed Treatment of Distal Radius Fracture.

J Orthop Trauma 2020 Jan;34(1):e26-e30

Department of Orthopaedic Surgery, Columbia University Medical Center, NY; and.

Objectives: To test the null hypothesis that there is no significant change in radiographic parameters, which determines an acceptable reduction, beyond 3 weeks in distal radius fractures with closed treatment.

Design: Retrospective review of a prospectively gathered registry of distal radius fractures.

Setting: Academic medical center.

Patients: Patients who underwent closed treatment of distal radius fracture.

Intervention: Sequential radiographic evaluation.

Main Outcome Measurements: Change of radiographic measurement including radial inclination, radial height, ulnar variance, articular tilt, teardrop angle, anteroposterior distance, intra-articular gap, and step-off. We compared postreduction radiographic parameters once within 2 weeks, at the third week, at cessation of immobilization, and analyzed the interobserver reliability test.

Results: There was a statistically significant difference between radiographic measurements, which determined an acceptable reduction between radiographs performed within 2 weeks versus the third week. Radial inclination and ulnar variance were statistically different at the third week compared with the time of cessation of immobilization. Seventy-seven percent of patients who had an acceptable reduction after 2 weeks maintained acceptable alignment at cessation of immobilization. Eighty-five percent of patients with acceptable reduction after 3 weeks maintained acceptable alignment at cessation of immobilization. Radial shortening >1.8 mm at the third week predicts an unacceptable radiographic outcome at cessation of immobilization (sensitivity 94.5% and specificity 90%).

Conclusion: Radiographic parameters that determine acceptable reduction for closed treatment of distal radius fractures change minimally after 3-week postacceptable closed reduction. Radial shortening at the third week can be used to predict an unacceptable radiographic outcome.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001606DOI Listing
January 2020

Musculoskeletal Health Literacy, Pain Catastrophization, and Sleep Quality: Effect on Functional Disability Scores.

J Surg Orthop Adv 2019 ;28(2):144-149

Trauma Training Center, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York.

Limited musculoskeletal health literacy, catastrophic pain thinking, and poor sleep quality may be associated with adverse long-term health outcomes, but are sparsely studied concomitantly in orthopedics. The purpose of this study was to assess how these factors influence baseline functional disability. Hand and wrist and foot and ankle patients presenting with a previously untreated complaint were enrolled and completed the Literacy in Musculoskeletal Problems questionnaire, Pain Catastrophization Scale (PCS), and Pittsburgh Sleep Quality Index (PSQI). Upper extremity patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and lower extremity patients completed the Foot and Ankle Outcome Score (FAOS) survey. DASH and FAOS scores were normalized to the same scale and termed "functional survey" (FS). Two hundred thirty-one patients (mean age 45.8 ± 16.8) were included in the analysis. PCS and PSQI were significantly correlated with FS score. The only other variables significantly correlated with FS score were insurance and diagnosis type. The variables PCS, PSQI, insurance, and diagnosis were entered into a multivariate analysis with FS score. All four variables significantly added to FS score in the model (R2 = .194, p < .001). Interventions that target both catastrophizing tendencies and sleep quality may independently improve functional outcomes. Further in-depth multifactorial research in this topic is critical to craft effective treatments with sustainable outcomes. (Journal of Surgical Orthopaedic Advances 28(2):144-149, 2019).
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October 2019

Wrist Denervation: Techniques and Outcomes.

Orthop Clin North Am 2019 Jul 16;50(3):345-356. Epub 2019 Apr 16.

New York Presbyterian-Columbia University Medical Center, 622 West, 168th Street PH 11-1119, New York City, NY 10032, USA. Electronic address:

Wrist denervation is a safe and effective procedure for the treatment of chronic wrist pain that can delay or eliminate the need for salvage or anatomically distorting procedure, such as proximal row carpectomy. The traditionally more extensive wrist denervation has evolved to procedures requiring fewer incisions. Efficacy of this procedure is corroborated by multiple publications either as a stand-alone procedure or as an adjunct to other procedures. This review provides an update on the status of wrist denervation.
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http://dx.doi.org/10.1016/j.ocl.2019.03.002DOI Listing
July 2019

Prospective Analysis of Hand Infection Rates in Elective Soft Tissue Procedures of the Hand: The Role of Preoperative Antibiotics.

Hand (N Y) 2021 01 15;16(1):81-85. Epub 2019 Apr 15.

The George Washington University Hospital, Washington, DC, USA.

The purpose of this study was to evaluate the efficacy of prophylactic antimicrobial prophylaxis in elective hand surgery in preventing postoperative infection. Between 2009 and 2012, we performed a multicenter trial in which patients undergoing elective hand surgeries were categorized into an antibiotic or control group depending on the center they were enrolled in. Surgical site infections were defined according to the Centers for Diseases Control and Prevention. In total, 434 patients were included: 257 did not receive antibiotics (control) and 177 received antibiotics at a mean age of 61.0 years. In the control group, comorbidities were more common with 23.7% (61/257) in comparison to the antibiotics group with 14.1% (25/177). Only one surgical site infection in each group was identified. One wound was opened surgically, and an antimicrobial treatment was indicated in both cases. In addition, we observed four complications in the control group and three complications in the antibiotics group which required conservative management. No significant differences in the two cohorts in infection rate (0.006% vs 0.003%, χ = 0.07, > .05) and complication rate (2.8% vs 1.6%, χ = 0.01, > .05) were found. Our prospective multicenter trial showed no significant difference in infection rate in elective hand surgery whether antibiotics were administered preoperatively or not.
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http://dx.doi.org/10.1177/1558944719842238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818027PMC
January 2021

Subcutaneous Transposition of the Flexor Pollicis Longus: Does It Provide Increased Length for Tendon Repair? A Cadaveric Study.

Hand (N Y) 2020 11 20;15(6):828-830. Epub 2019 Mar 20.

Columbia University Medical Center, New York, NY, USA.

Flexor pollicis longus (FPL) tendon lacerations typically occur via sharp mechanisms such as knife injury. When the injury is chronic, it may be difficult to perform a tension free repair, and tendon lengthening may be required. This article proposes a technique that transposes the proximal tendon stump over the thenar eminence subcutaneously, out of the carpal tunnel, in an attempt to gain additional tendon length by eliminating the sharp turn the FPL takes. A total of 17 cadaveric hands were used. The FPL tendon was identified and affixed to soft tissue in the distal forearm as well as at the thumb metacarpophalangeal (MP) joint with hypodermic needles. The tendon was then transected at the level of the MP joint of the thumb, removed from the carpal tunnel, and transposed on top of the thenar eminence to reach where it had been transected. The length gained by transposing the tendon was recorded by measuring the overlap of the tendon ends at the MP joint. The mean amount lengthened was 7.6 mm with a standard deviation of 2.4 mm, ranging from as little as 5 mm to as high as 13 mm. To our knowledge, transposition of FPL tendon is a novel technique that has not been reported. Based on our cadaveric study, it can be used to bridge gaps between approximately 5 mm and 10 mm. Clinically, this amount of gap could potentially be more easily managed by simply making the repair tighter than usual as opposed to transposing the tendon.
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http://dx.doi.org/10.1177/1558944719837014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850242PMC
November 2020

Treatment of Proximal Pole Scaphoid Fracture Nonunions With Intramedullary Cancellous Autograft and Cannulated Headless Compression Screw.

Tech Hand Up Extrem Surg 2019 Jun;23(2):88-93

New York Presbyterian Hospital, Columbia University Medical Center, New York, NY.

Management of proximal pole scaphoid nonunion remains a challenging problem. Multiple surgical techniques have been described, although no treatment has proven superior. Recent studies have questioned the need for vascularized bone grafting, even in in the setting of avascular proximal poles. We present a relatively simple technique of intramedullary autogeneous cancellous bone grafting that does not disturb the intact cortical shell of the nonunion, which has so far provided gratifying clinical results.
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http://dx.doi.org/10.1097/BTH.0000000000000229DOI Listing
June 2019

Torsion Does Not Affect Early Vein Graft Patency in the Rat Femoral Artery Model.

J Reconstr Microsurg 2019 May 30;35(4):299-305. Epub 2018 Oct 30.

Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York.

Background:  Torsion of vein grafts is a commonly cited reason for graft failure in clinical setting. Many microsurgery training courses have incorporated vein graft procedures in their curricula, and vein graft torsion is a common technical error made by the surgeons in these courses. To improve our understanding of the clinical reproducibility of practicing vein graft procedures in microsurgery training courses, this study aims to determine if torsion can lead to early vein graft failure in nonsurvival surgery rat models.

Methods:  Sprague-Dawley rats were divided into five cohorts with five rats per cohort for a total of 25 rats. Cohorts were labeled based on degree of vein graft torsion (0, 45, 90, 135, and 180 degrees). Torsion was created in the vein grafts at the distal arterial end by mismatching sutures placed between the proximal end of the vein graft and the distal arterial end. Vein graft patency was then verified 2 and 24 hours postoperation.

Results:  All vein grafts were patent 2 and 24 hours postoperation. At 2 hours, the average blood flow rate measurements for 0, 45, 90, 135, and 180 degrees of torsion were 0.37 ± 0.02, 0.38 ± 0.04, 0.34 ± 0.01, 0.33 ± 0.01, and 0.29 ± 0.02 mL/min, respectively. At 24 hours, they were 0.94 ± 0.07, 1.03 ± 0.15, 1.26 ± 0.22, 1.41 ± 0.11, and 0.89 ± 0.15 mL/min, respectively.

Conclusion:  Torsion of up to 180 degrees does not affect early vein graft patency in rat models. To improve the clinical reproducibility of practicing vein graft procedures in rat models, we suggest that microsurgery instructors assess vein graft torsion prior to clamp release, as vessel torsion does not seem to affect graft patency once the clamps are removed.
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http://dx.doi.org/10.1055/s-0038-1675224DOI Listing
May 2019

The Optimal Suture Placement and Bone Tunnels for TFCC Repair: A Cadaveric Study.

J Wrist Surg 2018 Nov 26;7(5):375-381. Epub 2018 Jun 26.

Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York.

 Transosseous repair of foveal detachment of the triangular fibrocartilage complex (TFCC) is effective for distal radioulnar joint stabilization. However, studies of the optimal foveal and TFCC suture positions are scant.  The purpose of this study was to clarify the optimal TFCC suture position and bone tunnels for transosseous foveal repair.  Seven cadavers were utilized. The TFCC was incised at the foveal insertion and sutured at six locations (TFCCs 1-6) using inelastic sutures. Six osseous tunnels were created in the fovea (foveae 1-6). Fovea 2 is located at the center of the circle formed by the ulnar head overlooking the distal end of the ulna (theoretical center of rotation); fovea 5 is located 2 mm ulnar to fovea 2. TFCC 5 is at the ulnar apex of the TFCC disc; TFCC 4 is 2 mm dorsal to TFCC 5. TFCC 1 to 6 sutures were then placed through each of the six osseous tunnels, resulting in 36 combinations, which were individually tested. The forearm was placed in five positions between supination and pronation, and the degree of suture displacement was measured. The position with the least displacement indicated the isometric point of the TFCC and fovea.  The mean distance of suture displacement was 2.4 ± 1.6 mm. Fovea 2, combined with any TFCC location, (0.7 ± 0.6 mm) and fovea group 5, combined with TFCC 4 location (0.8 ± 0.8) or with TFCC 5 location (0.9 ± 0.6) had statistically shorter suture displacements than any other fovea groups.  For TFCC transosseous repair, osseous tunnel position was more important than TFCC suture location.
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http://dx.doi.org/10.1055/s-0038-1661361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196092PMC
November 2018

Prevalence and Risk Factors of Limited Musculoskeletal Health Literacy in the Outpatient Setting: A Logistic Regression Model.

J Am Acad Orthop Surg 2019 May;27(10):e491-e498

From the Department of Orthopaedic Surgery, Trauma Training Center, Columbia University Medical Center, New York, NY.

Introduction: The purpose of this study was to determine the risk factors of limited musculoskeletal health literacy (MHL) in a general population of orthopaedic patients.

Methods: Patients presenting to either a foot or ankle surgeon or hand or wrist surgeon were given the Literacy in Musculoskeletal Problems (LiMP) questionnaire, a nine-item survey for assessing "limited" MHL (LiMP score < 6). After confirming group homogeneity, the two populations were analyzed together to determine factors significantly correlated with and predictive of limited MHL.

Results: Overall, 231 patients were included in the analysis. Average LiMP score was 5.4 ± 1.8, and 49% of participants had "limited" MHL. Chi-square analysis revealed that being non-Caucasian, using cigarettes, and having a less than college-level education were associated with a higher prevalence of "limited" MHL (P < 0.05). Logistic regression revealed that being of non-Caucasian race (P = 0.04) or having less than college-level education (P = 0.03) were significant independent predictors of "limited" MHL, with adjusted relative risks of 1.37 and 1.40, respectively.

Discussion: In this study, the patients at the greatest risk of limited MHL are often at the risk of many other complications. These results should be used as a groundwork to craft directives aimed at improving MHL and outcomes in these patients.
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http://dx.doi.org/10.5435/JAAOS-D-17-00712DOI Listing
May 2019

Cephalic venous aneurysm in the wrist.

Clin Imaging 2018 Nov - Dec;52:310-314. Epub 2018 Jul 5.

Department of Radiology, New York-Presbyterian Hospital at Columbia University, 622 West 168th St., MC-28, New York, NY 10032, USA. Electronic address:

Venous aneurysms are benign vascular lesions usually located in the neck, lower extremity, and abdomen, but rarely in the upper extremity. There may be a mistake or delay in diagnosis because they are uncommon. We report a case of a healthy 54-year-old man who had a cephalic venous aneurysm in his wrist that grew slowly over 20 years. The diagnosis was made on MRI and confirmed with excisional surgery. Radiologists should consider venous aneurysms in the differential when evaluating soft tissue masses as they will often be the first to make the correct diagnosis.
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http://dx.doi.org/10.1016/j.clinimag.2018.07.001DOI Listing
January 2019

A Novel Cadaveric Model of the Quadriga Effect.

J Am Acad Orthop Surg Glob Res Rev 2017 Nov 15;1(8):e062. Epub 2017 Nov 15.

Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY.

Introduction: The quadriga phenomenon results from excessive shortening of the flexor digitorum profundus (FDP) tendon to the middle, ring, or small finger.

Methods: Five cadaveric specimens were used to create a model for quadriga. The FDP tendons to the middle, ring, and small fingers were shortened in 5-mm increments, and the tip-to-palm (TTP) distance of adjacent fingers was recorded.

Results: Shortening of the middle finger FDP by 10 mm resulted in an average TTP distance of 6 mm in the ring finger and 5 mm in the small finger. Shortening the ring finger FDP by 10 mm produced an average TTP distance of 11 mm in the middle finger and 9 mm in the small finger. Shortening of the small finger FDP by 10 mm resulted in an average TTP distance of 14 mm in the middle finger and 10 mm in the ring finger.

Discussion: Shortening the FDP by as little as 10 mm produced a significant quadriga effect, which was more pronounced with shortening of the small and ring FDP tendons compared to the middle finger.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-17-00062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6132342PMC
November 2017

Histological Changes in the Rat Femoral Artery Following the Use of the Empty-and-Refill Test.

J Reconstr Microsurg 2018 May 22;34(4):270-276. Epub 2018 Jan 22.

Department of Orthopedic Surgery, Columbia University, New York, New York.

Background:  This study examines the effects of the empty-and-refill patency test on rat femoral arteries in the longer postoperative time period.

Methods:  A simple arterial anastomosis was performed bilaterally on 20 rats. The empty-and-refill test was performed unilaterally in all rats, leaving the contralateral artery as an internal control. Rats were divided into two cohorts of 10 rats and survived for 48 hours and 2 weeks. Vessel patency was assessed prior to closing and immediately prior to sacrifice. The femoral arteries were harvested bilaterally and hematoxylin and eosin stains were performed. The femoral artery distal to the anastomosis in the region of the empty-and-refill test was histologically evaluated.

Results:  All vessels were patent at the time of sacrifice. There was no statistical difference in the numeric scoring between the experimental and control vessels in the 48-hour cohort. Almost all vessels harvested at 48 hours showed endothelial cell loss distal to the anastomosis regardless of whether they underwent the empty-and-refill test. The only statistically significant difference in the 2-week cohort was an increase in adventitial smooth muscle proliferation in the experimental group. There were no other statistically significant results between the experimental and control groups at 2 weeks. An overall comparison of both cohorts revealed a statistically significant increase in endothelial cell number and intimal proliferation by 2 weeks postsurgery.

Conclusion:  The empty-and-refill test does not compromise rat femoral artery anastomotic patency, nor does it produce histological damage either 48 hours or 2 weeks postsurgery.
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http://dx.doi.org/10.1055/s-0037-1621727DOI Listing
May 2018

Comparison of Exposure in the Kaplan Versus the Kocher Approach in the Treatment of Radial Head Fractures.

Hand (N Y) 2019 03 22;14(2):253-258. Epub 2018 Jan 22.

2 Columbia University, New York City, NY, USA.

Background: The aim of this study was to compare the complete visible surface area of the radial head, neck, and coronoid in the Kaplan and Kocher approaches to the lateral elbow. The hypothesis was that the Kaplan approach would afford greater visibility due to the differential anatomy of the intermuscular planes.

Methods: Ten cadavers were dissected with the Kaplan and Kocher approaches, and the visible surface area was measured in situ using a 3-dimensional digitizer. Six measurements were taken for each approach by 2 surgeons, and the mean of these measurements were analyzed.

Results: The mean surface area visible with the lateral collateral ligament (LCL) preserved in the Kaplan approach was 616.6 mm in comparison with the surface area of 136.2 mm visible in the Kocher approach when the LCL was preserved. Using a 2-way analysis of variance, the difference between these 2 approaches was statistically significant. When the LCL complex was incised in the Kocher approach, the average visible surface area of the Kocher approach was 456.1 mm and was statistically less than the Kaplan approach. The average surface area of the coronoid visible using a proximally extended Kaplan approach was 197.8 mm.

Conclusions: The Kaplan approach affords significantly greater visible surface area of the proximal radius than the Kocher approach.
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http://dx.doi.org/10.1177/1558944717745662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436133PMC
March 2019
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