Publications by authors named "Scott H Kozin"

136 Publications

Reachable workspace with real-time motion capture feedback to quantify upper extremity function: A study on children with brachial plexus birth injury.

J Biomech 2021 Dec 30;132:110939. Epub 2021 Dec 30.

University of Delaware, Newark, DE, USA.

Clinical upper extremity (UE) functional assessments and motion capture measures are limited to a set of postures and/or motions that may provide an incomplete evaluation of UE functionality. Reachable workspace analysis offers a more global assessment of UE function, but is reliant on patient compliance with instructions and may result in underestimates of a patient's true UE function. This study evaluated a clinical tool that incorporates real-time visual feedback with motion capture to provide an innovative means of engaging patients to ensure a 'best effort' quantification of their available UE workspace. Reachable workspace for 10 children with brachial plexus birth injury was collected with and without real-time feedback on the affected and unaffected limbs. Real-time feedback consisted of subjects reaching for virtual targets surrounding their physical space using a virtual cursor controlled by the real-time location of their hand. Real-time feedback resulted in significantly greater workspace in multiple regions on both the affected (3/6 octants; mean differences 10.8%-20.0%) and unaffected (6/6 octants; mean differences 24.3%-40.0%) limbs. Use of real-time feedback also yielded significant interlimb differences in workspace across more regions (4/6 octants; mean differences 29.0%-39.9% vs. 1/6 octants; mean difference 17%). Finally, real-time feedback resulted in significant interlimb differences in median reach distance across more regions (4/6 octants; mean differences 7.5%-44.8% vs. 1/6 octants; mean difference 11.2%). A reachable workspace tool with real-time feedback results in more workspace and UE function recorded and offers a highly visual and intuitive depiction of a patient's UE abilities.
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http://dx.doi.org/10.1016/j.jbiomech.2021.110939DOI Listing
December 2021

Fixation of Displaced Medial Epicondylar Fractures in Adolescents.

JBJS Essent Surg Tech 2021 Jul-Sep;11(3). Epub 2021 Jul 14.

Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania.

Fractures of the medial epicondyle are often a marker of injury of the medial collateral ligament complex of the elbow, regardless of displacement. The medial epicondyle serves as the origin for the flexor/pronator mass superficially and the medial collateral ligament near the base. These fractures occur most commonly through the apophysis at the base of the epicondyle, making differentiation of muscular versus ligamentous avulsion difficult. Fractures associated with elbow dislocation and fractures with an intra-articular incarcerated medial epicondyle are ligamentous injuries, requiring at least intraoperative examination and most likely fixation of the fracture. Degree of displacement has traditionally been considered the deciding factor for fracture fixation, but this concept has been proven unreliable both in the literature and in our experience. Regardless of the degree of displacement, we recommend examination under anesthesia for all displaced fractures, with fixation of any fractures that render the elbow unstable to valgus stress.

Description: The patient is placed in the supine position, and an examination under anesthesia is performed. If the elbow is stable to valgus load, the patient is placed into a long arm cast and awakened from anesthesia. If the elbow is unstable, the patient is placed in the lateral decubitus position, and the arm is prepared and draped. The fingers and wrist are wrapped with a self-adhesive bandage in flexion to relax the flexor/pronator mass. Under tourniquet control, a curvilinear medial incision is made just dorsal to the medial epicondyle. The ulnar nerve is identified and transposed if necessary. A guidewire is placed through the fracture fragment and used as a joystick. The hand is then positioned on the posterior aspect of the hip to provide varus load to the elbow and assist with reduction. The medial epicondyle is reduced, and the guidewire is advanced unicortically. A 3.0-mm, partially threaded cannulated screw is then advanced over the guidewire. A long arm cast is applied after closure of the wound with buried absorbable sutures.

Alternatives: Nonoperative treatment in a cast has been suggested. Surgical variations include supine positioning, bicortical screws, and use of washers.

Rationale: Lateral decubitus positioning and wrapping of the hand and wrist in flexion facilitate reduction by both applying a varus load and relaxing the flexor/pronator mass. Unicortical fixation is sufficient and does not risk injury to anterolateral structures. Washers have a higher complication rate than screws alone and may not be necessary in most cases.
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http://dx.doi.org/10.2106/JBJS.ST.19.00075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505346PMC
July 2021

Scapulothoracic and Glenohumeral Contributions to Humerothoracic Kinematics in Single Versus Double Tendon Transfers in Patients with Brachial Plexus Birth Injury.

J Hand Surg Am 2021 Sep 3. Epub 2021 Sep 3.

Department of Biomechanics and Movement Science, University of Delaware, Newark, DE.

Purpose: Evidence suggests that patients with brachial plexus birth injury are more likely to retain midline function following a teres major tendon transfer without a concomitant latissimus dorsi transfer. Both procedures increase shoulder external rotation and abduction, but whether increased loss of midline frequency following double transfer is due to glenohumeral (GH) joint motion or scapulothoracic (ST) compensation is unknown. We hypothesized that double tendon transfers would exhibit greater GH external rotation than single tendon transfers, thus requiring greater ST rotation to internally rotate the shoulder, while GH and ST contributions to elevation remained equivalent between both groups.

Methods: Twenty-six postsurgical children with C5/C6 brachial plexus birth injuries participated in this study. Thirteen patients with single tendon transfers were matched with 13 with double tendon transfer. Coordinate systems of the thorax, scapula, and humerus were measured utilizing motion capture in 6 arm positions. Joint angles were calculated by the helical (ST) and modified globe method (GH and humerothoracic [HT]). Differences between groups were compared with repeated measures of multivariate analyses of variance for each position. Pending significant multivariate analyses of variance, univariate analyses of variance determined joint differences between transfer groups.

Results: Joint rotations from neutral were similar between groups in 5 of 6 tested positions, with double tendon transfers consistently demonstrating 15°-20˚ more internal rotation at the GH and HT joints. Still, only the internal rotation position showed statistically significant differences in GH and HT joint angles. The ST joint angles were similar in this position (45.2˚ and 48.5˚).

Conclusions: The arc of motion for patients with double tendon transfer was more internally rotated than in patients with single tendon transfer at the GH and HT joints for all positions. However, both groups demonstrated little active rotation from neutral. Based on this data, teres major-only tendon transfers may not reduce the risk of loss of midline function.

Type Of Study/level Of Evidence: Therapeutic III.
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http://dx.doi.org/10.1016/j.jhsa.2021.06.026DOI Listing
September 2021

The One-Bone Forearm in Children: Surgical Technique and a Retrospective Review of Outcomes.

J Hand Surg Am 2021 Jun 7. Epub 2021 Jun 7.

Department of Orthopedic Surgery, Shriners Hospitals for Children, Philadelphia, PA.

Purpose: The purpose of this study was to describe a technique of end-to-end rigid fixation of the distal radius to the proximal ulna. The shortening and radioulnar overlap in this technique yield a high union rate, large corrections, and few complications.

Methods: This retrospective chart review from 2 centers was undertaken in 39 patients (40 forearms) who underwent one-bone forearm operations between 2005 and 2019. There were 25 male and 14 female patients, with a mean age at surgery of 9.7 years (range 3 to 19 years; SD, 4.5 years). The diagnoses included brachial plexus birth injury, spinal cord injury, arthrogryposis multiplex congenita, cerebral palsy, ulnar deficiency with focal indentation, multiple hereditary exostosis, acute flaccid myelitis, and tumor.

Results: The average follow-up was 33.5 months (1.2-110.1 months; SD, 27.1 months). The 36 forearms in supination had an average supination contracture of 93° (range, 15° to 120°; SD, 15.4°). The 4 pronated arms had an average pronation contracture of 80° (range, 50° to 120°; SD, 29.2°). The average postoperative position was 22.8° of pronation (range, -15° to 45°; SD, 12.9°). The average correction obtained with our technique was 113° (range, 20° to 145°; SD, 22.9°). Radiographic union was demonstrated in 32 (80%) of the one-bone forearms by 10 weeks, 39 (97.5%) by 16 weeks, and 40 (100%) by 24 weeks. One patient had peri-implant fractures prior to union. No forearms required reoperation for nonunion.

Conclusions: One-bone forearm performed with this technique allows reliable healing and a large degree of correction.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.04.009DOI Listing
June 2021

Nerve Transfers for Restoration of Elbow Flexion in Patients With Acute Flaccid Myelitis.

J Hand Surg Am 2022 Jan 18;47(1):91.e1-91.e8. Epub 2021 May 18.

Department of Orthopaedic Surgery, Shriners Hospital for Children - Philadelphia, PA.

Purpose: The purpose of this study was to evaluate short- to midterm outcomes of patients with acute flaccid myelitis who underwent nerve transfers for restoration of elbow flexion.

Methods: Patients with a minimum of 10 months of follow up after undergoing nerve transfers to restore elbow flexion were clinically assessed using the Active Movement Scale (AMS). They were evaluated for any postoperative complications, particularly weakness in the distribution of the donor nerve(s). Fifteen of 25 consecutive patients who were treated using this surgical technique were included in the final analysis.

Results: All patients exhibited poor elbow flexion preoperatively (AMS 0 to 3). At a mean follow up of 17.3 months, 80% (15/25) of patients achieved excellent elbow flexion (AMS 6 or 7); 9 of these 15 had full active range of motion. Two patients achieved good elbow flexion (AMS 5) with antigravity movement to less than 50% of the passive range of motion. No cases of superficial or deep infection were reported, and all patients maintained identical motor function, relative to preoperative status, of the muscles innervated by the donor nerves.

Conclusions: Nerve transfer surgery has shown promising short- to midterm results for recovery of nerve and muscle function, particularly for the restoration of elbow flexion. We recommend this treatment option for patients not demonstrating clinical improvement after 6 to 9 months of incomplete recovery.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.02.029DOI Listing
January 2022

Outcomes of Osteochondral Autograft Transplantation in Pediatric Patients With Osteochondritis Dissecans of the Capitellum.

J Hand Surg Am 2021 11 23;46(11):1028.e1-1028.e15. Epub 2021 Apr 23.

Department of Orthopedic Surgery, Shriners Hospitals for Children, Philadelphia, PA.

Purpose: To assess the outcomes of osteochondral autograft transplantations in the treatment of osteochondritis dissecans of the capitellum in the pediatric population.

Methods: Between 2011 and 2016, 15 patients who had undergone osteochondral autograft transplantation at a mean age of 13.7 years at surgery were identified. The donor site was from the superolateral, non-weight-bearing surface of the lateral femoral condyle of the ipsilateral knee.

Results: Mean follow-up was 29.5 months, with no patients lost to follow-up. Mean arc of motion increased significantly from 121.9° preoperatively to 139.1° postoperatively. All 9 elite athletes returned to sports at an elite level: 7 returned to the same level of competition in the same sport, 1 retired from gymnastics due to multiple injuries but began diving at an elite level, and 1 retired from baseball unrelated to elbow symptoms but continued hockey at the same level. Of the 4 recreational athletes, all returned to sport. There were no intraoperative complications. The symptoms resolved completely in all but 2 patients, who improved over their preoperative condition. The donor site knee pain resolved in all patients at an average of 2.3 months. Postoperative imaging demonstrated the healing and incorporation of the plug in all patients.

Conclusions: In the treatment of osteochondritis dissecans of the capitellum, osteochondral autograft transplantation demonstrates excellent clinical and radiographic outcomes, with minimal short-term donor site morbidity and a high level of return to the sport.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.02.024DOI Listing
November 2021

Effect of Glenohumeral Reduction Type Combined With Tendon Transfer for Brachial Plexus Injury on Objective, Functional, and Patient-Reported Outcomes.

J Hand Surg Am 2021 07 30;46(7):624.e1-624.e11. Epub 2021 Jan 30.

Upper Extremity Center of Excellence, Shriners Hospital for Children; Department of Orthopaedic Surgery, Temple University, Philadelphia.

Purpose: Glenohumeral (GH) joint reductions are frequently performed during tendon transfer surgery for brachial plexus birth injuries (BPBI); however, the effect of reduction method (none required, closed, surgical) has not been assessed. This study compared objective, functional, and patient-reported outcomes between children who underwent a tendon transfer and (1) did not require GH reduction, (2) required concomitant closed GH reduction, or (3) required concomitant surgical GH reduction.

Methods: Fifty-four children with BPBI who previously underwent teres major and/or latissimus dorsi transfer with or without concomitant GH reduction participated. Joint reduction method was classified as none required (n = 21), closed (n = 9), or surgical (n = 24). Motion capture was collected in a neutral position, abduction, external rotation, and internal rotation. Glenohumeral joint angles and displacements were calculated. Joint angular displacements represented the differences between the joint angles in each terminal position and the joint angles of the arm at rest in the neutral position. A hand surgeon determined modified Mallet scores. Participants' parents completed the Brachial Plexus Profile Activity Short Form (BP-PRO-SF) to assess physical activity performance.

Results: The no-reduction group had significantly less GH elevation than the surgical-reduction group for all positions and significantly less GH elevation than the closed-reduction group for the neutral, external rotation, and internal rotation positions. There were no differences in GH rotation angles. Glenohumeral joint displacements from neutral and modified Mallet scores were similar. The no-reduction group demonstrated significantly greater BP-PRO-SF scores than the surgical-reduction group.

Conclusions: Patients who underwent a closed or surgical GH joint reduction consistently displayed more GH elevation. Clinically, this corresponds to an abduction contracture. Whereas increased abduction contracture provided a benefit of greater overhead motion, modified Mallet scores were similar between groups. The surgical-reduction group demonstrated lower BP-PRO-SF outcomes.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2020.11.021DOI Listing
July 2021

Assessment of the relationship between Brachial Plexus Profile activity short form scores and modified Mallet scores.

J Hand Ther 2020 Oct 31. Epub 2020 Oct 31.

Shriners Hospital for Children, Philadelphia, PA, USA.

Introduction: This study aims to assess the relationship between the modified Mallet classification and the Brachial Plexus Profile activity short form (BP-PRO activity SF). The therapist or surgeon classifies upper extremity movement for the modified Mallet classification, while the BP-PRO assesses parents' perceptions of difficulty performing activities.

Purpose: To provide a deeper understanding of the relationship of functional and perceived outcome measurements.

Study Design: Prospective, correlational design.

Methods: Eighty children with brachial plexus birth injuries were evaluated using the modified Mallet classification, while parents simultaneously answered the BP-PRO activity SF questions. All patients had undergone one of three surgical interventions to improve shoulder function. The relationship between the two measures, patient injury levels, and surgical histories were assessed.

Results: The average modified Mallet scores and BP-PRO activity SF scores weakly correlated (r = 0.312, P = .005) and both measures differentiated between C5-6 and C5-7 injury levels (P = .03 and P = .02, respectively). Conversely, the modified Mallet scores could differentiate between the three surgical groups (F = 8.2, P < .001), while the BP-PRO activity SF could not (P = .54).

Conclusion: The results suggest that these tools measure different aspects of patient outcomes. The Mallet classification may be more focused on shoulder motion than the BP-PRO activity SF. Additional questions that specifically require shoulder function could be incorporated into the BP-PRO activity SF to improve understanding of patient/parent perceptions of shoulder function for children with brachial plexus injuries. Clinicians should be aware of the strengths, weaknesses, and limitations of each outcome assessment tool for appropriate use and interpretation of results.
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http://dx.doi.org/10.1016/j.jht.2020.10.003DOI Listing
October 2020

ASSH 75 Years: An Update of Progress Over the Past 25 Years.

J Hand Surg Am 2020 Nov;45(11):1070-1081

Department of Clinical Orthopaedic Surgery, Northwestern University, Chicago, IL.

This article chronicles some of the major advancements made by the American Society for Surgery of the Hand over the past 25 years since the publication of William Newmeyer III's monograph, American Society for Surgery of the Hand: The First Fifty Years, in 1995. What is intangible and impossible to articulate in this article are the countless stories of relationship building, education, and research advancement that the programming and activities the American Society for Surgery of the Hand has provided.
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http://dx.doi.org/10.1016/j.jhsa.2020.08.015DOI Listing
November 2020

The Utilization of Nerve Transfer for Reestablishing Shoulder Function in the Setting of Acute Flaccid Myelitis: A Single-Institution Review.

Pediatr Neurol 2020 10 8;111:17-22. Epub 2020 Jul 8.

Shriners Hospital for Children, Philadelphia, Pennsylvania.

Background: Acute flaccid myelitis (AFM) is a rare disease of young children. The typical presentation involves acute-onset flaccid paralysis in one or more extremities with a nonspecific viral prodrome. Long-term outcomes demonstrate that functional recovery plateaus around six to nine months. The purpose of this study was to evaluate the efficacy of nerve transfers for restoring shoulder function in these patients.

Methods: A retrospective review of all patients diagnosed with AFM at a single institution. Shoulder function was evaluated using the active movement scale (AMS). Children at a minimum of six months after diagnosis with plateaued shoulder AMS scores of 4 or less were indicated for surgery.

Results: Eleven patients were identified with a mean time from symptom onset to surgery of 12 months. Average follow-up was 19 months. The mean AMS score at follow-up for shoulder external rotation and abduction was 4.6 and 2.8, respectively. A total of six different nerve transfers with five different donor nerves were used individually or in conjunction with each other. The most common transfers were from the spinal accessory nerve to the suprascapular nerve (n = 8) and from the intercostal nerves ×3 to the axillary nerve (n = 5). Patients who received a transfer from the radial nerve to the axillary nerve (n = 2) had the best functional returns, with the mean AMS score of 6.5 in both external rotation and abduction at follow-up.

Conclusion: Nerve transfer procedures may help restore shoulder function in the setting of AFM. Combination procedures that involve a transfer from the radial nerve to the axillary nerve may provide the best functional results.
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http://dx.doi.org/10.1016/j.pediatrneurol.2020.06.016DOI Listing
October 2020

What's New in Congenital Hand Surgery.

J Pediatr Orthop 2020 Sep;40(8):e753-e760

Department of Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, PA.

Background: Congenital conditions of the hand and upper extremity are a frequent source of consultation among pediatric orthopaedists and hand surgeons. Advances in the fields of molecular biology and genetics have helped to better understand some of these conditions and redefine previous classification systems. New outcome measurement tools have been used to assess surgical results and have brought into focus a different aspect of the patients' experience.

Methods: We searched PubMed database for papers related to the treatment of congenital hand anomalies published from January 1, 2015 to October 31, 2018. The search was limited to English articles yielding 207 papers. Three pediatric hand surgeons selected the articles based upon the criteria that the topic was germane, the article fell under the subheadings within the manuscript, and the conclusions were meaningful.

Results: A total of 40 papers were selected for review, based upon their quality and new findings. Research articles with significant findings were included for syndactyly, symbrachydactyly, cleft hand, polydactyly, radial longitudinal deficiency, congenital radio-ulnar synostosis, and macrodactyly.

Conclusions: Our knowledge of the embryology and pathophysiology of congenital upper extremity conditions continues to evolve. Functional assessments combined with patient and parent-reported outcomes have our understanding of the results following surgical procedures. Further research and standardization of our scientific data will provide better answers and higher quality of evidence.

Level Of Evidence: Level V-literature review and expert opinion.
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http://dx.doi.org/10.1097/BPO.0000000000001629DOI Listing
September 2020

Bipolar Latissimus Dorsi Transfer for Arthrogryposis Multiplex Congenita: Minimum 10-Month Follow-Up.

J Hand Surg Am 2020 Nov 29;45(11):1084.e1-1084.e7. Epub 2020 Jun 29.

Department of Orthopaedic Surgery, Shriners Hospital for Children Philadelphia, Philadelphia, PA.

Purpose: To examine the outcomes of patients who have undergone bipolar latissimus dorsi transfer for loss of elbow flexion in arthrogryposis multiplex congenita (AMC).

Methods: This study retrospectively evaluated 6 cases (5 patients) of bipolar latissimus dorsi transfer performed to restore active elbow flexion in pediatric patients with AMC. Elbow range of motion and strength were evaluated before and after surgery. Functional outcomes were evaluated by the patients' ability to perform activities of daily living. Complications and patient satisfaction were also evaluated at final follow-up.

Results: The patients were a mean age of 7.8 ± 3 years. The mean follow-up was 30.2 months (range, 10-44 months). At most recent follow-up, all cases reported improved function of the surgical extremity when performing activities of daily living and overall satisfaction. The postoperative active range of motion was 76° ± 14°. All cases had active elbow flexion against gravity. One patient was noted to have decreased muscle activation of the transfer 6 months after surgery, but strength improved by the 10-month follow-up. No other complications were noted.

Conclusions: We recommend bipolar latissimus dorsi transfer as a reliable option to restore functional elbow flexion in patients with AMC. Meticulous pedicle handling and assessment of the latissimus dorsi viability is paramount.

Type Of Study/level Of Evidence: Therapeutic V.
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http://dx.doi.org/10.1016/j.jhsa.2020.04.025DOI Listing
November 2020

Single Versus Double Tendon Transfer to Improve Shoulder External Rotation During the Treatment of Brachial Plexus Birth Palsy.

Hand (N Y) 2022 Jan 19;17(1):55-59. Epub 2020 Mar 19.

Shriners Hospital, Philadelphia, PA, USA.

Tendon transfers are commonly performed in patients with brachial plexus birth palsy (BPBP) to improve function. Transferring 2 tendons in patients with C5-7 injury has the potential complication of loss of midline function. The purpose of this study was to investigate whether a single tendon transfer (1TT) as opposed to the traditional double tendon transfer (2TT) resulted in any differences in functional outcomes in patients with C5-7 BPBP. A retrospective review of all patients with C5-7 BPBP who underwent tendon transfers to improve shoulder external rotation over a 5-year period was performed at 2 institutions. Outcomes were assessed using the modified Mallet (MM) classification scores. Twenty-two C5-7 patients had complete records of preoperative and postoperative MM scores, including 11 sex-matched patients in both the 1TT and 2TT groups. When comparing preoperative and postoperative MM categories, there were significant improvements in both the 1TT and 2TT groups for global abduction ( < .05 and < .01, respectively) and external rotation ( < .00001 for both). Modified Mallet (MM) hand to neck scores were significantly improved in the 2TT group ( < .05) but not in the 1TT group ( = .053). Internal rotation scores significantly decreased in both groups ( < .001). Both groups demonstrated significant increases in total scores from the preoperative MM scores ( < .01). : The 1TT and 2TT procedures result in substantial gains in upper extremity functions for patients with C5-7 BPBP as measured by the MM score, specifically within the global abduction and external rotation subcategories. However, a significant loss occurs in internal rotation for both groups.
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http://dx.doi.org/10.1177/1558944720911211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8721786PMC
January 2022

Hand and Wrist Injuries in the Pediatric Athlete.

Clin Sports Med 2020 Apr;39(2):457-479

The Sidney Kimmel Medical College of Thomas Jefferson University, Shriners Hospital for Children Philadelphia, 3551 North Broad Street, Philadelphia, PA 19140, USA.

This article examines the most common problematic hand and wrist injuries in the pediatric athlete. Hand and wrist injuries in the growing skeleton pose a different diagnostic and therapeutic challenge than in the mature skeleton. Ligaments are stronger than bone, and unossified cartilaginous sections of the skeleton are yet more susceptible to injury than bone. Although remodeling can correct for even moderate deformities if sufficient growth potential exists, remodeling cannot return the child to normal anatomy in many cases. Remodeling depends on intact periosteum, a nearby growing physis, and competent ligaments to direct remodeling via Hueter-Volkmann and Wolff's laws.
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http://dx.doi.org/10.1016/j.csm.2020.01.001DOI Listing
April 2020

Oblique Lateral Closing-Wedge Osteotomy for Cubitus Varus in Skeletally Immature Patients.

JBJS Essent Surg Tech 2019 Oct-Dec;9(4). Epub 2019 Nov 1.

St. Christopher's Hospital for Children, Philadelphia, Pennsylvania.

Background: We perform an oblique lateral closing-wedge osteotomy of the distal end of the humerus to correct cubitus varus deformity in children. This deformity is often the consequence of undertreatment, malreduction, or malunion of supracondylar humeral fractures. Although standard arcs of motion may be altered, cosmesis was traditionally considered a primary surgical indication. However, uncorrected cubitus varus leads to posterolateral rotatory instability of the elbow (PLRI), lateral condylar fractures, snapping medial triceps, and ulnar nerve instability. A contemporary understanding of these delayed sequelae has expanded our current indications. Detailed parameters predictive of late sequelae are needed to further specify surgical indications.

Description: We remove an oblique lateral closing wedge from the distal end of the humerus via a standard lateral approach. The osteotomy is angled away from the varus joint line such that lateral cortices after reduction lack prominence. Kirschner wires provide adequate fixation in young patients. In older children, extension is simultaneously corrected, and fragments are stabilized via plate osteosynthesis.

Alternatives: Patients who decline surgery are counseled regarding risks of delaying treatment until symptoms are present. PLRI manifests as lateral elbow pain or instability while rising from a chair. Once symptomatic, the lateral ulnar collateral ligament (LUCL) is irreversibly attenuated and morphologic changes in the ulnohumeral joint necessitate more extensive surgery to include distal humeral osteotomy, LUCL reconstruction, and possibly ulnar nerve transposition. Alternative osteotomy techniques are described and categorized as simple lateral closing wedge, step-cut, dome, 3-dimensional, or distraction osteogenesis. Simple closing-wedge osteotomies include a distal cut parallel to the joint line and retain a problematic lateral prominence (if the medial cortex is intact or the distal end of the humerus is not translated medially). Step-cut osteotomies theoretically minimize this lateral prominence while enhancing inherent stability. However, these additional cuts mandate wide surgical exposure despite similar outcomes. Three-dimensional planning employs computed tomography to create expensive anatomic cutting guides that address varus, extension, and internal rotation. However, residual internal rotation is generally well tolerated, derotation is associated with loss of fixation, and the extension deformity will successfully remodel in patients who are <10 years old. We employ 3-dimensional planning in skeletally mature patients with complex deformity and no remodeling potential.

Rationale: The oblique lateral closing wedge is ideal for skeletally immature patients because it is simple, reproducible, and efficient. It avoids the lateral prominence without increasing complexity or complications.
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http://dx.doi.org/10.2106/JBJS.ST.18.00107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6974307PMC
November 2019

Global Hand Surgery: Initiatives that Work (The Touching Hands Project): Why, When, and How!

Authors:
Scott H Kozin

Hand Clin 2019 11;35(4):499-506

Touching Hands Project, ASSH, Chicago, IL, USA; Shriners Hospitals for Children-Philadelphia, 3551 North Broad Street, Philadelphia, PA 19140, USA; Lewis Katz School of Medicine, Temple University School of Medicine, Philadelphia, PA, USA; Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA. Electronic address:

The Touching Hands Project was initiated as part of the American Society for Surgery of the Hand (ASSH) outreach effort in 2014. The project has expanded rapidly and has become a pillar along with education, research, clinical practice (patient care), and organizational excellence. This article explains the background behind The Touching Hands Project that leads to a groundswell of support for ASSH's commitment to outreach from the leadership, membership, and corporate members. The Touching Hands Project in collaboration with organizations with similar missions has greatly expanded hand care across the globe by focusing on education, patient care, surgery, and rehabilitation.
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http://dx.doi.org/10.1016/j.hcl.2019.07.016DOI Listing
November 2019

Early results of nerve transfers for restoring function in severe cases of acute flaccid myelitis.

Ann Neurol 2019 10 15;86(4):607-615. Epub 2019 Aug 15.

Department of Orthopedic Surgery, Shriners Hospital for Children-Philadelphia, Philadelphia, PA.

Objective: To describe early functional outcomes of nerve transfer surgery in a relatively large cohort of patients with acute flaccid myelitis (AFM).

Methods: A retrospective case analysis was made of patients with AFM treated with nerve transfer surgery between 2007 and 2018. Surgical criteria were persistent motor deficits after 6 months from onset and available donor nerves. Thirty-two patients with AFM were evaluated; 16 underwent nerve transfer surgeries. Motor function was evaluated by a licensed occupational therapist using the Active Movement Scale preoperatively and during follow-up examinations. Patients with 6 or more months of follow-up were included in the analysis. Patients with procedures other than nerve transfers were excluded.

Results: Sixteen patients with AFM had nerve transfers, with a male predominance (75%) and median age of 2.5 years (range = 4 months-12 years). Eleven patients had a minimum 6 months of follow-up. Nerve transfers to restore elbow function had 87% excellent recovery for elbow flexion and 67% for elbow extension. Finger and thumb extension were full against gravity in 1 patient (100%). Shoulder external rotation was excellent in 50% of patients and shoulder abduction in only 20%. Nine of 10 patients (90%) had resolution of shoulder pseudosubluxation following nerve transfer to the suprascapular nerve.

Interpretation: Patients with AFM with persistent motor deficits 6 to 9 months after onset benefit from nerve transfer surgery. Restoration of elbow function was more reliable than restoration of shoulder function. We recommend early referral of patients with incomplete recovery to a center experienced in nerve transfers for timely evaluation and treatment. ANN NEUROL 2019;86:607-615.
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http://dx.doi.org/10.1002/ana.25558DOI Listing
October 2019

Current Concepts in the Treatment of Lateral Condyle Fractures in Children.

J Am Acad Orthop Surg 2020 Jan;28(1):e9-e19

From the Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD (Dr. Abzug), the Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY (Dr. Dua), the Department of Orthopaedics (Dr. Kozin), Shriners Hospital for Children, and the Department of Orthopaedic Surgery (Dr. Herman), St. Christopher's Hospital for Children, Philadelphia, PA.

Lateral condyle fractures of the humerus are the second most common fracture about the elbow in children. The injury typically occurs as a result of a varus- or valgus-applied force to the forearm with the elbow in extension. Plain radiographs are sufficient in making the diagnosis; however, an elbow arthrogram permits optimal visualization of the articular surface in minimally displaced fractures. Traditionally, nonsurgical management is indicated for fractures with ≤2 mm of displacement and a congruent articular surface. Closed reduction and percutaneous pinning is performed for fractures with >2 mm of displacement with an intact cartilaginous hinge at the articular surface. Open reduction and internal fixation is often necessary for fractures with ≥4 mm of displacement or if there is articular incongruity. Complications include malunion, delayed presentation, fishtail deformity, lateral spurring, and growth arrest. Evolving management concepts include relative indications for surgical management, the optimal pin configuration, and the use of cannulated screw and bioresorbable fixation.
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http://dx.doi.org/10.5435/JAAOS-D-17-00815DOI Listing
January 2020

Double Versus Single Tendon Transfers to Improve Shoulder Function in Brachial Plexus Birth Palsy.

J Pediatr Orthop 2019 Jul;39(6):328-334

Shriners Hospital for Children, Philadelphia, PA.

Background: In children with brachial plexus birth palsy (BPBP) undergoing tendon transfers to augment shoulder external rotation, it is unclear whether transfer of the latissimus dorsi with its combined latissimus dorsi and teres major (cLT) versus isolated teres major (iTM) tendon transfer yield different outcomes.

Methods: Records of patients with BPBP who underwent shoulder tendon transfers to augment external rotation were retrospectively reviewed. Transfer type (cLT or iTM) was considered indiscriminate by virtue of surgeon preference. Modified Mallet Scale (mMS) and Active Movement Scale scores were recorded. Patients with <12 months' follow-up, C7 or lower palsy, humeral osteotomy, shoulder procedure(s) within 8 months, microsurgery within 1 year, or recurrent glenohumeral subluxation confirmed by postoperative imaging were excluded. Matched cohorts were identified within each tendon transfer group to yield similar preoperative shoulder function and glenohumeral alignment status. Outcomes for all tendon transfers as well as differences between cLT and iTM cohorts were analyzed.

Results: Among 121 cLT and 34 iTM transfers, 49 cLT and 14 iTM met the inclusion criteria. Subsequent matching of cohorts yielded 28 patients (14 cLT and 14 iTM). Average age at time of transfer was 3.0±1.4 years. Follow-up averaged 4.1±3.1 years. There were no statistically significant preoperative differences between cohorts, thus matching criteria were validated. Regardless of tendon(s) transferred, mMS external rotation improved (2.2 to 3.5, P<0.001), whereas mMS internal rotation decreased (3.8 to 3.2, P<0.001). When comparing matched cohorts, cLT transfer produced a greater mMS external rotation improvement than iTM (2.1 vs. 1.5, respectively; P=0.025). Loss of midline function (defined as mMS external rotation <3) occurred in 5 (35.7%) cLT and 2 (14.3%) iTM patients.

Conclusions: Both cLT or iTM transfer are effective at augmenting shoulder external rotation in children with C5-C6 BPBP. Furthermore, cLT transfers may yield a larger improvement in external rotation in certain patients. However, both techniques slightly decrease shoulder internal rotation. Given that more total cLT patients lost midline function among matched cohorts, iTM transfer may still be considered when limited midline function is a concern.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000000965DOI Listing
July 2019

Suprascapular Ligament Release From an Anterior Approach: An Anatomic Feasibility Study.

J Hand Surg Am 2019 Oct 4;44(10):900.e1-900.e4. Epub 2019 Feb 4.

Shriners Hospital for Children Philadelphia, Philadelphia, PA.

Purpose: The results of spinal accessory to suprascapular nerve transfers have been less reliable than other nerve transfers in the upper limb, possibly owing to compression of the nerve by the suprascapular ligament. The posterior approach has been advocated to allow for release of the ligament. The purpose of this study was to determine whether a ligament release is possible from the anterior approach.

Methods: Nine fresh-frozen cadavers were dissected to determine whether the ligament could be approached and released from the anterior approach. Complete ligament release was demonstrated by subluxation of the nerve out of the suprascapular notch.

Results: Ligament release was achieved in all specimens, although in one, confirmation of complete release required a posterior approach.

Conclusions: Release of the suprascapular ligament to eliminate a potential source of compression of the suprascapular nerve during spinal accessory to suprascapular nerve transfer is possible through an anterior approach.

Clinical Relevance: Release of the suprascapular ligament through an anterior approach allows this procedure to be performed through the same approach as brachial plexus exploration and spinal accessory nerve to suprascapular nerve transfer. This method could reduce surgical time and patient repositioning and avoid additional incisions.
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http://dx.doi.org/10.1016/j.jhsa.2018.12.005DOI Listing
October 2019

Loss of Midline Function in Brachial Plexus Birth Palsy Patients.

J Pediatr Orthop 2019 Mar;39(3):e232-e235

Shriners Hospital for Children, Philadelphia, PA.

Background: Loss of midline function impairs the child's ability to perform certain activities of daily living such as dressing, buttoning, and perineal care. The purpose of this study was to assess brachial plexus birth palsy (BPBP) patients with loss of midline function with respect to etiology and treatment.

Methods: A retrospective review of all BPBP patients with loss of midline function was performed. The modified Mallet scale was used with internal rotation assessed via hand on spine and hand to belly. Demographics, extent of BPBP, prior surgical intervention, procedure(s) performed to correct the loss of midline function, complications, and outcomes were assessed.

Results: In total, 20 patients were identified with loss of midline function as defined by the inability to reach midline and touch their umbilicus. Nineteen patients had previously undergone tendon transfers about the shoulder with or without arthroscopic capsular release to improve external rotation. After the initial surgery, modified Mallet scores improved 1 grade for abduction, hand to mouth, hand to neck, and external rotation without altering the hand to spine category. However, the internal rotation category (hand to umbilicus) decreased from an average 2.71 preoperatively to an average 2.15 postoperatively. Nine patients underwent a derotational humeral osteotomy to improve midline function. The average correction of internal rotation was 47.8 degrees (range, 20 to 85 degrees). After this surgery, modified Mallet scores remained unchanged for hand to spine; however, the scores improved back to 2.7 for the internal rotation category. Two complications were noted including 1 plate fracture and 1 fracture through a screw hole.

Conclusions: BPBP patients who undergo surgical procedures to improve shoulder external rotation and/or obtain joint reduction may inadvertently lose midline function. Derotational humeral osteotomy can effectively restore midline function, which is needed to perform activities of daily living. Surgical procedures to improve external rotation should be performed in a manner that minimizes limitation of midline functions.

Level Of Evidence: Level III-therapeutic.
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http://dx.doi.org/10.1097/BPO.0000000000001251DOI Listing
March 2019

Scapular Stabilization Limits Glenohumeral Stretching in Children With Brachial Plexus Injuries.

J Hand Surg Am 2019 Jan 20;44(1):63.e1-63.e9. Epub 2018 Jun 20.

Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE.

Purpose: To quantify the effects of scapular stabilization on scapulothoracic and glenohumeral (GH) stretching.

Methods: Motion capture data during external rotation and abduction with and without scapular stabilization were collected and analyzed for 26 children with brachial plexus birth palsy. These positions were performed by an experienced occupational therapist and by the child's caretaker. Scapulothoracic and GH joint angular displacements were compared between stretches with no stabilization, stabilization performed by the therapist, and stabilization performed by the caretaker. The relationship between the age and ability of the therapist and caretaker to perform the stretches with scapular stabilization was also assessed.

Results: During external rotation there were no significant differences in either the scapulothoracic or GH joint during stabilization by either the therapist or the caretaker. During abduction, both scapulothoracic and GH joint angular displacements were statistically different. Scapulothoracic upward rotation angular displacement significantly decreased with scapular stabilization by the therapist and caretaker. Glenohumeral elevation angular displacement significantly decreased with scapular stabilization performed by the therapist and caretaker. There were only weak correlations between age and the differences in scapulothoracic and GH joint angular displacement performed by both the therapist and the caretaker.

Conclusions: The findings of this study indicate that scapular stabilization may be detrimental to passive stretching of the GH joint in children, as demonstrated by a reduced stretch. Based on the findings of this study, we have changed our practice to recommend passive stretches without scapular stabilization for children aged 5 years and older with brachial plexus birth palsy. In infants and children aged less than 5 years, we now recommend stretching with and without scapular stabilization until the effect of scapular stabilization is objectively assessed in these age groups.

Level Of Evidence/type Of Study: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2018.04.025DOI Listing
January 2019

Ulnar Nerve Injury in Pediatric Midshaft Forearm Fractures: A Case Series.

J Orthop Trauma 2018 09;32(9):e359-e365

The Hand and Upper Extremity Center of Georgia, Atlanta, GA.

Objectives: To describe a midshaft forearm fracture pattern that places the ulnar nerve at risk in the pediatric population and provide 7 clinical case examples describing the injury pattern and treatment methods.

Design: Retrospective observational case series, review of literature, cadaver dissection, and treatment recommendations.

Setting: Multi-institutional, Southeast United States.

Patients: Seven pediatric patients (5 male and 2 female) with mean age of 8.7 years (range, 3-14) who sustained a significantly displaced closed, or grade I open, middle to distal one-third both-bone forearm fracture with subsequent ulnar nerve dysfunction.

Interventions: Manual reduction and casting of both-bone forearm shaft fractures, operative debridement, fracture fixation, nerve exploration, neurolysis, nerve repair, and nerve grafting.

Main Outcome Measurements: Radiographic fracture union, clinical ulnar nerve motor and sensory function testing, along with selective electric nerve testing and advanced imaging were monitored throughout follow-up postinjury.

Results: Five of 7 patients underwent surgical treatment and 2 others were treated with conservative measures. The ulnar nerve was entrapped within the fracture site of one patient with an open fracture along with partial nerve transection, and 4 patients were found to have the nerve encased in hypertrophic scar tissue or bony callus upon surgical exploration at 3-12 months postinjury.

Conclusions: The ulnar nerve lies in a precarious position in the middle to distal one-third forearm and is bound by anatomic constraints that place the nerve at risk of injury. This article offers a treatment algorithm that includes conservative treatment, acute exploration, early exploration (≤3 months), and late exploration (>3 months).

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001238DOI Listing
September 2018

Outcomes in Early Versus Late Presentation of Focal Fibrocartilaginous Dysplasia Affecting the Upper Extremity: A Review of 4 Cases.

J Pediatr Orthop 2018 Jul;38(6):e360-e368

Orthopaedic Surgery, Shriners Hospital for Children Philadelphia, Philadelphia, PA.

Background: Focal fibrocartilaginous dysplasia (FFCD) is a rare disorder of the upper and lower extremities. In the distal ulna, a ligamentous tether emerging from the metaphysis crosses the physis and restricts growth, leading to deformity. Lesion excision before radiocapitellar subluxation has been shown to restore growth and allow remodeling. We review the outcomes of 4 patients with FFCD of the distal ulna after the occurrence of radiocapitellar incongruity.

Methods: This retrospective review examined 4 patients diagnosed with FFCD of the distal ulna from 2007 to 2015. Diagnosis was based on radiographic parameters and pathology when available. The radiographic and functional outcomes are reported.

Results: Three males and 1 female patient presented at an average of 37.5 months (range, 22 to 48 mo) with ulnar FFCD and radiocapitellar joint incongruity. The first patient had progressive radiocapitellar dislocation, poor motion, pain, and deformity. The second patient presented for a third opinion after previous surgery secondary to deformity progression and radial head dislocation. These patients required salvage procedures with creation of a 1-bone forearm. Patient 3 had frank dislocation of the radiocapitellar joint, yet maintained functional motion. This family elected for continued observation. Patient 4 had a 50% subluxation of the radiocapitellar joint and underwent tether excision and ulnar lengthening with an external fixator. Both joint congruity and deformity improved with functional forearm and elbow motion.

Conclusions: Delayed treatment of ulnar FFCD may require salvage procedures to maximize function and provide pain relief.
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http://dx.doi.org/10.1097/BPO.0000000000001175DOI Listing
July 2018

Postoperative Loss of Midline Function in Brachial Plexus Birth Palsy.

J Hand Surg Am 2018 06 6;43(6):565.e1-565.e10. Epub 2017 Dec 6.

Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA.

Purpose: To identify the rate of and predictive variables for functionally limited shoulder internal rotation in postoperative patients with brachial plexus birth palsy.

Methods: Records of patients with brachial plexus birth palsy who had surgery on the affected upper extremity during a 10-year period were retrospectively reviewed. Patient demographics, physical examinations, and all upper extremity procedures were recorded. Loss of midline function (LOM) was defined as a Modified Mallet Scale or Active Movement Scale (AMS) internal rotation score <3. Exclusion criteria were <1-year follow-up after the most recent procedure, insufficient documentation, or preexisting LOM. Multivariable logistic regression was performed on 3 different scenarios of candidate variables to identify those associated with LOM. All scenarios included each procedure as a candidate variable. Scenario A additionally analyzed preprocedural AMS scores. Scenario B additionally analyzed preprocedural Modified Mallet Scale scores. Scenario C isolated the surgical pathway without preprocedural examination scores.

Results: Among 172 included patients, 34 (19.8%) developed LOM. Predictive variables associated with LOM included severity of initial palsy (C5-7, odds ratio 3.6; C5-T1, odds ratio 4.9), poor recovery of upper trunk motor function before the patient's first surgery (specifically Modified Mallet Scale abduction < 4, AMS elbow flexion < 3, and AMS wrist extension < 3), and patients who ultimately required surgical glenohumeral reduction (odds ratio 3.6). Age, number of procedures, closed shoulder reduction with casting, shoulder tendon transfers, and external rotation humeral osteotomies were not predictive of LOM.

Conclusions: Approximately 1 in every 5 patients with brachial plexus birth palsy will develop LOM after entering a surgical algorithm designed to improve shoulder external rotation. Patients with a more severe initial palsy (C5-7 or global), poor spontaneous recovery of upper trunk motor function (elbow flexion or wrist extension) before their first procedure, and those who ultimately require surgical glenohumeral joint reduction should be counseled as having a higher odds of LOM development.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2017.10.041DOI Listing
June 2018

Motion Necessary to Achieve Mallet Internal Rotation Positions in Children With Brachial Plexus Birth Palsy.

J Pediatr Orthop 2019 Jan;39(1):14-21

Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE.

Background: Upper extremity function in children with brachial plexus birth palsy (BPBP) is assessed with clinical tests such as the Mallet classification, which uses a hand to spine position to assess shoulder internal rotation, or the modified Mallet classification, which adds an additional internal rotation task (hand to belly). Children with BPBP frequently have difficulty performing the hand to spine task. This study compared scapulothoracic and glenohumeral (GH) parameters associated with successful completion of the hand to spine and hand to belly modified Mallet positions.

Methods: Motion capture measurement of 32 children with BPBP was performed in hand on spine, internal rotation (hand to belly), hand to mouth, and maximal humerothoracic extension positions. Modified Mallet scores were determined by a hand surgeon.

Results: Children with better hand to spine performance demonstrated significantly greater GH extension and a nonsignificant trend toward increased GH internal rotation compared with children with scores <3. Children with better internal rotation position performance demonstrated significantly greater GH internal rotation and no significant difference in GH extension. Hand on spine and internal rotation Mallet scores moderately correlated (Pearson r=0.469); however, 54% of children who could place their palms flat on their bellies could not reach behind their backs.

Conclusions: Successfully reaching behind one's back requires both internal rotation and extension, representing a multiplanar motion. The hand to belly performance is less affected by extension and should be considered for internal rotation assessment, particularly for children undergoing surgical intervention that may affect internal rotation.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1097/BPO.0000000000001010DOI Listing
January 2019

Commentary on "The Role for International Outreach in Hand Surgery".

Authors:
Scott H Kozin

J Hand Surg Am 2017 08;42(8):656

Touching Hands Project, American Society for Surgery of the Hand, Shriners Hospital for Children, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.jhsa.2017.05.025DOI Listing
August 2017

Combined Elbow Release and Humeral Rotational Osteotomy in Arthrogryposis.

J Hand Surg Am 2017 Nov 14;42(11):926.e1-926.e9. Epub 2017 Jul 14.

Shriners Hospital for Children of Philadelphia, Philadelphia, PA.

Purpose: The purpose of this study was to determine if a simultaneous posterior elbow release and humeral osteotomy to correct both the elbow extension contracture and the humeral internal rotation contracture in children with arthrogryposis can produce similar results as a posterior elbow release alone.

Methods: This study was a retrospective chart review of consecutive patients with arthrogryposis treated surgically for elbow extension contracture between 2007 and 2014. A total of 43 procedures in 36 patients had adequate available follow-up data and were included in the study. The postoperative range of motion reported was measured at the early follow-up (3-6 months), midterm follow-up (between 1 and 2 years), and the most recent long-term follow-up (after 2 years) from the date of surgery. Patients were grouped into 2 groups (simultaneous and release) based on the necessity of performing an ipsilateral humeral rotation osteotomy at the time of the release.

Results: At early follow-up, patients in both groups increased their total arc of motion. There was a significant difference in extension and arc of motion at midterm follow-up (between 1 and 2 years) between the simultaneous and the release groups with the simultaneous group significantly losing both terminal extension and total arc of motion. At more than 2 years follow-up, there remained a statistically significant difference in arc of motion, with the release group having a significantly larger arc of motion. Patients who underwent dual plating had a much larger arc of motion at early follow-up than the K-wire or single-plate fixation group, despite having similar preoperative extension, flexion, and arc of motion. This difference was also significant at late follow-up.

Conclusions: Patients with posterior release alone had significantly greater improvement in total arc of motion and significantly better elbow extension than patients who underwent a simultaneous humeral osteotomy. However, rigid fixation with early mobilization may yield results comparable with the release alone group.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2017.06.005DOI Listing
November 2017

Medial Femoral Condyle Microvascular Bone Transfer as a Treatment for Capitate Avascular Necrosis: Surgical Technique and Case Report.

J Hand Surg Am 2017 Oct 9;42(10):841.e1-841.e6. Epub 2017 May 9.

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA.

Avascular necrosis (AVN) of the capitate is a rare clinical entity for which a variety of treatment options have been described, ranging from immobilization to microvascular bone transfer. Outcomes following medial femoral condyle corticocancellous free flap reconstruction have not been reported for this specific pathology. We present the case of a 16-year-old girl with posttraumatic capitate AVN who was treated with curettage and medial femoral condyle corticocancellous vascularized bone grafting. At 18 months after surgery, the patient remains pain-free and had resumed all activities including lifeguarding by 6 months after surgery. This microsurgical technique, described previously for AVN of the scaphoid and lunate, may be applied in a similar fashion for the capitate with promising clinical results.

Type Of Study/level Of Evidence: Therapeutic V.
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http://dx.doi.org/10.1016/j.jhsa.2017.04.006DOI Listing
October 2017

Efficacy of 3 therapeutic taping configurations for children with brachial plexus birth palsy.

J Hand Ther 2018 Jul - Sep;31(3):357-370. Epub 2017 Apr 25.

Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA.

Study Design: Cross-sectional clinical measurement study.

Introduction: Scapular winging is a frequent complaint among children with brachial plexus birth palsy (BPBP). Therapeutic taping for scapular stabilization has been reported to decrease scapular winging.

Purpose Of The Study: This study aimed to determine which therapeutic taping construct was most effective for children with BPBP.

Methods: Twenty-eight children with BPBP participated in motion capture assessment with 4 taping conditions: (1) no tape, (2) facilitation of rhomboid major and rhomboid minor, (3) facilitation of middle and lower trapezius, and (4) facilitation of rhomboid major, rhomboid minor, and middle and lower trapezius (combination of both 2 and 3, referred to as combined taping). The participants held their arms in 4 positions: (1) neutral with arms by their sides, (2) hand to mouth, (3) hand to belly, and (4) maximum crossbody adduction (CBA). The scapulothoracic, glenohumeral and humerothoracic (HT) joint angles and joint angular displacements were compared using multivariate analyses of variance with Bonferroni corrections.

Results: Scapular winging was significantly decreased in both the trapezius and combined taping conditions in all positions compared with no tape. Rhomboids taping had no effect. Combined taping reduced HT CBA in the CBA position.

Conclusions: Rhomboid taping cannot be recommended for treatment of children with BPBP. Both trapezius and combined taping approaches reduced scapular winging, but HT CBA was limited with combined taping. Therefore, therapeutic taping of middle and lower trapezius was the most effective configuration for scapular stabilization in children with BPBP. Resting posture improved, but performance of the positions was not significantly improved.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jht.2017.03.001DOI Listing
November 2019
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