Publications by authors named "Virak Tan"

47 Publications

Coban Method for Removing a Constricting Ring.

Authors:
Virak Tan

Hand (N Y) 2019 Jan 6;14(1):133-134. Epub 2018 Sep 6.

1 Institute for Hand & Arm Surgery, Millburn, NJ, USA.

Background: Various techniques have been described for removal of a tight constricting ring from a finger. A novel procedure is described in this article.

Methods: The method is a modification of the string wrap or winding technique. A 1-inch Coban wrap, lubricant, and pickups are all that is required.

Results: The author has used this method to remove constricting rings from swollen and arthritic fingers in 5 patients. The technique has been successful in all cases, and no complications occurred.

Conclusions: The Coban method is a quick, easy, and inexpensive technique for ring removal from a finger. The technique should be taught to and known by every clinician who treats hand problems.
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http://dx.doi.org/10.1177/1558944718798855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6346368PMC
January 2019

Deep Friction Massage Versus Steroid Injection in the Treatment of Lateral Epicondylitis.

Hand (N Y) 2018 01 1;13(1):56-59. Epub 2017 Feb 1.

2 Institute for Hand & Arm Surgery, Harrison, NJ, USA.

Background: The aim of the study was to determine the efficacy of deep friction massage in the treatment of lateral epicondylitis by comparing outcomes with a control group treated with splinting and therapy and with an experimental group receiving a local steroid injection.

Methods: A randomized clinical trial was conducted to compare outcomes after recruitment of consecutive patients presenting with lateral epicondylitis. Patients were randomized to receive one of 3 treatments: group 1: splinting and stretching, group 2: a cortisone injection, or group 3: a lidocaine injection with deep friction massage. Pretreatment and posttreatment parameters of visual analog scale (VAS) pain ratings, Disabilities of the Arm, Shoulder and Hand (DASH) scores, and grip strength were measured.

Results: Outcomes were measured at early follow-up (6-12 weeks) and at 6-month follow-up. There was a significant improvement in VAS pain score in all treatment groups at early follow-up. DASH score and grip strength improved in the cortisone injection group and the deep friction massage group at early follow-up; these parameters did not improve in the splinting and stretching group. At 6-month follow-up, only patients in the deep friction massage group demonstrated a significant improvement in all outcome measures, including VAS pain score, DASH score, and grip strength.

Conclusions: Deep friction massage is an effective treatment for lateral epicondylitis and can be used in patients who have failed other nonoperative treatments, including cortisone injection.
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http://dx.doi.org/10.1177/1558944717692088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5755866PMC
January 2018

A Novel Screening Technique for Ulnar-Sided Carpometacarpal Dislocations.

Orthopedics 2017 Mar 28;40(2):e352-e356. Epub 2016 Dec 28.

Diagnosing ulnar-sided carpometacarpal joint dislocation is difficult, and more than half of injuries are missed on initial examination. The authors hypothesized that measuring the angle between the capitate and the metacarpals (capitate-metacarpal angle) on a plain radiograph would provide a simple, reliable tool to aid in the diagnosis of ulnar-sided carpometacarpal dislocation. This study retrospectively reviewed patients who underwent surgery for ulnar-sided carpometacarpal dislocation (study group). Two authors identified the contour of the capitate and the second, fourth, and fifth metacarpals on plain radiographs. The control group consisted of patients who had radiographs and no bony carpal or metacarpal pathology. Information on the contour of each bone was entered into MATLAB, version 8.5, software (MathWorks, Natick, Massachusetts), which calculated the 2-dimensional angles. A 3-dimensional model based on computed tomography scan data was used to obtain a "true lateral" image to account for variable rotation on plain radiographs. With the use of conventional lateral hand radiographs, the average capitate-metacarpal angle in the control group was 10° compared with 19° in the study group. Using a screening value of 15° on plain radiographs, the sensitivity of the capitate-metacarpal angle was 0.85 and the specificity was 0.79. Both 2-dimensional and 3-dimensional measurements showed that the angle between the capitate and the lesser metacarpals is a reliable screening tool for carpometacarpal dislocation. During evaluation of patients with posttraumatic hand pain, an increased capitate-metacarpal angle may indicate the need for advanced imaging studies to further evaluate the carpometacarpal joints. [Orthopedics. 2017; 40(2):e352-e356.].
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http://dx.doi.org/10.3928/01477447-20161219-04DOI Listing
March 2017

Computerized 3D morphological analysis of glenoid orientation.

J Orthop Res 2016 Apr 12;34(4):692-8. Epub 2015 Oct 12.

Department of Industrial & Systems Engineering, Rutgers University, Piscataway, New Jersey.

An accurate preoperative measurement of glenoid orientation is crucial for evaluating pathologies and successful total shoulder arthroplasty. Existing methods may be labor-intensive, observer-dependent, and sensitive to the misalignment between the scapula plane and CT scanning direction. In this study, we proposed a computation framework and performed an automated analysis of the glenoid orientation based on 3D surface data. Three-dimensional models of 12 scapulae were analyzed. The glenoid cavity and external anatomical features were automatically extracted from these 3D models. Glenoid version was calculated using the scapula plane and the fulcrum axis alternatively. Glenoid inclination was measured both relative to transverse axis of the scapula and the medial pole-inferior tip axis. The mean (±SD) of the fulcrum-based glenoid version was -0.55° (±4.17°), while the scapular-plane-based glenoid version was -5.05° (±3.50°). The mean (±SD) of glenoid inclinations based on the medial pole and inferior tip was 12.75° (±5.03°) while the mean (±SD) of the glenoid inclination based on the medial pole and glenoid center was 4.63° (±4.86°). Our computational framework was able to extract the reproducible morphological measures free of inter- and intra- observer variability. For the first time in 3D, we showed that the fulcrum axis was practically perpendicular to the glenoid plane normal (radial line), and thus extended the fulcrum-based glenoid version for quantifying 3D glenoid orientation.
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http://dx.doi.org/10.1002/jor.23053DOI Listing
April 2016

Dynamic Distraction External Fixation for Contracture of the Metacarpophalangeal Joint.

Tech Hand Up Extrem Surg 2015 Dec;19(4):143-6

*Division of Hand Surgery, Rothman Institute, Philadelphia, PA †Department of Orthopaedics, Rutgers New Jersey Medical School, Division of Hand and Microvascular Surgery, Newark, NJ.

Metacarpophalangeal (MP) joint contractures are common after traumatic injury, and can be difficult to manage. After surgical capsulectomy, it remains challenging to maintain motion that was obtained at the time of surgery. Our group uses a novel, prefabricated digital external fixator to provide both distraction, and motion therapy across the MP joint after surgical treatment of MP contracture. The purpose of this technique is to demonstrate the effectiveness of an adjunctive dynamic distraction external fixator for the maintenance of joint motion after surgical treatment of MP contractures of the border digits.
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http://dx.doi.org/10.1097/BTH.0000000000000096DOI Listing
December 2015

Complications associated with hinged external fixation for chronic elbow dislocations.

J Hand Surg Am 2015 Apr 24;40(4):730-7. Epub 2015 Feb 24.

Department of Orthopaedics, Rutgers University-New Jersey Medical School, Newark, NJ; Hand and Upper Extremity Center, Dallas, TX; Department of Surgery, Division of Orthopaedics, University of Toronto-Sunnybrook Health Science Center, Toronto, Ontario, Canada. Electronic address:

Purpose: To evaluate the outcomes of patients who underwent application of hinged external fixators for chronic elbow fracture-dislocations. We hypothesized that patients treated for this injury pattern can achieve satisfactory outcomes but encounter many complications and require numerous additional procedures.

Methods: We performed a retrospective review of 7 patients who were surgically treated with application of a hinged external fixator for chronic ulnohumeral elbow fracture-dislocation. Patients were included only if they had complete ulnohumeral dislocation of greater than 1 month's duration. Demographics, injury pattern, and range of motion were documented. Preoperative and postoperative range of motion was recorded and any treatment complications or additional surgeries were noted.

Results: The interval between the initial injury and index procedure averaged 8 months. All patients underwent initial treatment with open reduction internal fixation. Average arc of ulnohumeral motion improved from 26° (range, 0° to 60°) to 120° (range, 100° to 145°). Overall, 4 of 7 patients developed at least one complication during treatment. Three patients required additional procedures aside from removal of the hinged external fixator. These 3 patients underwent a total of 13 additional procedures.

Conclusions: Although patients can achieve good outcomes, realistic expectations should be set. Patients should be aware that surgery can be associated with a high risk of complications, potential treatment failure, and a need for additional surgical procedures.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2014.12.043DOI Listing
April 2015

Fracture pattern characteristics and associated injuries of high-energy, large fragment, partial articular radial head fractures: a preliminary imaging analysis.

J Orthop Traumatol 2015 Jun 27;16(2):125-31. Epub 2014 Dec 27.

Division of Hand Surgery, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, 10009, USA,

Background: High-energy radial head injuries often present with a large partial articular displaced fragment with any number of surrounding injuries. The objective of the study was to determine the characteristics of large fragment, partial articular radial head fractures and determine any significant correlation with specific injury patterns.

Materials And Methods: Patients sustaining a radial head fracture from 2002-2010 were screened for participation. Twenty-five patients with documented partial articular radial head fractures were identified and completed the study. Our main outcome measurement was computed tomography (CT)-based analysis of the radial head fracture. The location of the radial head fracture fragment was evaluated from the axial CT scan in relation to the radial tuberosity used as a reference point. The fragment was characterized by location as anteromedial (AM), anterolateral (AL), posteromedial (PM) or posterolateral (PL) with the tuberosity referenced as straight posterior. All measurements were performed by a blinded, third party hand and upper extremity fellowship trained orthopedic surgeon. Fracture pattern, location, and size were then correlated with possible associated injuries obtained from prospective clinical data.

Results: The radial head fracture fragments were most commonly within the AL quadrant (16/25; 64 %). Seven fracture fragments were in the AM quadrant and two in the PM quadrant. The fragment size averaged 42.5 % of the articular surface and spanned an average angle of 134.4(°). Significant differences were noted between AM (49.5 %) and AL (40.3 %) fracture fragment size with the AM fragments being larger. Seventeen cases had associated coronoid fractures. Of the total 25 cases, 13 had fracture dislocations while 12 remained reduced following the injury. The rate of dislocation was highest in radial head fractures that involved the AM quadrant (6/7; 85.7 %) compared to the AL quadrant (7/16; 43.7 %). No dislocations were observed with PM fragments. Ten of the 13 (78 %) fracture dislocations had associated lateral collateral ligament (LCL)/medial collateral ligament tear. The most common associated injuries were coronoid fractures (68 %), dislocations (52 %), and LCL tears (44 %).

Conclusion: The most common location for partial articular radial head fractures is the AL quadrant. The rate of elbow dislocation was highest in fractures involving the AM quadrant. Cases with large fragment, partial articular radial head fractures should undergo a CT scan; if associated with >30 % or >120(°) fracture arc, then the patient should be assessed closely for obvious or occult instability. These are key associations that hopefully greatly aid in the consultation and preoperative planning settings.

Level Of Evidence: Diagnostic III.
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http://dx.doi.org/10.1007/s10195-014-0331-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441642PMC
June 2015

Repeat emergency room visits for hand and wrist injuries.

J Hand Surg Am 2014 Apr 1;39(4):752-6. Epub 2014 Mar 1.

Department of Orthopaedics, Rutgers University-New Jersey Medical School, Newark, NJ. Electronic address:

Purpose: To characterize patients with hand or wrist injuries presenting to our university-based emergency department (ED) after a previous evaluation by an outside ED. We hypothesized that a majority of these patients did not require emergent care, most arrived during working hours, and a disproportionate number were uninsured.

Methods: We retrospectively reviewed 3,047 orthopedic hand consults from 2002 to 2010. Patients were included if our ED was the patient's second ED evaluation within 30 days for the same complaint. Demographics, diagnosis, referral instructions from the initial institution, date and time of ED visit, treatment received, and insurance status were recorded. Clinical urgency was quantified on an ordinal scale.

Results: A total of 325 patients met the inclusion criteria. The most common diagnoses were distal radius and metacarpal fractures. There were 266 (82%) patients with nonurgent diagnoses. A junior-level orthopedic resident treated and discharged 97% of patients from the ED. Sixty-two percent of the patients were uninsured, 32% had Medicaid, and 6% had commercial insurance or Medicare. There was a disproportionate percentage of uninsured and Medicaid patients compared with the payer mix of our state, orthopedic department, and ED. Ninety percent of patients presented on weekdays, and 84% arrived between 6 am and 6 pm.

Conclusions: Most patients who met our inclusion criteria presented to our ED during regular business hours. Most were uninsured and did not have a condition that warranted urgent or emergent evaluation and treatment. With limited resources, it is important that an appropriate follow-up plan from the initial ED be in place so that patients do not have to present to a second ED for the same problem.

Type Of Study/level Of Evidence: Prognostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2014.01.019DOI Listing
April 2014

Sequelae of foreign bodies in the wrist and hand.

Hand (N Y) 2013 Mar;8(1):77-81

Department of Orthopaedics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, 140 Bergen Street, ACC D1626, Newark, NJ 07103 USA.

Background: Penetrating injuries to the hand are a common occurrence in the emergency room, and embedment of foreign bodies is suspected in many of these cases. The existing literature offers little information on retained foreign bodies. The aim of this study was to identify characteristics, determine prevalence, and observe outcomes for retained foreign bodies in the wrist and hand.

Methods: Four hundred thirty-seven consecutive hand and wrist radiographs in 437 patients from the emergency department of a level 1 trauma center were reviewed for the presence of retained foreign bodies. Location, size, number, and type of foreign body were recorded. Patient demographics, mechanism of injury, associated injuries, and treatment were obtained from medical records. All subsequent hospital and outpatient encounters were reviewed. Follow-up period was 18 months (range, 1-40).

Results: Of 437 cases, 65 patients (15 %) had at least one retained foreign body. Nineteen patients underwent removal of foreign body at initial presentation. The average size of foreign bodies removed was 6 mm, compared to 3 mm for those retained. Of 46 patients where the foreign body was left in situ, two (4 %) developed symptoms directly related to the retained foreign body. One of these patients underwent removal.

Conclusions: This study supports the safe removal of foreign bodies which are easily accessible or when part of a broader procedure to repair injured structures. Otherwise, we advocate expectant management for all other patients, as the likelihood of persistent symptoms is low and only 2 % of retained foreign bodies required removal later.
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http://dx.doi.org/10.1007/s11552-012-9481-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3574488PMC
March 2013

Treatment of dorsal perilunate dislocations and fracture-dislocations using a standardized protocol.

Hand (N Y) 2012 Dec;7(4):380-7

Department of Orthopaedics, NYU Medical Center-Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003 USA.

Background: The aims of this study were to evaluate the associated injuries occurring with acute perilunate instability and to assess the clinical and radiographic outcomes of perilunate dislocations and fracture-dislocations treated with a combined dorsal and volar approach.

Methods: A total of 45 patients (46 wrist injuries) with perilunate dislocations and fracture-dislocations were prospectively evaluated. The size of the mid-carpal ligament tear, the location of the scapholunate ligament tear, and the presence of osteochondral fragments and of the dorsal radiocarpal ligament avulsions were recorded at injury. Final clinical and radiographic outcomes were evaluated in 25 cases (25 wrists) with a minimum of 6 months of follow-up.

Results: Intraoperative examination of the 46 cases with operative treatment showed the volar carpal ligament tear to be present 100 % of the time and to be an average length of 3.4 cm. Complete avulsion of the dorsal extrinsic radiocarpal ligaments was found in 65.2 % of cases. The scapholunate ligament was torn in 35 cases. Osteochondral fragments were found either volarly or dorsally in 74 % of the cases. The average flexion-extension arc was 82°, forearm rotation was 155°, and grip strength averaged 59 % of the uninjured hand. The average final scapholunate angle was 55° and the scapholunate gap was 2.2 mm.

Conclusion: Treatment of perilunate fracture-dislocations with a combined volar and dorsal approach results in reasonable and functional clinical results. The incidence of associated injuries with these carpal dislocations is high. Although the perilunate fracture-dislocations have a slightly better radiologic alignment than the dislocation group, the clinical outcome is similar.
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http://dx.doi.org/10.1007/s11552-012-9452-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508016PMC
December 2012

Current indications and outcomes of total wrist arthroplasty.

Orthop Clin North Am 2013 Jul 17;44(3):371-9, ix. Epub 2013 Apr 17.

Department of Orthopaedics, UMDNJ-New Jersey Medical School, New Jersey Orthopaedic Institute, 140 Bergen Street, ACC D-Level, Newark, NJ 07103, USA.

This article reviews the current indications and clinical outcomes of total wrist arthroplasty. The section on indications reviews both rheumatoid and nonrheumatoid arthritic conditions. The section on clinical outcomes examines the data regarding the 3 current total wrist implants approved by the Food and Drug Administration.
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http://dx.doi.org/10.1016/j.ocl.2013.03.008DOI Listing
July 2013

Transformation between different local coordinate systems of the scapula.

J Biomech 2012 Oct 29;45(15):2724-7. Epub 2012 Aug 29.

Liberty Mutual Research Institute for Safety, Hopkinton, MA 01748, USA.

The existence of multiple local coordinate systems (LCSs) for the scapula makes it difficult to compare the kinematics of the scapula across various studies and reports. This study aimed to build transformation matrices between different LCSs for the scapula and to provide the coordinates of previously measured muscles and ligaments around the scapula with respect to the International Society of Biomechanics (ISB) recommended LCS. The bony landmarks necessary for building various local coordinate systems were digitized on 13 CT scanned scapulae. The LCSs were built based on the digitized bony landmarks and then used for calculating the transformation equations. The approximate coordinates of 28 muscles and ligaments of the scapula were expressed with respect to the ISB-recommended LCS using the derived transformation equations. The results of this study may be used for the comparison of scapula kinematics data with respect to various LCSs and for building a scapula biomechanical model with respect to ISB-recommended LCS.
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http://dx.doi.org/10.1016/j.jbiomech.2012.08.021DOI Listing
October 2012

Distal radius osteotomy with intramedullary fixation for the treatment of Kienbock disease.

Tech Hand Up Extrem Surg 2012 Sep;16(3):153-8

Department of Orthopedics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ, USA.

Symptomatic Kienbock disease with ulnar-negative variance is commonly treated with a distal radius shortening osteotomy. Traditionally, the osteotomy is stabilized using dorsal or volar plating. Use of an intramedullary implant to stabilize the osteotomy in the treatment of this condition is demonstrated in this article. In addition to changing the mechanical loading through the lunate, the technique also allows for core decompression the distal radial metaphyseal bone that may further help in restoring the vascularity to the lunate. The authors believe that this technique is a valuable method that demonstrates both clinical and technical improvements in the treatment of Kienbock disease.
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http://dx.doi.org/10.1097/BTH.0b013e31825c79b9DOI Listing
September 2012

Perilunate injuries.

Hand (N Y) 2011 Mar 25;6(1):1-7. Epub 2010 Sep 25.

Division of Hand and Microvascular Surgery, Department of Orthopedics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, 140 Bergen Street, Newark, NJ 07103 USA.

Perilunate dislocations and fracture dislocations are most often a result of high-energy trauma, exerting an axial load with hyperextension and ulnar deviation of the wrist, along with intercarpal supination. Early treatment of perilunate injuries is necessary to optimize the clinical outcome. Although closed management has been the more commonly reported treatment for perilunate injuries, the current consensus is that anatomic restoration of carpal alignment has better results. The combined dorsal-volar approach offers the advantages of both approaches and is the preferred choice for the authors since it allows assessment of all the injured structures. The surgical techniques to restore carpal alignment and repair the scapholunate interosseous ligament are discussed. Current literature regarding treatment and prognosis is also included.
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http://dx.doi.org/10.1007/s11552-010-9293-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041883PMC
March 2011

Irreducible luxatio erecta humeri caused by an aberrant position of the axillary nerve.

J Shoulder Elbow Surg 2012 Jul 22;21(7):e6-9. Epub 2012 Feb 22.

Department of Orthopaedics, Division of Hand and Microvascular Surgery, University of Medicine and Dentistry of New Jersey-The New Jersey Medical School, Newark, NJ, USA.

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http://dx.doi.org/10.1016/j.jse.2011.11.022DOI Listing
July 2012

Initial management of open hand fractures in an emergency department.

Am J Orthop (Belle Mead NJ) 2011 Dec;40(12):E243-8

University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.

We retrospectively reviewed the cases of patients with open hand fractures and/or dislocations managed at our institution between 2001 and 2009. The management protocol consisted of irrigation and debridement, reduction (if necessary), splinting, and antibiotics administration in the emergency department. Patients with vascular compromise or severe mangling open wounds were taken to the operating room for treatment. Data regarding demographics, wound size and modified Gustilo-Anderson classification, and timing of interventions were recorded. Included in the study were 145 cases (91 class III, 41 class II, and 13 class I injuries). In 102 cases, definitive and final management took place in the emergency department; in the other 43 cases, additional management took place in the operating room. Antibiotics were administered within 4 hours after injury, and irrigation and debridement were performed within 6 hours. Each of the 2 infections (1.4%) developed in a class III injury. In open hand fractures, particularly type I and type II wounds, the protocol we followed can be appropriate when the injury is not the severe mangling type and does not require acute vascular repair.
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December 2011

Skin sterility after application of ethyl chloride spray.

J Bone Joint Surg Am 2012 Jan;94(2):118-20

New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey 07101, USA.

Background: Ethyl chloride topical anesthetic spray is labeled as nonsterile, yet it is widely used during injection procedures performed in an outpatient setting. The purpose of this study was to investigate the sterility of ethyl chloride topical anesthetic spray applied before an injection. Our a priori hypothesis was that application of the spray after the skin has been prepared would not alter the sterility of the injection site.

Methods: We conducted a prospective, blinded, controlled study to assess the effect of ethyl chloride spray on skin sterility. Fifteen healthy adult subjects (age, twenty-three to sixty-one years) were prepared for mock injections into both shoulders and both knees, although no injection was actually performed. Three culture samples were obtained from each site on the skin: one before skin preparation with isopropyl alcohol, one after skin preparation and before application of ethyl chloride, and one after ethyl chloride had been sprayed on the site. In addition, the sterility of the ethyl chloride was tested directly by inoculating cultures with spray from the bottles.

Results: Growth occurred in 70% of the samples obtained before skin preparation, 3% of the samples obtained after skin preparation but before application of ethyl chloride, and 5% of the samples obtained after the injection site had been sprayed with ethyl chloride. The percentage of positive cultures did not increase significantly after application of ethyl chloride (p = 0.65). Spraying of ethyl chloride directly on agar plates resulted in growth on 13% of these plates compared with 11% of the control plates; this difference was also not significant (p = 0.80).

Conclusions: Although ethyl chloride spray is not sterile, its application did not alter the sterility of the injection sites in the shoulder and knee.
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http://dx.doi.org/10.2106/JBJS.K.00229DOI Listing
January 2012

Comparative analysis of intramedullary nail fixation versus casting for treatment of distal radius fractures.

J Hand Surg Am 2012 Mar 20;37(3):460-468.e1. Epub 2011 Dec 20.

Department of Orthopedics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ 07103, USA.

Purpose: Intramedullary fixation is one treatment option for distal radius fractures. Our purpose was to compare the outcomes of intramedullary nailing to those of casting for these injuries.

Methods: From 2006 to 2009, we reviewed 63 adult patients with isolated distal radius fractures. Thirty-one patients had surgical fixation with an intramedullary device (IMN group) within 4 weeks of the injury, and 32 (cast group) had casting as definitive treatment of the fracture. Clinical outcomes (grip strength; Disabilities of the Arm, Shoulder, and Hand scores; active wrist range of motion; and complications) and radiographic indices (radial inclination, radial height, ulnar variance, and tilt) of both groups were analyzed for the 1-, 2-, 4-, 6-, and 12-month follow-up periods.

Results: The flexion-extension arc was significantly higher in the IMN group than in the cast group at 2-, 6-, and 12-month follow-up. The IMN group exhibited significantly greater grip strength and lower DASH scores throughout the follow-up period. At final follow-up, all radiographic indices were significantly better in the IMN group than in the cast group. There was no significant difference between the initial reduction to final position in the IMN group, but the cast group showed an increase in ulnar variance and a significant change in dorsal-volar tilt. In addition, the cast group experienced more clinical complications in the delayed period compared to the IMN group.

Conclusions: Intramedullary nail fixation, as compared to casting, results in less functional disability, not only in the early postoperative period but also up to a year after treatment. On the basis of our data, intramedullary fixation should be considered for patients with unstable extra-articular or simple intra-articular distal radius fractures.
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http://dx.doi.org/10.1016/j.jhsa.2011.10.041DOI Listing
March 2012

Cerebrovascular accident in a 19-year-old patient: a case report of posterior sternoclavicular dislocation.

J Shoulder Elbow Surg 2011 Oct;20(7):e1-4

Department of Orthopaedics, Hand, Upper Extremity & Microvascular Surgery, University of Medicine and Dentistry of New Jersey, Newark, NJ 07103, USA.

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http://dx.doi.org/10.1016/j.jse.2011.06.001DOI Listing
October 2011

Stratification of the risk factors of community-acquired methicillin-resistant Staphylococcus aureus hand infection.

J Hand Surg Am 2010 Jul 17;35(7):1135-41. Epub 2010 Jun 17.

Department of Orthopedics, University of Medicine and Dentistry, New Jersey Medical School, Newark, NJ 07103, USA.

Purpose: Several recent studies showed an increase in methicillin-resistant Staphylococcus aureus (MRSA) hand infections. The purpose of this study was to determine the prevalence of community-acquired MRSA hand infections in an urban setting and to determine independent risk factors for such infections.

Methods: A retrospective chart review of patients with hand infections was performed from 2002 to 2009. Those with community-acquired hand infections who had surgical irrigation and debridement and intraoperative culture were entered into the study. Patient demographics-including age and gender; mechanism of injury; infection risk factors (diabetes, chronic hepatitis, intravenous intravenousdrug use, and immune-compromised conditions); place of residence/housing status; history of hospitalization, prior antibiotics use and surgery; and culture results, erythrocyte sedimentation rate, C-reactive protein, and white blood cell count-were extracted from the medical records. Regression analyses were performed to identify significant risk factors for MRSA infection.

Results: A total of 102 patients met our inclusion criteria. The MRSA organism was identified in 32 patients. In the analysis of all the potential risk factors, only intravenous drug use showed significant correlation with MRSA infection.

Conclusions: In our patients, only intravenous drug use correlated with community-acquired MRSA hand infections. Patient education about intravenous drug use and empiric treatment with MRSA-appropriate antibiotics for intravenous drug users presenting with hand infections are recommended.

Type Of Study/level Of Evidence: Prognostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2010.03.039DOI Listing
July 2010

Effects of nonsteroidal anti-inflammatory drugs on flexor tendon adhesion.

J Hand Surg Am 2010 Jun;35(6):941-7

Department of Biochemistry and Molecular Biology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School and Graduate School of Biomedical Sciences, Newark, NJ, USA.

Purpose: Besides its anti-inflammatory effects, nonsteroidal anti-inflammatory drug therapy may affect tendon healing and the development of peritendinous adhesions. The purpose of this study was to compare the effect of nonselective (ibuprofen) and COX-2 selective (rofecoxib) nonsteroidal anti-inflammatory drugs on the adhesion formation after tendon repair.

Methods: We assigned 67 rabbits to one of 3 (placebo, ibuprofen, or rofecoxib) groups. The deep flexor tendon was transected, followed by a primary repair. Dosing of the medication began the day after surgery and continued for 27 days. The animals were immobilized in a cast for the first 14 days. Postoperatively, tendon adhesion formation was assessed histologically by calculating the total adhesion in serial axial tendon sections at 3 and 6 weeks and by range of motion measurements at 6 and 12 weeks. We measured range of motion by fixing the metacarpal, applying increasing weight to the free end of the flexor digitorum profundus, and measuring the flexion angle between the metacarpal and the proximal phalanx. Comparison was performed between the treatment groups, as well as to the unoperated forepaws.

Results: Based on histology, we found no difference between the treatment groups when determining the percentage of adhesion between the flexor tendon and its sheath. Control unoperated forepaws had a significantly greater range of metacarpophalangeal joint flexion than the surgically repaired groups. At 12 weeks, range of motion in the ibuprofen group was significantly better than the placebo (p=.009) and rofecoxib (p=.009) groups.

Conclusions: Ibuprofen has a more important effect in limiting adhesion formation compared with rofecoxib after flexor tendon repair. Because ibuprofen inhibits both COX-1 and COX-2, whereas rofecoxib only inhibits COX-2, ibuprofen therapy appears to offer a greater beneficial effect on tendon repair by reducing formation of adhesions.
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http://dx.doi.org/10.1016/j.jhsa.2010.02.033DOI Listing
June 2010

Treatment of extra-articular distal radial malunions with an intramedullary implant.

J Hand Surg Am 2010 Jun 15;35(6):892-9. Epub 2010 May 15.

Department of Orthopaedics, UMDNJ-New Jersey Medical School, Newark, NJ 07103, USA.

Purpose: Malunited distal radius fractures pose considerable problems, especially for young, active individuals. Surgical correction with osteotomy, bone grafting, and internal fixation with plates and screws has been the treatment of choice. Locked intramedullary fixation is an alternative technique to provide bony stability while minimizing soft tissue irritation in the management of acute distal radius fractures, with acceptable clinical results. The purpose of this study was to describe our experience with the use of an intramedullary device combined with grafting to repair distal radial malunions. This fixation device is inserted through the radial styloid and obtains distal fixation with 3 fixed-angle locking screws.

Methods: Thirteen patients underwent distal radius malunion repair with an intramedullary implant and grafting. There were 6 male and 7 female participants with an average age of 51 years (range, 18-72 y). Patients were evaluated at an average follow-up of 24 months (range, 13-38 mo). Clinical outcome was measured by range of motion of the wrist and forearm, and grip strength, and by using the Disabilities of the Arm, Shoulder, and Hand questionnaire. We analyzed radiographs to determine time to union and adequacy of correction.

Results: All of the malunions healed, with an average time to healing of 11 weeks. Patients' average range of motion at follow-up was 56 degrees of flexion, 66 degrees extension, 85 degrees pronation, and 84 degrees supination. Mean grip strength was 83% of the unaffected side, and the average Disabilities of the Arm, Shoulder, and Hand score was 21. Radiographs taken on the latest follow-up showed correction to the following average parameters: 20.6 degrees radial inclination, 11.0 mm radial height, +1.0 mm ulnar variance, and 2.1 degrees volar tilt.

Conclusions: The technique presented in this report demonstrates the effectiveness of an intramedullary nail combined with bone graft or graft substitute in repairing malunited fractures of the distal radius. The results show reliable correction of the deformity and good functional outcomes.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2010.02.032DOI Listing
June 2010

A comparison of the effects of ibuprofen and rofecoxib on rabbit fibula osteotomy healing.

Acta Orthop 2009 Oct;80(5):597-605

Department of Biochemistry, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ, USA.

Background And Purpose: Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase (COX) activity, which is the rate-limiting enzyme in the synthesis of prostaglandins. Previous studies have indicated that NSAID therapy, and in particular NSAIDs that specifically target the inflammatory cyclooxygenase (COX-2), impair bone healing. We compared the effects of ibuprofen and rofecoxib on fibula osteotomy healing in rabbits to determine whether nominal, continuous inhibition of COX-2 with rofecoxib would differentially affect fracture healing more than cyclical inhibition of COX-2 using ibuprofen, which inhibits COX-1 and COX-2 and has a short half-life in vivo.

Methods: Bilateral fibula osteotomies were done in 67 skeletally mature male New Zealand white rabbits. The rabbits were treated with placebo, rofecoxib (12.5 mg once a day), or ibuprofen (50 mg 3 times a day) for 28 days after surgery. Plasma ibuprofen levels were measured by HPLC analysis. Bone healing was assessed by histomorphometry at 3 and 6 weeks after osteotomy, and at 6 and 12 weeks by torsional mechanical testing.

Results: Plasma ibuprofen levels peaked and declined between successive doses. Fracture callus morphology was abnormal in the rofecoxib-treated rabbits and torsional mechanical testing showed that fracture healing was impaired. Ibuprofen treatment caused persistence of cartilage within the fracture callus and reduced peak torque at 6 weeks after osteotomy as compared to the fibulas from the placebo-treated rabbits. In the specimens allowed to progress to possible healing, non-union was seen in 5 of the 26 fibulas from the rofecoxib-treated animals as compared to 1 of 24 in the placebo group and 1 of 30 in the ibuprofen treatment group.

Interpretation: Continuous COX-2 inhibition as modeled by rofecoxib treatment appears to be more deleterious to fracture repair than cyclical cyclooxygenase inhibition as modeled by ibuprofen treatment. Ibuprofen treatment appeared to delay bone healing based upon the persistence of cartilage within the fracture callus and diminished shear modulus. Despite the ibuprofen-induced delay, rofecoxib treatment produced worse fracture (osteotomy) healing than ibuprofen treatment.
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http://dx.doi.org/10.3109/17453670903316769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2823333PMC
October 2009

Vacuum-assisted closure with external fixation of the hand.

Orthopedics 2009 Nov;32(11):829

Department of Orthopedics, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey 07103, USA.

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http://dx.doi.org/10.3928/01477447-20090922-16DOI Listing
November 2009

Acute forearm compartment syndrome secondary to local arterial injury after penetrating trauma.

J Trauma 2009 Apr;66(4):989-93

Division of Plastic and Reconstructive Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, 07101, USA.

Background: Acute compartment syndrome (ACS) is a well-described surgical emergency that requires an immediate diagnosis and emergent operative intervention. Failure to either make the diagnosis or to implement the appropriate treatment quickly can result in severe long-term morbidity. The purpose of this article is to document evidence that penetrating trauma which results in arterial injury may cause acute forearm compartment syndrome. As a result, this mechanism should alert surgeons to the possibility of acute compartment syndrome secondary to arterial injury.

Methods: A retrospective review of all penetrating trauma patients treated at our Level 1 Trauma Center was performed within 2001 and 2005. Patients who sustained penetrating injuries to the forearm were reviewed in detail and all patients diagnosed with acute forearm compartment syndrome in this setting were included in this article.

Results: Five cases of ACS of the forearm secondary to a mechanism rarely described in the surgical literature were documented over five years. All cases in this series were the result of a named forearm arterial injury sustained by penetrating trauma. Every patient in this article was taken emergently to the operating room for a fasciotomy following diagnosis.

Conclusion: This article establishes the incidence of a specific mechanism of ACS in our penetrating trauma population. As a result of these findings, a thorough evaluation of the forearm vasculature and a careful search for arterial injury is recommended at the time of fasciotomy. Securing a rapid diagnosis and executing early definitive management will result in fewer devastating long-term outcomes.
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http://dx.doi.org/10.1097/TA.0b013e31818c10e3DOI Listing
April 2009

Biomechanical stability of four fixation constructs for distal radius fractures.

Hand (N Y) 2009 Sep 5;4(3):272-8. Epub 2009 Feb 5.

Department of Orthopaedics, NJ Medical School, 140 Bergen St, ACC-D Level-Orthopaedics, Newark, NJ 07105, USA.

Implants available for distal radius fracture fixation include dorsal nonlocked plating (DNLP), volar locked plating (VLP), radial-ulnar dual-column locked plating (DCPs), and locked intramedullary fixation (IMN). This study examines the biomechanical properties of these four different fixation constructs. In 28 fresh-frozen radii, a wedge osteotomy was performed, creating an unstable fracture model and the four fixation constructs employed (DNLP, VLP, DCPs, and IMN). Dorsal bending loads were applied and bending stiffness, load to yield 5 mm displacement, and ultimate failure were measured. Bending stiffness for VLP (16.7 N/mm) was significantly higher than for DNLP (6.8 N/mm), while IMN (12.6 N/mm) and DCPs (11.8 N/mm) were similar. Ultimate load to failure occurred at 278.2 N for the VLP, 245.7 N for the IMN, and 52.0 N for the DNLP. The VLP was significantly stronger than the DNLP and DCPs, and the IMN and DCPs were stronger than the DNLP. The VLP has higher average bending stiffness, ultimate bending strength, and resistance to 5 mm displacement than the other constructs and significantly higher ultimate bending strength than the DCPs and DNLP. There was no statistically significant difference between the VLP and IMN. VLP and IMN fixation of distal radius fractures can achieve comparable stability.
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http://dx.doi.org/10.1007/s11552-008-9156-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724612PMC
September 2009

Foreign-body reaction to the Artelon CMC joint spacer: case report.

J Hand Surg Am 2008 Nov;33(9):1617-20

Department of Orthopaedics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School/University Hospital, Newark, NJ 07103, USA.

The Artelon CMC spacer (Small Bone Innovations, Inc., Morrisville, PA) is a relatively new device that was developed for the treatment of basal joint arthritis. It is composed of a biodegradable polycaprolactone-based polyurethane urea that acts to resurface the distal part of the trapezium and stabilize the trapeziometacarpal joint by augmenting the joint capsule. This is a case report of a foreign-body tissue reaction to the Artelon CMC spacer.
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http://dx.doi.org/10.1016/j.jhsa.2008.06.012DOI Listing
November 2008

Carpometacarpal joint disease: addressing the metacarpophalangeal joint deformity.

Hand Clin 2008 Aug;24(3):295-9, vii

Department of Orthopaedics, Division of Hand and Microvascular Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, ACC - D1626, 140 Bergen Street, Newark, NJ 07103, USA.

The successful surgical treatment of arthrosis of the carpometacarpal articulation of the thumb requires a thorough understanding and evaluation of the intercalated axis of the first ray. A hyperextension/adduction deformity commonly occurs at the metacarpophalangeal joint of the thumb with advanced stages of carpometacarpal arthrosis. Failure to recognize and treat the metacarpophalangeal deformity may result in continued pain and poor outcomes. Additionally, the stability of the ligament reconstruction may become compromised, resulting in recurrence of deformity and longitudinal collapse. This article presents an orderly means of clinical and radiographic evaluation of this deformity and recommends surgical treatments to correct hyperextension and maximize functional outcomes. A treatment algorithm is provided.
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http://dx.doi.org/10.1016/j.hcl.2008.03.013DOI Listing
August 2008