An Innovative Seven-year Physician Scientist Residency Training Program That Addresses the Shortage of Academic Surgeons.

Due to the declining number of scientifically trained physicians and increasing demand for high-quality literature, our institution pioneered a seven-year Physician Scientist Training Program (PSTP) to provide research-oriented residents the knowledge and skills for a successful academic career. The present study sought to identify orthopaedic surgeons with MD/PhD degrees, residency programs with dedicated research tracks, and to assess the effectiveness of the novel seven-year program in training prospective academic orthopaedic surgeons. Surgeons with MD/PhD degrees account for 2.3% of all 3,408 orthopaedic faculty positions in U.S. residency programs. During the last 23 years, our PSTP residents produced 752 peer-reviewed publications and received $349,354 from 23 resident-authored extramural grants. Eleven of our seven-year alumni practice orthopaedic surgery in an academic setting. The seven-year PSTP successfully develops clinically trained surgeon scientists with refined skills in basic science and clinical experimental design, grant proposals, scientific presentations, and manuscript preparation. (Journal of Surgical Orthopaedic Advances 31(3):144-149, 2022).

The risk of pain syndrome affecting a previously non-painful limb following trauma or surgery in patients with a history of complex regional pain syndrome.

BACKGROUND AND PURPOSE: Complex regional pain syndrome (CRPS) is a challenging complication after surgery or trauma. This study sought to determine the incidence of CRPS after a second inciting event in a previously unaffected extremity in patients with a history of an ongoing CRPS diagnosis in another extremity. METHODS: A retrospective review identified patients with CRPS seen in clinic over a 20-month period. The incidence of CRPS after subsequent surgery or injury in a previous unaffected extremity was determined and compared to an average incidence reported in the literature. RESULTS: Ninety-three patients had a diagnosis of primary CRPS. Nineteen (20.4%) developed CRPS in one or more additional extremity compared to the incidence of 23.4 per 100,000 (0.0234%) in the literature (odds ratio 1069.6, p<0.0001, 95% CI 562.0-2035.7). Twenty patients had a documented secondary injury or surgery in a second extremity. Fifteen (75%) developed secondary CRPS compared to a CRPS incidence rate of 6.4% following distal radius fracture, as determined by literature review (odds ratio 11.7, p<0.001, 95% CI 5.9-23.2). CONCLUSIONS: These result suggest that patients with a history of CRPS are more likely to develop secondary CRPS compared to the rates reported in the literature among the general population. IMPLICATIONS: Patients with a history of CRPS should be counselled that they may be at risk for developing secondary CRPS if they undergo surgery or sustain trauma to another extremity.

Double Distal Intraneural Fascicular Nerve Transfers for Lower Brachial Plexus Injuries.

PURPOSE: To evaluate outcomes following transfer of the supinator motor branch of the radial nerve (SMB) to the posterior interosseous nerve (PIN) and the pronator teres motor branch of median (PTMB) to the anterior interosseous nerve (AIN) in patients with lower brachial plexus injuries. METHODS: Since December 2010, 4 patients have undergone combined transfer of the SMB to PIN and PTMB to AIN for lower brachial plexus palsies. The study was prospectively designed, and the patients were followed for 4 years to monitor their functional improvement. RESULTS: One patient failed to return after his 4-month postoperative visit. The other 3 patients all regained M4 thumb and finger extension, and 2 recovered M4 thumb and finger flexion at the final evaluation, a mean 30 months after the nerve transfer surgeries. CONCLUSIONS: Combined transfer of the SMB to PIN and PTMB to AIN may lead to successful recovery of digital extrinsic flexion and extension in lower brachial plexus injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Decreased Range of Motion After Total Knee Arthroplasty Is Predicted by the Tampa Scale of Kinesiophobia.

BACKGROUND: Range of motion (ROM) is important for functional outcome after total knee arthroplasty (TKA); however, some patients hesitate to maximize their ROM postoperatively. The Tampa Scale of Kinesiophobia (TSK) measures patients' fear of movement. The primary purpose of this investigation was to determine whether TSK scores correlated with decreased ROM after primary TKA. A secondary purpose was to determine whether biofeedback could increase ROM after TKA. METHODS: Patients were recruited from the senior author's practice between June 2011 and March 2013. A clinical photograph was taken of each patient's knee in maximum passive flexion in the operating room immediately following closure. Patients were randomized to the control or photograph group before incision. A linear mixed model was implemented to determine whether the TSK score and viewing the photo correlated to ROM. RESULTS: Seventy-nine patients were analyzed for correlation between the TSK score and the knee ROM. Sixty patients were analyzed for correlation between viewing the clinical photograph and the knee ROM. The linear mixed model demonstrated a significant negative correlation between the TSK score and both active (ß = -0.47, P < .01) and passive (ß = -0.66, P < .001) knee flexions. There was a trend toward decreased knee flexion among patients shown their clinical photograph. CONCLUSION: The TSK was developed as a tool to identify patients at risk for maladaptive responses to painful stimuli. Our data suggest that the TSK may help arthroplasty surgeons identify patients at risk for decreased ROM after TKA. Showing patients a clinical photograph failed to increase ROM after TKA.

Comparison of Two Multimodal Pain Regimens Used for Postoperative Pain Control in Total Joint Arthroplasty Patients.

Postoperative pain control following total joint arthroplasty results in improved patient mobilization, participation in physical therapy, and potentially reduced hospital costs. It was hypothesized that using a multimodal pain protocol focusing on periarticular injections including liposomal bupivacaine would have improved results when compared with a parenteral opioid-based regimen. The results showed a decrease in length of stay and rate of discharge to skilled nursing facilities with the implementation of a novel multimodal pain protocol. Furthermore, there was no change in patient satisfaction before and after the execution of the new protocol. It was concluded that using a multimodal pain protocol based on periarticular injections can lead to decreased length of stay and a decrease in transfer to skilled nursing facilities without a change in patient satisfaction.

A chronically-denervated versus a freshly-harvested autograft for nerve repair in rats.

OBJECTIVES: Autologous nerve grafting remains the gold standard for repair of peripheral nerve injuries. Its use, however, is limited by donor nerve availability and donor site morbidity. This is especially problematic after failure of an initial autograft that requires a repeat nerve graft, resulting in a second surgical site with associated morbidity. Based on the molecular differences in nerve degeneration in the proximal and distal segments after transection, we hypothesized that a chronically-denervated proximal stump may be viable for autologous nerve repair. METHODS: 20 Sprague-Dawley rats underwent right sciatic nerve excision and sural nerve transection. After 8 weeks, nerve repair was performed by harvesting the proximal segment of the sural nerve (n=10) or a fresh sural nerve (n=10) from the contralateral hind limb. Electrophysiological changes were analyzed to compare the fresh and denervated grafts. RESULTS: Electrophysiological testing demonstrated higher compound motor action potential in the denervated group compared to the fresh autograft group, however this difference was not statistically significant (p=0.117). CONCLUSION: The proximal segment of a chronically-denervated sural nerve can be as effective as a fresh sural nerve for autologous repair of peripheral nerve injuries in a rodent model.

Randomized comparison of volar locking plates and intramedullary nails for unstable distal radius fractures.

PURPOSE: To compare minimally invasive intramedullary nails (IMN) and volar locking plates (VLP) for the treatment of unstable distal radius fractures by evaluating postoperative subjective, radiographic, and functional outcomes. The hypothesis was that IMN patients would have less pain and required less pain medication in the early postoperative period and returned to work earlier than VLP patients. METHODS: Sixty patients with closed, displaced, unstable, extra-articular, metaphyseal fractures of the distal radius were randomized to receive a VLP or an IMN for internal fixation. Functional outcomes (Quick Disabilities of the Arm, Shoulder, and Hand, Michigan Hand Questionnaire), radiographic measurements (ulnar variance, radial height, inclination, and volar tilt), and range of motion were assessed until final follow-up at 2 years after surgery. Narcotic pain medication use was documented for 5 weeks following surgery. RESULTS: There were 2 groups of 30 patients with IMN (mean age, 55 ± 14 y) or VLP (mean age, 55 ± 16 y) with similar demographics and comorbidities. Patients with IMN regained extension earlier but had similar range of motion to patients with VLP at final follow-up. There was similar improvement in Michigan Hand Questionnaire, Quick Disabilities of the Arm, Shoulder, and Hand, and strength between groups. Five weeks after surgery, fewer IMN patients required narcotic pain medication (13%) than VLP patients (33%). Radiographic outcomes were similar at final follow-up. There were 3 failures with IMN versus 1 failure with VLP. All 10 employed patients with IMN returned to previous work compared with 10 of the 12 employed patients with VLP. Time to return to work was similar for both groups. CONCLUSIONS: In a cohort of similar patients, IMN and VLP provided comparable improvement in functional and radiographic outcomes. Patients with IMN required less narcotic pain medication after surgery than VLP patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Five-year mortality for patients with end-stage renal disease who undergo upper extremity amputation.

PURPOSE: To compare the 5-year survival rate of patients on dialysis requiring an upper extremity amputation with those who did not require such surgery and to analyze whether such an amputation was prognostic for mortality. METHODS: The medical records of 20 consecutive patients with end-stage renal disease who received upper extremity amputations were reviewed. Control patients (n = 40) were matched based on age, sex, and duration of dialysis treatment. A Kaplan-Meier survival analysis was performed. RESULTS: The mean survival time after the index surgery for the surgical group was 4.95 years ± 0.90 years, and the mean survival for the control group was 8.40 years ± 0.61 years. The probability of death (the event) was statistically greater in the surgical group. The overall 5-year survival rates for the surgical and the nonsurgical groups were 35% (7 of 20) and 70% (28 of 40), respectively. Patients with diabetes in the surgical group had a significantly lower 5-year survival rate, a greater number of amputations, and a greater number of wound-healing failures. CONCLUSIONS: The 5-year survival rate from the index surgery of the surgical group was half that of the nonsurgical group. Increased mortality may be partially attributed to the poor vascular health of the patient. This analysis may help the hand surgeon to more effectively counsel patients with end-stage renal disease about the prognosis associated with an upper extremity amputation and, more importantly, supports the goal of timely intervention by the multidisciplinary team to optimize care planning and to improve surgical outcomes and quality of life. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Anatomic findings and outcomes associated with upper extremity arteriography and selective thrombolysis for acute finger ischemia.

OBJECTIVE: Limited evidence exists to guide clinical management of acute finger ischemia (AFI). To further inform diagnostic evaluation and decision making, we evaluated anatomic findings, procedural management, and amputation-free survival in an institutional cohort of patients with AFI. METHODS: Consecutive patients undergoing transfemoral upper extremity angiography for AFI were identified. Clinical, laboratory, and procedural data were collected retrospectively from medical records, and arteriograms were reviewed to characterize anatomic findings. Telephone interviews were used to determine long-term outcomes, and additional symptomatic assessments (Symptom Severity and Functional Status scale, the Cold Sensitivity Severity scale, and the McGill Pain Severity Scale) were available in a subgroup of patients. Outcomes included anatomic findings, use of thrombolysis, complications, and amputation-free survival. Descriptive statistics and survival analysis were used to evaluate results. RESULTS: Thirty-five patients (54% women) were analyzed with a median follow-up of 13.7 months. Symptom duration at time of presentation ranged from 1 to 28 days, and seven patients had tissue loss or gangrene, or both. Mean age was 47.7 ± 12.2 years. Baseline characteristics included smoking in 22 (65%), connective tissue disorder in 11 (31%), and history of repetitive hand trauma in 10 (29%). The most frequent anatomic location of arterial pathology identified during angiography was distal to the wrist (n = 32), including eight ulnar/radial aneurysms; upper arm (n = 3) and forearm (n = 8) lesions were less common. Sixteen patients were treated with catheter-directed thrombolysis, of which eight (50%) had interval anatomic improvement on repeat angiography. Procedure-related adverse events associated with angiography included bleeding (n = 3) and pseudoaneurysm (n = 1). Eleven of 35 patients had subsequent surgical revascularization at a median of 15 days after angiography. Estimated (standard error) amputation-free survival was 0.88 (0.07) at 1 month and 0.84 (0.08) at 6 months among patients without tissue loss or gangrene. Estimated 60-day amputation-free survival was 0.84 (standard error, 0.08). Overall amputation-free survival was similar between patients managed with vs without thrombolysis (P = .61), but subgroup analysis of those patients without tissue loss or gangrene at the time of presentation revealed a trend toward improved amputation-free survival with use of thrombolysis, with 60-day amputation-free survival of 0.92 vs 0.75 (P = .12). Persistent late symptoms were present in 17 patients (48.6%) at the last follow-up and were generally characterized as mild by functional and pain scale assessments. CONCLUSIONS: Angiography performed for AFI frequently identifies distal occlusive disease, and catheter-directed thrombolysis may expand revascularization options in select patients.

Rotator cuff injuries in professional and recreational athletes.

Professional and recreational athletes involved in contact sports and sports with repetitive overhead motion are at increased risk for rotator cuff tears. Shoulder anatomy, pathology, and biomechanics place unique stress on the rotator cuff tendons during sports activity. Athletes demand effective treatment to quickly return to elite competition. A PubMed search assessed treatment options providing expedited recovery time and return to competition. Twelve of 231 articles fit the objective criteria; 90.5% of professional contact athletes, 40% of professional overhead athletes, and 83.3% of recreational athletes fully recovered following rotator cuff tear surgical repair. Prompt surgical treatment for full-thickness rotator cuff tears may be appropriate for contact athletes and recreational overhead athletes. Although professional overhead athletes have low recovery rates, surgical repair of full-thickness rotator cuff tears may still be indicated. The authors propose a treatment algorithm based on the limited literature (mainly level 4 and 5 evidence).

Achieving accurate ligament balancing using robotic-assisted unicompartmental knee arthroplasty.

Unicompartmental knee arthroplasty (UKA) allows replacement of a single compartment in patients with limited disease. However, UKA is technically challenging and relies on accurate component positioning and restoration of natural knee kinematics. This study examined the accuracy of dynamic, real-time ligament balancing using a robotic-assisted UKA system. Surgical data obtained from the computer system were prospectively collected from 51 patients (52 knees) undergoing robotic-assisted medial UKA by a single surgeon. Dynamic ligament balancing of the knee was obtained under valgus stress prior to component implantation and then compared to final ligament balance with the components in place. Ligament balancing was accurate up to 0.53 mm compared to the preoperative plan, with 83% of cases within 1 mm at 0°, 30°, 60°, 90°, and 110° of flexion. Ligamentous laxity of 1.31 ± 0.13 mm at 30° of flexion was corrected successfully to 0.78 ± 0.17 mm (P < 0.05). Robotic-assisted UKA allows accurate and precise reproduction of a surgical balance plan using dynamic, real-time soft-tissue balancing to help restore natural knee kinematics, potentially improving implant survival and functional outcomes.

Distal locking using an electromagnetic field-guided computer-based real-time system for orthopaedic trauma patients.

OBJECTIVES: To compare the efficacy of distal interlocking during intramedullary nailing using a freehand technique versus an electromagnetic field real-time system (EFRTS). DESIGN: A prospective, randomized controlled trial. SETTING: Level I academic trauma center. PATIENTS/PARTICIPANTS: Patients older than 18 years who sustained a femoral or tibial shaft fracture amenable to antegrade intramedullary nailing were prospectively enrolled between August 2010 and November 2011. Exclusion criteria included injuries requiring retrograde nailing and open wounds near the location of the distal interlocks (distal third of the femur, knee, or distal tibia). INTERVENTION: Each patient had 2 distal interlocking screws placed: one using the freehand method and the other using EFRTS. MAIN OUTCOME MEASUREMENT: Techniques were compared on procedural time and number of interlocking screw misses. Two time points were measured: time 1 (time to find perfect circles/time from wand placement to drill initiation) and time 2 (drill initiation until completion of interlocking placement). RESULTS: Twenty-four tibia and 24 femur fractures were studied. EFRTS proved faster at times 1 and 2 (P < 0.0001 and P < 0.0002) and total time (P < 0.0001). This difference was larger for junior residents, though reached statistical significance for senior residents. Senior residents were faster with the freehand technique compared with junior residents (P < 0.004), but the 2 were similar using EFRTS (P = 0.41). The number of misses was higher with free hand compared with EFRTS (P = 0.02). CONCLUSION: These results suggest that EFRTS is faster than the traditional freehand technique and results in fewer screw misses. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Combined proximal nerve graft and distal nerve transfer for a posterior cord brachial plexus injury.

The treatment of patients with prolonged denervation from a posterior cord brachial plexus injury is challenging and no management guidelines exist to follow. The authors describe the case of a 26-year-old man who presented to our clinic for treatment 11 months after suffering a high-energy injury to the posterior cord of the brachial plexus. A combined 9-cm proximal cable nerve graft procedure and a pronator branch to the posterior interosseous nerve transfer were performed. Satisfactory deltoid, triceps, wrist, and finger extensor recovery was noted 3 years after surgery. Patients with prolonged denervation from posterior cord injuries can be successfully treated with a combination of a proximal nerve graft and a distal nerve transfer.

Mechanical properties of lower limb dermis following static and cyclic compression.

Lower extremity amputations and foot ulcers are complications associated with diabetes, and have been shown to affect diabetic African Americans (AA) three times as often as diabetic non-Hispanic Whites (NHW). Possible causes for the increased risk include ethnic differences in structure and function within the dermis of the lower extremity. Testing this hypothesis requires studying the mechanical properties of skin from different ethnic groups with and without the diagnosis of noninsulin-dependent diabetes. The purpose of this study was to develop a testing method to investigate changes in tensile mechanical properties resulting from static and cyclic compression of dermis harvested from patients undergoing lower extremity amputations. Full thickness dermal samples were obtained from 15 patients undergoing below-knee amputations. Sections of each sample were conditioned with a compressive static pressure (170 mmHg) or cyclic pressures (110-170 mmHg) for 4 hours to elicit collagen bundle remodeling. Skin samples were then tested in tension to obtain sub-plastic stress vs. strain mechanical behavior. Length of the stress-strain toe-region was examined to quantify the effect of collagen bundle remodeling. Toe-region mean lengths were 0.141±0.041, 0.146±0.034, and 0.164±0.064 strains for the control, cyclic, and statically compressed samples respectively (p>.05). These results suggest that the preconditioning regimes did not produce sufficient collagen remodeling to affect the tensile properties of full-thickness dermis. Future work will examine histology from each specimen to identify microstructural features associated with this trend.

The effect of botulinum neurotoxin-A on blood flow in rats: a potential mechanism for treatment of Raynaud phenomenon.

PURPOSE: Botulinum neurotoxin-A (BoNTA) is used to treat several disorders, including Raynaud phenomenon. Recent investigations cite toxin-induced increases in blood flow, but no mechanism for BoNTA's actions is proposed. This study hypothesized that local application of BoNTA causes arteriolar vasodilation through sympathetic blockade and results in increased blood flow. METHODS: Microvascular effects of BoNTA were assessed using a rat cremaster preparation. Cremaster microvascular diameters were measured in the muscle before and after treatment with the muscle paralytic agent gallamine triethiodide. Preparations were then treated with one of the following: BoNTA (4, 6, or 10 units), BoNTA dilution vehicle, or denatured BoNTA. Arteriolar diameters were measured repeatedly over the observation period. Additional preparations were treated with either tetrodotoxin or prazosin and rauwolscine before BoNTA to confirm that the observed vasodilatory responses were the result of sympathetic neural inhibition. RESULTS: The BoNTA application resulted in a significant dose-dependent vasodilation (13% to 15%) of observed cremaster arterioles. Control treatments did not cause vasodilation. Both tetrodotoxin and prazosin/rauwolscine treatments elicited similar vasodilatory effects, with no additional vasodilation elicited by BoNTA. Addition of sodium nitroprusside following BoNTA elicited further vasodilation. In addition, systemic arterial pressure was unaffected by the local administration of BoNTA. CONCLUSIONS: Local application of BoNTA results in arteriolar dilation that yields an approximate 69% increase in blood flow, without changing systemic arterial pressure. A BoNTA-mediated vasodilation through sympathetic blockade is a likely mechanism to explain the increase in blood flow reported after treatment with the toxin. CLINICAL RELEVANCE: The ability of BoNTA to inhibit sympathetic nervous input reduces vasoconstriction, which is the most likely mechanism for improvement seen in Raynaud phenomenon patients following BoNTA injection.

Complex regional pain syndrome of the upper extremity.

The diagnosis and management of complex regional pain syndrome is often challenging. Early diagnosis and intervention improve outcomes in most patients; however, some patients will progress regardless of intervention. Multidisciplinary management facilitates care in complex cases. The onset of signs and symptoms may be obvious or insidious; temporal delay is a frequent occurrence. Difficulty sleeping, pain unresponsive to narcotics, swelling, stiffness, and hypersensitivity are harbingers of onset. Multimodal treatment with hand therapy, sympatholytic drugs, and stress loading may be augmented with anesthesia blocks. If the dystrophic symptoms are controllable by medications and a nociceptive focus or nerve derangement is correctable, surgery is an appropriate alternative. Chronic sequelae of contracture may also be addressed surgically in patients with controllable sympathetically maintained pain.

Dose- and volume dependent-response to intramuscular injection of botulinum neurotoxin-A optimizes muscle force decrement in mice.

Botulinum neurotoxin-A (BoNTA) is a potent neurotoxin used to alter muscle tone to manage spasticity and to provide tendon bioprotection; however, the appropriate dose and injection volume to administer is not defined. Male mice (n = 120) received BoNTA injections into one gastrocnemius with either a constant volume (10 µl) with a variable dose (1, 3, 6 U/kg) or a constant dose (3 U/kg) in a variable volume (2.5, 5, 10, 20, 30 µl). Electromyographic (EMG) examination, muscle force generation (MFG), and wet muscle mass were measured in the ipsilateral and contralateral limbs at 1, 2, 4, or 12 weeks post-injection. MFG and EMG responses decreased to approximately 40% of contralateral after a 1 U/kg injection and 0% of contralateral by 3 and 6 U/kg injection at 1 week after injection. Neuromuscular blockade was greatest with a 10 µl injection volume. MFG, EMG examination, and wet muscle mass reached contralateral values 12 weeks after injection for all injection doses and volumes tested. Effective injection doses and volumes were identified for producing full and partial neuromuscular blockade in the mouse gastrocnemius. These findings have important clinical implications in the intramuscular administration of BoNTA to manage muscle tone.

Contributions of neural tone to in vivo passive muscle--tendon unit biomechanical properties in a rat rotator cuff animal model.

Passive viscoelastic properties of muscle-tendon units are key determinants of intra- and post-operative success. Atrophied, retracted, and stiff muscle-tendon units are technically challenging to manipulate and perform poorly after surgical repair. This study employs botulinum neurotoxin A (BoNT-A)-mediated inhibition of presynaptic acetylcholine release to examine in vivo neural contributions to soft-tissue biomechanical properties. In vivo load-relaxation and active muscle contractile force testing protocols were performed in the rat rotator cuff model. The passive properties were assessed using linear regression analysis and Fung's quasi-linear viscoelastic (QLV) model. BoNT-A injected muscle--tendon units had a significant reduction in force of contraction (p = 0.001). When compared to saline injected controls, the BoNT-A significantly decreased parameter 'A' of the QLV model, which represents the linear elastic response (p = 0.032). The viscous properties in the BoNT-A treatment group were not significantly different from saline injected controls, as determined by comparison of QLV model parameters 'C,' 'τ(1),' and 'τ(2).' In conclusion, neural tone contributes significantly to muscle-tendon unit passive biomechanical properties. Pre-surgical treatment with BoNT-A may improve the rehabilitation of muscle by altering its passive elastic properties. Accordingly, pharmacological modulation of skeletal muscle stiffness with BoNT-A increases flexibility, potentially improving function. Chemical denervation with BoNT-A may also improve the manipulation of stiff and difficult to mobilize muscles during surgical procedures.