Vascular Problems in Elite Throwing Athletes.

There are approximately 880 and 3,600 major league baseball and minor league baseball players who currently are active in their respective leagues, with thousands of players in the collegiate, high school, and little league ranks. Although relatively uncommon, vascular injuries, such as thoracic outlet syndrome, axillary artery compression, quadrilateral space syndrome, and direct vascular trauma, can afflict these players. These career- and limb-threatening injuries can mimic often seen muscular sprains and strains in their early stages with nonspecific symptoms, such as exertional fatigue, which can delay diagnosis with disastrous sequelae, including thrombus propagation, aneurysm rupture, and ischemia from distal embolization. The goal of this review is to discuss the pathophysiology, diagnosis, and treatment of these injuries to increase awareness of sport-related vascular phenomena among the hand and upper-extremity surgery community because these players typically are seen first in the training room or a hand specialist's office.

Traumatic Osteonecrosis of the Distal Ulna.

A 46-year-old male was referred to our clinic for persistent ulnar-sided wrist pain 9 weeks after sustaining a traumatic injury while playing volleyball. The patient unsuccessfully underwent nonoperative management for a suspected injury to the triangular fibrocartilage complex. After magnetic resonance imaging revealed a lesion of the distal ulna, he was treated with diagnostic wrist arthroscopy and Bowers hemiresection. The diagnosis of osteonecrosis was confirmed through histology. While traumatic osteonecrosis of the carpal bones has been described, no previous literature was found on traumatic osteonecrosis of the distal ulna. Treatment with diagnostic wrist arthroscopy and Bowers hemiresection resulted in an excellent outcome at 12 months after surgery.

Two-Screw Fixation of Scaphoid Waist Fractures.

Optimal fixation strategy for scaphoid waist fractures remains a contentious topic with options including using a single screw, 2 screws, or a scaphoid plate. Biomechanical studies favor 2-screw fixation with regards to higher load to failure, load to 2-mm displacement, energy absorbed, rotational stability, and stiffness. Furthermore, recent retrospective studies found increased union rate with 2 screws. Although conclusive clinical data are lacking, 2-screw fixation of a scaphoid waist fracture may theoretically allow the patient to start earlier range of motion and strengthening with greater confidence. Our experience with 2-screw fixation has been promising with all acute waist fractures healing and nonunions treated with 2 screws having high union and low reoperation rates.

Primary Anterolateral Ligament Rupture in Patients Requiring Revision Anterior Cruciate Ligament Reconstruction: A Retrospective Case-Control Magnetic Resonance Imaging Review.

PURPOSE: To compare the initial rate of anterolateral ligament (ALL) injury at the time of anterior cruciate ligament (ACL) rupture in patients who subsequently experienced ACL reconstruction graft failure versus patients who did not experience subsequent ACL reconstruction graft failure. METHODS: Our institution's electronic medical record database was queried for patients who underwent primary ACL reconstruction with subsequent ACL graft rupture. Exclusion criteria included unavailable MRI scan, chronic ACL injury, multi-ligamentous injury, previous ACL reconstruction, and age younger than 13 or older than 50 years. Each patient was paired with an age-, gender-, and graft-matched control who underwent ACL reconstruction without subsequent graft rupture. Each patient was diagnosed with an intact, partially injured, or fully ruptured ALL on initial MRI. The location of ALL injury was also noted. The incidence and location of ALL rupture were compared using χ2 analysis. RESULTS: 1,967 patients underwent primary ACL reconstruction. 128 patients experienced ACL graft rupture, and 55 patients (43%) had MRI scans available for review. 39 of these patients fulfilled inclusion criteria and were matched with a control patient. In the revision group, the ALL was diagnosed as intact, partially torn, and completely torn in 17, 14, and 8 patients, respectively, compared to 18, 13, and 8 patients, respectively in the control group. No difference was found in frequency of ALL rupture (Pearson χ2 = 0.066; P = .968) or rupture location (Pearson χ2 = 4.00, P = 0.135). CONCLUSIONS: The incidence of initial ALL injury as documented on MRI was not different in patients who experienced subsequent ACL graft rupture compared with patients who did not experience ACL graft rupture after primary ACL reconstruction. The ALL was more commonly injured on the tibial side in patients with ACL graft rupture and femoral-sided lesions were more common in control patients. LEVEL OF EVIDENCE: Level III, prognostic case-control study.

Timing of Olecranon Fracture Fixation Does Not Affect Early Complication or Reoperation Rates.

Purpose: Surgical fixation of olecranon fractures can lead to soft-tissue complications and return to the operating room for hardware removal. While some risk factors of complications after olecranon fracture fixation have been described, the effects of fixation timing on complications and reoperation have not been evaluated. The purpose of the present study was to assess whether the timing of olecranon fracture fixation affects complication and reoperation rates. Methods: All patients who underwent olecranon fracture open reduction and internal fixation at a single level 1 trauma center from January 2012 to February 2022 were included in the study. A retrospective review was performed to evaluate patients for inclusion and to identify patient demographic factors, medical comorbidities, concomitant injuries, mechanism of injury, and time to fixation. Operative and clinical notes were evaluated to identify fixation type and outcomes of interest. Patients were stratified into early, standard, and delayed fixation groups (0-3 days, 4-14 days, and >14 days, respectively) for independent analyses, and Fisher's exact test was used to identify differences in complications and reoperations between groups. Multivariate analysis was used to assess associations between patient demographic factors, complication rates, and time to surgery. Results: A total of 97 patients met inclusion criteria of having an olecranon open reduction and internal fixation and had a minimum follow-up of at least 10 weeks, with an average follow-up of 7.1 months. The average time to surgery in the overall cohort was 9.3 days. There were no differences in the number of total complications and rate of reoperation among the three cohorts. Smoking was found to be significantly associated with total complications, while open fracture was significantly associated with reoperation. Polytrauma and open fracture were significantly associated with earlier operation, while smoking was significantly associated with delayed fixation. Conclusions: The timing of fixation of displaced olecranon fractures does not significantly increase the rate of early complications or reoperation. Type of study/level of evidence: Symptom Prevalence Study III.

A review on the relationship between testosterone and the interpersonal/affective facet of psychopathy.

Testosterone (T) has received increasing interest in the recent years as a probable biological determinant in the etiology of male-biased clinical conditions such as psychopathy (i.e. psychopathy is more prevalent in men and leads to an earlier onset and more severe expression of antisocial and aggressive behavior in men compared to women). In this review, the authors evaluated the potential relationship between T and different constructs closely related to the core characteristics of psychopathy (affective empathy, fear-reactivity, and instrumental aggression). After a thorough examination of the literature, it is concluded that high T exposure in utero and high circulating T levels throughout important life phases (most notably adolescence) or in response to social challenges (e.g. social stress, competition) could be an important etiological risk factor in the emergence of psychopathic behavior. Nevertheless, studies consistently indicate that high T is not related to a significantly reduced fear-reactivity and is only indirectly associated with the increased levels of instrumental aggression observed in psychopathic individuals. Therefore, psychopathy is likely to arise from an interaction between high T levels and other biological and socio-psychological risk factors, such as a constitutionally based dampened fear-reactivity, insecure/disordered attachment processes in childhood, and social discrimination/rejection in adolescence and/or adulthood.

Adult Distal Radius Fracture Management.

Distal radius fractures (DRFs) are some of the most commonly encountered fractures, and the incidence is increasing. Optimal treatment remains controversial. Critical evaluation of the initial imaging is necessary to recognize fracture characteristics and stability. The fracture pattern, injury mechanism, soft-tissue injury, patient characteristics, and surgeon preference are generally taken into consideration when choosing the most appropriate modality. Volar plating has become the workhorse of surgical DRF management but is not without complications. The surgeon should be comfortable using a wide variety of techniques to customize the fixation to the fracture pattern. Recognition of potential dangers and use of intraoperative imaging techniques can mitigate complications. Goals of rehabilitation after the initial treatment of DRF include regaining motion, strength, and ultimately function while managing pain.

Simultaneous Use of Kocher-Langenbeck and Lateral Window Approaches for Transverse Acetabular Fracture Open Reduction and Internal Fixation: A Case Report.

CASE: An otherwise healthy 39-year-old man presented after a fall from 30 feet with a right transverse, transtectal acetabular fracture. The fracture was not reducible with an isolated anterior or posterior approach. A simultaneous combined approach was used in the lateral decubitus position. The fracture was appropriately reduced and stabilized. CONCLUSIONS: This combined approach with the patient in the lateral decubitus position was effective without requiring repositioning of the patient during surgery. This technique may be helpful for reduction of challenging transverse acetabular fractures.

A Cadaveric Study of the Mean Distance of the Radial Artery During the Approach to the First Carpometacarpal Joint.

Multiple surgical procedures have been described to treat first carpometacarpal (CMC) arthritis. Although the superiority of one procedure over the others continues to be a controversial topic, they all approach the trapezium and require careful attention to the surrounding structures. One potential complication is injury to the radial artery, which lies in close proximity to the trapezium and is often encountered during surgical approach. Using cadaveric specimens, the authors dissected to identify and isolate the radial artery as it travels in the forearm, wrist, and hand while being careful not to disturb its native course. The authors then measured the shortest distance interval from the radial artery to the first CMC joint and from the radial artery to the scaphotrapeziotrapezoidal joint. Descriptive statistics were calculated from these measurements and averaged over the various specimens. The mean distance of the radial artery to the closest segment of the volar CMC joint was 11.6±2.5 mm. The mean distance of the radial artery to the closest segment of the volar scaphotrapeziotrapezoidal joint was 1.6±1.8 mm. A precise understanding of nearby anatomy is paramount to a successful surgical treatment for first CMC arthritis and to avoid iatrogenic complications. The authors describe the mean distance from the radial artery to 2 major landmarks used during surgical treatment and provide insight to surgeons who perform these CMC reconstruction procedures to decrease the risk of intraoperative radial artery injury. [Orthopedics. 2018; 41(4):e541-e544.].

Factors Associated with Patient-Initiated Telephone Calls After Spine Surgery.

BACKGROUND: Telephone calls play a significant role in the follow-up care of postoperative patients. However, further data are needed to identify the determinants of patient-initiated telephone calls after surgery because these factors may also highlight potential areas of improvement in patient satisfaction and during the hospital discharge process. Therefore, the goal of this study is to determine the number of postoperative patient telephone calls within 14 days after surgery and establish the factors associated with patient-initiated calls and reasons for calling. METHODS: A retrospective chart review of all spine surgeries performed at our institution from January 1, 2014, through January 2, 2015, was completed. Patient demographics, perioperative and operative variables, and telephone encounter data were collected. The primary outcome was a patient-initiated telephone call within 14 days after surgery. Secondary outcomes included reporting and analyzing the reasons for patient phone calls, analyzing which procedures were associated with the most telephone calls, and conducting a multivariate analysis to determine independent risk factors for patient calls. RESULTS: Of the 488 patients who underwent surgical procedures, 222 patients (45.7%) made a telephone call within 14 days after surgery. There were 61 patients (27.48%) who called regarding pain control and 54 patients (23.87%) who called with bathing/dressing/wound questions. Other common categories include the following: other (21.17%), medication problems (15.77%), weight-bearing status/activity restrictions (5.14%), fever (3.15%), bowel management (1.35%), work notes (1.35%), and anticoagulation questions (0.45%). Factors associated with a telephone call within 14 days postoperatively included increased body mass index (P = 0.031), lower number of comorbidities (P = 0.043), telephone call within 2 weeks prior to surgery (P = 0.027), American Society of Anesthesiologists (ASA) score of 2 (P = 0.036), discharge disposition to home (P = 0.003), and elective procedure (P = 0.006). Multivariate analysis revealed that fusion procedures (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.05-4.45; P = 0.037) and ASA score of 3-4 (OR, 0.55; 95% CI, 0.31-0.96, P = 0.036) were independently associated with increased and decreased propensity, respectively, toward making a phone call within 2 weeks. CONCLUSIONS: Postoperative patient-initiated telephone calls within 14 days after spine surgery are very common, occurring after almost one half of all procedures. By evaluating such determinants, patient care can be improved by better addressing patient needs during and prior to discharge to prevent potential unnecessary postoperative calls and improve patient satisfaction.

Lumbosacral Epidural Lipomatosis: A Retrospective Matched Case-Control Database Study.

OBJECTIVE: We present the largest known consecutive series of patients with epidural lipomatosis (EL) to characterize demographics and clinical symptoms of patients with EL on magnetic resonance imaging (MRI), and compare these characteristics against a matched control group. METHODS: Patients evaluated for pathology requiring lumbar MRI imaging between September 2010 and September 2015 were retrospectively reviewed and included in this study if they were diagnosed with EL on a radiologic note during any visit to our medical center. One hundred ninety-nine patients fulfilled the study criteria and were included in the study cohort. A separate patient cohort of 199 unique, age- and gender-matched controls without lumbosacral EL was generated from a database of patients with lumbar MRI imaging during the same period. RESULTS: Average age at diagnosis was 54.9 years (range, 25-84 years). One hundred thirty-three patients (66.8%) were men. On univariate analysis, patients with EL were more likely to have history of smoking (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.23-2.94, P = 0.004), diabetes mellitus type 2 (OR 2.17, 95% CI 1.33-3.56, P = 0.002), or be on disability (OR 4.43, 95% CI 2.48-7.91, P < 0.001). Furthermore, patients with EL had significantly increased median body mass index compared with controls (36.7 vs. 29.4 kg/m2; P < 0.001). CONCLUSIONS: Patients with lumbosacral EL tend to be obese with a high incidence of type 2 diabetes mellitus, suggesting that this pathology may be a sequela of metabolic syndrome. Future research topics should include the pathogenesis of EL, as well as treatment outcomes of surgical versus primary care management.

Mesocorticolimbic dopamine functioning in primary psychopathy: A source of within-group heterogeneity.

Despite similar emotional deficiencies, primary psychopathic individuals can be situated on a continuum that spans from controlled to disinhibited. The constructs on which primary psychopaths are found to diverge, such as self-control, cognitive flexibility, and executive functioning, are crucially regulated by dopamine (DA). As such, the goal of this review is to examine which specific alterations in the meso-cortico-limbic DA system and corresponding genes (e.g., TH, DAT, COMT, DRD2, DRD4) might bias development towards a more controlled or disinhibited expression of primary psychopathy. Based on empirical data, it is argued that primary psychopathy is generally related to a higher tonic and population activity of striatal DA neurons and lower levels of D2-type DA receptors in meso-cortico-limbic projections, which may boost motivational drive towards incentive-laden goals, dampen punishment sensitivity, and increase future reward-expectancy. However, increasingly higher levels of DA activity in the striatum (moderate versus pathological elevations), lower levels of DA functionality in the prefrontal cortex, and higher D1-to-D2-type receptor ratios in meso-cortico-limbic projections may lead to increasingly disinhibited and impetuous phenotypes of primary psychopathy. Finally, in order to provide a more coherent view on etiological mechanisms, we discuss interactions between DA and serotonin that are relevant for primary psychopathy.

Systematic review, structural analysis, and new theoretical perspectives on the role of serotonin and associated genes in the etiology of psychopathy and sociopathy.

Since its theoretical inception, psychopathy has been considered by philosophers, clinicians, theorists, and empirical researchers to be substantially and critically explained by genetic factors. In this systematic review and structural analysis, new hypotheses will be introduced regarding gene-gene and gene-environment interactions in the etiology of psychopathy and sociopathy. Theory and research from neurobiological and behavioral sciences will be integrated in order to place this work in a broader conceptual framework and promote synergy across fields. First, a between groups comparison between psychopathy and sociopathy is made based on their specific dysfunctions in emotional processing, behavioral profiles, etiological pathways, HPA-axis functioning, and serotonergic profiles. Next, it is examined how various polymorphisms in serotonergic genes (e.g., TPH, 5HTT, HTR1A, HTR2A, HTR2C, and HTR3) might contribute either individually or interactively to the development of these disorders and through which specific biological and behavioral endophenotypes this effect could be mediated. A short introduction is made into mediating variables such as GABAergic functioning and testosterone which could potentially alter the decisive effect of serotonergic genotypes on behavior and physiology. Finally, critical commentary is presented on how to interpret the hypotheses put forward in this review.

A review on the relationship between testosterone and life-course persistent antisocial behavior.

Life-course persistent antisocial behavior is 10 to 14 times more prevalent in males and it has been suggested that testosterone levels could account for this gender bias. Preliminary studies with measures of fetal testosterone find inconsistent associations with antisocial behavior, especially studies that use the 2D:4D ratio as a proxy for fetal testosterone. However, circulating testosterone consistently shows positive associations with antisocial behaviors throughout childhood, adolescence, and adulthood, particularly in males. It is suggested that high fetal/circulating testosterone interactively influence the maturation and functionality of mesolimbic dopaminergic circuitry, right orbitofrontal cortex, and cortico-subcortical connectivity, resulting in a strong reward motivation, low social sensitivity, and dampened regulation of strong motivational/emotional processes. The link between these testosterone induced endophenotypes and actual display of antisocial behavior is strongly modulated by different social (e.g., social rejection, low SES) and genetic (e.g., MAOA, 5HTT) risk factors that can disturb socio-, psycho-, and biological development and interact with testosterone in shaping behavior. When these additional risk factors are present, the testosterone induced endophenotypes may increase the risk for a chronic antisocial lifestyle. However, behavioral endophenotypes induced by testosterone can also predispose towards socially adaptive traits such as a strong achievement motivation, leadership, fair bargaining behaviors, and social assertiveness. These adaptive traits are more likely to emerge when the high testosterone individual has positive social experiences that promote prosocial behaviors such as strong and secure attachments with his caregivers, affiliation with prosocial peers, and sufficient socioeconomic resources. A theoretical model is presented, various hypotheses are examined, and future venues for research are discussed.