Flexed elbow, abducted shoulder, forearm supinated (FABS) reconstruction from three-dimensional elbow MRI: diagnostic performance assessment in biceps head anatomy and pathology.

AIM: To determine inter-reader analysis and diagnostic performance on digitally reconstructed virtual flexed, abducted, supinated (FABS) imaging from three-dimensional (3D) isotropic elbow magnetic resonance imaging (MRI). MATERIALS AND METHODS: Six musculoskeletal radiologists independently evaluated elbow MRI images with virtual FABS reconstructions, blinded to clinical findings and final diagnoses. Each radiologist recorded a binary result as to whether the tendon was intact and if both heads were visible, along with a categorical value to the type of tear and extent of retraction in centimetres where applicable. Kappa and interclass correlation (ICC) were reported with 95% confidence intervals. Areas under the receiver operating curve (AUC) were reported. RESULTS: FABS reconstructions were obtained successfully in all 48 cases. With respect to tendon intactness, visibility of both heads, and type of tear, the Kappa values were 0.66 (0.53-0.78), 0.24 (0.12-0.37), and 0.55 (0.43-0.66), respectively. For the extent of retraction, the ICC was 0.85 (0.79-0.91) when including the tendons with and without retraction and 0.78 (0.61-0.91) when only including tendons with retraction. For tear versus no tear, AUC values were 0.82 (0.74-0.89) to 0.96 (0.91-1.01). CONCLUSION: Digital reconstruction of FABS positioning is feasible and allows good assessment of individual tendon head tears and retraction with high diagnostic performance.

A Comparison of Treatment of OCD Lesions of the Capitellum With Osteochondral Autograft and Allograft Transplantation.

Osteochondritis dissecans (OCD) of the capitellum occurs relatively infrequently but can be found in young overhead-throwing athletes, most commonly in baseball players and gymnasts. Although non-operative management can effectively treat stable lesions, unstable lesions can lead to debilitating symptoms of the elbow and diminished quality of life without surgical intervention. This article reviews methods of treating OCD of the capitellum categorized by stability, size, and patient characteristics, and seeks to familiarize the reader with the appropriate selection of osteochondral allograft versus autograft in treating large, unstable lesions. We complement this review with 3 case examples, each using either an osteochondral autograft or allograft, and discuss the decision-making methodology used in each case.

Fewer Than One in 20 Current Academic Orthopaedic Surgeons Have Obtained National Institutes of Health Funding.

BACKGROUND: National Institutes of Health (NIH) funding is a key driver of orthopaedic research, but it has become increasingly difficult to obtain in recent years. An understanding of the types of grants that are commonly funded, how productive they are, and the factors associated with obtaining funding may help orthopaedic surgeons better understand how to earn grants. QUESTIONS/PURPOSES: In this study, we sought to determine (1) the proportion of current academic orthopaedic surgeons who have obtained NIH grant funding, (2) the productivity of these grants by calculating grant productivity metrics, and (3) the factors (such as gender, subspecialty, and additional degrees) that are associated with obtaining grant funding. METHODS: Current academic orthopaedic surgeons at the top 140 NIH-funded institutions were identified via faculty webpages; 3829 surgeons were identified. Demographic information including gender (men constituted 88% of the group [3364 of 3829]), academic rank (full professors constituted 22% [856 of 3829]), additional degrees (those with MD-PhD degrees constituted 3% [121 of 3829]), leadership positions, and orthopaedic subspecialty was collected. Funding histories from 1985 through 2021 were collected using the NIH Research Portfolio Online Reporting Tools Expenditures and Results. Grant type, funding, publications, and citations of each article were collected. A previously used grant impact metric (total citations per USD 0.1 million) was calculated to assess grant productivity. Multivariable binomial logistic regression was used to evaluate factors associated with obtaining funding. RESULTS: Four percent (150 of 3829) of academic orthopaedic surgeons obtained USD 338.3 million in funding across 301 grants, resulting in 2887 publications over the entire study period. The R01 was the most commonly awarded grant in terms of the total number awarded, at 36% (108 of 301), as well as by funding, publications, and citations, although other grant types including T32, F32, R03, R13, and R21 had higher mean grant impact metrics. There was no difference between men and women in the by-gender percentage of academic orthopaedic surgeons who obtained funding (4% [135 of 3229] versus 3% [15 of 450]; odds ratio 0.9 [95% confidence interval 0.5 to 1.7]; p = 0.80). A department having a single funded PhD researcher may be associated with surgeon-scientists obtaining grant funding, but with the numbers available, we could not demonstrate this was the case (OR 1.4 [95% CI 0.9 to 2.2]; p = 0.12). CONCLUSION: Fewer than one in 20 academic orthopaedic surgeons have received NIH funding. R01s are the most commonly awarded grant, although others demonstrate increased productivity metrics. Future studies should investigate the role of co-principal investigators on productivity and the role of different funding sources. CLINICAL RELEVANCE: Individuals should pursue both R01 and non-R01 grants, and departments should consider cultivating relationships with funded PhDs. The specific research infrastructure and departmental policies of the most productive institutions and grants should be surveyed and emulated.

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.

Dual-energy CT-generated bone marrow oedema maps improve timely visualisation and recognition of acute lower extremity fractures.

AIM: To assesses whether utilising bone marrow oedema (BMO) maps improved fracture read times and reader confidence in a large series of acute lower extremity trauma dual-energy computed tomography (DECT) studies. MATERIALS AND METHODS: One hundred and six DECT studies, including 60 fracture cases and 46 non-fracture cases, were evaluated retrospectively in this cross-sectional study. Three-dimensional (3D) BMO maps were generated for each study and coded to display skeletal anatomy in blue and marrow oedema in green. Studies were interpreted by two readers in two timed stages (without and with BMO maps). Readers identified the number, anatomical location, and comminution of fractures. Reader confidence (five-point Likert scale) for fracture identification and anatomical regions where oedema was present was also recorded. RESULTS: Decreased read times (p<0.01) were observed when readers utilised BMO maps for their fracture search. The presence of oedema on BMO maps corresponded with associated fracture in 75.7% reads. No differences in reader confidence were observed as a result of using this BMO-guided technique (>95%, 5/5 for both readers with and without the aid of BMO maps). CONCLUSIONS: DECT BMO maps improve the speed of radiological identification of suspected acute lower extremity fractures with preserved reader confidence. It may help emergent detection of fractures, important for patient management and outcomes.

How to Be An Antiracist Hand Surgery Educator.

Racism that unjustly marginalizes black people in the United States is not a new concept. It underlies nearly every aspect of American history, leading to the systemic racism that is ingrained in our society today. With the recurrent theme of people of color having worse health outcomes than the majority community, it is important for hand surgeons to employ cultural competence and antiracist education to provide better care and support for patients, staff, students, and colleagues. In this article, we will provide a definitional framework, clinical examples, and practical pearls to promote change. To reduce racial and ethnic health care inequities and diversify the field of hand surgery, we must advocate on behalf of black and brown colleagues, staff, students, and/or friends to address racist policies and procedures.

Racial and Gender Discrimination in Hand Surgery Letters of Recommendation.

PURPOSE: We sought to evaluate hand surgery applicants' letters of recommendations to understand whether applicant and letter writer demographics contribute to racial and gender bias. METHODS: All applications submitted through the American Society for Surgery of the Hand match to a single institution fellowship program for the 2017 to 2019 application cycles were analyzed using validated text analysis software. Race/ethnicity information was derived from an analysis of applicant photos using the Face Secret Pro software. Primary outcome measures were differences in communal and agentic language used in letters of recommendation, stratified by both race/ethnicity and gender. RESULTS: A total of 912 letters of recommendation were analyzed for 233 applicants (51 female and 172 male). Of these, 88 were written by female letter writers and 824 were written by male letter writers. There were 8 Black, 12 Hispanic, 36 Asian, and 167 White applicants. Letter writers used more agentic language with Asian applicants and non-White applicants overall. Female letter writers used more communal terms and were not associated with applicant race or gender. CONCLUSIONS: Letters of recommendation in hand surgery demonstrate disparities in language based on race and gender. CLINICAL RELEVANCE: Alerting letter writers to the role of implicit bias will hopefully spur a discussion on tools to mitigate the use of biased language and provide a foundation for an equitable selection process. Efforts to improve policies and procedures pertaining to diversity and inclusion are paramount to ensuring that fellows more completely represent the population hand surgeons wish to serve.

Scheduling nab-paclitaxel combined with gemcitabine as first-line treatment for metastatic pancreatic adenocarcinoma.

BACKGROUND: Nab-paclitaxel plus gemcitabine (nabP+gemcitabine) offers modest survival gains for patients with metastatic pancreatic ductal adenocarcinoma (PDAC). Sequential scheduling of nabP+gemcitabine in a PDAC mouse model improved efficacy; this hypothesis was tested in a clinical trial. METHODS: Patients with previously untreated metastatic PDAC were randomised to receive nabP+gemcitabine administered either concomitantly on the same day, or sequentially, with gemcitabine administered 24 h after nabP. The primary outcome measure was progression-free survival (PFS). Secondary outcome measures were objective response rate (ORR), overall survival (OS), safety, quality of life (QoL) and predictive biomarkers. RESULTS: In total, 71 patients received sequential (SEQ) and 75 concomitant (CON) treatment. Six-month PFS was 46% with SEQ and 32% with CON scheduling. Median PFS (5.6 versus 4.0 months, hazard ratio [HR] 0.67, 95% confidence interval [95% CI] 0.47-0.95, p = 0.022) and ORR (52% versus 31%, p = 0.023) favoured the SEQ arm; median OS was 10.2 versus 8.2 months (HR 0.93, 95% CI 0.65-1.33, p = 0.70). CTCAE Grade ≥3 neutropaenia incidence doubled with SEQ therapy but was not detrimental to QoL. Strongly positive tumour epithelial cytidine deaminase (CDA) expression favoured benefit from SEQ therapy (PFS HR 0.31, 95% CI 0.13-0.70). CONCLUSIONS: SEQ delivery of nabP+gemcitabine improved PFS and ORR, with manageable toxicity, but did not significantly improve OS. CLINICAL TRIAL REGISTRATION: ISRCTN71070888; ClinialTrials.gov (NCT03529175).

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.

Initial experience of CT-guided pulsed radiofrequency ablation of the pudendal nerve for chronic recalcitrant pelvic pain.

AIM: To evaluate initial experience with computed tomography (CT)-guided pulsed radiofrequency ablation (pRFA) of the pudendal nerve in cases of recalcitrant neuropathic pelvic pain. Endpoints include technical feasibility, safety, and efficacy of therapy. MATERIALS AND METHODS: Ten patients who underwent pRFA ablation for neuropathic pudendal nerve pain during the trial period were followed for response to treatment for 6 months. Each patient was treated with pRFA under CT-guidance with concurrent perineural injection of anaesthetic and/or corticosteroid. Pain scores were then measured using a numeric rating scale at fixed intervals up to 6 months. RESULTS: All procedures were considered technically successful with no immediate complications. pRFA demonstrated improved duration of pain improvement compared to the most recent perineural injection (p=0.0195), but not compared to the initial injection (p=0.64). Reported pain scores were lower with pRFA than with both the first and most recent injection but this did not reach statistical significance (p=0.1094 and p=0.7539, respectively). CONCLUSION: Overall, pRFA of the pudendal nerve using CT-guidance can be a safe and effective therapy. This technique provides direct visualisation of the nerve to maximise safety and efficacy while offering a novel form of therapy for patients with chronic, recalcitrant pelvic pain.

Reduction of unnecessary repeat knee radiographs during osteoarthrosis follow-up visits in a large teaching medical center.

BACKGROUND: Professional organizations recommend against repeat radiographs for routine follow-up of osteoarthrosis. However, clinics frequently obtain radiographs during or before the clinical visit. The purpose of our project was to determine the baseline frequency of unnecessary knee radiographs and whether educational interventions can reduce this frequency. METHODS: This QI project was exempt from IRB review. Radiology reports of knee radiographs were searched in our database filtered by presence of the words "severe", "degenerative", "osteoarthritis", and similar variants. We reviewed 500 consecutive corresponding medical records to confirm the presence of severe osteoarthritis, and presence of a repeat radiograph within 6 months. Indications for repeat radiographs were determined. Repeat radiographs were counted as "non-indicated" when medical records revealed no new symptoms. A focused educational intervention was provided to the orthopedic and family practice departments. An additional 500 radiology reports were evaluated 9 months after intervention in the same manner and the rate of non-indicated radiographs was calculated. Follow-up review of additional 500 radiology reports at 1-year time point was performed. RESULTS: Our initial search returned 1517 reports. Upon evaluation of 500 studies, there were 112/500 repeat radiographs (22%); 77/500 (15%) of knee radiographs were not indicated. Upon initial follow-up evaluation of 500 studies, there were 52/500 repeat radiographs (10%) and 40/500 (8%) radiographs were not indicated. The reduction of unnecessary repeat knee radiographs rate was sustained at 1 year. CONCLUSIONS: Focused educational intervention results in a substantial (50%) reduction of the number of unnecessary repeat knee radiographs in patients with known severe OA.

Evaluation of giant cell tumors by diffusion weighted imaging-fractional ADC analysis.

BACKGROUND: A single ADC value is used in clinical practice on multi b-value acquisitions. Low b-value acquisitions are affected by intravoxel incoherent motion, which is dependent on perfusion. Giant cell tumors (GCTs) are known to exhibit early arterial enhancement and low ADC values. Mean, minimum and fractional ADC characteristics of osseous and tenosynovial GCTs are systematically evaluated. METHODS: Tenosynovial and osseous GCTs were included. Each lesion was evaluated on conventional MRI and DWI by two musculoskeletal radiologists. ADC was measured by placing an ROI on the most confluent enhancing portion of the lesion. Fractional and best fit ADC calculations were performed using MATLAB software. RESULTS: No statistically significant difference was found between tenosynovial and osseous lesions' ADC values. Mean ADC for all lesions was 1.0 × 10-3 mm2/s (SD = 0.2 × 10-3 mm2/s) and minimum ADC was 0.5 × 10-3 mm2/s (SD = 0.3 × 10-3 mm2/s). Average mean ADC value obtained from B50-B400 slope was 1.1 × 10-3 mm2/s (SD = 0.2 × 10-3 mm2/s), and the average mean ADC value obtained from B400-B800 slope was 0.8 × 10-3 mm2/s (SD = 0.1 × 10-3 mm2/s) [p-value <0.01]. CONCLUSION: Tenosynovial and osseous GCTs demonstrate similar and low ADC values, which become even lower when using high b-value pairs. Our study also supports the theory of intravoxel incoherent motion that becomes apparent at low b values as related to giant cell tumors, which are known to be hyperperfused.

Bone Graft Substitutes: Current Concepts and Future Expectations.

Owing to its osteoinductive and osteoconductive properties and the presence of osteogenic cells, freshly harvested autologous bone graft is the gold standard for skeletal reconstruction where there is inadequate native bone. Whereas these characteristics are difficult to replicate, engineered, commercially available bone graft substitutes aim to achieve a comparable osseoregenerative profile. This work furnishes the reader with an understanding of the predominant classes of bone graft substitutes available for reconstruction of upper extremity bone defects following trauma or oncological surgery. We review bone graft substitutes with respect to their mechanisms of action, their advantages and disadvantages, and their indications and contraindications. We provide examples of bone graft substitutes in clinical use and outline comparative costs. We also describe the future directions for this specific aspect of reconstructive surgery with a focus on the role of bioactive glass.

Adjuvant bevacizumab for melanoma patients at high risk of recurrence: survival analysis of the AVAST-M trial.

Background: Bevacizumab is a recombinant humanised monoclonal antibody to vascular endothelial growth factor shown to improve survival in advanced solid cancers. We evaluated the role of adjuvant bevacizumab in melanoma patients at high risk of recurrence. Patients and methods: Patients with resected AJCC stage IIB, IIC and III cutaneous melanoma were randomised to receive either adjuvant bevacizumab (7.5 mg/kg i.v. 3 weekly for 1 year) or standard observation. The primary end point was detection of an 8% difference in 5-year overall survival (OS) rate; secondary end points included disease-free interval (DFI) and distant metastasis-free interval (DMFI). Tumour and blood were analysed for prognostic and predictive markers. Results: Patients (n=1343) recruited between 2007 and 2012 were predominantly stage III (73%), with median age 56 years (range 18-88 years). With 6.4-year median follow-up, 515 (38%) patients had died [254 (38%) bevacizumab; 261 (39%) observation]; 707 (53%) patients had disease recurrence [336 (50%) bevacizumab, 371 (55%) observation]. OS at 5 years was 64% for both groups [hazard ratio (HR) 0.98; 95% confidence interval (CI) 0.82-1.16, P = 0.78). At 5 years, 51% were disease free on bevacizumab versus 45% on observation (HR 0.85; 95% CI 0.74-0.99, P = 0.03), 58% were distant metastasis free on bevacizumab versus 54% on observation (HR 0.91; 95% CI 0.78-1.07, P = 0.25). Forty four percent of 682 melanomas assessed had a BRAFV600 mutation. In the observation arm, BRAF mutant patients had a trend towards poorer OS compared with BRAF wild-type patients (P = 0.06). BRAF mutation positivity trended towards better OS with bevacizumab (P = 0.21). Conclusions: Adjuvant bevacizumab after resection of high-risk melanoma improves DFI, but not OS. BRAF mutation status may predict for poorer OS untreated and potential benefit from bevacizumab. Clinical Trial Information: ISRCTN 81261306; EudraCT Number: 2006-005505-64.

A Murine Model for Human ECO Syndrome Reveals a Critical Role of Intestinal Cell Kinase in Skeletal Development.

An autosomal-recessive inactivating mutation R272Q in the human intestinal cell kinase (ICK) gene caused profound multiplex developmental defects in human endocrine-cerebro-osteodysplasia (ECO) syndrome. ECO patients exhibited a wide variety of skeletal abnormalities, yet the underlying mechanisms by which ICK regulates skeletal development remained largely unknown. The goal of this study was to understand the structural and mechanistic basis underlying skeletal anomalies caused by ICK dysfunction. Ick R272Q knock-in transgenic mouse model not only recapitulated major ECO skeletal defects such as short limbs and polydactyly but also revealed a deformed spine with defective intervertebral disk. Loss of ICK function markedly reduced mineralization in the spinal column, ribs, and long bones. Ick mutants showed a significant decrease in the proliferation zone of long bones and the number of type X collagen-expressing hypertrophic chondrocytes in the spinal column and the growth plate of long bones. These results implicate that ICK plays an important role in bone and cartilage development by promoting chondrocyte proliferation and maturation. Our findings provided new mechanistic insights into the skeletal phenotype of human ECO and ECO-like syndromes.

Hallux valgus and metatarsus adductus measurements: inter-reader reliability and correlations on radiographs and MRI.

AIM: To assess inter-reader reliability of metatarsus adductus (MA) using the traditional method and Engel's angle (EA) on radiography and magnetic resonance imaging (MRI) and assess correlations with hallux valgus (HV). METHODS AND MATERIALS: Ninety consecutive patients with radiographs and MRI of the foot were included. Two readers measured HV angle (HVA), traditional metatarsus adductus angle (MAA), and EA on radiographs and HVA and EA on MRI. Three- and two-way mixed model analyses were used for reader agreements. Ninety-five percent bootstrap confidence intervals were calculated. The linear mixed model was used for association between HVA and EA/MAA. RESULTS: Mean age and male to female ratio was 54.2±15.4 and 0.4:1, respectively. Mean HVA and EA were 20.6±9.4 and 21.2±8, 21.2±8.3 and 22.4±7.5 on radiographs and MRI, respectively. Mean MAA was 18.5±5.7 on radiographs. Inter-reader agreement was good for EA (ICC=0.73, 0.6) and moderate for MAA (ICC=0.41). Positive correlations between HVA, MAA, and EA on radiographs and MRI were found, but none were statistically significant (p=0.44 and 0.87). CONCLUSION: Engel's angle is more reproducible. Although positive correlations exist between the degrees of HV and MA, they are not statistically significant.

Failed Thumb Carpometacarpal Arthroplasty: Common Etiologies and Surgical Options for Revision.

Carpometacarpal (CMC) arthroplasty surgery, although modifications have occurred over time, continues to be commonly performed and has provided patients with their desired pain relief and return of function. The complications of primary surgery, although relatively rare, can present in various clinical ways. An understanding of the underlying anatomy, pathology of coexisting conditions, and specific techniques used in the primary surgery is required to make the best recommendation for a patient with residual pain following primary CMC arthroplasty. The purpose of this review is to provide insights into the history of CMC arthroplasty and reasons for failure and to offer an algorithmic treatment approach for the clinical problem of persistent postoperative symptoms.

Radial Head Fracture Fixation Using Tripod Technique With Headless Compression Screws.

Radial head and neck fractures are one of the most common elbow fractures, comprising 2% to 5% of all fractures, and 30% of elbow fractures. Although uncomplicated Mason type I fractures can be managed nonsurgically, Mason type II-IV fractures require additional intervention. Mason type II-III fractures with 3 or fewer fragments are typically treated with open reduction and internal fixation using 2 to 3 lag screws. Transverse radial neck involvement or axial instability with screw-only fixation has historically required the additional use of a mini fragment T-plate or locking proximal radius plate. More recently, less invasive techniques such as the cross-screw and tripod techniques have been proposed. The purpose of this paper is to detail and demonstrate the proper implementation of the tripod technique using headless compression screws.

Case study: failure of superior capsular reconstruction using dermal allograft.

Superior capsular reconstruction (SCR) is a novel technique for treating irreparable rotator cuff tears in younger patients in whom a reverse total shoulder arthroplasty is not the optimal treatment choice. This case study describes a middle-aged male with a recurrent, massive, irreparable rotator cuff tear treated with SCR that subsequently failed at the glenoid attachment. The patient underwent successful arthroscopic revision of the SCR. The case illustrates the MRI and arthroscopic correlations of the failed dermal allograft reconstruction, which to our knowledge has not been previously shown in the radiology literature.