Age-related effects on the anterior and posterior hippocampal volumes in 6-21 year olds: A model selection approach.

Although recent studies support significant differences in intrinsic structure, function, and connectivity along the longitudinal axis of the hippocampus, few studies have investigated the normative development of this dimension. In addition, factors known to influence hippocampal structure, such as sex or puberty, have yet to be characterized when assessing age-related effects on its subregions. This study addresses this gap by investigating the relationship of the anterior (antHC) and posterior (postHC) hippocampus volumes with age, and how these are moderated by sex or puberty, in structural magnetic resonance imaging scans from 183 typically developing participants aged 6-21 years. Based on previous literature, we first anticipated that non-linear models would best represent the relationship between age and the antHC and postHC volumes. We found that age-related effects are region-specific, such that the antHC volume remains stable with increasing age, while the postHC shows a cubic function characterized by overall volume increase with age but a slower rate during adolescence. Second, we hypothesized that models, which include biological sex or pubertal status would best describe these relationships. Contrary to expectation, models comprising either biological sex or pubertal status did not significantly improve model performance. Further longitudinal research is needed to evaluate their effects on the antHC and postHC development.

Proximal Row Carpectomy Using Decellularized Dermal Allograft.

Wrist arthritis is a common problem. When managed early, motion-sparing procedures can be performed with successful outcomes. Proximal row carpectomy (PRC) has demonstrated good functional results and high patient satisfaction with up to 20-year follow-up. The majority of patients with longer follow-up have, however, exhibited radiographic signs of progressive degeneration of the radiocapitate space. Although radiographic changes have not been shown to correlate with wrist pain and function, it remains a concern and questions the durability of the radiocapitate articulation with continued patient follow-up, especially those who underwent the original procedure at a younger age. Several modifications have been proposed and used to address this concern, including radiocapitate arthroplasty, with either distal radius hemiarthroplasty or tissue interposition grafts. Theoretical benefits to these adjuncts include minimizing wear and preserving the radiocapitate articulation as well as expanding the utility of a PRC even in the setting of a wrist with arthritis of the capitate head. We describe our surgical technique for managing radiocarpal arthritis with PRC and decellularized dermal allograft. Dermal matrix allografts have proved to be a safe adjunct in various orthopedic procedures, including those in the wrist and hand. This technique adds another surgical option for the treatment of radiocarpal arthritis and expands the indications for PRC to include select patients with degeneration of the capitate head.

Restoring Isometry in Lateral Ulnar Collateral Ligament Reconstruction.

PURPOSE: To ascertain whether placing the humeral attachment of the lateral ulnar collateral ligament (LUCL) at the humeral center of rotation (hCOR) on the humerus would provide the most isometric reconstruction. METHODS: We analyzed 13 cadaver limbs from mid-humerus to the hand. The morphology of the ligament complex was assessed. The hCOR was then found using radiographic parameters. We chose 7 points on the humerus located at and around the hCOR and 3 points paralleling the supinator crest of the ulna and then calculated distances from these points using a digital caliper at 0°, 30°, 60°, 90°, and 130° flexion. Differences in potential ligamentous lengths (termed graft elongation) were then calculated and statistical analysis was performed. RESULTS: There was no perfectly isometric point along the humerus or ulna. However, in all specimens the hCOR was the most isometric point for the humeral reconstruction site, with an average graft elongation of 1.1 mm. Differences in humeral tunnel position dramatically affected graft elongation at all 3 ulnar insertions. Overall, ulnar position had a minimal effect on graft elongation. CONCLUSIONS: Although no perfectly isometric points were found, the humeral center of rotation consistently reproduced the most isometry when assessing graft elongation over range of motion. These data may assist surgeons in proper tunnel placement in LUCL reconstruction. CLINICAL RELEVANCE: In LUCL reconstruction, the humeral tunnel should be placed as close as possible to the center of rotation, whereas placement on the ulna is less critical.

Is valgus unloader bracing effective in normally aligned individuals: implications for post-surgical protocols following cartilage restoration procedures.

PURPOSE: Utilizing valgus unloader braces to reduce medial compartment loading in patients undergoing cartilage restoration procedures may be an alternative to non-weightbearing post-operative protocols in these patients. It was hypothesized that valgus unloader braces will reduce knee adduction moment during the stance phase in healthy subjects with normal knee alignment. METHODS: Gait analysis was performed on twelve adult subjects with normal knee alignment and no history of knee pathology. Subjects were fitted with an off-the-shelf adjustable valgus unloader brace and tested under five conditions: one with no brace and four with increasing valgus force applied by the brace. Frontal and sagittal plane knee angles and external moments were calculated during stance via inverse dynamics. Analyses of variance were used to assess the effect of the brace conditions on frontal and sagittal plane joint angles and moments. RESULTS: With increasing tension in the brace, peak frontal plane knee angle during stance shifted from 1.6° ± 4.2° varus without the brace to 4.1° ± 3.6° valgus with maximum brace tension (P = 0.02 compared with the no brace condition). Peak knee adduction moment and knee adduction impulse decreased with increasing brace tension (main effect of brace, P < 0.001). Gait velocity and sagittal plane knee biomechanics were minimally affected. CONCLUSION: The use of these braces following a cartilage restoration procedure may provide adequate protection of the repair site without limiting the patient's mobility.

Elbow Osteochondral Allograft Transplantation and Lateral Ulnar Collateral Ligament Repair with Internal Brace: A Case Report.

CASE: A 23-year-old woman with an Osborne-Cotterill lesion and posterolateral rotatory instability (PLRI) of the elbow was treated with osteochondral allograft transplantation (OCA) and lateral ulnar collateral ligament (LUCL) repair with internal brace. Two years after surgery, she reported resolution of pain and returned to all recreational activities. She reported no mechanical symptoms and no episodes of postoperative instability. CONCLUSION: PLRI can present with an Osborne-Cotterill lesion in addition to LUCL injury. The purpose of this case report was to describe the use of OCA to manage bony defects in the capitellum in addition to LUCL repair for patients with PLRI.

Predictive value of magnetic resonance imaging in outcomes of nonsurgical treatment of lateral epicondylitis.

BACKGROUND: The diagnosis of lateral epicondylitis is typically made on the basis of clinical history and examination. However, magnetic resonance imaging (MRI) is often used to supplement evaluation of the patient with a painful elbow and can identify extensor carpi radialis brevis (ECRB) tendon tears. The objective of this study was to determine if ECRB tear size on MRI could be used as a prognostic indicator for patients with recalcitrant lateral epicondylitis and partial ECRB tears. METHODS: Forty-one patients with recalcitrant lateral epicondylitis and a partial ECRB tear on MRI were identified (22 men and 19 women; age: 49 ± 8 years; height: 165 ± 36 mm; weight: 73 ± 18 kg). Patients were divided into two groups based on whether they underwent surgery or not. Nonsurgical treatment was evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire, and surgery was considered a failure of nonsurgical treatment. Nonsurgical treatment was variable and included a mixture of physical therapy, rest, injection therapy, and splinting. RESULTS: Of the 41 patients, 5 patients opted for immediate surgery and 36 patients were treated nonsurgically. Of those 36 patients, 11 patients had symptom relief, 19 patients had subsequent surgery, and 6 patients chose not to have surgery despite continued symptoms. Tear size on MRI did not differ significantly between the patients who had symptom relief with nonsurgical treatment and the other patients (7.7 ± 4.3 mm vs. 9.7 ± 2.5 mm, P = .07). DISCUSSION: Only 11 of 41 patients (27%) with recalcitrant lateral epicondylitis and ECRB tear had symptom relief with nonsurgical treatment. However, ECRB tendon defect size on MRI did not predict success or failure of nonsurgical treatment.

Proximal Row Carpectomy Using Decellularized Dermal Allograft: Preliminary Results.

Objective The purpose of this study was to evaluate the short-term outcomes of patients undergoing proximal row carpectomy (PRC) with interposition arthroplasty using a decellularized dermal allograft. Methods Patients with a minimum of 1-year follow-up after undergoing a PRC using decellularized dermal allograft were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as well as the modified Likert scale for patient satisfaction. Nine of ten (90%) consecutive patients who were treated using this surgical technique were available for follow-up. Results At a mean follow-up of 18 months, a total of nine patients achieved a mean flexion-extension arc of 113 degrees, pronosupination of 170.5 degrees, grip strength of 68 Ibs and pinch strength of 17 Ibs. Relative to the contralateral side, these values were 95, 100, 84 and 82%, respectively. There was significant improvement in the mean DASH score from 63.5 preoperatively to 23.8 postoperatively. Patient satisfaction postoperatively achieved a mean modified Likert score of 1.5. There was no evidence of radiocarpal joint space degeneration or dislocation in any of the patients. No patient suffered wound-related issues, foreign-body reaction to the graft, or other complications. Conclusion PRC with interposition arthroplasty using a decellularized dermal allograft in patients with degenerative changes at the lunate fossa or capitate demonstrates short-term outcomes comparable to what has been reported for routine PRC in patients without degenerative changes affecting the radiocapitate joint. This method of interposition arthroplasty expands the indications for PRC and may help avoid salvage, motion-sacrificing procedures in select patients with late-stage wrist arthritis. Level of Evidence This is a level IV, therapeutic study.

Thumb Ulnar Collateral Ligament Repair with Suture Tape Augmentation.

Background: The purpose of this study is to describe our technique of thumb ulnar collateral ligament (UCL) repair with suture tape augmentation and to evaluate the short-term outcomes in our initial series of patients treated with this method of repair. Methods: Patients with minimum one-year follow up after isolated UCL repair with suture tape augmentation were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and study-specific questions. Thirteen of 15 (87%) consecutive patients who were treated using this method of repair were available for follow-up, 9 with acute tears and 4 with chronic tears. Results: Average post-operative thumb metacarpophalangeal (MCP) and interphalangeal (IP) joint range-of-motion (ROM) was 0-57.5° and 0-71°, respectively, for chronic tears and 2.2-53.9° and 0-71°, respectively, for acute tears. Average grip and pinch strength relative to the unaffected hand was 102% and 84%, respectively, among patients with chronic tears and 103.3% and 88.7%, respectively, among those with acute tears. All patients demonstrated stability with a firm endpoint, relative to the unaffected thumb. The average QuickDASH score among all patients was 11.9 for the disability/symptom module, 0 for the sport module and 16.5 for the work module. Stiffness was reported among 4 patients and no patient suffered wound-related issues or other complications. Conclusions: Thumb UCL repair with suture tape augmentation demonstrates short-term outcomes comparable to what has been reported for other methods of repair. It may potentially allow for an expedited recovery and rehabilitation process.

Biomechanical comparison of a knotless suture anchor with standard suture anchor in the repair of type II SLAP tears.

PURPOSE: To compare the biomechanical strength of knotless suture anchors and standard suture anchors in the repair of type II SLAP tears. METHODS: Five pairs of cadaveric shoulders (10 shoulders) were dissected free of soft tissue except for the glenoid labrum and long head of the biceps tendon. Type II SLAP tears were created and repaired with 1 of 2 anchors: the Mitek Lupine suture anchor or the Mitek Bioknotless suture anchor (DePuy Mitek, Raynham, MA). All specimens were preloaded to 10 N, and loaded for 25 cycles in 10 N increments to a maximum of 200 N. If specimens were still intact after 200 N, they were loaded to ultimate failure. The load at which 2 mm of gapping occurred, load to ultimate failure, mode of failure, and the number of cycles to failure were compared using the Wilcoxon signed-rank test. RESULTS: Load to 2-mm gapping was lower (P = .042) for knotless anchors (70 N) versus knotted anchors (104 N), with similar differences for ultimate failure (74 N v 132 N; P = .043), cycles to 2-mm gapping (133 v 219 cycles; P = .042), and cycles to failure (143 v 297; P = .043). Eight of 10 specimens failed at the soft tissue interface (4 knotless, 4 knotted) and 2 failed by anchor pullout (1 knotted, 1 knotless). CONCLUSIONS: The results of this study suggest that repair of a type II SLAP with a Mitek knotted suture anchor and mattress suture configuration through the biceps anchor is stronger than repair with a Mitek knotless suture anchor. The most likely method of repair failure was at the suture-soft tissue interface regardless of the type of anchor used. The application of a suture anchor that requires arthroscopic knot tying may be preferable to a knotless anchor for the surgical repair of type II SLAP tears. CLINICAL RELEVANCE: Repair of type II SLAP tears with knotless suture anchors may allow for the avoidance of arthroscopic knot tying but is weaker than repair with standard suture anchors.

A new surgical technique for arthroscopic repair of the meniscus root tear.

Injury of the meniscal root can lead to meniscal extrusion and loss of normal hoop stress distribution by the meniscus. This has been shown to result in an excessive tibiofemoral contact pressures and has been associated with development of arthritis in the affected compartment of the knee. Repair of meniscal root avulsion has been shown to restore the normal contact stresses, and several techniques for such repair have been described. We report an all-arthroscopic technique that allows anatomic reattachment of the avulsed meniscal root, applicable to both the medial or lateral menisci. Our technique utilizes a novel retrograde reaming device to create a small intraosseous socket at the meniscal tibial attachment, and may be particularly useful for repairing meniscal root avulsions in knees with multiligamentous injuries.

Optimizing Achilles tendon repair: effect of epitendinous suture augmentation on the strength of achilles tendon repairs.

BACKGROUND: Epitendinous suture augmentation has been shown to increase gap resistance and overall strength in flexor tendon repairs of the hand. The purpose of this study was to evaluate the effect of various suture augmentation techniques in Achilles tendon repair. MATERIALS AND METHODS: Eighteen fresh-frozen cadaveric Achilles tendons were transected and repaired with a 4-strand Krackow core stitch. Suture augmentation was performed with 3 figure-of-eight stitches in 6 specimens and a running cross-stitch weave in 6 specimens. The other 6 specimens were not augmented. Each tendon was loaded to failure on an MTS. Force to failure (defined as peak force or force at 5 mm gapping), gapping resistance, stiffness, and elongation were compared. RESULTS: Force to failure (p < 0.001), stiffness (p < 0.01) and gapping resistance (p < 0.05) were increased by suture augmentation. Additionally failure force and gapping resistance for the cross-stitch augmentation was higher than the figure-of-eight augmentation (p < 0.05). CONCLUSION: Cross-stitch augmentation of Achilles tendon repair yields a stronger and stiffer repair with greater resistance to gapping. CLINICAL RELEVANCE: Achilles tendon repairs augmented with a cross stitch weave will be able to withstand substantially higher forces than non-augmented repairs.

Gamma hydroxybutyrate: an ethnographic study of recreational use and abuse.

Gamma hydroxybutyrate (GHB) is a psychoactive substance with complex neurophysiological activity and significant potential for abuse, addiction, and dangerous toxicity. In this study, a semistructured interview was administered to 17 subjects to investigate GHB use, including: manner of use; setting; positive and negative consequences; other drug history; and sexual practices. Respondents were overwhelmingly male, but otherwise had a broad demographic background. Settings varied from nightclubs to private use at home. There was significant variability in the drug obtained, which subjects found problematic because of the narrow therapeutic window and ease of accidental overdose. Common positive experiences included increased sexual desire, decreased sexual inhibitions, and decreased anxiety. Common negative consequences included oversedation, loss of consciousness, motor incoordination, and mental confusion. Nine subjects reported that they would use GHB again, some despite severe negative consequences. Although most subjects reported negative experiences, only three felt their use was problematic, and none sought treatment for GHB abuse or addiction. Subjects were highly drug-experienced, most commonly using MDMA, ketamine, cocaine, alcohol, and methamphetamine. Some reported that GHB could cause poor decision making in sexual situations. This effect has significant ramifications for issues such as date rape and control of sexually transmitted diseases, such as HIV.

Can Weakness in End-Range Plantar Flexion After Achilles Tendon Repair Be Prevented?

BACKGROUND: Disproportionate end-range plantar flexion weakness, decreased passive stiffness, and inability to perform a heel rise on a decline after Achilles tendon repair are thought to reflect increased tendon compliance or tendon lengthening. Since this was first noted, we have performed stronger repairs and avoided stretching into dorsiflexion for the first 12 weeks after surgery. HYPOTHESIS: Using stronger repairs and avoiding stretching into dorsiflexion would eliminate end-range plantar flexion weakness and normalize passive stiffness. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Achilles repairs with epitendinous augmentation were performed on 18 patients. Plantar flexion torque, dorsiflexion range of motion (ROM), passive joint stiffness, and standing single-legged heel rise on a decline were assessed at 43 ± 24 months after surgery (range, 9 months to 8 years). Maximum isometric plantar flexion torque was measured at 20° and 10° of dorsiflexion, neutral position, and 10° and 20° of plantar flexion. Passive dorsiflexion ROM was measured with a goniometer. Passive joint stiffness was computed from the increase in passive torque from 10° to 20° of dorsiflexion. Tendon thickness was measured by use of digital calipers. Plantar flexion electromyographic (EMG) data were recorded during strength and functional tests. Analysis of variance and chi-square tests were used to assess weakness and function. RESULTS: Marked weakness was evident on the involved side at 20° of plantar flexion (deficit, 26% ± 18%; P < .001), with no weakness at 20° of dorsiflexion (deficit, 6% ± 17%; P = .390). Dorsiflexion ROM was decreased 5.5° ± 8° (P = .015), and tendon width was 8 ± 3 mm greater on the involved side (P < .001). Passive joint stiffness was similar between the involved and noninvolved sides. Only 2 of 18 patients could perform a decline heel rise on the involved side compared with 18 of 18 on the noninvolved side (P = .01). No difference in EMG amplitude was found between the involved and noninvolved sides during the strength or heel rise tests. CONCLUSION: The use of stronger repair techniques and attempts to limit tendon elongation by avoiding dorsiflexion stretching did not eliminate weakness in end-range plantar flexion. EMG data confirmed that end-range weakness was not due to neural inhibition. Physiological changes that alter the force transmission capability of the healing tendon may be responsible for this continued impairment. This weakness has implications for high-demand jumping and sprinting after Achilles tendon repair.

Weakness in end-range plantar flexion after Achilles tendon repair.

BACKGROUND: Separation of tendon ends after Achilles tendon repair may affect the tendon repair process and lead to postoperative end-range plantarflexion weakness. HYPOTHESIS: Patients will have disproportionate end-range plantarflexion weakness after Achilles tendon repair. STUDY DESIGN: Descriptive laboratory study. METHODS: Four-strand core suture repairs of Achilles tendon were performed on 1 female and 19 male patients. Postoperatively, patients were nonweightbearing with the ankle immobilized for 4 weeks. Plantarflexion torque, dorsiflexion range of motion, passive joint stiffness, toe walking, and standing single-legged heel rise (on an incline, decline, and level surface) were assessed after surgery (mean, 1.8 years postoperative; range, 6 months-9 years). Maximum isometric plantarflexion torque was measured at 20 degrees and 10 degrees of dorsiflexion, neutral, and 10 degrees and 20 degrees of plantar flexion. Percentage strength deficit (relative to noninvolved leg) was computed at each angle. Passive dorsiflexion range of motion was measured goniometrically. Passive joint stiffness was computed from increase in passive torque between 10 degrees and 20 degrees of dorsiflexion, before isometric contractions. RESULTS: Significant plantarflexion weakness was evident on the involved side at 20 degrees and 10 degrees of plantar flexion (34% and 20% deficits, respectively; P <.001), with no torque deficits evident at other angles (6% at neutral, 3% at 10 degrees of dorsiflexion, 0% at 20 degrees of dorsiflexion). Dorsiflexion range of motion was not different between involved and noninvolved sides (P = .7). Passive joint stiffness was 34% lower on the involved side (P <.01). All patients could perform an incline heel rise; 14 patients could not perform a decline heel rise (P <.01). CONCLUSION: Disproportionate weakness in end-range plantar flexion, decreased passive stiffness in dorsiflexion, and inability to perform a decline heel rise are evident after Achilles tendon repair. Possible causes include anatomical lengthening, increased tendon compliance, and insufficient rehabilitation after Achilles tendon repair. CLINICAL RELEVANCE: Impairments will have functional implications for activities (eg, descending stairs and landing from a jump). Weakness in end-range plantar flexion may be an unrecognized problem after Achilles tendon repair.

Functional Outcomes After Double-Row Versus Single-Row Rotator Cuff Repair: A Prospective Randomized Trial.

BACKGROUND: The functional benefits of double-row (DR) versus single-row (SR) rotator cuff repair are not clearly established. PURPOSE: To examine the effect of DR versus SR rotator cuff repair on functional outcomes and strength recovery in patients with full-thickness tears. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Forty-nine patients were randomized to DR or SR repairs; 36 patients (13 women, 23 men; mean age, 62 ± 7 years; 20 SR, 16 DR) were assessed at a mean 2.2 ± 1.6 years after surgery (range, 1-7 years; tear size: 17 medium, 13 large, 9 massive). The following data were recorded prior to surgery and at follow-up: Penn shoulder score, American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) results; range of motion (ROM) for shoulder flexion, external rotation (ER) at 0° and 90° of abduction, and internal rotation (IR) at 90° of abduction; and shoulder strength (Lafayette manual muscle tester) in empty- and full-can tests, abduction, and ER at 0° of abduction. Treatment (SR vs DR) × time (pre- vs postoperative) mixed-model analysis of variance was used to assess the effect of rotator cuff repair. RESULTS: Rotator cuff repair markedly improved Penn, ASES, and SST scores (P < .001), with similar improvement between SR and DR repairs (treatment × time, P = .38-.10) and excellent scores at follow-up (DR vs SR: Penn, 91 ± 11 vs 92 ± 11 [P = .73]; ASES, 87 ± 12 vs 92 ± 12 [P = .21]; SST, 11.4 ± 1.0 vs 11.3 ± 1.0 [P = .76]). Patients with DR repairs lost ER ROM at 0° of abduction (preoperative to final follow-up, 7° ± 10° loss [P = .013]). ER ROM did not significantly change with SR repair (5° ± 14° gain, P = .16; treatment by time, P = .008). This effect was not apparent for ER ROM at 90° of abduction (treatment × time, P = .26). IR ROM improved from preoperative to final follow-up (P < .01; SR, 17° ± 27°; DR, 7° ± 21°; treatment × time, P = .23). Rotator cuff repair markedly improved strength in empty-can (54%), full-can (66%), abduction (47%), and ER (54%) strength (all P < .001), with no difference between SR and DR repairs (P = .23-.75). All clinical tests with the exception of the lift-off test were normalized at follow-up (P < .05). CONCLUSION: Outcomes were not different between SR or DR repair, with generally excellent outcomes for both groups. Rotator cuff repair and subsequent rehabilitation markedly improved shoulder strength.

Reconstruction of the coracoclavicular ligaments with tendon grafts: a comparative biomechanical study.

BACKGROUND: Numerous surgical techniques have been described to address injuries to the coracoclavicular ligaments. PURPOSE: To compare the biomechanical properties of tendon graft reconstructions with those of the native coracoclavicular ligaments and various other repair methods. STUDY DESIGN: Controlled laboratory study. METHODS: Eleven fresh-frozen human cadaveric shoulders were tensile tested to failure to compare the biomechanical properties of the native coracoclavicular ligaments, coracoacromial ligament transfer, No. 5 Mersilene suture repair, 5-mm Mersilene tape repair, and tendon graft reconstructions with gracilis, semitendinosus, and long toe extensor tendons. RESULTS: Reconstructions with semitendinosus, gracilis, or long toe extensor tendon grafts were found to have superior initial biomechanical properties compared with coracoacromial ligament transfer; failure strengths were as strong as those of the native coracoclavicular ligaments. Failure of the tendon grafts occurred through the midsubstance of the tendon graft, not at the fixation site. CONCLUSIONS: Tendon graft reconstruction may be an alternative to coracoacromial ligament transfer and may provide a permanent biologic reconstruction with superior initial biomechanical properties, including that of tensile strength. CLINICAL RELEVANCE: Use of tendon graft reconstruction may limit the need for postoperative immobilization and lead to an accelerated rehabilitation program.

Tumorlike lesions and benign tumors of the hand and wrist.

A broad spectrum of tumorlike lesions and neoplasms can occur in the hand and wrist, although with somewhat less frequency than in other parts of the body. A thorough understanding of the differential diagnosis of these lesions and a comprehensive strategy for evaluation are central for effective care. Plain radiographs are diagnostic for most bony lesions, whereas magnetic resonance imaging may be necessary to help differentiate a benign soft-tissue lesion from the rare malignant neoplasm. In spite of the complex anatomy, adherence to proper oncologic principles most often will lead to a satisfactory outcome.

Athletic hand injuries.

Hand injuries are among the most common injuries arising from athletic participation. Suboptimal outcomes from poorly treated athletic hand injuries can produce functionally disabling injuries. Careful assessment and, when needed, radiographic studies are critical for the accurate and complete diagnoses of hand injuries. Carefully thought out modifications may accelerate the time for return to competition. A thorough understanding of these many variables can enable the physician to minimize time lost without compromising care.

Circuit parties and patterns of drug use in a subset of gay men.

This study examined the characteristics of gay men attending circuit parties and their drug use. In particular, the role of methylenediomethamphetamine (MDMA, "ecstasy") was considered in relation to other drug use and sexual behavior. A one-page survey was distributed to 173 men attending a circuit party. Respondents were generally gay men, Caucasian, employed, and well-educated. Twenty-five percent self-identified as HIV-positive. Eighty-six percent reported using at least one substance on the day of the party; polydrug use was frequent. The most common substances were MDMA, ketamine, and methamphetamine. MDMA use was highly associated with ketamine, methamphetamine, and cocaine use. MDMA use was also associated with significantly more receptive anal intercourse. Circuit parties are settings of increased drug use and associated high-risk sexual behavior. A better understanding of these issues is needed to develop interventions aimed at reducing drug use and sexual risk taking among gay men who attend circuit parties.