The Iliac Crest Top Hat Bone Graft for Challenging Metacarpal Nonunion.

Metacarpal nonunion is a rare outcome of metacarpal injury, and little has been published about its management. Care typically includes open reduction and internal fixation with a possible bone graft, similar to the treatment of other nonunions. However, there is no literature guidance if traditional methods do not lead to union. To improve the treatment of these recalcitrant metacarpal diaphyseal nonunions, we proposed a new surgical technique using a "top hat" bone graft harvested from the iliac crest. The graft is carefully shaped to create a cancellous "crown," which is inserted into the nonunion site, and cortical "brims," which are used to secure the graft to the metacarpal. This has been successful in treating 2 cases of metacarpal nonunion that failed to heal with first-line intervention.

Congenital Upper-Extremity Differences: A Thematic Analysis of On-Line Discussion Boards.

PURPOSE: On-line discussion boards (DBs) are used by patients and family members to pose questions and share experiences with a broader community. Systematic analysis of the text posted to DBs about congenital upper-extremity (UE) differences may allow physicians to identify and address patients' questions and concerns better. METHODS: We used Google and Yahoo! Internet search engines to identify on-line DBs pertaining to congenital UE differences. Posts written between January 1, 2009 and January 1, 2019 were collected and analyzed. Each on-line post was coded by 2 researchers using 3 rounds of grounded theory: open coding, axial coding, and selective coding. This allowed comprehensive, central themes of the DBs to emerge. RESULTS: We collected 521 posts and analyzed 420 posts from 152 threads. A total of 163 unique users contributed to posts. Parents of a child with a congenital UE difference accounted for the majority of users (65%), most of which were postnatal (91%). Of posts written by patients, 48% expressed negative emotions pertaining to their difference, whereas 17% conveyed a positive experience. Five selective codes were identified from posts written by non-administrators: (1) Connecting With Others, (2) Emotional Aspects, (3) Treatment, (4) Diagnosis, and (5) Function. Connecting With Others was the most frequently assigned selective code; users were looking to establish a connection in 73% of posts. Posts seeking information (n = 106) were more often technical in nature than were posts providing information (54% vs 44%). Posts providing information (n = 206) were more often emotional (18% vs 13%). CONCLUSIONS: Individuals accessing on-line DBs are commonly searching for technical and emotional support from others. Through analysis and identification of the themes from these posts, we believe physicians should be proactive in addressing technical concerns through education and counseling, but should also validate emotional concerns and assist families and patients via support groups or connections to others. CLINICAL RELEVANCE: Treating surgeons can improve their care of patients with congenital UE differences by better understanding the needs of patients and their families that may not be elucidated in a traditional patient encounter.

Treatment of Radial Longitudinal Deficiency: An International Survey.

PURPOSE: The treatment of radial longitudinal deficiency (RLD) is highly variable without clear guidelines in the literature. The current study investigated variability among hand surgeons in treatment approaches for RLD patients with anomalies of the thumb and forearm. METHODS: An online survey was distributed to 105 self-identified North American pediatric hand surgeons and 23 international pediatric hand surgeons. The survey was developed after consideration of the controversies in RLD treatment. Variations in diagnostic approach, timing of treatment, surgical indications, and surgical techniques were presented in a 21-question survey. RESULTS: Seventy-four (57.8%) surgeons completed the survey. For type 2 hypoplastic thumb reconstruction, 81% of surgeons prefer the flexor digitorum superficialis transfer with others using the abductor digiti minimi transfer. Ninety-four percent and 100% of surgeons favored pollicization for type 3B and type 4 hypoplastic thumb, respectively. When performing pollicization, 88% of surgeons strive for tip-to-tip pinch, with 50% preferring 100° rotation and 38% greater than 120°, compared with 12% who preferred tip-to-side pinch. Nearly half of surgeons stated they would not recommend pollicization for a patient with a stiff index finger who utilizes ulnar prehension. Ninety percent of surgeons preferred observation for a type 1 radius. Type 2 treatment preferences were highly variable, the most common response being radius lengthening. For type 3/4 radius deficiency, surgeons were divided between soft tissue release with bilobed flap and centralization (42% and 36%, respectively). If radial deviation could not be passively corrected, 63% preferred an external fixator for soft tissue distraction before centralizing. Ulnar prehension functional pattern changed treatment for 45% of surgeons in type 3/4 radius. CONCLUSIONS: This study provides information on areas of agreement and disagreement in the treatment of RLD. Specifically, there was consensus for treatment of types 3B and 4 thumbs and type 1 radius. Consensus was lacking for the amount of rotation in positioning of the pollicized digit, the role of pollicization with the stiff index finger, and also in the treatment of types 2, 3, or 4 radius. CLINICAL RELEVANCE: This study provides a framework to establish treatment guidelines for thumb hypoplasia and RLD and has identified areas lacking consensus and that require additional study.

Are Women Proportionately Represented as Speakers at Orthopaedic Surgery Annual Meetings? A Cross-Sectional Analysis.

BACKGROUND: In spite of efforts to improve gender diversity in orthopaedic surgery, women remain underrepresented, particularly with increasing academic rank. Opportunities to speak at society meetings are an important component of building a national reputation and achieving academic promotions. However, little is known about the gender diversity of orthopaedic society annual meeting speakers. Data on this topic are needed to determine whether these speaking roles are equitably distributed between men and women, which is fundamental to equalizing professional opportunity in academic orthopaedic surgery. QUESTION/PURPOSES: (1) Is the gender diversity of invited speakers at annual orthopaedic subspecialty society meetings proportional to society membership? (2) Are there differences in the proportion of women invited to speak in technical sessions (defined as sessions on surgical outcomes, surgical technique, nonsurgical musculoskeletal care, or basic science) versus nontechnical sessions (such as sessions on diversity, work-life balance, work environment, social media, education, or peer relationships)? (3) Does the presence of women on the society executive committee and annual meeting program committee correlate with the gender diversity of invited speakers? (4) Do societies with explicit diversity efforts (the presence of a committee, task force, award, or grant designed to promote diversity, or mention of diversity as part of the organization's mission statement) have greater gender diversity in their invited speakers? METHODS: Seventeen national orthopaedic societies in the United States were included in this cross-sectional study of speakership in 2018. Each society provided the number of men and women members for their society in 2018. The genders of all invited speakers were tabulated using each society's 2018 annual meeting program. Speakers of all credentials and degrees were included. All manuscript/abstract presenters were excluded from all analyses because these sessions are selected by blinded scientific review. A Fisher's exact test was used to compare the proportion of women versus men in nontechnical speaking roles. The relationship between women in society leadership roles and women in all speaking roles was investigated using a linear regression analysis. A chi square test was used to compare the proportion of women in all speaking roles between societies with stated diversity efforts with societies without such initiatives. RESULTS: Overall, women society members were proportionately represented as annual meeting speakers, comprising 13% (4389 of 33,051) of all society members and 14% (535 of 3928) of all annual meeting speakers (% difference 0.6% [95% CI -0.8 to 1.5]; p = 0.60); however, representation of women speakers ranged from 0% to 33% across societies. Women were more likely than men to have nontechnical speaking roles, with 6% (32 of 535) of women's speaking roles being nontechnical, compared with 2% (51 of 3393) of men's speaking roles being nontechnical (OR 4.2 [95% CI 2.7 to 6.5]; p < 0.001). There was a positive correlation between the proportion of women in society leadership roles and the proportion of women in speaking roles (r = 0.73; p < 0.001). Societies with a stated diversity effort had more women as conference speakers; with 19% (375 of 1997) women speakers for societies with a diversity effort compared with 8% (160 of 1931) women speakers in societies without a diversity effort (OR 2.6 [95% CI 2.1 to 3.1]; p < 0.001). CONCLUSIONS: Although the percentage of women in speaking roles was proportional to society membership overall, our study identified opportunities to improve gender representation in several societies and in technical versus nontechnical sessions. Positioning more women in leadership roles and developing stated diversity efforts are two interventions that may help societies improve proportional representation; we recommend that all societies monitor the gender representation of speakers at their annual meetings and direct conference organizing committees to create programs with gender equity. CLINICAL RELEVANCE: Society leadership, national oversight committees, invited speakers, and conference attendees all contribute to the layers of accountability for equitable speakership at annual meetings. National steering committees such as the American Academy of Orthopaedic Surgeons Diversity Advisory Board should monitor and report conference speaker diversity data to create systemwide accountability. Conference attendees and speakers should critically examine conference programs and raise concerns if they notice inequities. With these additional layers of accountability, orthopaedic surgery annual meetings may become more representative of their society members.

Risk Factors for Nerve Injury After Total Hip Arthroplasty: A Case-Control Study.

BACKGROUND: Postsurgical acute nerve injury is rare but potentially devastating following total hip arthroplasty (THA). Previous literature suggests a wide range of incidence from 0.1% to 7.6%. Confirmed risk factors for these injuries remain unclear. METHODS: THA patients at our institution who developed nerve injury during their admission for THA between January 1, 1998, and December 31, 2013, were systematically identified and matched with 2 control subjects by surgical date. Relevant patient and surgical data were obtained through review of patient charts and electronic health records. We identified potential risk factors and calculated odds ratios (OR) using a conditional logistic regression model with a parsimonious stepwise approach. RESULTS: We identified 93 nerve injuries in 43,761 THAs (0.21%). The mean age of cases was 63 years. Adjusting for other factors in the model, patients <45 years were found to be at increased risk of developing nerve injury (OR, 7.17; P = .033). Similarly, patients with a history of tobacco use (OR, 1.90; P = .030) and a history of spinal surgery or disease (OR, 10.06; P < .001) were also associated with increased risk of nerve injury. For every 30-minute increase in surgery time after 1 hour, risk of nerve injury risk increased (OR, 1.48; P = .034). Assignment as first operative case of the morning was associated with a decreased risk of nerve injury (OR, 0.37, P = .043). CONCLUSION: This study demonstrates that nerve injury is a rare complication following THA at our institution. We found risk factors that are possibly modifiable factors such as lumbar spine disease, smoking, and time of surgical scheduling.

High-Sensitivity C-Reactive Protein: Retrospective Study of Potential Blood Biomarker of Inflammation in Acute Mild Traumatic Brain Injury.

OBJECTIVE: A panel of biomarkers is needed to definitively diagnose mild traumatic brain injury (mTBI). There is a clear role for the inclusion of an inflammatory biomarker. This study looked to find a relationship between high sensitivity C-reactive protein (hsCRP), an inflammatory biomarker, and mTBI. SETTING: Neurology department of high-volume tertiary orthopedic hospital. PARTICIPANTS: Individuals diagnosed with mTBI (n = 311, age 21 ± 12 years, 53% female). DESIGN: Retrospective cohort study. MAIN MEASURES: hsCRP levels; postconcussive symptoms; demographics. RESULTS: Continuous hsCRP levels were transformed into quartiles, as defined by less than 0.200 mg/L for quartile 1 (Q1); 0.200 to 0.415 mg/L for quartile 2 (Q2); 0.415 to 1.100 mg/L for quartile 3 (Q3); and greater than 1.100 mg/L for quartile 4 (Q4). Mean hsCRP was elevated in the cohort of individuals who presented within 1 week of injury and was found to significantly decrease between the first visit and 4 weeks postinjury (P = .016). Initial hsCRP level was positively correlated with age (r = 0.163, P = .004), and age significantly increased between quartiles (P = .013). Patients with increased age (odds ratio: 3.48) and those who endorsed headache (odds ratio: 3.48) or fatigue (odds ratio: 2.16) were significantly associated with increased risk of having an hsCRP level in Q4. CONCLUSION: hsCRP may be a viable addition to acute and longitudinal biomarker panels for diagnosis and prognosis of mTBI.

Longitudinal Resting State Functional Connectivity Predicts Clinical Outcome in Mild Traumatic Brain Injury.

Mild traumatic brain injury (mTBI) affects about 42 million people worldwide. It is often associated with headache, cognitive deficits, and balance difficulties but rarely shows any abnormalities on conventional computed tomography (CT) or magnetic resonance imaging (MRI). Although in most mTBI patients the symptoms resolve within 3 months, 10-15% of patients continue to exhibit symptoms beyond a year. Also, it is known that there exists a vulnerable period post-injury, when a second injury may exacerbate clinical prognosis. Identifying this vulnerable period may be critical for patient outcome, but very little is known about the neural underpinnings of mTBI and its recovery. In this work, we used advanced functional neuroimaging to study longitudinal changes in functional organization of the brain during the 3-month recovery period post-mTBI. Fractional amplitude of low frequency fluctuations (fALFF) measured from resting state functional MRI (rs-fMRI) was found to be associated with symptom severity score (SSS, r = -0.28, p = 0.002). Decreased fALFF was observed in specific functional networks for patients with higher SSS, and fALFF returned to higher values when the patient recovered (lower SSS). In addition, functional connectivity of the same networks was found to be associated with concurrent SSS, and connectivity immediately after injury (<10 days) was capable of predicting SSS at a later time-point (3 weeks to 3 months, p < 0.05). Specific networks including motor, default-mode, and visual networks were found to be associated with SSS (p < 0.001), and connectivity between these networks predicted 3-month clinical outcome (motor and visual: p < 0.001, default-mode: p < 0.006). Our results suggest that functional connectivity in these networks comprise potential biomarkers for predicting mTBI recovery profiles and clinical outcome.

Clinical Findings in a Multicenter MRI Study of Mild TBI.

Background: Uncertainty continues to surround mild traumatic brain injury (mTBI) diagnosis, symptoms, prognosis, and outcome due in part to a lack of objective biomarkers of injury and recovery. As mTBI gains recognition as a serious public health epidemic, there is need to identify risk factors, diagnostic tools, and imaging biomarkers to help guide diagnosis and management. Methods: One hundred and eleven patients (15-50 years old) were enrolled acutely after mTBI and followed with up to four standardized serial assessments over 3 months. Each encounter included a clinical exam, neuropsychological assessment, and magnetic resonance imaging (MRI). Chi-square and linear mixed models were used to assess changes over time and determine potential biomarkers of mTBI severity and outcome. Results: The symptoms most frequently endorsed after mTBI were headache (91%), not feeling right (89%), fatigue (86%), and feeling slowed down (84%). Of the 104 mTBI patients with a processed MRI scan, 28 (27%) subjects had white matter changes which were deemed unrelated to age, and 26 of these findings were deemed unrelated to acute trauma. Of the neuropsychological assessments tested, 5- and 6-Digit Backward Recall, the modified Balance Error Scoring System (BESS), and Immediate 5-Word Recall significantly improved longitudinally in mTBI subjects and differentiated between mTBI subjects and controls. Female sex was found to increase symptom severity scores (SSS) at every time point. Age ≥ 25 years was correlated with increased SSS. Subjects aged ≥ 25 also did not improve longitudinally on 5-Digit Backward Recall, Immediate 5-Word Recall, or Single-Leg Stance of the BESS, whereas subjects < 25 years improved significantly. Patients who reported personal history of depression, anxiety, or other psychiatric disorder had higher SSS at each time point. Conclusions: The results of this study show that 5- and 6-Digit Backward Recall, the modified BESS, and Immediate 5-Word Recall should be considered useful in demonstrating cognitive and vestibular improvement during the mTBI recovery process. Clinicians should take female sex, older age, and history of psychiatric disorder into account when managing mTBI patients. Further study is necessary to determine the true prevalence of white matter changes in people with mTBI.

Risk factors for acute nerve injury after total knee arthroplasty.

INTRODUCTION: In this we study identified potential risk factors for post-total knee arthroplasty (TKA) nerve injury, a catastrophic complication with a reported incidence of 0.3%-1.3%. METHODS: Patients who developed post-TKA nerve injury from 1998 to 2013 were identified, and each was matched with 2 controls. A multivariable logistic regression model was built to calculate odds ratios (ORs). RESULTS: Sixty-five nerve injury cases were identified in 39,990 TKAs (0.16%). Females (OR 3.28, P = 0.003) and patients with history of lumbar pathology (OR 6.12, P = 0.026) were associated with increased risk of nerve injury. Tourniquet pressure < 300 mm Hg and longer duration of anesthesia may also be risk factors. DISCUSSION: Surgical planning for females and patients with lumbar pathology should be modified to mitigate their higher risk of neurologic complications after TKA. Our finding that lower tourniquet pressure was associated with higher risk of nerve injury was unexpected and requires further investigation. Muscle Nerve 57: 946-950, 2018.