Influence of surgical performance on clinical outcome after osteosynthesis of distal radius fracture.

INTRODUCTION: Clinical outcome after surgery depends on the surgeon's level of expertise or performance. The present study of minimally invasive plate osteosynthesis (MIPO) with anterior plate for distal radius fracture assessed whether clinical outcome correlated with surgeon performance. METHODS: The series included 30 distal radius fractures: 15 operated on by 4 level III surgeons (Group 1) and 15 by 4 level V surgeons (Group 2), utilizing the MIPO technique. The surgical performance of all 8 surgeons was assessed using the OSATS global rating scale. Clinical outcomes were assessed at 3 months' follow-up using the modified Mayo score (MMS), in 4 grades: 0-64 (poor), 65-79 (moderate), 80-89 (good), and 90-100 (excellent). The QuickDASH score (QDASH) was also calculated, and complications were recorded. RESULTS: Median MMS was better for level V (75 = fair result) than level III surgeons (62 = poor result). Median QDASH score likewise was better in group 2 (9.1) than group 1 (22.7). In group 1, there were 2 paresthesias in the median nerve territory, 1 type-1 complex regional pain syndrome, and 1 hypoesthesia in the scar area. Mean correlation between the 2 scores was -0.68. Group 1 patients were on average 7 years older. The number of patients, number of surgeons and distribution of OA A and C fractures were almost identical in the two groups. On MMS, the overall result of the two groups was moderate (70.5), which can be explained by short mean follow-up. DISCUSSION: Quality of the clinical outcome on MMS and QDASH increased with surgical performance, with fewer complications. In the patients' interest, protocols for improving surgical performance should be implemented, for example, through deliberate practice.

Relationship between surgeons' position and the duration of the procedure during minimally invasive osteosynthesis of distal radius fractures.

This study aimed to assess the influence of the surgeon's position on procedure time in MIPO (Minimally Invasive Plate Osteosynthesis) for distal radius fracture. The hypothesis was that there was a correlation between procedure time and the surgeon's position in relation to the operated side. Thirteen surgeons (12 right-handed, 1 left-handed) operated on 421 distal radius fractures: 208 right-sided (R) and 213 left-sided (L). Surgeons stood either at the patient's head (H) or the feet (F). Procedure time and scar size were measured. Regardless of operated side (right or left), mean surgery time was 35.5 min (range, 14-71) with the surgeon at the head and 40.5 min (range, 11-119) with the surgeon at the feet. The difference (5 min) was statistically significant. When the right side was operated on, surgery time was 34.2 min (range, 14-66) with surgeon at the head and 41.1 min (range, 11-86) at the feet. The difference (6 min) was statistically significant. No other comparisons were significant. There was no correlation with surgeon's experience. Given that 1 min of operating room time costs between €10.80 and €29, savings of €54 to €145 per procedure can be achieved. The study hypothesis was confirmed, with a correlation between the surgeon's position in relation to the operated side and the duration of the operation. In conclusion, we recommend that surgeons position themselves at the patient's head for of distal radius fracture MIPO.

Acute Essex-Lopresti Syndrome: About a Case of Brachioradialis Tendon Transfer.

Background The classic treatment for acute Essex-Lopresti syndrome is closed reduction percutaneous pinning (CRPP) of the distal radioulnar joint (DRUJ). This work aimed to verify whether it was possible to add a transfer of the brachioradialis tendon to the pinning. Case Description The patient was a 39-year-old right-handed man, climbing instructor, who sustained the Mason II fracture and disjunction of the DRUJ. A transfer of the brachioradialis tendon severed from its muscle attach that was made through a bone tunnel passing through the radius and the neck of the ulna. The clinical and radiological result at the 6-month follow-up was satisfactory. Literature Review and Clinical Relevance Our results in a single case showed that the brachioradialis tendon transfer was useful in acute Essex-Lopresti syndrome.

Learning a MIPO technique for distal radius fractures: Mentoring versus simple experience versus deliberate practice.

BACKGROUND: Performance skills of a surgeon for a specific surgical technique range from 1 (novice) to 5 (expert). Mentoring can bring the surgeon to level 3. Simple experience rarely allows achievement of level 5, in contrast to deliberate practice, in which performance skills are improved by setting learning goals based on feedback about the trainee's previous performance. HYPOTHESIS: When learning a technique for the internal fixation of distal radius fractures, the level of performance skills achieved is higher with deliberate practice than with mentoring or simple experience. MATERIAL AND METHODS: Four surgeons each performed minimally invasive plate osteosynthesis (MIPO) of 15 distal radius fractures. The procedures were recorded by an HD camera. The first five fractures (step 1) were treated after mentoring, the next 5 fractures after reading an article and viewing a reference video (step 2), and the last 5 fractures after viewing and commenting 20 short videos highlighting possible errors (step 3). Each recording of the procedures performed by the surgeons was scored using the Objective Structured Assessment of Technical Skills (OSATS, 10 items on basic skills [B] and 10 on MIPO-specific skills [S]). RESULTS: For the basic skills, the mean OSATS scores (on 50) were 31 for step 1, 31 for step 2, and 43 for step 3. For the specific skills, the mean OSATS scores (on 50) were 25 for step 1, 29 for step 2, and 48 for step 3. For overall skills (B+S), the mean OSATS score (on 100) was 56 for step 1, 60 for step 2, and 91 for step 3. DISCUSSION: Our study confirms that the deliberate practice teaching method is more efficient in improving surgeon skills than simple experience. Deliberate practice consists of four essential steps: (i) setting a well-defined goal; (ii) being motivated to improve one's performance; (iii) receiving immediate feedback; and (iv) having multiple opportunities to repeat and gradually perfect one's performance. Our main hypothesis was verified, since the results of learning a MIPO technique, as assessed using the OSATS scale, were significantly better with a video-assisted deliberate practice technique than with mentoring or simple experience. CONCLUSION: Video-assisted deliberate practice deserves to be widely used in order to optimise learning curves and to improve risk management in surgery. LEVEL OF EVIDENCE: III.

A Nano-Dose Protocol For Cobb Angle Assessment in Children With Scoliosis: Results of a Phantom-based and Clinically Validated Study.

STUDY DESIGN: This was a prospective validation study with technical notes. OBJECTIVE: This study aimed to validate a new ultra-low-dose full-spine protocol for reproducible Cobb angle measurements-the "nano-dose" protocol. SUMMARY OF BACKGROUND DATA: Scoliosis is a 3-dimensional (3D) deformity of the spine characterized by 3D clinical parameters. Nevertheless, 2D Cobb angle remains an essential and widely used radiologic measure in clinical practice. Repeated imaging is required for the assessment and follow-up of scoliosis patients. The resultant high dose of absorbed radiation increases the potential risk of developing radiation-induced cancer in such patients. Micro-dose radiographic imaging is already available in clinical practice, but the radiation dose delivered to the patient could be further reduced. METHODS: An anthropomorphic child phantom was used to establish an ultra-low-dose protocol in the EOS Imaging System still allowing Cobb angle measurements, defined as nano-dose. A group of 23 consecutive children presenting for scoliosis assessment, 12 years of age or younger, were assessed with standard-dose or micro-dose and additional nano-dose full-spine imaging modalities. Intraobserver and interobserver reliability of determining the reliability of 2D Cobb angle measurements was performed. The dosimetry was performed in the anthropomorphic phantom to confirm theoretical radiation dose reduction. RESULTS: A nano-dose protocol was established for reliable Cobb angle measurements. Dose area product with this new nano-dose protocol was reduced to 5 mGy×cm, corresponding to one sixth of the micro-dose protocol (30 mGy×cm) and <1/40th of the standard-dose protocol (222 mGy×cm). Theoretical dose reduction, for posteroanterolateral positioning was confirmed using phantom dosimetry. Our study showed good reliability and repeatability between the 2 groups. Cobb variability was <5 degrees from the mean using 95% confidence intervals. CONCLUSIONS: We propose a new clinically validated nano-dose protocol for routine follow-up of scoliosis patients before surgery, keeping the radiation dose at a bare minimum, while allowing for reproducible Cobb angle measurements.

Minimally Invasive Plate Osteosynthesis for Extra-articular Distal Radius Fracture in Postmenopausal Women: Longitudinal versus Transverse Incision.

Background This work aimed to compare two mini-invasive palmar approaches (longitudinal and transverse) to osteosynthesize fractures of the distal radius. The main hypothesis was that the longitudinal technique gave smaller incisions. The secondary hypothesis was that the longitudinal technique would be better for the recovery of pain, functional scores, strength, and mobility. Materials and Methods The series included 30 extra-articular distal radius fractures in 30 patients (average age: 74 years) fixed with volar locking plate using a mini-invasive technique. Fifteen of these patients had a single longitudinal surgical approach (Group I), and 15 had a transverse approach that was completed with a longitudinal incision for the proximal screws (Group II). Results The combined average incision size was 14.73 mm in Group I and 19.8 mm in Group II. After 6 months, the pain was on average 1.4/10 (Group I) and 0.46/10 (Group II), the quick Disability of the Arm, Shoulder, and Hand was 13.63/100 (Group I) and 2.8/100 (Group II), Patient-Related Wrist Evaluation was 11.8/100 (Group I) and 5.97/100 (Group II), grip strength was 81.06% (Group I) and 72.13% (Group II), flexion was 88.13% (Group I) and 75% (Group II), extension was 86% (Group I) and 64.6% (Group II), ulnar inclination was 89% (Group I) and 78.67% (Group II), radial inclination was 89.73% (Group I) and 79.93% (Group II), pronation was 96.67% (Group I) and 81.46% (Group II), and supination was 91.93% (Group I) and 79.87% (Group II). Clinical Relevance The longitudinal technique gave smaller incisions than the transverse technique. Among the secondary hypotheses, all the variables were better with the longitudinal technique, except the pain, although without any significant difference.

Single-center, consecutive series study of the use of a novel platelet-rich fibrin matrix (PRFM) and beta-tricalcium phosphate in posterolateral lumbar fusion.

PURPOSE: To evaluate the radiographic and clinical outcomes of the combination of platelet-rich fibrin matrix (PRFM) with beta-tricalcium phosphate (ß-TCP) and bone marrow aspirate (BMA) as a graft alternative in posterolateral lumbar fusion procedures. METHODS: Researchers evaluated 50 consecutive patients undergoing one-level to three-level posterolateral lumbar fusion procedures, resulting in a total of 66 operated levels. The primary outcome was evidence of radiographic fusion at 1-year follow-up, assessed by three independent evaluators using the Lenke scoring system. Secondary outcomes included back and leg VAS scores, incidence of reoperations and complications, return-to-work status, and opioid use. RESULTS: At 1-year follow-up, radiographic fusion was observed in 92.4% (61/66) of operated levels. There was significant improvement in VAS scores for both back and leg pain (p < 0.05). Compared to baseline figures, the number of patients using opioid analgesics at 12-months decreased by 38%. The majority (31/50) of patients were retired, yet 68% of employed patients (n = 19) were able to return to work. No surgical site infections were noted, and no revision surgery at the operated level was required. CONCLUSIONS: This is the first report to analyze the combination of PRFM with ß-TCP and BMA for PLF procedures. Our results indicate a rate of fusion similar to those reported using iliac crest bone graft (ICBG), while avoiding donor site morbidity related to ICBG harvesting such as hematoma, pain, and infection. These slides can be retrieved under Electronic Supplementary Material.

Teaching of distal radius shortening osteotomy: three-dimensional procedural simulator versus bone procedural simulator.

In order to facilitate the learning of distal radius shortening osteotomy by junior surgeons, the main assumption was that using a three-dimensional procedural simulator was better than a bone procedural simulator. After viewing a video, ten junior surgeons performed a distal radius shortening osteotomy: five with a bone procedural simulator (Group 1) and five with a three-dimensional procedural simulator (Group 2). All subsequently performed the same surgery on fresh cadaveric bones. The duration of the procedure, shortening of the radius, and the level of osteotomy were significantly better in Group 2. The three-dimensional procedural simulator seems to teach distal radius osteotomy better than a bone model and could be useful in teaching and learning bone surgery of the wrist.

Regional Variations in Shear Strength and Density of the Human Thoracic Vertebral Endplate and Trabecular Bone.

BACKGROUND: Previous studies investigated the overall mechanical strength of the vertebral body; however, limited information is available on the biomechanical properties of different regions within the vertebral endplate and cancellous bone. In addition, the correlation between mechanical strength and various density measurements has not been studied yet. METHODS: Thoracic (T10) vertebrae were harvested from fifteen human cadaveric spines (average age: 77 years old). Twelve cylindrical cores of 7.2 mm (diameter) by 3.2 mm (height) were prepared from each vertebral body. Shear was produced using a stainless steel tubular blade and measured with a load cell from a mechanical testing machine. Optical and bulk densities were calculated before mechanical testing. Apparent, material, and ash densities were measured after testing. RESULTS: Material density and shear strength increased from anterior to lateral regions of both endplate and cancellous bone. Endplate shear strength was significantly lower in the anterior (0.52 ± 0.08 MPa) than in the lateral region (2.72 ± 0.59 MPa) (p=0.017). Trabecular bone maximum load carrying capacity was 5 times higher in the lateral (12 ± 2.74 N) (p=0.09) and 4.5 times higher in the central (10 ± 2.24 N) (p=0.2) than in the anterior (2 ± 0.60 N) regions. Mechanical strength positively correlated with ash density, and even moreso with material density. CONCLUSION: Shear strength was the lowest at the anterior region and highest at the lateral region for both endplate and cancellous bone. Material density had the best correlation with mechanical strength. Newer spinal implants could optimize the loading in the lateral aspects of both endplate and cancellous bone to reduce the likelihood of screw loosening and the subsidence of disc replacement devices. This study was reviewed by the SUNY Downstate Medical Center IRB Committee; IRB#: 533603-2.

Paper #9: Nano-Dose Protocol for 3D Reconstruction of the Spine in Early Onset Scoliosis: Preliminary Results of a Phantom Based and Clinically Validated Study using Stereo-Radiography.

This is a prospective study validating the reproducibility of 3D reconstruction of the spine using a new reduced micro-dose protocol. A pilot group of children with scoliosis underwent micro-dose- and additional reduced micro-dose (nano-dose) full-spine imaging. 3D reconstructions of both protocols were evaluated.

Optimizing surface characteristics for cell adhesion and proliferation on titanium plasma spray coatings on polyetheretherketone.

BACKGROUND: Titanium plasma spray coating on polyetheretherketone (PEEK) is a recent innovation to interbody spacer technology. The inherent hydrophobic properties of standard, uncoated PEEK implants can hamper cell attachment and bone healing during fusion. The addition of titanium coating not only offers initial stability due to increased surface roughness but also long-term stability due to bony ongrowth created from osteoconductive microenvironment on the device surface. The previously established hydrophilic and osteophilic properties of commercially pure titanium (CPTi) can potentially provide an ideal environment promoting cell attachment and bony ongrowth when applied at the end plate level of the fusion site. Because the surface material composition and topography is what seems to directly affect cell adhesion, it is important to determine the ideal titanium coating for the highest effectiveness. PURPOSE: The purpose of the study is to determine whether there is an optimal surface roughness for the titanium coatings and whether different polishing methods have a greater effect than roughness or topography in mediating cell adhesion to the surface. STUDY DESIGN/SETTING: The study was divided into two phases. In Phase 1, the effects of varying surface roughnesses on identical polishing method were compared. In Phase 2, the effect of varying polishing methods was compared on identical surface roughnesses. METHODS: Coating thickness, porosity, and surface roughness were characterized using an optical microscope as per ASTM F 1854 standards. For both phases, PEEK coupons with plasma-sprayed CPTi were used, and human mesenchymal stem cells (hMSCs) at an initial density of 25,000 cells/cm2 were seeded and cultured for 24 hours before fixation in 10% formalin. The cultured hMSCs were visualized by 4',6-diamidino-2-phenylindole (DAPI) staining, a fluorescent stain that binds to the DNA of living cells. Samples were imaged using an environmental scanning electron microscope (eSEM) (Carl Zeiss Microscopy, Thornwood, NY, USA) using a backscattered detector. RESULTS: Image analysis of the CPTi coatings showed uniform and rough surfaces. For Phase 1, roughness was evaluated as fine, medium, and coarse. The eSEM image analysis and cell counting by DAPI demonstrated that hMSCs have a tendency to form stronger adhesion and greater pseudopodia extensions on fine roughness surfaces. Individual hMSCs were seen forming cytoplasmic processes extending across the width of a pore. There was a 4- and 20-fold reduction in adhered hMSCs with an increase to medium and coarse roughnesses, respectively. For Phase 2, studied groups are (1) medium CPTi coating with zirconia polishing, (2) medium CPTi coating with CPTi polishing, and (3) fine CPTi coating with CPTi polishing. The eSEM image analysis and cell counting by DAPI demonstrated that hMSCs have a tendency to form stronger adhesion and greater pseudopodia extensions on Group 3 over the other two groups. There was a twofold reduction in adhered hMSCs on medium roughness relative to fine. No difference in cell adhesion was found between Groups 1 and 2. Individual hMSCs were seen forming cytoplasmic processes extending across the width of a pore. CONCLUSIONS: Previously, it was accepted without much scrutiny that surface coatings were beneficial. This study begins to discover that surface topography directly affects the potential for cells to adhere and proliferate and lead to greater surgical efficacy.

Current Concepts in Sports-Related Concussion.

Traumatic brain injury, specifically concussion, is prevalent in contact sports. In the United States (US) each year, 170 million adults participate in physical recreational activities, and 38 million children and adolescents participate in organized sports. The Centers for Disease Control estimate that in this group ~1.6 to 3.8 million concussions occur annually. Recent class-action lawsuits in the US filed by professional athletes against their respective leagues allege negligence in protecting them from concussions, and this has contributed to the attention received in the popular media. In response, concussion-related publications have increased exponentially during the past several years. Recent studies have challenged earlier assumptions that the effects of concussion are transient. Stronger links between concussion and neurodegenerative processes such as Alzheimer's disease-like conditions, depression, and heightened risk for suicide are being elucidated. In this article, we explore the current knowledge on concussion, including pathophysiology, management, and long-term effects. We conclude that more evidence-based results regarding guidelines for diagnosis, treatment, and return to play (RTP) are needed and should be the focus of future investigations. Attributing the etiology of certain neurodegenerative conditions to a history of concussion has been suggested in the current literature, but additional quantitative data regarding the pathophysiology and causality are needed as well. Bioengineers can have an important role in measuring the dynamic forces encountered during head impacts and their effects on the brain. These results can be effective in designing better helmets as well as improved playing surfaces to reduce the impact of such injuries. At this time, we believe that groups of people with heightened risk for concussion should be followed closely during longer periods of time and compared to matched controls. Such long-term studies are urgently needed to develop appropriate guidelines for safety and protect our young and adult athletes in the future.