43 results on '"Peter J. Apel"'
Search Results
2. Patients Who Undergo Rotator Cuff Repair Can Safely Return to Driving at 2 Weeks Postoperatively
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Ariel E. Badger, Linsen T. Samuel, Allison N. Tegge, Mariette Metrey, Miguel A. Perez, John R. Tuttle, and Peter J. Apel
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Arthroscopy ,Rotator Cuff ,Treatment Outcome ,Humans ,Orthopedics and Sports Medicine ,Surgery ,General Medicine ,Middle Aged ,Arthroplasty ,Retrospective Studies ,Rotator Cuff Injuries - Abstract
Evidence-based guidelines are lacking for return to driving following rotator cuff repair (RCR). As a result, surgeons are often overly conservative in their recommendations, placing potential undue burden on patients and their families. Therefore, the primary objective of this study was to formulate evidence-based return-to-driving guidelines.Thirty-two subjects planning to undergo primary RCR were enrolled. Driving fitness was assessed in a naturalistic setting with an instrumented vehicle on public streets with a safety monitor onboard. Driving kinematic measures and behavioral data were obtained from vehicle data and camera capture. Several driving tasks and maneuvers were evaluated, including parking, left and right turns, straightaways, yielding, highway merges, and U-turns. The total course length was 15 miles (24 km) and the course took 45 to 55 minutes to complete. The subjects' baseline drive was performed prior to RCR and postoperative drives occurred at 2, 4, 6, and 12 weeks after RCR. All drives consisted of identical routes, tasks, and maneuvers. Driving metrics were analyzed for differences between baseline and postoperative drives, including differences in gravitational force equivalents (g).Twenty-seven subjects (mean age, 58.6 years [range, 43 to 68 years]) completed all 5 drives. Of the 13 analyzed kinematic metrics measured from 14 of 17 driving events, all exhibited noninferiority across all postoperative drives (2 to 12 weeks) after RCR compared with baseline. Beginning at postoperative week 2, subjects generally braked less aggressively, steered more smoothly, and drove more stably. Kinematic metrics during the performance of specific maneuver types also showed noninferiority when compared with baseline. Of note, subjects drove more smoothly on highway merges starting at postoperative week 2 (minimum longitudinal acceleration, -0.35 g [95% confidence interval (CI), -0.050 to -0.019 g]; standard deviation of longitudinal acceleration, 0.008 g [95% CI, 0.003 to 0.013 g]), but exhibited more aggressive driving and acceleration on highway merges at postoperative week 12 (maximum absolute yaw, -0.8°/sec [95% CI, -1.2°/sec to -0.4°/sec]).Patients showed no clinically important negative impact on driving fitness as early as 2 weeks after RCR. Adaptive behaviors were present both preoperatively and postoperatively.Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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- 2023
3. Immobilization and Hand Therapy After Carpometacarpal Arthroplasty: A Systematic Review
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Patrick C. Barrett, Darren T. Hackley, Linsen T. Samuel, and Peter J. Apel
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Carpometacarpal joint ,Rehabilitation ,CMC arthroplasty ,Systematic review ,Surgery ,Orthopedics and Sports Medicine ,Immobilization timeframe ,Hand therapy - Abstract
Purpose: We provide a systematic review of the current literature regarding best practices in postoperative care following carpometacarpal arthroplasty, and compare these findings to current practices via reported survey data. Methods: The PubMed, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Science Direct, and Google Scholar databases were searched for relevant studies. English-language articles were included that assessed any aspect of postoperative care, including the immobilization time or rehabilitation strategy. In addition, studies were included that surveyed surgeons and hand therapists on current practices regarding this topic. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. Results: The initial search yielded 3,899 hits. Two systematic reviews were found, along with 5 studies that specifically tested the desired variables of the immobilization duration and type following carpometacarpal arthroplasty. Three relevant surveys were also found. Using the Oxford Centre for Evidence-Based Medicine Level of Evidence guidelines, we found moderate-quality evidence that (1) there is no additional benefit for extended cast immobilization (>6 weeks); and (2) a semirigid orthosis performs as well as a rigid orthosis. We found a lack of evidence regarding formal therapy versus no therapy, and a lack of evidence comparing therapy regimens. When analyzing the survey data, we found wide variation in practices among surgeons and therapists. Conclusions: Longer immobilization times (>6 weeks) and rigid orthotic devices provide no additional benefit over earlier immobilization and semirigid orthotic devices. There is a lack of evidence for the use of formal hand therapy or any specific rehabilitation protocol. Current practices in these areas vary widely among hand surgeons. Clinical relevance: Practices following carpometacarpal arthroplasty are widely variable, and guidance has previously been lacking. This review compiles the most recent data, as well as identifies gaps in the literature for future studies. Published version
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- 2022
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4. The Utility of Preoperative HbA1c as a Standardized Protocol in Elective Carpal Tunnel Release: A Retrospective Review of Clinical Outcomes
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Anthony E Capito, Patrick S Collins, Albert Yi-Que Truong, Melika Zarei, Peter J Apel, and Alicia Lozano
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Glycated Hemoglobin ,Reoperation ,Surgery Articles ,medicine.medical_specialty ,endocrine system diseases ,Wound dehiscence ,business.industry ,nutritional and metabolic diseases ,Retrospective cohort study ,Odds ratio ,medicine.disease ,Carpal Tunnel Syndrome ,Confidence interval ,Surgery ,Diabetes mellitus ,Carpal tunnel release ,medicine ,Humans ,Surgical Wound Infection ,Orthopedics and Sports Medicine ,Risk factor ,Carpal tunnel syndrome ,business ,Retrospective Studies - Abstract
Background: In an effort to reduce surgical complications, some institutions have implemented universal hemoglobin A1c (HbA1c) screening for all preoperative patients. However, the value of HbA1c screening for predicting clinically meaningful complications after elective carpal tunnel release (CTR) remains unclear. The purpose of this study was to investigate the clinically meaningful predicative value of HbA1c screening on postoperative complications following elective CTR. Methods: A retrospective cohort study of 790 patients who underwent CTR was performed. All patients had an HbA1c screening performed, regardless of whether they underwent the diagnosis for diabetes or not. Primary outcomes were overall complication rate, rates of major complications (readmission or reoperation), and rates of minor complications (surgical site infection and wound dehiscence). Patients were stratified into 3 groups based on HbA1c: HbA1c 8. Results: The overall complication rate for all groups was 4.8%. Rates of major complications were 0.4% for readmission and 0.1% for reoperation. For minor complications, the odds ratio (OR) for the HbA1c 7-8 group was 0.6 (95% confidence interval [CI], 0.14-1.77), and for the HbA1c >8 group, the OR was 1.6 (95% CI, 0.66-3.60). All minor complications resolved with outpatient treatment. There were no statistically significant differences between the groups for any comparisons. Conclusions: Elective CTR has a low complication rate. Routine preoperative screening of HbA1c is of little value in predicting clinically meaningful complications.
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- 2023
5. Including a Vessel Loop in Wound Closure Facilitates Suture Removal Following Open Carpal Tunnel Release
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Mary C. Frazier, L. Beren H. Tomooka, Nicholas Foeger, Hugh J. Hagan, and Peter J. Apel
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Orthopedics and Sports Medicine ,Surgery - Abstract
Background: Many hand surgeons prefer to close palmar wounds with non-absorbable mattress sutures. Suture removal can be painful and time-consuming. In this study, we investigated if suture removal can be facilitated by including a vessel loop in wound closure following open carpal tunnel release (CTR). Methods: Overall, 47 patients aged 18 to 75 undergoing elective primary open unilateral CTR completed this unblinded, prospective randomized controlled superiority trial. Subjects were randomized into 1 of 2 study arms: (1) wound closure without a vessel loop (standard, n = 28); or (2) wound closure with a vessel loop (vessel loop, n = 19). Data were collected on time for wound closure and for suture removal. A visual analog scale (VAS) was used to assess satisfaction and pain with suture removal. Results: There were no significant differences between the 2 groups in patient demographics or time for suture placement. Visual analog scale satisfaction with suture removal was significantly lower in the standard group (8.6 ± 2.6) compared to vessel loop group (9.9 ± 0.28, P < .05). VAS pain with suture removal was significantly higher in the standard group (2.6 ± 2.7) versus vessel loop group (0.68 ± 1.1, P < .01). Additionally, suture removal time was significantly longer in standard group (84 seconds ± 83) versus vessel loop group (31 seconds ± 13, P < .0001). Conclusions: Addition of a vessel loop in wound closure for primary open CTR increases patient satisfaction and reduces pain with and time taken for suture removal.
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- 2022
6. Modeled Wide-Awake, Local-Anesthetic, No-Tourniquet Surgical Procedures Do Not Impair Driving Fitness
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Miguel A. Perez, Allison N. Tegge, Ariel E Badger, Noah J. Orfield, Peter J Apel, and Maryam Davoodi
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Adult ,Male ,Automobile Driving ,medicine.medical_specialty ,Time Factors ,Lidocaine ,medicine.drug_class ,Kinematics ,Physical medicine and rehabilitation ,Kilometer ,medicine ,Humans ,Orthopedics and Sports Medicine ,Anesthetics, Local ,Parallel parking ,Tourniquet ,business.industry ,Local anesthetic ,General Medicine ,Evidence-based medicine ,Middle Aged ,Tourniquets ,Surgical procedures ,Carpal Tunnel Syndrome ,Female ,Surgery ,business ,Anesthesia, Local ,medicine.drug - Abstract
Background The use of wide-awake, local-anesthetic, no-tourniquet (WALANT) surgical techniques is increasingly common, and patients commonly ask whether they may drive home following these procedures. The impact of a numb hand and bulky dressing on driving fitness is unknown, and there is no literature to guide surgeons when counseling these patients. Thus, the primary objective of the present study was to determine driving fitness following a modeled-WALANT procedure. Methods Twelve right-handed individuals (6 male and 6 female) with an average age of 50 years (range, 38 to 64 years) were enrolled. An instrumented vehicle was used to obtain driving kinematic and behavioral data, thus allowing for a multidimensional assessment of driving fitness. Participants first performed a drive to establish baseline kinematic metrics. The route included both public streets and a closed course. Several driving tasks were assessed, including reverse parking, parallel parking, and perpendicular parking. The total course length was 18 miles (29 kilometers) and took 45 to 55 minutes to complete. After the first drive, 10 mL of 1% lidocaine was injected in the volar aspect of the right wrist and another 10 mL was injected into the right carpal tunnel to model the anesthetic used for a WALANT carpal tunnel release, and a bulky soft dressing was applied. The modeled-WALANT drive included an identical route and tasks, in addition to a surprise event to evaluate emergency responsiveness. Driving metrics were analyzed for noninferiority of the modeled-WALANT state to baseline driving. Results The modeled-WALANT state showed noninferiority to baseline driving on all 11 analyzed dimensions of driving behavior compared with the control drives. In the modeled-WALANT state, participants drove more conservatively, braked harder, and steered more smoothly. All participants safely performed the 3 parking tasks and emergency response maneuver. Driving fitness in the modeled-WALANT state was noninferior to driving fitness in the preoperative drive. Conclusions A modeled-WALANT state has no clinically relevant negative impact on driving fitness, and thus surgeons should not discourage patients from driving home after unilateral WALANT surgical hand procedures. Level of evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
- Published
- 2020
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7. An ultrashort video can teach residents to perform a fingertip injury repair
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Hugh J. Hagan, Noah J. Orfield, Damon R. Kuehl, Linsen T. Samuel, Peter J Apel, and Yazan Y. Alshawkani
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medicine.medical_specialty ,Physical medicine and rehabilitation ,Emergency Medicine ,medicine ,Original Contribution ,Emergency Nursing ,Injury repair ,Education - Abstract
BACKGROUND: Acute fingertip injuries are common. Providers in rural and underserved areas often transfer these patients due to lack of comfort and skill with treating these injuries. Current learners prefer short and high‐density educational material. It is unknown if basic hand procedures can be taught using ultrashort training videos. This study investigates whether fingertip repair can be taught using a 60‐second educational video viewed immediately prior to performing the procedure. METHODS: A standardized cadaveric fingertip injury model was developed. Twenty‐three emergency medicine residents each having minimal experience with fingertip injury repair were randomized into one of three study arms: A) no video, B) standard‐length (8‐minute) video, and C) ultrashort (60‐second) video. Each subject was presented with an injured cadaveric finger and asked to prepare for and perform the repair within a 30‐minute time frame. The repair was graded on a 10‐point scale following a standard rubric. Time to completion, preparedness, and subjects’ confidence were also assessed. Results were analyzed by one‐way ANOVA and Kruskal‐Wallis tests. RESULTS: Mean repair scores for the standard‐length video group (9.5 ± 0.3) and the ultrashort video group (9.2 ± 0.3) were significantly higher than those of the no video group (4.0 ± 0.3, p
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- 2022
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8. Fortuitous Eradication of an Aggressive Basal Cell Carcinoma Via Foreign Body Reaction to a Polyurethane Vacuum-Assisted Closure Sponge
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Peter J Apel, Hailey L. Gosnell, Alyssa N Wenzel, and Douglas J. Grider
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Male ,Surgical Sponges ,medicine.medical_specialty ,Neoplasm, Residual ,Skin Neoplasms ,medicine.medical_treatment ,Polyurethanes ,Dermatology ,Pathology and Forensic Medicine ,Resection ,Immune system ,Medicine ,Humans ,Basal cell carcinoma ,business.industry ,Vacuum assisted closure ,Foreign-Body Reaction ,Margins of Excision ,Surgical wound ,General Medicine ,Immunotherapy ,Middle Aged ,medicine.disease ,Surgery ,Carcinoma, Basal Cell ,Foreign body ,Positive Surgical Margin ,business ,Negative-Pressure Wound Therapy - Abstract
The foreign body reaction (FBR) is a well-documented immune reaction. Much of the literature on FBRs has focused on minimizing this immune response to mitigate the impact on medical implants. Here, we present a case that illustrates a serendipitous oncologic outcome from an FBR. A 54-year-old man presented with an aggressive basal cell carcinoma (BCC). At the first resection, he had broadly positive surgical margins. The surgical wound was temporized with a polyurethane wound vacuum assisted closure (VAC) device. He was lost to follow-up having retained a VAC sponge for a total of 12 weeks. A wide re-resection was performed 7 months after the initial resection. Exhaustive examination of the resected specimen was performed. There was an absence of any BCC, replaced by a widespread chronic FBR to polyurethane VAC sponge particles. This suggests that the foreign body immune response was sufficiently intense to eradicate any remaining BCC. This case illustrates the concept of an FBR as a novel method of local immunotherapy.
- Published
- 2021
9. Identification of Microsurgical Suture Needles in the Hand Using Plain Radiographs
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Francis, Bustos, Nathan S, Lanham, Noah J, Orfield, Peter J, Apel, and Cay M, Mierisch
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Radiography ,Orthopedics ,Sutures ,Needles ,Suture Techniques ,Humans - Abstract
Our objective is to determine if radiographs are adequate for identification of retained microsurgical needles. Four microsurgical needles ranging from 3.8 mm to 6.5 mm in length and 50 μ to 130 μ in diameter were affixed to an anthropomorphic phantom limb. Portable radiograph images were then obtained and viewed by a group of 20 subjects comprised of attending radiologists, attending orthopaedic surgeons, orthopaedic surgery residents and operating room nurses. For all subjects, 3.35 out of 4 needles were identified in a mean 4.7 minutes. Radiologists identified all four needles and needed the least amount of time (mean 2.3 minutes). Orthopaedic surgery attendings identified a mean 3.5 of 4 needles while orthopaedic surgery residents and operating room nurses identified a mean 3 of 4 needles. Identification of microsurgical needles is possible using digital radiographs but requires 2-5 minutes of searching the image and adjusting the windows. (Journal of Surgical Orthopaedic Advances 29(4):230-233, 2020).
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- 2021
10. Neonatal Forearm Compartment Syndrome Secondary to Intrauterine Brachiocephalic Arterial Thrombosis
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Noah J. Orfield, Peter J Apel, Cesar J. Bravo, and Keriann M. Schulkers
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medicine.medical_specialty ,Physical examination ,Compartment Syndromes ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,medicine.artery ,Brachiocephalic artery ,Humans ,Medicine ,Orthopedics and Sports Medicine ,Surgical treatment ,Muscle contracture ,Hemiplegic cerebral palsy ,030222 orthopedics ,medicine.diagnostic_test ,business.industry ,Infant, Newborn ,Forearm Injuries ,Thrombosis ,medicine.disease ,Fasciotomy ,Surgery ,Forearm ,Forearm compartment syndrome ,Ultrasonography ,business - Abstract
CASE A newborn presented with necrotic skin lesions and contractures of the right upper extremity. Ultrasonography indicated the presence of a brachiocephalic artery thrombosis, and clinical examination demonstrated a neonatal forearm compartment syndrome. Surgical treatment included decompressive fasciotomy of the right forearm. The right-sided brachiocephalic thrombosis resulted in left hemiplegic cerebral palsy. At the 3-year follow-up, the patient had near-normal function of the right upper extremity. This case has detailed preoperative video and follow-up to illustrate this rare but modifiable condition. CONCLUSION This case demonstrates a unique cause of neonatal forearm compartment syndrome (brachiocephalic arterial thrombosis) and the results of prompt surgical treatment.
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- 2021
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11. On the Road Again: Return to Driving Following Minor Hand Surgery
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Mary C. Frazier, Darren T. Hackley, Tonja M. Locklear, Ariel E. Badger, and Peter J. Apel
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Orthopedics and Sports Medicine ,Surgery - Abstract
Background: Patient return-to-driving following minor hand surgery is unknown. Through daily text message surveys, we sought to determine return-to-driving after minor hand surgery and the factors that influence return-to-driving. Methods: One hundred five subjects undergoing minor hand surgery received daily text messaging surveys postoperatively to assess: (1) if they drove the day before and if so; (2) whether they wore a cast, sling, or splint. Additional patient-, procedure-, and driving-related data were collected. Results: More than half of subjects, 54 out of 105, returned to driving by the end of postoperative day #1. While patient-related factors had no effect on return-to-driving, significant differences were seen in anesthesia type, procedure laterality, driving assistance, and distance. Return-to-driving was significantly later for subjects who had general anesthetic compared to wide awake local anesthetic with no tourniquet (4 ± 4 days vs 1 ± 3 days, P = 0.020), as well as for bilateral procedures versus unilateral procedures (5 ± 5 days vs 1 ± 3 days, P = 0.046). Lack of another driver and driving on highways led to earlier return-to-driving ( P = 0.040 and, P = 0.005, respectively). Conclusions: Most patients rapidly return to driving after minor hand surgery. Use of general anesthetic and bilateral procedures may delay return-to-driving. Confidential real-time text-based surveys can provide valuable information on postoperative return-to-driving and other patient behaviors.
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- 2022
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12. Donor-Site Outcomes for the Osteocutaneous Radial Forearm Free Flap
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Adam C. Satteson, Benjamin R. Graves, Ellen S. Satteson, Joshua D. Waltonen, Ethan R. Wiesler, Zhongyu Li, and Peter J. Apel
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Adult ,Male ,medicine.medical_specialty ,Mandible ,030230 surgery ,Free Tissue Flaps ,Transplant Donor Site ,03 medical and health sciences ,0302 clinical medicine ,Bone plate ,medicine ,Humans ,Head and neck ,Aged ,Retrospective Studies ,Aged, 80 and over ,Fracture Healing ,Bone Transplantation ,business.industry ,Graft Survival ,Soft tissue ,Retrospective cohort study ,Middle Aged ,Plastic Surgery Procedures ,Surgery ,Tendon ,Forearm ,Mandibular Neoplasms ,Treatment Outcome ,medicine.anatomical_structure ,Otorhinolaryngology ,Radial forearm free flap ,Fibula ,030220 oncology & carcinogenesis ,Tissue and Organ Harvesting ,Female ,Maxillofacial Injuries ,Complication ,business ,Bone Plates - Abstract
Background This study sought to characterize the donor-site complications associated with the osteocutaneous radial forearm free flap (ORFFF) used for mandibular reconstruction, as well as to compare donor-site complications between the ORFFF and fasciocutaneous radial forearm free flap (FRFFF). Methods An Institution Review Board approved, retrospective review identified all ORFFF and FRFFF performed for head and neck reconstruction with a single otolaryngology surgeon at an academic medical center over a 3-year period. Patients requiring an ORFFF underwent harvest of half of the diaphyseal diameter of the radius with prophylactic plating performed by hand surgeons. Donor-site outcomes including infection, skin graft loss, tendon exposure, neuropathy, radius fracture, hardware complications, and need for additional donor-site surgery were compared. Results In this study, 25 patients underwent ORFFF harvest, and 52 underwent FRFFF harvest. There was one radius fracture occurring in association with a hardware infection requiring reoperation. No fractures or other major donor-site complications were seen in the FRFFF group. Similar rates of minor complications were noted with skin graft take less than 50% in 4% (n = 1) and 8% (n = 4) with ORFFF and FRFFF, respectively, and tendon exposure in 8% (n = 2) and 15% (n = 8) with ORFFF and FRFFF, respectively. No soft tissue infections or sensory neuropathies were seen. Mean follow-up was 14.2 months for the ORFFF group and 11.7 months for the FRFFF group. Conclusion The risk of fracture following ORFFF harvest with prophylactic plating is small. Other donor-site complication rates were similar with both flap techniques.
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- 2017
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13. New Long-Term Opioid Prescription-Filling Behavior Arising in the 15 Months After Orthopaedic Surgery
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Andrew Gaddis, Peter J Apel, Cassandra Mierisch, David W Hartman, Noah J. Orfield, and Kyle B Russell
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Male ,medicine.medical_specialty ,Time Factors ,Anterior cruciate ligament ,MEDLINE ,Drug Prescriptions ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,Orthopedics and Sports Medicine ,Orthopedic Procedures ,030212 general & internal medicine ,Medical prescription ,Practice Patterns, Physicians' ,030222 orthopedics ,Pain, Postoperative ,business.industry ,General surgery ,General Medicine ,Evidence-based medicine ,Middle Aged ,Confidence interval ,Analgesics, Opioid ,medicine.anatomical_structure ,Opioid ,Orthopedic surgery ,Surgery ,Female ,business ,medicine.drug - Abstract
BACKGROUND The opioid crisis is a well-known public health issue. The risk of new long-term opioid prescription-filling behavior has been investigated after certain spinal procedures and total knee and hip arthroplasty. However, this has not been examined after many other common orthopaedic procedures. The purpose of this study was to determine the rates of long-term opioid prescription-filling behavior after common orthopaedic surgical procedures in patients who were not taking opioids preoperatively. METHODS This study utilized the Virginia All-Payer Claims Database (APCD), an insurance claims database with data from 3.7 to 4 million patients per year. Patients who underwent orthopaedic procedures and who had not filled an opioid prescription in the time period from 2 weeks to 1 year preceding the surgical procedure were selected for evaluation in our study. The percentage of these patients who then filled at least 10 prescriptions or a 120-day supply of opioids in the time period from 90 to 455 days following the surgical procedure was calculated for the 50 most commonly billed orthopaedic surgical procedures. RESULTS The rate of long-term opioid prescription-filling behavior in patients who were not taking opioids preoperatively for the 50 most common orthopaedic procedures was 5.3% (95% confidence interval, 5.1% to 5.5%). The highest rates were observed after spinal procedures. The lowest rates were seen after anterior cruciate ligament (ACL) reconstruction. Revision surgical procedures were found to have a significantly higher rate than primary procedures (p < 0.05). The rate was also related to increasing case complexity. CONCLUSIONS New long-term opioid prescription-filling behavior is common after orthopaedic surgical procedures in patients who were not taking opioids preoperatively. Risk factors include spine surgery, revision surgery, and cases with increased complexity. Orthopaedic surgeons need to be aware of this risk. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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- 2019
14. Effect of Prescription Size on Opioid Use and Patient Satisfaction After Minor Hand Surgery: A Randomized Clinical Trial
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Thomas Metzger, Peter J Apel, Andrew Gaddis, Cesar J. Bravo, Hugh J Hagan, Ehsan Dowlati, Cassandra Mierisch, Horatiu C. Dancea, and Cay M Mierisch
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Adult ,Male ,medicine.medical_specialty ,Drug Prescriptions ,law.invention ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Patient satisfaction ,Randomized controlled trial ,law ,Internal medicine ,medicine ,Humans ,Orthopedic Procedures ,Prospective Studies ,Medical prescription ,Practice Patterns, Physicians' ,Prospective cohort study ,Aged ,Pain, Postoperative ,business.industry ,Retrospective cohort study ,Hand surgery ,Middle Aged ,Hand ,Acetaminophen ,Analgesics, Opioid ,Opioid ,Patient Satisfaction ,030220 oncology & carcinogenesis ,030211 gastroenterology & hepatology ,Surgery ,Female ,business ,medicine.drug - Abstract
OBJECTIVE To determine the influence of initial prescription size on opioid consumption after minor hand surgeries. Secondary outcomes include efficacy of pain control, patient satisfaction, and refill requests. BACKGROUND Retrospective studies have shown that opioid prescriptions for acute pain after surgical procedures are often excessive in size, which encourages misuse. This is the first prospective randomized trial on the influence of initial prescription size on opioid consumption in the setting of acute postsurgical pain. METHODS In a prospective randomized trial at a single-academic institution, patients were provided an initial prescription of either 10 or 30 hydrocodone/acetaminophen (5/325 mg) pills after surgery. Two hundred opioid-naive patients, aged 19 to 69, undergoing elective outpatient minor hand surgeries were enrolled over 9 months, with a follow-up period of 10 to 14 days. RESULTS One hundred seventy-four patients were included in this analysis. Patients initially prescribed 30 pills (n = 79), when compared with patients initially prescribed 10 pills (n = 95), used significantly more opioid (P =
- Published
- 2019
15. Effects of age and insulin-like growth factor-1 on rat neurotrophin receptor expression after nerve injury
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Jiaozhong Cai, T. David Luo, Zhongyu Li, Timothy B. Alton, Peter J. Apel, William E. Sonntag, Thomas L. Smith, and Jonathan C. Barnwell
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0301 basic medicine ,medicine.medical_specialty ,Physiology ,Receptor expression ,medicine.medical_treatment ,03 medical and health sciences ,Cellular and Molecular Neuroscience ,Insulin-like growth factor ,0302 clinical medicine ,Physiology (medical) ,Internal medicine ,medicine ,Receptor ,Tibial nerve ,biology ,Nerve injury ,030104 developmental biology ,Endocrinology ,Nerve growth factor ,nervous system ,Peripheral nerve injury ,biology.protein ,Neurology (clinical) ,medicine.symptom ,030217 neurology & neurosurgery ,Neurotrophin - Abstract
INTRODUCTION Neurotrophin receptors, such as p75(NTR) , direct neuronal response to injury. Insulin-like growth factor-1 receptor (IGF-1R) mediates the increase in p75(NTR) during aging. The aim of this study was to examine the effect of aging and insulin-like growth factor-1 (IGF-1) treatment on recovery after peripheral nerve injury. METHODS Young and aged rats underwent tibial nerve transection with either local saline or IGF-1 treatment. Neurotrophin receptor mRNA and protein expression were quantified. RESULTS Aged rats expressed elevated baseline IGF-1R (34% higher, P = 0.01) and p75(NTR) (68% higher, P
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- 2016
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16. Evaluation and Treatment of Childhood Musculoskeletal Injury in the Office
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Peter J. Apel and Andrew W. Howard
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medicine.medical_specialty ,Braces ,Referral ,business.industry ,Primary care ,medicine.disease ,Radiography ,Casts, Surgical ,Fractures, Bone ,Full recovery ,Pediatrics, Perinatology and Child Health ,Ambulatory Care ,Musculoskeletal injury ,medicine ,Physical therapy ,Humans ,Treatment strategy ,Child ,business ,Musculoskeletal System ,Physical Examination - Abstract
Evaluation and treatment of acute musculoskeletal injuries can be rewarding for primary care providers. They are common presenting complaints, and with appropriate management, many patients make a full recovery in a short period of time. This article reviews basic principles of evaluation of acutely injured children, treatment strategies, and common injuries, and gives an overview of similar but more dangerous conditions that require referral.
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- 2014
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17. Smaller Opioid Prescriptions Reduce Opioid Use Without Decreasing Patient Satisfaction
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Cay M. Mierisch, Cassandra Mierisch, César J. Bravo, Andrew Gaddis, Peter J. Apel, and Horatiu C. Dancea
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021110 strategic, defence & security studies ,medicine.medical_specialty ,business.industry ,Opioid use ,0211 other engineering and technologies ,02 engineering and technology ,03 medical and health sciences ,0302 clinical medicine ,Patient satisfaction ,Opioid ,Emergency medicine ,Medicine ,Orthopedics and Sports Medicine ,Surgery ,Medical prescription ,030223 otorhinolaryngology ,business ,medicine.drug - Published
- 2018
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18. Glomus tumor and the contribution of nerve ultrasound, an additional case
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Francis O, Walker, L Andrew, Koman, and Peter J, Apel
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Humans ,Soft Tissue Neoplasms ,Glomus Tumor ,Ultrasonography - Published
- 2016
19. Effect of Intra-articular Pressurization Associated With Arthroscopy on the Immature Physis: Investigation in an Animal Model
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Cathy S. Carlson, Peter J. Apel, Erik J. Olson, G. Ryan Rieser, Thomas L. Smith, Josh B. Parker, Jianjun Ma, Jeffrey S. Shilt, D. Nicole Deal, and Vincent Novak
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Cartilage, Articular ,musculoskeletal diseases ,medicine.medical_specialty ,Knee Joint ,Epiphyseal plate ,Arthroscopy ,Pressure ,medicine ,Animals ,Orthopedics and Sports Medicine ,Femur ,Growth Plate ,Tibia ,Range of Motion, Articular ,Physis ,medicine.diagnostic_test ,business.industry ,General Medicine ,Surgery ,medicine.anatomical_structure ,Pediatrics, Perinatology and Child Health ,Orthopedic surgery ,Rabbits ,Range of motion ,business - Abstract
Background: Despite the increased use of arthroscopy in pediatric orthopaedics, there is a paucity of data regarding the potential long-term effects of this procedure on the immature physis. The purpose of this study was to test the hypothesis that elevated intra-articular pressures used during arthroscopic surgery do not result in growth disturbances or morphologic alterations in the epiphyseal plate. Methods: Twenty-seven 6-week-old skeletally immature New Zealand white rabbits were divided into experimental (n = 21) and control groups (n = 6). In the experimental group, a hydraulic pump was used to pressurize 1 randomly assigned knee joint per rabbit to intra-articular pressures of 120mm Hg for 2 hours. In the control group, rabbits received a sham intervention. All rabbits were killed at 6 months of age (skeletal maturity), and their tissues were evaluated grossly, radiographically, and histologically. Data collection included gross measurements (femur and tibia lengths, evaluation of varus/valgus angulation, and knee joint range of motion) and histologic analyses to determine whether morphologic changes were present in the articular cartilage or physis. Confidence intervals were used to test for statistical equivalence. Results: The pressurized and control groups had statistically equivalent gross measurements. No significant articular cartilage or physeal lesions were identified in histologic sections or radiographic studies. Conclusion: This study provided no evidence that arthroscopic pressurization of the knee joint to 120 mm Hg for 2 hours significantly affected physeal growth in a skeletally immature rabbit model. Clinical Relevance: This study provides the first direct evidence that arthroscopic pressurization of immature joints has no clinically significant adverse long-term effects. Therefore, novel uses of arthroscopy in pediatric patients should be explored without undue concern with regard to premature physeal closure.
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- 2010
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20. Volumetric Injury of the Physis During Single-Bundle Anterior Cruciate Ligament Reconstruction in Children: A 3-Dimensional Study Using Magnetic Resonance Imaging
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Jen Belzer, Kurt J. Nilsson, Peter J. Apel, Nathan L. Grimm, Kevin G. Shea, and Ronald P. Pfeiffer
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Male ,musculoskeletal diseases ,medicine.medical_specialty ,Anterior cruciate ligament reconstruction ,medicine.medical_treatment ,Anterior cruciate ligament ,Knee Injuries ,Arthroscopy ,Imaging, Three-Dimensional ,medicine ,Humans ,Orthopedics and Sports Medicine ,Femur ,Tibia ,Anterior Cruciate Ligament ,Child ,Physis ,medicine.diagnostic_test ,Drill ,business.industry ,Anterior Cruciate Ligament Injuries ,Plastic Surgery Procedures ,Prognosis ,musculoskeletal system ,Magnetic Resonance Imaging ,Surgery ,medicine.anatomical_structure ,Child, Preschool ,Orthopedic surgery ,Female ,business ,Nuclear medicine ,Follow-Up Studies - Abstract
Purpose: To determine the volume of injury to the physis during anterior cruciate ligament (ACL) reconstruction in pediatric patients. Methods: Magnetic resonance imaging scans of 10 pediatric knees were converted into 3-dimensional models. Computer-aided design/computer-aided manufacturing software placed drill holes (6, 7, 8, and 9 mm in diameter) in these models, simulating tunnels used for ACL reconstruction. The software was used to calculate total physeal volume and volume of physis removed by the tunnel. The ratio of physeal volume removed to the total physeal volume was determined. Results: For 6-, 7-, 8-, and 9-mm-diameter drill holes, the mean percent of physeal volume removed/total physeal volume was 1.6%, 2.2%, 2.9%, and 3.8%, respectively, for the tibia and 2.4%, 3.2%, 4.2%, and 5.4%, respectively, for the femur. For all subjects, the volume removed was less than 7.0% for the tibia and 9.0% for the femur by use of drill holes from 6 to 9 mm. The tibial drill hole was centrally placed in all cases compared with a more peripheral drill hole placement of the femur. Conclusions: Drill hole placement during ACL reconstruction produces a zone of physeal injury. The overall volume of injury is relatively low, which reduces the risk of physeal arrest. With careful drill hole placement, the region of injury is central on the tibia, and the total volume of injury can be less than 5.0% of the physeal volume. For the femur, the total volume can be less than 5.0% as well. However, the region of injury is peripheral, which carries a higher risk of physeal arrest. Clinical Relevance: A better understanding of the relation between the ACL and physis may guide the placement of drill holes, which have a lower risk of producing physeal arrest.
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- 2009
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21. Effect of locally delivered IGF-1 on nerve regeneration during aging: An experimental study in rats
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Peter J. Apel, Zhongyu Li, Timothy B. Alton, William E. Sonntag, Jianjun Ma, Casey Northam, and Michael F. Callahan
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medicine.medical_specialty ,Physiology ,Schwann cell ,Nerve injury ,Biology ,Neuromuscular junction ,Surgery ,Cellular and Molecular Neuroscience ,medicine.anatomical_structure ,Endocrinology ,Neurotrophic factors ,Postsynaptic potential ,Physiology (medical) ,Internal medicine ,Peripheral nerve injury ,medicine ,Neurology (clinical) ,Axon ,medicine.symptom ,Tibial nerve - Abstract
Age is an important predictor of neuromuscular recovery after peripheral nerve injury. Insulin-like growth factor 1 (IGF-1) is a potent neurotrophic factor that is known to decline with increasing age. The purpose of this study was to determine if locally delivered IGF-1 would improve nerve regeneration and neuromuscular recovery in aged animals. Young and aged rats underwent nerve transection and repair with either saline or IGF-1 continuously delivered to the site of the nerve repair. After 3 months, nerve regeneration and neuromuscular junction morphology were assessed. In both young and aged animals, IGF-1 significantly improved axon number, diameter, and density. IGF-1 also significantly increased myelination and Schwann cell activity and preserved the morphology of the postsynaptic neuromuscular junction (NMJ). These results show that aged regenerating nerve is sensitive to IGF-1 treatment.
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- 2009
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22. Syndrome de la traversée thoracobrachiale dû à une anomalie vasculaire comprimant le plexus brachial supérieur
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Zhongyu Li, George D. Chloros, Nicholas Crosby, and Peter J. Apel
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Rheumatology - Abstract
Resume Les etiologies vasculaires directement a l’origine d’un syndrome de la traversee thoracobrachiale (STTB) sont exceptionnelles en dehors des vaisseaux sous-claviers. Nous rapportons un cas unique d’une artere anormale, accompagnee de sa veine, comme etant la cause directe d’une compression du plexus brachial superieur entrainant un STTB. Tous les symptomes ont gueri apres un traitement chirurgical ayant comporte une ligature et une resection des vaisseaux anormaux. Cette observation montre que, meme si les etiologies vasculaires du STTB sont tout a fait rares, elles doivent etre envisagees parmi les causes possibles de ce syndrome.
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- 2009
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23. Peripheral Nerve Regeneration Using a Keratin-Based Scaffold: Long-Term Functional and Histological Outcomes in a Mouse Model
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L. Andrew Koman, Jeffrey P. Garrett, Anthony Atala, Paulina Sierpinski, Thomas L. Smith, Peter J. Apel, Mark Van Dyke, and Jianjun Ma
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Neural Conduction ,Action Potentials ,Sural nerve ,Sensory system ,macromolecular substances ,Nerve Fibers, Myelinated ,Mice ,Random Allocation ,Sural Nerve ,Keratin ,Animals ,Medicine ,Orthopedics and Sports Medicine ,Axon ,Tibial nerve ,chemistry.chemical_classification ,Tissue Scaffolds ,Guided Tissue Regeneration ,business.industry ,Hydrogels ,Recovery of Function ,Anatomy ,Axons ,Nerve Regeneration ,Compound muscle action potential ,surgical procedures, operative ,medicine.anatomical_structure ,chemistry ,Models, Animal ,Keratins ,Surgery ,Tibial Nerve ,business ,Sensory nerve - Abstract
Purpose The management of peripheral nerve injuries with segmental defects is a challenge to both patient and surgeon. Repairs under tension have a poor prognosis; sensory nerve allografts have donor site morbidity and suboptimal motor recovery, but remain the gold standard. The development of conduit-based repair strategies has evolved and these are promising for sensory nerves and short defects; however, no conduit filler is clinically available that improves motor recovery equivalent to sensory autografts. In this study, motor recovery using keratin-based hydrogel filler was compared with that for sensory nerve autografts and empty conduits. Methods Fifty-four mice were randomized into 3 treatment groups: empty conduit, sural nerve autograft, and keratin hydrogel-filled conduit. Animals were followed for 6 weeks, 3 months, and 6 months. Outcomes included compound motor action potential (CMAP), nerve area, myelinated axon number and density, and myelinated axon diameter. Results Neuromuscular recovery with keratin was greater than with empty conduits in most outcome measures. Nerves that regenerated through the keratin hydrogel had lower conduction delays, greater amplitudes, more myelinated axons, and larger axons than nerves that regenerated through empty conduits. Sensory nerve autografts and keratin hydrogel were statistically equivalent in CMAP measurements at 6 months. Moreover, keratin-filled conduits demonstrated greater axon density and larger average axon diameter than both empty conduits and autograft at 6 months. Conclusions In a mouse tibial nerve model, keratin hydrogels significantly improved electrophysiological recovery, compared with empty conduits and sensory nerve autografts, at an early time point of regeneration. Keratin hydrogels also produce long-term electrical and histological results superior to empty conduits and equivalent to sensory nerve autografts.
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- 2008
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24. The use of keratin biomaterials derived from human hair for the promotion of rapid regeneration of peripheral nerves
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Jianjun Ma, Jeffrey P. Garrett, Peter J. Apel, L. Andrew Koman, Paulina Sierpinski, Mark Van Dyke, David Klorig, Anthony Atala, and Thomas L. Smith
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Male ,Time Factors ,Materials science ,Biophysics ,Nerve guidance conduit ,Schwann cell ,Biocompatible Materials ,Bioengineering ,Cell Line ,Biomaterials ,Keratin ,medicine ,Animals ,Humans ,Peripheral Nerves ,chemistry.chemical_classification ,Regeneration (biology) ,Biomaterial ,Hydrogels ,Nerve injury ,Nerve Regeneration ,Rats ,Electrophysiology ,medicine.anatomical_structure ,Gene Expression Regulation ,chemistry ,Mechanics of Materials ,Ceramics and Composites ,Keratins ,medicine.symptom ,Epineurial repair ,Porosity ,Hair ,Biomedical engineering ,Lumen (unit) - Abstract
The management of trauma-associated nerve defects is difficult because of the absence of autologous donor motor or sensory nerves. Pre-clinical development and clinical experience has shown that damaged nerves can be surgically repaired using a tubular conduit interposed across the defect. Acceptable patient outcomes are achieved so long as the gap distance does not exceed a few centimeters. Although research in animals has demonstrated that nerve repair can be facilitated across slightly larger gaps by introducing a biomaterial filler into the conduit lumen, these biomaterials are not typically "neuroinductive" (i.e. capable of acting directly on regenerative cells to enhance nerve tissue formation beyond clinical limits). Moreover, their use does not often result in functional recovery equivalent to nerve autograft, the clinical gold standard. Here we show that a biomaterial gel made from the proteins found in human hair can mediate a robust nerve regeneration response, in part through activation of Schwann cells. In vitro, keratins extracted from human hair enhance the activity of Schwann cells by a chemotactic mechanism, increase their attachment and proliferation, and up-regulate expression of important genes. Moreover, these characteristics translate to improved functional nerve recovery in an animal model. These results suggest that a biomaterial derived from human hair keratins is neuroinductive and can facilitate an outcome comparable to autograft in a nerve injury model.
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- 2008
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25. Effects of age and insulin-like growth factor-1 on rat neurotrophin receptor expression after nerve injury
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T David, Luo, Timothy B, Alton, Peter J, Apel, Jiaozhong, Cai, Jonathan C, Barnwell, William E, Sonntag, Thomas L, Smith, and Zhongyu, Li
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Male ,Aging ,Age Factors ,Gene Expression ,Receptors, Nerve Growth Factor ,Rats, Inbred F344 ,Article ,Rats ,Receptor, IGF Type 1 ,nervous system ,Peripheral Nerve Injuries ,Rats, Inbred BN ,Animals ,Insulin-Like Growth Factor I - Abstract
INTRODUCTION: Neurotrophin receptors, such as p75(NTR), direct neuronal response to injury. Insulin-like growth factor-1 receptor (IGF-1R) mediates the increase in p75(NTR) during aging. The aim of this study was to examine the effect of aging and insulin-like growth factor-1 (IGF-1) treatment on recovery after peripheral nerve injury. METHODS: Young and aged rats underwent tibial nerve transection with either local saline or IGF-1 treatment. Neurotrophin receptor mRNA and protein expression were quantified. RESULTS: Aged rats expressed elevated baseline IGF-1R (34% higher, P =0.01) and p75(NTR) (68% higher, P
- Published
- 2015
26. Anterior Cruciate Ligament Injury in Pediatric and Adolescent Soccer Players: An Analysis of Insurance Data
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Ronald P. Pfeiffer, Jo Han Wang, Kevin G. Shea, Mike Curtin, and Peter J. Apel
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Male ,medicine.medical_specialty ,Adolescent ,Anterior cruciate ligament ,Total knee ,Insurance Claim Review ,Sex Factors ,Sex factors ,Soccer ,medicine ,Humans ,Orthopedics and Sports Medicine ,Child ,business.industry ,Anterior Cruciate Ligament Injuries ,Age Factors ,General Medicine ,musculoskeletal system ,medicine.disease ,ACL injury ,Surgery ,surgical procedures, operative ,medicine.anatomical_structure ,Increased risk ,El Niño ,Athletic Injuries ,Pediatrics, Perinatology and Child Health ,Physical therapy ,Female ,business ,Knee injuries ,human activities - Abstract
Injury claims from an insurance company specializing in soccer coverage were reviewed for a 5-year period. A total of 8215 injury claims (3340 females, 4875 males) were divided into three categories: (1) all injury, (2) knee injury, and (3) ACL injury. Knee injuries accounted for 22% of all injuries (30% female, 16% male). ACL injury claims represented 31% of total knee injury claims (37% female, 24% males). The youngest ACL injury was age 5. The ratio of knee injury/all injury increased with age. Compared with males, females demonstrated a higher ratio of knee injury/all injury and a higher ratio of ACL injury/all injury. This study demonstrates that ACL injury occurs in skeletally immature soccer players and that females appear to have an increased risk of ACL injury and knee injury compared with males, even in the skeletally immature. Future research related to ACL injury in females will need to consider skeletally immature patients.
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- 2004
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27. Glomus tumor and the contribution of nerve ultrasound, an additional case
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L. Andrew Koman, Francis O. Walker, and Peter J. Apel
- Subjects
Pathology ,medicine.medical_specialty ,Soft Tissue Neoplasm ,Physiology ,business.industry ,Nerve ultrasound ,Digit pain ,medicine.disease ,Glomus tumor ,030207 dermatology & venereal diseases ,03 medical and health sciences ,Cellular and Molecular Neuroscience ,0302 clinical medicine ,Physiology (medical) ,medicine ,Neoplasm ,Neurology (clinical) ,Ultrasonography ,business ,030217 neurology & neurosurgery - Published
- 2016
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28. Acute Injuries to the Lower Extremities in Pediatric and Adolescent Athletes
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Kevin G. Shea, Peter J. Apel, Michael J. Curtin, and Ronald P. Pfeiffer
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medicine.medical_specialty ,business.industry ,Adolescent athletes ,Rehabilitation ,Physical therapy ,medicine ,Physical Therapy, Sports Therapy and Rehabilitation ,Orthopedics and Sports Medicine ,business ,Immature skeleton - Published
- 2002
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29. The tibial attachment of the anterior cruciate ligament in children and adolescents: analysis of magnetic resonance imaging
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Paul D. Traughber, Ronald P. Pfeiffer, Kevin G. Shea, Larry D. Showalter, and Peter J. Apel
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Adult ,Male ,medicine.medical_specialty ,Adolescent ,Knee Joint ,Anterior cruciate ligament ,Adult women ,Sex Factors ,medicine ,Humans ,Orthopedics and Sports Medicine ,Femur ,Tibia ,Anterior Cruciate Ligament ,Child ,medicine.diagnostic_test ,business.industry ,Anterior Cruciate Ligament Injuries ,Age Factors ,Magnetic resonance imaging ,Anatomy ,musculoskeletal system ,medicine.disease ,Magnetic Resonance Imaging ,ACL injury ,Sagittal plane ,medicine.anatomical_structure ,Orthopedic surgery ,Female ,Surgery ,business ,human activities - Abstract
Recent studies have demonstrated that skeletally immature athletes with an ACL injury may require surgical reconstruction if they return to high-demand sports. This study used MRI to compare the anatomy of the ACL in skeletally immature and adult subjects. Measurements were recorded in the sagittal plane for the anterior-posterior dimension of the proximal tibia, and the anterior, center, and posterior limits of the ACL, and the roof inclination angle of the femur. These values were compared to established reference values for adult knee anatomy. In skeletally immature women ( n=7) the ACL anterior limit, center and posterior limit, and roof inclination angle were 28%, 46%, 63%, and 38 degrees, respectively, compared to 28%, 44%, 60%, and 35 degrees in adult women. In skeletally immature men ( n=15) the ACL anterior limit, center, posterior limit, and roof inclination angle were 27%, 43%, 59%, and 40 degrees, respectively, compared to 28%, 44%, 59%, and 37 degrees in adult men. In the younger subjects the overall dimensions of the proximal tibia were smaller than that in adults, but the anatomical landmarks for the ACL were proportional. If ACL reconstruction is performed in skeletally immature subjects, the smaller dimensions of the tibia need to be considered, and the use of anatomical landmarks is an important factor in graft placement
- Published
- 2002
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30. Somatosensory evoked potential monitoring of the brachial plexus during a woodward procedure for correction of Sprengel's deformity
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Peter J. Apel, Kevin G. Shea, William L. Bell, and Larry D. Showalter
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Male ,Shoulder ,medicine.medical_specialty ,Shoulder surgery ,Physiology ,medicine.medical_treatment ,Cellular and Molecular Neuroscience ,stomatognathic system ,Evoked Potentials, Somatosensory ,Monitoring, Intraoperative ,Physiology (medical) ,medicine ,Deformity ,Humans ,Brachial Plexus ,Palsy ,business.industry ,technology, industry, and agriculture ,Sprengel's deformity ,Nerve injury ,medicine.disease ,Osteotomy ,Surgery ,Treatment Outcome ,Brachial plexus injury ,Somatosensory evoked potential ,Child, Preschool ,Anesthesia ,Neurology (clinical) ,medicine.symptom ,business ,Brachial plexus - Abstract
Sprengel's deformity is the most common congenital deformity of the shoulder. A known complication of correcting this deformity is brachial plexus palsy. In this study we used somatosensory evoked potential (SSEP) monitoring during correction of a Sprengel's deformity and identified an early iatrogenic brachial plexus injury. The operation was modified, and permanent nerve injury was avoided. We recommend that SSEP monitoring be considered in procedures to correct Sprengel's deformity.
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- 2010
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31. Valgus slipped capital femoral epiphysis without posterior displacement: two case reports
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Nicholas A. Hutt, Peter J. Apel, Joe Guarino, and Kevin G. Shea
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musculoskeletal diseases ,medicine.medical_specialty ,Percutaneous ,Adolescent ,Radiography ,Imaging, Three-Dimensional ,Epiphyses, Slipped ,Hip Dislocation ,Humans ,Medicine ,Orthopedics and Sports Medicine ,Femur ,Displacement (orthopedic surgery) ,Child ,biology ,business.industry ,Anatomy ,medicine.disease ,biology.organism_classification ,Valgus ,Pediatrics, Perinatology and Child Health ,Orthopedic surgery ,Female ,Slippage ,Tomography, X-Ray Computed ,business ,Slipped capital femoral epiphysis - Abstract
Valgus slipped capital femoral epiphysis is a rare entity; approximately, 26 cases in 31 hips have been reported in the orthopedic literature since 1926. It has been argued that epiphyseal displacement occurs only in a posterior or posteromedial direction, and that the radiographic appearance of true valgus or lateral slippage is an optical illusion owing to the rotation of the femur. We present the cases of two sisters with bilateral lateral slipped capital femoral epiphysis without a posterior component of displacement. In these cases, the radiographs suggested that the direction of displacement was in the lateral plane and was confirmed with computerized tomography and three-dimensional reconstructions. Analysis demonstrated the absence of posterior slippage of the proximal femoral epiphysis. The slippage was treated with percutaneous screw placement. In cases in which the direction of the slip may be in question, advanced imaging techniques may be useful for precise determination of the screw placement. This may assist in the preoperative planning, and reduce the risk of inappropriate screw placement J Pediatr Orthop B 16:201–203 c 2007 Lippincott Williams & Wilkins.
- Published
- 2007
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32. Repair of peripheral nerve defects in rabbits using keratin hydrogel scaffolds
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Mark Van Dyke, L. Andrew Koman, Anthony Atala, Peter J. Apel, Paulina S. Hill, Jonathan C. Barnwell, and Thomas L. Smith
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Male ,Biomedical Engineering ,Bioengineering ,Sural nerve ,Biochemistry ,Hydrogel, Polyethylene Glycol Dimethacrylate ,Biomaterials ,Mice ,Peripheral nerve ,Keratin ,Medicine ,Animals ,Humans ,Peripheral Nerves ,chemistry.chemical_classification ,Wound Healing ,Tissue Scaffolds ,business.industry ,Guided Tissue Regeneration ,musculoskeletal, neural, and ocular physiology ,Muscles ,Anatomy ,Organ Size ,Recovery of Function ,musculoskeletal system ,Functional recovery ,nervous system diseases ,Electrophysiological Phenomena ,Nerve Regeneration ,Disease Models, Animal ,surgical procedures, operative ,nervous system ,chemistry ,Keratins ,Cattle ,Collagen ,Rabbits ,business - Abstract
Entubulation of transected nerves using bioabsorbable conduits is a promising alternative to sural nerve autografting, but full functional recovery is rarely achieved. Numerous studies have suggested that scaffold-based conduit fillers may promote axon regeneration, but no neuroinductive biomaterial filler has been identified. We previously showed that a nerve guide filled with keratin hydrogel actively stimulates regeneration in a mouse model, and results in functional outcomes superior to empty conduits at early time points. The goal of the present study was to develop a peripheral nerve defect model in a rabbit and assess the effectiveness of a keratin hydrogel filler. Although repairs with keratin-filled conduits were not as consistently successful as autograft overall, the use of keratin resulted in a significant improvement in conduction delay compared to both empty conduits and autograft, as well as a significant improvement in amplitude recovery compared to empty conduits when measurable regeneration did occur. Taking into account all study animals (i.e., regenerated and nonregenerated), histological assessment showed that keratin-treated nerves had significantly greater myelin thickness than empty conduits. These data support the findings of our earlier study and suggest that keratin hydrogel fillers have the potential to be used clinically to improve conduit repair.
- Published
- 2011
33. Effect of selective sensory denervation on fracture-healing: an experimental study of rats
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Michael F. Callahan, Daniel Crane, Peter J. Apel, Robert D. Teasdall, Thomas L. Smith, and Casey Northam
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Nervous system ,Male ,medicine.medical_specialty ,Bone healing ,Rats, Sprague-Dawley ,Peripheral Nervous System ,Medicine ,Animals ,Orthopedics and Sports Medicine ,Denervation ,Fracture Healing ,business.industry ,General Medicine ,Femoral fracture ,medicine.disease ,Confidence interval ,Surgery ,Rats ,Disease Models, Animal ,medicine.anatomical_structure ,Peripheral neuropathy ,Peripheral nervous system ,Anesthesia ,Peripheral nerve injury ,business ,Femoral Fractures - Abstract
Background: Interactions between the peripheral nervous system and the healing skeleton are poorly understood. Various clinical observations suggest that the nervous system interacts with and promotes fracture-healing. The purpose of this study was to examine the effect of selective sensory denervation on fracture-healing. Methods: Fifty-one Sprague-Dawley rats underwent unilateral placement of an intramedullary rod followed by creation of a standardized femoral fracture. One group of these rats underwent sensory denervation by means of a localized capsaicin injection, and the other did not. Subgroups were allocated for analysis of mRNA expression of collagen I and II and osteocalcin at three, seven, and fourteen days after the fracture. Additionally, histological examination was performed at four weeks; micro-computed tomography, at five weeks; and biomechanical testing, at six weeks. Results: The sensory-denervated group had significantly less collagen-I upregulation than the sensory-intact group at three days after the fracture (difference in means, forty-four-fold [95% confidence interval = 22.7 to 65.5-fold]; p < 0.001) and significantly less collagen-II upregulation at seven days after the fracture (difference in means, ninefold [95% confidence interval = 4.3 to 13.8-fold]; p < 0.001). In the sensory-denervated group, the fracture callus had a significantly larger cross-sectional area (difference in means, 15.6 mm2 [95% confidence interval = 0.78 to 30.5 mm2]; p = 0.043) and was less dense. Biomechanical testing revealed that sensory denervation significantly decreased the load to failure (difference in means, 28.7 N [95% confidence interval = 1.2 to 56.2 N]; p = 0.022). Conclusions: Sensory denervation negatively affects fracture-healing. These results offer insight into the nerve-bone interaction following injury. Clinical Relevance: These results are relevant to clinicians and researchers who are seeking to improve fracture-healing in patients with associated peripheral nerve injury or peripheral neuropathy.
- Published
- 2009
34. Effect of locally delivered IGF-1 on nerve regeneration during aging: an experimental study in rats
- Author
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Peter J, Apel, Jianjun, Ma, Michael, Callahan, Casey N, Northam, Timothy B, Alton, William E, Sonntag, and Zhongyu, Li
- Subjects
Aging ,Analysis of Variance ,Reverse Transcriptase Polymerase Chain Reaction ,Age Factors ,Neuromuscular Junction ,Nerve Fibers, Myelinated ,Axons ,Article ,Nerve Regeneration ,Rats ,GAP-43 Protein ,Animals ,RNA, Messenger ,Schwann Cells ,Insulin-Like Growth Factor I ,Tibial Nerve ,Muscle, Skeletal - Abstract
Age is an important predictor of neuromuscular recovery after peripheral nerve injury. Insulin-like growth factor 1 (IGF-1) is a potent neurotrophic factor that is known to decline with increasing age. The purpose of this study was to determine if locally delivered IGF-1 would improve nerve regeneration and neuromuscular recovery in aged animals. Young and aged rats underwent nerve transection and repair with either saline or IGF-1 continuously delivered to the site of the nerve repair. After 3 months, nerve regeneration and neuromuscular junction morphology were assessed. In both young and aged animals, IGF-1 significantly improved axon number, diameter, and density. IGF-1 also significantly increased myelination and Schwann cell activity and preserved the morphology of the postsynaptic neuromuscular junction (NMJ). These results show that aged regenerating nerve is sensitive to IGF-1 treatment.
- Published
- 2009
35. Keratin Biomaterials Activate Schwann Cells via Integrin‐Mediated Signaling and Promote Regeneration of Large Peripheral Nerve Defects in a Rabbit Model
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Bernard Tawfik, Thomas J. Smith, L. Andrew Koman, Paulina Sierpinski, Anthony Atala, Mark Van Dyke, and Peter J. Apel
- Subjects
chemistry.chemical_classification ,Pathology ,medicine.medical_specialty ,biology ,Regeneration (biology) ,Integrin ,Biochemistry ,Cell biology ,chemistry ,Peripheral nerve ,Keratin ,Genetics ,biology.protein ,Rabbit model ,medicine ,Molecular Biology ,Biotechnology - Published
- 2009
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36. How age impairs the response of the neuromuscular junction to nerve transection and repair: An experimental study in rats
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Peter J, Apel, Timothy, Alton, Casey, Northam, Jianjun, Ma, Michael, Callahan, William E, Sonntag, and Zhongyu, Li
- Subjects
Male ,Aging ,musculoskeletal, neural, and ocular physiology ,Neuromuscular Junction ,Receptors, Nicotinic ,musculoskeletal system ,Muscle Denervation ,Rats, Inbred F344 ,Article ,Nerve Regeneration ,Rats ,Up-Regulation ,nervous system ,Rats, Inbred BN ,Animals ,Trauma, Nervous System ,Myogenin ,RNA, Messenger ,Tibial Nerve ,Muscle, Skeletal - Abstract
Age is the most important predictor of clinical outcome after peripheral nerve injury. The stability of the neuromuscular junction (NMJ) after denervation is thought to be central to neuromuscular recovery. Stability is characterized by maintenance of the motor endplate and mRNA upregulation of the constituent nicotinic acetylcholinergic receptor (nAChR) subtypes and the muscle regulatory factors (MRFs). The purpose of this study was to determine the effect of age on the recovery and stability of the postsynaptic NMJ after peripheral nerve injury. Young and aged rats underwent transection and repair of the tibial nerve. At 1, 2, 4, 8, or 16 weeks following transection, the gastrocnemius was examined for electrical recovery, NMJ fragmentation and endplate area, mRNA, and protein levels of the MRFs and nAChR subtypes. After nerve injury, aged NMJ exhibited significant fragmentation and loss of motor endplate area while the young NMJ remained relatively stable. Concomitantly, age impaired peak upregulation of the MRFs and nAChRs. However, expression of gamma-nAChR and myogenin after nerve injury was not affected by age. These data support the claim that upregulation of the nAChRs and MRFs may play an important role in maintaining NMJ stability following nerve transection and repair. Furthermore, expression of gamma-nAChR and myogenin does not appear to prevent age-related NMJ fragmentation and loss of endplate area after nerve injury. These impairments of the aged NMJ response to injury may contribute to the poor neuromuscular recovery seen after nerve injury in this population.
- Published
- 2008
37. Brachial plexus birth palsy-associated shoulder deformity: a rat model study
- Author
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Jianjun Ma, Zhongyu Li, Peter J. Apel, Cathy S. Carlson, Thomas L. Smith, and L. Andrew Koman
- Subjects
musculoskeletal diseases ,Male ,medicine.medical_specialty ,Contracture ,Shoulders ,Rats, Sprague-Dawley ,Birth Injuries ,medicine ,Animals ,Orthopedics and Sports Medicine ,Range of Motion, Articular ,Brachial Plexus Neuropathies ,Palsy ,business.industry ,Shoulder Joint ,Anatomy ,Neurotomy ,medicine.disease ,Surgery ,Rats ,Joint Deformities, Acquired ,Brachial plexus injury ,Animals, Newborn ,Orthopedic surgery ,Models, Animal ,medicine.symptom ,Range of motion ,business ,Brachial plexus - Abstract
Purpose Although recovery occurs in the majority of cases of brachial plexus birth palsy (BPBP), long-term shoulder disability is relatively common. The aim of this study was to establish an animal model to study BPBP-associated shoulder deformities. Methods A right-side C5, C6 root neurotomy was performed under the surgical microscope in 5-day-old Sprague-Dawley rats (N = 9). The contralateral side served as a control. The development of shoulder deformity and range of motion loss were followed longitudinally. Animals were killed 4 months after surgery. Both shoulders were harvested, decalcified, and transected in the axial plane for glenoid version measurement and shoulder histology. Results All animals developed shoulder internal rotation contracture within 4 weeks after the C5, C6 neurotomy. The average shoulder external rotation loss was 52° ± 7, 59° ± 10, and 82° ± 11 in comparison with the control side 1, 2, and 4 months after neurotomy, respectively. Glenoid version changed from 2° ± 2 of retroversion (left side) to 8° ± 3 of anteversion. Five shoulders were subluxated clinically with a pseudoglenoid formation observed radiographically. Histologic study demonstrated marked glenoid and humeral head deformities. Conclusions This neonatal rat model clearly demonstrated typical shoulder deformities similar to that resulting from Erb's palsy. This model can be useful in studying BPBP-associated shoulder deformities.
- Published
- 2007
38. Human Hair Derived Keratins Mediate Schwann Cell Behavior in vitro and Facilitate Rapid Peripheral Nerve Regeneration in vivo
- Author
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Jianjun Ma, Anthony Atala, Paulina Sierpinski, Jeffrey P. Garrett, Peter J. Apel, L. Andrew Koman, Mark Van Dyke, and Thomas L. Smith
- Subjects
chemistry.chemical_classification ,Pathology ,medicine.medical_specialty ,Regeneration (biology) ,Schwann cell ,Biology ,Biochemistry ,In vitro ,medicine.anatomical_structure ,chemistry ,Peripheral nerve ,In vivo ,Keratin ,Genetics ,medicine ,Molecular Biology ,Biotechnology - Published
- 2007
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39. The anatomy of the proximal tibia in pediatric and adolescent patients: implications for ACL reconstruction and prevention of physeal arrest
- Author
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Peter J. Apel, Kevin G. Shea, Paul D. Traughber, and Ronald P. Pfeiffer
- Subjects
musculoskeletal diseases ,Male ,medicine.medical_specialty ,Adolescent ,Anterior cruciate ligament ,Proximal tibia ,Physeal arrest ,Imaging, Three-Dimensional ,Image Processing, Computer-Assisted ,Medicine ,Humans ,Orthopedics and Sports Medicine ,Tibia ,Growth Plate ,Anterior Cruciate Ligament ,Child ,Physis ,Bone Development ,medicine.diagnostic_test ,business.industry ,Anterior Cruciate Ligament Injuries ,Magnetic resonance imaging ,Anatomy ,musculoskeletal system ,Magnetic Resonance Imaging ,medicine.anatomical_structure ,Epiphysis ,Orthopedic surgery ,Surgery ,Female ,business ,Tomography, X-Ray Computed - Abstract
Although the treatment of anterior cruciate ligament (ACL) tears in skeletally immature patients is still controversial, several studies have advocated ACL reconstruction in selected patients to prevent secondary injury. The proximal tibial physis is a structure at risk during ACL reconstruction in young patients, and physeal growth complications have been reported after surgery in this area. The relationship between the ACL and the proximal tibial physeal/apophyseal regions is poorly understood. This study examined the MRI anatomy of the ACL and the proximal tibia apophysis and epiphysis. MRIs of 59 skeletally immature knees were reviewed (Average age = 12.75 years, range 6–15) to define the anatomy of the epiphyseal and apophyseal regions. Measurements were recorded in three parasagittal planes: (1) at the lateral border of the patellar tendon, (2) the lateral edge of the ACL insertion, and (3) the medial edge of the ACL insertion. A single three-dimensional (3D) computed tomography (CT) scan was used to evaluate the position of standard drill holes used in ACL reconstruction to assess for potential degree of injury to the epiphyseal and apophyseal growth plates. In the parasagittal planes, the average height of the epiphysis was 19.6, 20.7, and 21.5 mm at the lateral border of the patellar tendon, the lateral border of the ACL, and the medial border of the ACL, respectively. At the level of the same landmarks, the apophysis extended below the physis at an average of 20.2, 16.8, and 7.0 mm, respectively. Expressed as a percentage of epiphysis height this was an average of 104, 82, and 33%, respectively. Examination of 3D CT images revealed that variations in drill hole placement had effects on the volume of injury to the proximal tibial physis and apophysis. Drill holes that started more medial, distal, and with a steeper angle of inclination reduced the amount of physis and apophysis violated when compared with holes placed more lateral, proximal, and with a shallow angle of inclination. The proximal tibial physis and apophysis is vulnerable to injury by drill hole placement during ACL reconstruction in skeletally immature patients. This paper defines the anatomic relationship of the apophyseal and epiphyseal regions of the physis in the proximal tibia. The volume of injury to the physis can be reduced by avoiding tunnel placement that is too lateral or too proximal on the tibia. A better understanding of these relationships may guide the placement of tibial drill holes, which have a lower risk of producing significant physeal damage.
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- 2006
40. Contributors
- Author
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John A. Abraham, Paolo Aglietti, Jay C. Albright, Allen F. Anderson, Peter J. Apel, Nigel M. Azer, Luke H. Balsamo, David B. Bendor, Charles B. Berde, Treg D. Brown, Bernard Cahill, W. Dilworth Cannon, Michelina Cassella, Henry G. Chambers, Antonio Ciardullo, Jennifer L. Cook, Pierluigi Cuomo, J.T. Davis, Harvey N. Dulberg, Pierre A. d'Hemecourt, Avery D. Faigenbaum, John M. Flynn, Peter J. Fowler, John Franco, Theodore J. Ganley, Mark C. Gebhardt, Peter G. Gerbino, Carl Gustafson, Vincenzo Guzzanti, László Hangody, Christopher D. Harner, Richard Y. Hinton, Charles P. Ho, Christopher Iobst, Mary Lloyd Ireland, Matthias Jacobi, Roland P. Jakob, Diego Jaramillo, James R. Kasser, Danielle A. Katz, Kevin E. Klingele, Mininder S. Kocher, Roger V. Larson, Kevin H. Latz, Ronald E. Losee, Anthony C. Luke, Nicola Maffulli, Jung Y. Mah, Bert R. Mandlebaum, Lyle J. Micheli, Tom Minas, Paul J. Moroz, Martha Meaney Murray, Michael F. Murray, Andrés T. Navedo-Rivera, Scott C. Nelson, Jason H. Nielson, Michael J. O'Brien, Norman Y. Otsuka, Susan M. Ott, George A. Paletta, Ron Pfeiffer, Gábor Ráthonyi, Kathleen Richard, William G. Rodkey, Senthilkumar Sadhasivam, Frederic Shapiro, Krishn M. Sharma, Kevin G. Shea, Angela D. Smith, Carl L. Stanitski, Deborah Stanitski, J. Richard Steadman, Andrea Stracciolini, Edward C. Sun, Robert P. Sundel, John M. Tokish, Brett L. Wasserlauf, Jason K.F. Wong, Amy L. Woodward, and Yi-Meng Yin
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- 2006
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41. Injury of the Medial Collateral Ligament, Posterior Cruciate Ligament, and Posterolateral Complex in Skeletally Immature Patients
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Kevin G. Shea, Peter J. Apel, and Ron Pfeiffer
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Medial collateral ligament ,medicine.anatomical_structure ,business.industry ,Posterior cruciate ligament ,Medicine ,Anatomy ,business - Published
- 2006
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42. Anterior cruciate ligament injury in paediatric and adolescent patients: a review of basic science and clinical research
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Kevin G. Shea, Peter J. Apel, and Ronald P. Pfeiffer
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Male ,medicine.medical_specialty ,Sports medicine ,Adolescent ,Knee Joint ,Basic science ,Anterior cruciate ligament ,Physical Therapy, Sports Therapy and Rehabilitation ,Physeal arrest ,Dogs ,Risk Factors ,Epidemiology ,Medicine ,Animals ,Humans ,Orthopedics and Sports Medicine ,Orthopedic Procedures ,Risk factor ,Anterior Cruciate Ligament ,Child ,Bone Development ,business.industry ,musculoskeletal, neural, and ocular physiology ,Anterior Cruciate Ligament Injuries ,Leg length ,musculoskeletal system ,Surgery ,surgical procedures, operative ,Clinical research ,medicine.anatomical_structure ,Athletic Injuries ,Models, Animal ,Female ,Rabbits ,business ,human activities - Abstract
Anterior cruciate ligament (ACL) injuries are recognised with greater frequency in children and adolescents. Non-operative treatment of ACL injuries in children may lead to knee instability and secondary injuries, especially in those who return to sports. ACL reconstruction is controversial in skeletally immature patients because of potential damage to the proximal tibial and distal femoral physes, which may lead to premature arrest and/or leg length discrepancies. This paper reviews studies of ACL injuries in children and adolescents, and examines basic science and clinical studies concerning physeal arrest secondary to ACL reconstruction tunnels. Some animal studies support the conclusion that ACL reconstructions in children have the potential to cause growth disturbances, and there are reports of growth plate complications due to ACL reconstruction in skeletally immature patients. There is evidence that ACL reconstruction can be performed in select skeletally immature patients, but the risk of growth plate complications must be considered.
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- 2003
43. Tunnel Placement in Anterior Cruciate Reconstruction
- Author
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Kevin G. Shea and Peter J. Apel
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medicine.medical_specialty ,Graft failure ,business.industry ,Tibial tunnel ,Anterior cruciate ligament ,Anterior knee pain ,Anterior margin ,General Medicine ,Surgery ,Nonoperative treatment ,medicine.anatomical_structure ,Preliminary report ,medicine ,Orthopedics and Sports Medicine ,business - Abstract
To The Editor: We read with great interest Anderson's article “Transepiphyseal Replacement of the Anterior Cruciate Ligament in Skeletally Immature Patients. A Preliminary Report” (2003;85:1255-63). Anterior cruciate ligament injury is being recognized more frequently in children and adolescents, and development of an operative protocol for treating this injury is needed. As Anderson discussed, nonoperative treatment is likely to result in a poor outcome, especially for athletes. We compliment Dr. Anderson on the quality of his work and the detailed follow-up information. In the past fifteen years, extensive work has been done, most notably by Stephen Howell, on the optimum placement of the tibial tunnel during anterior cruciate reconstruction. Howell and others have shown that impingement of the graft may occur if it is placed too far anteriorly, leading to anterior knee pain, impaired extension, and graft failure. In order to avoid impingement of the graft on the roof of the intercondylar notch, the graft should emerge on the tibial plateau in the posterior aspect of the footprint of the anterior cruciate ligament1 and be placed such that it is posterior to the intercondylar roof2. The location of the tibial footprint of the anterior cruciate ligament in children has been documented. It can be found in children by measuring posteriorly from the anterior margin of the tibial tubercle … Corresponding author: Kevin G. Shea, MD 600 North Robbins Road, Suite 401 Boise, ID 83702 kgshea{at}aol.com
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- 2004
- Full Text
- View/download PDF
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