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Background: The use of ultrasound in the diagnosis of cubital tunnel syndrome (CuTS) is an attractive alternative to electrodiagnostic (EDX) studies, but its utility is binary with poor severity correlation. We hypothesize that increasing ulnar nerve cross-sectional area (CSA) and power Doppler measurement of intraneural vascularity may predict the extent of disease. Methods: We identified 20 elbows from patients with a history of CuTS and 20 elbows in 10 asymptomatic controls. Electrodiagnosis was performed for symptomatic patients. Gray-scale ultrasound and power Doppler ultrasound were performed to measure CSA and intraneural vascularity in all participants. Functional measures, Boston Carpal Tunnel Questionnaire (BCTQ), and Patient-Reported Outcomes Measurement Information System surveys were also completed. Results: A strong positive correlation was found between CSA and motor nerve conduction velocity (MNCV) decrease between elbow and forearm, which increased when BCTQ >2 was used as a screening criterion. Increased CSA also demonstrated a high positive predictive value (PPV) in predicting MNCV changes, but poor ability to predict axonal loss. In contrast, power Doppler ultrasound demonstrated 100% PPV and 94% negative predictive value (NPV) in predicting severe CuTS (defined as compound motor action potential [CMAP] amplitude Conclusions: Cross-sectional area is a sensitive method for identifying changes in MNCV and amplitude but does not stratify disease severity, as defined by diminished CMAP amplitude and/or evidence of denervation on EMG. The presence of increased intraneural vascularity is relatively sensitive but highly specific for axonal loss. The combination of nerve CSA, BCTQ screening, and power Doppler ultrasound may provide an alternative means for CuTS assessment.

Peripheral nerve trauma impacts both social and occupational quality of life. Patients are typically young and subsequently suffer from lifelong disability. Unlike the central nervous system, the peripheral nervous system has the capacity to regenerate along previous or new connections. Yet, complete functional recovery has been an elusive clinical objective despite the development of advanced microsurgical techniques to repair nerves. In recent decades significant amount of work has expanded the focus towards establishing new facets of adjuvant treatment to improve nerve regeneration. One potential therapy is the application of electric stimulation of peripheral nerves immediately following microsurgical repair. Mounting pre-clinical and clinical evidence demonstrated the efficacy of electrical stimulation in improving nerve regeneration and functional recovery. In this paper, we review the potential therapeutic benefits of electrical stimulation and the current limitations of regeneration after nerve injury. We also summarize the proposed mechanisms of electrical stimulation in increasing the regenerative capacity of peripheral nerves, including evidence from human clinical trials. Finally, we discuss stimulation parameters and safety profiles with an eye towards future treatment strategies. Combining electrical stimulation with conductive scaffolds has the potential to improve successful nerve regeneration and may have profound clinical implications to nerve injury patients.

Background There is variability in access to and utilization of orthopaedic care, particularly for those with Medicaid insurance. One potential contributor is perceived unwillingness of surgeons and hospitals to accept underinsured patients. We used administrative data to examine the payer mix for select inpatient orthopaedic surgical procedures at all hospitals within a single region, hypothesizing that the delivery of orthopaedic surgery to Medicaid beneficiaries varies highly at the hospital level. Methods Using administrative data, we analyzed inpatient hospitalizations for elective cases (total knee or hip arthroplasty; spinal decompression or fusion) and trauma cases (hip hemiarthroplasty; femoral or tibial and fibular fracture repair) among 22 hospitals in a single region from 2011 to 2016 for patients who were 18 to 64 years of age. The primary outcome was the percentage of each hospital's caseload with Medicaid listed as the primary payer. The secondary outcome measured each hospital's Medicaid percentage against the percentage of Medicaid-insured individuals within 10 miles of the hospital (Medicaid share ratio), using a ratio of 1 as a benchmark. To quantify variation, we calculated a weighted coefficient of variation of the Medicaid share ratio for all cases combined, elective cases only, and trauma cases only. Results For all cases (n = 19,204), the mean percentage of Medicaid-funded surgical procedures was 7.6% (range, 0.2% to 57.3%). The mean Medicaid share ratio was 1.0 (range, 0.05 to 4.20). Across 22 hospitals, the weighted coefficient of variation for Medicaid share was 69, indicating very high variation. For elective cases alone, the mean percentage of Medicaid-funded surgical procedures was 5.5% (range, 0.2% to 64.6%). The mean Medicaid share ratio was 0.71 (range, 0.05 to 4.73), and the weighted coefficient of variation was 93. For trauma cases alone, Medicaid-funded surgical procedures were 14.7% (range, 0.0% to 35.7%). The mean Medicaid share ratio was 2.0 (range, 0 to 3.93), and the weighted coefficient of variation was 34. Conclusions Delivery of care was highly variable when benchmarking against the insurance composition of each hospital's surrounding community. Although generalizability to other regions is limited, our findings support previously asserted notions that delivery of orthopaedic care may differ on the basis of socioeconomic markers (such as insurance status). If not addressed, these inequities may exacerbate existing racially and socioeconomically based disparities in care.

BACKGROUND Overlapping surgery occurs when a single surgeon is the primary surgeon for >1 patient in separate operating rooms simultaneously. The surgeon is present for the critical portions of each patient's operation although not present for the entirety of the case. While overlapping surgery has been widely utilized across surgical subspecialties, few large studies have compared the safety of overlapping and nonoverlapping surgery. METHODS In this retrospective cohort study, we reviewed the charts of patients who had undergone orthopaedic surgery at our ambulatory surgery center during the period of April 2009 and October 2015. A database of operations, including patient and surgical characteristics, was compiled. Complications had been identified and logged into the database by surgeons monthly over the study period. These monthly reports and case logs were reviewed retrospectively to identify complications. Propensity-score weighting and logistic regression models were used to determine the association between outcomes and overlapping surgery. RESULTS A total of 22,220 operations were included. Of these, 5,198 (23%) were overlapping, and 17,022 (77%) were nonoverlapping. The median duration of surgery overlap was 8 minutes (quartile 1 to quartile 3, 3 to 16 minutes); no operations were concurrent. After weighting, the only continuous variables that differed significantly between the groups were operative time (median, 57 compared with 56 minutes for the overlapping and the nonoverlapping group, respectively; p = 0.022), anesthesia time (median, 97 compared with 93 minutes; p < 0.001), and total tourniquet time (median, 26 compared with 22 minutes; p = 0.0093). Multivariable logistic regression models did not demonstrate an association between overlapping surgery and surgical site infection, noninfection surgical complications, hospitalization, or morbidity. CONCLUSIONS These data suggest that there is no association between briefly overlapping surgery and surgical site infection, noninfection surgical complications, hospitalization, and morbidity. When practiced in the manner described herein, overlapping orthopaedic surgery can be a safe practice in the ambulatory setting. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons’ rationale for treatment approaches. We hypothesized that distal nerve transfers would be preferred over exploration and nerve grafting of the brachial plexus. Methods We conducted semi-structured interviews with BPI surgeons to discuss 3 case vignettes: pan-plexus injury, upper trunk injury, and lower trunk injury. The interview guide included questions regarding overall treatment strategy, indications and utility of brachial plexus exploration, and the role of nerve grafting and/or nerve transfers. Interview transcripts were coded by 2 researchers. We performed inductive thematic analysis to collate these codes into themes, focusing on the role of brachial plexus exploration in the treatment of BPI. Results Most surgeons routinely explore the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries. Reasons to explore included the importance of obtaining a definitive root level diagnosis, perceived availability of donor nerve roots, timing of anticipated recovery, plans for distal reconstruction, and the potential for neurolysis. Very few explore lower trunk injuries, citing concern with technical difficulty and unfavorable risk-benefit profile. Conclusions Our analysis suggests that supraclavicular exploration remains a foundational component of surgical management of BPI, despite increasing utilization of distal nerve transfers. Availability of abundant donor axons and establishing an accurate diagnosis were cited as primary reasons in support of exploration. This analysis of surgeon interviews characterizes contemporary practices regarding the role of brachial plexus exploration in the treatment of BPI.

Operative intervention for distal radius fractures is typically reserved for patients with displaced fractures that may result in bothersome compromises in function, although patient-specific factors (age, activity level, and preference) are considered. Operative intervention is associated with earlier improvement in function but exposes the patient to the risk of anesthesia and surgery. Although surgery is associated with an initial increase in cost of care, the benefits of earlier return to activity may offset these increases. Efforts to contain cost through implant selection, use of ambulatory surgical centers, and judicious referrals for postoperative therapy can aid surgeons in delivering high-value care.

The following is a concise review of the Pediatric Pulmonary Medicine Core reviewing pediatric pulmonary infections, diagnostic assays, and imaging techniques presented at the 2021 American Thoracic Society Core Curriculum. Molecular methods have revolutionized microbiology. We highlight the need to collect appropriate samples for detection of specific pathogens or for panels and understand the limitations of the assays. Considerable progress has been made in imaging modalities for detecting pediatric pulmonary infections. Specifically, lung ultrasound and lung magnetic resonance imaging are promising radiation-free diagnostic tools, with results comparable with their radiation-exposing counterparts, for the evaluation and management of pulmonary infections. Clinicians caring for children with pulmonary disease should ensure that patients at risk for nontuberculous mycobacteria disease are identified and receive appropriate nontuberculous mycobacteria screening, monitoring, and treatment. Children with coronavirus disease (COVID-19) typically present with mild symptoms, but some may develop severe disease. Treatment is mainly supportive care, and most patients make a full recovery. Anticipatory guidance and appropriate counseling from pediatricians on social distancing and diagnostic testing remain vital to curbing the pandemic. The pediatric immunocompromised patient is at risk for invasive and opportunistic pulmonary infections. Prompt recognition of predisposing risk factors, combined with knowledge of clinical characteristics of microbial pathogens, can assist in the diagnosis and treatment of specific bacterial, viral, or fungal diseases.

Background The concept of utilizing a nerve conduit for augmentation of a primary nerve repair has been advocated as a method to prevent neural scarring and decrease adhesions. Despite clinical use, little is known about the effects of a nerve conduit wrapped around a primary repair. To better understand this, we investigated the histologic and functional effects of use of a nerve conduit wrapped around a rat sciatic nerve repair without tension. Methods Twenty Lewis' rats were divided into two groups of 10 rats each. In each group, unilateral sciatic nerve transection and repair were performed, with the opposite limb utilized as a matched control. In the first group, direct repair alone was performed; in the second group, this repair was augmented with a porcine submucosa conduit wrapped around the repair site. Sciatic functional index (SFI) was measured at 6 weeks with walking track analysis in both groups. Nonsurvival surgeries were then performed in all animals to harvest both the experimental and control nerves to measure histomorphometric parameters of recovery. Histomorphometric parameters assessed included total number of neurons, nerve fiber density, nerve fiber width, G-ratio, and percentage of debris. Unpaired t-test was used to compare outcomes between the two groups. Results All nerves healed uneventfully but compared with direct repair; conduit usage was associated with greater histologic debris, decreased axonal density, worse G-ratio, and worse SFI. No significant differences were found in total axon count or gastrocnemius weight. Conclusion In the absence of segmental defects, conduit wrapping primary nerve repairs seem to be associated with worse functional and mixed histologic outcomes at 6 weeks, possibly due to debris from conduit resorption. While clinical implications are unclear, more basic science and clinical studies should be performed prior to widespread adoption of this practice.

The leading cause of adult brachial plexus injuries is trauma resulting from a closed traction injury secondary to a high-velocity motor vehicle accident. Ninety percent of patients suffer supraclavicular lesions. A widened shoulder-neck angle at the time of injury with an adducted shoulder predisposes upper trunk injury, while shoulder abduction predisposes lower trunk injury. Penetrating open injuries, such as gunshot wounds and lacerations, are less common and usually result in infraclavicular injury with concomitant vascular injury. Glenohumeral dislocations and sports-related brachial plexus lesions also represent other causes of closed traction injuries. Nontraumatic brachial plexus injuries include iatrogenic injuries related to patient positioning and regional anesthetics, primary and metastatic brachial plexus tumors, and neuralgic amyotrophy.

Background Implementing exercises in the form of video games, otherwise known as exergaming, has gained recent attention as a way to combat health issues resulting from sedentary lifestyles. However, these exergaming apps have not been developed for exercises that can be performed in wheelchairs, and they tend to rely on whole-body movements. Objective This study aims to develop a mobile phone app that implements electromyography (EMG)-driven exergaming, to test the feasibility of using this app to enable people in wheelchairs to perform exergames independently and flexibly in their own home, and to assess the perceived usefulness and usability of this mobile health system. Methods We developed an Android mobile phone app (Workout on Wheels, WOW-Mobile) that senses upper limb muscle activity (EMG) from wireless body-worn sensors to drive 3 different video games that implement upper limb exercises designed for people in wheelchairs. Cloud server recordings of EMG enabled long-term monitoring and feedback as well as multiplayer gaming. Bench testing of data transmission and power consumption were tested. Pilot testing was conducted on 4 individuals with spinal cord injury. Each had a WOW-Mobile system at home for 8 weeks. We measured the minutes for which the app was used and the exergames were played, and we integrated EMG as a measure of energy expended. We also conducted a perceived usefulness and usability questionnaire. Results Bench test results revealed that the app meets performance specifications to enable real-time gaming, cloud storage of data, and live cloud server transmission for multiplayer gaming. The EMG sampling rate of 64 samples per second, in combination with zero-loss data communication with the cloud server within a 10-m range, provided seamless control over the app exergames and allowed for offline data analysis. Each participant successfully used the WOW-Mobile system at home for 8 weeks, using the app for an average of 146 (range 89-267) minutes per week with the system, actively exergaming for an average of 53% of that time (39%-59%). Energy expenditure, as measured by integrated EMG, was found to be directly proportional to the time spent on the app (Pearson correlation coefficient, r=0.57-0.86, depending on the game). Of the 4 participants, 2 did not exercise regularly before the study; these 2 participants increased from reportedly exercising close to 0 minutes per week to exergaming 58 and 158 minutes on average using the WOW-Mobile fitness system. The perceived usefulness of WOW-Mobile in motivating participants to exercise averaged 4.5 on a 5-point Likert scale and averaged 5 for the 3 participants with thoracic level injuries. The mean overall ease of use score was 4.25 out of 5. Conclusions Mobile app exergames driven by EMG have promising potential for encouraging and facilitating fitness for individuals in wheelchairs who have maintained arm and hand mobility.

Radiocarpal dislocations are rare, but serious injuries. The shearing and rotation forces associated with these injuries lead to extrinsic carpal ligament damage and associated fractures of the distal radius and carpus. Prompt reduction and stabilization via surgical repair are critical to providing satisfactory outcomes. These injuries are often complex and are associated with variable injury patterns of osseous, ligamentous, and soft tissues. Knowledge and comfort with multiple surgical approaches and repair techniques can help the surgeon achieve better outcomes.

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3- to 4-year recurring cycle of topics. These topics will be presented at the 2020 International Conference. Below is the pediatric pulmonary medicine core, including pediatric hypoxemic respiratory failure; modalities in noninvasive management of chronic respiratory failure in childhood; surgical and nonsurgical management of congenital lung malformations; an update on smoke inhalation lung injury; an update on vaporizers, e-cigarettes, and other electronic delivery systems; pulmonary complications of sarcoidosis; pulmonary complications of congenital heart disease; and updates on the management of congenital diaphragmatic hernia.

The purpose of this study was to assess the expression of molecular markers and epineural blood flow after differing degrees of nerve injury to identify potential tools to predict nerve recovery in a rat sciatic nerve model.A total of 72 rats were divided into nine groups. Each group was subjected to one of three crush injuries, created by applying one of three vascular clamps for 30 seconds. Vascularity was assessed with laser Doppler flowmetry before and after crush, and at nonsurvival surgery. Nonsurvival surgeries were performed 6 hours, 2 weeks, or 6 weeks later with nerve conduction studies and muscle strength testing. Expression of matrix metalloproteinase 9 (MMP-9) and matrix metalloproteinase 2 (MMP-2) in each nerve was quantified using with enzyme linked immunosorbent analysis.Persistent hyperemia was noted in the zone of injury compared with baseline at 2 weeks and 6 weeks in the groups that displayed incomplete recovery. Expression of MMP-9 at 6 hours increased with increasing severity of crush and was inversely related to tibialis anterior muscle force recovery. The ratio of MMP-9:MMP-2 expression correlated well with recovery of compound nerve action potential amplitude at 6 weeks.Resolution of nerve hyperemia may correlate with nerve recovery from trauma, but early measures of nerve blood flow after injury are not prognostic of recovery. Ratio of MMP-9:MMP-2 expression 6 hours after injury correlates with recovery of compound nerve action potential at 6 weeks, while MMP-9 expression alone predicts tibialis anterior recovery. These findings together suggest that increased MMP-9 expression is a potentially useful marker of more severe nerve injury.

Background:. Treatment of pan-brachial plexus injuries has evolved significantly over the past 2 decades, with refinement and introduction of new surgical techniques, particularly free functional muscle transfer. The extent to which contemporary brachial plexus surgeons utilize various techniques as part of their treatment algorithm for pan-plexus injuries and the rationale underlying these choices remain largely unknown. Methods:. A case scenario was posed to 12 brachial plexus surgeons during semi-structured qualitative interviews. The case involved a young patient presenting 6 weeks after a pan-plexus injury from a motorcycle accident. Surgeons were asked to formulate a treatment plan. Inductive thematic analysis was used to identify commonalities and variation in approach to treatment. Results:. For shoulder function, the majority of surgeons would graft from a viable C5 nerve root, if possible, though the chosen target varied. Two-thirds of the surgeons would address elbow flexion with nerve transfers, though half would combine this with a free functional muscle transfer to increase elbow flexion strength. Free functional muscle transfer was the technique of choice to restore finger flexion. Finger extension, intrinsic function, and sensation were not prioritized. Conclusions:. Our study sheds light on current trends in the approach to pan-plexus injuries in the U.S. and identifies areas of variability that would benefit from future study. The optimal shoulder target and the role for grafting to the MCN for elbow flexion merit further investigation. The role of FFMT plays an increasingly prominent role in treatment algorithms.

In the recent decade, mobile exergaming has emerged as a way to motivate physical activity and thereby increase fitness. It has been found that those which encourage social interaction and multiplayer gaming leads to better fitness outcomes than single player games [1]. However, none have yet to tailor exergames for people who use wheelchairs due to lower mobility impairment. We present a mobile exergaming and fitness tracking app in which the exergames are tailored toward people in wheelchairs and features a virtual community which allows social interaction through multiplayer gaming and leaderboard features. We hypothesized that users would find the multiplayer games more useful for improving fitness than the single player games. However, perceived usefulness survey results indicate overall satisfaction with the main design features but not a particular preference for the multiplayer gaming over single player gaming. Users overall found the app useful and easy to use, and the results provide indication that the virtual community created through the multiplayer feature of the mobile exergaming app does promote and enhance exercising.Clinical relevance— Multiplayer gaming was designed into a mobile fitness app to encourage exercise amongst individuals in wheelchairs. The virtual community created is expected to increase activity levels and its many associated health benefits in this community, promote a greater sense of belonging, and increase social participation.

Background: After traumatic brachial plexus injuries (BPI), the sudden loss of physical function is often accompanied by psychological distress. Given the complex nature and relative infrequency of the injury, BPI patients will often use online resources for information about their injury as well as emotional support. Questions/Purpose: Recognizing the influence of social media, we sought to search a popular social media platform to identify challenges faced by BPI patients and strategies used to overcome these challenges. Methods: We searched “traumatic brachial plexus injury” on Facebook and selected the 2 most popular BPI support groups. We collected posts regarding traumatic BPI from November 1, 2018 through November 1, 2019. We performed inductive and deductive thematic analysis of the posts to identify recurring topics, knowledge gaps, and peer interaction dynamics. Results: We analyzed 7694 posts from the 2 Facebook support groups. The following themes emerged: (1) BPI patients express discontent regarding the inability to use their arm and the slow or stagnant pace of recovery; (2) BPI patients are frustrated over their inability to retain their preinjury livelihood; and (3) BPI patients emphasize that acceptance and moving on are key components of adjustment to their condition. Some patients described the role of limb amputation in achieving these goals. Conclusions: Our analysis demonstrates the areas in which BPI patients are in need of emotional support. Adjustment to BPI might be facilitated through multidisciplinary care that addresses emotional aspects of recovery and emphasizes self-management skills, in addition to the traditional focus on physical function.

Purpose: The economic implications of brachial plexus injuries (BPI) in the United States are not well understood. The purpose of our study was to quantify the direct costs associated with surgical treatment of BPI after traumatic injury in adults, which would enable future study of the societal value of surgical reconstruction. Methods: Using an administrative database of patients with commercial insurance, a cohort of patients aged 18 to 64 years with BPI treated surgically from 2007 to 2015 was assembled and assessed for index admission associated with BPI surgery and all payments toward claims (including medical, surgical, therapy, and pharmacy claims) for 1 year after surgery. Results: Among 189 patients undergoing surgery for BPI, median direct payments were $38,816 (interquartile range: $18,209 to $72,411; minimum: $3,512; maximum: $732,641). Conclusions: Relative to recently published data for the indirect cost of traumatic BPI (median: $801,723), direct payments for 1 year after surgical treatment represent 4.6% of the total long-term cost of BPI. In the context of existing literature demonstrating cost-effectiveness in models of BPI surgical care, our data suggest that surgery and other interventions to maximize return to work after traumatic BPI in adults may be beneficial to society. Type of study/level of evidence: Economic and Decision Analyses IV. Key words: Brachial plexus injury, Cost of surgery, Surgical reconstruction, Trauma

Introduction:. The American Orthopaedic Association introduced standardized letters of recommendations (SLORs) to improve on traditional letters of recommendations by “providing a global prospective on an applicant.” However, no study has defined the utilization of SLORs, the distribution of applicant ratings in SLORs, or the impact of sex, race, or degree of involvement between the letter writer and applicant on SLOR domain ratings. Methods:. One-hundred seventy-nine applications were randomly selected from all applicants submitted to a single, academic orthopaedic residency program. A single reviewer extracted both applicant characteristics and SLOR characteristics from applications. Descriptive statistics, chi-square tests, and nonparametric one-way analysis of variance analysis were conducted. Results:. Six hundred twenty-eight letters of recommendation from 179 applicants were analyzed. Four hundred ninety-seven of 628 (79.1%) letters contained a SLOR. Mean percentile ratings were calculated for all the following domains: patient care (mean ± SD = 86.7 ± 8.7), medical knowledge (87.2 ± 8.6), interpersonal and communication (87.7 ± 9.3), procedural (86.6 ± 8.9), research (88.9 ± 9.0), ability to work within a team (89.6 ± 8.4), professionalism (90.8 ± 7.3), initiative and drive (90.6 ± 7.6), and commitment to orthopaedic surgery (91.1 ± 6.7). Forty-eight percent of applicants were indicated as “ranked to guarantee match.” When compared with male applicants, female applicants demonstrated higher percentile ratings in patient care (88.6 ± 8.2 vs. 86.3 ± 8.7, p = 0.010), interpersonal and communication skills (90.6 ± 7.3 vs. 86.9 ± 9.6, p < 0.001), and ability to work within a team (91.3 ± 6.3 vs. 89.2 ± 8.8, p = 0.045). Higher United States Medical Licensing Examination step 1 (r = 0.08, p = 0.05) and step 2 scores (r = 0.10, p = 0.02) correlated with higher medical knowledge ratings. The number of publications (r = 0.3, p < 0.001) and presentations (r = 0.25, p < 0.001) correlated with research ratings. Conclusion:. SLORs demonstrated a profound ceiling effect, potentially limiting the utility of the instrument for the comparison of applicants. Future modifications to this instrument may include measures to better delineate between applicants.

Adult brachial plexus injuries result in profound functional deficits, debilitating pain, substantial mental health implications, and extensive economic impacts. Their initial evaluation includes a detailed physical examination, electrodiagnostic studies, advanced imaging, and patient counseling. A team-based approach, led by a peripheral nerve surgeon and including hand therapists, electrodiagnosticians, mental health experts, and pain-management specialists, is used to provide optimal longitudinal care during the lengthy recovery process. The options for the surgical management of brachial plexus injuries include exploration, neurolysis, nerve grafting, nerve transfer, free functional muscle transfer, tendon transfer, arthrodesis, and amputation. When treated within 6 months, the outcomes are favorable for the restoration of essential shoulder and elbow function. Free functional muscle transfer is a powerful tool to address elbow flexion and rudimentary grasp in both primary and delayed settings. The restoration of hand function remains a challenge for patients with complete brachial plexus injury. The purpose of this review is to summarize foundational concepts in diagnosis and management, discuss current trends and controversial topics, and address areas for future investigation.

Introduction: The American Orthopaedic Association introduced standardized letters of recommendations (SLORs) to improve on traditional letters of recommendations by “providing a global prospective on an applicant.” However, no study has defined the utilization of SLORs, the distribution of applicant ratings in SLORs, or the impact of sex, race, or degree of involvement between the letter writer and applicant on SLOR domain ratings. Methods: One-hundred seventy-nine applications were randomly selected from all applicants submitted to a single, academic orthopaedic residency program. A single reviewer extracted both applicant characteristics and SLOR characteristics from applications. Descriptive statistics, chi-square tests, and nonparametric one-way analysis of variance analysis were conducted. Results: Six hundred twenty-eight letters of recommendation from 179 applicants were analyzed. Four hundred ninety-seven of 628 (79.1%) letters contained a SLOR. Mean percentile ratings were calculated for all the following domains: patient care (mean ± SD = 86.7 ± 8.7), medical knowledge (87.2 ± 8.6), interpersonal and communication (87.7 ± 9.3), procedural (86.6 ± 8.9), research (88.9 ± 9.0), ability to work within a team (89.6 ± 8.4), professionalism (90.8 ± 7.3), initiative and drive (90.6 ± 7.6), and commitment to orthopaedic surgery (91.1 ± 6.7). Forty-eight percent of applicants were indicated as “ranked to guarantee match.” When compared with male applicants, female applicants demonstrated higher percentile ratings in patient care (88.6 ± 8.2 vs. 86.3 ± 8.7, p = 0.010), interpersonal and communication skills (90.6 ± 7.3 vs. 86.9 ± 9.6, p < 0.001), and ability to work within a team (91.3 ± 6.3 vs. 89.2 ± 8.8, p = 0.045). Higher United States Medical Licensing Examination step 1 (r = 0.08, p = 0.05) and step 2 scores (r = 0.10, p = 0.02) correlated with higher medical knowledge ratings. The number of publications (r = 0.3, p < 0.001) and presentations (r = 0.25, p < 0.001) correlated with research ratings. Conclusion: SLORs demonstrated a profound ceiling effect, potentially limiting the utility of the instrument for the comparison of applicants. Future modifications to this instrument may include measures to better delineate between applicants.

Background:. Letters of recommendation (LOR) are an important component of trainee advancement and assessment. Examination of word use in LOR has demonstrated significant differences in how letter writers describe female and male applicants. Given the emphasis on increasing both gender and racial diversity among orthopaedic surgeons, we aimed to study gender and racial differences in LOR for applicants to orthopaedic surgery residencies. Methods:. All applications submitted to a single, academic orthopaedic residency program in 2018 were included. Self-identified gender and race were recorded. The LOR were analyzed via a text analysis software program using previously described categories of communal, agentic, grindstone, ability, and standout words. We examined the relative frequency of word use in letters for (1) male and female applicants and (2) white and underrepresented in orthopaedics (UiO) applicants, with the subgroup analysis based on whether standardized (using the American Orthopaedic Association template) or traditional (narrative) LOR were used. Results:. Two thousand six hundred twenty-five LOR were submitted for 730 applicants (79% men). Fifty-nine percent of applicants were self-identified as white, and 34% were self-identified as UiO. In traditional LOR, standout words (odds ratio [OR] 1.07; p = 0.01) were more likely to be used in letters for women compared with men, with no difference in any other word-use category. In standardized LOR, there were no gender-based differences in any word category. In traditional LOR, grindstone words (OR = 0.96; p = 0.02) were more likely to be used in letters for UiO than white applicants, whereas standout words (OR = 1.05; p = 0.04) were more likely to be used in letters for white candidates. In standardized LOR, there were no race-based differences in any word category use. Conclusions:. Small differences were found in the categories of words used to describe male and female candidates and white and UiO candidates. These differences were not present in the standardized LOR compared with traditional LOR. It is possible that the use of standardized LOR may reduce gender- and race-based bias in the narrative assessment of applicants.

Targeted muscle reinnervation after upper-extremity amputation has demonstrated improved outcomes with myoelectric prosthesis function and postoperative neuropathic pain. This technique has been established in the setting of shoulder disarticulation as well as transhumeral and transradial amputations, but a detailed technique of targeted muscle reinnervation with free tissue transfer from the volar forearm after forequarter amputation has not yet been described. Here, we describe a technique using a volar forearm filet flap to achieve simultaneously satisfactory soft tissue coverage after resection of a tumor from the chest wall and targeted muscle reinnervation of the brachial plexus.

The medical device industry has long been subject to criticism for lack of price transparency and minimal regulations surrounding device approval, which have functioned as barriers to providing quality and cost-effective care. Recent health care reforms aimed at overcoming these barriers, including improving market approval regulations, increasing postmarket surveillance, and using comparative effectiveness research, have drastically changed industry practices. These reforms have also prompted increasingly cost-aware health care practices, which have encouraged new trends in medical device innovation such as frugal innovation and deinstitutionalization. This article explores the challenges faced by industry, physicians, and patients in light of these reforms.

BACKGROUND: Emotional and social characteristics may influence rehabilitation and recovery after traumatic brachial plexus injury. PURPOSES: We sought to investigate if traumatic brachial plexus injury patients have different levels of social support and employ distinct coping strategies from uninjured control subjects. In addition, we studied which coping strategies are more commonly used among traumatic brachial plexus injury patients. METHODS: Questionnaires for social support (Interpersonal Support Evaluation List and Social Support Questionnaire) and coping strategies (Brief-Coping Orientation to Problems Experienced) were administered to traumatic brachial plexus injury patients and an age- and sex-matched volunteer cohort (without brachial plexus injury). RESULTS: There were no differences in interpersonal support (mean [SD] = 26.0 [8.6], 26.5 [6.8]), number of persons available for emotional support, and satisfaction with support between traumatic brachial plexus injury patients (n = 36) and volunteers (n = 43). The following coping strategies were more common among traumatic brachial plexus injury patients: active coping, self-distraction, denial, behavioral disengagement, venting, planning, self-blame, and acceptance. CONCLUSION: Patients with traumatic brachial plexus injury have similar levels of social support as healthy volunteers but are more likely to use an array of coping strategies. Surgeons and other clinicians should be aware of coping strategies favored by patients, particularly the potential for behaviors detrimental to recovery such as behavioral disengagement, self-blame, and denial. This work will inform future investigations into the influence of social support and coping strategies on clinical outcomes after traumatic brachial plexus injury. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-020-09814-z) contains supplementary material, which is available to authorized users.

The complexity of each brachial plexus injury (BPI) pattern and physiologic limitations of nerve regeneration create challenges for BPI patients and their surgeons. Detailed assessment via physical examination, electrodiagnostic studies, and advanced imaging can aid the surgeon in predicting the prognosis for each patient’s neurologic recovery and provide an outline for reconstructive priorities. Surgical exploration of the brachial plexus confirms the injury pattern and guides the overall treatment strategies. A multimodal reconstructive strategy including nerve grafting, extraplexal nerve transfers, distal intraplexal nerve transfers, and free-functioning muscle transfers is designed for each patient to accomplish the goals of providing a pain-free helper hand. Additional reconstructive procedures such as tendon transfers and selective joint arthrodeses are used after the results of the initial reconstructive efforts have been declared. Beyond the neurologic components of BPI, the surgeon must be attuned to the social and psychological sequelae of this devastating injury. This review contains 10 figures, 1 table, and 60 references. Key Words: brachial plexus injury, elbow flexion, free-functioning muscle transfer, nerve grafting, nerve transfer, reconstruction, shoulder abduction, , tendon transfer

BACKGROUND: Scaphoid fractures treated non-operatively and operatively may be complicated by nonunion. QUESTIONS/PURPOSES: We sought to test the primary hypothesis that the incidence density of scaphoid fracture treatment is higher than previously estimated, to determine the frequency and risk factors for nonunion treatment, and to determine whether the frequency of surgical treatment increased over time. METHODS: The MarketScan(®) database was queried for all records of treatment (casting and surgery) for closed scaphoid fractures over a 6-year period. We examined subsequent claims to determine frequency of additional procedures for nonunion treatment (revision fixation or vascularized grafting occurring 28 days or more after initial treatment). Trend analyses were used to determine whether changes in frequency of surgical treatment or revision procedure occurred. RESULTS: The estimated incidence density of scaphoid fracture is 10.6 per 100,000 person-years in a commercially insured population of less than 65 years of age. Of 8923 closed scaphoid fractures, 29 and 71% were treated with surgery and casting, respectively. The frequency of surgical treatment rose significantly, from 22.1% in 2006 to 34.1% in 2012. The frequency of nonunion treatment was 10.8% after surgery and 3% after casting; neither changed over time. Younger age, male sex, and surgical treatment are associated with a higher risk of nonunion treatment. CONCLUSIONS: Our estimated incidence of scaphoid fracture is higher than previously reported. The increased enthusiasm in the USA to surgically treat scaphoid fractures is reflected by our trend analysis. The frequency of surgical treatment for presumed nonunion after initial surgical management for closed scaphoid fractures exceeded 10%. Given the increased utilization of surgery, surgeons and patients should be aware of the frequency of nonunion treatment to inform treatment decisions. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-018-9619-3) contains supplementary material, which is available to authorized users.

Purpose Although volar plating of the distal radius is performed frequently, the necessity of distal bicortical fixation in the metaphyseal and epiphyseal areas of the distal radius has not been proven. This study aimed primarily to quantify the ability of unicortical distal screws to maintain operative reduction of adult distal radius fractures and secondarily to determine if unicortical screw lengths could be predicted based on anatomical measurements. Methods This prospective trial enrolled 75 adult patients undergoing volar locking plate fixation of a unilateral distal radius fracture at a tertiary center. Study inclusion required screw fixation in the distal rows of the plate performed with unicortical screw placement. The primary outcome was maintenance of operative reduction, according to predefined parameters, quantified by comparing initial operative reduction to final reduction after fracture healing. Repeated measures analysis of variance analyzed for systematic change in radiographic parameters between injury, operative, and healed images. Correlation coefficients quantified the relationship of screw lengths with lunate width and other anatomical measurements. Results Seventy-five patients (mean age, 54 years ± 15 years; 79% women) were enrolled and followed to fracture union. Fracture severity varied and included AO type A (40%), B (12%), and C (48%) fractures. There was no significant change in mean lateral translation, intra-articular gap, intra-articular stepoff, radial inclination, or lateral tilt of the radius between the time of fixation and union for the cohort. Two patients lost reduction (increased dorsal tilt, 10°, 20°, respectively), potentially attributable to provision of unicortical fixation (3%; 95% confidence interval [95% CI], 0%–9%). No extensor tenosynovitis or extensor tendon ruptures occurred. Eighty percent of screws were 18 mm or less and screw lengths were not correlated with lunate width or any other anatomical measurements. Conclusions Unicortical distal fixation during volar locking plate fixation effectively maintains operative reductions of distal radius fractures while potentially minimizing the incidence of extensor tendon ruptures. Type of study/level of evidence Therapeutic IV.

The physiologic limitations of neural regeneration make peripheral nerve surgery challenging to both the surgeon and the patient. Presence of nerve gaps and local wound factors may all influence outcome, suggesting that barriers to reduce perineural scarring, minimize fibrosis, and avoid ischemia would be beneficial. To examine the evidence supporting their use, we reviewed the autologous and commercially-available options for barriers against scarring around a nerve. Numerous clinical case series demonstrated the effectiveness and safety of local/rotational flaps and autologous vein wrapping when used in the presence of recurrent compressive neuropathy. Translational research in animal models support the biocompatibility of commercially-available nerve wraps following nerve repair. To date, there are no reports of clinical use of commercially-available nerve wraps in acute nerve repair, but a growing number of case series demonstrate their effectiveness and safety in chronic compressive neuropathy. Limited clinical evidence exists to support the efficacy of flap coverage in acute nerve repairs, including the use of vein.

Background Existing scapholunate interosseous ligament (SLIL) reconstruction techniques include fixation spanning the radiocarpal joint, which do not reduce the volar aspect of the scapholunate interval and may limit wrist motion. Questions/Purpose This study tested the ability of an SLIL reconstruction technique that approximates both the volar and dorsal scapholunate intervals, without spanning the radiocarpal joint, to restore static scapholunate relationships. Materials and Methods Scapholunate interval, scapholunate angle, and radiolunate angle were measured in nine human cadaveric specimens with the SLIL intact, sectioned, and reconstructed. Fluoroscopic images were obtained in six wrist positions. The reconstruction was performed by passing tendon graft through bone tunnels from the dorsal surface toward the volar corner of the interosseous surface. After reduction of the scapholunate articulation, the graft was tensioned within the lunate bone tunnel, secured with an interference screw in the scaphoid, and sutured to the dorsal SLIL remnant. Differences among testing states were evaluated using repeated measures ANOVA. Results There was a significant increase in the scapholunate interval in all wrist positions after complete SLIL disruption. Compared with the disrupted state, there was a significant decrease in scapholunate interval in all wrist positions after reconstruction using a tendon graft and interference screw. Conclusion Our SLIL reconstruction technique reconstructs the volar and dorsal ligaments of the scapholunate joint and adequately restores static measures of scapholunate stability. This technique does not tether the radiocarpal joint and aims to optimize volar reduction. Clinical Relevance Our technique offers an alternative option for SLIL reconstruction that successfully restores static scapholunate relationships.

Homo sapiens constitute the only currently obligate bipedal mammals and, as it stands, upright bipedal locomotion is a defining characteristic of humans. Indeed, while the evolution to bipedalism has allowed for the upper limbs to be liberated from ground contact during ambulation, their role in locomotion is far from obsolete. Rather, there is reason to believe that arm swing offers important mechanical and neurological advantages to bipedal locomotion. In this short review, we present some compelling findings on the neural connections between the arms and legs during human locomotion. We begin with a description of the importance of arm swing during walking from a mechanical perspective. Then, we examine evidence for the existence of interappendicular connections that converge along with peripheral afferents, descending inputs, and propriospinal projections, onto the neural circuits innervating the muscles of the arms and legs. The varied effects of interappendicular coupling on the neural control of locomotion are also examined in cases of neurological injury. We use the insight gained from these collected works as well as those from our own studies on locomotor training to discuss strategies to use interappendicular connections to rehabilitate walking in individuals experiencing loss of function after debilitating spinal cord injury.

Rapid, inexpensive, and sensitive nucleic acid detection may aid point-of-care pathogen detection, genotyping, and disease monitoring. The RNA-guided, RNA-targeting clustered regularly interspaced short palindromic repeats (CRISPR) effector Cas13a (previously known as C2c2) exhibits a "collateral effect" of promiscuous ribonuclease activity upon target recognition. We combine the collateral effect of Cas13a with isothermal amplification to establish a CRISPR-based diagnostic (CRISPR-Dx), providing rapid DNA or RNA detection with attomolar sensitivity and single-base mismatch specificity. We use this Cas13a-based molecular detection platform, termed Specific High-Sensitivity Enzymatic Reporter UnLOCKing (SHERLOCK), to detect specific strains of Zika and Dengue virus, distinguish pathogenic bacteria, genotype human DNA, and identify mutations in cell-free tumor DNA. Furthermore, SHERLOCK reaction reagents can be lyophilized for cold-chain independence and long-term storage and be readily reconstituted on paper for field applications., United States. Air Force Office of Scientific Research (Grant FA9550-14-1-0060), Defense Threat Reduction Agency (DTRA) (Grant HDTRA1-14-1-0006), National Institute of Mental Health (U.S.) (Grant 5DP1-MH100706), National Institutes of Health (U.S.) (Grant 1R01-MH110049)

The current health-care system in the United States has numerous barriers to quality, accessible, and affordable musculoskeletal care for multiple subgroups of our population. These hurdles include complex cultural, educational, and socioeconomic factors. Tertiary referral centers provide a disproportionately large amount of the care for the uninsured and underinsured members of our society. These gaps in access to care for certain subgroups lead to inappropriate emergency room usage, lengthy hospitalizations, increased administrative load, lost productivity, and avoidable complications and/or deaths, which all represent a needless burden on our health-care system. Through advocacy, policy changes, workforce diversification, and practice changes, orthopaedic surgeons have a responsibility to seek solutions to improve access to quality and affordable musculoskeletal care for the communities that they serve.

Online video resources have increasingly become a common way to effectively share scientific research ideas and engage viewers at many levels of interest or expertise. While synthetic biology is a comparatively young field, it has accumulated online videos across a spectrum of content and technical depth. Such video content can be used to introduce viewers to synthetic biology, supplement college course content, teach new lab skills and entertain. Here, we compile online videos concerning synthetic biology into public YouTube playlists tailored for six different, though potentially overlapping, audiences: those wanting an introduction to synthetic biology, those wanting to get quick overviews of specific topics within synthetic biology, those wanting teaching or public lectures, those wanting more technical research lectures, those wanting to learn lab protocols and those interested in the International Genetically Engineered Machine competition.

Traumatic brachial plexus injuries (BPIs) disproportionately affect young, able-bodied individuals. Beyond direct costs associated with medical treatment, there are far-reaching indirect costs related to disability and lost productivity. Our objective was to estimate per-patient indirect cost associated with BPI. METHODS: We estimated indirect costs as the sum of (1) short-term wage loss, (2) long-term wage loss, and (3) disability payments. Short-term (6-month) wage loss was the product of missed work days and the average earnings per day. The probability of return to work was derived from a systematic review of the literature, and long-term wage loss and disability payments were estimated. Monte Carlo simulation was used to perform a sensitivity analysis of long-term wage loss by varying age, sex, and return to work simultaneously. Disability benefits were estimated from U.S. Social Security Administration data. All cost estimates are in 2018 U.S. dollars. RESULTS: A systematic review of the literature demonstrated that the patients with BPI had a mean age of 26.4 years, 90.5% were male, and manual labor was the most represented occupation. On the basis on these demographics, our base case was a 26-year-old American man working as a manual laborer prior to BPI, with an annual wage of $36,590. Monte Carlo simulation estimated a short-term wage loss of $22,740, a long-term wage loss of $737,551, and disability benefits of $353,671. The mean total indirect cost of traumatic BPI in the Monte Carlo simulations was $1,113,962 per patient over the post-injury lifetime (median: $801,723, interquartile range: $22,740 to $2,350,979). If the probability of the patient returning to work at a different, lower-paying job was doubled, the per-patient total indirect cost was $867,987. CONCLUSIONS: BPI can have a far-reaching economic impact on both individuals and society. If surgical reconstruction enables patients with a BPI to return to work, the indirect cost of this injury decreases. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Brachial plexus injury (BPI) is a life-altering event, and surgical treatment of BPI is costly ($66 million nationwide in 2006 alone). Despite the sizable costs associated with surgically treated BPI, the incidence of such cases in adults in the USA remains unknown. QUESTIONS/PURPOSES: We sought to provide an estimate of the national incidence of surgically treated BPI in the USA and to determine whether changes have occurred over time. METHODS: We sought to identify privately insured adults ages 18 through 64 years who underwent BPI surgery between 2008 and 2014 in the IBM® MarketScan® Commercial Database. We then extrapolated those data to the same age group in the general population (all insurance types were considered), using data from the National Health Interview Survey and a study on the proportion of BPI surgery cases covered by private insurance to estimate the national incidence. We also used the Cochran–Armitage trend test to evaluate for statistically significant changes in BPI incidence over time in MarketScan private insurance data. RESULTS: We identified 966 patients surgically treated for BPI in the MarketScan database in the study period. The average annual incidence of surgically treated BPI in this population of privately insured patients was 0.64 per 100,000 (range, 0.38 to 1.03). When extrapolated to all payers, the average annual incidence was 0.89 per 100,000 people (range, 0.53 to 1.47). In the MarketScan data, there was a statistically significant overall increase in the incidence of surgically treated BPI from 2008 through 2014 (0.47 per 100,000 to 1.03 per 100,000). CONCLUSION: The estimated annual incidence of surgically treated BPI is 0.89 per 100,000 persons in the USA, and the incidence has increased over time. These findings can serve as a baseline for further studies of disease epidemiology and societal and financial impact. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-019-09741-8) contains supplementary material, which is available to authorized users.

Individuals with lower mobility impairment face many barriers to regular, appropriately intense exercise. To combat these barriers and the resulting cardiometabolic disease risk, we are developing a mobile fitness system to promote and facilitate exercises which can be done in wheelchairs in the convenience of one’s home. This mobile fitness system exploits computing and wireless sensing to promote exercise in a number of ways: (A) monitoring a fitness metric which users find a reliable and trustworthy; (B) gamifying exercises; (C) healthy, friendly competition with other users; and (D) providing text notifications as reminders to exercise.

Background Overlapping surgery is attracting increased scrutiny. The American College of Surgeons states that the attending surgeon must be present for all critical portions of a surgical procedure; however, critical portions of surgical procedures are not defined. We hypothesized that a Delphi panel process would measure consensus on critical portions of 3 common hand surgical procedures. Methods We used a Delphi process to achieve consensus on the critical portions of carpal tunnel release, ulnar nerve transposition, and open reduction and internal fixation of the distal part of the radius. The panelists were 10 hand surgeons (7 fellowship-trained surgeons and 3 fellows). Following an in-person discussion to finalize steps for each procedure, 2 online rounds were completed to rate steps from 1 (not critical) to 9 (extremely critical). We operationalized consensus as ≥80% of ratings within the same range: 1 to 3 (not critical), 4 to 6 (somewhat critical), and 7 to 9 (critical). Because of a lack of consensus on some steps after round 2, another in-person discussion and a third online round were conducted to rate only steps involving disagreement or somewhat critical ratings using a dichotomous scale (critical or not critical). Results Following the first 2 rounds, there was consensus on 19 of 24 steps (including 3 steps being somewhat critical) and no consensus on 5 of 24 steps. At the end of round 3, there was consensus on all but 2 steps (identification of the medial antebrachial cutaneous nerve in ulnar nerve transposition and clinical assessment of joint stability in open reduction and internal fixation of the distal part of the radius), with moderate disagreement (3 compared with 7) for both. Conclusions The panel reached consensus on the designation of critical or noncritical for all steps of a carpal tunnel release, all but 1 step of an ulnar nerve transposition, and all but 1 step of open reduction and internal fixation of the distal part of the radius. The lack of consensus on whether 2 of the steps are critical leaves this determination at the discretion of the attending surgeon. The findings of our Delphi panel provide guidance to our division on which portions of the surgical procedure are critical and thus require the attending surgeon's presence.

Purpose To test the effectiveness of a novel locking pin cap to attach a K-wire rigidly to a volar locking plate and resist fracture displacement compared with commercially available alternatives. Methods Two different methods of fracture fixation were tested on a total of 12 Sawbones models with volar shear distal radius fracture (6/group). The fragments were fixed with either 2 commercially available pin plates (industry standard) or a volar plate with 2 locking screws fixing the scaphoid facet and 2 pins locked to the plate with a novel locking pin cap in the lunate facet. Axial load conditioning was performed followed by sinusoidal loading to 250 N at 50 mm/s. A motion capture system was used to assess the relative movement of the fracture fragments relative to the intact shaft. The strength of the fixation construct was quantified by (1) the force required to achieve a 2-mm gap between the shaft and fracture fragments and (2) ultimate load to failure. Results One industry standard pin plate demonstrated disassociation of the pin from the plate after fatigue conditioning. This did not occur in the locking pin cap group. The locking pin cap construct group was able to sustain a significantly higher load compared with the industry standard when the construct was displaced to the 2-mm gap. The locking pin cap also significantly increased the ultimate load to failure compared with the industry standard. Conclusions The novel locking pin cap creates a fixed-angle attachment of a K-wire to an existing locking screw hole in a plate. This fixed-angle K-wire is significantly stronger in preventing gap formation and resisting ultimate failure than commercially available plates that use bent K-wires. Clinical relevance The development of novel techniques to secure small articular fragments may ultimately improve clinical outcomes.