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The authors hypothesized that the infection rates of open hand fractures treated in a delayed manner would not be higher than those treated immediately. The authors performed a retrospective chart review of patients treated between January 2008 and July 2014 at a Level 1 Trauma Center. Delayed (> 24 hours) versus early (< 24 hours) surgical treatment groups were identified for comparison to determined infection rates. One hundred twenty-nine patients with open hand fractures were compared. Fifty-eight received delayed treatment (> 24 hours), and 71 received immediate surgical treatment (< 24 hours). When adjusted for the severity of injury, there were no significant differences on the rate of infection and rate of reoperation between washout and antibiotics in the emergency department versus immediate surgical treatment. There were no differences in infection rates or reoperation for nonunions with respect to surgical intervention timing. (Journal of Surgical Orthopaedic Advances 33(4):222-224, 2024).

Introduction: There is little research on the efficacy of flipped classroom (FC) models of learning in formal orthopaedic didactic curricula. The primary aim of this study was to compare resident Orthopaedic In-Training Examination (OITE) scores before and after implementation of an FC curriculum at a single academic institution., Methods: An FC didactic model consisting of 3 hour-long weekly sessions focusing on highly tested topics was implemented for the start of the 2021 to 2022 academic year. The curriculum was based on the Orthobullets PASS curriculum. The OITE scores were measured 3 years before and 3 years after the implementation of the novel curriculum., Results: Mean in-training scores as a program against national peers increased from the 29th percentile precurriculum implementation to 75th percentile postcurriculum implementation (p < 0.001)., Conclusion: At a single academic institution, average OITE scores increased significantly after implementation of an FC model. Consideration should be given to changing traditional lecture-based curricula to models that more effectively engage resident learners., Level of Evidence: Level III: Retrospective Cohort Study. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A692)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Appropriate management of radial head fractures is integral to prevent long-term consequences like chronic pain and loss of motion. Advanced imaging systems, like micro-computed tomography (μCT), are valuable for understanding radial head fracture patterns as they utilize micrometer scale resolution to define important parameters of bone health like cortical density and trabecular thickness. The purpose of this study was to identify and describe the structural morphology of the radial head utilizing μCT. Nine fresh-frozen cadaveric human radii were divided into four equal quadrants, based, and labeled as posteromedial, posterolateral, anteromedial, and anterolateral. Quadrants were scanned with a SCANCO MicroCT40 with both cortical and cancellous bone density measurements at a resolution of 36.0 μm. Bone density, direct trabecular number, and trabecular thickness were recorded as milligrams of hydroxyapatite/cm 3 . A one-way repeated measures ANOVA was performed to compare the bone densities, trabecular number, and trabecular thickness of each of the four quadrants (p < 0.05). The posteromedial quadrant contained substantially more bone than other quadrants. Significantly greater bone densities were found in the posteromedial quadrant (148.1 mg of HA/cm 3 ) compared to the anteromedial quadrant (54.6 mg of HA/cm 3 ), posterolateral quadrant (137.5 mg of HA/cm 3 ) compared to the anteromedial quadrant (54.6 mg of HA/cm 3 ), and posterolateral quadrant (137.5 mg of HA/cm 3 ) compared to the anterolateral quadrant (58.1 mg of HA/cm 3 ). The trabecular number was not significantly different between quadrants. Trabecular thickness was significantly lower in the anterolateral (0.1417 mg of HA/cm 3 ) and anteromedial (0.1416 mg of HA/cm 3 ) quadrants compared to the posteromedial (0.1809 mg of HA/cm 3 ) quadrant. The posterior half of the radial head was found to have a higher density of columns and arches compared to the anterior half. The microstructure of trabecular bone in the distal radius forms columns, struts, and arches, which allow for efficient transmission of stress through the bone. The microstructure of the radial head has similar microarchitecture to the distal radius with the present study identifying the presence of columns and arches in the radial head. These structures, along with trabecular density, in the posterior radial head may explain the lower incidence of fractures involving the posterior half of the radial head. Furthermore, our study supports the idea that the high incidence of fractures involving the anterolateral quadrant is due to microarchitecture characteristics and the relative lack of supportive structures compared to other areas. The novel insight gained from this study will aid in the development of advanced interventions for preventative measures and better treatment of radial head fractures like more satisfactory purchase when screws are directed towards the denser posteromedial quadrant., (© 2024 American Association of Clinical Anatomists and British Association of Clinical Anatomists.)

Background: Nitinol memory compression staples have been proposed as an effective alternative to compression screws for capitolunate arthrodesis (CLA) for scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrist. The purpose of this study was to compare the clinical outcomes of CLA for SNAC or SLAC wrist treatment using either compression screws or nitinol staples., Methods: In all, 47 patients with CLA for SLAC or SNAC wrist with screws or nitinol staples were retrospectively identified. Primary outcome was fusion on radiographs and/or computed tomography. Secondary outcomes were hardware-related complications (HWCs) and other complications, range of motion, grip strength, and patient-reported outcome measures (PROMs), including Visual Analogue Pain scale; Disabilities of the Arm, Shoulder, and Hand score; and patient-rated wrist evaluation., Results: Of the 47 eligible patients, 40 (85%) were included: 31 patients in the staple group and 9 patients in the screw group. The average age was 49 (17-80) years. There was an 89% union rate for the screw group and a 97% union rate for the staple group. Two patients had screw backout: one who went onto union after screw removal and the other who went onto nonunion after hardware removal. There were 2 (6.5%) HWCs in the staple group. One patient had staple loosening requiring revision and the other dorsal impingement requiring staple removal after radiographic union. In all subsequent cases, the staples were countersunk with no impingement. No significant differences existed between any additional outcomes., Conclusions: We found no differences between nitinol staples and screws for CLA regarding HWCs or PROMs. Nitinol staples may offer additional benefits as a safe and effective alternative to compression screws for wrist fusions.

Background: Telemedicine is an evolving tool to increase patients' access to subspecialty care. Since 2014, Arkansas has been utilizing telemedicine in the evaluation of patients with hand injuries. The purpose of this study is to assess the effect of this novel telemedicine system for the management of hand trauma on patient transfer. Methods: We reviewed data from the first year of the telemedicine program (2014) and compared it to data from the year prior (2013). Data collection from both years included number of hand consults and need for transfer. From the 2014 data, we also recorded the use of telemedicine, type of transfer, distance of transfer, and time to disposition. Results: During 2013 (pre-telemedicine), there were 263 hand traumas identified. In all, 191 (73%) injuries required transfer to a higher level of care, while 72 (23%) were managed locally. In the first year of the telemedicine program (2014), a total of 331 hand injuries were identified. A total of 298 (90%) resulted in telemedicine consultation with 65% (195) utilizing video encounters. After telemedicine consultation, local management was recommended for 164 injuries (55%) while transfer was recommended for 134 (45%). Using telemedicine, there was a significant decrease in the percentage of transfer for hand injuries ( P < .001). Conclusions: The telemedicine program was well utilized and provided patients throughout the state with continuous access to fellowship trained hand surgeons including regions where hand subspecialty care is not available. The program resulted in a significant decrease in the number of hospital transfers for the management of acute hand trauma.

The posterior approach is a commonly employed exposure of the elbow that provides excellent visualization and efficacy for various orthopedic procedures, including total elbow arthroplasty (TEA) and fracture care. The posterior approach to the elbow has been associated with an increased rate of wound complications, including infection, skin necrosis, and wound dehiscence. Despite an association between these complications and decreased elbow perfusion, data regarding the intrinsic anatomic etiology for preferential complications in this area has been scarcely reported in the literature. This study characterizes the subdermal and cutaneous vascular perfusion about the elbow by describing the predominant direction of circulation, subdermal anastomoses, and volume of perfusion through cadaveric modeling using computed tomography angiography (CTA). Fifteen upper extremity cadaver specimens were prepared with injection of radiographic contrast directly into the axillary artery immediately preceding CTA imaging of each specimen. Sectra IDS7 software for Windows was used for analysis of all images to produce superimposed axial and 3-D reconstructions of each CTA series. From these images it was discerned that the predominant direction of flow in the posterior elbow integument is anterior medial to posterior lateral. Both the posterior medial and posterior lateral subdermal vascular networks emanate from proximally derived medial arterial sources with few anastomoses and minimal collateral perfusion from the anterolateral location. Consequently, it is important to preserve medial subdermal vascular structures to prevent ischemic wound complications. This is especially true in previously incised elbow integuments. Clin. Anat. 32:509-514, 2019. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

Control of independent digital flexion and extension has remained an elusive goal in myoelectric prosthetics for upper extremity amputees. We first performed a cadaver study to determine the feasibility of transferring the interossei muscles for each digit to the dorsum of the hand without damaging the neurovascular pedicles. Once this capability was ensured, a clinical case was performed transferring the interossei of the middle and ring fingers to the dorsum of the hand where they could serve as a myoelectric signal for a partial hand amputee to allow individual digital control with a myoelectric prosthesis. Before surgery, it was impossible to detect an independent signal for each interossei; however, after the surgery, signals were reliably detected, which allowed these muscles to serve as myosites for finger flexion using a myoelectric prosthesis and move each digit independently. This concept of salvaging innervated and perfused muscles from an amputated part and transferring them into the more proximal and superficial portion of a salvaged limb has broad applications for improved myoelectric prosthetic control., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Nondisplaced scaphoid fractures can be effectively treated nonoperatively, with union rates approaching or, in some series, exceeding the rates attained with operative intervention. The evidence supports equal outcomes when using a short arm or long arm cast for the closed treatment of nondisplaced scaphoid fractures. Also, equivalent outcomes have been demonstrated with or without a thumb spica component to the cast. Operative intervention is the recommended treatment for displaced scaphoid fractures. Advanced imaging should be obtained if clinical suspicion is present for a scaphoid fracture with negative radiographs more than 2 weeks after the injury. In some settings, it may even be more cost-effective to obtain advanced imaging sooner.

Skeletal metastases of breast cancer and subsequent osteolysis connote a dramatic change in the prognosis for the patient and significantly increase the morbidity associated with disease. The cytokine interleukin 8 (IL-8/CXCL8) is able to directly stimulate osteoclastogenesis and bone resorption in mouse models of breast cancer bone metastasis. In this study, we determined whether circulating levels of IL-8 were associated with increased bone resorption and breast cancer bone metastasis in patients and investigated IL-8 action in vitro and in vivo in mice. Using breast cancer patient plasma (36 patients), we identified significantly elevated IL-8 levels in bone metastasis patients compared with patients lacking bone metastasis (p<0.05), as well as a correlation between plasma IL-8 and increased bone resorption (p<0.05), as measured by NTx levels. In a total of 22 ER+ and 15 ER- primary invasive ductal carcinomas, all cases examined stained positive for IL-8 expression. In vitro, human MDA-MB-231 and MDA-MET breast cancer cell lines secrete two distinct IL-8 isoforms, both of which were found to stimulate osteoclastogenesis. However, the more osteolytic MDA-MET-derived full length IL-8(1-77) had significantly higher potency than the non-osteolytic MDA-MB-231-derived IL-8(6-77), via the CXCR1 receptor. MDA-MET breast cancer cells were injected into the tibia of nude mice and 7days later treated daily with a neutralizing IL-8 monoclonal antibody. All tumor-injected mice receiving no antibody developed large osteolytic bone tumors, whereas 83% of the IL-8 antibody-treated mice had no evidence of tumor at the end of 28days and had significantly increased survival. The pro-osteoclastogenic activity of IL-8 in vivo was confirmed when transgenic mice expressing human IL-8 were examined and found to have a profound osteopenic phenotype, with elevated bone resorption and inherently low bone mass. Collectively, these data suggest that IL-8 plays an important role in breast cancer osteolysis and that anti-IL-8 therapy may be useful in the treatment of the skeletal related events associated with breast cancer., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Trisomy 21 affects virtually every organ system and results in the complex clinical presentation of Down syndrome (DS). Patterns of differences are now being recognized as patients' age and these patterns bring about new opportunities for disease prevention and treatment. Low bone mineral density (BMD) has been reported in many studies of males and females with DS yet the specific effects of trisomy 21 on the skeleton remain poorly defined. Therefore we determined the bone phenotype and measured bone turnover markers in the murine DS model Ts65Dn. Male Ts65Dn DS mice are infertile and display a profound low bone mass phenotype that deteriorates with age. The low bone mass was correlated with significantly decreased osteoblast and osteoclast development, decreased bone biochemical markers, a diminished bone formation rate and reduced mechanical strength. The low bone mass observed in 3 month old Ts65Dn mice was significantly increased after 4 weeks of intermittent PTH treatment. These studies provide novel insight into the cause of the profound bone fragility in DS and identify PTH as a potential anabolic agent in the adult low bone mass DS population.

During development, growth factors and hormones cooperate to establish the unique sizes, shapes and material properties of individual bones. Among these, TGF-beta has been shown to developmentally regulate bone mass and bone matrix properties. However, the mechanisms that control postnatal skeletal integrity in a dynamic biological and mechanical environment are distinct from those that regulate bone development. In addition, despite advances in understanding the roles of TGF-beta signaling in osteoblasts and osteoclasts, the net effects of altered postnatal TGF-beta signaling on bone remain unclear. To examine the role of TGF-beta in the maintenance of the postnatal skeleton, we evaluated the effects of pharmacological inhibition of the TGF-beta type I receptor (TbetaRI) kinase on bone mass, architecture and material properties. Inhibition of TbetaRI function increased bone mass and multiple aspects of bone quality, including trabecular bone architecture and macro-mechanical behavior of vertebral bone. TbetaRI inhibitors achieved these effects by increasing osteoblast differentiation and bone formation, while reducing osteoclast differentiation and bone resorption. Furthermore, they induced the expression of Runx2 and EphB4, which promote osteoblast differentiation, and ephrinB2, which antagonizes osteoclast differentiation. Through these anabolic and anti-catabolic effects, TbetaRI inhibitors coordinate changes in multiple bone parameters, including bone mass, architecture, matrix mineral concentration and material properties, that collectively increase bone fracture resistance. Therefore, TbetaRI inhibitors may be effective in treating conditions of skeletal fragility.