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Background: No investigation has analyzed the time from injury to operative intervention and its effect on complications and functional outcomes in distal radius fractures. This investigation aimed to establish whether the time to surgical intervention from injury was associated with the observed rate of complications in distal radius fractures. Methods: A retrospective review of all orthopedic trauma patients who came to our center was conducted from 2008 through 2014. Patients who sustained closed distal radius fractures were included. A postoperative complication following distal radius fracture was defined as reoperation, superficial or deep infection, complex regional pain syndrome, new-onset carpal tunnel syndrome, tendon irritation, and symptomatic hardware. Results: In all, 190 patients were included in the study with a mean age of 48 years (SD ±14.7). According to the AO-Müller/Orthopaedic Trauma Association classification, radiographs revealed 80 A fractures, 15 B fractures, and 95 C fractures. Thirty distal radii were fixed within 0 to 3 days after injury, 91 patients within 4 to 10 days, and 69 patients after 10 days. Overall, 28 complications (14.7%) were identified. There was no statistical difference in the rate of complications between the time interval groups ( P = .17). Conclusions: Despite the increased popularity of surgical intervention for distal radius fractures, the optimal parameters to maximize patient outcomes have yet to be clearly defined. Time to intervention did not affect the rate of postoperative complication and range of motion.

Background: Cartilage transplants in the patellofemoral joint have demonstrated lower success rates than in the femoral condyles. This is likely related to the more complex morphology and biomechanics of the joint. While previous studies have evaluated cartilage surface matching and congruence, little work has been done to study the associated subchondral bone congruency in these grafts. Purpose: To determine if differences in patellar morphology play a role in the alignment of the donor patellar osteochondral allograft subchondral bone with the native patellar subchondral bone. Study Design: Controlled laboratory study. Methods: A total of 20 (10 Wiberg I and 10 Wiberg II/III) fresh-frozen human patellae were designated as recipients and size-matched to both a Wiberg I and a Wiberg II/III patellar donor. A 16-mm osteochondral allograft transplant to the central ridge of the patella was performed in random order with each matched donor. Transplanted patellae underwent a nano—computed tomography (nano-CT) scan, were digitally reconstructed, and were superimposed on the initial nano-CT scan of the native recipient patella. MATLAB was used to determine the surface height deviation between the native and donor subchondral bone surfaces. DragonFly 3-dimensional imaging software was used to measure subchondral bone step-off heights at the native-donor interface. Differences between matched and unmatched grafts were compared using a 2-way analysis of variance and the Sidak post hoc test. Results: Subchondral bone surface deviation did not differ between Wiberg matched and unmatched allografts. The step-off height was significantly greater in unmatched (1.38 ± 0.49 mm) compared with matched (1.14 ± 0.52 mm) plugs ( P = .015). The lateral quadrant step-off differed between matched (0.89 ± 0.43 mm) and unmatched (1.60 ± 0.78 mm) grafts ( P = .007). Conclusion: While unmatched Wiberg patellar osteochondral allograft implantation did not result in significantly different subchondral bone surface height deviations, there was a significant difference in the circumferential subchondral bone step-off height in the lateral quadrant. Further investigation using finite element analysis modeling will help determine the role of subchondral bone surface on shear and compression force distributions in these areas. Clinical Relevance: Given that subchondral bone stiffness and morphology play a role in cartilage health, subchondral bone congruency may play a role in graft survival. Understanding how this congruency plays a role in cartilage force distribution will help surgeons improve the long-term success of osteochondral allograft transplants.

Objectives: Recent research has shown that implanting a patellar osteochondral allograft with a non-matched surface morphology (i.e., Wiberg classification) does not create increased chondral surface deviation or circumferential step-off in the donor plug compared to the native patella. While much of the research on patellar osteochondral allografts has been focused on chondral surface matching, little has been done to determine if the subchondral bone alignment at the donor:native interface plays a role in graft healing, local force distribution, and long term success of the allograft transplant. Previous work in our lab demonstrated that even when the patellar cartilage surface was well matched, notable differences in subchondral bone alignment were observed. The purpose of this study was therefore to use surface contour mapping of subchondral bone to determine if differences in Wiberg classification play a role in the ability of donor patellar osteochondral allograft subchondral bone to align with the native patellar subchondral bone when treating osteochondral defects of the patellar apex. The hypothesis was that patellar surface morphology would have an effect on subchondral bone surface height deviation and circumferential step-off when performing osteochondral allograft transplants of the patellar apex. Methods: Sixty fresh frozen human patellae were acquired from a national donor procurement company. Twenty (10 Wiberg I and 10 Wiberg II/III) patellae were designated as the recipient and then nano-CT scanned. Each recipient was size-matched (within ±2mm tibial width) to both a Wiberg I and a Wiberg II/III patellar donor. A 16mm circular osteochondral “defect” centered on the central ridge of the patella was then created in the recipient patella. A randomly-ordered donor Wiberg I or Wiberg II/III plug was harvested from a homologous location and transplanted into the recipient. The recipient was then nano-CT scanner, digitally reconstructed, and superimposed on the initial nano-CT scan of the native recipient patella. After careful atraumatic removal of the first donor plug, the process was repeated using the other allograft plug. MATLAB was used to determine the root mean square (RMS) surface height deviation between the native and donor subchondral bone surfaces. Dragonfly 3D imaging software was used to measure the RMS subchondral bone step-off height at 3° increments around the circumference of the graft. Surface height deviation and circumferential step-off height were analyzed for the whole surface and by quadrant to determine if there were local differences. ANOVA was used to compare surface deviation and step-off heights between matched and unmatched grafts. Sidak’s multiple comparison test was used to complete sub-analysis between patellar graft quadrants. Comparisons were made between matched and unmatched grafts in terms of the RMS surface height deviation and step-off, as well as in the percentage of measurements that were more than 0.5mm, 1mm, and 2mm proud or sunken relative to the native surface. Results: There were no significant differences in RMS subchondral bone surface height deviation between matched and unmatched Wiberg plugs as a whole or by quadrant (RMS range = 0.69 to 0.97mm, p = 0.45 – 1.0). There was a significant difference in RMS circumferential step-off height between matched (1.14 ± 0.52mm) and unmatched (1.38 ± 0.49mm) Wiberg plugs ( p=0.015). The majority of these increased step-off measurements occurred in the lateral quadrant with lateral quadrant RMS step-off of 0.89 ± 0.43mm in matched grafts and 1.60 ± 0.78mm in unmatched grafts ( p=0.007). There was also a significant difference in the percent of step-off measurements greater than 2mm sunken in the lateral quadrant between matched and unmatched grafts (5.17 ± 20.87% matched, 24.5 ± 36.39% unmatched, p=0.028). There were no significant differences between matched and unmatched grafts for any other comparison using 0.5, 1, or 2mm cut-offs for circumferential step-off or surface height deviation. Combining all allografts, the respective proportion of surface deviation and circumferential step-off height measurements that were above the stated thresholds were as follows: 31% and 34% for a 0.5mm threshold, 15% and 21% for a 1mm threshold, and 2% and 8% for a 2mm threshold. Conclusions: While unmatched Wiberg patella osteochondral allograft implantation did not result in significantly different subchondral bone surface height deviations, there were significant differences in circumferential subchondral bone step-off heights. The majority of step-off height differences between Wiberg matched and unmatched osteochondral allografts occurred in the lateral quadrant. In comparison to previous data evaluating differences in the cartilage surface match in these patellar OCA transplants, the deviations and step-off heights in the subchondral bone identified in the current study were approximately 0.5mm greater than the differences in the cartilage surface. These findings therefore suggest there is greater variability in the alignment of the subchondral bone in these patellar osteochondral allografts than there is in the cartilage surface. Further investigation using finite element analysis modeling will help determine the implications of subchondral bone surface deviation and circumferential step-off on local cartilage:bone compression and shear force distribution. These studies may shed light on the mechanisms of failure in patellar osteochondral transplants and may help to better understand the contribution of subchondral bone alignment in OCA healing and long-term outcome.

Background: Pelvic incidence (PI) is an important variable in assessing spinopelvic balance that is associated with hip pathology. A lateral radiograph of the pelvis can be used to measure PI, but this view is not routinely performed in the clinical setting during evaluation of hip pain. The false-profile (FP) radiographic view of the hip is commonly obtained to measure acetabular coverage. Purpose: To evaluate the tolerance of PI measurements to pelvic rotation and assess the feasibility of using an FP radiograph to obtain an accurate measurement of PI. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A mathematical model was developed to predict the change in PI with rotation. Fluoroscopic images were obtained of 6 reconstructed cadaveric adult pelvis and femur specimens at varying degrees of rotation, including a perfect lateral and FP image. PI was measured with the midpoint between the centers of the femoral heads as a reference point. The findings were confirmed clinically by retrospectively reviewing FP radiographs and computed tomography (CT) scans of 40 clinical patients. PI was measured on FP radiographs and CT scans by 2 independent reviewers. Results: With dry cadaveric pelvis specimens, the discrepancy in PI measured between fluoroscopic FP and lateral views was 1.6° (95% CI, 0.7°-2.4°). There was excellent agreement between CT and FP radiographs with regard to measurement of PI (intraclass correlation coefficient = 0.92; 95% CI, 0.78-0.98). Mean discrepancy in PI measured between the 40 clinical FP radiographs and CT scans was 2.8° (range, 0.1°-9.1°). Conclusion: Increased rotation from a lateral view results in greater error in measuring PI, although relatively nominally with a 2.8° error with the 25° of rotation in clinical true FP views. These data demonstrate that FP radiographs can be used to measure PI with reasonable accuracy.

The relative importance and use of motor evaluation to diagnose carpal tunnel syndrome (CTS) is not clear. Because the ulnar nerve is not affected in CTS, we evaluated comparing the strength of the median-nerve innervated muscles to the ulnar innervated muscles in the same patient, through manual muscle testing (MMT) and a handheld dynamometer. Our purpose was to evaluate whether this method, which takes into account patient-dependent factors that would affect both groups of muscles equally, can provide better assessment of CTS. A retrospective case-control review of MMT and dynamometer-measured strength for CTS was performed. The study was performed retrospectively but prior to surgery or other treatment. There were 28 cases (CTS) and 14 controls (without CTS). Positive nerve conduction tests defined cases. MMT of the thenar musculature was found to be unreliable as a test for CTS. Comparisons to ulnar nerve innervated muscle strength did not improve sensitivity or specificity of the MMT examination. Use of the dynamometer improved sensitivity and specificity of motor testing in CTS over MMT. Motor evaluation is important for the diagnosis of CTS, but further study is warranted, specifically to define the method of motor evaluation and delineate the subgroup of patients (predominantly thenar motor presentation) that would benefit most from motor testing and motor-focused treatment.

BACKGROUND: Scapular body fractures generally occur as a result of high-energy, direct trauma to the shoulder sustained in automobile accidents. While such mechanisms have been well described, little is known about scapular body fractures sustained during sporting activities. QUESTIONS/PURPOSES: We sought to systematically review the literature on scapular body fracture sustained during sporting activity, recording rates and mechanisms of injury, management strategies, and return-to-sport times. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review of studies conducted between 1985 and 2017. Inclusion criteria were studies examining scapular body fractures sustained during sporting activity, fracture management, and patient outcomes. Exclusion criteria were studies on non-sporting-related fractures and those not reporting fracture management or patient outcomes. RESULTS: Nine studies encompassing ten cases of scapular body fracture sustained during sporting activity were identified, with acute trauma responsible for 70% of fractures. No patient sustained any associated injuries. Fractures were treated conservatively in 90% of cases, with no reported complications. Mean overall time to return to sport was 2.5 months, while no significant difference in return to sport was appreciated in athletes with acute versus fatigue fractures. CONCLUSION: Scapular body fractures in athletes occur primarily from muscle contraction against a resisted force in the upper extremity during contact sports. Unlike non-sporting fractures, these fractures usually involve low-energy mechanisms without associated injury and conservative treatment is usually successful. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-018-9624-6) contains supplementary material, which is available to authorized users.

Supplemental material, DS_10.1177_0363546518780938 for Use of the False-Profile Radiographic View to Measure Pelvic Incidence by Ryan T. Li, Raymond W. Liu, Mithun Neral, Heath Gould, Emily Hu, Shane Nho and Michael J. Salata in The American Journal of Sports Medicine

Our purpose was to compare postoperative complications and rate of plate removal in titanium and stainless-steel plating of distal radius fractures (DRF). Patients following DRF were randomly fixed with titanium or stainless-steel plates using the same plating system. Complications, second surgeries, and plate prominence were documented. A total of 41 patients were treated with stainless-steel and 22 with titanium plates. Average follow-up was 60 ± 5.6 months. There was no difference in demographics, fracture characteristics, or follow-up between the groups. Plate prominence was found in 50% of radiographs (mean distance: 1.4 mm). Four titanium plates and three stainless-steel plates were removed (11%). Mean time to plate removal was 18.4 ± 4.6 months. There was no difference in removal rates between the groups. Plate material and prominence, age, fracture comminution and smoking status were not associated with plate removal. Our results support using volar and dorsal plates regardless of the plate material.

The literature evaluating external anatomical measurements and carpal tunnel syndrome (CTS) remains inconclusive. The purpose of this study was to compare hand- shape measurements of patients with and without (CTS). A retrospective case - control study of participants with suspected CTS (male/female ratio of 0.69) was performed. Nerve conduction tests (NCT) defined 65 involved hands (CTS) and 73 control hands. The relationship between 3 different hand index ratios (measuring palm length and width) and CTS (defined by NCT) was evaluated using Generalized Estimating Equations model (GEE) with the binary outcome of CTS. Palmar Length/Palmar Width index had the strongest and negative association with CTS with greatest sensitivity and specificity to detect CTS. Hands with more square shape had increased tendency to be diagnosed with CTS. Hand indices that include the shape of the palm may help identify patients with greater likelihood of developing CTS for early screening and prevention.

The ability of cells to detect and respond to nucleotide signals in the local microenvironment is essential for vascular homeostasis. The enzyme ectonucleotide tri(di)phosphohydrolase-1 (ENTPD1, also known as CD39) on the surface of leukocytes and endothelial cells metabolizes locally released, intravascular ATP and ADP, thereby eliminating these prothrombotic and proinflammatory stimuli. Here, we evaluated the contribution of CD39 to atherogenesis in the apolipoprotein E–deficient (ApoE-deficient) mouse model of atherosclerosis. Compared with control ApoE-deficient animals, plaque burden was markedly increased along with circulating markers of platelet activation in Cd39+/–Apoe–/– mice fed a high-fat diet. Plaque analysis revealed stark regionalization of endothelial CD39 expression and function in Apoe–/– mice, with CD39 prominently expressed in atheroprotective, stable flow regions and diminished in atheroprone areas subject to disturbed flow. In mice, disturbed flow as the result of partial carotid artery ligation rapidly suppressed endothelial CD39 expression. Moreover, unidirectional laminar shear stress induced atheroprotective CD39 expression in human endothelial cells. CD39 induction was dependent upon the vascular transcription factor Kruppel-like factor 2 (KLF2) binding near the transcriptional start site of CD39. Together, these data establish CD39 as a regionalized regulator of atherogenesis that is driven by shear stress.

Background he lack of structural support remains a challenge in the treatment of comminuted distal radius fractures. Calcium phosphate and calcium sulfate bone cement has been used in other fracture locations in addition to fixation and has been shown to allow for retention of reduction in difficult cases. Methods A case-control retrospective review of 34 consecutive distal radius fractures treated with surgery was performed with the patients classified by Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification. Complications and postoperative radiographs were evaluated. Results Cement was used in the most difficult cases. Radial height was retained in both groups. Volar tilt was significantly better in the cement group. There were no significant differences between the case and control groups for any complication. No complications related to the use of the cement were found. Conclusions The use of bone cement as an adjunct to fixation of distal radius fractures seems to include minimal risks and may afford a technical advantage in maintaining reduction during surgery for difficult fractures. Since there is an aspect of fracture difficulty that we cannot control for by using radiographic assessment alone, cement may provide an advantage over fixation without cement, despite similar outcomes. Bone cement can be part of the “tool box” for difficult distal radius fractures. Further study is necessary to define the technical advantages and limitations of each particular cement product.

Purpose To evaluate the clinical effectiveness of metacarpophalangeal (MCP) arthroplasty for nonrheumatic arthritis. We hypothesized that MCP arthroplasty would produce significant improvement in objective measures of hand function, pain relief, and overall patient satisfaction. Methods This retrospective study evaluated 30 patients with 38 MCP arthroplasties for nonrheumatic arthritis over a 12-year period. Follow-up assessment was completed at an average of 56 months after surgery. Objective measures included range of motion; grip and pinch strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and visual analog pain score. A subjective patient questionnaire was used to assess patient satisfaction. Results There was marked improvement between preoperative and follow-up range of motion, DASH, and pain. Linear regression showed strong correlations between preoperative measurements and improvement at follow-up. No difference was detected for grip or pinch strength. Results of the questionnaire showed that 73% were very satisfied, 87% would definitely do it again, and 70% experienced rare or no pain. Follow-up x-rays showed 5° mean angulation and 2-mm mean subsidence compared with immediate postoperative x-rays. Four arthroplasties (11%) required revision. Conclusions This study showed improved range of motion and DASH score, excellent pain relief, and excellent patient satisfaction in patients undergoing MCP arthroplasty for nonrheumatic arthritis. Patients with more severe range of motion limitation, DASH score, and pain score experienced a greater improvement of these measures at follow-up. Strength improvement was limited although it remained comparable to the nonoperated hand. Angulation, subsidence, and complications in the study population were consistent with those reported in the literature. Type of study/level of evidence Therapeutic III.