فهرست مطالب pedro beredjiklian

The primary purpose of this study was to compare the rates of nonunion among different osteotomy designs (company brand) and the rates of nonunion between oblique and transverse osteotomies. We secondarily aimed to assess the differences in reoperation and hardware removal rates after ulnar shortening osteotomy (USO).
A retrospective cohort study of patients undergoing ulnar shortening osteotomy between 2015 and 2022 in our institute amongst 17 providers resulted in 92 consecutive patients. We included skeletally mature patients who underwent USO for the ulnar impingement abutment diagnosis. Demographic information was collected, including age, gender, race/ethnicity, BMI, and medical comorbidities. Six brand-specific devices were used and compared to the conventional plate fixation. Nonunion was determined based on the final available radiograph with a minimum follow-up of four months.
Of the 92 patients, 83 (90%) had a bone union. There is a remarkable difference in union among implant brands, although statistical analysis was not performed due to the small number of patients in each group. Transverse osteotomy was significantly related to a higher nonunion rate. Out of nine patients with resultant nonunion (10%), three healed after revision surgery (3.2%), two were lost to follow-up (2.2%), and four remained asymptomatic despite radiographic nonunion (4.6%). Plate removal was performed in four patients (4.3%), all of whom were in the union group.
Patients should be informed about the nonunion rate with possible subsequent secondary surgery. Using procedure-specific devices may have mitigated the risk of nonunion.
Level of evidence: III

This study examines the pattern of muscular contraction and the intensity of this contraction of the biceps and triceps following elbow surgery. We performed a prospective electromyographic study of 16 patients undergoing 19 surgical procedures on the elbow joint. We measured the resting EMG signal intensity of the biceps and triceps of the operated and the normal sides at 90 degrees. We then calculated the peak EMG signal intensity during passive elbow flexion and extension of the operated side. Seventeen of 19 elbows (89%) displayed a co-contraction pattern of the biceps and triceps near the end of flexion and extension during the passive range of motion. The co-contraction pattern was observed near the end of the range of motion in both flexion and extension. In addition to the observed co-contraction patterns, we detected higher contraction intensities for the biceps and triceps muscles in all patients in both flexion and extension for the elbows, which had been treated surgically. Further analysis suggests an inverse correlation between the biceps contraction intensity and the arc of motion measured at the latest follow-up. The co-contraction pattern and increased contraction intensity of periarticular muscle groups may result in internal splinting mechanisms, contributing to the development of elbow joint stiffness, which is frequently observed following elbow surgery. Level of evidence: III

To investigate the reliability of orthopedic hand surgeons to evaluate radiographic healing in initial andfollow-up radiographs of the conservatively treated metacarpal shaft and neck fractures. The rationale for this studywas to reduce the rate of unnecessary, routine radiographs when treating metacarpal fractures. Forty sets of digital x-rays, twenty at the initial visit and twenty at the 4-week follow-up, were randomlyselected and reviewed. Three hand surgeons evaluated the x-rays for (1) fracture location, (2) radiograph timing,(3) healing status, (4) percentage healed, (5) angulation, and (6) confidence in healing status. Observers reviewedstudies in random order and evaluated the same set of radiographs one month after the initial review. Intra- andinterobserver agreements were analyzed using Fleiss’ kappa (κ) for all parameters and all possible observerpairings. Interobserver and intraobserver reliability was highest when evaluating fracture location and lowest whenassessing the percentage healed. The interobserver reliability was fair for radiograph timing and healing status andfair-to-moderate for angulation. The intraobserver reliability was moderate for radiograph timing and healing status andmoderate-to-substantial for angulation. Observers correctly differentiated initial vs. follow-up images 62% of the timeand reported to feel somewhat certain in their evaluation of healing status. When evaluating initial and 4-week follow-up radiographs, hand surgeons were somewhat confidentin their assessment of healing but had less than substantial intra- and interobserver reliability following radiographicevaluation. Due to their poor reproducibility, routine radiographs may be unnecessary when evaluating conservativelytreated metacarpal fractures. Further studies and guidelines that identify clear indications for the use of routine imagingin metacarpal fracture care are warranted.Level of evidence: II

The median artery is an embryonic structure that typically regresses during gestation. Occasionally, the artery remains and is then termed a persistent median artery (PMA). A PMA can be associated with other anatomic anomalies, and has been known to contribute to carpal tunnel syndrome (CTS). Recent literature has observed an increase in PMA prevalence, speculated to indicate microevolutionary change. We performed a prospective observational study to investigate the current prevalence rate of PMA in patients undergoing carpal tunnel release (CTR).  Institutional review board approval was obtained. From October 2020 to January 2021, patients ≥18 years old undergoing open CTR by 9 orthopaedic hand surgeons were included in analysis. Patients undergoing endoscopic CTR were excluded. Intraoperatively, the carpal tunnel was evaluated for the presence of a PMA, median nerve anomalies, or any other anatomic anomalies. If a patient underwent bilateral CTR during the study, only one side was included in analysis as determined randomly.  Three hundred and sixty open CTRs in 327 patients were performed during the study. Twenty-seven PMAs were identified, for an overall prevalence rate of 8.3%. The average age of patients with a PMA was 63.6 years (SD 13.3 years), consisting of 15 men and 12 women. There were no statistical differences in age, gender, or laterality between patients that did and did not have a PMA. Thirty-three patients underwent bilateral CTR during the study, with 3 being found to have a PMA unilaterally, and zero having a PMA bilaterally. Two bifid median nerves (0.6%) were also identified. This study represents the highest prevalence rate of PMA directly observed in CTR patients reported to date (8.3%). A PMA is not a rare finding, and it should be recognized and protected during CTR. Occasionally, a PMA can be the cause of an acute presentation of CTS. Level of evidence: IV

The recurrence of ganglion cysts after surgical excision has a reported rate of 4% to 40%. Recurrence rateafter revision surgical excision is unknown. The purpose of this study was to define the incidence of recurrent ganglion cystsin patients who underwent a secondary excision procedure. With Institutional Review Board approval, we retrospectively identified by CPT code and reviewed charts ofpatients who had recurrent ganglion cyst excision performed over a five-year period (2010 – 2014). Recurrence was definedas reappearance of a cyst in the same area as it was previously. Demographic information including recurrences andrevision surgeries was collected in addition to outcome variables such as patient satisfaction, pain levels, and functionallimitations. Out of the 42 revision cases identified 20 patients were reached. Mean time to recurrence of the cyst after the firstganglion cyst excision was 2.5 years (range: 1 month - 12 years). After the second ganglion cyst excision, three patients(15%) had a recurrence, each occurring within one year (mean: 11 months; range: 9-12). One of the three patients underwenta third successful ganglion cyst excision. The other two patients declined surgical intervention to date. Patients without asecond recurrence (n=17) reported an average pain score of 0.1 (range: 0-2) on a scale of 1-10. Three (18%) reported somedifficulty with day-to-day activities due to their scar. Seven (41%) patients reported at least transient numbness or tingling.Mean satisfaction was 9.8 on a scale of 1-10, and 100% reported that they would undergo another ganglion cyst excisionshould they ever have another recurrence. Patients should be advised about the risk of recurrence after re-excision of ganglion cysts, which was notedto be 15% in our cohort. This rate of recurrence is similar to that of primarily excised cysts.Level of evidence: III

Computer assisted three-dimensional (3D) printing of anatomic models using advanced imaging haswide applications within orthopaedics. The purpose of this study is to evaluate the 3D printing accuracy of carpalbones. Seven cadaveric wrists underwent CT scanning, after which select carpal bones (scaphoid, capitate, lunate,and trapezium) were dissected in toto. Dimensions including length, circumference, and volume were measured directlyfrom the cadaver bones. The CT images were converted into 3D printable stereolithography (STL) files. The STL fileswere converted into solid prints using a commercially available 3D printer. The 3D printed models’ dimensions weremeasured and compared to those of the cadaver bones. A paired t-test was performed to determine if a statisticallysignificant difference existed between the mean measurements of the cadavers and 3D printed models. The intraclasscorrelation coefficients (ICC) between the two groups were calculated to measure the degree of agreement. On average, the length and circumference of the 3D printed models were within 2.3 mm and 2.2 mm,respectively, of the cadaveric bones. There was a larger discrepancy in the volume measured, which on average waswithin 0.65 cc (15.9%) of the cadaveric bones. These differences were not statistically significant (P > 0.05). Therewas strong agreement between all measurements except the capitate’s length and lunate’s volume. 3D printing can add value to patient care and improve outcomes. This study demonstrates that 3D printingcan both accurately and reproducibly fabricate boney models that closely resemble the corresponding cadaveric anatomy.Level of evidence: V

Distribution of radiographic images in the outpatient setting on compact discs-recordable (CD-R) iscommonplace. Opening, manipulating and interpreting these can be challenging. This study evaluated the availabilityand ease of use of CD-R to evaluate digital images in an outpatient orthopedic setting. 118 CD-R containing diagnostic studies were evaluated by seven board certified orthopaedic surgeons.Surgeon age and self-perceived “tech savvy” scores were tabulated using a visual analog scale (VAS). Surgeonsevaluated: ability and number of computers to open, autorun, and specific reader software. Time to load was recordedin seconds, type of study, presence of “not for diagnostic use”, and if the disc required additional software. Studies weregraded using a VAS for ease of opening, ability to move from image to image and/or between series, to manipulatethe image, and to zoom and pan. There were 79 radiographs, 29 MRI’s, and 10 CT scans. Seven (6%) had to be manually opened andfour (3%) required software installation. Thirteen (11%) contained a warning that the studies should not be used fordiagnostic purposes. Six (5%) of the studies could not be opened. For the opened studies, average time from diskinsertion to image was 43.7 seconds overall (range 3-350), 65.3 seconds (range 21-191) for MRI and CT, and 35.2seconds (range 5-177) for radiographs. The present digital imaging systems include different software types and a variety of interfaces.Improving this would decrease time and effort necessary to open and evaluate these studies, and improveefficiency.Level of evidence: III

The goal of this study was to compare the two types of orthoses, prefabricated soft splints versus short thermoplastic custom-made splints, that are the most commonly used for the management of first carpometacarpal (CMC) osteoarthritis (OA). We conducted a meta-analysis and systematic review in the literature based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We extracted the outcomes of disability scores, pain scores, grip and pinch strength and gathered the unified data accordingly. We included five randomized clinical trials with 230 patients with the mean age of 61 years and the mean follow-up of 8.1 weeks. The results of the pooled data demonstrated only a statistically significant difference in disability scores among splints in favor of the prefabricated splints. The rest of the outcome measures consisting of pain, grip strength, and pinch strength were not statistically different. According to our systematic review and meta-analysis, both thumb-based splints improved pain and function in the first CMC OA in a short-term follow-up, nevertheless the efficacy of prefabricated splints in abatement of disability scores was significantly higher than custom-made splints. In contrast, the other outcome measures including pain, grip and pinch strength were improved identically after wearing either of the splints. Level of evidence: II

Surgical site infection (SSI) remains a concern in shoulder surgery, especially during arthroplasty. While many studies have explored the characteristics and efficacy of different sterilizing solutions, no study has evaluated the method of application. The purpose of this study was to compare two popular pre surgical preparatory applications (two 4 x 4 cm gauze sponges and applicator stick) in their ability to cover the skin of the shoulder.
Two orthopedic surgeons simulated the standard pre-surgical skin preparation on 22 shoulders of volunteer subjects. Each surgeon alternated between an applicator stick and two sterile 4x4 cm gauze sponges. Skin preparation was performed with a commercially available solution that can be illuminated under UV-A light. Advanced imageanalysis software was utilized to determine un-prepped areas. A two-tailed paired t-test was performed to compare percentage of un-prepped skin.
The applicator stick method resulted in a significantly higher percentage of un prepped skin (27.25%, Range 10-49.3) than the gauze sponge method (15.37%, Range 5-32.8, P=0.002). Based on image evaluation, most unprepped areas were present around the axilla.
Based on our findings, the use of simple gauze sponges for pre-surgical preparatory application of sterilization solution may result in a lower percent of un-prepped skin than commercially available applicator stick. Orthopaedic surgeons and operating room staff should be careful during the pre-surgical sterile preparation of the shoulder, especially the region around the axilla, in order to reduce the potential risk of surgical site infection.

Object: The gold standard for evaluating bone mineral density is dual energy x-ray absorptiometry (DEXA). Prior studies have shown poor reliability using analog wrist X-rays in diagnosing osteoporosis. Our goal was to investigate if there was improved diagnostic value to visual assessment of digital hand X-rays in osteoporosis screening. We hypothesized that similar to analog counterparts, digital hand X-rays have poor correlation and reliability in determining bone mineral density (BMD) relative to DEXA.
We prospectively evaluated female patients older than 65 years who presented to our hand clinic with digital hand and wrist X-rays as part of their evaluation over six months. Patients who had a fracture and were without DEXA scans within the past two years were excluded. Five fellowship-trained hand surgeons, blinded to DEXA T-scores, evaluated the x-rays over two assessments separated by four weeks and classified them as osteoporotic, osteopenic, or normal BMD. Accuracy relative to DEXA T-score, interobserver and intraobserver rates were calculated.
Thirty four patients met the inclusion criteria and a total of 340 x-rays reviews were performed. The assessments were correct in 169 cases (49%) as compared to the DEXA T-scores. A mean weighted kappa coefficient of agreement between observers was 0.29 (range 0.02-0.41) reflecting a fair agreement. The first and second assessment for all five physicians was 0.46 (range 0.19-0.78) reflecting a moderate agreement. Grouping osteoporosis and osteopenia together compared to normal, the accuracy, interobserver and intraobserver rates increased to 63%, 0.42 and 0.54 respectively.
Abnormally low BMD is a common occurrence in patients treated for upper extremity disorders. There is poor accuracy relative to DEXA scan and only fair agreement in diagnosing osteoporosis using visual assessments of digital x-rays.

Ganglion cysts are the most common wrist tumors, and 60 -70% originate dorsally from the scapholunate interval. Ossification of these lesions is exceedingly rare, with only one such lesion located in the finger reported in the literature. We present a case of an ossified dorsal wrist ganglion in a 68-year-old woman.

Tendon transfers in hand patients are a commonly performed procedure after extensor tendon rupture. However, the standard side to side technique is not applicable in every patient. We present a case of a musician with unique demands to demonstrate the option to customize surgical technique and therapy regimen to the unique needs of each patient. An extensor indicis proprius to extensor digitorum communis transfer was performed in a 73 year old musician. A controlled active motion therapy protocol was followed. The patients musical practice regimen was incorporated into the therapy. The patient was able to independently extend her ring and small fingers in order to play her instrument and resumed play within one month postoperatively.
A patient’s functional goals including avocations need to be considered when selecting the appropriate surgical and therapeutic approach