School of Medicine

BACKGROUND: A novel device integrating both local anesthetic delivery and peripheral nerve stimulation (PNS) to treat postoperative pain is under development. The device uses a catheter-over-needle design that permits ultrasound-guided percutaneous insertion. An integrated electrode and pulse generator enable PNS for up to 28 days. Such an approach may represent a paradigm shift in postoperative pain management by enabling the delivery of (1) a single-injection peripheral nerve block, (2) a continuous peripheral nerve block, and (3) neuromodulation-all through a single system that can be placed in a timeframe comparable with that of a traditional single-injection nerve block. The current prospective pilot study was executed under a US Food and Drug Investigational Device Exemption to develop insertion and management protocols, as well as assess the feasibility and safety of using the device to treat postoperative pain. METHODS: Preoperatively, adults (n=20) undergoing moderate-to-severely painful ambulatory shoulder or foot/ankle surgery had a device (RELAY, Gate Science, Moultonborough, NH) inserted under ultrasound guidance adjacent to the brachial plexus or sciatic nerve, respectively. Accurate insertion was confirmed with a 10 mL bolus of lidocaine via the catheter followed by bupivacaine (10 mL). If a continuous infusion was indicated, a portable pump was used to infuse ropivacaine (6-8 mL/h, 500 mL reservoir). Electric current was delivered using the integrated pulse generator for 7 days, followed by removal at home. Participants were contacted for data collection on postoperative days 1-5, 7, 8, and 14. RESULTS: During the first seven postoperative days, the median (IQR) "average" daily pain intensity as measured with the numeric rating scale (NRS) was 2 [0, 3]. Following postoperative day 1, daily average and maximum/worst NRS was less than 2 and 5, respectively. Regarding the "worst" (maximum) pain level over the entire study period of Days 0-14, 7 (35%) experienced mild pain (NRS<4), 10 (50%) moderate pain (NRS 4-7), and 3 (15%) severe pain (NRS>7). Cumulative oxycodone consumption the first week was a median of 43 (18, 73) mg. CONCLUSIONS: This novel device successfully delivered a single-injection local anesthetic bolus, a continuous perineural infusion, and concurrent/subsequent electrical current. A randomized, sham-controlled clinical trial appears warranted. CLINICALTRIALSGOV : NCT06818708.

Background: Intervertebral disc (IVD) degeneration (IVDD) is a major cause of global disability. Three papers on puncture models of IVDD were published 20 years ago, transforming the application of preclinical animal models for pathophysiology and therapeutic screening studies. Methods: Narrative review describing historic and current usage of preclinical puncture models of IVDD, documenting their introduction to induce slow, progressive IVDD and evolution to include many injury types broadly called "puncture models." IVDD puncture models were reviewed for variability in species, needle gauge, puncture depth, IVD compartment, injectates, angle of puncture, motion of needle, and IVDD phenotype mimicked. Results: IVD puncture models gained prominence following seminal 2005 publications describing needle puncture to induce slow, progressive IVDD for screening therapies. Specific details of puncture methods were described for controlling injury severity to induce IVDD phenotypes, including slow progressive IVDD, severe IVDD, chronic IVDD, disc herniation, and Modic-like changes. Common measurements for characterizing IVDD were also described. Conclusions: Surgically induced IVD puncture injury animal models have evolved over decades to include many variations simulating distinct clinical phenotypes of IVDD. To facilitate cross-study comparisons, we recommend reporting a common set of injury features including needle gauge, puncture depth, injectates, puncture angle changes, needle motion, involvement of endplate and surrounding tissues, and phenotypes of IVDD mimicked. Surgically induced "outside-in" puncture injury models are valuable tools to test specific hypotheses and screening therapies.

BACKGROUND: Surgical patient hospital readmissions are costly to the health care system. The Affordable Care Act Hospital Readmissions Reduction Program introduced penalties for high hospital readmission rates. We performed a retrospective study evaluating factors associated with readmission in hand surgical inpatients. METHODS: We performed a retrospective chart review on 566 patients admitted to a level 1 trauma center for hand trauma or infection from January 1, 2016, to December 31, 2019. Data included demographics, social history, medical problems, comorbidities, procedure details, and admission and readmission details. A multivariable regression analysis was performed to identify factors associated with hospital readmission within 30 days. RESULTS: Cigarette smoking (P = .048), bite wound (P = .038), laceration wound (P = .028), laceration repair (P < .01), open reduction internal fixation (P = .041), and disposition to a skilled nursing facility (P = .017) were significantly associated with readmission to the hospital within 30 days. For patients who underwent emergency department interventions, alcohol use (P = .034), houselessness (P = .046), and malnutrition (P = .036) were additional factors associated with readmission. CONCLUSIONS: Immediately irremediable factors such as tobacco and alcohol abuse, malnutrition, and houselessness should be considered as exemptions for penalties levied on health care systems for readmissions. Initiating targeted interventions, such as detoxification, smoking cessation, housing assistance, and improved nutrition, may reduce readmission risk and could improve patient outcomes.

PURPOSE: This cross-sectional study investigates the utility of the quantitative ultrashort echo time (UTE) adiabatic T_1ρ (UTE-Adiab-T_1ρ) magnetic resonance imaging (MRI) in detecting potential differences in Achilles tendons and entheses of patients with psoriatic arthritis disease (PsA) compared with asymptomatic volunteers. MATERIAL AND METHOD: The Achilles tendons of forty-four PsA patients (59 ± 15 years old, 38 % female) and thirty-seven asymptomatic volunteers (32 ± 10 years old, 51 % female) were scanned on a 3 T clinical scanner in the sagittal plane using a 3-inch surface coil. The 3D UTE-Adiab-T_1ρ sequences with fat saturation (FS) were used to measure UTE-Adiab-T_1ρ. Tenderness of the tendons, the SF-12 health survey, and visual analog scale (VAS) were recorded for the patients. The Kruskal Wallis test was used to examine the differences in UTE-Adiab-T1_ρ values between asymptomatic volunteers and patients, as well as subgroups of patients with pain in the Achilles tendon region and those treated with Biologics. Spearman's correlation coefficients were calculated between UTE-Adiab-T_1ρ and patient evaluations. P values < 0.05 were considered significant. RESULTS: UTE-Adiab-T_1ρ was significantly higher for the PsA group compared with the asymptomatic group in the enthesis (11.4 ± 2.6 ms vs. 10.4 ± 2.4 ms) and tensile tendon regions (9.8 ± 2.8 ms vs. 7.7 ± 1.7 ms). PsA patients with active Achilles pain showed significantly lower T1ρ in the entheses compared with other patients (10.7 ± 2.6 ms vs. 11.7 ± 2.5 ms). PsA patients treated with Biologics showed significantly lower T_1ρ values in the tendon compared with other patients (9.5 ± 2.5 ms vs. 10.3 ± 3.3 ms). The VAS score of patients showed a significant negative but weak correlation (R = -0.2) with UTE-Adiab-T1ρ of the enthesis. Correlations with SF-12 scores were not significant. CONCLUSION: This study highlighted the UTE-Adiab-T_1ρ sequence capability in evaluating tendons and entheses and their potential involvement in PsA disease or response to therapies.

Skeletal muscle has a classic structure function relationship; both skeletal muscle microstructure and architecture are directly related to force generating capacity. Biopsy, the gold standard for evaluating muscle microstructure, is highly invasive, destructive to muscle, and provides only a small amount of information about the entire volume of a muscle. Similarly, muscle fiber lengths and pennation angles, key features of muscle architecture predictive of muscle function, are traditionally studied via cadaveric dissection. Noninvasive techniques such as diffusion magnetic resonance imaging (dMRI) offer quantitative approaches to study skeletal muscle microstructure and architecture. Despite its prevalence in applications for musculoskeletal research, clinical adoption is hindered by a lack of understanding regarding its sensitivity to clinically important biomarkers such as muscle fiber cross-sectional area. This review aims to elucidate how dMRI has been utilized to study skeletal muscle, covering fundamentals of muscle physiology, dMRI acquisition techniques, dMRI modeling, and applications where dMRI has been leveraged to noninvasively study skeletal muscle changes in response to disease, aging, injury, and human performance. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 2.

Background: Bernese periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia and femoroacetabular impingement has become increasingly common, with a corresponding increase in the incidence of adverse outcomes. The rate of major neurological injury (excluding lateral femoral cutaneous nerve injury) during PAO has been reported to be around 2%. Previous publications have recommended the use of intraoperative neuromonitoring (IONM) to mitigate risk of major neurological injury during PAO, but its use has not become universal among PAO surgeons as it has among spine surgeons. The purpose of this study was to report the incidence and clinical significance of IONM alerts in a single-surgeon, consecutive cohort of patients treated with Bernese PAO. Methods: After a permanent peripheral nerve injury during a PAO without IONM, IONM has been used at our institution in every PAO. Motor evoked potentials and somatosensory monitoring are performed throughout the procedure. We conducted a retrospective review of all PAOs performed after this practice change between 2017 and 2023. Medical records were reviewed for all IONM alerts, surgical team responses to alerts, and postoperative neurological status. Results: All 94 PAOs performed with IONM in 82 patients during the study period were included. The mean age was 19 years (range 11-38). Significant IONM alerts occurred in 10 of 94 PAOs (11%) in 10 patients. Of these 10 alerts, 6 resulted in action taken by the surgical team including adjustment of acetabular fragment correction, leg repositioning, or stockinette or boot loosening. The remaining 4 alerts were due to anesthetic or systemic causes or technical issues with the neuromonitoring electrodes. No patients had a detectable neurological deficit postoperatively. Conclusions: IONM may produce alerts in approximately 1 in 9 periacetabular osteotomies. These alerts are actionable and may improve patient safety and minimize the non-negligible risk of major nerve injury. This study provides additional evidence to support the utility of IONM in PAO. Level of Evidence: Level III-retrospective cohort study. See Instructions for Authors for a complete description of levels of evidence.

PurposeWhile treatment modalities for Maisonneuve fractures involving the proximal third of the fibula are established, no studies to date have reported outcomes associated with syndesmotic-only fixation of middle third fibular shaft fractures. The purpose of this study was to evaluate outcomes associated with syndesmotic-only fixation in the treatment of Maisonneuve fractures involving the middle third of the fibula.MethodsA retrospective review was conducted on 257 cases of syndesmotic ankle instability with associated fibular fractures at a level 1 trauma center between 2013 and 2023. Patients were divided into cohorts based on fibular fracture location in the proximal, middle, or distal third of the fibula. The Chi-square test of independence, two-sample t-test, and analysis of variance were used to compare outcome measures between cohorts.ResultsSixty-six patients were identified including 48% (n = 32) with proximal third fibular fractures, 20% (n = 13) with middle third fibular fractures, and 32% (n = 21) with distal third fibular fractures. Rates of infection, loss of reduction, wound healing complications, and reoperation did not vary significantly between cohorts. Functional outcome measures including range of motion, time to weight-bearing, and tibiofibular/medial clear space measurements at final follow-up were similar across cohorts.ConclusionPatients with Maisonneuve fractures involving the middle third of the fibula demonstrated positive outcomes with syndesmotic fixation alone, with no documented cases of infection, loss of reduction, or wound healing issues. By demonstrating maintenance of anatomic reduction and low rates of complications, our results support the use of syndesmotic-only fixation in the treatment of middle third Maisonneuve fractures.

BACKGROUND: Concomitant carpal injuries with dislocations and fracture-dislocations of the carpometacarpal joints (CMCD/FD) are often hard to see on plain radiographs, making advanced imaging a useful diagnostic adjunct. We aim to: (1) characterize bony injury patterns with CMCD/FD; and (2) determine the frequency that preoperative computed tomography (CT) scans change surgical management. METHODS: A retrospective review was performed of patients who underwent operative fixation of CMCD/FD from 2006 to 2021. X-ray and CT scan diagnoses were reviewed and correlated to intraoperative findings and procedures performed. Statistical analyses were performed to evaluate the frequency in which CT scans changed management and the frequency of new intraoperative diagnoses. RESULTS: Seventy-five patients were identified. All patients had a preoperative x-ray, and 27 patients (36%) additionally had a CT scan. Patients who sustained high-velocity trauma were significantly more likely to obtain a CT scan than patients with low-velocity trauma (P = .019); however, the number of additional diagnoses was not significantly associated with trauma velocity (P = .35). Computed tomography scans significantly increased the number of diagnoses (P < .001) and changed operative management in 58% of cases. Six of the 48 patients (12.5%) that did not receive a CT scan had new intraoperative diagnoses, which changed the procedure for five of these patients. New intraoperative diagnoses were identified significantly more when patients did not have a CT scan (P = .04). CONCLUSIONS: Obtaining a CT scan in CMCD/FD patients changed the patient's diagnosis at a significant rate and changed operative management roughly half of the time. The authors recommend routine CT scans be obtained in patients with CMCD/FD.

Background: Consensus regarding which children within orthopedics would benefit from venous thromboembolism (VTE) prophylaxis is lacking. Our objective was to explore the incidence and epidemiology of VTE within pediatric orthopedics through a multicenter review across the United States. Methods: Encompassing 13 pediatric centers nationwide, VTE incidence rates with 95% confidence interval (CIs) were determined for all pediatric nonorthopedic patients (PNOPs) in general (age 0-18 years) and compared with pediatric orthopedic patients (POPs) from both inpatient and outpatient settings between 2014 and 2017. Demographics, risk factors, presence of prophylaxis, treatment, and outcomes for POP VTEs were analyzed using descriptive statistics. Results: Of 10,040,937 total unique patients, the overall 4-year VTE incidence for PNOPs was 2.1 per 10,000 patients (CI 2.01-2.19). Of 141,545 POPs, the VTE incidence was 8.0 per 10,000 patients (CI 6.61-9.63). The weighted median age for POP VTEs was higher than that for PNOP VTEs (11.5 vs. 8.0 years, p = 0.001). Of the 113 POP VTEs, 97 eligible patients (median age 13.3 years, 56% male) with complete data were further analyzed: 85% (82/97) underwent orthopedic surgery for trauma, infection, or an elective procedure. Orthopedic procedures (49%), bacteremia (46%), central venous catheters (38%), and trauma (28%) were the most common risk factors associated with VTE development, mostly occurring during the initial hospitalization (65%). Thirty-four percent (33/97) of VTE cases had received prophylaxis, predominantly pharmacological (26/33, 79%), administered postoperatively. Ninety-seven percent (94/97) of POP VTEs were treated with anticoagulation, most frequently low-molecular-weight heparin (79%). Twenty-two percent of POP VTEs experienced complications, 2 (2%) of which were deaths, with one having received postoperative VTE prophylaxis. Conclusions: Although relatively rare, the true incidence of pediatric orthopedic-related VTE may be greater than that of nonpediatric orthopedic VTE, with child mortality occurring in a small minority of cases. In children diagnosed with VTE, one third had received VTE prophylaxis. Identifying at-risk children undergoing orthopedic surgery and establishing best practice safety protocols for VTE prevention are critical to prevent associated morbidity and mortality. Level of Evidence: Level III-Retrospective comparative study. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Posterolateral rotatory instability (PLRI) results from lateral ulnar collateral ligament (LCL) deficiency. The lateral pivot shift test is used to diagnose PLRI but can be difficult to perform and is poorly tolerated. We present a new maneuver, the Posterior Radiocapitellar Subluxation Test (PRST), that we believe is easier to perform. The purpose of this study was to compare the efficacy and reproducibility of the PRST with the lateral pivot shift test. METHODS: We obtained 10 cadaveric upper extremity specimens, performed a Kocher approach on each, released the LCL origin in 5, then closed. The specimens were randomized, and 3 attending orthopedic surgeons and 1 resident blindly performed the PRST then the lateral pivot shift test after re-randomization and assessed presence or absence of PLRI. This process was repeated the following day. The data for each test were analyzed for sensitivity, specificity, and accuracy. RESULTS: For the blinded testing when comparing PRST with the pivot shift test, overall accuracy was 77.5%, compared with 67.5% (P = .03), sensitivity was 75.0%, compared with 50.0% (P = .003), and specificity was 80.0%, compared with 85.0% (P = .55). Conclusions: The PRST appears to be at least as accurate as the lateral pivot shift test, with comparable intraobserver and interobserver reliability.