Surgery Commons^™

Optimal Management Of Post-Traumatic Radioulnar Synostosis, Arthur Lee Osterman, Melissa S. Arief

Department of Orthopaedic Surgery Faculty Papers

Post-traumatic radioulnar synostosis is a rare complication after forearm or elbow injury that can result in loss of motion and significant disability. Risk factors include aspects of the initial trauma and of the surgical treatment of that trauma. Surgical intervention for synostosis is the standard of care and is determined based on the location of the bony bridge. Surgical timing is recommended between 6 months and 2 years with recent advocacy for the 6- to 12-month period after radiographs demonstrate bony maturation but early enough to prevent further stiffness and contractures. For most types of synostosis, surgical resection with interposition …

Tnf-Α Promotes Nuclear Enrichment Of The Transcription Factor Tonebp/Nfat5 To Selectively Control Inflammatory But Not Osmoregulatory Responses In Nucleus Pulposus Cells., Zariel I. Johnson, Alexandra C. Doolittle, Joseph W. Snuggs, Irving M. Shapiro, Christine L. Le Maitre, Makarand V. Risbud

Department of Orthopaedic Surgery Faculty Papers

Intervertebral disc degeneration (IDD) causes chronic back pain and is linked to production of proinflammatory molecules by nucleus pulposus (NP) and other disc cells. Activation of tonicity-responsive enhancer-binding protein (TonEBP)/NFAT5 by non-osmotic stimuli, including proinflammatory molecules, occurs in cells involved in immune response. However, whether inflammatory stimuli activate TonEBP in NP cells and whether TonEBP controls inflammation during IDD is unknown. We show that TNF-α, but not IL-1β or LPS, promoted nuclear enrichment of TonEBP protein. However, TNF-α-mediated activation of TonEBP did not cause induction of osmoregulatory genes. RNA sequencing showed that 8.5% of TNF-α transcriptional responses were TonEBP-dependent and …

Prospects And Limitations Of Improving Skeletal Growth In A Mouse Model Of Spondyloepiphyseal Dysplasia Caused By R992c (P.R1192c) Substitution In Collagen Ii., Machiko Arita, Jolanta Fertala, Cheryl Hou, James Kostas, Andrzej Steplewski, Andrzej Fertala

Department of Orthopaedic Surgery Faculty Papers

Skeletal dysplasias form a group of skeletal disorders caused by mutations in macromolecules of cartilage and bone. The severity of skeletal dysplasias ranges from precocious arthropathy to perinatal lethality. Although the pathomechanisms of these disorders are generally well defined, the feasibility of repairing established aberrant skeletal tissues that developed in the presence of mutant molecules is currently unknown. Here, we employed a validated mouse model of spondyloepiphyseal dysplasia (SED) that enables temporal control of the production of the R992C (p.R1192C) collagen II mutant that causes this disease. Although in our earlier studies we determined that blocking the expression of this …

New Horizons In Spine Research: Intervertebral Disc Repair And Regeneration., James C Iatridis, James Kang, Rita Kandel, Makarand V. Risbud

Department of Orthopaedic Surgery Faculty Papers

No abstract provided.

Distal Interphalangeal Joint Arthrodesis Complicated By Postoperative Infection: A Rare Presentation Of Disseminated Herpes Simplex Virus., Meredith N. Osterman, Michael P. Gaspar

Department of Orthopaedic Surgery Faculty Papers

Postoperative infection after elective arthrodesis of the interphalangeal joint is an uncommon complication often necessitating urgent debridement. We present the rare case of a female patient with a history of oral herpetic lesions, who underwent elective arthrodesis of the middle and index fingers for treatment of erosive osteoarthritis and subsequently developed a postoperative herpetic infection at the surgical site.

Rna Sequencing Reveals A Role Of Tonebp Transcription Factor In Regulation Of Pro-Inflammatory Genes In Response To Hyperosmolarity In Healthy Nucleus Pulposus Cells: A Homeostatic Response?, Zariel I. Johnson, Irving M. Shapiro, Makarand V. Risbud

Department of Orthopaedic Surgery Faculty Papers

Transcription factor tonicity-responsive enhancer-binding protein (TonEBP/NFAT5) is critical for osmo-adaptation and extracellular matrix homeostasis of nucleus pulposus (NP) cells in their hypertonic tissue niche. Recent studies implicate TonEBP signaling in inflammatory disease and rheumatoid arthritis pathogenesis. However, broader functions of TonEBP in the disc remain unknown. RNA sequencing was performed on NP cells with TonEBP knockdown under hypertonic conditions. 1140 TonEBP-dependent genes were identified and categorized using Ingenuity Pathway Analysis. Bioinformatic analysis showed enrichment of matrix homeostasis and cytokine/chemokine signaling pathways. C-C motif chemokine ligand 2 (CCL2), interleukin 6 (IL6), tumor necrosis factor (TNF), and nitric oxide synthase 2 (NOS2) …

Evaluation And Management Of Sleep Disorders In The Hand Surgery Patient., Michael P. Gaspar, Patrick M. Kane, Sidney M. Jacoby, Patrick S. Gaspar, A. Lee Osterman

Department of Orthopaedic Surgery Faculty Papers

Despite posing a significant public health threat, sleep disorders remain poorly understood and often underdiagnosed and mismanaged. Although sleep disorders are seemingly unrelated, hand surgeons should be mindful of these because numerous conditions of the upper extremity have known associations with sleep disturbances that can adversely affect patient function and satisfaction. In addition, patients with sleep disorders are at significantly higher risk for severe, even life-threatening medical comorbidities, further amplifying the role of hand surgeons in the recognition of this condition.

Geographic And Age-Based Variations In Medicare Reimbursement Among Assh Members., Michael P. Gaspar, Patrick M. Kane, Grace B. Honik, Eon K. Shin, Sidney M. Jacoby, A. Lee Osterman

Department of Orthopaedic Surgery Faculty Papers

Background: The purpose of this study was to investigate how American Society for Surgery of the Hand (ASSH) members' Medicare reimbursement depends on their geographical location and number of years in practice. Methods: Demographic data for surgeons who were active members of the ASSH in 2012 were obtained using information publicly available through the US Centers for Medicare and Medicaid Services (CMS). "Hand-surgeons-per-capita" and average reimbursement per surgeon were calculated for each state. Regression analysis was performed to determine a relationship between (1) each state's average reimbursement versus the number of ASSH members in that state, (2) average reimbursement versus …

Medicare Reimbursement For Total Joint Arthroplasty: The Driving Forces., Eric M. Padegimas, Kushagra Verma, Benjamin Zmistowski, Richard H. Rothman, James J. Purtill, Michael Howley

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: Total joint arthroplasty is a large and growing part of the U.S. Medicare budget, drawing attention to how much providers are paid for their services. The purpose of this study was to examine the variables that affect total joint arthroplasty reimbursement. Along with standard economic variables, we include unique health-care variables. Given the focus on value in the Affordable Care Act, the model examines the relationship of the quality of care to total joint arthroplasty reimbursement. We hoped to find that reimbursement patterns reward quality and reflect standard economic principles.

METHODS: Multivariable regression was performed to identify variables that …

Outcomes And National Trends For The Surgical Treatment Of Lumbar Spine Trauma., Doniel Drazin, Miriam Nuno, Faris Shweikeh, Alex R. Vaccaro, Eli Baron, Terrence T. Kim, J. Patrick Johnson

Department of Orthopaedic Surgery Faculty Papers

Introduction. Operative treatment of lumbar spine compression fractures includes fusion and/or cement augmentation. Our aim was to evaluate postoperative differences in patients treated surgically with fusion, vertebroplasty, or kyphoplasty. Methods. The Nationwide Inpatient Sample Database search for adult vertebral compression fracture patients treated 2004-2011 identified 102,316 surgical patients: 30.6% underwent spinal fusion, 17.1% underwent kyphoplasty, and 49.9% underwent vertebroplasty. Univariate analysis of patient and hospital characteristics, by treatment, was performed. Multivariable analysis was used to determine factors associated with mortality, nonroutine discharge, complications, and patient safety. Results. Average patient age: fusion (46.2), kyphoplasty (78.5), vertebroplasty (76.7) (p < .0001). Gender, race, household income, hospital-specific characteristics, and insurance differences were found (p ≤ .001). Leading comorbidities were hypertension, osteoporosis, and diabetes. Risks for higher mortality (OR 2.0: CI: 1.6-2.5), nonroutine discharge (OR 1.6, CI: 1.6-1.7), complications (OR 1.1, CI: 1.0-1.1), and safety related events (OR 1.1, CI: 1.0-1.1) rose consistently with increasing age, particularly among fusion patients. Preexisting comorbidities and longer in-hospital length of stay were associated with increased odds of nonroutine discharge, complications, and patient safety. Conclusions. Fusion patients had higher rates of poorer outcomes compared to vertebroplasty and kyphoplasty cohorts. Mortality, nonroutine discharge, complications, and adverse events increased consistently with older age.

The Role Of Sonic Hedgehog Signaling In Osteoclastogenesis And Jaw Bone Destruction., Tsuyoshi Shimo, Kenichi Matsumoto, Kiyofumi Takabatake, Eriko Aoyama, Yuichiro Takebe, Soichiro Ibaragi, Tatsuo Okui, Naito Kurio, Hiroyuki Takada, Kyoichi Obata, Pai Pang, Masahiro Iwamoto, Hitoshi Nagatsuka, Akira Sasaki

Department of Orthopaedic Surgery Faculty Papers

Sonic hedgehog (SHH) and its signaling have been identified in several human cancers, and increased levels of its expression appear to correlate with disease progression and metastasis. However, the role of SHH in bone destruction associated with oral squamous cell carcinomas is still unclear. In this study we analyzed SHH expression and the role played by SHH signaling in gingival carcinoma-induced jawbone destruction. From an analysis of surgically resected lower gingival squamous cell carcinoma mandible samples, we found that SHH was highly expressed in tumor cells that had invaded the bone matrix. On the other hand, the hedgehog receptor Patched …

Predicting Revision Following In Situ Ulnar Nerve Decompression For Patients With Idiopathic Cubital Tunnel Syndrome., Michael P. Gaspar, Patrick M. Kane, Dechporn Putthiwara, Sidney M. Jacoby, A. Lee Osterman

Department of Orthopaedic Surgery Faculty Papers

PURPOSE: To determine the incidence of revision and potential risk factors for needing revision surgery following in situ ulnar nerve decompression for patients with idiopathic cubital tunnel syndrome (CTS).

METHODS: We conducted a retrospective chart review of all patients treated at 1 specialty hand center with an open in situ ulnar nerve decompression for idiopathic CTS from January 2006 through December 2010. Revision incidence was determined by identifying patients who underwent additional surgeries for recurrent or persistent ulnar nerve symptoms. Bivariate analysis was performed to determine which variables had a significant influence on the need for revision surgery.

RESULTS: Revision …

Variables Prognostic For Delayed Union And Nonunion Following Ulnar Shortening Fixed With A Dedicated Osteotomy Plate., Michael P. Gaspar, Patrick M. Kane, Ralph C Zohn, Taylor Buckley, Sidney M. Jacoby, Eon K. Shin

Department of Orthopaedic Surgery Faculty Papers

PURPOSE: To examine potential risk factors for the development of delayed or nonunion following elective ulnar shortening osteotomy using a dedicated osteotomy plating system.

METHODS: We performed a retrospective review of all patients who underwent elective ulnar shortening using the TriMed single osteotomy dynamic compression plating system by 1 of 2 fellowship-trained hand surgeons over a 5-year period. Demographic data and medical, surgical, and social histories were reviewed. Time to bony union was determined radiographically by a blinded reviewer. Bivariate statistical analysis was performed to examine the effect of explanatory variables on the time to union and the incidence of …

Disc In Flames: Roles Of Tnf-Α And Il-1Β In Intervertebral Disc Degeneration., Z I Johnson, Z R Schoepflin, H Choi, I M Shapiro, M V Risbud

Department of Orthopaedic Surgery Faculty Papers

The intervertebral disc is an important mechanical structure that allows range of motion of the spinal column. Degeneration of the intervertebral disc--incited by aging, traumatic insult, genetic predisposition, or other factors--is often defined by functional and structural changes in the tissue, including excessive breakdown of the extracellular matrix, increased disc cell senescence and death, as well as compromised biomechanical function of the tissue. Intervertebral disc degeneration is strongly correlated with low back pain, which is a highly prevalent and costly condition, significantly contributing to loss in productivity and health care costs. Disc degeneration is a chronic, progressive condition, and current …

Understanding Nucleus Pulposus Cell Phenotype: A Prerequisite For Stem Cell Based Therapies To Treat Intervertebral Disc Degeneration., Hyowon Choi, Zariel I. Johnson, Makarand V. Risbud

Department of Orthopaedic Surgery Faculty Papers

Intervertebral disc (IVD) degeneration and associated low back pain (LBP) remains a major burden to our society without significant improvements in treatment strategies or patient's quality of life. While the recent cell-transplantation studies for treatment of degenerative disc disease have shown promising results, to better gauge the success and functional outcomes of these therapies, it is crucial to understand if transplanted cells give rise to healthy nucleus pulposus (NP) tissue. NP cell phenotype is unique and is defined by expression of a characteristic set of markers that reflect specialized physiology and function. This review summarizes phenotypic markers that mirror the …

Boning Up On Autophagy: The Role Of Autophagy In Skeletal Biology., Irving Shapiro, Robert Layfield, Martin Lotz, Carmine Settembre, Caroline Whitehouse

Department of Orthopaedic Surgery Faculty Papers

From an evolutionary perspective, the major function of bone is to provide stable sites for muscle attachment and affording protection of vital organs, especially the heart and lungs (ribs) and spinal cord (vertebrae and intervertebral discs). However, bone has a considerable number of other functions: serving as a store for mineral ions, providing a site for blood cell synthesis and participating in a complex system-wide endocrine system. Not surprisingly, bone and cartilage cell homeostasis is tightly controlled, as is the maintenance of tissue structure and mass. While a great deal of new information is accruing concerning skeletal cell homeostasis, one …

Allograft Reconstruction For Digital Nerve Loss., John S Taras, Nirav Amin, Nimit Patel, Lucy A Mccabe

Department of Orthopaedic Surgery Faculty Papers

PURPOSE: To investigate the outcomes of digital nerve repairs using processed nerve allograft for defects measuring 30 mm or less.

METHODS: Seventeen patients with 21 digital nerve lacerations in the hand underwent reconstruction with processed nerve allograft. Outcome data for 14 patients with 18 digital nerve lacerations were available for analysis. Postoperative outcome data were recorded at a minimum of 12 months and an average of 15 months. The average nerve gap measured 11 mm (range, 5-30 mm). Outcome measures included postoperative sensory examination as assessed by Semmes-Weinstein monofilaments and static and moving 2-point discrimination. Pain was graded using a …

Predictors Of Treatment Outcomes In Geriatric Patients With Odontoid Fractures: Aospine North America Multi-Centre Prospective Gof Study., Michael G Fehlings, Ranganathan Arun, Alex R. Vaccaro, Paul M Arnold, Jens R Chapman, Branko Kopjar

Department of Orthopaedic Surgery Faculty Papers

STUDY DESIGN: Multicenter prospective cohort study.

OBJECTIVE: To identify patient and treatment characteristics associated with treatment success or failure in the management of odontoid fractures.

SUMMARY OF BACKGROUND DATA: Odontoid fractures are the most common cervical spine fractures in the elderly and represent a significant management challenge with widely divergent views regarding operative versus nonoperative management.

METHODS: A total of 159 patients 65 years and older with radiographically confirmed type II odontoid fractures were enrolled at 10 sites in the United States and 1 site in Canada between January 2006 and May 2009. Subjects were followed at 6 and 12 …

An Organ Culture System To Model Early Degenerative Changes Of The Intervertebral Disc., Ravi K Ponnappan, Dessislava Z Markova, Paul Jd Antonio, Hallie B Murray, Alexander R Vaccaro, Irving M Shapiro, D Greg Anderson, Todd J Albert, Makarand V Risbud

Department of Orthopaedic Surgery Faculty Papers

ABSTRACT: INTRODUCTION: Back pain, a significant source of morbidity in our society, is related to the degenerative changes of the intervertebral disc. At present, the treatment of disc disease consists of therapies that are aimed at symptomatic relief. This shortcoming stems in large part from our lack of understanding of the biochemical and molecular events that drive the disease process. The goal of this study is to develop a model of early disc degeneration using an organ culture. This approach is based on our previous studies that indicate that organ culture closely models molecular events that occur in vivo in …

Potent Inhibition Of Heterotopic Ossification By Nuclear Retinoic Acid Receptor-Γ Agonists., Kengo Shimono, Wei-En Tung, Christine Macolino, Amber Hsu-Tsai Chi, Johanna H Didizian, Christina Mundy, Roshantha A Chandraratna, Yuji Mishina, Motomi Enomoto-Iwamoto, Maurizio Pacifici, Masahiro Iwamoto

Department of Orthopaedic Surgery Faculty Papers

Heterotopic ossification consists of ectopic bone formation within soft tissues after surgery or trauma. It can have debilitating consequences, but there is no definitive cure. Here we show that heterotopic ossification was essentially prevented in mice receiving a nuclear retinoic acid receptor-γ (RAR-γ) agonist. Side effects were minimal, and there was no significant rebound effect. To uncover the mechanisms of these responses, we treated mouse mesenchymal stem cells with an RAR-γ agonist and transplanted them into nude mice. Whereas control cells formed ectopic bone masses, cells that had been pretreated with the RAR-γ agonist did not, suggesting that they had …

Correlation Of C2 Fractures And Vertebral Artery Injury., Tao Ding, Mitchell Maltenfort, Huilin Yang, Harvey Smith, John Ratliff, Alexander Vaccaro, D Greg Anderson, James Harrop

Department of Orthopaedic Surgery Faculty Papers

STUDY DESIGN: Retrospective review of prospectively collected data.

SUMMARY OF BACKGROUND DATA: Vertebral artery injuries (VAI) occur commonly after cervical spine trauma. No study has yet examined the association between VAI and specific variants of C2 fractures.

OBJECTIVE: To evaluate the incidence of VAI (as defined by magnetic resonance imaging/angiography [MRI/A]) in subtypes of C2 fractures. To define the association between the incidence, morphology, and severity of C2 fractures, based on fracture angulation and comminution, and the occurrence of VAI.

METHODS: Patients admitted to the hospital with C2 fractures between October 2006 and December 2008 to a tertiary care referral …

Acellular Dermal Regeneration Template For Soft Tissue Reconstruction Of The Digits., John S. Taras, Anthony Sapienza, Josh B. Roach, John P. Taras

Department of Orthopaedic Surgery Faculty Papers

PURPOSE: Trauma to the digits often leaves soft tissue defects with exposed bone, joint, and/or tendon that require soft tissue replacement. The objective of this study was to evaluate the effectiveness of acellular dermal regeneration template combined with full-thickness skin grafting for soft tissue reconstruction in digital injuries with soft tissue defects.

METHODS: Acellular dermal regeneration template was used to reconstruct digital injuries with exposed bone, joint, tendon, and/or hardware not amenable to treatment with healing by secondary intention, rotation flaps, or primary skin grafts. Acellular dermal regeneration template was applied to 21 digits in 17 patients. Nineteen digits had …

Reactive Oxygen And Nitrogen Species Induce Protein And Dna Modifications Driving Arthrofibrosis Following Total Knee Arthroplasty., Theresa A Freeman, Javad Parvizi, Craig J Della Valle, Marla J Steinbeck

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: Arthrofibrosis, occurring in 3%-4% of patients following total knee arthroplasty (TKA), is a challenging condition for which there is no defined cause. The hypothesis for this study was that disregulated production of reactive oxygen species (ROS) and nitrogen species (RNS) mediates matrix protein and DNA modifications, which result in excessive fibroblastic proliferation.

RESULTS: We found increased numbers of macrophages and lymphocytes, along with elevated amounts of myeloperoxidase (MPO) in arthrofibrotic tissues when compared to control tissues. MPO expression, an enzyme that generates ROS/RNS, is usually limited to neutrophils and some macrophages, but was found by immunohistochemistry to be expressed …

Passing The Boards: Can Usmle And Orthopaedic In-Training Examination Scores Predict Passage Of The Abos Part-I Examination?, Gregg R Klein, Matthew S Austin, Susan Randolph, Peter F Sharkey, Alan S Hilibrand

Department of Orthopaedic Surgery Faculty Papers

No abstract provided.