Publications

Survivors of focal neurological injuries experience accelerated bone loss, particularly in the paretic upper extremity, substantially increasing the risk of fragility fractures. Mechanical unloading, neuromuscular impairment, and altered bone remodeling contribute to rapid reductions in bone mineral density and unfavorable changes in bone geometry within the first year after stroke and brachial plexus palsy. Despite growing evidence, bone health assessment is rarely incorporated into routine poststroke care, and referrals often occur only after fracture. This article discusses the role of hand surgeons and proposes practical screening, multidisciplinary care strategies, and interventions to improve early detection, prevention, and management of upper extremity fragility fractures.

OBJECTIVE: Although many authors have shown the safety of outpatient spine surgery, few have compared same-day spine surgery in the ambulatory surgical center (ASC) versus the hospital outpatient department (HOPD). The purpose of this study was to compare the safety of anterior cervical arthrodesis/arthroplasty or lumbar decompression with same-day discharge performed at the ASC versus HOPD.

METHODS: After IRB approval, a retrospective, propensity-matched, comparative cohort analysis of a statewide, prospective, multicenter, spine-specific database (Michigan Spine Surgery Improvement Collaborative [MSSIC]) was undertaken. Patients who underwent lumbar decompression or anterior cervical arthrodesis/arthroplasty (1 or 2 levels) with same-day discharge from January 1, 2021, to June 30, 2023, were reviewed. The HOPD/ASC matched cohorts were created at a ratio of 4:1 based on BMI, American Society of Anesthesiologists physical status class (ASA), and operative levels. The primary outcome variables investigated included any complication, return to operating room (OR) within 90 days, and emergency department (ED) visit or readmission within 30 and 90 days. Secondary outcome measures investigated included patient-reported outcome (PRO) measures at 90 days and 1 year and return to work at 90 days and 1 year. Differences between HOPD and ASC patients were tested using univariate comparisons for both the anterior cervical and lumbar decompression cohorts. Multivariate analysis was performed for the lumbar decompression group.

RESULTS: After matching, 3351 patients who underwent outpatient lumbar decompression (2679 HOPD and 672 ASC) and 806 patients who underwent anterior cervical arthrodesis/arthroplasty (644 HOPD and 162 ASC) were included in the analysis. In the univariate analysis for anterior cervical arthrodesis/arthroplasty, there were no differences between HOPD and ASC groups in terms of any complication, PROs at 90 days or 1 year, and return to work at 90 days and 1 year (p > 0.05). In the univariate analysis of the lumbar decompression group, there were higher rates of complications and return to the OR for the ASC group compared to the HOPD group (8% vs 5.5% [p = 0.01] and 4.9% vs 2.1% [p < 0.001], respectively), which remained in the multivariate analysis (incidence rate ratio [IRR] 1.5 [p = 0.001] and IRR 2.3 [p < 0.001], respectively). There were no differences between the groups in terms of PROs at 90 days and 1 year.

CONCLUSIONS: Although both outpatient anterior cervical surgery and lumbar decompression can be performed safely and effectively in ASC and HOPD, there is a slightly higher risk of return to the OR for patients who undergo lumbar decompression in the ASC. Given similar outcomes, future studies should focus on patient and payer cost differences between ASC and HOPD.

INTRODUCTION: High-velocity gunshot-related humeral fractures are complex injuries often associated with a high rate of nonunion, infection, and poor functional outcome. In low- and middle-income countries these injuries are further complicated by delayed presentation and implant unavailability. Staged management with spanning external fixation followed by internal fixation with intramedullary nail or plate has been well described in the literature; however, the use of a circular frame as a definitive treatment has been very seldom mentioned.

MATERIALS AND METHODS: Six high-velocity gunshot-related humeral fractures cases were treated with a single stack half ring circular external fixator as a definitive surgery performed by a single surgeon. Aspects related to surgical technique, fracture reduction, infection prevention, and restoration of upper limb function using circular frame external fixator are described.

RESULTS: Fracture union was achieved with circular fixation alone in 5 of the 6 patients. One patient developed a nonunion and required a second operation with a lateral compression plate combined with iliac crest autograft. The median circular fixator time was 16 weeks, and the median elbow range of motion was from 0° to 130° of flexion. The median shoulder range of motion was from 0° to 170° of overhead extension. The median Quick-DASH score was 4.5. No patients developed pin site infections.

CONCLUSION: Single-stage definitive treatment with a circular external fixator may be a valid option, not only for surgeons working in resource-constrained environments, for high-velocity gunshot fractures of the humerus. Patients' cultural acceptance and maintenance of the external device far exceeded our expectations.

BACKGROUND: Prior studies suggest familial clustering of rotator cuff tears (RCT) but are limited by sample size or by approach and no study has estimated narrow-sense heritability of RCT. We perform a comprehensive assessment on the familial heritability of RCT.

METHODS: We utilized data from three studies: the cuffGen study, BioVU and UK Biobank (UKB). In cuffGen, imaging confirmed RCT cases and controls completed a baseline questionnaire inquiring about their family history of RCT. In BioVU and UKB, RCT status was identified using electronic health record (EHR) data, while family relatedness was estimated empirically with genome-wide genetic array data. We then evaluated the association between family relatedness and RCT status in all three studies using multivariable-adjusted logistic regression models while adjusting for age, sex, race/ethnicity, and genetic principal components (when appropriate). Then utilizing genetic data in BioVU and UKB, we estimated narrow-sense/SNP-based heritability for RCT, employing linkage disequilibrium score regression approach.

RESULTS: In the cuffGen study, RCT cases were more likely to report any family history of RCT (Adjusted Odds Ratio [AOR]: 1.82; 95%CI 1.23-2.70) than controls. The association was stronger in first-degree relatives (AOR- 1.59; 95%CI 1.12-2.26), than in second-degree relatives. In BioVU and UKB, familial relatedness is also associated with increased odds of RCT (BioVU: AOR- 1.21; 95%CI 1.13-1.30; UKB: AOR- 1.09; 95%CI 1.04-1.15). However, the strongest associations were observed in third-degree relatives in BioVU (AOR: 1.56; 95%CI 1.10-2.14) and second-degree relatives in UKB (AOR: 1.25; 95%CI 1.12-1.39) rather than first-degree relatives. In SNP-based heritability analyses, we observed less than 1% of heritability of RCT was explained by SNPs (0.2% in BioVU, 0.75% in UKB) suggesting minimal contribution of genetic factors in heritability of RCT.

CONCLUSION: While rotator cuff tears (RCT) cluster within families, SNP-based heritability explains less than 1% contribution to heritability of symptomatic RCT. These data suggest that genetic factors alone may have a minimal impact on symptomatic RCT susceptibility, while non-genetic familial factors, such as environmental or healthcare-related factors represent plausible alternative explanations that warrant further investigation.

LEVEL OF EVIDENCE: Prognostic Level III.

PURPOSE: To assess and compare the associative value of comorbidity fracture-specific index (CFI) versus the Charlson comorbidity index (CCI) in identifying patients at risk for early complications after open reduction and internal fixation (ORIF) of distal radius fractures (DRFs).

METHODS: We performed a single-center retrospective cohort study including patients ≥40 years who underwent ORIF for closed DRF using a volar locking plate with a minimum of 1 year follow-up. CCI and CFI scores were calculated based on comorbidities over the prior 15 years. The primary outcome was 90-day postoperative complications. We used logistic regression to compare CCI and CFI and their association with complications, adjusting for age, sex, smoking status, and ethnicity. We used Pearson correlation and the intraclass correlation coefficient to assess the relationship and agreement between CCI and CFI.

RESULTS: Among the 317 patients, 16.7% (n = 53) experienced complications. There were no statistically significant differences in CCI or CFI in patients with and without complications. After adjusting for covariates, each increase by 1 in CCI and CFI, increased the odds of complications; however, these effects were not statistically significant. CCI and CFI were strongly correlated and showed high agreement.

CONCLUSIONS: CCI and CFI scores did not significantly differ between patients with and without complications after DRF and were not significantly associated with postoperative complications after adjusting for covariates. The strong correlation and agreement between CCI and CFI suggest they capture a similar comorbidity burden in this patient population. Neither CCI nor CFI demonstrated good discriminative ability in identifying patients at risk for early complications after ORIF of DRF.

TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

PURPOSE: To evaluate and compare the responses of ChatGPT and Google Gemini to common patient questions about scaphoid fracture and scaphoid nonunion, and to compare responses between hand fellowship-trained orthopedic and plastic surgeons.

METHODS: A list of 30 common patient questions about scaphoid fracture and nonunion was developed and classified using Norman Webb's Depth of Knowledge levels 1-4. Each question was input into ChatGPT-4o and Google Gemini 2.0 Flash. An evaluation guide was created with four domains for each response, each rated on a Likert scale from 1-5: accuracy, clarity, Artificial Intelligence Response Metric, and comparison to an in-person clinician interaction. Responses were evaluated by three orthopedic and three plastic hand surgeons. Statistical comparisons were performed using nonparametric tests to assess differences between AI platforms, domains, question complexity, and surgical specialty.

RESULTS: There were no considerable differences between mean Likert scale scores for ChatGPT and Google Gemini. Plastic surgeons rated responses higher than orthopedic surgeons overall and for ChatGPT. Google Gemini performed better for DOK level 2 and level 3 questions. ChatGPT's responses had greater clarity. For both platforms, ratings for clinician comparability across all DOK levels were considerably lower than scores for all other metrics.

CONCLUSIONS: Our findings suggest that ChatGPT and Google Gemini offer clinical use for patient care regarding scaphoid fracture and nonunion. However, clinician comparability was not a key strength for either platform, highlighting a key area for improvement for AI-based large language models in clinical application.

TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic V.

OBJECTIVE: To determine how sarcopenia and malnutrition affect fracture-healing outcomes and to identify clinical implications for screening and peri-fracture care.

METHODS: A PRISMA-guided search (PubMed/MEDLINE, Cochrane Central, Cochrane Library; last search June 25, 2024; English language) identified in vivo human and animal studies evaluating fracture healing in the presence of sarcopenia or malnutrition. Two reviewers independently screened records, extracted data, and assessed the risk of bias using the MINORS tool.

PRIMARY OUTCOME: nonunion (as defined in each study).

SECONDARY OUTCOMES: time-to-union, surgical complications, mortality, and biomechanical properties. Owing to heterogeneity, a structured narrative synthesis was performed.

RESULTS: Twelve studies met criteria: seven human (four malnutrition; three sarcopenia) and five animal (malnutrition). Large database studies linked malnutrition to higher nonunion risk (e.g., OR ≈2.0) and to post-operative complications and mortality. Definitions of malnutrition and sarcopenia varied widely across studies and included biochemical markers, anthropometric measures, imaging-based muscle assessments, and clinical screening tools. Due to this heterogeneity, associations with fracture healing outcomes were evaluated using study-level definitions rather than standardized diagnostic thresholds. Small clinical cohorts have associated sarcopenia with higher nonunion rates, and in one randomized pilot study, dietary protein/energy, combined with exercise, improved function and reduced pain while modestly shortening the time-to-union. Animal models consistently demonstrated lower BMD/BMC, altered callus composition, and reduced early mechanical strength under protein restriction, with partial reversal after re-feeding. Study heterogeneity and moderate-to-poor quality limited generalizability.

CONCLUSIONS: Across human and animal data, malnutrition and sarcopenia adversely affect fracture healing, increasing the risk of nonunion and complications, and impairing early callus quality. These findings highlight the importance of early identification of sarcopenia and nutritional risk in fracture patients. While emerging data suggest potential benefit from targeted interventions, the current evidence remains limited, underscoring the need for adequately powered randomized trials before routine clinical implementation.

LEVEL OF EVIDENCE: Systematic Review, I.

AIMS: In the follow-up of patients with mitral regurgitation (MR), assessment of left ventricular (LV) dilatation using standard echocardiography often yields inconsistent results. We investigated whether measuring 3D LV end-systolic volume (3DLVESV) improves risk stratification in moderate or greater MR.

METHODS AND RESULTS: In the prospective 3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation (3D-PRIME) study, 227 patients -142 with primary (PMR) and 85 secondary MR (SMR)- underwent 2D/3D echocardiography. 3DLVESV was increased if ≥41.5/35 mL/m², and LV end-systolic diameter (LVESD) enlarged if ≥39.8/34.8 mm in men/women. The primary outcome was a composite of MR progression towards intervention, death, or heart failure hospitalization (HFH). Death or HFH was a secondary outcome.At baseline, 28% of PMR and 54% of SMR patients had increased 3DLVESV. After 21 (15-25) months, increased 3DLVESV was associated with 1.9-fold (1.2-3.2) higher adjusted risk of the primary outcome in PMR, and 4.1-fold (1.6-10.7) higher risk of death or HFH in SMR (P < 0.05). 3DLVESV and LVESD concordantly identified LV dilatation in 20% of PMR patients and were discordant in 27%. Both patients with increased 3DLVESV only, and those with increased both 3DLVESV and LVESD, had high risk of the primary outcome after adjusting for recommendations for intervention in PMR: HR 7.1 (2.9-16.9) and 4.9 (2.1-11.1), respectively (P < 0.001).

CONCLUSION: Increased 3DLVESV is associated with a higher risk of adverse events in patients with significant MR. In PMR, evaluating LV dilatation using both 3DLVESV and LVESD may enhance risk stratification and aid in patient selection for close follow-up.

CLINICALTRIALSGOV IDENTIFIER: NCT04442828, 17 April 2020.

OBJECTIVES: Randomized controlled trials (RCTs) of the Collaborative Care Model demonstrate strong evidence for effectively managing depression in a stepped-care approach across diverse patient populations. Despite alignment with the American Society of Clinical Oncology guidelines, which recommend a stepped-care approach for managing depression and anxiety in cancer patients, implementation of collaborative care in cancer centers remains limited and sparse real-world data exist. The Supportive Oncology Collaborative, a program integrating behavioral health and palliative care, was developed at an NCI-designated academic cancer center. This study aims to evaluate depression outcomes within this collaborative care program.

METHODS: A retrospective analysis was conducted on patients with at least 2 Patient Health Questionnaire-9 (PHQ-9) scores recorded within a 12-month period between January 2022 and December 2023 at 1 regional campus. Depression response, defined as a 50% reduction in PHQ-9 scores, was assessed at 12 and 24 weeks. Response rates were compared to those reported in RCTs of collaborative care.

RESULTS: Mean PHQ-9 scores were 17.3 at baseline (n = 47), 11.1 at 12 weeks (n = 43), and 10.1 at 24 weeks (n = 22). Depression response rates were 34.9% at 12 weeks (n = 43) and 54.5% at 24 weeks (n = 22).

SIGNIFICANCE OF RESULTS: We observed depression response rates comparable to those reported in RCTs of collaborative care in individuals with cancer. However, the high proportion of missing data highlights the difficulty of tracking outcomes in real-world clinical settings and the need for further evaluation and strategies to improve data completeness.

Epilepsy is a highly prevalent chronic central nervous system disorder that imposes substantial societal and economic burdens. Inconsistent associations of alcohol consumption, identified as a major global health risk factor, with epilepsy risk have been reported. The aim of the present study was to assess the relationship between alcohol use and epilepsy and to identify potential underlying mechanisms, with a particular focus on the role of neutrophil extracellular traps (NETs), using an integrated multiomic approach. We assessed the global risk of alcohol consumption for epilepsy using data from the Global Burden of Disease Study 2021, and we conducted a Mendelian randomization (MR) analysis to evaluate causality. Additionally, we employed machine learning algorithms and protein-protein interaction networks to identify key genes. Our results indicate that alcohol consumption significantly contributes to the risk of epilepsy, as confirmed by MR analysis (odds ratio = 1.30, 95% confidence interval 1.06-1.60; p = 0.011). Functional enrichment analysis revealed pathways related to NET formation, whereas machine learning identified key genes such as myeloperoxidase (MPO) and neutrophil elastase. Animal and molecular experiments confirmed that acute alcohol exposure increases the susceptibility to epileptic seizures, whereas the MPO inhibitor 4-aminobenzoic acid hydrazide showed therapeutic potential for alcohol-induced epilepsy. This study provides novel insights into the role of NETs in alcohol-induced epilepsy and highlights potential therapeutic targets, thereby contributing to the development of innovative treatment strategies for epilepsy prevention and management.