Publications

Study DesignTranslational rodent study.ObjectivesTo investigate (1) chemokine-mediated mesenchymal stem cell mobilization and homing to the intervertebral disc and (2) using this technique to mitigate intervertebral disc degeneration in a rat model.Methods(1) Recruitment of mesenchymal stem cells (MSCs) to intervertebral discs (IVD) was investigated using intradiscal chemokines. Hydrogel containing SDF-1, RANTES, MCP-1, or empty control was injected intradiscally, followed by near-infrared (NIR) imaging to observe MSC localization. (2) A rat IVD degeneration model was induced by annular puncture. Intradiscal RANTES injection and/or systemic AMD3100 injection was performed. Longitudinal imaging and histological analyses including Rutges Score (histologic degeneration) assessed IVD degeneration mitigation post-treatment up to 12-weeks. Statistical analyses included ANOVA and mixed-effects models to evaluate recruitment, retention, and regenerative potential of MSCs.Results(1) 24 rats were included in the investigation of MSC recruitment. In vivo NIR signal on 1-day post-intervention was highest with RANTES (P < .05). Ex vivo NIR signal at 14-days post-intervention was highest with RANTES (P < .05). (2) 36 IVD degeneration model rats underwent intradiscal RANTES and/or AMD3100 injection. AMD3100-treated groups showed larger nucleus pulposus (NP) volumes and reduced histologic damage, with lower Total Rutges scores (P = .004). RANTES treatment alone reduced Total Rutges scores (P = .009) and protected against IVD height loss at 6 weeks.ConclusionsIntradiscal delivery of RANTES/CCL5 promotes a sustained and targeted recruitment of MSCs to the IVD. In a rat model of IVD degeneration, administration of systemic AMD3100 and intradiscal RANTES mitigates IVD degeneration.

PURPOSE: Hand surgery fellowships include trainees from orthopedic, plastic, and general surgery. These pathways present an opportunity to examine variations in graduate medical education structures, such as program size, sponsoring department, and leadership composition. Limited research exists on the characteristics of these programs. The purpose of this study is to assess the structural and leadership characteristics of the Accreditation Council of Graduate Medical Education-accredited hand surgery fellowships in the United States. We hypothesized that characteristics (ie, faculty-to-fellow ratios and case volume) vary by specialty sponsorship. Leadership, although shaped by merit-based criteria, faces challenges in achieving broader demographic diversity.

METHODS: A cross-sectional analysis of 95 US hand surgery fellowship programs was conducted in 2025. Program characteristics were compared by region and specialty sponsorship.

RESULTS: Most programs were orthopedic-sponsored (n = 74, 77.9%), followed by plastic surgery (n = 19, 20.0%) and general surgery (n = 2, 2.11%). Programs averaged 2.22 fellows (SD = 1.35), with a faculty-to-fellow ratio of 3.98 (SD = 2.01) and an annual case volume of 846 per fellow (SD = 332). Orthopedic-sponsored programs had more fellows on average, a lower faculty-to-fellow ratio, and were less open to general surgery applicants compared to plastic surgery-sponsored programs. No notable regional differences were found in these characteristics. Program directors were predominantly men (n = 81, 85.3%) and orthopedic-trained (n = 70, 73.7%).

CONCLUSIONS: Hand surgery fellowships show consistent structural features, with notable differences between orthopedic- and plastic surgery-sponsored programs in enrollment, faculty-to-fellow ratios, and openness to general surgery applicants. Women leadership underrepresentation warrants further evaluation.

TYPE OF STUDY/LEVEL OF EVIDENCE: Cross-sectional descriptive study, level IV.

OBJECTIVES: The interest in bacteriophage therapy has significantly increased due to the rising prevalence of antibiotic-resistant bacterial infections. However, the pharmacology of bacteriophage therapy has not been systematically reviewed. This scoping review aims to summarize the current state of bacteriophage pharmacokinetics and pharmacodynamics research to identify knowledge gaps and guide future research.

METHODS: Following PRISMA-ScR guidelines, we conducted a scoping review through December 18th, 2023 of MEDLINE (Ovid), PubMed, Embase (Elsevier), Web of Science Core Collection (Clarivate), and Cochrane Central. We included studies that presented original data on the pharmacokinetics and pharmacodynamics of bacteriophage therapy for in vivo infection treatment.

RESULTS: In total, 34 in vivo studies were identified varying in multiple dimensions, including model organisms, target bacteria, delivery vehicles, modes of administration, and phage type. The scoping review maps the current research landscape of in vivo bacteriophage pharmacology.

CONCLUSIONS: Bacteriophage therapy shows notable promise as a potential alternative or therapeutic adjunct to antibiotics in clinical disease settings. Several studies of phage pharmacokinetics and pharmacodynamics have been conducted; however, these studies differ in multiple dimensions, complicating attempts to develop general principles for standardized phage administration. Further, significant gaps remain in understanding the numerous intrinsic phage and host factors that might affect the pharmacokinetics and pharmacodynamics of phage therapy in vivo.

PURPOSE: The purpose of this study was to evaluate the current geographic distribution of hand surgeons across the United States and characterize differences in patient access to medical care.

METHODS: We used the American Academy of Orthopaedic Surgeons, the American Association for Hand Surgery, and the American Society for Surgery of the Hand databases and Doximity to locate orthopedic, plastic, and general surgery-trained hand surgeons in the United States as of December 2024. Details about practice location and corresponding socioeconomic information from US counties were gathered. Counties were divided into those with hand surgeons and those without. Geographic and socioeconomic details were compared.

RESULTS: A total of 2,733 hand surgeons were identified. These surgeons primarily practiced in metropolitan and affluent areas. California, New York, Florida, and Pennsylvania had the most hand surgeons. The District of Columbia, Rhode Island, Connecticut, New Hampshire, and Vermont had the highest ratios of surgeons per person. Geographically, the West had the lowest number of hand surgeons, in contrast to the South, which maintained the most. Only 18.3% of US counties had at least one hand surgeon, and 32.9% of these counties had only one. Counties with hand surgeons had higher median incomes, lower poverty rates, and higher unemployment rates than counties without surgeons.

CONCLUSIONS: There is marked variation in the geographic distribution of hand surgeons. Western and economically disadvantaged regions appear to face significant shortages. To address these shortages, strategies such as growing medical education to increase interest in hand surgery, enhancing mentorship opportunities, and incentivizing practice in underserved areas are needed. Telemedicine and rural training programs could also play an important role in increasing access to care in remote locations.

LEVEL OF EVIDENCE: Cross-sectional study, III.

Endoscopic spine surgery (ESS) represents a development in minimally invasive procedures, offering the potential benefits of reduced tissue disruption, shorter recovery times, and enhanced precision. This review traces the historical development of ESS, explores its core techniques-including transforaminal, interlaminar, and biportal approaches-and evaluates its role in treating conditions like herniated disks and spinal stenosis. By comparing clinical outcomes of ESS with standard open surgery, this article highlights the importance of patient selection, surgeon expertise, and evidence-based practice. Challenges, such as the steep learning curve, limitations in visualization, and risk of complications, are discussed, along with strategies for integrating ESS into modern spine care. The review concludes by identifying research gaps and opportunities for technological advancements, aiming to guide surgeons in adopting ESS and improving patient outcomes.

Peripheral nerve injuries lead to diminished function and pain via nociplastic phenomena. We propose a new strategy called directed functional reinnervation, in which nerves are reassigned to new peripheral targets with the intention of altering circuit function. Here, we redirect the saphenous sensory nerve into a skeletal muscle graft to curb nociplasticity and provide benign sensations or useful inputs for prosthetic applications. Electrophysiological functional characterization demonstrated robust afferent responses to mechanical stimulation of the muscle. Immunofluorescence staining indicated widespread innervation of various synapses within the muscle graft. With immediate graft placement, the injured nerve's dorsal root ganglia revealed comparable levels of nociceptive markers to uninjured nerves, suggesting a molecular basis for the prevention of pain sensitization. These findings contribute to the mechanism by which skeletal muscle grafts alleviate neuropathic pain and can be used as a sensory transmitter in conjunction with neural interfaces.

Supracondylar humerus fractures (SCHFs) are common injuries among children and typically occur after a fall on an outstretched hand. SCHFs may present with neurovascular injury specifically to the brachial artery and/or median nerve (or its deep motor branch), ulnar nerve, and/or radial nerve. Thorough examination of a patient's neurovascular status is imperative to appropriately guide treatment and determine whether a referral is needed. Minimally displaced SCHFs may be treated nonsurgically, whereas displaced injuries often require surgery. Displaced SCHFs may be treated nonsurgically with traction and splinting, but providers should expect a high rate of complications and notable disability. Of equal importance to consider is the status of the soft tissues. In resource-limited settings, such as rural or district hospitals, surgery for more severe SCHFs may not be feasible because of lack of fluoroscopy, implants, or staff adequately trained in musculoskeletal trauma. In these situations, referral to a hospital with increased resources and surgical capabilities is recommended when possible. We present an approach to the triage and treatment of SCHFs in various resource-constrained environments, broadly applicable to low- and middle-income countries.

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.

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.