Amy Ladd, MD

All Publications

• Strengthening the Pipeline: Promoting Diversity into Orthopedic Surgery. Clinics in sports medicine van Niekerk, M., O'Mara, A., Kha, S., Zhou, J., McAdams, T. A., Ladd, A., Shea, K., Frick, S., Maloney, W. J., Chu, C. R. 2024; 43 (2): 253-270

  Abstract

  The United States is a nation of diverse racial and ethnic origins. Athletes represent the full spectrum of the nation's population. However, the orthopedic surgeons who serve as team physicians are Caucasian and male with staggeringly few exceptions. This manuscript provides an overview of the current status and barriers to diversity among orthopedic team physicians, along with strategies to address the issue. Specifically, pipeline initiatives implemented at one academic medical school and orthopedic surgery department are summarized as potential models that can be further developed by other institutions to enhance diversity in orthopedic surgery.

  View details for DOI 10.1016/j.csm.2023.07.007

  View details for PubMedID 38383108

• Opportunistic hand radiographs to screen for low forearm bone mineral density: a prospective and retrospective cohort study. BMC musculoskeletal disorders O'Mara, A., Kerkhof, F., Kenney, D., Segovia, N., Asbell, P., Ladd, A. L. 2024; 25 (1): 159

  Abstract

  Low bone mineral density affects 53% of women over age 65 in the US, yet many are unaware and remain untreated. Underdiagnosis of forearm osteoporosis and related fragility fractures represent missed warning signs of more deadly, future fractures. This study aimed to determine if hand radiographs could serve as early, simple screening tools for predicting low forearm bone mineral density (BMD).We evaluated posterior-anterior (PA) hand radiographs (x-rays) and Dual-energy X-ray absorptiometry (DXA) scans of 43 participants. The ratio of the intramedullary cavity to total cortical diameter of the second metacarpal (second metacarpal cortical percentage (2MCP)) was used as a potential diagnostic marker. Mixed-effects linear regression was performed to determine correlation of 2MCP with BMD from various anatomic regions. Repeated measures ANOVAs were used to compare BMD across sites. An optimal 2MCP cutoff for predicting forearm osteopenia and osteoporosis was found using Receiver Operating Curves.2MCP is directly correlated with BMD in the forearm. The optimal 2MCP of 48.3% had 80% sensitivity for detecting osteoporosis of the 1/3 distal forearm. An 2MCP cutoff of 50.8% had 84% sensitivity to detect osteoporosis of the most distal forearm. Both 2MCP cutoffs were more sensitive at predicting forearm osteoporosis than femoral neck T-scores.These findings support the expansion of osteoporosis screening to include low-cost hand x-rays, aiming to increase diagnosis and treatment of low forearm BMD and fractures. Proposed next steps include confirming the optimal 2MCP cutoff at scale and integrating automatic 2MCP measurements into PAC systems.

  View details for DOI 10.1186/s12891-023-07127-w

  View details for PubMedID 38378510

  View details for PubMedCentralID 3767038

• Validation of Inertial Measurement Units for Analyzing Golf Swing Rotational Biomechanics. Sensors (Basel, Switzerland) Kim, S. E., Burket Koltsov, J. C., Richards, A. W., Zhou, J., Schadl, K., Ladd, A. L., Rose, J. 2023; 23 (20)

  Abstract

  Training devices to enhance golf swing technique are increasingly in demand. Golf swing biomechanics are typically assessed in a laboratory setting and not readily accessible. Inertial measurement units (IMUs) offer improved access as they are wearable, cost-effective, and user-friendly. This study investigates the accuracy of IMU-based golf swing kinematics of upper torso and pelvic rotation compared to lab-based 3D motion capture. Thirty-six male and female professional and amateur golfers participated in the study, nine in each sub-group. Golf swing rotational kinematics, including upper torso and pelvic rotation, pelvic rotational velocity, S-factor (shoulder obliquity), O-factor (pelvic obliquity), and X-factor were compared. Strong positive correlations between IMU and 3D motion capture were found for all parameters; Intraclass Correlations ranged from 0.91 (95% confidence interval [CI]: 0.89, 0.93) for O-factor to 1.00 (95% CI: 1.00, 1.00) for upper torso rotation; Pearson coefficients ranged from 0.92 (95% CI: 0.92, 0.93) for O-factor to 1.00 (95% CI: 1.00, 1.00) for upper torso rotation (p < 0.001 for all). Bland-Altman analysis demonstrated good agreement between the two methods; absolute mean differences ranged from 0.61 to 1.67 degrees. Results suggest that IMUs provide a practical and viable alternative for golf swing analysis, offering golfers accessible and wearable biomechanical feedback to enhance performance. Furthermore, integrating IMUs into golf coaching can advance swing analysis and personalized training protocols. In conclusion, IMUs show significant promise as cost-effective and practical devices for golf swing analysis, benefiting golfers across all skill levels and providing benchmarks for training.

  View details for DOI 10.3390/s23208433

  View details for PubMedID 37896527

  View details for PubMedCentralID PMC10611231

• Reply to Letter to the Editor: Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Chou, L. B., Johnson, B., Shapiro, L. M., Pun, S., Cannada, L. K., Chen, A. F., Valone, L. C., Van Nortwick, S. S., Ladd, A. L., Finlay, A. K. 2023; 7 (9)

  View details for DOI 10.5435/JAAOSGlobal-D-23-00130

  View details for PubMedID 37678820

  View details for PubMedCentralID PMC10484368

• A review of wear debris in thumb base joint implants. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Mangan, F., Spece, H., Weiss, A. C., Ladd, A. L., Stockmans, F., Kurtz, S. M. 2023

  Abstract

  Polymers and metals, such as polyethylene (PE) and cobalt chrome (CoCr), are common materials used in thumb-based joint implants, also known as CMC (Carpometacarpal) arthroplasty. The purpose of this review was to investigate the reported failure modes related to wear debris from these type of materials in CMC implants. The impact of wear debris on clinical outcomes of CMC implants was also examined. Potential adverse wear conditions and inflammatory particle characteristics were also considered.A literature search was performed using PRISMA guidelines and 55 studies were reviewed including 49 cohort studies and 6 case studies. Of the 55 studies, 38/55 (69%) focused on metal-on-polyethylene devices, followed by metal-on-metal (35%), and metal-on-bone (4%).The summarized data was used to determine the frequency of failure modes potentially related to wear debris from metals and/or polymers. The most commonly reported incidents potentially relating to debris were implant loosening (7.1%), osteolysis (1.2%) and metallosis (0.6%). Interestingly the reported mechanisms behind osteolysis and loosening greatly varied. Inflammatory reactions, while rare, were generally attributed to metallic debris from metal-on-metal devices. Mechanisms of adverse wear conditions included implant malpositioning, over-tensioning, high loading for active patients, third-body debris, and polyethylene wear-through. No specific examination of debris particle characterization was found, pointing to a gap in the literature.This review underscores the types of failure modes associated with wear debris in CMC implants. It was found that failure rates and adverse wear conditions of CMC implants of any design are low and the exact relationship between wear debris and implant incidences, such as osteolysis and loosening remains uncertain. The authors note that further research and specific characterization is required to understand the relationship between debris and implant failure.

  View details for DOI 10.1007/s00590-023-03622-x

  View details for PubMedID 37439887

  View details for PubMedCentralID 8183150

• Dorsal Subluxation of the First Metacarpal During Thumb Flexion is an Indicator of Carpometacarpal Osteoarthritis Progression. Clinical orthopaedics and related research Morton, A. M., Moore, D. C., Ladd, A. L., Weiss, A. C., Molino, J., Crisco, J. J. 2023

  Abstract

  BACKGROUND: Measurable changes in patients with progression of thumb carpometacarpal (CMC) osteoarthritis (OA) include joint space narrowing, osteophyte formation, subluxation, and adjacent-tissue changes. Subluxation, an indication of mechanical instability, is postulated as an early biomechanical indicator of progressing CMC OA. Various radiographic views and hand postures have been proposed to best assess CMC subluxation, but 3D measurements derived from CT images serve as the optimal metric. However, we do not know which thumb pose yields subluxation that most indicates OA progression.QUESTIONS/PURPOSES: Using osteophyte volume as a quantitative measure of OA progression, we asked: (1) Does dorsal subluxation vary by thumb pose, time, and disease severity in patients with thumb CMC OA (2) In which thumb pose(s) does dorsal subluxation most differentiate patients with stable CMC OA from those with progressing CMC OA? (3) In those poses, what values of dorsal subluxation indicate a high likelihood of CMC OA progression?METHODS: Between 2011 and 2014, 743 patients were seen at our institutions for trapeziometacarpal pain. We considered individuals who were between the ages of 45 and 75 years, had tenderness to palpation or a positive grind test result, and had modified Eaton Stage 0 or 1 radiographic thumb CMC OA as potentially eligible for enrollment. Based on these criteria, 109 patients were eligible. Of the eligible patients, 19 were excluded because of a lack of interest in study participation, and another four were lost before the minimum study follow-up or had incomplete datasets, leaving 86 (43 female patients with a mean age of 53 ± 6 years and 43 male patients with a mean age of 60 ± 7 years) patients for analysis. Twenty-five asymptomatic participants (controls) aged 45 to 75 years were also prospectively recruited to participate in this study. Inclusion criteria for controls included an absence of thumb pain and no evidence of CMC OA during clinical examination. Of the 25 recruited controls, three were lost to follow-up, leaving 22 for analysis (13 female patients with a mean age of 55 ± 7 years and nine male patients with a mean age of 58 ± 9 years). Over the 6-year study period, CT images were acquired of patients and controls in 11 thumb poses: neutral, adduction, abduction, flexion, extension, grasp, jar, pinch, grasp loaded, jar loaded, and pinch loaded. CT images were acquired at enrollment (Year 0) and Years 1.5, 3, 4.5, and 6 for patients and at Years 0 and 6 for controls. From the CT images, bone models of the first metacarpal (MC1) and trapezium were segmented, and coordinate systems were calculated from their CMC articular surfaces. The volar-dorsal location of the MC1 relative to the trapezium was computed and normalized for bone size. Patients were categorized into stable OA and progressing OA subgroups based on trapezial osteophyte volume. MC1 volar-dorsal location was analyzed by thumb pose, time, and disease severity using linear mixed-effects models. Data are reported as the mean and 95% confidence interval. Differences in volar-dorsal location at enrollment and rate of migration during the study were analyzed for each thumb pose by group (control, stable OA, and progressing OA). A receiver operating characteristic curve analysis of MC1 location was used to identify thumb poses that differentiated patients whose OA was stable from those whose OA was progressing. The Youden J statistic was used to determine optimized cutoff values of subluxation from those poses to be tested as indicators of OA progression. Sensitivity, specificity, negative predictive values, and positive predictive values were calculated to assess the performance of pose-specific cutoff values of MC1 locations as indicators of progressing OA.RESULTS: In flexion, the MC1 locations were volar to the joint center in patients with stable OA (mean -6.2% [95% CI -8.8% to -3.6%]) and controls (mean -6.1% [95% CI -8.9% to -3.2%]), while patients with progressing OA exhibited dorsal subluxation (mean 5.0% [95% CI 1.3% to 8.6%]; p < 0.001). The pose associated with the most rapid MC1 dorsal subluxation in the progressing OA group was thumb flexion (mean 3.2% [95% CI 2.5% to 3.9%] increase per year). In contrast, the MC1 migrated dorsally much slower in the stable OA group (p < 0.001), at only a mean of 0.1% (95% CI -0.4% to 0.6%) per year. A cutoff value of 1.5% for the volar MC1 position during flexion at enrollment (C-statistic: 0.70) was a moderate indicator of OA progression, with a high positive predictive value (0.80) but low negative predictive value (0.54). Positive and negative predictive values of subluxation rate in flexion (2.1% per year) were high (0.81 and 0.81, respectively). The metric that most indicated a high likelihood of OA progression (sensitivity 0.96, negative predictive value 0.89) was a dual cutoff that combined the subluxation rate in flexion (2.1% per year) with that of loaded pinch (1.2% per year).CONCLUSION: In the thumb flexion pose, only the progressing OA group exhibited MC1 dorsal subluxation. The MC1 location cutoff value for progression in flexion was 1.5% volar to the trapezium , which suggests that dorsal subluxation of any amount in this pose indicates a high likelihood of thumb CMC OA progression. However, volar MC1 location in flexion alone was not sufficient to rule out progression. The availability of longitudinal data improved our ability to identify patients whose disease will likely remain stable. In patients whose MC1 location during flexion changed < 2.1% per year and whose MC1 location during pinch loading changed < 1.2% per year, the confidence that their disease would remain stable throughout the 6-year study period was very high. These cutoff rates were a lower limit, and any patients whose dorsal subluxation advanced faster than 2% to 1% per year in their respective hand poses, were highly likely to experience progressive disease.CLINICAL RELEVANCE: Our findings suggest that in patients with early signs of CMC OA, nonoperative interventions aimed to reduce further dorsal subluxation or operative treatments that spare the trapezium and limit subluxation may be effective. It remains to be determined whether our subluxation metrics can be rigorously computed from more widely available technologies, such as plain radiography or ultrasound.

  View details for DOI 10.1097/CORR.0000000000002575

  View details for PubMedID 36877171

• Helping Surgeons' Hands: A Biomechanical Evaluation of Ergonomic Instruments. The Journal of hand surgery Putnam, J. G., Kerkhof, F. D., Shah, K., Richards, A. W., Ladd, A. 2023

  Abstract

  PURPOSE: "Ergonomic" is a common descriptor for a desk or computer workspace but is a term rarely used to describe a surgical instrument. Instead, surgeons spend many hours in inconvenient positions, often using instruments that are not ergonomic. Improving the ergonomics of surgical instruments may decrease the required force for simple tasks and allow for more efficient surgery.METHODS: To evaluate the impact of ergonomic surgical instruments, the authors developed ergonomic screwdriver handles. The shape and size of these handles were engineered using previous dental studies and 3-dimensional modeling to create an ideal handle for specific glove sizes. Participants were recruited to test 3 different ergonomic handle sizes against a standard screwdriver while assessing digital peak force, digital contact area, and participant preference. Ten participants (3 women) with glove sizes ranging from 6 to 8 were evaluated.RESULTS: Ergonomic screwdriver handles sized for glove sizes 6 and 7 required significantly less thumb peak force than the standard screwdriver for all participants (702 N for glove size 6 and 567 N for glove size 7 ergonomic screwdrivers, vs 1780 N for "one size fits all" standard screwdriver). Participants consistently preferred screwdrivers that required lower thumb and index finger forces. All ergonomic handles required lower thumb and index finger force. Eighty percent of participants preferred a screwdriver modeled within 1 glove size of their own.CONCLUSIONS: Improved ergonomic handles require less force and are preferred by surgeons.CLINICAL RELEVANCE: The significant decrease in thumb peak force for glove sizes 6 and 7 suggests that there is room for ergonomic improvement in instruments, especially for surgeons with smaller hands. Manufacturing ergonomic screwdriver handles and using the evolving convenience of 3-dimensional printing may help to develop a more comfortable work environment for surgeons.

  View details for DOI 10.1016/j.jhsa.2022.12.006

  View details for PubMedID 36746690

• Potential biomechanical risk factors on developing lead knee osteoarthritis in the golf swing. Scientific reports Kim, S. E., Pham, N. S., Park, J. H., Ladd, A., Lee, J. 2022; 12 (1): 22653

  Abstract

  The load on the lead knee joint during a golf swing is greater than that observed during gait. However, current evidence regarding golf swing biomechanics for risks associated with knee osteoarthritis (OA) is limited. Therefore, this study investigated golf swing styles associated with knee adduction and abduction moments, which are considered to be crucial loading regions of the medial and lateral compartments of knee OA, respectively. Thirteen professional male golfers performed five shots using a 5-iron club, and their swings were recorded using a motion capture system with two force platforms for the feet. A regression analysis was performed to calculate the correlation coefficients between the peak knee adduction and abduction moments of the lead leg and varus/valgus angle, toe-out angle, stance width, weight transfer, and shoulder sway. Swinging with a narrower stance width at address (r =  - 0.62, p = 0.02) with more weight shift (r = 0.66, p = 0.014) and shoulder sway (r = 0.79, p = 0.001) towards the target during the downswing were associated with a higher peak knee adduction of the lead leg, whereas a greater valgus angle at address (r = 0.60, p = 0.03) was associated with a higher peak knee abduction of the lead leg. Based on these findings, we anticipate future research to support postural changes, particularly a wider stance width and restricted shoulder sway for golfers who are classified to be at high risk of developing medial compartment knee OA, as well as a lower valgus (tibial medial tilt) angle at address for those classified to be at high risk of developing lateral compartment knee OA.

  View details for DOI 10.1038/s41598-022-27160-4

  View details for PubMedID 36587045

• The swing performance Index: Developing a single-score index of golf swing rotational biomechanics quantified with 3D kinematics. Frontiers in sports and active living Zhou, J. Y., Richards, A., Schadl, K., Ladd, A., Rose, J. 2022; 4: 986281

  Abstract

  Golf swing generates power through coordinated rotations of the pelvis and upper torso, which are highly consistent among professionals. Currently, golf performance is graded on handicap, length-of-shot, and clubhead-speed-at-impact. No performance indices are grading the technique of pelvic and torso rotations. As an initial step toward developing a performance index, we collected kinematic metrics of swing rotational biomechanics and hypothesized that a set of these metrics could differentiate between amateur and pro players. The aim of this study was to develop a single-score index of rotational biomechanics based on metrics that are consistent among pros and could be derived in the future using inertial measurement units (IMU).Golf swing rotational biomechanics was analyzed using 3D kinematics on eleven professional (age 31.0 ± 5.9 years) and five amateur (age 28.4 ± 6.9 years) golfers. Nine kinematic metrics known to be consistent among professionals and could be obtained using IMUs were selected as candidate variables. Oversampling was used to account for dataset imbalances. All combinations, up to three metrics, were tested for suitability for factor analysis using Kaiser-Meyer-Olkin tests. Principal component analysis was performed, and the logarithm of Euclidean distance of principal components between golf swings and the average pro vector was used to classify pro vs. amateur golf swings employing logistic regression and leave-one-out cross-validation. The area under the receiver operating characteristic curve was used to determine the optimal set of kinematic metrics.A single-score index calculated using peak pelvic rotational velocity pre-impact, pelvic rotational velocity at impact, and peak upper torso rotational velocity post-impact demonstrated strong predictive performance to differentiate pro (mean ± SD:100 ± 10) vs. amateur (mean ± SD:82 ± 4) golfers with an AUC of 0.97 and a standardized mean difference of 2.12.In this initial analysis, an index derived from peak pelvic rotational velocity pre-impact, pelvic rotational velocity at impact, and peak upper torso rotational velocity post-impact demonstrated strong predictive performance to differentiate pro from amateur golfers. Swing Performance Index was developed using a limited sample size; future research is needed to confirm results. The Swing Performance Index aims to provide quantified feedback on swing technique to improve performance, expedite training, and prevent injuries.

  View details for DOI 10.3389/fspor.2022.986281

  View details for PubMedID 36619352

  View details for PubMedCentralID PMC9816382

• The biomechanics of osteoarthritis in the hand: Implications and prospects for hand therapy. Journal of hand therapy : official journal of the American Society of Hand Therapists Kerkhof, F., Kenney, D., Ogle, M., Shelby, T., Ladd, A. 2022

  Abstract

  The unique anatomy of the human hand makes it possible to carefully manipulate tools, powerfully grasp objects, and even throw items with precision. These apparent contradictory functions of the hand, high mobility for manual dexterity vs high stability during forceful grasping, imply that daily activities impose a high strain on a relatively instable joint. This makes the hand susceptible to joint disorders such as osteoarthritis. Both systemic (eg, genetics, hormones) and mechanical factors (eg, joint loading) are important in the development of osteoarthritis, but the precise pathomechanism remains largely unknown. This paper focuses on the biomechanical factors in the disease process and how hand therapists can use this knowledge to improve treatment and research.Multiple factors are involved in the onset and development of osteoarthritis in the hand. Comprehension of the biomechanics helps clinicians establish best practices for orthotics intervention, exercise, and joint protection programs even in de absence of clear evidence-based guidelines. The effect and reach of hand therapy for OA patients can be expanded substantially when intervention parameters are optimized and barriers to early referrals, access reimbursement, and adherence are addressed. Close and early collaboration between hand therapists and primary care, women's health, rheumatology, and hand surgery providers upon diagnosis, and with hand surgeons pre and postoperatively, combined with advances in the supporting science and strategies to enhance adherence, appear to be a promising way forward.

  View details for DOI 10.1016/j.jht.2022.11.007

  View details for PubMedID 36509610

• Using a finite element model of the thumb to study Trapeziometacarpal joint contact during lateral pinch. Clinical biomechanics (Bristol, Avon) Dong, M., Kerkhof, F., Deleu, G., Vereecke, E., Ladd, A. 2022; 101: 105852

  Abstract

  BACKGROUND: Finite element (FE) analysis is widely used in different fields of orthopaedic surgery, however, its application to the trapeziometacarpal joint has been limited due to the small size, complex biconcave-convex joint geometry, and complex musculature. The goal of this study was to improve upon existing models by creating a muscle-driven FE thumb model and use the model to simulate the biomechanical effect of hand therapy exercises and ligament reconstructive surgeries.METHODS: Bone and cartilage geometry were based on a CT dataset of a subject performing a static lateral pinch task. A previously validated musculoskeletal model was utilized to extract electromyography (EMG)-driven muscle forces. Five ligaments with biomechanical significance were modeled as springs using literature values and attached according to their anatomical landmarks.FINDINGS: The biomechanical consequence of various interventions was proxied as a change in the maximum cartilage stress. The result shows tightening the dorsal ligament complex (dorsal radial ligament, dorsal central ligament, posterior oblique ligament) is the most effective, achieving a stress reduction of 4.8%. Five exercises used in hand therapies were modeled, among which thenar eminence strengthening showed the most prominent stress reduction of 4.0%. Four ligament reconstructive surgeries were modeled, with Eaton-Littler reconstruction showed the most significant stress reduction of 25.0%.INTERPRETATION: Among the routinely utilized treatment options for early thumb osteoarthritis, we found that three methods: dorsal ligament imbrication, thenar eminence exercise, and the Eaton-Littler method may confer biomechanical advantages cartilage loading. These advantages align with the clinically observed favorable outcomes.

  View details for DOI 10.1016/j.clinbiomech.2022.105852

  View details for PubMedID 36521409

• The Environmental Impact of Orthopaedic Surgery. The Journal of bone and joint surgery. American volume Saleh, J. R., Mitchell, A., Kha, S. T., Outterson, R., Choi, A., Allen, L., Chang, T., Ladd, A. L., Goodman, S. B., Fox, P., Chou, L. 2022

  Abstract

  ➤: There are a growing number of opportunities within the field of orthopaedic surgery to address climate change and investigate ways to promote sustainability.➤: Orthopaedic surgeons can take a proactive role in addressing climate change and its impacts within the areas of operating-room waste, carbon emissions from transportation and implant manufacturing, anesthetic gases, and water usage.➤: Future studies are needed to further these initiatives on quantifying and decreasing environmental impact and furthering sustainable use of our resources.

  View details for DOI 10.2106/JBJS.22.00548

  View details for PubMedID 36574633

• Bone morphological changes of the trapezium and first metacarpal with early thumb osteoarthritis progression. Clinical biomechanics (Bristol, Avon) Morton, A. M., Peipert, L. J., Moore, D. C., Ladd, A. L., Weiss, A. C., Molino, J., Crisco, J. J. 2022; 100: 105791

  Abstract

  BACKGROUND: Thumb carpometacarpal osteoarthritis is characterized by osteophyte growth and changes in the curvature of the articular surfaces of the trapezium and first metacarpal. The aim of this longitudinal study was to quantify in-vivo bone morphology changes with osteoarthritis progression.METHODS: The study analyzed an observational dataset of 86 subjects with early thumb osteoarthritis and 22 age-matched asymptomatic controls. CT scans of subjects' affected hands were acquired at enrollment (year 0), and at 1.5, 3, 4.5, and 6-year follow-up visits. Osteoarthritic subjects were classified into stable and progressive groups, as defined by osteophyte volume and the rate of osteophyte growth. Trapezium height, width, and volar facet recession, along with first metacarpal volar beak recession and recession angle, were quantified.FINDINGS: Mean trapezium width increased 12% over six years in the progressive osteoarthritis group. Trapezium volar recession of the progressive osteoarthritis group was significantly greater than stable at enrollment (P<0.0001) and year 6 (P<0.0001). The first metacarpal volar beak of the progressive osteoarthritis group recessed significantly faster than stable (P=0.0004) and control (P=0.0003). In year 6, volar beak surfaces in subjects with progressive osteoarthritis were flatter with reduced curvature, measuring -8.7±4.0 degrees, compared to the stable osteoarthritis (P<0.0001) and control groups (P=0.0003), which maintained nominal curvatures, measuring 0.7±2.5 and 0.2±3.2 degrees, respectively.INTERPRETATION: Our results demonstrate significant recession and reduction in the angle of the first metacarpal volar beak in progressive osteoarthritis. Flattening of the first metacarpal volar beak may have important associations with carpometacarpal joint contact and loading migrations, further propagating osteophyte formation and bony remodeling. This work highlights the volar beak of the first metacarpal as a region of morphology change with disease.

  View details for DOI 10.1016/j.clinbiomech.2022.105791

  View details for PubMedID 36228419

• The Role of the Flexor Carpi Radialis Groove in Trapeziometacarpal Osteoarthritis. Hand (New York, N.Y.) Mitchell, A. R., Kerkhof, F. D., Wadhwa, H., Ladd, A. L. 2022: 15589447221120844

  Abstract

  BACKGROUND: Thumb carpometacarpal (CMC) osteoarthritis (OA) is a common condition. The contribution of surrounding ligaments and tendons to the stability of the CMC joint is likely altered in OA. The flexor carpi radialis (FCR) tendon runs in the trapezial FCR groove and is often noted to be frayed during CMC arthroplasty. We hypothesized that decreased integrity of the FCR tendon is related to FCR groove morphology and is associated with increased severity of CMC OA.METHODS: We examined 3-dimensional surface models based on computed tomography (CT) scans of explanted trapezia from patients who underwent thumb CMC arthroplasty. Fraying of the FCR tendon was rated intraoperatively. Measurements were taken of the FCR groove to evaluate its morphology. Preoperative thumb CMC radiographs for each patient were scored using the modified Eaton classification system and the Thumb Osteoarthritis Index. Differences in the tendon groups were examined, and multivariable linear regression models were used to test the association between tendon group and FCR groove measurement.RESULTS: There were 136 patients who were categorized into 4 tendon groups: intact, minor fraying, fraying, and ruptured. There were no differences between the tendon groups on any measures.CONCLUSIONS: Our findings do not demonstrate a significant influence of FCR groove morphology on FCR tendon fraying in CMC arthroplasty patients. We also did not find a significant association between the FCR tendon state and degree of radiographic CMC OA. Further studies should investigate the in vivo FCR tendon to evaluate its tearing and inflammation in relation to basilar thumb pain.

  View details for DOI 10.1177/15589447221120844

  View details for PubMedID 36050929

• A Shared Genetic Architecture Between Adhesive Capsulitis and Dupuytren's Disease. Journal of shoulder and elbow surgery Kim, S. K., Khan, C., Ladd, A. L., Tashjian, R. Z. 2022

  Abstract

  BACKGROUND: The etiology of adhesive capsulitis involves inflammation, thickening and fibrosis of the shoulder capsule. The underlying genetic factors are poorly understood. The purpose of this study was to identify genetic variants associated with adhesive capsulitis utilizing the UK Biobank (UKB) cohort and compare them with variants associated with Dupuytren's disease investigating a common etiology between the two fibrotic disorders.METHODS: Genome-Wide Association (GWA) Study: A GWAS was performed using data from UKB with 10,773 cases of adhesive capsulitis. A second GWAS was performed with 8,891 cases of Dupuytren's disease. Comparison of adhesive capsulitis and Dupuytren's disease: A comparison of association statistics was performed between diseases using the data from both GWAS. Validation of SNPs Previously Reported to Show an Association with Dupuytren's Disease or Adhesive Capsulitis: SNPs previously reported from candidate gene studies for adhesive capsulitis and Dupuytren's disease were tested for association with adhesive capsulitis and Dupuytren's disease using the summary statistics from their respective GWAS.RESULTS: The UKB GWAS for adhesive capsulitis identified six loci that reached genome-wide statistical significance: a cluster of 11 closely-linked SNPs on chromosome 1; a single SNP on chromosome 2; a single SNP on chromosome 14; two closely-linked SNPs on chromosome 21; 33 closely-linked SNPs on chromosome 22; and three closely-linked SNPs on the X chromosome. These SNPs were associated with 8 different genes including TSPAN2/NGF, SATB2, MRPL52/MMP14, ERG, WNT7B and FGF13. A GWAS for Dupuytren's disease was performed and a comparison to the adhesive capsulitis GWAS showed 13 loci significantly associated with both phenotypes. A validation attempt of six previously reported SNPs associated with adhesive capsulitis using UKB summary statistics was unable to confirm any of the previously reported SNPs (all p>0.19). All 23 previously reported SNPs associated with Dupuytren's disease were confirmed using the UKB summary statistics (p < 2.1 x 10-3) CONCLUSION: This GWAS investigating adhesive capsulitis has identified six novel loci involving 8 different genes to be associated with adhesive capsulitis. A GWAS investigating Dupuytren's disease was performed and compared to the adhesive capsulitis GWAS and 13 common loci were identified between the two disorders with genes involved in pathologic fibrosis. We were unable to validate the SNPs in candidate genes previously reported to be associated with adhesive capsulitis although we were able to confirm all previously reported SNPs associated with Dupuytren's disease. The strong genetic overlap between the adhesive capsulitis and Dupuyten's disease loci suggests a similar etiology between the two diseases.

  View details for DOI 10.1016/j.jse.2022.07.005

  View details for PubMedID 35987430

• Characterization of Trapezial Pommel in Relation to Radiographic and Wear Patterns in Carpometacarpal Osteoarthritis. Hand (New York, N.Y.) Bourdillon, A. T., Shapiro, L., Kerkhof, F. D., Segovia, N. A., Weiss, A. P., Ladd, A. L. 2022: 15589447221093670

  Abstract

  Trapezial pommel, or ulnar osteophyte positioned at the vertex of the saddle-shaped facet, is a consistent structural appearance in osteoarthritis (OA) of the first carpometacarpal. This study investigates its relation to radiographic measures (modified Eaton staging and thumb OA [ThOA] index) and wear patterns (trapezial surface morphology and cartilaginous eburnation).In all, 137 whole trapezia were explanted from 116 patients and evaluated for Eaton staging, morphology (saddle, cirque, or dish), and eburnation (degree of cartilaginous effacement) of the articular surface of the trapezium. In total, 131 Robert's views and 126 stress views were reviewed by 2 blinded senior surgeons for ThOA index and pommel size. Statistical analyses included Spearman correlation and linear regression.Standardized pommel size achieved good intrarater reliability (correlation coefficient: 0.80-0.98) and moderate interrater reliability (correlation coefficient: 0.60-0.67). The ThOA index and pommel size were significantly correlated across Robert's (rs = 0.51) and stress views (rs = 0.64). The ThOA index better distinguished between stages compared with pommel size. All the radiographic measures inversely correlated with preserved cartilage and varied across morphologies. Pommel size differed significantly between dish and saddle, and the ThOA index was significantly different between all morphologies when using stress views.We reliably quantified the pommel feature and demonstrated significant correlations with other radiographic and topologic measures of arthritic disease. If future studies can demonstrate that the pommel is a pathogenic process in ThOA and its correction can curb disease progression, the identification of the pommel feature may help guide targeted intervention.

  View details for DOI 10.1177/15589447221093670

  View details for PubMedID 35642728

• Evaluation of the PROMIS Upper Extremity Against Validated Patient-Reported Outcomes in Patients with Early Carpometacarpal Osteoarthritis. The Journal of hand surgery Garcia-Lopez, E., Moore, D. C., Kenney, D. E., Ladd, A. L., Weiss, A. C., Crisco, J. J. 2022

  Abstract

  PURPOSE: Internal consistency, construct, and criterion validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) v1.2 were evaluated in patients with early-stage carpometacarpal (CMC) osteoarthritis (OA). We hypothesized that in patients with early CMC OA, PROMIS UE scores would: (1) be lower than those in asymptomatic controls; (2) correlate with established patient-reported outcomes; (3) correlate with pinch and grip strengths; and (4) not correlate with radiographic disease progression.METHODS: Patients with early CMC OA (modified Eaton stage 0 or 1) and matched asymptomatic control patients completed the PROMIS UE, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation at 2 time points. The PROMIS UE's internal consistency was evaluated by Cronbach's alpha, construct validity by Spearman correlation coefficients among the patient-reported outcome measures, and criterion validity using measures of strength. A floor or ceiling effect was indicated if more than 15% of patients achieved the lowest or highest possible score.RESULTS: The PROMIS UE had high internal consistency. Patients with early CMC OA had a lower score than healthy controls (average, 42 vs 54, respectively). We observed moderate to high correlations between the PROMIS UEv1.2, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation and good criterion validity when compared to key pinch and grip strengths. The PROMIS UE did not correlate to radiographic disease severity.CONCLUSIONS: The PROMIS UE had a high correlation with Australian and Canadian Osteoarthritis Hand Index and a moderate correlation with Patient-Rated Wrist-Hand Evaluation. The PROMIS UE had high internal consistency and good criterion validity.CLINICAL RELEVANCE: The PROMIS UE is a valid assessment for disability in patients with early CMC OA and can serve as a clinical adjunct to an outcome assessment.

  View details for DOI 10.1016/j.jhsa.2022.03.003

  View details for PubMedID 35527094

• Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS Chou, L. B., Johnson, B., Shapiro, L. M., Pun, S., Cannada, L. K., Chen, A. F., Valone, L. C., Van Nortwick, S. S., Ladd, A. L., Finlay, A. K. 2022; 6 (5)

  View details for DOI 10.5435/JAAOSGlobal-D-22-00031

  View details for Web of Science ID 000810990000001

• Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Chou, L. B., Johnson, B., Shapiro, L. M., Pun, S., Cannada, L. K., Chen, A. F., Valone, L. C., Van Nortwick, S. S., Ladd, A. L., Finlay, A. K. 2022; 6 (5)

  Abstract

  INTRODUCTION: Cancer is the second leading cause of death among women in the United States. Previous studies demonstrate a higher prevalence of cancer among female orthopaedic surgeons. This study aimed to provide an updated prevalence of breast and all-cause cancer among female orthopaedic surgeons using a larger and more current study population.METHODS: We distributed surveys to female orthopaedic surgeons in national orthopaedic specialty societies. Six hundred seventy-two survey responses were collected. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) based on gender-specific, race-specific, and age-specific cancer prevalence statistics in the US population. We compared the distribution of breast cancer risk factors with that of women in the 2018 and 2009 California Health Interview Survey.RESULTS: Fifty-one of the 672 surveyed surgeons reported a diagnosis of invasive cancer. Twenty reported breast cancer with a prevalence higher among female orthopaedic surgeons compared with the US female population (SPR: 2.89, 95% CI: 2.16 to 3.81, P < 0.001). The breast cancer prevalence was also higher among orthopaedic surgeons compared with the US female population (SPR: 3.97, 95% CI: 2.43 to 6.14, P = 0.003).DISCUSSION: The increased prevalence of breast and all-cause cancer among a larger and more diverse cohort of female orthopaedic surgeons confirms previous studies and provides an update regarding a concerning public health issue within this specialty.

  View details for DOI e22.00031

  View details for PubMedID 35587823

• Adhesive Taping Shows Better Cosmetic Outcomes Than Tissue Adhesives for Sutured Upper Extremity Incisions: A Single-Blind Prospective Randomized Controlled Trial ORTHOPEDICS Mcquillan, T. J., Vora, M., Hawkins, J., Kenney, D., Diaz, R., Ladd, A. L. 2022; 45 (1): E42-E46

  Abstract

  Adhesive taping is commonly used to reinforce wound closure and approximate minor lacerations. Recently, tissue adhesives such as 2-octylcyanoacrylate have gained popularity because of their high tensile strength, bacteriostatic properties, and spontaneous peeling. We sought to evaluate the cosmetic result of upper extremity incisions closed primarily by subcuticular suture, randomizing the application of tissue adhesive vs adhesive taping to different halves of the same surgical incision. Subjects were recruited from patients undergoing common procedures at the senior surgeon's hand surgery clinic. After primary closure, we applied either quarter-inch adhesive tape or tissue adhesive to the proximal and distal aspects of the wounds, based on a preoperative randomization protocol. We assessed the scars at approximately 3 months (range, 2-5 months). Subjects completed a validated scar assessment questionnaire, and a blinded photograph was obtained to allow 2 independent surgeons to assess the scar. Mean age was 63 years (SD, 11.8 years; range, 21-88 years); 56% of patients were women, and 44% were men. Most of the incisions were open carpal tunnel release and thumb carpometacarpal arthroplasty (14 each). Adhesive taping showed a better overall mean score based on evaluation by the hand surgeons, a finding that was statistically significant. The greatest differences were observed between color and size, but no subcategories were significantly different. Patients reported nonstatistical, but slightly better overall cosmetic outcomes with adhesive taping rather than tissue adhesive. Adhesive strips provide a modest but significant improvement in cosmetic outcomes vs more expensive tissue adhesive. Future evaluation of closure methods that evaluate cost, speed of application, suture technique, and dressing will optimize scar appearance. [Orthopedics. 2022;45(1):e42-e46.].

  View details for DOI 10.3928/01477447-20211101-08

  View details for Web of Science ID 000759519200014

  View details for PubMedID 34734780

• Ultrasound of Thumb Muscles and Grasp Strength in Early Thumb Carpometacarpal Osteoarthritis. The Journal of hand surgery Lai, C., Kenney, D., Kerkhof, F., Finlay, A., Ladd, A., Roh, E. 2021

  Abstract

  PURPOSE: The pathophysiology of thumb carpometacarpal (CMC) osteoarthritis (OA) involves complex interactions between the ligaments and muscles supporting the joint. Factors such as muscle volume and strength may be more relevant in early disease. We used ultrasound as a noninvasive method to explore differences in the intrinsic hand muscles of patients with early CMC OA, as determined using physical exam and radiographs, and healthy controls. We also assessed differences in grip strength.METHODS: A convenience sample of postmenopausal women with early CMC OA diagnosed using a physical examination or radiographs was recruited from an orthopedic clinic specializing in hand surgery. Healthy controls who were matched for age and hand dominance were recruited from the same clinic. We used ultrasound to determine the length of the first metacarpal and the muscle thickness of the abductor pollicis brevis, opponens pollicis (OPP), and first dorsal interosseous. Grip strength measurements were taken using a standard Jamar dynamometer and 2 custom-designed tools for cylindrical grasp and pinch strength.RESULTS: Twenty-three subjects were enrolled, with a total of 32 thumbs measured: 15 thumbs with arthritis and 17 healthy thumbs. Multivariable logistic regression models indicated that thumbs with thicker OPP had 0.85 lower odds (95% CI= 0.71-0.97) of early OA, adjusting for hand dominance and the first metacarpal length. Linear regression models indicated no association between early OA and grip strength.CONCLUSIONS: The size of OPP may have a weak association with the diagnosis of early OA.CLINICAL RELEVANCE: This study supports further exploration of the role of OPP in stabilizing the CMC joint, particularly with regard to minimizing joint subluxation. This may be clinically relevant to providers who treat patients with CMC OA early in the course of the disease, when nonsurgical treatment is the most relevant.

  View details for DOI 10.1016/j.jhsa.2021.07.021

  View details for PubMedID 34509311

• Representation of Male and Female Orthopedic Surgeons in Specialty Societies ORTHOPEDICS Attia, A. C., Brown, S. M., Ladd, A. L., Mulcahey, M. K. 2021; 44 (5): 289-+

  Abstract

  Women represent only 15.3% of all residents and fellows in the field of orthopedic surgery. The rate of increase of women in the field of orthopedics continues to lag behind all other surgical specialties. The purpose of this study was 2-fold: (1) to evaluate male/female representation in orthopedic specialty societies and (2) to examine the involvement of male/female orthopedic surgeons on committees, in leadership roles, at annual meetings, and in receipt of monetary awards. A 12-question, anonymous survey was distributed to the executive directors of all 23 orthopedic specialty societies. The survey included questions about the breakdown of male/female membership as well as male/female orthopedic surgeon participation in various functions of the society. Fourteen (60.9%) of 23 executive directors from orthopedic specialty societies responded to the survey. Seven (50.0%) of 14 survey respondents reported society membership of more than 1000. Six (42.9%) of 14 survey respondents reported male membership of more than 1000, while only the Ruth Jackson Orthopaedic Society reported female membership of more than 1000. Eleven (78.6%) of 14 survey respondents (eg, American Association of Hip and Knee Surgeons, American Orthopaedic Foot and Ankle Society, American Orthopaedic Society for Sports Medicine) reported having more than 10 men in leadership positions, whereas 13 (92.9%) of 14 respondents reported 10 or fewer women in leadership positions. Most orthopedic specialty societies have lower female than male membership, fewer women in leadership positions, and fewer monetary awards granted to women compared with men. This disparity was more evident in anatomic societies (eg, American Association of Hip & Knee Surgeons, American Orthopaedic Foot and Ankle Society) compared with general orthopedic societies (eg, Ruth Jackson Orthopaedic Society, Orthopaedic Research Society). Female orthopedic surgeons remain underrepresented in orthopedic specialty societies. [Orthopedics. 2021;44(5):289-292.].

  View details for DOI 10.3928/01477447-20210819-04

  View details for Web of Science ID 000703453700018

  View details for PubMedID 34590954

• Musculoskeletal Education in Medical Schools: a Survey in California and Review of Literature. Medical science educator Wang, T., Xiong, G., Lu, L., Bernstein, J., Ladd, A. 2021; 31 (1): 131-136

  Abstract

  Though musculoskeletal complaints account for roughly one-quarter of primary care and emergency department visits, only 2% of US medical school curriculum is devoted to musculoskeletal disease. Many graduating students demonstrate poor knowledge and report low confidence in treating musculoskeletal disorders. This study defines the current state of musculoskeletal curriculum of medical schools in detail to identify variations and potential shortcomings.All eleven medical schools in California were invited to participate in an in-depth survey detailing the design and content of their musculoskeletal curriculum.A response rate of 100% was achieved. Overall, schools devoted an average of 58.7 h to musculoskeletal medicine, of which more than half was spent covering anatomy. The primary instructor for musculoskeletal medicine was a clinician in four schools (36.4%). Six schools offered a dedicated musculoskeletal physical exam course. No schools required students to complete a clinical rotation in musculoskeletal medicine. There was high variability among institutions when evaluating core subject coverage.There is large variation in the content and structure of musculoskeletal instruction among California medical schools. Increased curricular time, integration of preclinical and clinical experiences, greater specialist participation, and standardized objectives may provide more consistent and comprehensive musculoskeletal education.The online version contains supplementary material available at 10.1007/s40670-020-01144-3.

  View details for DOI 10.1007/s40670-020-01144-3

  View details for PubMedID 34457873

  View details for PubMedCentralID PMC8368391

• Musculoskeletal Education in Medical Schools: a Survey in California and Review of Literature MEDICAL SCIENCE EDUCATOR Wang, T., Xiong, G., Lu, L., Bernstein, J., Ladd, A. 2021; 31 (1): 131–36

  View details for DOI 10.1007/s40670-020-01144-3

  View details for Web of Science ID 000624450200025

• ASSH 75 Years: An Update of Progress Over the Past 25 Years. The Journal of hand surgery Abzug, J. M., Bednar, J. M., Ezaki, M., Hammert, W., Jain, S. A., Kozin, S. H., Ladd, A. L., Nagle, D. J. 2020; 45 (11): 1070–81

  Abstract

  This article chronicles some of the major advancements made by the American Society for Surgery of the Hand over the past 25 years since the publication of William Newmeyer III's monograph, American Society for Surgery of the Hand: The First Fifty Years, in 1995. What is intangible and impossible to articulate in this article are the countless stories of relationship building, education, and research advancement that the programming and activities the American Society for Surgery of the Hand has provided.

  View details for DOI 10.1016/j.jhsa.2020.08.015

  View details for PubMedID 33153531

• Radiographic Progression of Thumb CMC Osteoarthritis: A Systematic Review. Journal of hand surgery global online Shapiro, L. M., McQuillan, T. J., Kerkhof, F. D., Ladd, A. 2020; 2 (6): 343-348

  Abstract

  Thumb carpometacarpal (CMC) osteoarthritis (OA) is a prevalent disease that causes pain and disability. Determining the progression of CMC OA is problematic given the lack of consensus for classifications and scoring systems. We performed a systematic review to (1) determine which imaging modalities or scoring systems are used to evaluate CMC OA progression, and (2) describe the progression of CMC OA through available metrics.This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An English language literature search was performed in July 2019 and included studies evaluating CMC OA progression with an imaging modality or radiographic scoring system, with a minimum 1-year follow-up. Studies were analyzed with respect to their methodology, scoring systems, and relevant findings.The initial search yielded 4,097 articles, 10 of which met inclusion criteria. Study size varied from 32 to 289 subjects; many subjects were included in multiple cohorts. Eight studies used radiography whereas 2 used scintigraphy. Estimates of progression varied from 20% to 70% (with large variation in follow-up time); the magnitude of progression varied from 3% to 48% (joint space narrowing) and from 0.6 to 1 points (Kellgren-Lawrence scale). The percentage of subjects who progressed and the progression degree varied widely and depended on follow-up length and the scoring system used.A paucity of literature exists to measure CMC OA progression; there is a lack of uniformly accepted imaging modality, scoring system, or follow-up interval. This absence provides the opportunity to determine consensus techniques and metrics to assess the natural history of thumb CMC OA.Diagnostic III.

  View details for DOI 10.1016/j.jhsg.2020.09.001

  View details for PubMedID 35415524

  View details for PubMedCentralID PMC8991744

• Letter to the Editor: Art in Science: The 'Pygmy' Chair and the Tenodesis Effect. Clinical orthopaedics and related research Kwong, J. W., Ladd, A. L. 2020

  View details for DOI 10.1097/CORR.0000000000001459

  View details for PubMedID 32925245

• Rotational stability of scaphoid waist non-union bone graft and fixation techniques. The Journal of hand surgery Gire, J. D., Thio, T., Behn, A. W., Kamal, R. N., Ladd, A. L. 2020

  Abstract

  PURPOSE: Rotational instability of scaphoid fracture nonunions can lead to persistent nonunion. We hypothesized that a hybrid Russe technique would provide improved rotational stability compared with an instrumented corticocancellous wedge graft in a cadaver model of scaphoid nonunion.METHODS: A volar wedge osteotomy was created at the scaphoid waist in 16 scaphoids from matched-pair specimens. A wedge was inset at the osteotomy site or a 4* 16-mm strut was inserted in the scaphoid and a screw was placed along the central axis (model 1). The construct was cyclically loaded in torsion until failure. The screw was removed and the proximal and distal poles were debrided. A matching wedge and packed cancellous bone graft or an 8* 20-mm strut was shaped and fit inside the proximal and distal pole (model 2). A screw was placed and testing was repeated.RESULTS: In the first model, there was no significant difference in cycles to failure, target torque, or maximal torque between the strut graft and the wedge graft. Cycles to failure positively correlated with estimated bone density for the wedge graft, but not for the strut graft. In the second model, the strut graft had significantly higher cycles to failure, greater target torque, and higher maximal torque compared with the wedge graft. The number of cycles to failure was not correlated with estimated bone density for the wedge or the strut grafts.CONCLUSIONS: The hybrid Russe technique of inlay corticocancellous strut and screw fixation provides improved rotational stability compared with a wedge graft with screw fixation for a cadaver model of scaphoid waist nonunion with cystic change.CLINICAL RELEVANCE: The hybrid Russe technique may provide better rotational stability for scaphoid waist nonunions when the proximal or distal scaphoid pole is compromised, such as when there is extensive cystic change, when considerable debridement is necessary, or with revision nonunion surgery.

  View details for DOI 10.1016/j.jhsa.2020.05.012

  View details for PubMedID 32654765

• Single Assessment Numeric Evaluation (SANE) in Hand Surgery: Does a One-Question Outcome Instrument Compare Favorably? The Journal of hand surgery Gire, J. D., Koltsov, J. C., Segovia, N. A., Kenney, D. E., Yao, J., Ladd, A. L. 2020

  Abstract

  PURPOSE: Patient-reported outcome measures are increasingly used to measure patient status, impairments, and disability, but often require lengthy surveys and place a considerable burden on patients. We hypothesized that the Single Assessment Numeric Evaluation (SANE), composed of a single question, would be a valid and responsive instrument to provide a global assessment of hand function.METHODS: The SANE, Patient-Reported Outcomes Measurement Information System-Upper Extremity (PROMIS-UE), and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) data are routinely collected electronically in our hand and upper-extremity center. To identify our cohort, we used Current Procedural Terminology codes to query our electronic medical record research data repository for the 7 most common hand surgery procedures performed over 2 years from December 2016 to 2018. These procedures included carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, wrist arthroscopy, distal radius fracture fixation, first dorsal compartment release, and cubital tunnel release. Patients undergoing a single isolated procedure with questionnaires obtained in the preoperative and/or postoperative period were included in the analysis. Convergent validity, coverage, and responsiveness for each instrument were assessed.RESULTS: We identified 214 patients for inclusion. The SANE score had a moderate to strong correlation with the QuickDASH and PROMIS-UE. Floor and ceiling effects for the SANE were less than 10% at baseline and follow-up. Overall, the QuickDASH was the most responsive, followed by SANE and PROMIS-UE; all 3 instruments exceeded the acceptable thresholds for responsiveness and demonstrated significant changes before to after surgery. Responsiveness of the SANE varied by procedure and was acceptable for carpal tunnel release, carpometacarpal arthroplasty, wrist arthroscopy, and trigger finger release.CONCLUSIONS: The single-item SANE is a reasonable measure of global function in patients undergoing common hand procedures and demonstrates psychometric properties comparable to those of the PROMIS-UE and QuickDASH outcome scores.CLINICAL RELEVANCE: The SANE score is a reasonable outcome measure of global hand function that may have utility in demonstrating response to treatment in a practice setting and may provide a useful adjunct to multiple-item measures in clinical research studies.

  View details for DOI 10.1016/j.jhsa.2020.03.024

  View details for PubMedID 32482496

• An Anatomical Evaluation of the Trapezium and Its Relationship to Basilar Joint Osteophytic Change. Hand (New York, N.Y.) Flanagan, C. D., Tamer, P. n., Cooperman, D. R., Crisco, J. J., Ladd, A. L., Liu, R. W. 2020: 1558944720946490

  Abstract

  To perform a comprehensive osteologic investigation into trapezium anatomy and investigate the relationship between anatomical factors and osteophyte formation, focusing on sex-specific differences.This was a cadaveric study involving 1233 trapezia and first metacarpals. Two subgroups ("Control" and "Main Study") were established. The "Control" cohort was used to identify features of the trapezium in specimens devoid of osteophytic change. The prevalence and severity of osteophytic change were investigated in the "Main Study" cohort. Sex differences were specifically assessed. Regression analyses were used to identify factors associated with osteophyte formation.Three discrete surface morphologies exist at the trapezium trapeziometacarpal (TM) facet: heart, quadrilateral, and bean. Controlling for height, men have a larger trapezium TM facet surface area. However, the trapezium assumes the same off-center saddle shape in both sexes. The presence of osteophytes at the basilar joint is a common finding; no differences in osteologic prevalence exist between sexes. The progression of osteophytic change complements the radiographic Eaton-Littler classification system. The trapezium TM facet increases the surface area with incremental osteophyte involvement, with the degree of surface area expansion correlated with increases in the severity of osteophytic change. Increased age, increased surface area, bean morphology, and decreased volar joint depth are associated with more severe osteophyte formation.Anatomical features of the trapezium may contribute to osteophyte development. Although the prevalence of osteophytic disease appears equal between sexes, sex differences exist in some anatomical parameters. These differences may help explain the increased prevalence of symptomatic basilar joint disease in women.

  View details for DOI 10.1177/1558944720946490

  View details for PubMedID 32935598

• The Association of AUSCAN and PRWHE Patient-reported Outcome Measures With Radiographic Progression of Early Thumb Carpometacarpal Arthritis at 36-Month Follow-up Is Limited to Subtle Changes in the Pain Subscale. Hand (New York, N.Y.) Gil, J. A., Kleiner, J. n., McQuillan, T. J., Kenney, D. n., Ladd, A. L., Weiss, A. C., Crisco, J. J. 2020: 1558944720928489

  Abstract

  There is a paucity of literature that examines how patient-reported outcomes correspond to early radiographic progression of thumb carpometacarpal (CMC) osteoarthritis (OA). This study examines how Australian/Canadian Osteoarthritis Hand Index (AUSCAN) and Patient-Rated Hand and Wrist Evaluation (PRWHE) scores change over 36 months in subjects with early CMC OA.Ninety-one subjects with symptomatic early thumb CMC OA were enrolled. Differences in AUSCAN and PRWHE scores were measured between subjects at baseline and at 18-month follow-up, and between the subjects at baseline and at 36-month follow-up. Radiographic progression was defined as an increase in modified Eaton Stage. Differences in AUSCAN and PRWHE scores were compared between these 2 groups in order to determine if radiographic progression was associated with a greater change in AUSCAN and PRWHE at 18- and 36-month follow-up.At 18- and 36-month follow-up visits, there were no significant differences in AUSCAN or PRWHE compared to baseline. Multivariable logistic regression analysis did not reveal any significant differences between subjects with radiographic progression to subjects without radiographic progression at 18-month follow-up. At 36-month follow-up, this analysis did demonstrate that subjects with evidence of radiographic progression had a significant increase in the PRWHE pain subscale.AUSCAN and PRWHE scores were not found to significantly progress at 18-month and 36-month follow-up. However, when comparing the subset of subjects with and without radiographic OA, subjects with early CMC OA who had 1 stage of radiographic progression were found to have a significantly higher intensity of pain on the PRWHE pain subscale at 36-month follow-up.

  View details for DOI 10.1177/1558944720928489

  View details for PubMedID 32935579

• Patient Willingness to Pay for Faster Return to Work or Smaller Incisions. Hand (New York, N.Y.) Alokozai, A., Lindsay, S. E., Eppler, S. L., Fox, P. M., Ladd, A. L., Kamal, R. N. 2019: 1558944719890039

  Abstract

  Background: Value-based health care models such as bundled payments and accountable care organizations can penalize health systems and physicians for excess costs leading to low-value care. Health systems can minimize these extra costs by constraining diagnostic (eg, magnetic resonance imaging utilization) or treatment options with debatable necessity in the setting of clinical equipoise. Instead of restricting more expensive treatments, it is plausible that health systems could instead recoup the extra costs of these treatments by charging patients supplementary out-of-pocket charges (cost sharing). The primary aim of this exploratory study was to assess hand surgery patient willingness to pay supplementary out-of-pocket charges for a procedure that theoretically leads to an earlier return to work or smaller incisions when there are 2 procedures that lead to similar results (clinical equipoise). Methods: A total of 122 patients completed a questionnaire that included demographic information, a financial distress assessment, a series of scenarios asking patients the degree to which they are willing to pay extra for the procedure choice, as well as their perspective of how much insurers should be responsible for these additional costs. Results: Patients were willing to pay out-of-pocket to some degree for a procedure that leads to earlier return to work and smaller incision size when compared with a similar alternative procedure, but noted that insurers should bear a greater burden of costs. Approximately 10% of patients were willing to pay maximum amounts ($2500+) for earlier return to work (3, 7, and 14 days earlier) and smaller incision sizes of any length. Conclusions: Some patients may be willing to pay out-of-pocket and cost share for procedures that lead to earlier return to work and smaller incisions in the setting of clinical equipoise. As such, when developing and implementing alternative payment models, health systems could potentially offer services with debatable necessity in the setting of equipoise for a supplementary out-of-pocket charge.

  View details for DOI 10.1177/1558944719890039

  View details for PubMedID 31791156

• Automatic segmentation of the thumb trapeziometacarpal joint using parametric statistical shape modelling and random forest regression voting. Computer methods in biomechanics and biomedical engineering. Imaging & visualization Schneider, M. T., Zhang, J., Crisco, J. J., Weiss, A. C., Ladd, A. L., Nielsen, P. M., Besier, T. 2019; 7 (3): 297-301

  Abstract

  We propose an automatic pipeline for creating shape modelling suitable parametric meshes of the trapeziometacarpal (TMC) joint from clinical CT images for the purpose of batch processing and analysis. The method uses 3D random forest regression voting (RFRV) with statistical shape model (SSM) segmentation. The method was demonstrated in a validation experiment involving 65 CT images, 15 of which were randomly selected to be excluded from the training set for testing. With mean root mean squared (RMS) errors of 1.066 mm and 0.632 mm for the first metacarpal and trapezial bones respectively, and a segmentation time of ~2 minutes per CT image, the preliminary results showed promise for providing accurate 3D meshes of TMC joint bones for batch processing.

  View details for DOI 10.1080/21681163.2018.1501765

  View details for PubMedID 31275767

  View details for PubMedCentralID PMC6608596

• Osteophyte Growth in Early Thumb Carpometacarpal Osteoarthritis. Osteoarthritis and cartilage Crisco, J. J., Morton, A. M., Moore, D. C., Kahan, L. G., Ladd, A. L., Weiss, A. C. 2019

  Abstract

  OBJECTIVE: Osteophyte formation is a critical part of the degeneration of a joint with osteoarthritis (OA). While often qualitatively described, few studies have succeeded in quantifying osteophyte growth over time. Using computed tomography (CT) image data from a longitudinal, observational study of thumb carpometacarpal (CMC) OA, our aim was to quantify osteophyte growth volume and location over a three-year period in men and women.METHOD: Ninety patients with early thumb OA were recruited and assessed at baseline, 1.5 years, and 3 years with CT imaging. Osteophyte volume and location on the trapezium and first metacarpal were determined using a library of 46 healthy subjects as a nonarthritic reference database.RESULTS: There was a significant increase in osteophyte volume for women and men over the three-year follow-up in the trapezium (86.8mm3 to 120.5mm3 and 165.1mm3 to 235.3mm3, means respectively) and in the proximal metacarpal (63mm3 to 80.4mm3, and 115.8mm3 to 161.7mm3, respectively). The location of osteophyte initiation and growth was consistent across subjects and was located in non-opposing regions on the trapezium and first metacarpal. Osteophyte growth occurred about the radial and ulnar margins of the trapezial facet, while on the proximal metacarpal, growth occurred principally about the volar and dorsal margins of the facet.CONCLUSION: Osteophyte growth occurred in early thumb osteoarthritis over three years. Growth was localized in specific, non-opposing regions on the trapezium and metacarpal, raising intriguing questions about the triggers for their formation, whether the mechanisms are mechanical, biological or a combination of both.

  View details for DOI 10.1016/j.joca.2019.05.008

  View details for PubMedID 31136802

• Histopathological analysis of the synovium in trapeziometacarpal osteoarthritis. The Journal of hand surgery, European volume Rein, S., Okogbaa, J., Hagert, E., Manthey, S., Ladd, A. 2019: 1753193419848600

  Abstract

  Dorsoradial and anterior oblique ligaments were harvested during surgery in 13 patients with symptomatic trapeziometacarpal osteoarthritis, which had been graded preoperatively by a modified Eaton-Littler radiographic grading. Ligaments, including the periligamentous synovium, were stained with S100 protein, neurotrophic receptor p75, protein gene product 9.5, calcitonin gene related peptide, acetylcholine, substance P, neuropeptide Y, noradrenaline, N-methyl-D-aspartate-receptor and Met/Leu-enkephalin. The synovium was classified as showing no, low-grade or high-grade synovitis. Free nerve endings had higher immunoreactivity for substance P than for N-methyl-D-aspartate-receptor, enkephalin and noradrenaline. The synovial stroma had less immunoreactivity for N-methyl-D-aspartate-receptor than for noradrenaline, substance P and calcitonin gene related peptide. There was no relation between the grade of osteoarthritis and the visual pain analogue scale, synovitis score, immunoreactivity of all antibodies and quantity of free nerve endings or blood vessels. Synovium in trapeziometacarpal joint osteoarthritis produces several neuromediators causing a polymodal neurogenic inflammation and which may serve as biomarkers for osteoarthritis or therapeutic targets.

  View details for DOI 10.1177/1753193419848600

  View details for PubMedID 31109229

• The Orthopaedic Workforce Is Not as Diverse as the Population It Serves: Where Are the Minorities and the Women? AOA Critical Issues Symposium JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Harrington, M. A., Rankin, E., Ladd, A. L., Mason, B. S. 2019; 101 (8)

  View details for DOI 10.2106/JBJS.18.01010

  View details for Web of Science ID 000465087700001

• Automatic segmentation of the thumb trapeziometacarpal joint using parametric statistical shape modelling and random forest regression voting COMPUTER METHODS IN BIOMECHANICS AND BIOMEDICAL ENGINEERING-IMAGING AND VISUALIZATION Schneider, M. Y., Zhang, J., Crisco, J. J., Weiss, A. C., Ladd, A. L., Nielsen, P. F., Besier, T. 2019; 7 (3): 297–301

  View details for DOI 10.1080/21681163.2018.1501765

  View details for Web of Science ID 000471785300008

• Golf Swing Rotational Velocity: The Essential Follow-Through. Annals of rehabilitation medicine Steele, K. M., Roh, E. Y., Mahtani, G., Meister, D. W., Ladd, A. L., Rose, J. 2018; 42 (5): 713–21

  Abstract

  OBJECTIVE: To evaluate if shoulder and pelvic angular velocities differ at impact or peak magnitude between professional and amateur golfers. Golf swing rotational biomechanics are a key determinant of power generation, driving distance, and injury prevention. We hypothesize that shoulder and pelvic angular velocities would be highly consistent in professionals.METHODS: Rotational velocities of the upper-torso and pelvis throughout the golf swing and in relation to phases of the golf swing were examined in 11 professionals and compared to 5 amateurs using three-dimensional motion analysis.RESULTS: Peak rotational velocities of professionals were highly consistent, demonstrating low variability (coefficient of variation [COV]), particularly upper-torso rotational velocity (COV=0.086) and pelvic rotational velocity (COV=0.079) during down swing. Peak upper-torso rotational velocity and peak X-prime, the relative rotational velocity of uppertorso versus pelvis, occurred after impact in follow-through, were reduced in amateurs compared to professionals (p=0.005 and p=0.005, respectively) and differentiated professionals from most (4/5) amateurs. In contrast, peak pelvic rotational velocity occurred in down swing. Pelvic velocity at impact was reduced in amateurs compared to professionals (p=0.019) and differentiated professionals from most (4/5) amateurs.CONCLUSION: Golf swing rotational velocity of professionals was consistent in pattern and magnitude, offering benchmarks for amateurs. Understanding golf swing rotational biomechanics can guide swing modifications to help optimize performance and prevent injury.

  View details for PubMedID 30404420

• Golf Swing Rotational Velocity: The Essential Follow-Through ANNALS OF REHABILITATION MEDICINE-ARM Steele, K. M., Roh, E. Y., Mahtani, G., Meister, D. W., Ladd, A. L., Rose, J. 2018; 42 (5): 713–21

  View details for DOI 10.5535/arm.2018.42.5.713

  View details for Web of Science ID 000449459700008

• Bennett Fractures: A Biomechanical Model and Relevant Ligamentous Anatomy. The Journal of hand surgery Kang, J. R., Behn, A. W., Messana, J., Ladd, A. L. 2018

  Abstract

  PURPOSE: This study examined a palmar beak fracture model to determine which thumb carpometacarpal (CMC) joint ligament is the primary ligament relevant to the pattern of injury.METHODS: Six fresh-frozen cadaveric wrists were used. The radius, ulna, and first metacarpal were secured and tested with a materials testing system, holding the wrist in 20° extension, 20° ulnar deviation, and 30° palmar abduction of the first metacarpal. Testing consisted of preconditioning cycles followed by compressive loading at 100 mm/s. We confirmed fractures with fluoroscopy and dissected the specimens to examine the CMC joint ligaments. The metacarpal was stressed through a range of motion to determine which maneuvers reduced or displaced the fractures.RESULTS: Our model successfully created palmar beak fractures in all cadaveric specimens. All fractures were displaced and intra-articular. The anterior oblique ligament (AOL) was thin and partially attached to the palmar beak fracture fragment. The ulnar collateral ligament was attached in its entirety to the fracture fragment and represented a thicker, more robust ligament compared with the AOL. Radial abduction and pronation of the metacarpal reduced fracture displacement. Extension of the CMC joint or tensioning the AOL did not decrease fracture displacement.CONCLUSIONS: This model successfully created a reproducible and clinically relevant palmar beak fracture in a biomechanical setting. The primary ligament attached to the palmar beak fracture fragment was the ulnar collateral ligament, and not the AOL as previously described. These findings suggest that the AOL may not be a substantial contributor to palmar beak fracture morphology.CLINICAL RELEVANCE: A refined description of the ligamentous anatomy of the palmar break fracture enhances opportunities for improved reduction and treatment of this common hand injury.

  View details for DOI 10.1016/j.jhsa.2018.04.024

  View details for PubMedID 29891266

• Therapy Concepts for the Proximal Interphalangeal Joint HAND CLINICS Douglass, N. P., Ladd, A. L. 2018; 34 (2): 289-+

  Abstract

  The principles of hand therapy for proximal interphalangeal joint disorders include protecting injured structures, minimizing patient discomfort, and optimizing patient recovery. Comprehension of hand anatomy, the nature of the injury being treated, and the phases of healing are critical when designing a safe and effective hand therapy program. Hand therapists use a combination of orthoses, guided exercises, and modalities to improve edema, sensitivity, range of motion, and function.

  View details for PubMedID 29625646

• The Teleology of the Thumb: On Purpose and Design JOURNAL OF HAND SURGERY-AMERICAN VOLUME Ladd, A. L. 2018; 43 (3): 248–59

  Abstract

  The Andrew J. Weiland Medal is presented by the American Society for Surgery of the Hand to a midcareer researcher dedicated to advancing patient care in the field of hand surgery. The Weiland Medal for 2017 was presented to the author at the annual meeting of the American Society for Surgery of the Hand. The purpose of this article is to present current evidence on how biomechanics and morphology influence the pathophysiology of thumb carpometacarpal joint osteoarthritis.

  View details for DOI 10.1016/j.jhsa.2018.01.002

  View details for Web of Science ID 000426453300007

  View details for PubMedID 29502577

  View details for PubMedCentralID PMC5841599

• Polydactyly of the Hand. The Journal of the American Academy of Orthopaedic Surgeons Comer, G. C., Potter, M., Ladd, A. L. 2018; 26 (3): 75–82

  Abstract

  Polydactyly is one of the most common congenital hand deformities managed by orthopaedic surgeons. It is most often found in isolation; however, rarely, it may be associated with genetic syndromes. Polydactyly is classified as postaxial, preaxial, or central depending on the radioulnar location of the duplicated digits. Postaxial polydactyly, which affects the ulnar side of the hand, is most common and is typically managed with excision or suture ligation of the supernumerary digit. Preaxial polydactyly, which affects the thumb or radial side of the hand, often requires reconstructive techniques to ensure a functional, stable thumb. Central polydactyly is much less common, and reconstruction can be challenging.

  View details for PubMedID 29309292

• Polydactyly of the Hand JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Comer, G. C., Potter, M., Ladd, A. L. 2018; 26 (3): 75–82

  View details for DOI 10.5435/JAAOS-D-16-00139

  View details for Web of Science ID 000441210600003

• Trapeziometacarpal joint contact varies between men and women during three isometric functional tasks MEDICAL ENGINEERING & PHYSICS Schneider, M. Y., Zhang, J., Crisco, J. J., Weiss, A. C., Ladd, A. L., Mithraratne, K., Nielsen, P., Besier, T. 2017; 50: 43–49

  Abstract

  Trapeziometacarpal (TMC) joint osteoarthritis (OA) affects women two to six times more than men, and is influenced by stresses and strains in the cartilage. The purpose of this study was to characterise sex and age differences in contact area and peak stress location of the healthy TMC joint during three isometric tasks including pinch, grasp and jar twist. CT images of the hand from 50 healthy adult men and women were used to create a statistical shape model that was used to create finite element models for each subject and task. Force-driven simulations were performed to evaluate cartilage contact area and peak stress location. We tested for sex and age differences using Principal Component Analysis, linear regression, and Linear Discriminant Analysis. We observed sex differences in peak stress location during pinch (p = .0206), grasp (p = .0264), and jar twist (p = .0484). The greatest sex differences were observed during jar twist, where 94% of peak stresses in men were located in the centre compared with 50% in the central-volar region in women. These findings show that peak stress locations are more variable in women during grasp and jar twist than men, and suggest that women may employ different strategies to perform these tasks.

  View details for PubMedID 29107572

• CORR Insights (R): What Demographic and Clinical Characteristics Correlate With Expectations With Trapeziometacarpal Arthritis? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2017; 475 (11): 2712–15

  View details for PubMedID 28569373

  View details for PubMedCentralID PMC5638730

• Candidate Quality Measures for Hand Surgery JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Akelman, E., Ruch, D. S., Richard, M. J., Ladd, A., Got, C., Blazar, P., Yao, J., Kakar, S., Harris, A. S., Ring, D., Hand Surg Quality Consortium 2017; 42 (11): 859-+

  Abstract

  Quality measures are tools used by physicians, health care systems, and payers to evaluate performance, monitor the outcomes of interventions, and inform quality improvement efforts. A paucity of quality measures exist that address hand surgery care. We completed a RAND/UCLA (University of California Los Angeles) Delphi Appropriateness process with the goal of developing and evaluating candidate hand surgery quality measures to be used for national quality measure development efforts.A consortium of 9 academic upper limb surgeons completed a RAND/UCLA Delphi Appropriateness process to evaluate the importance, scientific acceptability, usability, and feasibility of 44 candidate quality measures. These addressed hand problems the panelists felt were most appropriate for quality measure development. Panelists rated the measures on an ordinal scale between 1 (definitely not valid) and 9 (definitely valid) in 2 rounds (preliminary round and final round) with an intervening face-to-face discussion. Ratings from 1 to 3 were considered not valid, 4 to 6 as equivocal or uncertain, and 7 to 9 as valid. If no more than 2 of the 9 ratings were outside the 3-point range that included the median (1-3, 4-6, or 7-9), the panelists were considered to be in agreement. If 3 or more of the panelists' ratings of a measure were within the 1 to 3 range and 3 or more ratings were in the 7 to 9 range, the panelists were considered to be in disagreement.There was agreement on 43% (19) of the measures as important, 27% (12) as scientifically sound, 48% (21) as usable, and 59% (26) as feasible to complete. Ten measures met all 4 of these criteria and were, therefore, considered valid measurements of quality. Quality measures that were developed address outcomes (patient-reported outcomes for assessment and improvement of function) and processes of care (utilization rates of imaging, antibiotics, occupational therapy, ultrasound, and operative treatment).The consortium developed 10 measures of hand surgery quality using a validated methodology. These measures merit further development.Quality measures can be used to evaluate the quality of care provided by physicians and health systems and can inform quality and value-based reimbursement models.

  View details for DOI 10.1016/j.jhsa.2017.07.005

  View details for Web of Science ID 000415601300001

  View details for PubMedID 28818350

• Incidence of Acute Complications Following Surgery for Syndactyly and Polydactyly: An Analysis of the National Surgical Quality Improvement Program Database from 2012 to 2014 JOURNAL OF HAND SURGERY-AMERICAN VOLUME McQuillan, T. J., Hawkins, J. E., Ladd, A. L. 2017; 42 (9)

  View details for DOI 10.1016/j.jhsa.2017.05.011

  View details for Web of Science ID 000437892100003

• Integrating Musculoskeletal Education and Patient Care at Medical Student-Run Free Clinics. PM & R : the journal of injury, function, and rehabilitation McQuillan, T., Wilcox-Fogel, N., Kraus, E., Ladd, A., Fredericson, M. 2017

  Abstract

  Student-run free clinics (SRFCs) have emerged as an important educational component of United States (US) medical schools. Despite the prevalence of musculoskeletal (MSK) problems presenting to SRFCs, students and clinics are often unprepared to diagnose and to treat common MSK complaints.We sought to determine the scope of diagnosis and treatment at a medical student-run free clinic specializing in musculoskeletal care using physical medicine and rehabilitation (PM&R) residents. Secondary goals included reviewing student satisfaction and determining the appropriateness of the clinic in medical education.Retrospective chart review, anonymous online survey.Primary care, free student clinic affiliated with tertiary academic medical center.A total of 20 medical student volunteers, 6 PM&R residents, and 91 community patients.We established a musculoskeletal clinic as a specialty referral clinic for the 2 primary care SRFCs with institutional support from a partner medical school. We then reviewed clinical operations retrospectively using electronic medical records and student satisfaction based on an online survey.We analyzed patient demographics and chief complaints, referrals provided, and medical services rendered. We also used a 5-point Likert scale to assess student satisfaction.A monthly musculoskeletal referral clinic was established with the oversight of PM&R attendings and residents. The clinic received 91 referrals and managed 61 unique patients over a 2.5-year study period. The most common presentations to the clinic involved knee pain (n = 17, 27.9%) and back pain (n = 16, 26.2%). Pro bono relationships with community and institutional partners enabled all patients to receive medical examinations, physical therapy visits, plain film radiographs, and insurance consultations free of charge. Student satisfaction with teaching and patient care was high, with 19 of 20 students reporting their experience as "good" or "excellent."SRFCs represent an underused opportunity to enhance MSK education among medical students by treating a variety of common MSK complaints in an underserved population.To be determined.

  View details for DOI 10.1016/j.pmrj.2017.03.008

  View details for PubMedID 28389399

• Reduction in Cylindrical Grasp Strength Is Associated With Early Thumb Carpometacarpal Osteoarthritis CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Coughlan, M. J., Bourdillon, A., Crisco, J. J., Kenney, D., Weiss, A., Ladd, A. L. 2017; 475 (2): 522-528

  Abstract

  Advanced thumb carpometacarpal (CMC) osteoarthritis (OA) can cause substantial impairment in hand function, from grasping heavy objects to fine manipulation of implements and tools. In the clinical setting, we commonly measure the grip strength of gross grasp with a hand dynamometer in patients with CMC OA. Cylindrical grasp, which requires more thumb contribution than gross grasp, is an alternative method of measuring grip strength and one that may provide insight into thumb-related conditions. Because gross grasp and cylindrical grasp use the thumb in different planes, measurement of gross grasp alone might underestimate impairment. Therefore, it is important to evaluate cylindrical grasp as well. To our knowledge this tool has yet to be examined in a population with early thumb CMC OA.(1) Is cylindrical grasp and gross grasp strength reduced in subjects with early thumb CMC OA compared with asymptomatic control subjects? (2) What is the association of cylindrical and gross grasp to thumb CMC OA after adjusting for age, sex, and hand dominance?We recruited 90 subjects with early symptomatic and radiographic thumb CMC OA and 38 asymptomatic healthy control subjects for this multisite controlled study. Demographic information, hand examination, comprehensive histories, plain film radiographs, and cylindrical and gross grasp strength data were collected on all 128 subjects. Mean grasp strength was calculated for cylindrical and gross grasp in the population with early CMC OA and the control population. A t-test was performed on cylindrical and gross grasp to evaluate the difference between the mean in the control and early CMC OA populations. We used separate linear regression models for the two types of grasp to further quantify the association of grasp with a diagnosis of early thumb CMC OA controlling for age, sex, and whether the subject used their dominant or nondominant hand in the study.Cylindrical grasp was weaker in the population with thumb CMC OA compared with healthy control subjects (6.3 ± 2.7 kg versus 8.4 ± 2.5 kg; mean difference, 2.1; 95% CI, 1.1-3.1; p < 0.001), but there was no difference in gross grasp force (29.6 ± 11.6 kg versus 31.4 ± 10.1 kg; mean difference, 1.7; 95% CI, -2.5 to 6.0; p = 0.425). When adjusting for age, sex, and handedness, cylindrical grasp reduction was related to CMC OA (β = -2.3; standard error [SE], 0.46; p < 0.001) (Y-intercept = 8.2; SE, 1.8; R(2) = 0.29), whereas gross grasp was not reduced in early thumb CMC OA (β = -2.8; SE, 1.6; p = 0.072) (Y-intercept = 34.3; SE, 6.3; R(2) = 0.48).A reduction in cylindrical grasp is associated with early symptomatic and radiographic CMC OA, whereas gross grasp is not associated with early thumb CMC OA, suggesting that cylindrical grasp may be a better tool to detect changes in thumb and hand function seen during early disease stages.Cylindrical grasp may serve as a more-sensitive measure for detecting early changes in early CMC OA. The associated decline in hand function also might provide an opportunity for measuring the effectiveness of treatment and intervention.

  View details for DOI 10.1007/s11999-016-5151-2

  View details for Web of Science ID 000391931600039

  View details for PubMedCentralID PMC5213951

• Incidence of Acute Complications Following Surgery for Syndactyly and Polydactyly: An Analysis of the National Surgical Quality Improvement Program Database from 2012 to 2014. The Journal of hand surgery McQuillan, T. J., Hawkins, J. E., Ladd, A. L. 2017; 42 (9): 749.e1–749.e7

  Abstract

  Congenital hand differences are infrequent phenomena, and their treatment represents a relatively small fraction of cases performed by hand surgeons. Little is known about the incidence of wound complications and acute postoperative problems given the relative rarity of these procedures. This study sought to characterize the incidence of complications within 30 days of surgery for congenital hand differences.The National Surgical Quality Improvement Program (NSQIP) contains prospective data regarding 30-day morbidity from 64 pediatric centers across the United States. Data from all available years (2012-2014) were queried for Current Procedural Terminology (CPT) codes pertinent to the treatment of congenital hand differences. Bivariate statistics, Fisher exact tests and Poisson 95% confidence intervals (95% CI) were used to assess the incidence of complications and examine risk factors for these outcomes.We identified a total of 1,656 congenital hand cases that represented 4 different CPT codes, including surgery for simple syndactyly, complex syndactyly, and polydactyly. The overall incidence of complications was 2.2% (95% CI, 1.6%-3.1%; n = 37) with the most common complication being superficial surgical site infection (1.7%; 95% CI, 1.1%-2.4%) followed by related readmission (0.3%; 95% CI, 0.1%-0.7%). There was a higher incidence of complications observed in patients undergoing complex syndactyly repair (5.2% for complex syndactyly repair vs 2.3% for all others).The rate of acute complications following procedures to correct syndactyly and polydactyly is low, the most common of which is superficial surgical site infection. The incidence of acute complications may be helpful in counseling patients and families. We suggest that further research must prioritize collecting data on long-term functional outcomes.Therapeutic II.

  View details for PubMedID 28648327

• The AUSCAN and PRWHE Demonstrate Comparable Internal Consistency and Validity in Patients With Early Thumb Carpometacarpal Osteoarthritis. Hand (New York, N.Y.) McQuillan, T. J., Vora, M. M., Kenney, D. E., Crisco, J. J., Weiss, A. C., Ebert, K. A., Snelgrove, K. E., Sarnowski, A. n., Ladd, A. L. 2017: 1558944717729217

  Abstract

  The Australian/Canadian Osteoarthritis Hand Index (AUSCAN) and Patient-Rated Wrist-Hand Evaluation (PRWHE) are 2 patient-related outcome measures to assess pain and disability in patients with osteoarthritis (OA). The purpose of this study was to evaluate the AUSCAN and PRWHE in a large-scale, longitudinal cohort of patients with early thumb carpometacarpal (CMC) OA.We obtained baseline data on 135 individuals (92 with early CMC OA participants and 43 asymptomatic controls) and at follow-up (year 1.5) on 83 individuals. We assessed the internal consistency using Cronbach alpha, and construct and criterion validity using other pain scales and objective measures of strength, respectively. We also examined the correlation between the AUSCAN and PRWHE and correlation coefficients at baseline and follow-up, as well as the correlation between changes in these instruments over the follow-up period.Internal consistency was high for both AUSCAN and PRWHE totals and subscales (Cronbach α > 0.70). Both instruments demonstrated construct validity compared with the Verbal Rating Scale ( r = 0.52-0.60, P < .01), an assessment of pain, and moderate criterion validity compared with key pinch and grip strength ( r = -.24 to -.33, P < .05). These instruments were highly correlated with each other at baseline and follow-up time points ( r = 0.76-.94, P < .01), and changes in a patient's total scores over time were also correlated ( r = 0.83, P < .01).The AUSCAN and PRWHE are both valid assessments for pain and/or disability in patients with early thumb CMC OA.

  View details for PubMedID 28934868

• Changes in Local Bone Density in Early Thumb Carpometacarpal Joint Osteoarthritis. The Journal of hand surgery Schreiber, J. J., McQuillan, T. J., Halilaj, E. n., Crisco, J. J., Weiss, A. P., Patel, T. n., Kenney, D. n., Ladd, A. L. 2017

  Abstract

  Thumb carpometacarpal (CMC) osteoarthritis (OA) represents a major source of functional morbidity. The effects of early CMC OA on loading and use patterns potentially lead to changes in local bone density and microarchitecture. Hounsfield units (HU), a quantitative attenuation coefficient obtained from computed tomography (CT) scans, have been shown to be a reliable marker of bone density. We hypothesized that early CMC OA is associated with lower local bone density about the CMC joint as assessed by HU.We examined HU units from CT scans in 23 asymptomatic subjects and 91 patients with early CMC OA. The HU measurements were obtained within cancellous portions of the trapezium, capitate, first and third metacarpal bases, and distal radius. Linear regression models, with age and sex included as covariates, were used to assess the relationship between CMC OA and HU values at each anatomical site.Early OA patients had significantly lower HU than asymptomatic subjects within the trapezium (mean, 377 HU vs 436 HU) and first metacarpal bases (265 HU vs 324 HU). No significant group differences were noted at the capitate, third metacarpal, or distal radius. Male sex and younger age were associated with significantly higher HU at all the anatomical sites, except the first metacarpal base, where age had no significant effect.Subjects presenting with early CMC OA had significantly lower bone density as assessed with HU at the thumb CMC joint (trapezium and first metacarpal base). Early thumb CMC OA and discomfort may lead to diminished loading across the basal joint, producing focal disuse osteopenia. These findings in symptomatic early arthritis suggest a relationship between symptoms, functional use of the CMC joint, and local bone density.Diagnostic II.

  View details for PubMedID 29029863

• Reduction in Cylindrical Grasp Strength Is Associated With Early Thumb Carpometacarpal Osteoarthritis. Clinical orthopaedics and related research Coughlan, M. J., Bourdillon, A., Crisco, J. J., Kenney, D., Weiss, A., Ladd, A. L. 2016: -?

  Abstract

  Advanced thumb carpometacarpal (CMC) osteoarthritis (OA) can cause substantial impairment in hand function, from grasping heavy objects to fine manipulation of implements and tools. In the clinical setting, we commonly measure the grip strength of gross grasp with a hand dynamometer in patients with CMC OA. Cylindrical grasp, which requires more thumb contribution than gross grasp, is an alternative method of measuring grip strength and one that may provide insight into thumb-related conditions. Because gross grasp and cylindrical grasp use the thumb in different planes, measurement of gross grasp alone might underestimate impairment. Therefore, it is important to evaluate cylindrical grasp as well. To our knowledge this tool has yet to be examined in a population with early thumb CMC OA.(1) Is cylindrical grasp and gross grasp strength reduced in subjects with early thumb CMC OA compared with asymptomatic control subjects? (2) What is the association of cylindrical and gross grasp to thumb CMC OA after adjusting for age, sex, and hand dominance?We recruited 90 subjects with early symptomatic and radiographic thumb CMC OA and 38 asymptomatic healthy control subjects for this multisite controlled study. Demographic information, hand examination, comprehensive histories, plain film radiographs, and cylindrical and gross grasp strength data were collected on all 128 subjects. Mean grasp strength was calculated for cylindrical and gross grasp in the population with early CMC OA and the control population. A t-test was performed on cylindrical and gross grasp to evaluate the difference between the mean in the control and early CMC OA populations. We used separate linear regression models for the two types of grasp to further quantify the association of grasp with a diagnosis of early thumb CMC OA controlling for age, sex, and whether the subject used their dominant or nondominant hand in the study.Cylindrical grasp was weaker in the population with thumb CMC OA compared with healthy control subjects (6.3 ± 2.7 kg versus 8.4 ± 2.5 kg; mean difference, 2.1; 95% CI, 1.1-3.1; p < 0.001), but there was no difference in gross grasp force (29.6 ± 11.6 kg versus 31.4 ± 10.1 kg; mean difference, 1.7; 95% CI, -2.5 to 6.0; p = 0.425). When adjusting for age, sex, and handedness, cylindrical grasp reduction was related to CMC OA (β = -2.3; standard error [SE], 0.46; p < 0.001) (Y-intercept = 8.2; SE, 1.8; R(2) = 0.29), whereas gross grasp was not reduced in early thumb CMC OA (β = -2.8; SE, 1.6; p = 0.072) (Y-intercept = 34.3; SE, 6.3; R(2) = 0.48).A reduction in cylindrical grasp is associated with early symptomatic and radiographic CMC OA, whereas gross grasp is not associated with early thumb CMC OA, suggesting that cylindrical grasp may be a better tool to detect changes in thumb and hand function seen during early disease stages.Cylindrical grasp may serve as a more-sensitive measure for detecting early changes in early CMC OA. The associated decline in hand function also might provide an opportunity for measuring the effectiveness of treatment and intervention.

  View details for PubMedID 27822895

• Quality Measures That Address the Upper Limb JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Ring, D., Akelman, E., Ruch, D. S., Richard, M. J., Ladd, A., Got, C., Blazar, P., Yao, J., Kakar, S. 2016; 41 (11): 1041-1048

  Abstract

  Physicians, health care systems, and payers use quality measures to judge performance and monitor the outcomes of interventions. Practicing upper-limb surgeons desire quality measures that are important to patients and feasible to use, and for which it is fair to hold them accountable.Nine academic upper-limb surgeons completed a RAND/University of California-Los Angeles Delphi Appropriateness process to evaluate the importance, feasibility, and accountability of 134 quality measures identified from systematic review. Panelists rated measures on an ordinal scale between 1 (definitely not valid) and 9 (definitely valid) in 2 rounds (preliminary round and final round) with an intervening face-to-face discussion. Ratings from 1 to 3 were considered not valid, 4 to 6 were equivocal or uncertain, and 7 to 9 were valid. If no more than 2 of the 9 ratings were outside the 3-point range that included the median (1-3, 4-6, or 7-9), panelists were considered to be in agreement. If 3 or more ratings of a measure were within the 1 to 3 range whereas 3 or more ratings were in the 7 to 9 range, panelists were considered to be in disagreement.There was agreement that 58 of the measures are important (43%), 74 are feasible (55%), and surgeons can be held accountable for 39 (29%). All 3 thresholds were met for 33 measures (25%). A total of 36 reached agreement for being unimportant (48%) and 57 were not suited for surgeon accountability (43%).A minority of upper-limb quality measures were rated as important for care, feasible to complete, and suitable for upper-limb surgeon accountability.Before health systems and payers implement quality measures, we recommend ensuring their importance and feasibility to safeguard against measures that may not improve care and might misappropriate attention and resources.

  View details for DOI 10.1016/j.jhsa.2016.07.107

  View details for Web of Science ID 000387632600001

  View details for PubMedID 27577525

• Pearls: Snakes in the Grass and Other Surgical Gems CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2016; 474 (11): 2357–58

  View details for PubMedID 27562786

  View details for PubMedCentralID PMC5052215

• The Perry Initiative's Medical Student Outreach Program Recruits Women Into Orthopaedic Residency CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Lattanza, L. L., Meszaros-Dearolf, L., O'Connor, M. I., Ladd, A., Bucha, A., Trauth-Nare, A., Buckley, J. M. 2016; 474 (9): 1962-1966

  Abstract

  Orthopaedic surgery lags behind other surgical specialties in terms of gender diversity. The percentage of women entering orthopaedic residency persistently remains at 14% despite near equal ratios of women to men in medical school classes. This trend has been attributed to negative perceptions among women medical students of workplace culture and lifestyle in orthopaedics as well as lack of exposure, particularly during medical school when most women decide to enter the field. Since 2012, The Perry Initiative, a nonprofit organization that is focused on recruiting and retaining women in orthopaedics, had conducted extracurricular outreach programs for first- and second-year female medical students to provide exposure and mentoring opportunities specific to orthopaedics. This program, called the Medical Student Outreach Program (MSOP), is ongoing at medical centers nationwide and has reached over 300 medical students in its first 3 program years (2012-2014).(1) What percentage of MSOP participants eventually match into orthopaedic surgery residency? (2) Does MSOP impact participants' perceptions of the orthopaedics profession as well as intellectual interest in the field?The percentage of program alumnae who matched into orthopaedics was determined by annual followup for our first two cohorts who graduated from medical school. All program participants completed a survey immediately before and after the program that assessed the impact of MSOP on the student's intention to pursue orthopaedics as well as perceptions of the field and intellectual interest in the discipline.The orthopaedic surgery match rate for program participants was 31% in our first graduating class (five of 16 participants in 2015) and 28% in our second class (20 of 72 participants in 2016). Pre/post program comparisons showed that the MSOP influenced students' perceptions of the orthopaedics profession as well as overall intellectual interest in the field.The results of our study suggest that The Perry Initiative's MSOP positively influences women to choose orthopaedic surgery as a profession. The match rate for program alumnae is twice the percentage of females in current orthopaedic residency classes. Given these positive results, MSOP can serve as a model, both in its curricular content and logistic framework, for other diversity initiatives in the field.

  View details for DOI 10.1007/s11999-016-4908-y

  View details for PubMedID 27245771

• Gendered Innovations in Orthopaedic Science: Hollywood and Orthopaedics: Through the Glass Ceiling-Darkly CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2016; 474 (6): 1379-1382

  View details for DOI 10.1007/s11999-016-4786-3

  View details for PubMedID 26987864

• Quality Measurement: A Primer for Hand Surgeons JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Kakar, S., Ruch, D., Richard, M. J., Akelman, E., Got, C., Blazar, P., Ladd, A., Yao, J., Ring, D. 2016; 41 (5): 645-651

  Abstract

  As the government and payers place increasing emphasis on measuring and reporting quality and meeting-specific benchmarks, physicians and health care systems will continue to adapt to meet regulatory requirements. Hand surgeons' involvement in quality measure development will help ensure that our services are appropriately assessed. Moreover, by embracing a culture of quality assessment and improvement, we will improve patient care while demonstrating the importance of our services in a health care system that is transitioning from a fee-for-service model to a fee-for-value model. Understanding quality and the tools for its measurement, and the application of quality assessment and improvement methods can help hand surgeons continue to deliver high-quality care that aligns with national priorities.

  View details for DOI 10.1016/j.jhsa.2015.10.002

  View details for PubMedID 26576831

• A Unified Approach to Outcomes Assessment for Distal Radius Fractures JOURNAL OF HAND SURGERY-AMERICAN VOLUME Waljee, J. F., Ladd, A., MacDermid, J. C., Rozental, T. D., Wolfe, S. W. 2016; 41 (4): 565-573

  Abstract

  Distal radius fractures are one of the most common upper extremity injuries. Currently, outcome assessment after treatment of these injuries varies widely with respect to the measures that are used, timing of assessment, and the end points that are considered. A more consistent approach to outcomes assessment would provide a standard by which to assess treatment options and best practices. In this summary, we review the consensus regarding outcomes assessment after distal radius fractures and propose a systematic approach that integrates performance, patient-reported outcomes, pain, complications, and radiographs.

  View details for DOI 10.1016/j.jhsa.2016.02.001

  View details for PubMedID 26952734

• Quality Measures in Upper Limb Surgery. journal of bone and joint surgery. American volume Kamal, R. N., Ring, D., Akelman, E., Yao, J., Ruch, D. S., Richard, M., Ladd, A., Got, C., Blazar, P., Kakar, S. 2016; 98 (6): 505-510

  Abstract

  Quality measures are now commonplace and are increasingly tied to financial incentives. We reviewed the existing quality measures that address the upper limb and tested the null hypothesis that structure (capacity to deliver care), process (appropriate care), and outcome (the result of care) measures are equally represented.We systematically reviewed MEDLINE/PubMed, Embase, Google Scholar, the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures addressing upper limb surgery. Measures were characterized as structure, process, or outcome measures and were categorized according to their developer and their National Strategy for Quality Improvement in Health Care (National Quality Strategy) priority as articulated by the U.S. Department of Health & Human Services.We identified 134 quality measures addressing the upper limb: 131 (98%) process and three (2%) outcome measures. The majority of the process measures address the National Quality Strategy priority of effective clinical care (90%), with the remainder addressing communication and care coordination (5%), person and caregiver-centered experience and outcomes (4%), and community/population health (1%).Our review identified opportunities to develop more measures in the structure and outcome domains as well as measures addressing patient and family engagement, public health, safety, care coordination, and efficient use of resources. The most common existing measures-process measures addressing care-might not be the best measures of upper limb surgery quality given the relative lack of evidence for their use in care improvement.

  View details for DOI 10.2106/JBJS.15.00651

  View details for PubMedID 26984919

• Weaker Functional Pinch Strength Is Associated With Early Thumb Carpometacarpal Osteoarthritis CLINICAL ORTHOPAEDICS AND RELATED RESEARCH McQuillan, T. J., Kenney, D., Crisco, J. J., Weiss, A., Ladd, A. L. 2016; 474 (2): 557-561

  Abstract

  The thumb carpometacarpal (CMC) joint orchestrates pinch in its various positions, and thumb CMC osteoarthritis (OA) is a major source of orthopaedic morbidity. Self-reported pain, weakness, and physical examination may not correspond to radiographic findings when diagnosing early thumb CMC OA. Weakness is a prominent feature of the disease, but little evidence exists to quantify self-reported loss of strength with time, or to compare weakness with that of a nonarthritic population during early disease.We asked: (1) Is pinch strength in subjects with early thumb CMC OA less than that in asymptomatic control subjects; and (2) weakness in which pinch position (key, tripod, or tip pinch) has the strongest association with early OA diagnosis?For this case-control study, we recruited 23 subjects who were asymptomatic and 91 with early OA for comprehensive history, physical examination, strength measurements, pain surveys, and radiographic evaluation. We used multivariate logistic regression to quantify the association between declining pinch strength and early OA diagnosis after controlling for age, sex, and BMI. This analysis was performed for three different pinch positions (key, tripod, and tip pinch) to evaluate which measurement was most closely associated with diagnosis.Pinch strength was less in patients with early thumb CMC OA. Key pinch had the most robust association with OA diagnosis, in which a 20% decrease in key pinch strength from the control subjects' baseline was associated with a 10% increase in the OA diagnosis (95% CI, 3%-16%; p = 0.004). This had a stronger association with OA diagnosis than tip pinch, in which a 20% decrease in strength was associated with a 6% increase in early CMC OA (95% CI, 1.0%-11%; p = 0.031). Tripod pinch also was associated to a lesser extent; a 20% reduction in tripod pinch led to a 5% increase in OA (95% CI, 1.3%-9%; p = 0.048).Decreasing pinch strength, especially key pinch, is associated with early CMC arthritis before the development of extensive radiographic disease.Weakness in pinch strength, especially key pinch, is an important feature in the pathogenesis of early CMC OA and may appear before radiographic disease is present or advanced. These findings suggest a role for intervention in early disease for promoting nonoperative joint protection and strengthening, and designing surgical procedures aimed to delay or prevent clinical and radiographic progression.

  View details for DOI 10.1007/s11999-015-4599-9

  View details for Web of Science ID 000368021900047

  View details for PubMedCentralID PMC4709288

• Gendered Innovations in Orthopaedic Science: Sex, Lies, and Stereotype: In Praise of the Systematic Review CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2016; 474 (1): 27-30

  View details for DOI 10.1007/s11999-015-4577-2

  View details for Web of Science ID 000368022600007

  View details for PubMedCentralID PMC4686503

• Early osteoarthritis of the trapeziometacarpal joint is not associated with joint instability during typical isometric loading. Journal of orthopaedic research Halilaj, E., Moore, D. C., Patel, T. K., Ladd, A. L., Weiss, A. C., Crisco, J. J. 2015; 33 (11): 1639-1645

  Abstract

  The saddle-shaped trapeziometacarpal (TMC) joint contributes importantly to the function of the human thumb. A balance between mobility and stability is essential in this joint, which experiences high loads and is prone to osteoarthritis (OA). Since instability is considered a risk factor for TMC OA, we assessed TMC joint instability during the execution of three isometric functional tasks (key pinch, jar grasp, and jar twist) in 76 patients with early TMC OA and 44 asymptomatic controls. Computed tomography images were acquired while subjects held their hands relaxed and while they applied 80% of their maximum effort for each task. Six degree-of-freedom rigid body kinematics of the metacarpal with respect to the trapezium from the unloaded to the loaded task positions were computed in terms of a TMC joint coordinate system. Joint instability was expressed as a function of the metacarpal translation and the applied force. We found that the TMC joint was more unstable during a key pinch task than during a jar grasp or a jar twist task. Sex, age, and early OA did not have an effect on TMC joint instability, suggesting that instability during these three tasks is not a predisposing factor in TMC OA. © 2015 Orthopaedic Research Society. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/jor.22936

  View details for PubMedID 25941135

• Altered Innervation Pattern in Ligaments of Patients with Basal Thumb Arthritis. Journal of wrist surgery Ludwig, C. A., Mobargha, N., Okogbaa, J., Hagert, E., Ladd, A. L. 2015; 4 (4): 284-291

  Abstract

  Purpose The population of mechanoreceptors in patients with osteoarthritis (OA) lacks detailed characterization. In this study, we examined the distribution and type of mechanoreceptors of two principal ligaments in surgical subjects with OA of the first carpometacarpal joint (CMC1). Methods We harvested two ligaments from the CMC1 of eleven subjects undergoing complete trapeziectomy and suspension arthroplasty: the anterior oblique (AOL) and dorsal radial ligament (DRL). Ligaments were divided into proximal and distal portions, paraffin-sectioned, and analyzed using immunoflourescent triple staining microscopy. We performed statistical analyses using the Wilcoxon Rank Sum test and ANOVA with post-hoc Bonferroni and Tamhane adjustments. Results The most prevalent nerve endings in the AOL and DRL of subjects with OA were unclassifiable mechanoreceptors, which do not currently fit into a defined morphological scheme. These were found in 11/11 (100%) DRLs and 7/11 (63.6%) AOLs. No significant difference existed with respect to location within the ligament (proximal versus distal) of mechanoreceptors in OA subjects. Conclusion The distribution and type of mechanoreceptors in cadavers with no to mild OA differ from those in surgical patients with OA. Where Ruffini endings predominate in cadavers with no to mild OA, unclassifiable corpuscles predominate in surgical patients with OA. These findings suggest an alteration of the mechanoreceptor population and distribution that accompanies the development of OA. Clinical Relevance Identification of a unique type and distribution of mechanoreceptors in the CMC1 of symptomatic subjects provides preliminary evidence of altered proprioception in OA.

  View details for DOI 10.1055/s-0035-1564982

  View details for PubMedID 26649261

• Older asymptomatic women exhibit patterns of thumb carpometacarpal joint space narrowing that precede changes associated with early osteoarthritis. Journal of biomechanics Halilaj, E., Moore, D. C., Patel, T. K., Laidlaw, D. H., Ladd, A. L., Weiss, A. C., Crisco, J. J. 2015; 48 (13): 3643-3649

  Abstract

  In small joints, where cartilage is difficult to image and quantify directly, three-dimensional joint space measures can be used to gain insight into potential joint pathomechanics. Since the female sex and older age are risk factors for carpometacarpal (CMC) joint osteoarthritis (OA), the purpose of this in vivo computed tomography (CT) study was to determine if there are any differences with sex, age, and early OA in the CMC joint space. The thumbs of 66 healthy subjects and 81 patients with early stage CMC OA were scanned in four range-of-motion, three functional-task, and one neutral positions. Subchondral bone-to-bone distances across the trapezial and metacarpal articular surfaces were computed for all the positions. The joint space area, defined as the articular surface that is less than 1.5mm from the mating bone, was used to assess joint space. A larger joint space area typically corresponds to closer articular surfaces, and therefore a narrower joint space. We found that the joint space areas are not significantly different between healthy young men and women. Trends indicated that patients with early stage OA have larger CMC joint space areas than healthy subjects of the same age group and that older healthy women have larger joint space areas than younger healthy women. This study suggests that aging in women may lead to joint space narrowing patterns that precede early OA, which is a compelling new insight into the pathological processes that make CMC OA endemic to women.

  View details for DOI 10.1016/j.jbiomech.2015.08.010

  View details for PubMedID 26323995

• Older asymptomatic women exhibit patterns of thumb carpometacarpal joint space narrowing that precede changes associated with early osteoarthritis JOURNAL OF BIOMECHANICS Halilaj, E., Moore, D. C., Patel, T. K., Laidlaw, D. H., Ladd, A. L., Weiss, A. C., Crisco, J. J. 2015; 48 (13): 3634-3640

  Abstract

  In small joints, where cartilage is difficult to image and quantify directly, three-dimensional joint space measures can be used to gain insight into potential joint pathomechanics. Since the female sex and older age are risk factors for carpometacarpal (CMC) joint osteoarthritis (OA), the purpose of this in vivo computed tomography (CT) study was to determine if there are any differences with sex, age, and early OA in the CMC joint space. The thumbs of 66 healthy subjects and 81 patients with early stage CMC OA were scanned in four range-of-motion, three functional-task, and one neutral positions. Subchondral bone-to-bone distances across the trapezial and metacarpal articular surfaces were computed for all the positions. The joint space area, defined as the articular surface that is less than 1.5mm from the mating bone, was used to assess joint space. A larger joint space area typically corresponds to closer articular surfaces, and therefore a narrower joint space. We found that the joint space areas are not significantly different between healthy young men and women. Trends indicated that patients with early stage OA have larger CMC joint space areas than healthy subjects of the same age group and that older healthy women have larger joint space areas than younger healthy women. This study suggests that aging in women may lead to joint space narrowing patterns that precede early OA, which is a compelling new insight into the pathological processes that make CMC OA endemic to women.

  View details for DOI 10.1016/j.jbiomech.2015.08.010

  View details for Web of Science ID 000365367700011

• Men and women have similarly shaped carpometacarpal joint bones JOURNAL OF BIOMECHANICS Schneider, M. T., Zhang, J., Crisco, J. J., Weiss, A. P., Ladd, A. L., Nielsen, P., Besier, T. 2015; 48 (12): 3420-3426

  View details for DOI 10.1016/j.jbiomech.2015.05.031

  View details for Web of Science ID 000363069900066

  View details for PubMedID 26116042

• Denosumab, a Potential Alternative to the Surgical Treatment of Distal Radius Giant Cell Tumor of Bone: Case Report. journal of hand surgery Park, M. J., Ganjoo, K. N., Ladd, A. L. 2015; 40 (8): 1620-1624

  Abstract

  Juxta-articular giant cell tumors can pose major surgical challenges. Aggressive distal radius giant cell tumors often require complex reconstructive procedures that are associated with numerous complications. We present a case of a 25-year old man with a Campanacci grade 3 giant cell tumor of the distal radius that was successfully treated with denosumab without complex reconstructive procedures. At 3.5-year follow-up and 1-year drug free period, the patient remained asymptomatic without histologic evidence of recurrent tumor. With denosumab therapy, patients can potentially avoid surgery and achieve a successful outcome.

  View details for DOI 10.1016/j.jhsa.2015.03.018

  View details for PubMedID 25935517

• Gendered Innovations in Orthopaedic Science: Women (and Men) Who Rock CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2015; 473 (8): 2460–63

  View details for PubMedID 26077611

  View details for PubMedCentralID PMC4488206

• In vivo recruitment patterns in the anterior oblique and dorsoradial ligaments of the first carpometacarpal joint JOURNAL OF BIOMECHANICS Halilaj, E., Rainbow, M. J., Moore, D. C., Laidlaw, D. H., Weiss, A. C., Ladd, A. L., Crisco, J. J. 2015; 48 (10): 1893-1898

  Abstract

  The anterior oblique ligament (AOL) and the dorsoradial ligament (DRL) are both regarded as mechanical stabilizers of the thumb carpometacarpal (CMC) joint, which in older women is often affected by osteoarthritis. Inferences on the potential relationship of these ligaments to joint pathomechanics are based on clinical experience and studies of cadaveric tissue, but their functions has been studied sparsely in vivo. The purpose of this study was to gain insight into the functions of the AOL and DRL using in vivo joint kinematics data. The thumbs of 44 healthy subjects were imaged with a clinical computed tomography scanner in functional-task and thumb range-of-motion positions. The origins and insertion sites of the AOL and the DRL were identified on the three-dimensional bone models and each ligament was modeled as a set of three fibers whose lengths were the minimum distances between insertion sites. Ligament recruitment, which represented ligament length as a percentage of the maximum length across the scanned positions, was computed for each position and related to joint posture. Mean AOL recruitment was lower than 91% across the CMC range of motion, whereas mean DRL recruitment was generally higher than 91% in abduction and flexion. Under the assumption that ligaments do not strain by more than 10% physiologically, our findings of mean ligament recruitments across the CMC range of motion indicate that the AOL is likely slack during most physiological positions, whereas the DRL may be taut and therefore support the joint in positions of CMC joint abduction and flexion.

  View details for DOI 10.1016/j.jbiomech.2015.04.028

  View details for Web of Science ID 000358459800029

• Male and Female Differences in Musculoskeletal Disease JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Wolf, J. M., Cannada, L., Van Heest, A. E., O'Connor, M. I., Ladd, A. L. 2015; 23 (6): 339-347

  Abstract

  Gender differences exist in the presentation of musculoskeletal disease, and recognition of the differences between men and women's burden of disease and response to treatment is key in optimizing care of orthopaedic patients. The role of structural anatomy differences, hormones, and genetics are factors to consider in the analysis of differential injury and arthritic patterns between genders.

  View details for DOI 10.5435/JAAOS-D-14-00020

  View details for Web of Science ID 000354975900003

• Management of complications of congenital hand disorders. Hand clinics Comer, G. C., Ladd, A. L. 2015; 31 (2): 361-375

  Abstract

  This article reviews treatment and presents complications seen in the treatment of 7 common congenital hand differences, including syndactyly, camptodactyly, ulnar and radial polydactyly, thumb hypoplasia, radial longitudinal deficiency, and epidermolysis bullosa. The management of these conditions is challenging but has evolved over the last several decades with refined understanding of the disease processes and treatments. The goal of this article is to synthesize prior knowledge and provide further insights into these conditions that will help the surgeon avoid treatment complications.

  View details for DOI 10.1016/j.hcl.2015.01.011

  View details for PubMedID 25934210

• Management of Complications of Congenital Hand Disorders HAND CLINICS Comer, G. C., Ladd, A. L. 2015; 31 (2): 361-?

  Abstract

  This article reviews treatment and presents complications seen in the treatment of 7 common congenital hand differences, including syndactyly, camptodactyly, ulnar and radial polydactyly, thumb hypoplasia, radial longitudinal deficiency, and epidermolysis bullosa. The management of these conditions is challenging but has evolved over the last several decades with refined understanding of the disease processes and treatments. The goal of this article is to synthesize prior knowledge and provide further insights into these conditions that will help the surgeon avoid treatment complications.

  View details for DOI 10.1016/j.hcl.2015.01.011

  View details for Web of Science ID 000355028300021

  View details for PubMedID 25934210

• Gendered Innovations in Orthopaedic Science: Civil Liberties, Darwin, and the Evolution of Science CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2015; 473 (5): 1560-1565

  View details for DOI 10.1007/s11999-015-4178-0

  View details for PubMedID 25666144

• In vivo recruitment patterns in the anterior oblique and dorsoradial ligaments of the first carpometacarpal joint. Journal of biomechanics Halilaj, E., Rainbow, M. J., Moore, D. C., Laidlaw, D. H., Weiss, A. C., Ladd, A. L., Crisco, J. J. 2015

  Abstract

  The anterior oblique ligament (AOL) and the dorsoradial ligament (DRL) are both regarded as mechanical stabilizers of the thumb carpometacarpal (CMC) joint, which in older women is often affected by osteoarthritis. Inferences on the potential relationship of these ligaments to joint pathomechanics are based on clinical experience and studies of cadaveric tissue, but their functions has been studied sparsely in vivo. The purpose of this study was to gain insight into the functions of the AOL and DRL using in vivo joint kinematics data. The thumbs of 44 healthy subjects were imaged with a clinical computed tomography scanner in functional-task and thumb range-of-motion positions. The origins and insertion sites of the AOL and the DRL were identified on the three-dimensional bone models and each ligament was modeled as a set of three fibers whose lengths were the minimum distances between insertion sites. Ligament recruitment, which represented ligament length as a percentage of the maximum length across the scanned positions, was computed for each position and related to joint posture. Mean AOL recruitment was lower than 91% across the CMC range of motion, whereas mean DRL recruitment was generally higher than 91% in abduction and flexion. Under the assumption that ligaments do not strain by more than 10% physiologically, our findings of mean ligament recruitments across the CMC range of motion indicate that the AOL is likely slack during most physiological positions, whereas the DRL may be taut and therefore support the joint in positions of CMC joint abduction and flexion.

  View details for DOI 10.1016/j.jbiomech.2015.04.028

  View details for PubMedID 25964211

• Correlation of clinical disease severity to radiographic thumb osteoarthritis index. journal of hand surgery Ladd, A. L., Messana, J. M., Berger, A. J., Weiss, A. C. 2015; 40 (3): 474-482

  Abstract

  To determine if a slight modification of the 1987 Eaton-Glickel staging and interpreting 4 standardized radiographs for trapeziometacarpal (TMC) osteoarthritis (OA) improved analysis, to determine if a quantifiable index measurement from a single Robert (pronated anteroposterior) view enhanced reproducibility, and to examine whether improved radiographic staging correlated to clinically relevant disease and thus support validity.We analyzed 4 thumb radiographs (posteroanterior, lateral, Robert, and stress views) in 60 consecutive subjects representing an adult population spectrum of asymptomatic to advanced disease. Two experienced hand surgeons (A.L.L. and A.P.C.W.), 1 chief resident (A.J.B.), and 1 medical student (J.M.M.) performed the analysis on each subject's radiographs. We analyzed all 4 radiographs for Eaton and modified Eaton staging and then later analyzed only the Robert view for the thumb osteoarthritis (ThOA) index measurement. The radiographs were randomized and reread a week later for each classification at separate times. Surgically excised trapeziums from 20/60 subjects were inspected for first metacarpal surface disease and correlated to the 3 classifications.All 3 staging classifications demonstrated high reproducibility, with the intraclass correlation coefficient averaging 0.73 for the Eaton, 0.83 for the modified Eaton, and 0.95 for the ThOA index. Articular wear and metacarpal surface eburnation correlated highest to the ThOA index, with advanced disease 1.55 or greater correlating to Eaton III/IV and modified Eaton stage 3/4 in a linear relationship.The ThOA index based on a Robert view provided a measurable alternative to Eaton staging and correlated to severity of surgically relevant thumb TMC OA.A simple reproducible radiographic measurement may enhance TMC OA classification and provide a reliable means to predict clinical disease.Diagnostic II.

  View details for DOI 10.1016/j.jhsa.2014.11.021

  View details for PubMedID 25617217

• In Vivo kinematics of the trapeziometacarpal joint during thumb extension-flexion and abduction-adduction. journal of hand surgery Crisco, J. J., Halilaj, E., Moore, D. C., Patel, T., Weiss, A. C., Ladd, A. L. 2015; 40 (2): 289-296

  Abstract

  The primary aim of this study was to determine whether the in vivo kinematics of the trapeziometacarpal (TMC) joint differ as a function of age and sex during thumb extension-flexion (Ex-Fl) and abduction-adduction (Ab-Ad) motions.The hands and wrists of 44 subjects (10 men and 11 women with ages 18-35 y and 10 men and 13 women with ages 40-75 y) with no symptoms or signs of TMC joint pathology were imaged with computed tomography during thumb extension, flexion, abduction, and adduction. The kinematics of the TMC joint were computed and compared across direction, age, and sex.We found no significant effects of age or sex, after normalizing for size, in any of the kinematic parameters. The Ex-Fl and Ab-Ad rotation axes did not intersect, and both were oriented obliquely to the saddle-shaped anatomy of the TMC articulation. The Ex-Fl axis was located in the trapezium and the Ab-Ad axis was located in the metacarpal. Metacarpal translation and internal rotation occurred primarily during Ex-Fl.Our findings indicate that normal TMC joint kinematics are similar in males and females, regardless of age, and that the primary rotation axes are nonorthogonal and nonintersecting. In contrast to previous studies, we found Ex-Fl and Ab-Ad to be coupled with internal-external rotation and translation. Specifically, internal rotation and ulnar translation were coupled with flexion, indicating a potential stabilizing screw-home mechanism.The treatment of TMC pathology and arthroplasty design require a detailed and accurate understanding of TMC function. This study confirms the complexity of TMC kinematics and describes metacarpal translation coupled with internal rotation during Ex-Fl, which may explain some of the limitations of current treatment strategies and should help improve implant designs.

  View details for DOI 10.1016/j.jhsa.2014.10.062

  View details for PubMedID 25542440

• A comprehensive overview of osteoporotic fracture treatment. Instructional course lectures Wolf, J. M., Cannada, L. K., Lane, J. M., Sawyer, A. J., Ladd, A. L. 2015; 64: 25-36

  Abstract

  Osteoporosis is a worldwide epidemic, affecting more than 75 million people in the United States, Europe, and Japan. At a consensus conference in 1990, European and American leaders defined osteoporosis as a disease characterized by low bone mass, microarchitectural deterioration of bone tissue, and a resulting increase in fracture risk. In 2000, the National Institutes of Health modified this definition, describing osteoporosis as a skeletal disorder characterized by compromised bone strength and a predisposition for increased fracture risk. It was emphasized that bone strength, which is a more comprehensive concept than bone mass, integrates the concepts of both bone density and bone quality. As orthopaedic surgeons, recognizing osteoporosis and its healthcare implications is critical to optimize the musculoskeletal health of patients of all ages and both sexes.

  View details for PubMedID 25745892

• The 2014 ABJS Nicolas Andry Award: The Puzzle of the Thumb: Mobility, Stability, and Demands in Opposition CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L., Crisco, J. J., Hagert, E., Rose, J., Weiss, A. C. 2014; 472 (12): 3605-3622

  Abstract

  The paradoxical demands of stability and mobility reflect the purpose and function of the human thumb. Its functional importance is underscored when a thumb is congenitally absent, injured, or afflicted with degenerative arthritis. Prevailing literature and teaching implicate the unique shape of the thumb carpometacarpal (CMC) joint, as well as its ligament support, applied forces, and repetitive motion, as culprits causing osteoarthritis (OA). Sex, ethnicity, and occupation may predispose individuals to OA.What evidence links ligament structure, forces, and motion to progressive CMC disease? Specifically: (1) Do unique attributes of the bony and ligamentous anatomy contribute to OA? (2) Can discrete joint load patterns be established that contribute to OA? And (3) can thumb motion that characterizes OA be measured at the fine and gross level?We addressed the morphology, load, and movement of the human thumb, emphasizing the CMC joint in normal and arthritic states. We present comparative anatomy, gross dissections, microscopic analysis, multimodal imaging, and live-subject kinematic studies to support or challenge the current understanding of the thumb CMC joint and its predisposition to disease.The current evidence suggests structural differences and loading characteristics predispose the thumb CMC to joint degeneration, especially related to volar or central wear. The patterns of degeneration, however, are not consistently identified, suggesting influences beyond inherent anatomy, repetitive load, and abnormal motion.Additional studies to define patterns of normal use and wear will provide data to better characterize CMC OA and opportunities for tailored treatment, including prevention, delay of progression, and joint arthroplasty.

  View details for Web of Science ID 000344647200003

  View details for PubMedCentralID PMC4397810

• Gendered Innovations in Orthopaedic Science: From Access to Zygote: A Gender and Orthopaedics Lexicon CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2014; 472 (12): 3629-3631

  View details for DOI 10.1007/s11999-014-3987-x

  View details for PubMedID 25300512

• Editor's Spotlight/Take 5: The 2014 ABJS Nicolas Andry Award: The Puzzle of the Thumb: Mobility, Stability, and Demands in Opposition CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Leopold, S. S. 2014; 472 (12): 3601-3604

  View details for Web of Science ID 000344647200002

  View details for PubMedID 25287522

• The 2014 ABJS Nicolas Andry Award: The puzzle of the thumb: mobility, stability, and demands in opposition. Clinical orthopaedics and related research Ladd, A. L., Crisco, J. J., Hagert, E., Rose, J., Weiss, A. C. 2014; 472 (12): 3605-3622

  Abstract

  The paradoxical demands of stability and mobility reflect the purpose and function of the human thumb. Its functional importance is underscored when a thumb is congenitally absent, injured, or afflicted with degenerative arthritis. Prevailing literature and teaching implicate the unique shape of the thumb carpometacarpal (CMC) joint, as well as its ligament support, applied forces, and repetitive motion, as culprits causing osteoarthritis (OA). Sex, ethnicity, and occupation may predispose individuals to OA.What evidence links ligament structure, forces, and motion to progressive CMC disease? Specifically: (1) Do unique attributes of the bony and ligamentous anatomy contribute to OA? (2) Can discrete joint load patterns be established that contribute to OA? And (3) can thumb motion that characterizes OA be measured at the fine and gross level?We addressed the morphology, load, and movement of the human thumb, emphasizing the CMC joint in normal and arthritic states. We present comparative anatomy, gross dissections, microscopic analysis, multimodal imaging, and live-subject kinematic studies to support or challenge the current understanding of the thumb CMC joint and its predisposition to disease.The current evidence suggests structural differences and loading characteristics predispose the thumb CMC to joint degeneration, especially related to volar or central wear. The patterns of degeneration, however, are not consistently identified, suggesting influences beyond inherent anatomy, repetitive load, and abnormal motion.Additional studies to define patterns of normal use and wear will provide data to better characterize CMC OA and opportunities for tailored treatment, including prevention, delay of progression, and joint arthroplasty.

  View details for DOI 10.1007/s11999-014-3901-6

  View details for PubMedID 25171934

• Thumb Carpometacarpal Ligaments Inside and Out: A Comparative Study of Arthroscopic and Gross Anatomy from the Robert A. Chase Hand and Upper Limb Center at Stanford University (vol 2, Pg 55, 2014) JOURNAL OF WRIST SURGERY Zhang, A. Y., Van Nortwick, S., Hagert, E., Yao, J., Ladd, A. L. 2014; 3 (4): E1

  View details for DOI 10.1055/s-0033-1338108

  View details for Web of Science ID 000218747600001

• Gendered Innovations in Orthopaedic Science: Title IX Education: Book Learnin' and Bone Mendin'. Clinical orthopaedics and related research Ladd, A. L. 2014; 472 (9): 2586-2589

  View details for DOI 10.1007/s11999-014-3738-z

  View details for PubMedID 24964885

• The morphology of the thumb carpometacarpal joint does not differ between men and women, but changes with aging and early osteoarthritis. Journal of biomechanics Halilaj, E., Moore, D. C., Laidlaw, D. H., Got, C. J., Weiss, A. C., Ladd, A. L., Crisco, J. J. 2014; 47 (11): 2709-2714

  Abstract

  The high prevalence of thumb carpometacarpal (CMC) joint osteoarthritis (OA) in women has been previously linked to the articular morphology of the trapezium. Studies report conflicting results on how the articular shapes of male and female trapezia compare to one another, however, mainly because their findings are based on data from older cadaveric specimens. The purpose of this in vivo study was to dissociate the effect of sex from that of aging and early OA by using cohorts of healthy young and healthy older subjects, as well as patients with early stage OA. Computed tomography scans from 68 healthy subjects and 87 arthritic subjects were used to obtain 3-D bone models. The trapezial and metacarpal articular surfaces were manually delineated on scaled bone models and compared between sex, age, and health groups by using polar histograms of curvature and average curvatures. We found no sex-related differences, but significant age-group and health-group differences, in the articular surfaces of both bones. Older healthy subjects had higher curvature in the concave and lower curvature in the convex directions of both the trapezial and metacarpal saddles than healthy young subjects. Subjects with early OA had significantly different metacarpal and trapezial articular shapes from healthy subjects of the same age group. These findings suggest that aging and OA affect the articular shape of the CMC joint, but that, in contrast to previously held beliefs, inherent sex differences are not responsible for the higher incidence of CMC OA in women.

  View details for DOI 10.1016/j.jbiomech.2014.05.005

  View details for PubMedID 24909332

• The Sports Bra, the ACL, and Title IX - The Game in Play CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2014; 472 (6): 1681-1684

  View details for DOI 10.1007/s11999-014-3606-x

  View details for PubMedID 24723143

• Ultrastructure and Innervation of Thumb Carpometacarpal Ligaments in Surgical Patients With Osteoarthritis CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Mobargha, N., Ludwig, C., Ladd, A. L., Hagert, E. 2014; 472 (4): 1146-1154

  Abstract

  BACKGROUND: The complex configuration of the thumb carpometacarpal (CMC-1) joint relies on musculotendinous and ligamentous support for precise circumduction. Ligament innervation contributes to joint stability and proprioception. Evidence suggests abnormal ligament innervation is associated with osteoarthritis (OA) in large joints; however, little is known about CMC-1 ligament innervation characteristics in patients with OA. We studied the dorsal radial ligament (DRL) and the anterior oblique ligament (AOL), ligaments with a reported divergent presence of mechanoreceptors in nonosteoarthritic joints. QUESTIONS/PURPOSES: This study's purposes were (1) to examine the ultrastructural architecture of CMC-1 ligaments in surgical patients with OA; (2) to describe innervation, specifically looking at mechanoreceptors, of these ligaments using immunohistochemical techniques and compare the AOL and DRL in terms of innervation; and (3) to determine whether there is a correlation between age and mechanoreceptor density. METHODS: The AOL and DRL were harvested from 11 patients with OA during trapeziectomy (10 women, one man; mean age, 67 years). The 22 ligaments were sectioned in paraffin and analyzed using immunoflourescent triple staining microscopy. RESULTS: In contrast to the organized collagen bundles of the DRL, the AOL appeared to be composed of disorganized connective tissue with few collagen fibers and little innervation. Mechanoreceptors were identified in CMC-1 ligaments of all patients with OA. The DRL was significantly more innervated than the AOL. There was no significant correlation between innervation of the DRL and AOL and patient age. CONCLUSIONS: The dense collagen structure and rich innervation of the DRL in patients with OA suggest that the DRL has an important proprioceptive and stabilizing role. CLINICAL RELEVANCE: Ligament innervation may correlate with proprioceptive and neuromuscular changes in OA pathophysiology and consequently support further investigation of innervation in disease prevention and treatment strategies.

  View details for DOI 10.1007/s11999-013-3083-7

  View details for Web of Science ID 000332576400016

  View details for PubMedID 23761171

• In Vivo Kinematics of the Thumb Carpometacarpal Joint During Three Isometric Functional Tasks CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Halilaj, E., Rainbow, M. J., Got, C., Schwartz, J. B., Moore, D. C., Weiss, A. C., Ladd, A. L., Crisco, J. J. 2014; 472 (4): 1114-1122

  Abstract

  The thumb carpometacarpal (CMC) joint is often affected by osteoarthritis--a mechanically mediated disease. Pathomechanics of the CMC joint, however, are not thoroughly understood due to a paucity of in vivo data.We documented normal, in vivo CMC joint kinematics during isometric functional tasks. We hypothesized there would be motion of the CMC joint during these tasks and that this motion would differ with sex and age group. We also sought to determine whether the rotations at the CMC joint were coupled and whether the trapezium moved with respect to the third metacarpal.Forty-six asymptomatic subjects were CT-scanned in a neutral position and during three functional tasks (key pinch, jar grasp, jar twist), in an unloaded and a loaded position. Kinematics of the first metacarpal, third metacarpal, and the trapezium were then computed.Significant motion was identified in the CMC joint during all tasks. Sex did not have an effect on CMC joint kinematics. Motion patterns differed with age group, but these differences were not systematic across the tasks. Rotation at the CMC joint was generally coupled and posture of the trapezium relative to the third metacarpal changed significantly with thumb position.The healthy CMC joint is relatively stable during key pinch, jar grasp, and jar twist tasks, despite sex and age group.Our findings indicate that directionally coupled motion patterns in the CMC joint, which lead to a specific loading profile, are similar in men and women. These patterns, in addition to other, nonkinematic influences, especially in the female population, may contribute to the pathomechanics of the osteoarthritic joint.

  View details for DOI 10.1007/s11999-013-3063-y

  View details for Web of Science ID 000332576400012

  View details for PubMedID 23681597

  View details for PubMedCentralID PMC3940759

• Intra- and interobserver reliability of the eaton classification for trapeziometacarpal arthritis: a systematic review. Clinical orthopaedics and related research Berger, A. J., Momeni, A., Ladd, A. L. 2014; 472 (4): 1155-1159

  Abstract

  Trapeziometacarpal, or thumb carpometacarpal (CMC), arthritis is a common problem with a variety of treatment options. Although widely used, the Eaton radiographic staging system for CMC arthritis is of questionable clinical utility, as disease severity does not predictably correlate with symptoms or treatment recommendations. A possible reason for this is that the classification itself may not be reliable, but the literature on this has not, to our knowledge, been systematically reviewed.We therefore performed a systematic review to determine the intra- and interobserver reliability of the Eaton staging system.We systematically reviewed English-language studies published between 1973 and 2013 to assess the degree of intra- and interobserver reliability of the Eaton classification for determining the stage of trapeziometacarpal joint arthritis and pantrapezial arthritis based on plain radiographic imaging. Search engines included: PubMed, Scopus(®), and CINAHL. Four studies, which included a total of 163 patients, met our inclusion criteria and were evaluated. The level of evidence of the studies included in this analysis was determined using the Oxford Centre for Evidence Based Medicine Levels of Evidence Classification by two independent observers.A limited number of studies have been performed to assess intra- and interobserver reliability of the Eaton classification system. The four studies included were determined to be Level 3b. These studies collectively indicate that the Eaton classification demonstrates poor to fair interobserver reliability (kappa values: 0.11-0.56) and fair to moderate intraobserver reliability (kappa values: 0.54-0.657).Review of the literature demonstrates that radiographs assist in the assessment of CMC joint disease, but there is not a reliable system for classification of disease severity. Currently, diagnosis and treatment of thumb CMC arthritis are based on the surgeon's qualitative assessment combining history, physical examination, and radiographic evaluation. Inconsistent agreement using the current common radiographic classification system suggests a need for better radiographic tools to quantify disease severity.

  View details for DOI 10.1007/s11999-013-3208-z

  View details for PubMedID 23917991

• Functional task kinematics of the thumb carpometacarpal joint. Clinical orthopaedics and related research Luker, K. R., Aguinaldo, A., Kenney, D., Cahill-Rowley, K., Ladd, A. L. 2014; 472 (4): 1123-1129

  Abstract

  Abnormal biomechanical loading has been identified as an associated risk factor of osteoarthritis in the wrist and hand. Empirical data to date are insufficient to describe the role of altered biomechanics in thumb carpometacarpal (CMC) arthritis.This is a pilot study to evaluate motion analysis of the upper extremity while performing functional tasks. We wished to describe the in vivo kinematics of the thumb and hand in relation to the larger joints of the upper extremity in subjects without arthritis in functional positions at rest and while loading the CMC joint. If reproducible, we then planned to compare kinematics between these subjects and a subject with advanced thumb CMC arthritis.In vivo kinematics of the hand and upper extremity during the functional tasks of grasp, jar opening, and pinch with and without loading of the CMC joint were evaluated using cameras and a motion-capture system in four asymptomatic female subjects and one female subject with advanced radiographic (Eaton Stage IV) osteoarthritis.Kinematics of the hand and upper extremity can be reliably quantified. Loading of the CMC joint did not alter the hand and forearm kinematics in control subjects. In the subject with osteoarthritis, the adduction-extension deformity at the CMC joint resulted in kinematic alterations as compared with the four control subjects.This study represents preliminary steps in defining thumb CMC position, motion, and loading associated with activities of daily living. These findings enhance our understanding of motion at the CMC joint and how it differs in arthritic patients.Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

  View details for DOI 10.1007/s11999-013-2964-0

  View details for PubMedID 23549712

  View details for PubMedCentralID PMC3940744

• Guest Editorial : The Robert's View: A Historical and Clinical Perspective. Clinical orthopaedics and related research Ladd, A. L. 2014; 472 (4): 1097-1100

  View details for DOI 10.1007/s11999-013-3428-2

  View details for PubMedID 24363184

• Editorial comment: symposium: thumb carpometacarpal arthritis. Clinical orthopaedics and related research Ladd, A. L. 2014; 472 (4): 1093-1094

  View details for DOI 10.1007/s11999-013-3348-1

  View details for PubMedID 24186467

• Let's Talk About Sex, Baby: Gendered Innovations in Orthopaedic Science. Clinical orthopaedics and related research Ladd, A. L. 2014; 472 (3): 793-795

  View details for DOI 10.1007/s11999-013-3456-y

  View details for PubMedID 24442840

• Recommendation for measuring clinical outcome in distal radius fractures: a core set of domains for standardized reporting in clinical practice and research ARCHIVES OF ORTHOPAEDIC AND TRAUMA SURGERY Goldhahn, J., Beaton, D., Ladd, A., MacDermid, J., Hoang-Kim, A. 2014; 134 (2): 197-205

  Abstract

  Lack of standardization of outcome measurement has hampered an evidence-based approach to clinical practice and research.We adopted a process of reviewing evidence on current use of measures and appropriate theoretical frameworks for health and disability to inform a consensus process that was focused on deriving the minimal set of core domains in distal radius fracture.We agreed on the following seven core recommendations: (1) pain and function were regarded as the primary domains, (2) very brief measures were needed for routine administration in clinical practice, (3) these brief measures could be augmented by additional measures that provide more detail or address additional domains for clinical research, (4) measurement of pain should include measures of both intensity and frequency as core attributes, (5) a numeric pain scale, e.g. visual analogue scale or visual numeric scale or the pain subscale of the patient-reported wrist evaluation (PRWE) questionnaires were identified as reliable, valid and feasible measures to measure these concepts, (6) for function, either the Quick Disability of the arm, shoulder and hand questionnaire or PRWE-function subscale was identified as reliable, valid and feasible measures, and (7) a measure of participation and treatment complications should be considered core outcomes for both clinical practice and research.We used a sound methodological approach to form a comprehensive foundation of content for outcomes in the area of distal radius fractures. We recommend the use of symptom and function as separate domains in the ICF core set in clinical research or practice for patients with wrist fracture. Further research is needed to provide more definitive measurement properties of measures across all domains.

  View details for DOI 10.1007/s00402-013-1767-9

  View details for Web of Science ID 000330729700007

  View details for PubMedID 23728832

• Thumb carpometacarpal joint congruence during functional tasks and thumb range-of-motion activities. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference Halilaj, E., Moore, D. C., Patel, T. K., Laidlaw, D. H., Ladd, A. L., Weiss, A. C., Crisco, J. J. 2014; 2014: 4354-4357

  Abstract

  Joint incongruity is often cited as a possible etiological factor for the high incidence of thumb carpometacarpal (CMC) joint osteoarthritis (OA) in older women. There is evidence suggesting that biomechanics plays a role in CMC OA progression, but little is known about how CMC joint congruence, specifically, differs among different cohorts. The purpose of this in vivo study was to determine if CMC joint congruence differs with sex, age, and early stage OA for different thumb positions. Using CT data from 155 subjects and a congruence metric that is based on both articular morphology and joint posture, we did not find any differences in CMC joint congruence with sex or age group, but found that patients in the early stages of OA exhibit lower congruence than healthy subjects of the same age group.

  View details for DOI 10.1109/EMBC.2014.6944588

  View details for PubMedID 25570956

• Trapezial topography in thumb carpometacarpal arthritis. Journal of wrist surgery Van Nortwick, S., Berger, A., Cheng, R., Lee, J., Ladd, A. L. 2013; 2 (3): 263-270

  Abstract

  Objective Contradictory reported arthritic patterns of the metacarpal surface of the trapezium include preferential volar wear, radial wear, and dorsal-ulnar sparing. We investigated whether a predominant wear pattern exists in surgical trapeziectomy for advanced thumb carpometacarpal (CMC) arthritis. Methods We examined 36 intact trapezia from 34 thumb CMC arthroplasty patients over an 18-month period. The first metacarpal articular surface revealed three consistent morphology patterns: (1) saddle, (2) dish, and (3) cirque. The saddle represented cartilage loss with preservation of the normal trapezial morphology. The dish shape represented concave curvature, with loss of the normal saddle configuration. The cirque shape represented preferential volar concave wear, disrupting the convex volardorsal arc. Two surgeons classified the randomized specimens twice, blinded to patient identity and each other's categorization. Radiographic Eaton staging was correlated retrospectively for 35 of 36 of the trapezial specimens. Eight specimens were further quantified with micro-computed tomography (micro-CT). Results Thirty-six trapezia were classified as follows: 17 (47%) saddle, 12 (33%) dish, and 7 (19%) cirque. Intra-rater reliability was 0.97 and 0.95; inter-rater reliability in the second round was 0.95. The 36 trapezia represented 27 female (75%) and 9 male (25%) patients; 18 (50%) represented the dominant hand. Age at surgery averaged 64 (33-76). Complete cartilage loss of the entire metacarpal surface was seen in 15 (42%) of all specimens. Osteophyte presence was typically minimal in the saddle group; the dish group had characteristic extensive rimming osteophytes in a 91% female population (11/12), and the cirque group had volar osteophytes. Radiographic severity ranged from Eaton stage II to IV; less severe radiographic staging (Eaton II) predominated in the saddle configuration; advanced Eaton III-IV disease predominated in both cirque and dish shapes. Micro-CT verified the three discrete shapes with volardorsal and radioulnar orientation measurements. Conclusion The metacarpal surface of the trapezium demonstrates three distinct patterns of wear in arthritic surgical specimens. Sex, dominance, age distribution, and Eaton stage varied across the different shapes. Level of Evidence Level 3 Study Type Observational.

  View details for DOI 10.1055/s-0033-1350088

  View details for PubMedID 24436826

• How Surgeons Make Decisions When the Evidence Is Inconclusive JOURNAL OF HAND SURGERY-AMERICAN VOLUME Hageman, M. S., Guitton, T. G., Ring, D., Sci Variation Grp 2013; 38A (6): 1202-1208

  Abstract

  To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive.We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant."According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice.Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons.Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

  View details for DOI 10.1016/j.jhsa.2013.02.032

  View details for Web of Science ID 000320342500023

  View details for PubMedID 23647639

• Trapezium trabecular morphology in carpometacarpal arthritis. journal of hand surgery Lee, A. T., Williams, A. A., Lee, J., Cheng, R., Lindsey, D. P., Ladd, A. L. 2013; 38 (2): 309-315

  Abstract

  In thumb carpometacarpal osteoarthritis, current evidence suggests that degenerative, bony remodeling primarily occurs within the trapezium. Nevertheless, the pathomechanics involved and the most common sites of wear remain controversial. Quantifying structural bone morphology characteristics with high-resolution computed tomography CT (micro-CT) infer regions of load transmission. Using micro-CT, we investigated whether predominant trabecular patterns exist in arthritic versus normal trapeziums.We performed micro-CT analysis on 13 normal cadaveric trapeziums and 16 Eaton stage III to IV trapeziums. We computationally divided each specimen into 4 quadrants: volar-ulnar, volar-radial, dorsal-radial, and dorsal-ulnar. Measurements of trabecular bone morphologic parameters included bone volume ratio, connectivity, trabecular number, and trabecular thickness. Using analysis of variance with post hoc Bonferroni/Dunn correction, we compared osteoarthritic and normal specimen quadrant measurements.No significant difference existed in bone volume fraction between the osteoarthritic and normal specimens. Osteoarthritic trapeziums, however, demonstrated significantly higher trabecular number and connectivity than nonosteoarthritic trapeziums. Comparing the volar-ulnar quadrant of osteoarthritis and normal specimens collectively, this quadrant in both consistently possessed significantly higher bone volume fraction, trabecular number, and connectivity than the dorsal-radial and volar-radial quadrants.The significantly greater trabecular bone volume, thickness, and connectivity in the volar-ulnar quadrant compared with the dorsal-radial and dorsal-ulnar quadrants provides evidence that the greatest compressive loads at the first carpometacarpal joint occur at the volar-ulnar quadrant of the trapezium, representing a consistently affected region of wear in both normal and arthritic states.These findings suggest that trapezial trabecular morphology undergoes pathologic alteration. This provides indirect evidence that changes in load transmission occur with thumb carpometacarpal joint arthritis development.

  View details for DOI 10.1016/j.jhsa.2012.10.038

  View details for PubMedID 23267754

• Thumb carpometacarpal ligaments inside and out: a comparative study of arthroscopic and gross anatomy from the robert a. Chase hand and upper limb center at stanford university. Journal of wrist surgery Zhang, A. Y., Van Nortwick, S., Hagert, E., Ladd, A. L. 2013; 2 (1): 55-62

  Abstract

  Purpose We propose to identify and correlate arthroscopic internal ligaments with external ligaments, providing an accurate roadmap for arthroscopic ligament and joint anatomy. Ligamentous laxity is considered an important risk factor in developing the common basilar arthritis of the thumb. Controversy exists as to the precise ligamentous anatomy of the thumb carpometacarpal (CMC) joint (CMC-I); description of the internal arthroscopic anatomy is limited. Methods We performed CMC-I joint arthroscopy using the 1-Ulnar (1U) and thenar portals in five cadavers, seeking to identify the following seven ligaments arthroscopically: the superficial anterior oblique ligament (sAOL), deep anterior oblique ligament (dAOL), ulnar collateral ligament (UCL), dorsal trapeziometacarpal ligament (DTM-1), posterior oblique ligament (POL), dorsal central ligament (DCL), and dorsal radial ligament (DRL). After grading articular changes of the trapezium, we passed Kirschner wires (K-wires) (0.028) outside-in to mark the arthroscopic insertion of each ligament on the trapezium. Gross dissection was performed to confirm the wire placement; the anatomic identity and position of joint stabilizing ligaments, and the location of frequently used portals. Results The volar ligaments-the sAOL, dAOL, and UCL-were highly variable in their arthroscopic appearance and precise location. The sAOL is a thin veil of membranous tissue that variably drapes across the anterior joint capsule. The reported dAOL and UCL, in our study, correlated to a thickened portion of this veil around the volar beak and was not consistently identified with gross dissection. In contrast, the arthroscopic appearance and location of the dorsal ligaments-DTM-I, POL, DCL, and DRL-were consistent in all specimens. Conclusion Our study further defines and correlates the arthroscopic and external ligamentous anatomy of the CMC-I joint.

  View details for DOI 10.1055/s-0033-1333683

  View details for PubMedID 24436790

  View details for PubMedCentralID PMC3656572

• Trapezium Trabecular Morphology in Carpometacarpal Arthritis JOURNAL OF HAND SURGERY-AMERICAN VOLUME Lee, A. T., Williams, A. A., Lee, J., Cheng, R., Lindsey, D. P., Ladd, A. L. 2013; 38A (2): 309-315

  Abstract

  In thumb carpometacarpal osteoarthritis, current evidence suggests that degenerative, bony remodeling primarily occurs within the trapezium. Nevertheless, the pathomechanics involved and the most common sites of wear remain controversial. Quantifying structural bone morphology characteristics with high-resolution computed tomography CT (micro-CT) infer regions of load transmission. Using micro-CT, we investigated whether predominant trabecular patterns exist in arthritic versus normal trapeziums.We performed micro-CT analysis on 13 normal cadaveric trapeziums and 16 Eaton stage III to IV trapeziums. We computationally divided each specimen into 4 quadrants: volar-ulnar, volar-radial, dorsal-radial, and dorsal-ulnar. Measurements of trabecular bone morphologic parameters included bone volume ratio, connectivity, trabecular number, and trabecular thickness. Using analysis of variance with post hoc Bonferroni/Dunn correction, we compared osteoarthritic and normal specimen quadrant measurements.No significant difference existed in bone volume fraction between the osteoarthritic and normal specimens. Osteoarthritic trapeziums, however, demonstrated significantly higher trabecular number and connectivity than nonosteoarthritic trapeziums. Comparing the volar-ulnar quadrant of osteoarthritis and normal specimens collectively, this quadrant in both consistently possessed significantly higher bone volume fraction, trabecular number, and connectivity than the dorsal-radial and volar-radial quadrants.The significantly greater trabecular bone volume, thickness, and connectivity in the volar-ulnar quadrant compared with the dorsal-radial and dorsal-ulnar quadrants provides evidence that the greatest compressive loads at the first carpometacarpal joint occur at the volar-ulnar quadrant of the trapezium, representing a consistently affected region of wear in both normal and arthritic states.These findings suggest that trapezial trabecular morphology undergoes pathologic alteration. This provides indirect evidence that changes in load transmission occur with thumb carpometacarpal joint arthritis development.

  View details for DOI 10.1016/j.jhsa.2012.10.038

  View details for Web of Science ID 000314739400012

  View details for PubMedCentralID PMC3932241

• The scaphoid. Orthopedic clinics of North America Sendher, R., Ladd, A. L. 2013; 44 (1): 107-120

  Abstract

  The scaphoid is vitally important for the proper mechanics of wrist function. Its unique morphology from its boat like shape to its retrograde blood supply can present with challenges in the presence of a fracture. Almost completely covered with articular cartilage, this creates precise surface loading demands and intolerance to bony remodeling. Fracture location compounds risk of malunion and non-union. Scaphoid fractures may significantly impair wrist function and activities of daily living, with both individual and economic consequences.

  View details for DOI 10.1016/j.ocl.2012.09.003

  View details for PubMedID 23174330

• The thumb carpometacarpal joint: anatomy, hormones, and biomechanics. Instructional course lectures Ladd, A. L., Weiss, A. C., Crisco, J. J., Hagert, E., Wolf, J. M., Glickel, S. Z., Yao, J. 2013; 62: 165-179

  Abstract

  Although there are many surgical options to treat thumb carpometacarpal (CMC) arthritis, a precise etiology for this common disorder remains obscure. To better understand the physiology of the thumb CMC joint and treat pathology, it is helpful to examine the biomechanics, hormonal influences, and available surgical treatment options, along with the evolutionary roots of the thumb; its form and function, its functional demands; and the role of supporting ligaments based on their location, stability, and ultrastructure. It is important to appreciate the micromotion of a saddle joint and the role that sex, age, and reproductive hormones play in influencing laxity and joint disease. Minimally invasive surgery is now challenging prevailing treatment principles of ligament reconstruction and plays a role in thumb CMC joint procedures.

  View details for PubMedID 23395023

• Hand Made/Hand in Art: Hands in Repose JOURNAL OF HAND SURGERY-AMERICAN VOLUME Ladd, A. L. 2012; 37A (10): 2136-2136

  View details for DOI 10.1016/j.jhsa.2012.06.018

  View details for Web of Science ID 000309846700026

• Macroscopic and microscopic analysis of the thumb carpometacarpal ligaments: a cadaveric study of ligament anatomy and histology. journal of bone and joint surgery. American volume Ladd, A. L., Lee, J., Hagert, E. 2012; 94 (16): 1468-1477

  Abstract

  Stability and mobility represent the paradoxical demands of the human thumb carpometacarpal joint, yet the structural origin of each functional demand is poorly defined. As many as sixteen and as few as four ligaments have been described as primary stabilizers, but controversy exists as to which ligaments are most important. We hypothesized that a comparative macroscopic and microscopic analysis of the ligaments of the thumb carpometacarpal joint would further define their role in joint stability.Thirty cadaveric hands (ten fresh-frozen and twenty embalmed) from nineteen cadavers (eight female and eleven male; average age at the time of death, seventy-six years) were dissected, and the supporting ligaments of the thumb carpometacarpal joint were identified. Ligament width, length, and thickness were recorded for morphometric analysis and were compared with use of the Student t test. The dorsal and volar ligaments were excised from the fresh-frozen specimens and were stained with use of a triple-staining immunofluorescent technique and underwent semiquantitative analysis of sensory innervation; half of these specimens were additionally analyzed for histomorphometric data. Mixed-effects linear regression was used to estimate differences between ligaments.Seven principal ligaments of the thumb carpometacarpal joint were identified: three dorsal deltoid-shaped ligaments (dorsal radial, dorsal central, posterior oblique), two volar ligaments (anterior oblique and ulnar collateral), and two ulnar ligaments (dorsal trapeziometacarpal and intermetacarpal). The dorsal ligaments were significantly thicker (p < 0.001) than the volar ligaments, with a significantly greater cellularity and greater sensory innervation compared with the anterior oblique ligament (p < 0.001). The anterior oblique ligament was consistently a thin structure with a histologic appearance of capsular tissue with low cellularity.The dorsal deltoid ligament complex is uniformly stout and robust; this ligament complex is the thickest morphometrically, has the highest cellularity histologically, and shows the greatest degree of sensory nerve endings. The hypocellular anterior oblique ligament is thin, is variable in its location, and is more structurally consistent with a capsular structure than a proper ligament.

  View details for PubMedID 22992815

• Macroscopic and Microscopic Analysis of the Thumb Carpometacarpal Ligaments A Cadaveric Study of Ligament Anatomy and Histology JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Ladd, A. L., Lee, J., Hagert, E. 2012; 94A (16): 1468-1477

  Abstract

  Stability and mobility represent the paradoxical demands of the human thumb carpometacarpal joint, yet the structural origin of each functional demand is poorly defined. As many as sixteen and as few as four ligaments have been described as primary stabilizers, but controversy exists as to which ligaments are most important. We hypothesized that a comparative macroscopic and microscopic analysis of the ligaments of the thumb carpometacarpal joint would further define their role in joint stability.Thirty cadaveric hands (ten fresh-frozen and twenty embalmed) from nineteen cadavers (eight female and eleven male; average age at the time of death, seventy-six years) were dissected, and the supporting ligaments of the thumb carpometacarpal joint were identified. Ligament width, length, and thickness were recorded for morphometric analysis and were compared with use of the Student t test. The dorsal and volar ligaments were excised from the fresh-frozen specimens and were stained with use of a triple-staining immunofluorescent technique and underwent semiquantitative analysis of sensory innervation; half of these specimens were additionally analyzed for histomorphometric data. Mixed-effects linear regression was used to estimate differences between ligaments.Seven principal ligaments of the thumb carpometacarpal joint were identified: three dorsal deltoid-shaped ligaments (dorsal radial, dorsal central, posterior oblique), two volar ligaments (anterior oblique and ulnar collateral), and two ulnar ligaments (dorsal trapeziometacarpal and intermetacarpal). The dorsal ligaments were significantly thicker (p < 0.001) than the volar ligaments, with a significantly greater cellularity and greater sensory innervation compared with the anterior oblique ligament (p < 0.001). The anterior oblique ligament was consistently a thin structure with a histologic appearance of capsular tissue with low cellularity.The dorsal deltoid ligament complex is uniformly stout and robust; this ligament complex is the thickest morphometrically, has the highest cellularity histologically, and shows the greatest degree of sensory nerve endings. The hypocellular anterior oblique ligament is thin, is variable in its location, and is more structurally consistent with a capsular structure than a proper ligament.

  View details for DOI 10.2106/JBJS.K.00329

  View details for Web of Science ID 000307745100005

  View details for PubMedCentralID PMC3412634

• Titanium integration with bone, welding, and screw head destruction complicating hardware removal of the distal radius: report of 2 cases. journal of hand surgery Van Nortwick, S. S., Yao, J., Ladd, A. L. 2012; 37 (7): 1388-1392

  Abstract

  Increasingly, surgeons treat distal radius fractures with locking plate systems. Recent case reports have focused on technical insertion errors resulting in removal difficulties: poor drilling orientation or cross-threading, destruction of the screw head, and filling of the screw recess with tissue. We report 2 complications of titanium locked plate removal secondary to in vivo reactions including titanium integration with bone and mechanical binding between the titanium screw and plate. We clarify and discuss terminology relevant to implant removal, including cold-welding, galling, fretting, and anodization. Even with optimal technique, in situ reactions can complicate titanium implant removal.

  View details for DOI 10.1016/j.jhsa.2012.04.027

  View details for PubMedID 22652178

• Training Improves Interobserver Reliability for the Diagnosis of Scaphoid Fracture Displacement CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Buijze, G. A., Guitton, T. G., van Dijk, C., Ring, D., Sci Variation Grp 2012; 470 (7): 2029-2034

  Abstract

  The diagnosis of displacement in scaphoid fractures is notorious for poor interobserver reliability.We tested whether training can improve interobserver reliability and sensitivity, specificity, and accuracy for the diagnosis of scaphoid fracture displacement on radiographs and CT scans.Sixty-four orthopaedic surgeons rated a set of radiographs and CT scans of 10 displaced and 10 nondisplaced scaphoid fractures for the presence of displacement, using a web-based rating application. Before rating, observers were randomized to a training group (34 observers) and a nontraining group (30 observers). The training group received an online training module before the rating session, and the nontraining group did not. Interobserver reliability for training and nontraining was assessed by Siegel's multirater kappa and the Z-test was used to test for significance.There was a small, but significant difference in the interobserver reliability for displacement ratings in favor of the training group compared with the nontraining group. Ratings of radiographs and CT scans combined resulted in moderate agreement for both groups. The average sensitivity, specificity, and accuracy of diagnosing displacement of scaphoid fractures were, respectively, 83%, 85%, and 84% for the nontraining group and 87%, 86%, and 87% for the training group. Assuming a 5% prevalence of fracture displacement, the positive predictive value was 0.23 in the nontraining group and 0.25 in the training group. The negative predictive value was 0.99 in both groups.Our results suggest training can improve interobserver reliability and sensitivity, specificity and accuracy for the diagnosis of scaphoid fracture displacement, but the improvements are slight. These findings are encouraging for future research regarding interobserver variation and how to reduce it further.

  View details for DOI 10.1007/s11999-012-2260-4

  View details for Web of Science ID 000305211800029

  View details for PubMedID 22290132

  View details for PubMedCentralID PMC3369105

• Titanium Integration With Bone, Welding, and Screw Head Destruction Complicating Hardware Removal of the Distal Radius: Report of 2 Cases JOURNAL OF HAND SURGERY-AMERICAN VOLUME Van Nortwick, S. S., Yao, J., Ladd, A. L. 2012; 37A (7): 1388-1392

  Abstract

  Increasingly, surgeons treat distal radius fractures with locking plate systems. Recent case reports have focused on technical insertion errors resulting in removal difficulties: poor drilling orientation or cross-threading, destruction of the screw head, and filling of the screw recess with tissue. We report 2 complications of titanium locked plate removal secondary to in vivo reactions including titanium integration with bone and mechanical binding between the titanium screw and plate. We clarify and discuss terminology relevant to implant removal, including cold-welding, galling, fretting, and anodization. Even with optimal technique, in situ reactions can complicate titanium implant removal.

  View details for DOI 10.1016/j.jhsa.2012.04.027

  View details for Web of Science ID 000310670700013

• Innervation Patterns of Thumb Trapeziometacarpal Joint Ligaments JOURNAL OF HAND SURGERY-AMERICAN VOLUME Hagert, E., Lee, J., Ladd, A. L. 2012; 37A (4): 706-714

  Abstract

  The human thumb trapeziometacarpal (TM) joint is a unique articulation that allows stability during pinch and grip and great degrees of mobility. Because the saddle-shaped articulating surfaces of the TM joint are inherently unstable, joint congruity depends on the action of restraining ligaments and periarticular muscles. From other joints, it is known that proprioceptive and neuromuscular joint stability depend on afferent information from nerve endings within ligaments. We hypothesize that the TM joint ligaments may similarly be innervated, indicating a possible proprioceptive function of the joint.We harvested 5 TM joint ligaments in entirety from 10 fresh-frozen cadaver hands with no or only minor signs of osteoarthritis and suture-marked them for proximal-distal orientation. The ligaments harvested were the dorsal radial, dorsal central, posterior oblique, ulnar collateral, and anterior oblique ligaments. After paraffin-sectioning, we stained the ligaments using a triple-antibody immunofluorescent technique and analyzed them using immunofluorescence microscopy.Using the triple-stain technique, mechanoreceptors could be classified as Pacinian corpuscles, Ruffini endings, or Golgi-like endings. The 3 dorsal ligaments had significantly more nerve endings than the 2 volar ligaments. Most of the nerve endings were close to the bony attachments and significantly closer (P = .010) to the metacarpal insertion of each ligament. The anterior oblique ligament had little to no innervation in any of the specimens analyzed.The TM joint ligaments had an abundance of nerve endings in the dorsal ligaments but little to no innervation in the anterior oblique ligament. The Ruffini ending was the predominant mechanoreceptor type, with a greater density in the mobile metacarpal portion of each ligament.Presence of mechanoreceptors in the dorsal TM joint ligaments infers a proprioceptive function of these ligaments in addition to their biomechanical importance in TM joint stability.

  View details for DOI 10.1016/j.jhsa.2011.12.038

  View details for Web of Science ID 000302756300012

• Innervation patterns of thumb trapeziometacarpal joint ligaments. journal of hand surgery Hagert, E., Lee, J., Ladd, A. L. 2012; 37 (4): 706-714 e1

  Abstract

  The human thumb trapeziometacarpal (TM) joint is a unique articulation that allows stability during pinch and grip and great degrees of mobility. Because the saddle-shaped articulating surfaces of the TM joint are inherently unstable, joint congruity depends on the action of restraining ligaments and periarticular muscles. From other joints, it is known that proprioceptive and neuromuscular joint stability depend on afferent information from nerve endings within ligaments. We hypothesize that the TM joint ligaments may similarly be innervated, indicating a possible proprioceptive function of the joint.We harvested 5 TM joint ligaments in entirety from 10 fresh-frozen cadaver hands with no or only minor signs of osteoarthritis and suture-marked them for proximal-distal orientation. The ligaments harvested were the dorsal radial, dorsal central, posterior oblique, ulnar collateral, and anterior oblique ligaments. After paraffin-sectioning, we stained the ligaments using a triple-antibody immunofluorescent technique and analyzed them using immunofluorescence microscopy.Using the triple-stain technique, mechanoreceptors could be classified as Pacinian corpuscles, Ruffini endings, or Golgi-like endings. The 3 dorsal ligaments had significantly more nerve endings than the 2 volar ligaments. Most of the nerve endings were close to the bony attachments and significantly closer (P = .010) to the metacarpal insertion of each ligament. The anterior oblique ligament had little to no innervation in any of the specimens analyzed.The TM joint ligaments had an abundance of nerve endings in the dorsal ligaments but little to no innervation in the anterior oblique ligament. The Ruffini ending was the predominant mechanoreceptor type, with a greater density in the mobile metacarpal portion of each ligament.Presence of mechanoreceptors in the dorsal TM joint ligaments infers a proprioceptive function of these ligaments in addition to their biomechanical importance in TM joint stability.

  View details for DOI 10.1016/j.jhsa.2011.12.038

  View details for PubMedID 22464234

• RECOMMENDATION FOR MEASURING CLINICAL OUTCOME IN DISTAL RADIUS FRACTURES IOF-ECCEO European Congress on Osteoporosis and Osteoarthritis / 2nd IOF-ESCEO Pre-Clinical Symposium Goldhahn, J., Beaton, D., Ladd, A., MacDermid, J., Hoang-Kim, A. SPRINGER LONDON LTD. 2012: S341–S341

  View details for Web of Science ID 000309259600568

• Immunofluorescent Triple-Staining Technique to Identify Sensory Nerve Endings in Human Thumb Ligaments CELLS TISSUES ORGANS Lee, J., Ladd, A., Hagert, E. 2012; 195 (5): 456-464

  Abstract

  Ligament innervation purportedly plays a critical role in stability, proprioception and pathology of joints with minimal bony constraints. The human thumb carpometacarpal (CMC) joint is such a joint: with a complex saddle configuration and wide circumduction, its constraint is primarily ligamentous and it is prone to osteoarthritis. CMC reconstruction is the most commonly performed arthritis surgery in the upper extremity. Little, however, is known about CMC ligament innervation. We describe a novel triple-staining immunofluorescence technique using the markers for low-affinity neurotrophin receptor p75, the pan-neuronal marker protein gene product (PGP) 9.5 and 4',6'-diamidino-2-phenylindole (DAPI) to simultaneously detect and differentiate between specific sensory nerve endings: the Pacini corpuscles, the Ruffini endings and nerve fascicles. Five primary CMC ligaments (dorsal radial, dorsal central, posterior oblique, anterior oblique and ulnar collateral ligaments) were harvested from 10 fresh-frozen human cadaver hands. Following paraffin sectioning, each ligament was stained using a triple-stain technique and imaged with fluorescence microscopy. Multidimensional acquisition permitted simultaneous capture of images at different wavelengths. Pacini corpuscles were distinguished by their distinct p75 immunoreactive capsules, and Ruffini endings by their overlapping p75 and PGP9.5 immunoreactive dendritic nerve endings. Simultaneous use of PGP9.5, p75 and DAPI immunofluorescence to analyze innervation patterns in human ligaments provides descriptive analysis of staining patterns and receptor structure as well as clues as to the proprioceptive function of CMC ligaments and the joint as a whole. Our novel findings of CMC ligament innervation augment the study of normal and pathological joint mechanics in this joint so prone to osteoarthritis.

  View details for DOI 10.1159/000327725

  View details for PubMedID 21832813

• Interobserver reliability of radial head fracture classification: two-dimensional compared with three-dimensional CT. journal of bone and joint surgery. American volume Guitton, T. G., Ring, D. 2011; 93 (21): 2015-2021

  Abstract

  The Broberg and Morrey modification of the Mason classification of radial head fractures has substantial interobserver variation. This study used a large web-based collaborative of experienced orthopaedic surgeons to test the hypothesis that three-dimensional reconstructions of computed tomography (CT) scans improve the interobserver reliability of the classification of radial head fractures according to the Broberg and Morrey modification of the Mason classification.Eighty-five orthopaedic surgeons evaluated twelve radial head fractures. They were randomly assigned to review either radiographs and two-dimensional CT scans or radiographs and three-dimensional CT images to determine the fracture classification, fracture characteristics, and treatment recommendations. The kappa multirater measure (κ) was calculated to estimate agreement between observers.Three-dimensional CT had moderate agreement and two-dimensional CT had fair agreement among observers for the Broberg and Morrey modification of the Mason classification, a difference that was significant. Observers assessed seven fracture characteristics, including fracture line, comminution, articular surface involvement, articular step or gap of ≥2 mm, central impaction, recognition of more than three fracture fragments, and fracture fragments too small to repair. There was a significant difference in kappa values between three-dimensional CT and two-dimensional CT for fracture fragments too small to repair, recognition of three fracture fragments, and central impaction. The difference between the other four fracture characteristics was not significant. Among treatment recommendations, there was fair agreement for both three-dimensional CT and two-dimensional CT.Although three-dimensional CT led to some small but significant decreases in interobserver variation, there is still considerable disagreement regarding classification and characterization of radial head fractures. Three-dimensional CT may be insufficient to optimize interobserver agreement.

  View details for DOI 10.2106/JBJS.J.00711

  View details for PubMedID 22048097

• Rotational Biomechanics of the Elite Golf Swing: Benchmarks for Amateurs JOURNAL OF APPLIED BIOMECHANICS Meister, D. W., Ladd, A. L., Butler, E. E., Zhao, B., Rogers, A. P., Ray, C. J., Rose, J. 2011; 27 (3): 242-251

  Abstract

  The purpose of this study was to determine biomechanical factors that may influence golf swing power generation. Three-dimensional kinematics and kinetics were examined in 10 professional and 5 amateur male golfers. Upper-torso rotation, pelvic rotation, X-factor (relative hip-shoulder rotation), O-factor (pelvic obliquity), S-factor (shoulder obliquity), and normalized free moment were assessed in relation to clubhead speed at impact (CSI). Among professional golfers, results revealed that peak free moment per kilogram, peak X-factor, and peak S-factor were highly consistent, with coefficients of variation of 6.8%, 7.4%, and 8.4%, respectively. Downswing was initiated by reversal of pelvic rotation, followed by reversal of upper-torso rotation. Peak X-factor preceded peak free moment in all swings for all golfers, and occurred during initial downswing. Peak free moment per kilogram, X-factor at impact, peak X-factor, and peak upper-torso rotation were highly correlated to CSI (median correlation coefficients of 0.943, 0.943, 0.900, and 0.900, respectively). Benchmark curves revealed kinematic and kinetic temporal and spatial differences of amateurs compared with professional golfers. For amateurs, the number of factors that fell outside 1-2 standard deviations of professional means increased with handicap. This study identified biomechanical factors highly correlated to golf swing power generation and may provide a basis for strategic training and injury prevention.

  View details for PubMedID 21844613

• Measuring wrist and hand function: Common scales and checklists INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Hoang-Kim, A., Pegreffi, F., Moroni, A., Ladd, A. 2011; 42 (3): 253-258

  Abstract

  A hand and wrist disorder affects a patient's overall well-being and health-status. One concept serves as the foundation for all further consideration: in order to have confidence in your results when assessing patients with wrist and hand limitations, the clinician and researcher must choose standardised patient-oriented instruments that address the primary aims of the study. In this paper, we assess the quality of reviews published on patient oriented instruments in current use for assessing function of the hand and wrist joint. We highlight features of commonly used scales that improve readers' confidence in the choice and application of these outcome instruments.A literature search (1950-January 2010) was performed using the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life). Titles and abstracts (n=341) were screened by two reviewers independently. The GRADE approach was used to assess the quality of ten reviews and the inclusion of clinimetric properties were assessed using the COSMIN checklist.We included three systematic reviews rated moderate to high (2 hand injury instrument reviews and 1 wrist fracture outcome review). Recommendations of use and an overview are provided for the disability of the arm, shoulder and hand questionnaire (DASH), QuickDASH, the Michigan hand questionnaire (MHQ), the patient-rated wrist hand evaluation outcome questionnaire (PRWHE) and the carpal tunnel questionnaire (CTQ) scales with established measurement properties.The DASH, a region-specific 30-item questionnaire is the most widely tested instrument in patients with wrist and hand injuries. The MHQ can provide good value to patients with hand injuries. Although, the CTQ is the most sensitive to clinical change, the DASH and MHQ have shown to be sufficiently responsive to outcome studies of carpal tunnel syndrome. The PRWHE has a good construct validity and responsiveness, which is only slightly better than the DASH to assess patients with wrist injuries. As the quality of patient-oriented validation continues to increase then the instruments can be selected more carefully. We will then be able to see that the future orthopaedic care of patients with hand and wrist injuries may also improve.

  View details for DOI 10.1016/j.injury.2010.11.050

  View details for Web of Science ID 000287019700006

  View details for PubMedID 21159335

• Temporal-spatial parameters of the upper limb during a Reach & Grasp Cycle for children GAIT & POSTURE Butler, E. E., Ladd, A. L., Lamont, L. E., Rose, J. 2010; 32 (3): 301-306

  Abstract

  The objective of this study was to characterize normal temporal-spatial patterns during the Reach & Grasp Cycle and to identify upper limb motor deficits in children with cerebral palsy (CP). The Reach & Grasp Cycle encompasses six sequential tasks: reach, grasp cylinder, transport to self (T(1)), transport back to table (T(2)), release cylinder, and return to initial position. Three-dimensional motion data were recorded from 25 typically developing children (11 males, 14 females; ages 5-18 years) and 12 children with hemiplegic CP (2 males, 10 females; ages 5-17 years). Within-day and between-day coefficients of variation for the control group ranged from 0 to 0.19, indicating good repeatability of all parameters. The mean duration of the Cycle for children with CP was nearly twice as long as controls, 9.5±4.3s versus 5.1±1.2s (U=37.0, P=.002), partly due to prolonged grasp and release durations. Peak hand velocity occurred at approximately 40% of each phase and was greater during the transport (T(1), T(2)) than non-transport phases (reach, return) in controls (P<.001). Index of curvature was lower during transport versus non-transport phases for all children. Children with CP demonstrated an increased index of curvature during reach (U=46.0, P=.0074) and an increased total number of movement units (U=16.5, P<.0001) compared to controls, indicating less efficient and less smooth movements. Total duration of the Reach & Grasp Cycle (rho=.957, P<.0001), index of curvature during reach and T(1) (rho=.873, P=.0002 and rho=.778, P=.0028), and total number of movement units (rho=.907, P<.0001) correlated strongly with MACS score. The consistent normative data and the substantial differences between children with CP and controls reflect utility of the Reach & Grasp Cycle for quantitative evaluation of upper limb motor deficits.

  View details for DOI 10.1016/j.gaitpost.2010.05.013

  View details for PubMedID 20558067

• Three-dimensional kinematics of the upper limb during a Reach and Grasp Cycle for children GAIT & POSTURE Butler, E. E., Ladd, A. L., Louie, S. A., Lamont, L. E., Wong, W., Rose, J. 2010; 32 (1): 72-77

  Abstract

  The ability to reach, grasp, transport, and release objects is essential for activities of daily living. The objective of this study was to develop a quantitative method to assess upper limb motor deficits in children with cerebral palsy (CP) using three-dimensional motion analysis. We report kinematic data from 25 typically developing (TD) children (11 males, 14 females; ages 5-18 years) and 2 children with spastic hemiplegic CP (2 females, ages 14 and 15 years) during the Reach and Grasp Cycle. The Cycle includes six sequential tasks: reach, grasp cylinder, transport to mouth (T(1)), transport back to table (T(2)), release cylinder, and return to initial position. It was designed to represent a functional activity that was challenging yet feasible for children with CP. For example, maximum elbow extension was 43+/-11 degrees flexion in the TD group. Consistent kinematic patterns emerged for the trunk and upper limb: coefficients of variation at point of task achievement for reach, T(1), and T(2) for trunk flexion-extension were (.11, .11, .11), trunk axial rotation (.06, .06, .06), shoulder elevation (.13, .11, .13), elbow flexion-extension (.25, .06, .23), forearm pronation-supination (.08, .10, .11), and wrist flexion-extension (.25, .21, .22). The children with CP demonstrated reduced elbow extension, increased wrist flexion and trunk motion, with an increased tendency to actively externally rotate the shoulder and supinate the forearm during T(1) compared to the TD children. The consistent normative data and clinically significant differences in joint motion between the CP and TD children suggest the Reach and Grasp Cycle is a repeatable protocol for objective clinical evaluation of functional upper limb motor performance.

  View details for DOI 10.1016/j.gaitpost.2010.03.011

  View details for PubMedID 20378351

• New concepts in the treatment of distal radius fractures. Instructional course lectures Taras, J. S., Ladd, A. L., Kalainov, D. M., Ruch, D. S., Ring, D. C. 2010; 59: 313-332

  Abstract

  Fracture of the distal radius is the type of fracture most commonly seen in emergency departments. The understanding of nonsurgical and surgical care of distal radius fractures is evolving with recently developed methods of fixation. It is worthwhile to review some new methods of treatment, the role of bone grafting and synthetic substitutes, the principles of complex fracture management, and the treatment of common complications of distal radius fractures.

  View details for PubMedID 20415388

• Upper-Limb Evolution and Development: Skeletons in the Closet Congenital Anomalies and Evolution's Template 6th Triennial Symposium on Science and the Surgery of Congenital Upper-Limb Malformations Ladd, A. L. JOURNAL BONE JOINT SURGERY INC. 2009: 19–25

  View details for DOI 10.2106/JBJS.I.00284

  View details for Web of Science ID 000267673900003

• Upper-limb evolution and development: skeletons in the closet. Congenital anomalies and evolution's template. The Journal of bone and joint surgery. American volume Ladd, A. L. 2009; 91 Suppl 4: 19-25

  View details for DOI 10.2106/JBJS.I.00284

  View details for PubMedID 19571063

• Surgical treatment of thumb carpometacarpal joint arthritis: a single institution experience from 1995-2005. Hand (New York, N.Y.) Park, M. J., Lichtman, G., Christian, J. B., Weintraub, J., Chang, J., Hentz, V. R., Ladd, A. L., Yao, J. 2008; 3 (4): 304-310

  Abstract

  There are numerous techniques for the surgical management of thumb carpometacarpal (CMC) joint arthritis. The four senior authors of this study employ three such techniques: trapeziectomy with hematoma distraction arthroplasty, hemitrapeziectomy with osteochondral allograft, and ligament reconstruction tendon interposition (LRTI). This study examines the three commonly utilized procedures at a single institution. This study examines the 10-year experience from 1995-2005 with a minimum 3-month follow-up. Disabilities of the arm, shoulder, and hand (DASH) scores, pre-and postoperative pinch strength, and operative time were examined. After approval from the institutional review board of our institution was obtained, all patients treated surgically by three of the senior authors were contacted via mail and phone. Each patient was asked to complete and return a DASH questionnaire. Of the 115 patients treated during that period, 60 participated in this study. Each patient's final postoperative pinch measurement was obtained from occupational therapy and clinic records. This pinch strength was compared to the preoperative pinch and contralateral pinch strength. Lastly, the total operative time for each procedure was obtained from the operative record. The only significant finding in this study was a shorter mean operative time with the trapeziectomy group (76.90 min) and osteochondral allograft group (90.45 min) when compared to the LRTI group (139.00 min; p = 0.001 and p = 0.001, respectively). We found no significant difference between groups in terms of DASH score and pinch strength. There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of the LRTI. This presents further evidence that potentially, "less is more" in the treatment of thumb CMC arthritis. We used a retrospective study design to evaluate potential differences between the three surgical techniques described above, therapeutic, levels III-IV.

  View details for DOI 10.1007/s11552-008-9109-z

  View details for PubMedID 18780018

  View details for PubMedCentralID PMC2584226

• Muscle moment arms in the first dorsal extensor compartment after radial malunion. A cadaver study. journal of bone and joint surgery. American volume LaRoque, E. S., Murray, W. M., Langley, S., Hariri, S., Levine, B. P., Ladd, A. L. 2008; 90 (9): 1979-1987

  Abstract

  Functional loss is a common complication of the fractured distal part of the radius. The purpose of the present study was to determine if the moment arms of the first dorsal extensor compartment are altered by distal radial fracture malunion. We hypothesized that the moment arms of the abductor pollicis longus and extensor pollicis brevis are significantly affected by dorsal angulation, radial inclination, and radial shortening, the most common deformities accompanying distal radial malunion.Moment arms of the extensor pollicis brevis and abductor pollicis longus were estimated in twelve cadaver wrists with use of the tendon-displacement method, which involves calculating the moment arm as the derivative of tendon displacement with respect to joint angle. Tendon displacement was quantified in different wrist postures before and after a closing-wedge osteotomy simulating a complex malunion of an extra-articular radial fracture.The simulated distal radial malunion resulted in a decrease in the wrist flexion moment arm for both the extensor pollicis brevis (p = 0.0003) and the abductor pollicis longus (p < 0.0001). The wrist flexion moment arms for the extensor pollicis brevis and abductor pollicis longus decreased by a mean (and standard deviation) of 114% +/- 75% and 77% +/- 50%, respectively, after the osteotomy. The wrist radial deviation moment arms for the extensor pollicis brevis and abductor pollicis longus increased by 16% +/- 26% (p = 0.071) and 28% +/- 44% (p = 0.043), respectively, after the osteotomy. Radiographs of the wrist that were made before and after the osteotomy indicated that radial tilt changed from 11.1 degrees of volar angulation to 14.8 degrees of dorsal angulation, radial inclination decreased from 21.8 degrees to 7.7 degrees, and radial height decreased from 11.6 to 4.4 mm.Distal radial malunion alters the mechanical advantage of the muscles in the first dorsal extensor compartment.

  View details for DOI 10.2106/JBJS.G.01015

  View details for PubMedID 18762659

• Muscle moment arms in the first dorsal extensor compartment after radial malunion - A cadaver study JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME LaRoque, E. S., Murray, W. M., Langley, S., Hariri, S., Levine, B. P., Ladd, A. L. 2008; 90A (9): 1979-1987

  Abstract

  Functional loss is a common complication of the fractured distal part of the radius. The purpose of the present study was to determine if the moment arms of the first dorsal extensor compartment are altered by distal radial fracture malunion. We hypothesized that the moment arms of the abductor pollicis longus and extensor pollicis brevis are significantly affected by dorsal angulation, radial inclination, and radial shortening, the most common deformities accompanying distal radial malunion.Moment arms of the extensor pollicis brevis and abductor pollicis longus were estimated in twelve cadaver wrists with use of the tendon-displacement method, which involves calculating the moment arm as the derivative of tendon displacement with respect to joint angle. Tendon displacement was quantified in different wrist postures before and after a closing-wedge osteotomy simulating a complex malunion of an extra-articular radial fracture.The simulated distal radial malunion resulted in a decrease in the wrist flexion moment arm for both the extensor pollicis brevis (p = 0.0003) and the abductor pollicis longus (p < 0.0001). The wrist flexion moment arms for the extensor pollicis brevis and abductor pollicis longus decreased by a mean (and standard deviation) of 114% +/- 75% and 77% +/- 50%, respectively, after the osteotomy. The wrist radial deviation moment arms for the extensor pollicis brevis and abductor pollicis longus increased by 16% +/- 26% (p = 0.071) and 28% +/- 44% (p = 0.043), respectively, after the osteotomy. Radiographs of the wrist that were made before and after the osteotomy indicated that radial tilt changed from 11.1 degrees of volar angulation to 14.8 degrees of dorsal angulation, radial inclination decreased from 21.8 degrees to 7.7 degrees, and radial height decreased from 11.6 to 4.4 mm.Distal radial malunion alters the mechanical advantage of the muscles in the first dorsal extensor compartment.

  View details for DOI 10.2106/JBJS.G.01015

  View details for Web of Science ID 000259049300021

• Reprint of diagnostic imaging of the shoulder. Journal of hand therapy Ladd, A. L. 2007; 20 (2): 202-208

  View details for PubMedID 17533098

• Diagnostic imaging of the shoulder (Reprinted from Journal of Hand Therapy, vol 2, pg 84-9, 1989) JOURNAL OF HAND THERAPY Ladd, A. L. 2007; 20 (2): 202-209

  View details for DOI 10.1097/j.jht.2007.02.002

  View details for Web of Science ID 000247234400008

• The David L. Bassett Stereoscopic Atlas of Human Anatomy: Developing a Specialized Collection within the Stanford MediaServer Digital Library 7th ACM/IEEE Joint Conference on Digital Libraries Durack, J. C., Kung, S., Chase, R. A., Ladd, A. L., Krebs, M., Dev, P. ASSOC COMPUTING MACHINERY. 2007: 506–506

  View details for Web of Science ID 000266062800108

• What orthopaedic surgery residents need to know about the hand and wrist? BMC medical education Wadey, V. M., Ladd, A., Dev, P., Walker, D. 2007; 7: 33-?

  Abstract

  To develop a Core Curriculum for Orthopaedic Surgery; and to conduct a national survey to assess the importance of curriculum items as judged by orthopaedic surgeons with primary affiliation non-academic. Attention for this manuscript was focused on determining the importance of topics pertaining to adult hand and wrist reconstruction.A 281-item questionnaire was developed and consisted of three sections: 1) Validated Musculoskeletal Core Curriculum; 2) Royal College of Physician and Surgeons of Canada (RCPSC) Specialty Objectives and; 3) A procedure list. A random group of 131 [out of 156] orthopaedic surgeons completed the questionnaire. Data were analyzed descriptively and quantitatively using histograms, a Modified Hotel ling's T2-statistic 1 with p-value determined by a permutation test, and the Benjamini-Hochberg/Yekutieli procedure131/156 (84%) orthopaedic surgeons participated in this study. 27/32 items received an average mean score of at least 3.0/4.0 by all respondents thus suggesting that 84% of the items are either "probably important" or "important" to know by the end of residency (SD range 0.007-0.228). The Benjamini-Hochberg procedure demonstrated that for 80% of the 32 x 31/2 = 496 possible pairs of hand and wrist questions did not appear to demonstrate the same distribution of ratings given that one question was different from that of another question.This study demonstrates with reliable statistical evidence, agreement on the importance of 27/32 items pertaining to hand and wrist reconstruction is included in a Core Curriculum for Orthopaedic Surgery. Residency training programs need ensure that educational opportunities focusing on the ability to perform with proficiency procedures pertaining to the hand and wrist is taught and evaluated in their respective programs.

  View details for PubMedID 17919336

  View details for PubMedCentralID PMC2175502

• Thrombin peptide TP508 stimulates cellular events leading to angiogenesis, revascularization and repair of dermal and musculoskeletal tissues 13th International Symposium on Bone Circulation Ryaby, J. T., Sheller, M. R., Levine, B. P., Bramlet, D. G., Ladd, A. L., Carney, D. H. JOURNAL BONE JOINT SURGERY INC. 2006: 132–139

  Abstract

  The thrombin peptide, TP508, also known as Chrysalin (OrthoLogic, Tempe, Arizona), is a twenty-three-amino-acid peptide that represents a portion of the receptor-binding domain of the native human thrombin molecule that has been identified as the binding site for a specific class of receptors on fibroblasts and other cells. Preclinical studies with this peptide have shown that it can accelerate tissue repair in both soft and hard tissues by mechanisms that appear to involve up-regulation of genes that initiate a cascade of healing events. These events include recruitment and activation of inflammatory cells, directed migration of cells (chemotaxis), cell proliferation, elaboration of extra-cellular matrix, and accelerated revascularization of the healing tissues. Early preclinical dermal wound-healing studies showed that TP508 accelerated healing of both incisional wounds and full-thickness excisional wounds in normal and ischemic skin. In all of these studies, the accelerated healing was associated with increased neovascularization across the incision or in the granulating wound bed. Studies in a rat fracture model have also shown that TP508 accelerates the rate of fracture repair. Gene array analysis of fracture callus from control and TP508-treated fractures indicated that TP508 treatment was associated with an up-regulation of early response elements, inflammatory mediators, and genes related to angiogenesis. Similar to what had been seen in dermal wounds, histology from rat fracture callus twenty-one days after treatment indicated that fractures treated with TP508 had significantly more large functional blood vessels than did fractures in the control animals. In vitro studies support these in vivo data and indicate that TP508 may have a direct angiogenic effect by promoting the rate of new vessel growth. The results from phase-1 and phase-2 human clinical studies have shown a positive stimulatory effect of TP508 in the healing of diabetic ulcers and in the repair of fractures to the distal aspect of the radius. Collectively, these studies suggest that TP508 accelerates tissue repair by initiating a cascade of events that lead to an increased rate of tissue revascularization and regeneration.

  View details for DOI 10.2106/JBJS.F.00892

  View details for Web of Science ID 000241848000020

• Thrombin peptide TP508 stimulates cellular events leading to angiogenesis, revascularization, and repair of dermal and musculoskeletal tissues. journal of bone and joint surgery. American volume Ryaby, J. T., Sheller, M. R., Levine, B. P., Bramlet, D. G., Ladd, A. L., Carney, D. H. 2006; 88: 132-139

  Abstract

  The thrombin peptide, TP508, also known as Chrysalin (OrthoLogic, Tempe, Arizona), is a twenty-three-amino-acid peptide that represents a portion of the receptor-binding domain of the native human thrombin molecule that has been identified as the binding site for a specific class of receptors on fibroblasts and other cells. Preclinical studies with this peptide have shown that it can accelerate tissue repair in both soft and hard tissues by mechanisms that appear to involve up-regulation of genes that initiate a cascade of healing events. These events include recruitment and activation of inflammatory cells, directed migration of cells (chemotaxis), cell proliferation, elaboration of extra-cellular matrix, and accelerated revascularization of the healing tissues. Early preclinical dermal wound-healing studies showed that TP508 accelerated healing of both incisional wounds and full-thickness excisional wounds in normal and ischemic skin. In all of these studies, the accelerated healing was associated with increased neovascularization across the incision or in the granulating wound bed. Studies in a rat fracture model have also shown that TP508 accelerates the rate of fracture repair. Gene array analysis of fracture callus from control and TP508-treated fractures indicated that TP508 treatment was associated with an up-regulation of early response elements, inflammatory mediators, and genes related to angiogenesis. Similar to what had been seen in dermal wounds, histology from rat fracture callus twenty-one days after treatment indicated that fractures treated with TP508 had significantly more large functional blood vessels than did fractures in the control animals. In vitro studies support these in vivo data and indicate that TP508 may have a direct angiogenic effect by promoting the rate of new vessel growth. The results from phase-1 and phase-2 human clinical studies have shown a positive stimulatory effect of TP508 in the healing of diabetic ulcers and in the repair of fractures to the distal aspect of the radius. Collectively, these studies suggest that TP508 accelerates tissue repair by initiating a cascade of events that lead to an increased rate of tissue revascularization and regeneration.

  View details for PubMedID 17079379

• Evaluation of a surgical simulator for learning clinical anatomy MEDICAL EDUCATION Hariri, S., Rawn, C., Srivastava, S., Youngblood, P., Ladd, A. 2004; 38 (8): 896-902

  Abstract

  New techniques in imaging and surgery have made 3-dimensional anatomical knowledge an increasingly important goal of medical education. This study compared the efficacy of 2 supplemental, self-study methods for learning shoulder joint anatomy to determine which method provides for greater transfer of learning to the clinical setting.Two groups of medical students studied shoulder joint anatomy using either a second-generation virtual reality surgical simulator or images from a textbook. They were then asked to identify anatomical structures of the shoulder joint as they appeared in a videotape of a live arthroscopic procedure.The mean identification scores, out of a possible score of 7, were 3.1 +/- 1.3 for the simulator group and 2.9 +/- 1.5 for the textbook group (P = 0.70). Student ratings of the 2 methods on a 5-point Likert scale were significantly different. The simulator group rated the simulator more highly as an effective learning tool than the textbook group rated the textbook (means of 3.2 +/- 0.7 and 2.6 +/- 0.5, respectively, P = 0.02). Furthermore, the simulator group indicated that they were more likely to use the simulator as a learning tool if it were available to them than the textbook group was willing to use the textbook (means of 4.0 +/- 1.2 and 3.0 +/- 0.9, respectively, P = 0.02).Our results show that this surgical simulator is at least as effective as textbook images for learning anatomy and could enhance student learning through increased motivation. These findings provide insight into simulator development and strategies for learning anatomy. Possible explanations and future research directions are discussed.

  View details for DOI 10.1111/j.1365-2929.2004.01897.x

  View details for Web of Science ID 000223249000017

  View details for PubMedID 15271051

• Initial evaluation of a shoulder arthroscopy simulator: Establishing construct validity JOURNAL OF SHOULDER AND ELBOW SURGERY Srivastava, S., Youngblood, P. L., Rawn, C., Hariri, S., Heinrichs, W. L., Ladd, A. L. 2004; 13 (2): 196-205

  Abstract

  Formal evaluation of surgical simulators is essential before their introduction into training programs. We report our assessment of the Mentice Corp Procedicus shoulder arthroscopy simulator. This study tests the hypothesis of construct validity that experienced surgeons will score better on the simulator than individuals with minimal to no experience with the technique. Thirty-five subjects were stratified into three groups (novice, intermediate, and expert) based on their past 5 years' experience with shoulder arthroscopies. Each subject had an identical session on the simulator and completed anatomic identification, hook manipulations, and scope navigation exercises. We found statistically significant differences among the three groups in hook manipulation and scope navigation exercises, with the expert group performing the exercises more quickly (P =.013) and more accurately (P =.002) than the other two groups. No statistically significant differences were found among the groups in the identification of anatomic landmarks. Experts rated the simulator as an effective teaching tool, giving it a mean score of 4.22 and 4.44 (maximum, 5) for teaching instrument control and triangulation, respectively.

  View details for DOI 10.1016/j.jse.2003.12.009

  View details for PubMedID 14997099

• Norian SRS cement compared with conventional fixation in distal radial fractures - A randomized study JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Cassidy, C., Jupiter, J. B., Cohen, M., Delli-Santi, M., Fennell, C., Leinberry, C., Husband, J., Ladd, A., Seitz, W. R., Constanz, B. 2003; 85A (11): 2127-2137

  Abstract

  A prospective, randomized multicenter study was conducted to evaluate closed reduction and immobilization with and without Norian SRS (Skeletal Repair System) cement in the management of distal radial fractures. Norian SRS is a calcium-phosphate bone cement that is injectable, hardens in situ, and cures by a crystallization reaction to form dahllite, a carbonated apatite equivalent to bone mineral.A total of 323 patients with a distal radial fracture were randomized to treatment with or without Norian SRS cement. Stratification factors included fracture type (intra-articular or extra-articular), hand dominance, bone density, and the surgeon's preferred conventional treatment (cast or external fixator). The subjects receiving Norian SRS underwent a closed reduction followed by injection of the cement percutaneously or through a limited open approach. Wrist motion, beginning two weeks postoperatively, was encouraged. Control subjects, who had not received a Norian SRS injection, underwent closed reduction and application of a cast or external fixator for six to eight weeks. Supplemental Kirschner wires were used in specific instances in both groups. Patients were followed clinically and radiographically at one, two, four, and between six and eight weeks and at three, six, and twelve months. Patients rated pain and the function of the hand with use of a visual analog scale. Quality of life was assessed with use of the Short Form-36 (SF-36) health status questionnaire. Complications were recorded.Significant clinical differences were seen at six to eight weeks postoperatively, with better grip strength, wrist range of motion, digital motion, use of the hand, and social and emotional function, and less swelling in the patients treated with Norian SRS than in the control group (p < 0.05). By three months, these differences had normalized except for digital motion, which remained significantly better in the group treated with Norian SRS (p = 0.015). At one year, no clinical differences were detected. Radiographically, the average change in ulnar variance was greater in the patients treated with Norian SRS (+2.0 mm) than in the control group (+1.4 mm) (p < 0.02). No differences were seen in the total number of complications, including loss of reduction. The infection rate, however, was significantly higher (p < 0.001) in the control group (16.7%) than in the group treated with Norian SRS (2.5%) and the infections were always related to external fixator pins or Kirschner wires. Four patients with intra-articular extravasation of cement were identified; no sequelae were observed at twenty-four months. Cement was seen in extraosseous locations in 112 (70%) of the SRS-treated patients; loss of reduction was highest in this subgroup (37%). The extraosseous material had disappeared in eighty-three of the 112 patients by twelve months.Our results indicate that fixation of a distal radial fracture with Norian SRS cement may allow for accelerated rehabilitation. A limited open approach and supplemental fixation with Kirschner wires are recommended. Additional or alternate fixation is necessary for complex articular fractures.

  View details for Web of Science ID 000186423600010

• Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study. journal of bone and joint surgery. American volume Cassidy, C., Jupiter, J. B., Cohen, M., Delli-Santi, M., Fennell, C., Leinberry, C., Husband, J., Ladd, A., Seitz, W. R., Constanz, B. 2003; 85-A (11): 2127-2137

  Abstract

  A prospective, randomized multicenter study was conducted to evaluate closed reduction and immobilization with and without Norian SRS (Skeletal Repair System) cement in the management of distal radial fractures. Norian SRS is a calcium-phosphate bone cement that is injectable, hardens in situ, and cures by a crystallization reaction to form dahllite, a carbonated apatite equivalent to bone mineral.A total of 323 patients with a distal radial fracture were randomized to treatment with or without Norian SRS cement. Stratification factors included fracture type (intra-articular or extra-articular), hand dominance, bone density, and the surgeon's preferred conventional treatment (cast or external fixator). The subjects receiving Norian SRS underwent a closed reduction followed by injection of the cement percutaneously or through a limited open approach. Wrist motion, beginning two weeks postoperatively, was encouraged. Control subjects, who had not received a Norian SRS injection, underwent closed reduction and application of a cast or external fixator for six to eight weeks. Supplemental Kirschner wires were used in specific instances in both groups. Patients were followed clinically and radiographically at one, two, four, and between six and eight weeks and at three, six, and twelve months. Patients rated pain and the function of the hand with use of a visual analog scale. Quality of life was assessed with use of the Short Form-36 (SF-36) health status questionnaire. Complications were recorded.Significant clinical differences were seen at six to eight weeks postoperatively, with better grip strength, wrist range of motion, digital motion, use of the hand, and social and emotional function, and less swelling in the patients treated with Norian SRS than in the control group (p < 0.05). By three months, these differences had normalized except for digital motion, which remained significantly better in the group treated with Norian SRS (p = 0.015). At one year, no clinical differences were detected. Radiographically, the average change in ulnar variance was greater in the patients treated with Norian SRS (+2.0 mm) than in the control group (+1.4 mm) (p < 0.02). No differences were seen in the total number of complications, including loss of reduction. The infection rate, however, was significantly higher (p < 0.001) in the control group (16.7%) than in the group treated with Norian SRS (2.5%) and the infections were always related to external fixator pins or Kirschner wires. Four patients with intra-articular extravasation of cement were identified; no sequelae were observed at twenty-four months. Cement was seen in extraosseous locations in 112 (70%) of the SRS-treated patients; loss of reduction was highest in this subgroup (37%). The extraosseous material had disappeared in eighty-three of the 112 patients by twelve months.Our results indicate that fixation of a distal radial fracture with Norian SRS cement may allow for accelerated rehabilitation. A limited open approach and supplemental fixation with Kirschner wires are recommended. Additional or alternate fixation is necessary for complex articular fractures.

  View details for PubMedID 14630841

• Magnetic resonance imaging in diagnosis of chronic posterolateral rotatory instability of the elbow. American journal of orthopedics (Belle Mead, N.J.) Grafe, M. W., McAdams, T. R., Beaulieu, C. F., Ladd, A. L. 2003; 32 (10): 501-503

  Abstract

  Posterolateral rotatory instability of the elbow can be difficult to diagnose and requires a high degree of clinical suspicion. Cases of chronic posterolateral rotatory instability (symptoms present more than 1 year) may be an even more perplexing subgroup. This is a case report of a patient with a 30-year history of intermittent elbow instability. Clinical examination was equivocal, and magnetic resonance imaging was unable to define any ligamentous injury around the elbow. Examination under anesthesia and surgical findings were consistent with complete disruption of the lateral ulnar collateral ligament. The 12-month follow-up after surgical reconstruction showed complete resolution of symptoms. Posterolateral rotatory instability is a diagnosis largely made by examination under anesthesia. A thorough history and a high clinical suspicion are necessary to support the physician's decision to place the patient under anesthesia. Confirmation of a chronic tear of the lateral ulnar collateral ligament of the elbow with magnetic resonance imaging can be difficult and sometimes misleading.

  View details for PubMedID 14620091

• The effect of pronation and supination on the minimally displaced scaphoid fracture CLINICAL ORTHOPAEDICS AND RELATED RESEARCH McAdams, T. R., Spisak, S., Beaulieu, C. F., Ladd, A. L. 2003: 255-259

  Abstract

  The amount of rotation that occurs at the scaphoid waist fracture site with pronation and supination of the forearm is studied in 10 upper extremities from cadavers. Two colinear metal markers were placed in the osteotomized scaphoid and a below-the-elbow cast was applied. Spiral volumetric computed tomography scanning of the scaphoid was done with multiplanar reformation to evaluate displacement of the metal markers. Four of the 10 specimens also were studied without any immobilization. The total magnitude of motion from pronation to supination averaged 0.2 mm in the specimens with a below-the-elbow thumb spica cast, and 2.4 mm in specimens without immobilization. The current study showed no significant rotation at the minimally displaced scaphoid waist fracture site during pronation and supination in a below-the-elbow cast. Furthermore, there is unacceptable rotation at the fracture site in the absence of a cast. Based on this study, a below-the-elbow thumb spica cast seems adequate for fracture immobilization; however, clinical correlation is needed.

  View details for DOI 10.1097/01.blo.0000069886.31220.86

  View details for PubMedID 12782882

• Educational tools in support of the Stanford MediaServer Joint Conference on Digital Libraries Stevenson, D., Chao, C. C., Srivastava, S., Durack, J. C., Ladd, A., Montgomery, K., Dev, P. IEEE COMPUTER SOC. 2003: 377–377

  View details for Web of Science ID 000183728000055

• Reconstruction of the hand in Apert syndrome: A simplified approach PLASTIC AND RECONSTRUCTIVE SURGERY Chang, J., Danton, T. K., Ladd, A. L., Hentz, V. R. 2002; 109 (2): 465-470

  Abstract

  Children born with Apert acrocephalosyndactyly pose great challenges to the pediatric hand surgeon. Reconstructive dilemmas consist of shortened, deviated phalanges and extensive skin deficits following syndactyly release. We present a 10-year review of patients with Apert acrocephalosyndactyly who were treated with a simplified surgical approach. Between 1986 and 1996, 10 patients with Apert syndrome underwent reconstructive surgery of their hands. The overall strategy involved early bilateral separation of syndactylous border digits at 1 year of age, followed by sequential unilateral middle syndactyly mass separation with thumb osteotomy and bone grafting as needed. In these 10 patients, a total of 53 web spaces were released, 49 of which involved osteotomies for complex syndactyly. Only local flaps and full-thickness skin grafts from the groin were used in all cases to achieve soft-tissue coverage. To date, seven of the 53 web spaces have needed revision (revision rate, 13 percent). Eleven thumb osteotomies (nine opening wedge and two closing wedge) were performed. Bone grafts from the proximal ulna or from other digits were used in all cases. To date, none of these thumb osteotomies have needed revision. This early, simplified approach to the complex hand anomalies of Apert acrocephalosyndactyly has been successful in achieving low revision rates and excellent functional outcomes as measured by gross grasp and pinch and by patient and parent satisfaction.

  View details for PubMedID 11818821

• The role of bone graft and alternatives in unstable distal radius fracture treatment ORTHOPEDIC CLINICS OF NORTH AMERICA Ladd, A. L., Pliam, N. B. 2001; 32 (2): 337-351

  Abstract

  The increased prevalence of unstable fractures of the distal radius has stimulated the development of new technologies and new surgical techniques for treating these complex injuries. New developments also contribute to the expectation that orthopedic surgeons should be able to treat the fractured distal radius more successfully by achieving early stability, early function, and better outcomes. The continuous introduction of commercial bone graft substitutes and graft extenders has provided a large array of implantable materials. Rigorous comparison of the commercially available bone graft substitutes is difficult not only because of their diversity but also because uniformly accepted preclinical assays and comparable clinical studies have not been performed. Despite the lack of complete data, however, available data and collective experience suggest that bone graft substitutes can provide improved treatment methods and outcomes.

  View details for Web of Science ID 000168987600011

  View details for PubMedID 11331546

• Dynamic evaluation of shoulder instability using open MR imaging 14th International Congress and Exhibition on Computer Assisted Radiology and Surgery (CARS 2000) Beaulieu, C. F., Dillingham, M. F., Hodge, D. K., Butts, K., Gold, G. E., Thabit, G. H., Ladd, A. L., Bergman, A. G. ELSEVIER SCIENCE BV. 2000: 309–314

  View details for Web of Science ID 000165685600052

• Use of bone-graft substitutes in distal radius fractures. journal of the American Academy of Orthopaedic Surgeons Ladd, A. L., Pliam, N. B. 1999; 7 (5): 279-290

  Abstract

  The development of bone-graft substitutes potentially provides the benefits of bone grafting without the risks of autograft harvest. During the past few years, the US Food and Drug Administration has approved several different types of products. These vary considerably in composition, structural strength, osteoinductive and osteoconductive potential, and mechanisms and rates at which they are resorbed or remodeled. The products now approved for orthopaedic applications in the United States include those based on naturally occurring materials (e.g., demineralized human bone matrix, bovine collagen mineral composites, and processed coralline hydroxyapatite) as well as synthetic materials (e.g., calcium sulfate pellets, bioactive glass, and calcium phosphate cement). Materials in development include variations on available products and a new generation of biologically active materials employing growth factors. Rigorous comparison of the products is difficult, as there are no universally accepted preclinical assays and comparable clinical studies. Despite the limitations of the data now available, controlled studies and anecdotal reports suggest that use of bone-graft substitutes may result in improved treatment outcomes for patients with fractures of the distal radius.

  View details for PubMedID 10504355

• Biomechanical evaluation of fixation of intra-articular fractures of the distal part of the radius in cadavera: Kirschner wires compared with calcium-phosphate bone cement. journal of bone and joint surgery. American volume Yetkinler, D. N., Ladd, A. L., Poser, R. D., Constantz, B. R., Carter, D. 1999; 81 (3): 391-399

  Abstract

  The purpose of this study was to compare the biomechanical efficacy of an injectable calcium-phosphate bone cement (Skeletal Repair System [SRS]) with that of Kirschner wires for the fixation of intraarticular fractures of the distal part of the radius.Colles fractures (AO pattern, C2.1) were produced in ten pairs of fresh-frozen human cadaveric radii. One radius from each pair was randomly chosen for stabilization with SRS bone cement. These ten radii were treated with open incision, impaction of loose cancellous bone with use of a Freer elevator, and placement of the SRS bone cement by injection. In the ten control specimens, the fracture was stabilized with use of two horizontal and two oblique Kirschner wires. The specimens were cyclically loaded to a peak load of 200 newtons for 2000 cycles to evaluate the amount of settling, or radial shortening, under conditions simulating postoperative loading with the limb in a cast. Each specimen then was loaded to failure to determine its ultimate strength.The amount of radial shortening was highly variable among the specimens, but it was consistently higher in the Kirschner-wire constructs than in the bone fixed with SRS bone cement within each pair of radii. The range of shortening for all twenty specimens was 0.18 to 4.51 millimeters. The average amount of shortening in the SRS constructs was 50 percent of that in the Kirschner-wire constructs (0.51+/-0.34 compared with 1.01+/-1.23 millimeters; p = 0.015). With the numbers available, no significant difference in ultimate strength was detected between the two fixation groups.This study showed that fixation of an intra-articular fracture of the distal part of a cadaveric radius with biocompatible calcium-phosphate bone cement produced results that were biomechanically comparable with those produced by fixation with Kirschner wires. However, the constructs that were fixed with calcium-phosphate bone cement demonstrated less shortening under simulated cyclic load-bearing.

  View details for PubMedID 10199278

• Biomechanical evaluation of fixation of intra-articular fractures of the distal part of the radius in cadavera: Kirschner wires compared with calcium-phosphate bone cement JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Yetkinler, D. N., Ladd, A. L., Poser, R. D., Constantz, B. R., Carter, D. 1999; 81A (3): 391-399

  Abstract

  The purpose of this study was to compare the biomechanical efficacy of an injectable calcium-phosphate bone cement (Skeletal Repair System [SRS]) with that of Kirschner wires for the fixation of intraarticular fractures of the distal part of the radius.Colles fractures (AO pattern, C2.1) were produced in ten pairs of fresh-frozen human cadaveric radii. One radius from each pair was randomly chosen for stabilization with SRS bone cement. These ten radii were treated with open incision, impaction of loose cancellous bone with use of a Freer elevator, and placement of the SRS bone cement by injection. In the ten control specimens, the fracture was stabilized with use of two horizontal and two oblique Kirschner wires. The specimens were cyclically loaded to a peak load of 200 newtons for 2000 cycles to evaluate the amount of settling, or radial shortening, under conditions simulating postoperative loading with the limb in a cast. Each specimen then was loaded to failure to determine its ultimate strength.The amount of radial shortening was highly variable among the specimens, but it was consistently higher in the Kirschner-wire constructs than in the bone fixed with SRS bone cement within each pair of radii. The range of shortening for all twenty specimens was 0.18 to 4.51 millimeters. The average amount of shortening in the SRS constructs was 50 percent of that in the Kirschner-wire constructs (0.51+/-0.34 compared with 1.01+/-1.23 millimeters; p = 0.015). With the numbers available, no significant difference in ultimate strength was detected between the two fixation groups.This study showed that fixation of an intra-articular fracture of the distal part of a cadaveric radius with biocompatible calcium-phosphate bone cement produced results that were biomechanically comparable with those produced by fixation with Kirschner wires. However, the constructs that were fixed with calcium-phosphate bone cement demonstrated less shortening under simulated cyclic load-bearing.

  View details for Web of Science ID 000079315300012

• MR arthrography of the wrist: Scanning-room injection of the radiocarpal joint based on clinical landmarks AMERICAN JOURNAL OF ROENTGENOLOGY Beaulieu, C. F., Ladd, A. L. 1998; 170 (3): 606-608

  View details for Web of Science ID 000072129500013

  View details for PubMedID 9490938

• Repair of five distal radius fractures with an investigational cancellous bone cement: A preliminary report JOURNAL OF ORTHOPAEDIC TRAUMA Jupiter, J. B., Winters, S., Sigman, S., Lowe, C., Pappas, C., Ladd, A. L., Van Wagoner, M., Smith, S. T. 1997; 11 (2): 110-116

  Abstract

  The purpose of the study was to evaluate the feasibility of Norian SRS bone cement injected percutaneously into a distal radius following reduction in both preventing loss of reduction as well as safety.The study was a prospective clinical study with an established protocol.The study was conducted at the Massachusetts General Hospital following approval of the institutions Investigational Review Board. All patients were required to read and approve an informed consent document.While twenty patients' radiographs fulfilled the requirement of a dorsally displaced extraarticular fracture to have occurred within 72 hours of presentation, only five consented to participate fully and one voluntarily withdrew after a six-month follow-up.All fractures were reduced under regional or general anesthesia, and the Norian SRS was introduced via a catheter system into the metaphyseal defect of the fracture. A short arm cast was applied and remained in place for six weeks.Radiographic parameters of fracture reduction were measured prospectively by an independent radiologist throughout the 12 months of the study. Clinical parameters of hand and wrist function were measured prospectively by an independent occupational therapist.At 12-month follow-up, radial length was a mean 9.9 mm with an average loss of < 1 mm; radial angle maintained at a mean 25.4 degrees; volar angle was within normal range (0-21 degrees) in 4; and 1 patient had a dorsal angle of 7 degrees. Wrist motion improved 50 percent between 6 weeks and 3 months and improved further by 12 months when grip strength reached a mean of 88 percent of the contralateral side. Dorsal and volar extrusion of injected Norian SRS in 4 patients resorbed over time. There were no clinically significant adverse effects or complications.Norian SRS proved to be clinically safe and effective as a cancellous bone cement to maintain fracture reduction of unstable extraarticular distal radius fractures.

  View details for Web of Science ID 000071405600008

  View details for PubMedID 9057146

• Clinical comments CLINICAL JOURNAL OF SPORT MEDICINE Ladd, A. L. 1997; 7 (1): 65-65

  View details for Web of Science ID A1997WE03800017

• Surgical treatment and postoperative splinting of recessive dystrophic epidermolysis bullosa. journal of hand surgery Ladd, A. L., Kibele, A., Gibbons, S. 1996; 21 (5): 888-897

  Abstract

  Digital contractures and pseudosyndactyly, common manifestations in recessive dystrophic epidermolysis bullosa, cause significant functional impairment. The deformities progress with time, although surgery may delay the progression. The role of surgical intervention, hand therapy, and the use of prolonged splinting was examined in seven children (nine hands) with recessive dystrophic epidermolysis bullosa with an average age of 5 years, 8 months (range, 1 year, 10 months to 16 years, 4 months). The technique of surgery, postoperative regimen, and splinting differ from those previously reported. Surgery includes "de-cocooning" the hand and fingers, manipulating contracted joints, and full-thickness skin grafting to dermal defects. Surgery and the postoperative regimen of rigid night splints and web-retaining gloves for day wear has allowed arrest or minimal progression of contractures in complaint patients in short-term follow-up study of an average of 17 months (range, 12-28 months). An interdisciplinary team of physicians and surgeons, therapists, and nurses makes this care regimen possible and influences family compliance.

  View details for PubMedID 8891991

• Surgical treatment and postoperative splinting of recessive dystrophic epidermolysis bullosa JOURNAL OF HAND SURGERY-AMERICAN VOLUME Ladd, A. L., Kibele, A., Gibbons, S. 1996; 21A (5): 888-897

  Abstract

  Digital contractures and pseudosyndactyly, common manifestations in recessive dystrophic epidermolysis bullosa, cause significant functional impairment. The deformities progress with time, although surgery may delay the progression. The role of surgical intervention, hand therapy, and the use of prolonged splinting was examined in seven children (nine hands) with recessive dystrophic epidermolysis bullosa with an average age of 5 years, 8 months (range, 1 year, 10 months to 16 years, 4 months). The technique of surgery, postoperative regimen, and splinting differ from those previously reported. Surgery includes "de-cocooning" the hand and fingers, manipulating contracted joints, and full-thickness skin grafting to dermal defects. Surgery and the postoperative regimen of rigid night splints and web-retaining gloves for day wear has allowed arrest or minimal progression of contractures in complaint patients in short-term follow-up study of an average of 17 months (range, 12-28 months). An interdisciplinary team of physicians and surgeons, therapists, and nurses makes this care regimen possible and influences family compliance.

  View details for Web of Science ID A1996VK55300027

• Reconstructive osteotomy for malunion of the distal radius CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L., HUENE, D. S. 1996: 158-171

  Abstract

  Common misconceptions about distal radius fractures result in undertreatment of many fractures, particularly in an active population. Loss of reduction of the fracture may cause a symptomatic malunion. Fourteen patients with an average age of 39 years (range, 21-65 years) underwent reconstructive procedures for radial malunions. The common malunion healed in a position of dorsal angulation, loss of radial inclination, and radial shortening. Ten patients had been treated by closed means, and 4 had undergone earlier surgical procedures without acceptable healing position of the fracture. Seven patients underwent a radial osteotomy alone, 5 patients had an osteotomy with an ulnar leveling procedure, and 2 patients had a Sauvé-Kapandji procedure alone. The average improvement in radial inclination was 14 degrees (range, 0 degrees-34 degrees), volar tilt 21 degrees (range, 2 degrees-33 degrees), and improvement in a positive ulnar variance by 6.8 mm (range, 0-48 mm). The complication rate was 29%, with a followup of 29 months (range, 12-43 months). Functional improvement was notable in 12 of 14 patients. Surgical reconstruction for malunions is technically difficult and may not completely restore the anatomy. Patient satisfaction, however, in terms of increased function, decreased pain, and decreased deformity is sufficiently high to warrant reconstructive treatment.

  View details for Web of Science ID A1996UP16900021

  View details for PubMedID 8641060

• Functional Restoration of the Upper Extremity in Tetraplegia" in Surgery of the Hand and Upper Extremity - Vincent Hentz, A. 1996
• Reconstructive Osteotomy for Malunion of the Distal Radius. Symposium on Problem Fractures of the Hand and Wrist Clinical Orthopaedics and Related Research Ladd, A., Huene, DS 1996; 327: 158-171
• SURGICAL-TREATMENT OF EPIDERMOLYSIS-BULLOSA (RECESSIVE DYSTROPHIC) AND POSTOPERATIVE SPLINTING Ladd, A. L., Kibele, A. BLACKWELL SCIENCE PUBL INC CAMBRIDGE. 1994: 850–50

  View details for Web of Science ID A1994QA80300052

• Diagnostic imaging of the shoulder. Journal of hand therapy Ladd, A. L. 1994; 7 (2): 84-89

  View details for PubMedID 8038881

• DUPUYTREN CONTRACTURE - MR IMAGING FINDINGS AND CORRELATION BETWEEN MR SIGNAL INTENSITY AND CELLULARITY OF LESIONS AMERICAN JOURNAL OF ROENTGENOLOGY YACOE, M. E., Bergman, A. G., Ladd, A. L., Hellman, B. H. 1993; 160 (4): 813-817

  Abstract

  Dupuytren's contracture is a common fibrosing disorder of the hand which often results in progressive and debilitating flexion contractures of the fingers. Recurrence after surgical release is common and may be related, in part, to the cellularity of the lesion. We describe the MR appearance of Dupuytren's contracture and correlate signal characteristics with the degree of cellularity of the lesion.A total of 11 hands in 10 patients were studied. All patients had surgical resection after MR imaging (median interval, 3 days). The surgical and pathologic findings were correlated with the MR findings. The signal characteristics of the lesions were correlated with the histologic findings.We found that MR imaging was accurate for detecting Dupuytren's contracture and depicting its extent. The lesions include subcutaneous nodules, usually at the level of the distal palmar crease, and cords that lie parallel and superficial to the flexor tendons. The cords had a uniformly low signal intensity (similar to the signal intensity of tendon) on both T1- and T2-weighted images in 18 of 22 cases, whereas the remaining four cases had a low to intermediate signal intensity on T1-weighted images (a slightly higher signal intensity than that of tendon) and a low signal intensity on T2-weighted images. Histologically, the cords were hypocellular and composed of dense collagen. Most nodules had an intermediate signal intensity (similar to that of muscle) on both T1- and T2-weighted images (10 of 13 cases), usually stippled with focal areas of lower signal intensity. Histologically, these nodules were mostly cellular. Three of the nodules had a low signal intensity on both T1- and T2-weighted images and were hypocellular histologically.We conclude that MR imaging can be used to define palmar involvement in Dupuytren's contracture. The signal characteristics of the lesions correlate with the degree of cellularity of the lesions as seen histologically. The ability to assess preoperatively the cellularity of lesions of Dupuytren's contractures may be of prognostic significance, because highly cellular lesions tend to have higher rates of recurrence after surgery than do hypocellular lesions.

  View details for Web of Science ID A1993KU60200024

  View details for PubMedID 8456670

• INSITU HYBRIDIZATION STUDIES OF STROMELYSIN AND COLLAGENASE MESSENGER-RNA EXPRESSION IN RHEUMATOID SYNOVIUM ARTHRITIS AND RHEUMATISM Gravallese, E. M., Darling, J. M., Ladd, A. L., Katz, J. N., Glimcher, L. H. 1991; 34 (9): 1076-1084

  Abstract

  Destructive joint changes in rheumatoid arthritis (RA) are thought to be mediated in part by the neutral proteinases collagenase and stromelysin. Collagenase messenger RNA (mRNA) has been previously localized to the synovial lining layer. In this study, synovial tissue from 8 patients with RA and 2 patients with osteoarthritis was examined for proteinase production by in situ hybridization. Stromelysin mRNA localized predominantly to the synovial lining layer cells. In serial sections, collagenase mRNA was shown to be localized to the same tissue areas as those producing stromelysin mRNA, and grain counts revealed a direct correlation between production of stromelysin mRNA and production of collagenase mRNA. All patients with RA were producing collagenase and stromelysin mRNA in detectable amounts. One of 2 osteoarthritis patients was producing these metalloproteinases, but in levels below those found in the RA patients. These data support the identity of the synovial lining cells as the major synovial cells producing collagenase and stromelysin in RA and provide new evidence for the coordinate production of collagenase and stromelysin in RA in vivo.

  View details for Web of Science ID A1991GG33700002

  View details for PubMedID 1657007

• REFLEX SYMPATHETIC IMBALANCE - RESPONSE TO EPIDURAL BLOCKADE AMERICAN JOURNAL OF SPORTS MEDICINE Ladd, A. L., DeHaven, K. E., Thanik, J., Patt, R. B., Feuerstein, M. 1989; 17 (5): 660-668

  Abstract

  Eleven patients (two male, nine female) were treated with epidural sympathetic blockade for reflex sympathetic imbalance, an incomplete manifestation of reflex sympathetic dystrophy. Each had developed severe pain, sensitivity, and disability disproportionate to associated trauma. One patient injured an ankle, and the remaining 10 patients one or both knees (12 knees). Seven patients had undergone previous surgery. All but one had a favorable response to initial blockade. This individual eventually failed treatment despite surgical sympathectomy. Seven have required readministration of a block for clinical relapse. Mean followup was 22 months (range, 10 to 41 months). Five underwent extensive psychological testing. All have required adjunctive forms of therapy including physical therapy, transcutaneous electrical nerve stimulation (TENS), antiinflammatory or other nonnarcotic agents. Recovery is typically prolonged, particularly if the diagnosis is delayed. Close attention to, and therefore prevention of, situations that trigger its recurrence is essential for successful rehabilitation.

  View details for Web of Science ID A1989AU44700013

  View details for PubMedID 2610282

• Congenital cervical stenosis presenting as transient quadriplegia in athletes. Report of two cases. journal of bone and joint surgery. American volume Ladd, A. L., Scranton, P. E. 1986; 68 (9): 1371-1374

  Abstract

  The cases of two patients in whom complete but transient quadriplegia developed after an injury that was incurred while playing football are presented. Both patients were found to have a congenitally narrow cervical vertebral canal. Critical stenosis resulting in the transient quadriplegia occurred after a presumed injury to a cervical disc. In our opinion, a myelogram should be made for patients with a history of transient quadriplegia, numbness, or a burning sensation down the back or the lower extremities, even if other radiographic studies are interpreted as negative. Patients who have stenosis of the cervical spine should be advised to discontinue participation in contact sports.

  View details for PubMedID 3782208

• CONGENITAL CERVICAL STENOSIS PRESENTING AS TRANSIENT QUADRIPLEGIA IN ATHLETES - REPORT OF 2 CASES JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Ladd, A. L., Scranton, P. E. 1986; 68A (9): 1371-1374

  Abstract

  The cases of two patients in whom complete but transient quadriplegia developed after an injury that was incurred while playing football are presented. Both patients were found to have a congenitally narrow cervical vertebral canal. Critical stenosis resulting in the transient quadriplegia occurred after a presumed injury to a cervical disc. In our opinion, a myelogram should be made for patients with a history of transient quadriplegia, numbness, or a burning sensation down the back or the lower extremities, even if other radiographic studies are interpreted as negative. Patients who have stenosis of the cervical spine should be advised to discontinue participation in contact sports.

  View details for Web of Science ID A1986F359300009