Brian W. Yang

All Publications

• Quality of ChatGPT Responses to Frequently Asked Questions in Carpal Tunnel Release Surgery. Plastic and reconstructive surgery. Global open Amen, T. B., Torabian, K. A., Subramanian, T., Yang, B. W., Liimakka, A., Fufa, D. 2024; 12 (5): e5822

  Abstract

  Although demonstrating remarkable promise in other fields, the impact of artificial intelligence (including ChatGPT in hand surgery and medical practice) remains largely undetermined. In this study, we asked ChatGPT frequently asked patient-focused questions surgeons may receive in clinic from patients who have carpel tunnel syndrome (CTS) and evaluated the quality of its output.Using ChatGPT, we asked 10 frequently asked questions that hand surgeons may receive in the clinic before carpel tunnel release (CTR) surgery. Included questions were generated from the authors' own experiences regarding conservative and operative treatment of CTS.Responses from the following 10 questions were included: (1) What is CTS and what are its signs and symptoms? (2) What are the nonsurgical options for CTS? (3) Should I get surgery for CTS? (4) What is a CTR and how is it preformed? (5) What are the differences between open and endoscopic CTR? (6) What are the risks associated with CTR and how frequently do they occur? (7) Does CTR cure CTS? (8) How much improvement in my symptoms can I expect after CTR? (9) How long is the recovery after CTR? (10) Can CTS recur after surgery?Overall, the chatbot provided accurate and comprehensive information in response to most common and nuanced questions regarding CTS and CTR surgery, all in a way that would be easily understood by many patients. Importantly, the chatbot did not provide patient-specific advice and consistently advocated for consultation with a healthcare provider.

  View details for DOI 10.1097/GOX.0000000000005822

  View details for PubMedID 38756958

  View details for PubMedCentralID PMC11098167

• One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation. The Journal of hand surgery Haeberle, H. S., DeFrancesco, C. J., Yang, B. W., Victoria, C., Wolfe, S. W. 2024; 49 (4): 329-336

  Abstract

  Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction.From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared.Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis.At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique.Therapeutic IV.

  View details for DOI 10.1016/j.jhsa.2023.12.012

  View details for PubMedID 38244024

• Anatomical front and back reconstruction sustains radiographic alignment: a comparison to three-ligament tenodesis. The Journal of hand surgery, European volume Yang, B. W., Victoria, C., Lee, S. K., Wolfe, S. W. 2024; 49 (1): 60-65

  Abstract

  Multiple techniques exist to reconstruct the scapholunate interosseous ligament, though none have demonstrated superiority. This study compares 1-year radiographic outcomes of the three-ligament tenodesis and the anatomical front and back reconstruction. All patients who underwent reconstruction of their scapholunate interosseous ligament at one institution with either anatomical front and back reconstruction or three-ligament tenodesis between 2011 and 2020 were retrospectively reviewed. At 52-week follow-up, anatomical front and back reconstruction maintained a statistically significant improvement in scapholunate gap, corrected radiolunate angle and dorsal scaphoid translation, while three-ligament tenodesis demonstrated no sustained improvement in any parameter. The improvement in dorsal scaphoid translation was significantly greater for patients undergoing anatomical front and back reconstruction compared with three-ligament tenodesis at the 16-weeks postoperative timepoint (-1.0 mm, -0.3 mm). Anatomical front and back reconstruction demonstrates sustained improvement in radiographic outcomes at 1 year when compared with three-ligament tenodesis. By addressing both volar and dorsal critical ligament restraints, adoption of anatomical front and back reconstruction for advanced stage scapholunate interosseous ligament injuries should be considered.Level of evidence: IV.

  View details for DOI 10.1177/17531934231192343

  View details for PubMedID 37751490

• Referral Patterns Associated With Delayed Care for Traumatic Brachial Plexus Injuries. The Journal of hand surgery Yang, B. W., Rahman, R., Urban, C., Victoria, C., Lee, S. K. 2023

  Abstract

  Traumatic brachial plexus injuries (BPI) are devastating, time-sensitive conditions that often require definitive treatment at academic tertiary care centers. Delays to presentation and surgery have been associated with inferior outcomes. In this study, we evaluate referral patterns associated with delayed presentation and late surgery in traumatic BPI patients.Patients diagnosed with a traumatic BPI at our institution from 2000 to 2020 were identified. Medical charts were reviewed for demographic characteristics, prereferral work-up, and referring provider characteristics. Delayed presentation was defined as greater than 3 months from date of injury to initial evaluation by our brachial plexus specialists. Late surgery was defined as greater than 6 months from date of injury. Multivariable logistic regression was used to identify factors associated with delayed presentation or surgery.A total of 99 patients were included, 71 of whom underwent surgery. Sixty-two patients presented delayed (62.6%), with 26 receiving late surgery (36.6%). There were similar rates of delayed presentation or late surgery by referring provider specialty. Patients whose initial diagnostic EMG was ordered by the referring provider prior to initial presentation at our institution were more likely to have a delayed presentation (76.2% vs 31.3%) and undergo late surgery (44.9% vs 10.0%).Delayed presentation and late surgery in traumatic BPI patients were associated with initial diagnostic EMG ordered by the referring provider.Delayed presentation and surgery have been associated with inferior outcomes in traumatic BPI patients. We recommend that providers direct patients with clinical concern of traumatic BPI directly to a brachial plexus center without further work-up before referral and encourage referral centers to accept these patients.

  View details for DOI 10.1016/j.jhsa.2023.05.007

  View details for PubMedID 37389495

• Intraneural ganglion cyst of the peroneal nerve at the lateral knee: A case report and literature review RRNMF Neuromuscular Journal Morena, J., Yang, B., Lee, S., Paul, D., Leung, D. 2023; 4 (4)

  View details for DOI 10.17161/rrnmf.v4i4.19881

• Teaching in Orthopaedic Surgery: Effective Strategies for Educating the Modern Learner in a Modern Surgical Practice. JB & JS open access Koo, A., Almeida, B. A., Kerluku, J., Yang, B., Fufa, D. 2022; 7 (3)

  Abstract

  Prioritizing the education of orthopaedic surgery residents and fellows is essential for the future of the field. This review highlights strategies that educators may find useful in improving their teaching skills for the modern orthopaedic surgery learner. Educators may benefit from focusing on active, effortful, and repetitive engagement in lecture; setting clear expectations to help track progress in clinic; and breaking skills into smaller steps in context of a framework when teaching procedural skills. Providing objective assessment and growth-oriented feedback helps establish a close rapport between educator and trainee while encouraging personal development. Through a remediation process that examines deficiency in core areas and equitability of the learning environment, the trainee and the educator may engage in a fair discussion that prevents trainees from falling behind. Finally, in the era of COVID-19, e-learning and virtual simulations have become increasingly used as effective modalities for teaching clinical knowledge and procedures to trainees. The medical education landscape has been changing at a rapid pace, and by evaluating and adapting to the novel educational models of today, the modern orthopaedic surgeon ensures a learning environment that is equitable, effective, and inspiring for the orthopaedic surgeon of tomorrow.

  View details for DOI 10.2106/JBJS.OA.22.00005

  View details for PubMedID 35999853

  View details for PubMedCentralID PMC9387961

• Pediatric injuries related to electric scooter use: a national database review. Journal of pediatric orthopedics. Part B Cohen, L. L., Geller, J. S., Yang, B. W., Allegra, P. R., Dodds, S. D. 2022; 31 (2): e241-e245

  Abstract

  Electric scooter (e-scooter) use and resulting injuries have grown exponentially since expansion into ridesharing in 2017. No study has described pediatric e-scooter injuries and focused on their impact in an adolescent cohort. Our primary purpose was to describe the epidemiology of admitted pediatric e-scooter injuries and compare them with existing literature on adults. We queried the National Electronic Injury Surveillance System for e-scooter injuries between 2015 and 2019 in patients 0-18 years old. Injuries caused by an e-scooter to a nonrider were removed. Patients admitted to the hospital were analyzed and weighted national estimates were calculated. A P value of <0.05 was considered significant. Nine hundred and two pediatric patients were treated for an e-scooter injury at an emergency department (ED) between 2015 and 2019. Among those admitted (n = 47), 72.3% were men, and the average age at injury was 11.3 years. Among all injuries (n = 56), the most common diagnosis was fracture (24/56, 42.9%). The 19% (9/47) of patients that experienced polytrauma were significantly older than those with single injuries (P < 0.001). ED admissions grew by 616% from 2017 to 2018. Children experience a greater rate of fractures and polytrauma from e-scooters compared to adults, but fewer facial injuries despite a similar rate of head trauma. The incidence of pediatric head injuries indicates a lack of helmet use similar to adults. Lawmakers should consider bolstering e-scooter regulations to decrease pediatric injuries.

  View details for DOI 10.1097/BPB.0000000000000879

  View details for PubMedID 34050120

• Utility of Stability and Tear Location in a Classification System for Discoid Meniscus Surgical Planning. Journal of pediatric orthopedics Yang, B., Logan, C. A., Feroe, A. G., Kocher, S. D., Williams, K. A., Kocher, M. S. 2022; 42 (1): e50-e54

  Abstract

  Despite the presence of multiple classification systems for discoid meniscus, no system has yet to demonstrate utility in predicting the need for meniscal repair. The purpose of this study was to correlate characteristics associated with meniscal repair and propose a model that can inform preoperative planning and initial counseling of surgical plans and expectations.Medical and operative records of 434 knees with lateral discoid meniscus in children and adolescents treated between 1991 and 2016 were reviewed retrospectively to determine the surgical procedure performed (saucerization with or without meniscal repair), discoid meniscal morphology and stability, and location and type of any associated tear. Univariate associations between discoid meniscal characteristics and surgery type were calculated and a logistic regression model of surgery type was generated.In univariate models, unstable menisci (93%, or 179/204, P<0.001) and menisci with tears extending peripherally (75%, or 85/204, P<0.001) were more likely to receive surgery with repair. In isolation, instability demonstrated 89% sensitivity and 94% specificity in predicting surgery with repair. A logistic regression model including stability, tear, and their interaction (stability×tear) showed that that the odds of unstable lateral discoid menisci receiving surgery with repair was 114 times higher than stable menisci (P<0.001) while lateral discoid menisci with peripherally extending tears had 6.4 times higher odds of receiving repair than those that had an isolated central tear (P<0.001).Stability and tear location of lateral discoid menisci were associated with surgical treatment in univariate and logistic regression models. The proposed classification system, in which menisci are classified by stability [Stable (S0), Unstable (S1), morphology (Incomplete (M0), Complete (M1))], and tear [No tear (T0), Central tear, isolated (T1), or Central tear, peripheral extension (T2)], is easily remembered and predicts surgical repair for discoid menisci. This scheme can serve to inform preoperative planning and initial counseling of primary surgical management and postoperative expectations. Subsequent research should develop a system that predicts meniscal survival and patient outcomes following the index operation.Level III.

  View details for DOI 10.1097/BPO.0000000000001975

  View details for PubMedID 34889833

• Long-term Minimum 15-Year Follow-up After Lateral Discoid Meniscus Rim Preservation Surgery in Children and Adolescents. Journal of pediatric orthopedics Lins, L. A., Feroe, A. G., Yang, B., Williams, K. A., Kocher, S. D., Sankarankutty, S., Micheli, L. J., Kocher, M. S. 2021; 41 (9): e810-e815

  Abstract

  Discoid meniscus is a congenital variant typically affecting the lateral meniscus of the knee. Historically, surgical intervention when symptomatic consisted of total meniscectomy; however, after degenerative changes were observed, current treatments now focus on rim preservation with arthroscopic saucerization and meniscal repair for instability, when indicated. The purpose of our study was to examine long-term patient-reported outcomes of lateral discoid meniscus (LDM) treated with meniscal-preserving techniques.Ninety-eight patients treated arthroscopically for LDM at a single institution at a minimum of 15 years ago were retrospectively identified and contacted by mailers and telephone to participate. Subjective functional outcomes and patient satisfaction data were collected using a questionnaire that included the validated International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm Score, Marx Activity Rating Scale, Tegner Activity Score, and Western Ontario and McMaster University Osteoarthritis Index Osteoarthritis Index. Patient and surgical characteristics and patient-reported outcomes were summarized by mean and SD, median and interquartile range (interquartile range), or frequency and percent, as appropriate.Of the 46 patients contacted (response rate of 46/98 eligible), 25 (54%) completed the questionnaires. The mean (±SD) age at initial surgery was 10.8 (±3.4) and 30.3 (±3.7) years at final follow-up. The mean (±SD) follow-up time from initial surgery was 19.5 (±2.8) years (range, 16 to 27). Patient-reported outcomes included: International Knee Documentation Committee 77.4±17.2, Lysholm 78.6±21, Western Ontario and McMaster University Osteoarthritis Index 7.6±11.3, Tegner Activity 7 (of 10), and Marx Activity Rating Scale 8 (of 10). Eleven (44%) cases underwent subsequent LDM-related surgery on the ipsilateral knee(s). There were no cases of total knee replacement.Overall, patient-reported outcomes were favorable at a minimum of 15-year follow-up after rim-preserving saucerization of LDM. While two thirds of patients were satisfied with their surgical outcomes, nearly half of patients underwent revision saucerization with or without meniscal repair. Subsequent long-term follow-up studies with objective outcome measures are important to further elucidate the natural history of LDM and understand how rim-preserving procedures may prevent the development of degenerative processes.Level IV-case series, prognostic study.

  View details for DOI 10.1097/BPO.0000000000001903

  View details for PubMedID 34411050

• Articular Cartilage Repair in the Knee: Postoperative Imaging. The journal of knee surgery Yang, B. W., Brusalis, C. M., Fabricant, P. D., Greditzer, H. G. 2021; 34 (1): 2-10

  Abstract

  Diagnostic and therapeutic advancements have improved clinical outcomes for patients with focal chondral injuries of the knee. An increased number and complexity of surgical treatment options have, in turn, resulted in a commensurate proliferation of patients requiring postoperative evaluation and management. In addition to patient-reported clinical outcomes, magnetic resonance imaging (MRI) offers clinicians with noninvasive, objective data to assist with postoperative clinical decision making. However, successful MRI interpretation in this setting is clinically challenging; it relies upon an understanding of the evolving and procedure-specific nature of normal postoperative imaging. Moreover, further research is required to better elucidate the correlation between MRI findings and long-term clinical outcomes. This article focuses on how specific morphologic features identified on MRI can be utilized to evaluate patients following the most commonly performed cartilage repair surgeries of the knee.

  View details for DOI 10.1055/s-0040-1716357

  View details for PubMedID 32898909

• Inter-rater and Intrarater Reliabilities of the Identification of a "Gothic Arch" in the Acetabulum of Children With Cerebral Palsy. Journal of pediatric orthopedics Miller, S., Habib, E., Bone, J., Schaeffer, E., Yang, B. W., Shea, J., Maleki, A., Shore, B. J., Mulpuri, K. 2021; 41 (1): 6-10

  Abstract

  Progressive hip displacement in children with cerebral palsy (CP) is monitored by measuring migration percentage (MP) on anteroposterior (AP) pelvis radiographs. Accurate measurement of MP requires the lateral margin of the ossified acetabulum to be identified for the placement of Perkin's line. It has been suggested that when there is an erosion of the acetabular rim, described as a gothic arch, the midpoint of the arch be used for the placement of Perkin's line. However, this requires that there be agreement on what constitutes a gothic arch. The purpose of this study was to evaluate the inter-rater and intrarater reliabilities of identifying a gothic arch on pelvis radiographs.An online survey with 100 AP pelvis images (200 hips) of children with CP was sent to international experts. Participants were asked to identify which hip(s) had a gothic arch (left, right, both, and neither). The Fleiss κ statistic for inter-rater reliability was calculated. Eight weeks later, the images were shuffled and redistributed to calculate intrarater reliability.The initial survey was completed by 10 participants with 9 participants completing the second survey. The average inter-rater κ value was 0.18 [95% confidence interval (CI), 0.14-0.23] and 0.19 (95% CI, 0.14-0.24) for the 2 surveys, respectively. Among the pediatric orthopaedic surgeons subgroup, the κ values were 0.06 (95% CI, 0.02-0.1) and 0.08 (95% CI, 0.03-0.13). The average intrarater reliability κ value was 0.61 (95% CI, 0.2-1), ranging from 0.32 to 0.86.There were poor inter-rater and moderate intrarater reliabilities in identifying a gothic arch on AP pelvis radiographs in children with CP. Further characterization and clarification of what constitutes a gothic arch are required. The lack of agreement on the identification of a gothic arch may negatively impact the measurement of MP and referrals to a pediatric orthopaedic surgeon.

  View details for DOI 10.1097/BPO.0000000000001615

  View details for PubMedID 32558745

  View details for PubMedCentralID PMC7727464

• Correction to: At the US Epicenter of the COVID-19 Pandemic, an Orthopedic Residency Program Reorganizes. HSS journal : the musculoskeletal journal of Hospital for Special Surgery Morse, K. W., Wessel, L. E., Premkumar, A., James, E. W., Anatone, A. J., Barth, K., Bovonratwet, P., Jordan, Y., Retzky, J., Suhardi, V., Thacher, R., Uppstrom, T., Yang, B., Bido, J., Carey, E., Defrancesco, C., Elbuluk, A., Lebrun, D., Ondeck, N., Pompeu, Y., Schimizzi, G., Shafi, K., Apostolakos, J. M., Barber, L. A., Brusalis, C. M., Driscoll, D. A., Ellsworth, B., Langhans, M., Shen, T., Wright-Chisem, J., Conti, M., Eliasberg, C., Goeb, Y., Henry, J., Lin, K. M., Lovecchio, F., Samuel, A., Dvorzhinskiy, A., Goodbody, C., Gruskay, J., Heaps, B., Hurwit, D., Kahlenberg, C., Rauck, R., Steinhaus, M., Bostrom, M., Cross, M., Fabricant, P. D., Felix, K., Green, D., Kim, H. J., Leali, A., Memnon, C. M., O'Brasky, M., Ranawat, A., Robbins, L., Nwachukwu, B. U., Fufa, D. T. 2020; 16 (Suppl 1): 135-136

  Abstract

  [This corrects the article DOI: 10.1007/s11420-020-09765-5.].

  View details for DOI 10.1007/s11420-020-09780-6

  View details for PubMedID 32952466

  View details for PubMedCentralID PMC7491015

• Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe? The Journal of arthroplasty Bovonratwet, P., Yang, B. W., Wang, Z., Ricci, W. M., Lane, J. M. 2020; 35 (11): 3180-3187

  Abstract

  With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

  View details for DOI 10.1016/j.arth.2020.06.005

  View details for PubMedID 32624381

• Occipital Plate Fixation in the Pediatric Population. Journal of pediatric orthopedics Cohen, L. L., Yang, B. W., Glotzbecker, M. P., Emans, J. B., Karlin, L. I., Snyder, B. D., Hresko, M. T., Hedequist, D. J. 2020; 40 (9): 462-467

  Abstract

  Occipital plate fixation has been shown to improve outcomes in cervical spine fusion. There is a paucity of literature describing occipital plate fixation, especially in the pediatric population. The authors reviewed a case series of 34 patients at a pediatric hospital who underwent cervical spine fusion with occipital plate fixation between 2003 and 2016. This study describes how occipital plates aid the cervical spine union in a case series of diverse, complex pediatric patients.Our orthopaedic database at our institution was queried for patients undergoing an instrumented cervical spine procedure between 2003 and 2016. Medical records were used to collect diagnoses, fusion levels, surgical technique, and length of hospitalization, neurophysiological monitoring, complications, and revision procedures.Thirty-four patients met the inclusion criteria. The mean age was 10.9 years (range, 3-21 y). Indications for surgery included cervical instability, basilar invagination, and os odontoideum. These indications were often secondary to a variety of diagnoses, including trisomy 21, Klippel-Feil syndrome, and rheumatoid arthritis. The mean length of hospitalization was 10 days (range, 2 to 80 d). There were no cases of intraoperative dural leak, venous sinus bleeding from occipital screw placement, or implant-related complications. Postoperative complications included 2 cases of nonunion. Eight patients (24%) had follow-up surgery, only 3 (9%) of which were instrumentation revisions. Both patients with nonunion had repeat occipitocervical fixation procedures and achieved union with revision.Occipital plate fixation was successful for pediatric cervical spine fusion in this diverse cohort. The only procedure-related complication demonstrated was delayed union or nonunion and implant loosening (4/34, 12%) and there were no plate-related complications. This novel case series shows that occipital plate fixation is safe and effective for pediatric patients with complex diagnoses.Level IV-case series.

  View details for DOI 10.1097/BPO.0000000000001564

  View details for PubMedID 32301850

• Use of recombinant human bone morphogenetic protein for revision cervical spine fusion in children with Down syndrome: a case series. Journal of neurosurgery. Pediatrics Cohen, L. L., Yang, B. W., O'Neill, N. P., Proctor, M. R., Glotzbecker, M. P., Hedequist, D. J. 2020; 25 (5): 535-539

  Abstract

  Patients with trisomy 21 (Down syndrome; DS) often have atlantoaxial instability (AAI), which, if severe, causes myelopathy and neurological deterioration. Children with DS and AAI who undergo cervical spine fusion have a high rate of nonunion requiring revision surgery. Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a TGF-β growth factor that is used to induce bone formation in spine fusion. Although previous studies in the adult population have reported no reduction in pseudarthrosis rates with the use of rhBMP-2, there is a lack of literature in the pediatric DS population. This study describes the use of rhBMP-2 in children with DS and AAI during revision to treat nonunion.A retrospective review of a cervical spine fusion database (n = 175) was conducted. This database included all cervical spine fusions using modern instrumentation at the authors' institution from 2002 to 2019. Patients with DS who underwent a revision utilizing rhBMP-2 were included in the study. The number of prior fusions, use of rhBMP-2 in fusions, length of stay, halo use, and surgical data were collected. Postoperative complications and length of follow-up were also recorded.Eight patients (75% female) met the inclusion criteria. The average age at revision with rhBMP-2 was 11 years (range 3-19 years). All patients were diagnosed with nonunion after an initial cervical fusion. All revisions were posterior fusions of C1-2 (n = 2) or occiput to cervical (n = 6). All revisions included implant revisions, iliac crest bone grafting, and rhBMP-2 use. One patient required irrigation and debridement of an rhBMP-induced seroma. Another patient required return to the operating room to repair a dural tear. There were no neurological, infectious, airway, or implant-related complications. Revision utilizing rhBMP-2 achieved fusion in 100% (n = 8) of patients. The average length of follow-up was 42.6 months. All patients demonstrated solid fusion mass on the last radiograph.This is the first case series reporting the successful use of rhBMP-2 to facilitate cervical spine fusion in patients with DS after previous nonunion. In addition, few rhBMP-2-related postoperative complications occurred.

  View details for DOI 10.3171/2019.11.PEDS19622

  View details for PubMedID 32005018

• Surgical Fixation Using Screw-Rod Construct Instrumentation for Upper Cervical Instability in Pediatric Down Syndrome Patients SPINE DEFORMITY Yang, B. W., Hedequist, D. J., Proctor, M. R., Troy, M., Hresko, M. T., Glotzbecker, M. P. 2019; 7 (6): 957-961

  View details for DOI 10.1016/j.jspd.2019.03.002

  View details for Web of Science ID 000671884300016

• Prevalence of Cozen's Phenomenon of the Proximal Tibia. Journal of pediatric orthopedics Yang, B. W., Shore, B. J., Rademacher, E., May, C., Watkins, C. J., Glotzbecker, M. P. 2019; 39 (6): e417-e421

  Abstract

  There has been little investigation into the epidemiology of Cozen's phenomenon, genu valgum as a complication of proximal tibial metaphysis fractures. In this study, we present a large case series of proximal tibia fractures in children to describe the prevalence, epidemiology, and characteristics associated with Cozen's phenomenon following proximal tibial fracture in children.We searched the orthopedic database at our institution for all patients aged 1 to 8 years old with proximal tibia fractures presenting for initial fracture management between January 1, 2014 and December 31, 2017. Demographic data, mechanism of injury, fracture characteristics, and the presence of a concurrent fibula fracture were determined from the medical records. Initial and follow-up valgus angulation was measured as the angle between a line perpendicular to the proximal tibial physis and a line drawn along the axis of the tibia. Differences in the rate of valgus angulation by mechanism of injury and fracture type were compared.In total, 181 fractures in 181 patients were included in our study (98 male, 83 female). The average age at injury was 4.55 years (range, 1.02 to 7.95 y); 140 patients (77.3%, 140/181) had initial valgus angulation of <4 degrees; 20 of these patients (14.3%, 20/140) developed angulation of at least 4 degrees at some point during follow-up at an average of 0.8 months (range, 0.2 to 1.9 mo); 4 patients (20.0%, 4/20) with <4 degrees of initial angulation had persistent valgus angulation of 5 degrees at latest follow-up. Two of these patients were not scheduled to return because the provider did not determine the valgus angulation to be clinically meaningful. The 2 other patients were asymptomatic and continued to receive nonoperative management. No patients in our series required surgical correction of valgus deformity.Cozen's phenomenon is an uncommon complication of proximal tibial metaphysis fractures. Eliminating unnecessary radiographs and clinical visits for our pediatric trauma patients will improve the quality and value of care delivery.Level IV.

  View details for DOI 10.1097/BPO.0000000000001354

  View details for PubMedID 30817417

• Outcomes of Meniscus Repair in Children and Adolescents. Current reviews in musculoskeletal medicine Yang, B. W., Liotta, E. S., Paschos, N. 2019; 12 (2): 233-238

  Abstract

  The purpose of this study was to review the clinical and functional outcomes of meniscus repair in children and adolescents.The sequel of meniscal tears and the outcome of meniscus repair have been well studied in adults. However, these topics have received less attention in the pediatric population despite the high prevalence and potentially critical effect on long-term knee function in children. Meniscus repair has a healing rate ranging from 33 to 100% with less than 40% reoperation rate. Several factors have been suggested to play a role in healing, such as concomitant ACL reconstruction and complexity of the tear. There is a lack of standardization among the utilization of functional outcome and activity level questionnaires across studies; however, most report improved function postoperatively. Other important considerations include bucket handle tears, the discoid meniscus, rehabilitation and return to sports, and alternatives after failed meniscus repair. Based on the favorable outcomes reported, meniscus repair should be attempted in most meniscus tears in children.

  View details for DOI 10.1007/s12178-019-09554-6

  View details for PubMedID 31123921

  View details for PubMedCentralID PMC6542894

• Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective. Journal of children's orthopaedics Yang, B. W., Waters, P. M. 2019; 13 (3): 330-333

  Abstract

  Closed reduction under conscious sedation in the emergency department (ED) has been demonstrated to provide cost-effective, timely care. There has been little research into the efficacy of conscious sedation and reduction from an orthopaedic trauma perspective. This study describes the epidemiology and outcomes associated with fracture conscious sedation and reduction in our level I paediatric ED.All fracture patients presenting overnight to our level I trauma centre ED between 01 June 2016 and 30 June 2017 were identified. Patient records were reviewed to determine diagnoses, treatments and outcomes. The rate of repeat intervention after successful conscious sedation and reduction and rate of changes in management in which the orthopaedic resident's overnight management plan to provide procedural sedation was altered to surgical intervention after morning case review rounds was calculated.Conscious sedation and reduction was performed on a total of 386 patients covering ten fracture types during the course of our study, with distal radius fractures (n = 167, 43.3%) comprising the majority of cases. A total of 53 cases (13.7%, 53/386) lost alignment and required repeat intervention, consisting of 33 cases (8.5%, 33/386) that required repeat surgery and 5.2% (20/386) that required cast wedging. In all, 12 patients (3.1%, 12/386) initially reduced under conscious sedation required a change in management and surgical intervention. There were five cases of growth arrest and two cases of malunion.Conscious sedation and reduction provides an alternative to general anaesthesia for many paediatric trauma injuries without compromising patient outcomes.IV.

  View details for DOI 10.1302/1863-2548.13.190013

  View details for PubMedID 31312274

  View details for PubMedCentralID PMC6598038

• Implementation of an Orthopedic Trauma Program to Safely Promote Resident Autonomy. Journal of graduate medical education Yang, B. W., Waters, P. M. 2019; 11 (2): 207-213

  Abstract

  There is ongoing tension in graduate medical education between progressive resident autonomy with entrustable professional activities and the need for supervision to ensure patient safety.We implemented a pediatric orthopedic surgical trauma safety program that utilized a postcall review conference to provide residents graduated responsibility learning opportunities during overnight trauma call without compromising patient safety.In the program, all orthopedic trauma cases seen in our main tertiary hospital emergency department by the overnight orthopedic resident were reviewed in a case conference. For 1 year, we performed an analysis of all fracture patients who were treated in the emergency department by our orthopedic surgery residents. From June 1, 2016, through June 30, 2017, all care delivery encounters were reviewed for decision-making errors, technical errors, and complication rates. Two resident groups rotated through our institution over the course of the study.During the year of analysis, all 1298 fracture patients seen overnight in the main tertiary hospital emergency department were reviewed. From the first to the second halves of their rotations, the rate of resident decision-making errors (3.1% [12 of 385] to 2.3% [9 of 399]) and technical errors (9.1% [35 of 395] to 7.3% [29 of 399]) decreased. Excluding decision-making and technical errors, the complication rate for patients discharged home was 3.4% (27 of 784).Residents demonstrated decreased decision-making and technical error rates on overnight call while maintaining low complication rates.

  View details for DOI 10.4300/JGME-D-18-00277.1

  View details for PubMedID 31024655

  View details for PubMedCentralID PMC6476100

• Victors: a web-based knowledge base of virulence factors in human and animal pathogens. Nucleic acids research Sayers, S., Li, L., Ong, E., Deng, S., Fu, G., Lin, Y., Yang, B., Zhang, S., Fa, Z., Zhao, B., Xiang, Z., Li, Y., Zhao, X. M., Olszewski, M. A., Chen, L., He, Y. 2019; 47 (D1): D693-D700

  Abstract

  Virulence factors (VFs) are molecules that allow microbial pathogens to overcome host defense mechanisms and cause disease in a host. It is critical to study VFs for better understanding microbial pathogenesis and host defense mechanisms. Victors (http://www.phidias.us/victors) is a novel, manually curated, web-based integrative knowledge base and analysis resource for VFs of pathogens that cause infectious diseases in human and animals. Currently, Victors contains 5296 VFs obtained via manual annotation from peer-reviewed publications, with 4648, 179, 105 and 364 VFs originating from 51 bacterial, 54 viral, 13 parasitic and 8 fungal species, respectively. Our data analysis identified many VF-specific patterns. Within the global VF pool, cytoplasmic proteins were more common, while adhesins were less common compared to findings on protective vaccine antigens. Many VFs showed homology with host proteins and the human proteins interacting with VFs represented the hubs of human-pathogen interactions. All Victors data are queriable with a user-friendly web interface. The VFs can also be searched by a customized BLAST sequence similarity searching program. These VFs and their interactions with the host are represented in a machine-readable Ontology of Host-Pathogen Interactions. Victors supports the 'One Health' research as a vital source of VFs in human and animal pathogens.

  View details for DOI 10.1093/nar/gky999

  View details for PubMedID 30365026

  View details for PubMedCentralID PMC6324020

• The utility of stability and tear location in a classification system for discoid meniscus surgical planning Orthop J Sports Med Yang, B. W., Logan, C., Tepolt, F., Paschos, N., Kocher, M. S. 2019; 7 (3)

  View details for DOI 10.1177/2325967119S00168

• C2 Translaminar Screw Fixation in Children. Journal of pediatric orthopedics Yang, B. W., Glotzbecker, M. P., Troy, M., Proctor, M. R., Hresko, M. T., Hedequist, D. J. 2018; 38 (6): e312-e317

  Abstract

  Axis (C2) screw fixation has been shown to be effective in treating disorders that necessitate cervical stabilization. Although translaminar C2 screws have demonstrated clinical efficacy in adults, this technique has not yet been thoroughly investigated in children. This study describes the indications, technique, and results of translaminar C2 screw fixation in a case series of pediatric cervical spine disorders.We searched the orthopaedic database at our institution for patients who had undergone a cervical spinal fusion that encompassed C2 between 2007 and 2017. Operative records were reviewed to determine if C2 screw fixation was performed and, if so, the type of C2 screw fixation. Clinical data with regard to patient age at surgery, diagnosis, procedure details, intraoperative complications, and postoperative complications were recorded. Preoperative and postoperative computer tomographic scans were reviewed to determine laminar measurements and containment, respectively.In total, 39 C2 translaminar screws were placed in 23 patients that met our inclusion criteria. The mean age was 12.6 years (range, 5.2 to 17.8 y) with a mean of 2 levels fused (range, 1 to 6). Diagnoses included 7 patients with instability related to skeletal dysplasia, 6 os odontoideum, 4 congenital deformities, 3 basilar invaginations, 2 cervical spine tumors, and 1 fracture. Indications for C2 translaminar screws included 14 cases with distorted anatomy favoring C2 translaminar screws, 6 cases without explicit reasoning for translaminar screw usage in the patient records, and 3 cases with intraoperative vertebral artery injury (1 sacrificed secondary to tumor load and 2 others injured during exposure because of anomalous anatomy). The vertebral artery injuries were not due to placement of any instrumentation. There were no screw-related intraoperative or postoperative complications and no neurological injuries. All patients demonstrated clinical union or healing on follow-up with no episodes of nonunion.Translaminar C2 screw fixation can be reliably used in the pediatric population. Our series contained no screw-related complications, no neurological injuries, and all patients demonstrated clinical union or healing.Level IV-Case series.

  View details for DOI 10.1097/BPO.0000000000001176

  View details for PubMedID 29664878

• A Dedicated Satellite Trauma Orthopaedic Program Operating Room Safely Increases Capacity. The Journal of bone and joint surgery. American volume Waters, P. M., Yang, B. W., White, D., Barth, E., Chiang, V., Mizrahi-Arnaud, A., Sparks, W. 2018; 100 (10): e70

  Abstract

  Providing high-value care for urgent orthopaedic trauma patients requires effective and timely treatment. Herein, we describe the implementation of an innovative program utilizing the operating room (OR) capacity of a satellite campus to decrease stress on a pediatric tertiary care center without jeopardizing patient safety.In addition to the daily emergency surgical room on the main campus, a dedicated orthopaedic trauma surgery OR was established in a satellite hospital location for 3 days per week in the summer and for 2 days per week for the rest of the year. Nonemergency, non-multitrauma operative fracture cases presenting to our tertiary care facility emergency department or orthopaedic clinic were considered for satellite referral. Eligible patients required clearance for transfer via orthopaedic, emergency department, and anesthesia checklists. An opt-out policy was established for provider judgment or patient family concern to overrule transfer decisions. Selected patients were discharged home with satellite OR scheduling or approved for same-day satellite location admission. Short elective cases were performed when openings existed in the schedule.From June 1, 2016, through June 30, 2017, 480 cases (372 trauma, 108 elective) were completed in our satellite OR. The most common trauma cases that were treated in the satellite OR were type-II supracondylar humeral fractures (n = 76). Summer months averaged 41.75 trauma cases and 11.25 elective cases per month, with 3.15 trauma cases and 0.85 elective cases per day. Nonsummer months averaged 22.78 trauma cases and 7.00 elective cases per month, with 2.93 trauma and 0.90 elective cases per day. Of the 17 postoperative issues, the greatest number (n = 7 [41%]) involved symptomatic hardware. The remaining complications were not surgeon or geographic-site-specific. There were no intraoperative complications, compartment syndrome episodes, or patients who required transfer back to our tertiary care facility for unexpected or serious medical issues.With the proper screening protocols in place for appropriate patient selection, the use of a dedicated satellite orthopaedic trauma OR can increase capacity without compromising patient safety.

  View details for DOI 10.2106/JBJS.17.01368

  View details for PubMedID 29762292

• Adult Tethered Cord Syndrome Following Chiari Decompression. World neurosurgery Jackson, C., Yang, B. W., Bi, W. L., Chiocca, E. A., Groff, M. W. 2018; 112: 205-208

  Abstract

  Adult tethered cord syndrome is a rare neurologic disorder that classically presents with back or leg pain, weakness, and urinary dysfunction. Spinal cord tethering has been associated with acquired Chiari malformations. Whereas the effects of tethered cord release on Chiari malformation symptoms have been described previously, we report an unusual case of acquired tethered cord syndrome following Chiari decompression.We report a 68-year-old man with a history of distant T12-level spinal cord injury and 2 weeks of progressive bilateral lower extremity weakness. The patient underwent a T12-L1 laminectomy in 1977, complicated by arachnoiditis and syringomyelia, with eventual placement of a syringopleural shunt. He remained neurologically stable until 2012, when he underwent a suboccipital craniectomy for Chiari decompression for new-onset headache and dysphagia. Ten days later, the patient noted progressive leg weakness and radiographic evidence of spinal cord tethering at the T11-T12 level. A T10-L1 laminectomy and medical facetectomy was undertaken for detethering with postoperative recovery of ambulatory function with assistance.Our patient exhibited an unusual acquisition of tethered cord syndrome. The tethering of the spinal cord may have been triggered by arachnoid adhesions from initial lumbar surgery 35 years before presentation and subsequently exacerbated by alterations of cerebrospinal fluid dynamics after Chiari decompression. Given the potentially devastating sequelae of tethered cord syndrome, investigation of cerebrospinal fluid flow dynamics may be beneficial before operative intervention in patients with risk factors for a tethered cord who exhibit adult-onset Chiari malformation.

  View details for DOI 10.1016/j.wneu.2018.01.165

  View details for PubMedID 29409774

• Orthopaedic Device Approval Through the Premarket Approval Process: A Financial Feasibility Analysis for a Single Center. The Journal of bone and joint surgery. American volume Yang, B. W., Iorio, M. L., Day, C. S. 2017; 99 (6): e26

  Abstract

  The 2 main routes of medical device approval through the U.S. Food and Drug Administration are the premarket approval (PMA) process, which requires clinical trials, and the 510(k) premarket notification, which exempts devices from clinical trials if they are substantially equivalent to an existing device. Recently, there has been growing concern regarding the safety of devices approved through the 510(k) premarket notification. The PMA process decreases the potential for device recall; however, it is substantially more costly and time-consuming. Investors and medical device companies are only willing to invest in devices if they can expect to recoup their investment within a timeline of roughly 7 years. Our study utilizes financial modeling to assess the financial feasibility of approving various orthopaedic medical devices through the 510(k) and PMA processes. The expected time to recoup investment through the 510(k) process ranged from 0.585 years to 7.715 years, with an average time of 2.4 years; the expected time to recoup investment through the PMA route ranged from 2.9 years to 24.5 years, with an average time of 8.5 years. Six of the 13 orthopaedic device systems that we analyzed would require longer than our 7-year benchmark to recoup the investment costs of the PMA process. With the 510(k) premarket notification, only 1 device system would take longer than 7 years to recoup its investment costs. Although the 510(k) premarket notification has demonstrated safety concerns, broad requirements for PMA authorization may limit device innovation for less-prevalent orthopaedic conditions. As a result, new approval frameworks may be beneficial. Our report demonstrates how current regulatory policies can potentially influence orthopaedic device innovation.

  View details for DOI 10.2106/JBJS.16.00050

  View details for PubMedID 28291189

• The effects of weight loss and bariatric surgery on knee osteoarthritis Bariatric Times Yang, B. W. 2017; 14 (2): 18-20
• A systematic review of spinal research conducted using the National Surgical Quality Improvement Program. The spine journal : official journal of the North American Spine Society Marjoua, Y., Xiao, R., Waites, C., Yang, B. W., Harris, M. B., Schoenfeld, A. J. 2017; 17 (1): 88-95

  Abstract

  Over the course of the last decade, interest in the use of large data repositories for clinical research in orthopedic and spine surgery has grown substantially. Detractors maintain that the clinical relevance of research conducted using large registries is limited, and that the academic influence of such studies is minimal. Such contentions have not been empirically evaluated.This study sought to perform a systematic review of spinal research conducted using the National Surgical Quality Improvement Program (NSQIP).This is a systematic review.Impact factor (IF) of the journal of publication and number of citations of published articles conducted using the NSQIP.Orthopedic and spine-specific NSQIP articles published from January 1, 2007 to July 31, 2015, were identified through a query of PubMed or Medline, Embase, Web of Science, and Scopus. Articles were classified by journal of publication, year of publication, study topic, study purpose, and method of statistical analysis. Spine surgical publications were compared with other orthopedic research conducted using the NSQIP. The primary dependent variables for the purposes of statistical testing were IF of the journal in which the article was published and the number of citations for each publication. Negative binomial regression was used to evaluate the characteristics of papers associated with increased IF and number of citations.Of the 1,525 articles identified in the initial search, 114 studies were considered eligible for inclusion in the systematic review. The average IF for the journals publishing orthopedic NSQIP articles was 2.75 (standard deviation [SD] 1.22, range 0-5.28), whereas it was 2.52 (SD 0.81, range 1.38-5.28) for spinal research. The average number of citations per article was 6.08 (SD 10.9, range 0-69) and 6.4 (SD 12.0, range 0-69) for spine-specific studies. Following negative binomial regression, only IF (regression coefficients [RC] 0.31; 95% confidence intervals [CI] 0.08, 0.55) and the year of publication (RC -1.29; 9% CI -1.64, -0.95) were found to have a statistically significant association with number of citations. Among spine-specific research articles, only the year of publication was found to influence the number of citations (RC -1.29; 95% CI -1.94, -0.64).Our findings indicate that the academic impact of orthopedic and spine surgical research conducted using NSQIP is highly variable, with most publications found to have relatively low impact. As our evaluation of study characteristics associated with high-impact publications and increased citations were unable to uncover factors that are likely translatable, we suggest following research design guidelines that highlight best practices when using large datasets for orthopedic research.

  View details for DOI 10.1016/j.spinee.2016.08.013

  View details for PubMedID 27520079

• Musculoskeletal Workforce Needs: Are Physician Assistants and Nurse Practitioners the Solution? AOA Critical Issues. The Journal of bone and joint surgery. American volume Day, C. S., Boden, S. D., Knott, P. T., O'Rourke, N. C., Yang, B. W. 2016; 98 (11): e46

  Abstract

  Growth estimates and demographic shifts of the population of the United States foreshadow a future heightened demand for musculoskeletal care. Although many articles have discussed this growing demand on the musculoskeletal workforce, few address the inevitable need for more musculoskeletal care providers. As we are unable to increase the number of orthopaedic surgeons because of restrictions on graduate medical education slots, physician assistants (PAs) and nurse practitioners (NPs) represent one potential solution to the impending musculoskeletal care supply shortage. This American Orthopaedic Association (AOA) symposium report investigates models for advanced practice provider integration, considers key issues affecting PAs and NPs, and proposes guidelines to help to assess the logistical and educational possibilities of further incorporating NPs and PAs into the orthopaedic workforce in order to address future musculoskeletal care needs.

  View details for DOI 10.2106/JBJS.15.00950

  View details for PubMedID 27252443

• How a Lumbar Diskectomy Influenced Medical Malpractice and the Landscape of Health Care. World neurosurgery Yang, B. W., Bi, W. L., Smith, T. R., Brewster, R., Gormley, W. B., Dunn, I. F., Laws, E. R. 2016; 86: 88-92

  Abstract

  Jeff Chandler was one of Hollywood's top leading men in the 1950s and 1960s. In 1961, at the peak of his career, Chandler died of complications following an aortic-iliac injury during a routine lumbar diskectomy. The subsequent public outcry and malpractice suit resulted in an unprecedented settlement award.Chandler's lawsuit marked a pivotal time in the evolution of medical malpractice and monetary awards. Before 1960, malpractice legal claims were rare, with little impact on the practice of medicine. Chandler's award, however, dwarfed the average malpractice verdict for its time and would influence the relationship between medicine and the legal world. This case helped issue a radical increase in total expenditure on medical liability insurance, frequency of successful claims, average numbers of neurosurgical malpractice suits, and financial award sizes. The trend ensuing from this time has continued to the contemporary era. To link Chandler's case to the current malpractice climate, we highlight the relationship of the case with 3 factors comprising the legal argument for the perpetuation of medical malpractice: 1) contingency fees, 2) citizen juries, and 3) the nature of tort law.This case illustrates an inflection point in American medical malpractice expenditure increases beginning in the 1960s to a current estimated $55.6 billion. As we investigate ways to provide value in health care, it is important to consider the historical factors that have influenced the status quo when seeking strategies to reform the malpractice system on both sides of the value equation: quality and cost.

  View details for DOI 10.1016/j.wneu.2015.09.039

  View details for PubMedID 26409087

• Protegen: a web-based protective antigen database and analysis system. Nucleic acids research Yang, B., Sayers, S., Xiang, Z., He, Y. 2011; 39 (Database issue): D1073-8

  Abstract

  Protective antigens are specifically targeted by the acquired immune response of the host and are able to induce protection in the host against infectious and non-infectious diseases. Protective antigens play important roles in vaccine development, as biological markers for disease diagnosis, and for analysis of fundamental host immunity against diseases. Protegen is a web-based central database and analysis system that curates, stores and analyzes protective antigens. Basic antigen information and experimental evidence are curated from peer-reviewed articles. More detailed gene/protein information (e.g. DNA and protein sequences, and COG classification) are automatically extracted from existing databases using internally developed scripts. Bioinformatics programs are also applied to compute different antigen features, such as protein weight and pI, and subcellular localizations of bacterial proteins. Presently, 590 protective antigens have been curated against over 100 infectious diseases caused by pathogens and non-infectious diseases (including cancers and allergies). A user-friendly web query and visualization interface is developed for interactive protective antigen search. A customized BLAST sequence similarity search is also developed for analysis of new sequences provided by the users. To support data exchange, the information of protective antigens is stored in the Vaccine Ontology (VO) in OWL format and can also be exported to FASTA and Excel files. Protegen is publically available at http://www.violinet.org/protegen.

  View details for DOI 10.1093/nar/gkq944

  View details for PubMedID 20959289

  View details for PubMedCentralID PMC3013795