Norman Ramirez

Background/Objectives: The median nerve exhibits clinically relevant anatomical variability, with critical implications for surgical exposure, regional anesthesia, peripheral nerve repair, and diagnostic imaging. Despite extensive descriptive reports, quantitative morphometric analyses incorporating biological sex and donor record population classification remain limited, particularly among Hispanic cadaveric cohorts. Methods: This multi-institutional cadaveric study evaluated median nerve formation and segmental morphometry in 82 anatomical donors, each contributing paired bilateral upper limbs (164 upper limbs total), classified in institutional records as Puerto Rican, Caucasian, or African American. Standardized dissections were performed from the brachial plexus to the distal forearm, and linear measurements were obtained between predefined anatomical landmarks using digital calipers. Results: Mixed-effects modeling was used to evaluate morphometric differences associated with biological sex, donor record population classification, and anatomical location. Male specimens demonstrated localized differences in proximal median nerve formation, including a longer medial cord contribution on the left side. Population group comparisons identified greater measured morphometric distances in the Puerto Rican cohort compared with Caucasian and African American cohorts. Normalized LEH/MEH ratios did not differ between sexes, suggesting that some absolute differences may reflect limb-size scaling rather than proportional shifts in nerve position. Conclusions: These findings provide standardized landmark-based morphometric data and support the value of population-sensitive anatomical reference data for surgical planning and imaging-based interpretations of median nerve morphology.

Background: Postoperative pain management in orthopaedic trauma surgery is critical. Amid the opioid crisis, nonopioid analgesia offers a promising alternative. We aim to evaluate the feasibility of a multimodal regimen, including intravenous ketorolac, oral acetaminophen, and oral gabapentin, in managing postoperative pain after femur shaft fractures treated with intramedullary nailing. Methods: We conducted a prospective cohort study to evaluate the postoperative pain of patients with isolated femur shaft fractures treated with intramedullary nailing. The experimental group consisted of 29 patients, while the control group consisted of 42 patients who received standard opioid-based pain management. The outcomes measured were the Visual Analog Scale (VAS) scores and the morphine milligram equivalents every 12 hours until 48 hours postoperatively. Results: Patient demographics were comparable between the experimental and control groups, with a significant age difference (31 vs. 40; P = 0.002) but not in sex, body mass index, smoking status, or diabetes prevalence. We observed no significant differences in VAS scores at 12, 24, 36, and 48 hours after surgery. In addition, there was a marked reduction in opioid usage in the experimental group, with P-values < 0.001 at each time point. Conclusion: The study concludes that the coadministration of ketorolac, acetaminophen, and gabapentin is an effective opioid-sparing alternative for postoperative pain in isolated femur shaft fractures. Future research could benefit from a more diverse patient population in orthopaedic trauma to further validate our results and explore long-term outcomes. Level of Evidence: Prospective Cohort Study; Level 2.

Case: An 88-year-old woman presented with worsening right hip pain over 2 years. Radiographs were unremarkable, but magnetic resonance imaging identified a femoral neck lesion. A computed tomography–guided biopsy revealed a zellballen pattern of cells positive for chromogranin and synaptophysin. Further workup, including a metaiodobenzylguanidine scan confirmed focal uptake at the right femoral neck. After multidisciplinary discussion, and shared decision-making with the patient, conservative management was chosen. Conclusion: Primary intraosseous paragangliomas are rare, with this case representing only the second reported in femur and third in the appendicular skeleton. It underscores the importance of a multimodal diagnostic approach, individualized treatment plans, and multidisciplinary collaboration.

Background: Spondylothoracic dysostosis (STD), also known as Jarcho-Levin syndrome (JLS), is a rare autosomal recessive disorder affecting the formation of the spine, characterized by a complete bilateral fusion of the ribs at the costovertebral junction, producing a “crablike” appearance of the thorax. Despite being declared a core indication for a V-osteotomy vertical expandable prosthetic titanium rib (VEPTR) expansion thoracoplasty of the posterior thorax, the natural history of STD in untreated subjects remains poorly documented. In this study, we report radiographic and pulmonary function findings and Patient-Reported Outcomes Measurement Information System (PROMIS) and 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24) scores for untreated adult subjects with STD to gain insights into the natural history. Methods: We identified 11 skeletally mature, untreated subjects with STD. Findings on medical evaluation, demographics, radiographic parameters, pulmonary function, genetic testing results, PROMIS measures, and EOSQ-24 scores were assessed. Results: Five male and 6 female subjects (mean age, 32.3 years [range, 15 to 70 years]) with a confirmed STD diagnosis based on radiographs and genetic testing were evaluated. Mean body mass index (BMI) was 24.4 kg/m² (range, 18 to 38.9 kg/m²), and mean thoracic height was 16 cm (range, 12 to 17 cm). Pulmonary function tests (PFTs) showed a mean forced vital capacity (FVC) of 22% of predicted, mean forced expiratory volume in 1 second (FEV1) of 24% of predicted, and FEV1/FVC ratio of 107% of predicted. The mean PROMIS dyspnea score was 40 ± 8 points (range, 27.7 to 52.1 points). The mean total EOSQ-24 score was 77.3 ± 18 points (range, 43.9 to 93.2 points). Conclusions: Our study characterizes the natural history of STD in untreated subjects. We confirmed the expected restrictive pattern in pulmonary function, but interestingly, our subjects exhibited better EOSQ scores compared with those reported in neuromuscular populations. PFT results and thoracic height did not correspond to PROMIS and EOSQ scores, questioning the use of those parameters as a surgical indication. We therefore suggest that the STD diagnosis as an absolute indication for VEPTR expansion thoracoplasty surgery be reconsidered. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The third segment of the axillary artery (TSAA) is the main vascular supply to the muscles of the upper limb. Numerous studies have reported atypical branching patterns of the TSAA, which can complicate operative interventions involving structures supplied by this segment of the artery. Our current study evaluated a previously undescribed branching pattern in the TSAA, in which the subscapular artery gave rise to an unusual posterior humeral circumflex artery, and a second subscapular artery. In addition, a third variant was found in the origin of the thoracodorsal artery: two collateral horizontal arteries supplying the deep medial surface of the latissimus dorsi muscle. Vascular anatomical variants may affect the classical upper limb interventions requiring modification of the traditional surgical approaches. This case report aims to evaluate these variants from a clinical perspective regarding the management of upper limb trauma, axillary, breast, and muscle flap surgery.

Background: Adequate pain control after total knee arthroplasty (TKA) has been associated with improved patient mobility and satisfaction, and is a task that has historically relied on opioids. Multimodal analgesic regimens can be considered a therapeutic alternative for postoperative pain control to avoid opioid consumption and its adverse side effects. This study aimed to evaluate the use of a multimodal analgesia protocol based on nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as an alternative to reduce opioid consumption in Hispanic patients undergoing primary TKA. Methods: An institutional review board-approved, randomized controlled trial evaluated postoperative pain control after TKA in a Hispanic population. The experimental opioid-sparing group received 30-mg ketorolac intravenously every 6 hours and 1-g acetaminophen orally every 6 hours as the patient requested. The experimental group had the option to use morphine and oxycodone combined with acetaminophen as a rescue therapy. The control group received opioids in the form of 0.1-mg/kg morphine intravenously every 6 hours and/or oxycodone combined with acetaminophen (2.5 and 325 mg), 2 tablets orally every 6 hours, as the patient requested. Sociodemographic, operative, and immediate postoperative data and pain intensity measurements according to the numerical rating scale (NRS) were compared between groups. Analgesic efficacy was assessed according to the NRS scores at 12, 24, and 48 hours postoperatively. Results: Eighty-one Hispanic patients met inclusion criteria: 42 patients in the experimental group and 39 patients in the control group. None of the patients in the experimental group requested oxycodone combined with acetaminophen as a rescue therapy. Only 2 patients in the experimental group used a mean of 3.0 ± 1.4 mg of rescue morphine; in comparison, the control group consumed a mean of 28.0 ± 7.9 mg of morphine and 64.8 ± 26.0 mg of oxycodone per patient. A pain intensity decrease was observed in the experimental and control groups, with no postoperative evaluation differences at 12 hours (6.7 ± 2.9 compared with 5.9 ± 2.8; p = 0.209), 24 hours (6.2 ± 2.0 compared with 6.1 ± 2.2; p = 0.813), and 48 hours (4.7 ± 2.1 compared with 4.6 ± 1.7; p = 0.835). Conclusions: The use of a multimodal analgesic regimen based on intravenous ketorolac and oral acetaminophen was adequate in reducing postoperative pain and opioid consumption in Hispanic patients undergoing TKA. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Early-onset scoliosis (EOS) is a well-known orthopaedic manifestation in patients with myelomeningocele. The rib-based growing system (RBGS) has been proposed as an alternative for these individuals because of the poor outcomes with traditional surgical techniques. We aimed to describe the effect of RBGS in patients with nonambulatory EOS myelomeningocele. Methods: We retrospectively reviewed the Pediatric Spine Study Group Multicenter Database for all patients with nonambulatory EOS myelomeningocele treated with RBGS from 2004 to 2019. Demographics, surgical data, radiographic findings, and postoperative complications were obtained. The quality-of-life parameters were assessed postoperatively using the Early-onset Scoliosis Questionnaire-24. Results: Thirty patients (18 women; 60%) were patients with nonambulatory EOS myelomeningocele treated with RBGS. The mean age at the initial surgery was 5.3 years. The thoracic (T1-T12) spine height showed a significant increase from initial surgery to the most recent follow-up (P < 0.001). Spine (T1-S1) height was also significantly increased (P < 0.001). The postoperative complication rate was 87%. The Early-onset Scoliosis Questionnaire-24 demonstrates significant improvements in the quality-of-life scores (P = 0.037). Conclusion: This study demonstrated that RBGS could improve the reported quality-of-life scores in patients with nonambulatory EOS myelomeningocele when assessed with an EOS-oriented tool. Moreover, we confirmed the ability of RBGS to hold or even correct spinal deformity.

Objective: This study aimed to investigate burnout rates in Hispanic surgical residents. Design: A three-part cross-sectional survey was distributed to Hispanic surgical residents at the University of Puerto Rico Medical Science Campus. The survey consisted of demographic information, the General Health Questionnaire-12 (GHQ-12), and the Maslach Burnout Inventory (MBI) questionnaire. Descriptive statistics and pairwise correlations were performed to compare groups and responses. Setting: The study took place at the University of Puerto Rico Medical Science Campus, particularly at the external clinics of the medical sciences campus ('ASEM'). Participants: Surgical residents from surgical programs including Orthopaedic surgery, urology, otolaryngology, general surgery, ophthalmology, obstetrics-gynecology, and maxillofacial surgery from the University of Puerto Rico –Medical Sciences Campus. A total of 95 Hispanic surgical residents completed all three sections of the questionnaire (Response Rate = 85%, 95/112). Results: A total of 95/112 (85%) residents completed all three sections of the questionnaire, with 64.2% (61/95) meeting the criteria for burnout. The average age of residents was 30 years, and 37% were female. Residents reported working an average of 67.6 hours a week. The GHQ-12 indicated that 29.5% of residents reported significant psychiatric morbidity. Conclusion: Burnout rates in Hispanic surgical residents were found to be higher compared to burnout rates in non-Hispanic physicians. Earlier stages of residency are associated with higher rates of burnout. In addition, increased work hours and sleep deprivation were associated with higher rates of burnout. However, no correlation was found between marital status, debt level, age, sex, and burnout rates. Psychiatric morbidity (GHQ-12 scale) was associated with higher burnout rates.

Purpose The aim of this study was to evaluate the associated factors of patients with LSS who undergo reoperation after a PLSF in a Hispanic-American population. Methods A retrospective single-center review was performed from all non-age-related Hispanic-Americans with LSS who underwent one or two-level PLSF from 2008 to 2018. Baseline characteristics were analyzed between the reoperation and no-reoperation group using a bivariate and multivariate analyses. Results Out of 425 patients who underwent PLSF, 38 patients underwent reoperation. At a two-year follow-up, the reoperation rate was 6.1% (26/425), mostly due to pseudoarthrosis (39.5%), recurrent stenosis (26.3%), new condition (15.8%), infection (10.5%), hematoma (5.3%), and dural tear (2.6%). Patients who underwent reoperation were more likely to have a preoperative history of epidural steroid injection (ESI) (OR 5.18, P = 0.009), four or more comorbidities (OR 2.69, P = 0.028), and operated only with a posterolateral fusion without intervertebral fusion (OR 2.15, P = 0.032). Finally, the multivariable analysis showed that ESI was the only independent associated factor in patients who underwent reoperation after a PLSF in our group. Conclusion Among this population who underwent surgery, a reoperation rate at two years of follow-up was less than ten percent. Our study did not find any associated factor inherent to Hispanic-Americans, as ethnic group, who were reoperated after LSS.

Tenosynovial chondromatosis (TC) is a rare progressive benign tumor from the synovial lining of tendon sheath. The TC mostly affects males between the ages 30 to 50 years old at the ventral side of wrist. There are two different forms of TC that have been proposed in previous studies: an idiopathic cause (primary TC) and a joint related diseases cause (secondary TC). Even though trauma has been written to be a common reason for TC, a case of a secondary TC affecting the dorsal wrist following a triquetrum fracture has never been written before. The aim of this report is to present a rare case of a solitary post-traumatic TC at the dorsal wrist following a triquetrum fracture. We describe the clinical presentation, imaging modalities, histopathological and treatment challenges to manage this difficult lesion.