Bio

Bio


Dr. Robin Kamal is an Assistant Professor in the Department of Orthopaedic Surgery. He completed his undergraduate and medical education at the University of Missouri, and graduated with Alpha Omega Alpha and Cum Laude honors. During his education he completed research fellowships at the National Institutes of Health and the University of Iowa. He went on to complete a residency in Orthopaedic Surgery at Brown University as well as a fellowship in Orthopaedic Trauma. During his training at Brown, he was trained in wrist biomechanics as a research fellow at the University of Barcelona. Dr. Kamal then completed a second fellowship in Hand, Upper Extremity, and Microvascular Surgery at Duke University. There he was trained in free vascularized fibula transfers.

Dr. Kamal's research program focuses on the following:
1) Value-based healthcare: Studying novel payment models, variation in quality, cost analyses, and high-value clinical care pathways
2) Defining quality in orthopedic surgery: He currently is a member of the Hand Surgery Quality Consortium, a multi center collaborative with the mission of studying quality
3) Wrist kinematics and kinetics in the normal and injured wrist: Studying the factors the influence wrist motion to inform patient-specific wrist reconstructions

Dr. Kamal is an editor of the textbook Comprehensive Board Review in Orthopaedic Surgery. He has a wrist research grant from the American Society for Surgery of the Hand, a quality measure development grant from the American Academy of Orthopaedic Surgeons, has served as a grant reviewer for the Department of Defense, and is an Emerging Leader for the American Orthopaedic Association. He serves as the Vice-Chair of the Quality Measures Committee for the American Society for Surgery of the Hand and as Chair of the Carpal Tunnel Quality Measure Workgroup. He is a consulting editor for the Journal of Hand Surgery.

His main surgical interests are in trauma and reconstructive surgery of the upper limb (hand, wrist, elbow, shoulder). He strives to provide his patients the highest quality care possible - a commitment he makes his foremost priority. His research and clinical practice are devoted to improving hand, wrist, and elbow function and he treats upper extremity instability/arthritis (finger, wrist, or elbow joint replacement), sports/athletic injuries and fracture care including nonunion/malunion, and minimally invasive arthroscopy.

Clinical Focus


  • Hand, Wrist, and Elbow Surgery
  • Upper Extremity Trauma
  • Hand Surgery

Academic Appointments


Administrative Appointments


  • Consulting Editor, American Family Physician (2016 - Present)
  • Consulting Editor, Journal of Oncology Practice (2016 - Present)
  • Consulting Editor, Journal of Shoulder and Elbow Surgery (2016 - Present)
  • Consulting Editor, Journal of Hand Surgery (2015 - Present)
  • Member, Volunteer Services Committee, American Society for Surgery of the Hand (2014 - Present)
  • Member, Performance Measures Task Force of the American Society for Surgery of the Hand (2014 - Present)
  • Member, Hand Surgery Quality Consortium (2014 - Present)
  • Clinician Scholar Development Program, AAOS/OREF/ORS (2012 - Present)
  • Emerging Leader, American Orthopaedic Association (2011 - Present)
  • Information Services Advisory Committee, Rhode Island Hospital (2011 - 2012)
  • President, UMKC School of Medicine Student Body Member (2005 - 2006)
  • Alumni Board, UMKC School of Medicine (2004 - 2006)

Honors & Awards


  • Award for Community Service, UMKC School of Medicine Schaffer (2004)
  • Alpha Omega Alpha (AOA), UMKC School of Medicine (2006)
  • Award For Research, St. Louis Friends of UMKC School of Medicine (2007)
  • Alumni Association Award for Outstanding Research, UMKC School of Medicine (2007)
  • Award for Scientific presentation at Annual Meeting, “Best of the AAOS” (2012)

Boards, Advisory Committees, Professional Organizations


  • Candidate Member, American Academy of Orthopaedic Surgeons (2007 - Present)
  • Registered Disaster Responder, American Academy of Orthopaedic Surgeons (2013 - Present)
  • Candidate Member, American Society for Surgery of the Hand (2011 - Present)
  • Candidate Member, American Association for Hand Surgery (2011 - Present)
  • Emerging Leader, American Orthopaedic Association (2011 - Present)
  • Member, International Society of Orthopaedic Surgery and Traumatology (SICOT) (2012 - Present)
  • Candidate Member, Orthopaedic Trauma Association (2013 - Present)

Professional Education


  • Board Certification: Hand Surgery, American Board of Orthopaedic Surgery (2017)
  • Board Certification: Orthopaedic Surgery, American Board of Orthopaedic Surgery (2016)
  • Fellowship:Hasbro Children's Hospital (2013) RI
  • Residency:Hasbro Children's Hospital (2012) RI
  • Internship:Hasbro Children's Hospital (2008) RI
  • Assistant Professor, Stanford University Medical Center, Department of Orthopaedic Surgery Chase Hand and Upper Limb Center
  • Fellowship, Duke University Medical Center, Hand, Upper Extremity, and Microvascular
  • Fellowship, Brown University/Rhode Island Hospital, Orthopaedic Trauma
  • Residency, Brown University/Rhode Island Hospital, Orthopaedic Surgery
  • Internship, Brown University/Rhode Island Hospital, General Surgery
  • Doctor of Medicine, Cum Laude, University of Missouri-Kansas City School of Medicine, Doctor of Medicine

Community and International Work


  • Hand and Burn Surgery, La Paz, Bolivia

    Partnering Organization(s)

    ReSurge International and ASSH

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • English Teacher, Santa Domingo, Dominican Republic

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Medical Mission, San Lucas, Guatemala

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Orthopaedic Trauma, Hospital Roberto Calderon, Managua, Nicaragua

    Topic

    Orthopaedic Trauma

    Partnering Organization(s)

    Orthopaedic Overseas

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Orthopaedic Trauma, Adventist Hospital, Port-Au-Prince, Haiti

    Topic

    Trauma and Hand Surgery

    Partnering Organization(s)

    Loma Linda University

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

Research & Scholarship

Current Research and Scholarly Interests


Wrist and Elbow Injuries and Quality Measures in Orthopaedic Surgery

Projects


  • Does Ligament Elasticity Affect Carpal Kinematics?

    Location

    palo alto

  • Quality Measure Development in Hand Surgery

    Location

    palo alto

  • Patient-Centered Education Tools

    Location

    palo alto

Teaching

2017-18 Courses


Publications

All Publications


  • Quality Measures in Breast Reconstruction: A Systematic Review. Annals of plastic surgery Nazerali, R. N., Finnegan, M. A., Divi, V., Lee, G. K., Kamal, R. N. 2017

    Abstract

    The importance of providing quality care over quantity of care, and its positive effects on health care expenditure and health, has motivated a transition toward value-based payments. The Centers for Medicare and Medicaid Services and private payers are establishing programs linking financial incentives and penalties to adherence to quality measures. As payment models based on quality measures are transitioned into practice, it is beneficial to identify current quality measures that address breast reconstruction surgery as well as understand gaps to inform future quality measure development.We performed a systematic review of quality measures for breast reconstruction surgery by searching quality measure databases, professional society clinical practice guidelines, and the literature. Measures were categorized as structure, process, or outcome according to the Donabedian domains of quality.We identified a total of 27 measures applicable to breast reconstruction: 5 candidate quality measures specifically for breast reconstruction surgery and 22 quality measures that relate broadly to surgery. Of the breast reconstruction candidate measures, 3 addressed processes and 2 addressed outcomes. Seventeen of the general quality measures were process measures and 5 were outcome measures. We did not identify any structural measures.Currently, an overrepresentation of process measures exists, which addresses breast reconstruction surgery. There is a limited number of candidate measures that specifically address breast reconstruction. Quality measure development efforts on underrepresented domains, such as structure and outcome, and stewarding the measure development process for candidate quality measures can ensure breast reconstruction surgery is appropriately evaluated in value-based payment models.

    View details for DOI 10.1097/SAP.0000000000001088

    View details for PubMedID 28570449

  • Impact of Health Literacy on Time Spent Seeking Hand Care. Hand (New York, N.Y.) Alokozai, A., Bernstein, D. N., Sheikholeslami, N., Uhler, L., Ring, D., Kamal, R. N. 2017: 1558944717708027-?

    Abstract

    Patients with limited health literacy may have less knowledge and fewer resources for efficient access and navigation of the health care system. We tested the null hypothesis that there is no correlation between health literacy and total time spent seeking hand surgery care.New patients visiting a hand surgery clinic at a suburban academic medical center were asked to complete a questionnaire to determine demographics, total time spent seeking hand surgery care, and outcomes. A total of 112 patients were included in this study.We found health literacy levels did not correlate with total time seeking hand surgery care or from booking an appointment to being evaluated in clinic.In this suburban academic medical center, patients with low health literacy do not spend more time seeking hand surgery care and do have longer delays between seeking and receiving care. The finding that-at least in this setting-health literacy does not impact patient time seeking hand care suggests that resources to improve health disparities can be focused elsewhere in the care continuum.

    View details for DOI 10.1177/1558944717708027

    View details for PubMedID 28513193

  • Association of Lunate Morphology With Carpal Instability in Scapholunate Ligament Injury. Hand (New York, N.Y.) Pang, E. Q., Douglass, N., Kamal, R. N. 2017: 1558944717709073-?

    Abstract

    We examined the relationship between lunate morphology (type 1 without a medial facet; type II with a medial facet) and dorsal intercalated segmental instability (DISI) in patients with scapholunate ligament injuries. We tested the primary null hypothesis that there is no relationship between lunate morphology and development of DISI. Secondary analysis compared the agreement of classifying lunate morphology based on the presence of a medial lunate facet, capitate-to-triquetrum (CT) distance, and magnetic resonance imaging (MRI).We performed a retrospective chart review of patients with known scapholunate ligament injuries from 2001 to 2016. Posterior-anterior radiographs and MRI, when available, were evaluated. CT distances were measured as a secondary classification method. DISI and scapholunate instability were determined as radiolunate angle >15° and scapholunate angle >60°, respectively. Differences between groups were determined using chi-square analysis with significance set at P < .05. Agreement between plain radiographs, MRI, and CT distance was calculated using the kappa statistic.Our search found 58 of 417 patients who met inclusion criteria; 41 of 58 had type II and 17 of 58 had type I lunates. There was no significant difference between groups in regard to DISI or scapholunate instability. Subanalysis using MRI alone or correcting any discrepancy between plain film and MRI classification, using MRI as the standard, found no difference between groups in regard to DISI or scapholunate instability.In patients with scapholunate ligament injuries, there are no differences in the development of DISI or scapholunate instability between patients with type I and type II lunates.

    View details for DOI 10.1177/1558944717709073

    View details for PubMedID 28525962

  • Simple Assessment of Global Bone Density and Osteoporosis Screening Using Standard Radiographs of the Hand. journal of hand surgery Schreiber, J. J., Kamal, R. N., Yao, J. 2017

    Abstract

    Osteoporosis and fragility fractures have consequences both at the individual level and to the overall health care system. Although dual-energy x-ray absorptiometry (DXA) is the reference standard for assessing bone mineral density (BMD), other, simpler tools may be able to screen bone quality provisionally and signal the need for intervention. We hypothesized that the second metacarpal cortical percentage (2MCP) calculated from standard radiographs of the hand or wrist would correlate with hip BMD derived from DXA and could provide a simple screening tool for osteoporosis.Two hundred patients who had hand or wrist radiographs and hip DXA scans within 1 year of each other were included in this series. Mid-diaphyseal 2MCP was calculated as the ratio of the cortical diameter to the total diameter. We assessed the correlation between 2MCP and total hip BMD. Subjects were stratified into normal, osteopenic, and osteoporotic cohorts based on hip t scores, and thresholds were identified to optimize screening sensitivity and specificity.Second metacarpal cortical percentage correlated significantly with BMD and t scores from the hip. A 2MCP threshold of less than 60% optimized sensitivity (88%) and specificity (60%) for discerning osteopenic subjects from normal subjects, whereas a threshold of less than 50% optimized sensitivity (100%) and specificity (91%) for differentiating osteoporotic from normal subjects.By demonstrating that global BMD may be assessed from 2MCP, these data suggest that radiographs of the hand and wrist may have a role in accurately screening for osteopenia and osteoporosis. This simple investigation, which is already used ubiquitously for patients with hand or wrist problems, may identify patients at risk for fragility fractures and allow for appropriate referral or treatment.Diagnostic II.

    View details for DOI 10.1016/j.jhsa.2017.01.012

    View details for PubMedID 28242242

  • Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release. journal of bone and joint surgery. American volume Zhang, S., Vora, M., Harris, A. H., Baker, L., Curtin, C., Kamal, R. N. 2016; 98 (23): 1970-1977

    Abstract

    Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost.We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test.Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001).Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique.Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

    View details for PubMedID 27926678

  • 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

  • Carpal Kinematics and Kinetics JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Starr, A., Akelman, E. 2016; 41 (10): 1011-1018

    Abstract

    The complex interaction of the carpal bones, their intrinsic and extrinsic ligaments, and the forces in the normal wrist continue to be studied. Factors that influence kinematics, such as carpal bone morphology and clinical laxity, continue to be identified. As imaging technology improves, so does our ability to better understand and identify these factors. In this review, we describe advances in our understanding of carpal kinematics and kinetics. We use scapholunate ligament tears as an example of the disconnect that exists between our knowledge of carpal instability and limitations in current reconstruction techniques.

    View details for DOI 10.1016/j.jhsa.2016.07.105

    View details for Web of Science ID 000385340300008

    View details for PubMedID 27569785

  • High Disparity Between Orthopedic Resident Interest and Participation in International Health Electives ORTHOPEDICS Zhang, S., Shultz, P., Daniels, A., Akelman, E., Kamal, R. N. 2016; 39 (4): E680-E686

    Abstract

    Few orthopedic surgical residency programs offer international health electives (IHEs). Efforts to expand these programs have been increasing across medical disciplines. Whether orthopedic residents will participate remains unknown. This study quantified and characterized orthopedic resident interest and barriers to IHEs in US residency programs. A web-based survey was administered to residents from 154 US orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education 2014 to 2015. Questions assessed demographics and program background, previous medical experience abroad, barriers to participation, and level of interest in participating in an international health elective during their training and beyond. Twenty-seven (17.5%) residency programs responded. Chi-square analysis showed that residents who expressed interest in participating were significantly more likely to have experience abroad compared with those who expressed no interest (P<.004). Analysis using Mann-Whitney U test suggested that those who expressed interest were more likely to believe IHEs are important to resident training (P<.0011; mean Likert scale score of 3.7 vs 2.6), provide valuable experience (P<.001; mean Likert scale score of 4.2 vs 3.2), and should be required for orthopedic residencies (P<.001; mean Likert scale score of 2.8 vs 1.9). Residents are strongly interested in participating in IHEs during their training, and many may integrate global health into future practices. Residents perceive lack of funding and scheduling flexibility as barriers preventing them from participating. Prior experience abroad influences level of interest, and international clinical experience may enhance future perception of its value. [Orthopedics. 2016; 39(4):e680-e686.].

    View details for DOI 10.3928/01477447-20160419-02

    View details for Web of Science ID 000393105500014

    View details for PubMedID 27111074

  • Quality and Value in an Evolving Health Care Landscape. journal of hand surgery Kamal, R. N. 2016; 41 (7): 794-799

    Abstract

    Demonstrating and improving value of care continues to be increasingly important in hand surgery. To prepare for emerging models that transition payment from volume to value, hand surgeons will benefit from a clear understanding of quality, cost, and value. National organizations and both public and private payers increasingly advocate for patient-reported outcome measures for pay for reporting and pay for performance initiatives. These are intended to incentivize providers and health systems to improve patient-centered care while minimizing costs. Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models.

    View details for DOI 10.1016/j.jhsa.2016.05.016

    View details for PubMedID 27374791

  • 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 Web of Science ID 000375509500008

    View details for PubMedID 26576831

  • Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Daniels, A. H., Depasse, J. M., Kamal, R. N. 2016; 24 (4): 213-219

    Abstract

    Burnout is a syndrome marked by emotional exhaustion, depersonalization, and low job satisfaction. Rates of burnout in orthopaedic surgeons are higher than those in the general population and many other medical subspecialties. Half of all orthopaedic surgeons show symptoms of burnout, with the highest rates reported in residents and orthopaedic department chairpersons. This syndrome is associated with poor outcomes for surgeons, institutions, and patients. Validated instruments exist to objectively diagnose burnout, although family members and colleagues should be aware of early warning signs and risk factors, such as irritability, withdrawal, and failing relationships at work and home. Emerging evidence indicates that mindfulness-based interventions or educational programs combined with meditation may be effective treatment options. Orthopaedic residency programs, departments, and practices should focus on identifying the signs of burnout and implementing prevention and treatment programs that have been shown to mitigate symptoms.

    View details for DOI 10.5435/JAAOS-D-15-00148

    View details for Web of Science ID 000372851200001

    View details for PubMedID 26885712

  • 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

  • Subject-Specific Carpal Ligament Elongation in Extreme Positions, Grip, and the Dart Thrower's Motion JOURNAL OF BIOMECHANICAL ENGINEERING-TRANSACTIONS OF THE ASME Rainbow, M. J., Kamal, R. N., Moore, D. C., Akelman, E., Wolfe, S. W., Crisco, J. J. 2015; 137 (11)

    View details for DOI 10.1115/1.4031580

    View details for Web of Science ID 000362842900006

    View details for PubMedID 26367853

  • Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures. Hand clinics Desai, M. J., Kamal, R. N., Richard, M. J. 2015; 31 (3): 409-416

    Abstract

    The prevalence of ligamentous injury associated with fractures of the distal radius is reported to be as high as 69% with injury to the scapholunate interosseous ligament and lunotriquetral interosseous ligament occurring in 16% to 40% and 8.5% to 15%, respectively. There is a lack of consensus on which patients should undergo advanced imaging, arthroscopy, and treatment and whether this changes their natural history. Overall, patients with high-grade intercarpal ligament injuries are shown to have longer-term disability and sequelae compared with those with lower-grade injuries. This article reviews the diagnosis and treatment options for these injuries.

    View details for DOI 10.1016/j.hcl.2015.04.009

    View details for PubMedID 26205702

  • Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures. Hand clinics Desai, M. J., Kamal, R. N., Richard, M. J. 2015; 31 (3): 409-416

    View details for DOI 10.1016/j.hcl.2015.04.009

    View details for PubMedID 26205702

  • Ulnar shortening osteotomy for distal radius malunion. Journal of wrist surgery Kamal, R. N., Leversedge, F. J. 2014; 3 (3): 181-186

    Abstract

    Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis. Level IV.

    View details for DOI 10.1055/s-0034-1384747

    View details for PubMedID 25097811

  • Salvage of Distal Radius Nonunion With a Dorsal Spanning Distraction Plate JOURNAL OF HAND SURGERY-AMERICAN VOLUME Mithani, S. K., Srinivasan, R. C., Kamal, R., Richard, M. J., Leversedge, F. J., Ruch, D. S. 2014; 39 (5): 981-984

    Abstract

    Treatment of nonunion after previous instrumentation of distal radius fractures represents a reconstructive challenge. Resultant osteopenia provides a poor substrate for fixation, often necessitating wrist fusion for salvage. A spanning dorsal distraction plate (bridge plate) can be a useful adjunct to neutralize forces across the wrist, alone or in combination with nonspanning plates to achieve union, salvage wrist function, and avoid wrist arthrodesis in distal radius nonunion.

    View details for DOI 10.1016/j.jhsa.2014.02.006

    View details for Web of Science ID 000335422200025

    View details for PubMedID 24679491

  • Post-traumatic Raynaud's phenomenon following volar plate injury. Rhode Island medical journal (2013) Chodakiewitz, Y. G., Daniels, A. H., Kamal, R. N., Weiss, A. C. 2014; 97 (4): 24-26

    Abstract

    Post-traumatic Raynaud's phenomenon following non-penetrating or non-repetitive injury is rare. We report a case of Raynaud's phenomenon occurring in a single digit 3 months following volar plate avulsion injury. Daily episodes of painless pallor of the digit occurred for 1 month upon any exposure to cold, resolving with warm water therapy. Symptoms resolved after the initiation of hand therapy, splinting, and range-of- motion exercises.

    View details for PubMedID 24660212

  • Quality of internet health information on thumb carpometacarpal joint arthritis. Rhode Island medical journal (2013) Kamal, R. N., Paci, G. M., Daniels, A. H., Gosselin, M., Rainbow, M. J., Weiss, A. C. 2014; 97 (4): 31-35

    Abstract

    The Internet has become a heavily used source of health information. No data currently exists on the quality and characteristics of Internet information regarding carpometacarpal (CMC) arthritis.The search terms "cmc arthritis," "basal joint arthritis," and "thumb arthritis" were searched using Google and Bing. Search results were evaluated independently by four reviewers. Classification and content specific review was performed utilizing a weighted 100-point information quality scale.Of the 60 websites reviewed, 27 were unique pages with 6 categorized as academic and 21 as non- academic. Average score on content specific review of academic websites was 56.8 and for non-academic was 42.7 (p=0.054). Average Flesch-Kincaid Grade Level for academic websites was 12.4, and for non-academic was 9.9 (p=0.015).Internet health information regarding thumb CMC arthritis is primarily non-academic in nature, of generally poor quality, and at a reading level far above the U.S. average reading level of 6th grade. Higher-quality websites with more complete content and appropriate readability are needed.The quality of Internet health information regarding thumb CMC arthritis is suboptimal.

    View details for PubMedID 24660214

  • Nerve compression syndromes of the upper extremity: diagnosis, treatment, and rehabilitation. Rhode Island medical journal (2013) Mansuripur, P. K., Deren, M. E., Kamal, R. 2013; 96 (5): 37-39

    Abstract

    Nerve compression syndromes of the upper extremity, including carpal tunnel syndrome, cubital tunnel syndrome, posterior interosseous syndrome and radial tunnel syndrome, are common in the general population. Diagnosis is made based on patient complaint and history as well as specific exam and study findings. Treatment options include various operative and nonoperative modalities, both of which include aspects of hand therapy and rehabilitation.

    View details for PubMedID 23641462

  • Extensive Subcutaneous Emphysema Resembling Necrotizing Fasciitis ORTHOPEDICS Kamal, R. N., Paci, G. M., Born, C. T. 2013; 36 (5): 671-675

    Abstract

    Necrotizing fasciitis is an aggressive, invasive soft tissue infection. Because it can rapidly progress to patient instability, prompt diagnosis followed by urgent debridement is critical to decreasing mortality. Despite the importance of early diagnosis, necrotizing fasciitis remains a clinical diagnosis, with little evidence in the literature regarding the effectiveness of diagnostic tools or criteria. Common clinical findings are nonspecific, including pain, blistering, crepitus, and swelling with or without fever and a known infection source.This article describes a patient who was transferred to the authors' institution from another hospital, where she had been taken following seizure activity and was treated with antibiotics for suspected cellulitis at the intravenous catheter placement site on her left dorsal hand. On admission to the current authors' institution, she presented with pain and swelling in the setting of significant left upper-extremity emphysema. She had undergone a left shoulder arthroscopy 4 weeks previously. Vital signs were within normal limits, and a preoperative chest radiograph was read as normal. The patient underwent an emergent fasciotomy, irrigation and debridement of the left upper extremity, and intravenous antibiotics for suspected necrotizing fasciitis. Intraoperative findings indicative of infection were absent, and a left apical pneumothorax was later found on postoperative chest imaging.In a stable patient with a normal chest radiograph on presentation who demonstrates upper-extremity crepitus suspicious for necrotizing fasciitis, a chest computed tomography scan may be indicated to rule out an intrathoracic source.

    View details for DOI 10.3928/01477447-20130426-34

    View details for Web of Science ID 000319811900037

    View details for PubMedID 23672900

  • Total Wrist Arthroplasty JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Weiss, A. C., Kamal, R. N., Shultz, P. 2013; 21 (3): 140-148

    Abstract

    Over the past 40 years, total wrist arthroplasty (TWA) has emerged as a cost-effective treatment option for wrist arthritis. First-generation implant designs have changed tremendously; current devices are designed to enhance wrist stability, provide greater implant longevity, and minimize surgical and postoperative complications. Although arthrodesis remains the standard for surgical management, TWA outcomes demonstrate that the procedure has excellent clinical promise. Additional prospective studies are needed to compare outcomes of wrist arthrodesis with those of TWA with current implants.

    View details for DOI 10.5435/JAAOS-21-03-140

    View details for Web of Science ID 000317444900003

    View details for PubMedID 23457064

  • In vivo kinematics of the scaphoid, lunate, capitate, and third metacarpal in extreme wrist flexion and extension. journal of hand surgery Rainbow, M. J., Kamal, R. N., Leventhal, E., Akelman, E., Moore, D. C., Wolfe, S. W., Crisco, J. J. 2013; 38 (2): 278-288

    Abstract

    Insights into the complexity of active in vivo carpal motion have recently been gained using 3-dimensional imaging; however, kinematics during extremes of motion has not been elucidated. The purpose of this study was to determine motion of the carpus during extremes of wrist flexion and extension.We obtained computed tomography scans of 12 healthy wrists in neutral grip, extreme loaded flexion, and extreme loaded extension. We obtained 3-dimensional bone surfaces and 6-degree-of-freedom kinematics for the radius and carpals. The flexion and extension rotation from neutral grip to extreme flexion and extreme extension of the scaphoid and lunate was expressed as a percentage of capitate flexion and extension and then compared with previous studies of active wrist flexion and extension. We also tested the hypothesis that the capitate and third metacarpal function as a single rigid body. Finally, we used joint space metrics at the radiocarpal and midcarpal joints to describe arthrokinematics.In extreme flexion, the scaphoid and lunate flexed 70% and 46% of the amount the capitate flexed, respectively. In extreme extension, the scaphoid extended 74% and the lunate extended 42% of the amount the capitates extended, respectively. The third metacarpal extended 4° farther than the capitate in extreme extension. The joint contact area decreased at the radiocarpal joint during extreme flexion. The radioscaphoid joint contact center moved onto the radial styloid and volar ridge of the radius in extreme flexion from a more proximal and ulnar location in neutral.The contributions of the scaphoid and lunate to capitate rotation were approximately 25% less in extreme extension compared with wrist motion through an active range of motion. More than half the motion of the carpus when the wrist was loaded in extension occurred at the midcarpal joint.These findings highlight the difference in kinematics of the carpus at the extremes of wrist motion, which occur during activities and injuries, and give insight into the possible etiologies of the scaphoid fractures, interosseous ligament injuries, and carpometacarpal bossing.

    View details for DOI 10.1016/j.jhsa.2012.10.035

    View details for PubMedID 23266007

  • The effect of the dorsal intercarpal ligament on lunate extension after distal scaphoid excision. journal of hand surgery Kamal, R. N., Chehata, A., Rainbow, M. J., Llusá, M., Garcia-Elias, M. 2012; 37 (11): 2240-2245

    Abstract

    After a distal scaphoid excision, most wrists develop a mild form of carpal instability-nondissociative with dorsal intercalated segment instability. Substantial dysfunctional malalignment is only occasionally seen. We hypothesized that distal scaphoid excision would lead to carpal instability-nondissociative with dorsal intercalated segment instability in cadavers and that the dorsal intercarpal (DIC) ligament plays a role in preventing such complications.We used 10 cadaver upper extremities in this experiment. A customized jig was used to load the wrist with 98 N. Motion of the capitate and lunate was monitored using the Fastrak motion tracking system. Five specimens had a distal scaphoid excision first, followed by excision of the DIC ligament, whereas the other 5 specimens first had excision of the DIC ligament and then had a distal scaphoid excision. Rotation of the lunate and capitate was calculated as a sum of the relative motions between each intervention and was compared with its original location before intervention (control) for statistical analysis.Distal scaphoid excision and subsequent DIC ligament excision both led to significant lunate extension. DIC ligament excision alone resulted in lunate flexion that was not statistically significant. After DIC ligament excision, distal scaphoid excision led to significant lunate extension. Capitate rotation was minimal in both groups, verifying that the overall wrist position did not change with loading.Distal scaphoid excision leads to significant lunate extension through an imbalance in the force couple between the scaphotrapeziotrapezoidal joint and the triquetrum-hamate joint. The DIC ligament may serve as a secondary stabilizer to the lunocapitate joint and prevent further lunate extension with the wrist in neutral position.The development of a clinically symptomatic carpal instability-nondissociative with dorsal intercalated segment instability with lunocapitate subluxation after distal scaphoid excision may be due to an incompetent DIC ligament.

    View details for DOI 10.1016/j.jhsa.2012.07.029

    View details for PubMedID 23044477

  • Elongation of the dorsal carpal ligaments: a computational study of in vivo carpal kinematics. journal of hand surgery Rainbow, M. J., Crisco, J. J., Moore, D. C., Kamal, R. N., Laidlaw, D. H., Akelman, E., Wolfe, S. W. 2012; 37 (7): 1393-1399

    Abstract

    The dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments play an important role in scapholunate and lunotriquetral stability. The purpose of this study was to compute changes in ligament elongation as a function of wrist position for the DRC and the scaphoid and trapezoidal insertions of the DIC.We developed a computational model that incorporated a digital dataset of ligament origin and insertions, bone surface models, and in vivo 3-dimensional kinematics (n = 28 wrists), as well as an algorithm for computing ligament fiber path.The differences between the maximum length and minimum length of the DRC, DIC scaphoid component, and DIC trapezoidal component over the entire range of motion were 5.1 ± 1.5 mm, 2.7 ± 1.5 mm, and 5.9 ± 2.5 mm, respectively. The DRC elongated as the wrist moved from ulnar extension to radial flexion, and the DIC elongated as the wrist moved from radial deviation to ulnar deviation.The DRC and DIC lengthened in opposing directions during wrist ulnar and radial deviation. Despite complex carpal bone anatomy and kinematics, computed fiber elongations were found to vary linearly with wrist position. Errors between computed values and model predictions were less than 2.0 mm across all subjects and positions.The relationships between ligament elongation and wrist position should further our understanding of ligament function, provide insight into the potential effects of dorsal wrist incisions on specific wrist ranges of motion, and serve as a basis for modeling of the wrist.

    View details for DOI 10.1016/j.jhsa.2012.04.025

    View details for PubMedID 22633233

  • Updates on Disaster Preparedness and Progress in Disaster Relief JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Pollak, A. N., Born, C. T., Kamal, R. N., Adashi, E. Y. 2012; 20: S54-S58

    Abstract

    Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and nongovernmental organizations, and medical associations struggled to mount an effective humanitarian aid response. The experiences of these groups have led to changes at their institutions regarding disaster preparedness and response to future events. One of the main challenges in a humanitarian medical response to a disaster is determining when to end response efforts and return responsibility for delivery of medical care back to the host nation. For such a transition to occur, the host nation must have the capacity to deliver medical care. In Haiti, minimal capacity to deliver such care existed before the earthquake, making subsequent transition difficult. If successful, several initiatives proposed to improve disaster response and increase surgical capacity in Haiti could be deployed to other low- and middle-income countries.

    View details for DOI 10.5435/JAAOS-20-08-S54

    View details for Web of Science ID 000307199000013

    View details for PubMedID 22865138

  • In Vivo Triquetrum-Hamate Kinematics through a Simulated Hammering Wrist Motion J Bone Joint Surg Am Kamal, R., et al 2012
  • The Use of Near-Infrared Spectrometry for the Diagnosis of Lower-extremity Compartment Syndrome ORTHOPEDICS Bariteau, J. T., Beutel, B. G., Kamal, R., Hayda, R., Born, C. 2011; 34 (3)
  • Total Wrist Athroplasty in the Non-Rheumatoid Patient J Hand Surg Am. Kamal, R. 2011
  • Arthroscopic Treatment of Radiocarpal Dislocation: A Case Report Journal of Bone and Joint Surgery Kamal, R., et al 2011
  • Effects on cytokines and histology by treatment with the ace inhibitor captopril and the antioxidant retinoic acid in the monocrotaline model of experimentally induced lung fibrosis CURRENT PHARMACEUTICAL DESIGN Baybutt, R. C., Herndon, B. L., Umbehr, J., Mein, J., Xue, Y., Reppert, S., Van Dillen, C., Kamal, R., Halder, A., Moteni, A. 2007; 13 (13): 1327-1333

    Abstract

    Monocrotaline (MCT), a pyrrolizidine alkaloid extracted from the shrub Crotalaria spectabilis, induces in the lungs of many mammalian species severe hypertension and fibrosis. Previous work with MCT-induced lung disease in rats has shown that some of the steps to progressive fibrosis can be interrupted or decreased by intervention with retinoic acid (RA) or with the angiotensin converting enzyme inhibitor, captopril. This report emphasizes the pathology and cytokines present in lungs of rats in the MCT model of hypertension and fibrosis in 8 treatment groups, six per group: (1) controls, not treated; (2) captopril; (3) RA; (4) combined captopril and RA. Groups 5-8 replicated groups 1-4 and also received MCT subcutaneously. Tissues were harvested at 28 days for histopathology and measurement of cytokines TGFbeta, TNFalpha, interleukin 6, and IFN_. TGFbeta was depressed at 28 days by MCT, an effect reversed by a combination of captopril and RA. RA influences production of an important Th1 cytokine, IFN_, and demonstrated the greatest limitation of MCT-induced TNFalpha. The MCT-induced lung pathology of vasculitis, interstitial pneumonia and fibrosis was limited by captopril. Smooth muscle actin was overexpressed in MCT treated animals receiving RA, an effect reduced with captopril. Overall, the study confirmed the existence of a protective effect for both captopril and RA from MCT-induced lung damage at 30 days. No synergistic or antagonistic activity was observed when the two drugs were administered together. Each of the drugs exerts different and particular effects on serum and tissue levels of various cytokines, suggesting that each drug is efficient at different points of attack in the control of lung fibrosis.

    View details for Web of Science ID 000247013200005

    View details for PubMedID 17506718

  • Retinoic Acid-High Diet controls M1/M2 Activation Phenotypes in Macrophages and Protects from Monocrotaline-Induced Pulmonary Fibrosis Nutrition Research Kamal, R., et al 2004