Dr. Ladd graduated from Dartmouth College with an AB in History, received her MD from SUNY Upstate Medical University, completed Orthopaedic Residency at the University of Rochester, and completed the Harvard Combined Hand Surgery Fellowship. She was a fellow at L'Institut de la Main in Paris, France prior to joining the Stanford University faculty in 1990.

Clinical Focus

  • Hand Surgery
  • Hand and Upper Extremity Surgery
  • Orthopaedic Surgery
  • Pediatric Hand Problems

Academic Appointments

Administrative Appointments

  • Assistant Dean for Student Advising, Stanford University School of Medicine (2013 - 2014)
  • Professor - Med Center Line (by courtesy), Plastic/Reconstructive Surgery (2005 - 2014)
  • Chief of Chase Hand & Upper Limb Center, Stanford University School of Medicine (2005 - 2014)
  • Chief of the Children's Hand Clinic, Lucile Salter Packard Children's Hospital at Stanford (1991 - 2014)
  • Head of Outreach, SUMMIT (Stanford University Medical Media Information Technologies) (2001 - 2004)
  • Chief, Hand and Upper Extremity Section, Department of Surgery, Palo Alto VA Medical Center, Palo Alto, CA (1990 - 1998)

Honors & Awards

  • Nicolas Andry Award: "significant contribution to musculoskeletal research", Association of Bone and Joint Surgeons (2014)
  • Compere Award, Outstanding Scientific Paper, Twentieth Century Orthopaedic Association (2012)
  • Emanuel B. Kaplan Excellence in Anatomy Award, American Society for Surgery of the Hand (2012)
  • Dean's Award for Distinguished Teaching, Stanford University (2010)
  • Career Development Award, OREF/RJOS/DePuy (2010)
  • Best Doctors in America database, Selected by peers (2007-2013)
  • Iris Litt Fund, Instititute for Women & Gender at Stanford (2004)
  • Sterling Bunnell Traveling Fellowship, American Society for Surgery of the Hand (2000-2001)
  • Poster Exhibit Award, Best Scientific Content Honorable Mention, American Society for Surgery of the Hand Annual Meeting (2003)
  • Outstanding Faculty Physician Award, Cowell Student Health Center, Stanford University (1998)
  • Woman of Achievements award, San Jose Mercury News & Women’s Fund (1997)

Boards, Advisory Committees, Professional Organizations

  • President, Ruth Jackson Orthopaedic Society (2013 - 2014)
  • Board Member, Perry Outreach Initiative (2013 - Present)
  • Board Member, California Orthopaedic Association (2009 - 2013)

Professional Education

  • Fellowship:Brigham and Women's Hospital Harvard Medical School (1990) MA
  • Internship:Pacific Medical Center Seattle (1986)
  • Board Certification: Hand Surgery, American Board of Orthopaedic Surgery (1994)
  • Board Certification: Orthopaedic Surgery, American Board of Orthopaedic Surgery (1992)
  • Residency:University of Rochester School of Medicine (1989) NY
  • Medical Education:SUNY Upstate Medical University (1984) NY
  • AB, Dartmouth College, History (1980)
  • MD, SUNY Upstate Medical University, Medicine (1984)

Community and International Work

  • Chinle Navajo Reservation, Chinle, AZ



    Partnering Organization(s)

    US Dept of Interior

    Populations Served

    Navajo Nation



    Ongoing Project


    Opportunities for Student Involvement


  • Interplast, VIetnam


    surgical care of children with hand anomalies and problems

    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

1. The kinematics and forces associated with thumb carpometcarpal (CMC) function and pathology: current RO1 NIH grant evaluating the thumb position for normal functional tasks as determined with CT scans. The study evaluates normal subjects, and subjects with early arthritis over a 3 year period. Several related studies are underway.

2. The anatomy, microstructure, and immunofluorescent characteristics of the thumb CMC joint: The ligaments of the thumb CMC joint are purportedly looser in women, and wear out in arthritis. Our studies to date do not fully support this concept, and we approach further study through a variety of quantitative techniques. These include anatomical dissection, histomorphometric analysis, immunofluorescent staining to determine proprioceptive mechanoreceptors, and the histology and micro-CT analysis of trabecular wear.

3. Pathomechaniics of CMC arthritis: biomechanical wear, injury, genetic, and environmental causes: A variety of studies, including biomechanical testing, demographic analysis, and co-institutional study is underway.

4. Archiving, vitalizing, and innovating medical and surgical knowledge, most recently with innovative iBook monographs: a thumb CMC arthritis iBook and Anatomy iBook for patient education will be published in 2013, and the next iBook planned is congenital anomalies of the hand.


2014-15 Courses


Journal Articles

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


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

    View details for DOI 10.1016/j.jhsa.2014.11.021

    View details for PubMedID 25617217

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


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

    View details for DOI 10.1016/j.jhsa.2014.10.062

    View details for PubMedID 25542440

  • The 2014 ABJS Nicolas Andry Award: The Puzzle of the Thumb: Mobility, Stability, and Demands in Opposition CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L., Crisco, J. J., Hagert, E., Rose, J., Weiss, A. C. 2014; 472 (12): 3605-3622
  • Gendered Innovations in Orthopaedic Science: Title IX Education: Book Learnin' and Bone Mendin'. Clinical orthopaedics and related research Ladd, A. L. 2014; 472 (9): 2586-2589

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

    View details for PubMedID 24964885

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


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

    View details for DOI 10.1016/j.jbiomech.2014.05.005

    View details for PubMedID 24909332

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


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

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

    View details for Web of Science ID 000332576400016

    View details for PubMedID 23761171

  • Functional Task Kinematics of the Thumb Carpometacarpal Joint CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Luker, K. R., Aguinaldo, A., Kenney, D., Cahill-Rowley, K., Ladd, A. L. 2014; 472 (4): 1123-1129


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

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

    View details for Web of Science ID 000332576400013

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

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

    View details for PubMedID 24363184

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

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

    View details for PubMedID 24186467

  • Intra- and Interobserver Reliability of the Eaton Classification for Trapeziometacarpal Arthritis: A Systematic Review CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Berger, A. J., Momeni, A., Ladd, A. L. 2014; 472 (4): 1155-1159


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

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

    View details for Web of Science ID 000332576400017

  • Let's Talk About Sex, Baby: Gendered Innovations in Orthopaedic Science CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ladd, A. L. 2014; 472 (3): 793-795
  • Recommendation for measuring clinical outcome in distal radius fractures: a core set of domains for standardized reporting in clinical practice and research ARCHIVES OF ORTHOPAEDIC AND TRAUMA SURGERY Goldhahn, J., Beaton, D., Ladd, A., MacDermid, J., Hoang-Kim, A. 2014; 134 (2): 197-205


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

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

    View details for Web of Science ID 000330729700007

    View details for PubMedID 23728832

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


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

    View details for DOI 10.1055/s-0033-1350088

    View details for PubMedID 24436826

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


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

    View details for DOI 10.1016/j.jhsa.2012.10.038

    View details for Web of Science ID 000314739400012

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


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

    View details for DOI 10.1055/s-0033-1333683

    View details for PubMedID 24436790

  • The Scaphoid ORTHOPEDIC CLINICS OF NORTH AMERICA Sendher, R., Ladd, A. L. 2013; 44 (1): 107-?
  • The thumb carpometacarpal joint: anatomy, hormones, and biomechanics. Instructional course lectures Ladd, A. L., Weiss, A. C., Crisco, J. J., Hagert, E., Wolf, J. M., Glickel, S. Z., Yao, J. 2013; 62: 165-179


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

    View details for PubMedID 23395023

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


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

    View details for DOI 10.1016/j.ocl.2012.09.003

    View details for PubMedID 23174330

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


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

    View details for PubMedID 22992815

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


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

    View details for DOI 10.1016/j.jhsa.2012.04.027

    View details for PubMedID 22652178

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


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

    View details for DOI 10.1016/j.jhsa.2011.12.038

    View details for PubMedID 22464234

  • Innervation Patterns of Thumb Trapeziometacarpal Joint Ligaments JOURNAL OF HAND SURGERY-AMERICAN VOLUME Hagert, E., Lee, J., Ladd, A. L. 2012; 37A (4): 706-714
  • Immunofluorescent Triple-Staining Technique to Identify Sensory Nerve Endings in Human Thumb Ligaments CELLS TISSUES ORGANS Lee, J., Ladd, A., Hagert, E. 2012; 195 (5): 456-464


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

    View details for DOI 10.1159/000327725

    View details for Web of Science ID 000302872900007

    View details for PubMedID 21832813

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


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

    View details for Web of Science ID 000294093000009

    View details for PubMedID 21844613

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


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

    View details for DOI 10.1016/j.injury.2010.11.050

    View details for Web of Science ID 000287019700006

    View details for PubMedID 21159335

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


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

    View details for DOI 10.1016/j.gaitpost.2010.05.013

    View details for Web of Science ID 000283459100004

    View details for PubMedID 20558067

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


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

    View details for DOI 10.1016/j.gaitpost.2010.03.011

    View details for Web of Science ID 000279581000014

    View details for PubMedID 20378351

  • Upper-Limb Evolution and Development: Skeletons in the Closet Congenital Anomalies and Evolution's Template JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Ladd, A. L. 2009; 91A: 19-25
  • Muscle moment arms in the first dorsal extensor compartment after radial malunion. A cadaver study. journal of bone and joint surgery. American volume LaRoque, E. S., Murray, W. M., Langley, S., Hariri, S., Levine, B. P., Ladd, A. L. 2008; 90 (9): 1979-1987


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

    View details for DOI 10.2106/JBJS.G.01015

    View details for PubMedID 18762659

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

    View details for PubMedID 17533098

  • The David L. Bassett Stereoscopic Atlas of Human Anatomy: Developing a Specialized Collection within the Stanford MediaServer Digital Library PROCEEDINGS OF THE 7TH ACM/IEE JOINT CONFERENCE ON DIGITAL LIBRARIES Durack, J. C., Kung, S., Chase, R. A., Ladd, A. L., Krebs, M., Dev, P. 2007: 506-506
  • Evaluation of a surgical simulator for learning clinical anatomy MEDICAL EDUCATION Hariri, S., Rawn, C., Srivastava, S., Youngblood, P., Ladd, A. 2004; 38 (8): 896-902


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

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

    View details for Web of Science ID 000223249000017

    View details for PubMedID 15271051

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


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

    View details for DOI 10.1016/j.jse.2003.12.009

    View details for Web of Science ID 000220272700014

    View details for PubMedID 14997099

  • Norian SRS cement compared with conventional fixation in distal radial fractures - A randomized study JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Cassidy, C., Jupiter, J. B., Cohen, M., Delli-Santi, M., Fennell, C., Leinberry, C., Husband, J., Ladd, A., Seitz, W. R., Constanz, B. 2003; 85A (11): 2127-2137
  • Magnetic resonance imaging in diagnosis of chronic posterolateral rotatory instability of the elbow. American journal of orthopedics (Belle Mead, N.J.) Grafe, M. W., McAdams, T. R., Beaulieu, C. F., Ladd, A. L. 2003; 32 (10): 501-503


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

    View details for PubMedID 14620091

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


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

    View details for DOI 10.1097/01.blo.0000069886.31220.86

    View details for Web of Science ID 000183379000030

    View details for PubMedID 12782882

  • Educational tools in support of the Stanford MediaServer 2003 JOINT CONFERENCE ON DIGITAL LIBRARIES, PROCEEDINGS Stevenson, D., Chao, C. C., Srivastava, S., Durack, J. C., Ladd, A., Montgomery, K., Dev, P. 2003: 377-377
  • Reconstruction of the hand in Apert syndrome: A simplified approach PLASTIC AND RECONSTRUCTIVE SURGERY Chang, J., Danton, T. K., Ladd, A. L., Hentz, V. R. 2002; 109 (2): 465-470


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

    View details for Web of Science ID 000173678000008

    View details for PubMedID 11818821

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


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

    View details for Web of Science ID 000168987600011

    View details for PubMedID 11331546

  • Dynamic evaluation of shoulder instability using open MR imaging CARS 2000: COMPUTER ASSISTED RADIOLOGY AND SURGERY Beaulieu, C. F., Dillingham, M. F., Hodge, D. K., Butts, K., Gold, G. E., Thabit, G. H., Ladd, A. L., Bergman, A. G. 2000; 1214: 309-314
  • Use of bone-graft substitutes in distal radius fractures. journal of the American Academy of Orthopaedic Surgeons Ladd, A. L., Pliam, N. B. 1999; 7 (5): 279-290


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

    View details for PubMedID 10504355

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


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

    View details for Web of Science ID 000079315300012

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

    View details for Web of Science ID 000072129500013

    View details for PubMedID 9490938

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


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

    View details for Web of Science ID 000071405600008

    View details for PubMedID 9057146

  • Clinical comments CLINICAL JOURNAL OF SPORT MEDICINE Ladd, A. L. 1997; 7 (1): 65-65
  • Surgical treatment and postoperative splinting of recessive dystrophic epidermolysis bullosa JOURNAL OF HAND SURGERY-AMERICAN VOLUME Ladd, A. L., Kibele, A., Gibbons, S. 1996; 21A (5): 888-897


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

    View details for Web of Science ID A1996VK55300027

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


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

    View details for Web of Science ID A1996UP16900021

    View details for PubMedID 8641060

  • Functional Restoration of the Upper Extremity in Tetraplegia" in Surgery of the Hand and Upper Extremity - Vincent Hentz, A. 1996
  • Reconstructive Osteotomy for Malunion of the Distal Radius. Symposium on Problem Fractures of the Hand and Wrist Clinical Orthopaedics and Related Research Ladd, A., Huene, DS 1996; 327: 158-171
  • Diagnostic imaging of the shoulder. Journal of hand therapy Ladd, A. L. 1994; 7 (2): 84-89

    View details for PubMedID 8038881



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

    View details for Web of Science ID A1993KU60200024

    View details for PubMedID 8456670



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

    View details for Web of Science ID A1991GG33700002

    View details for PubMedID 1657007

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