Faculty Bibliography

PURPOSE: To directly compare single-loaded suture anchors (SSA) with double-loaded suture anchors (DSA) to help surgeons optimize the operative technique, time, and cost of Bankart repairs. METHODS: A literature review was performed using the PubMed and SCOPUS databases. Studies that directly compared SSA and DSA for Bankart repairs, or indirectly compared them by collecting relevant data despite a different objective, were included. RESULTS: A total of two studies were included, both of which were cadaveric laboratory studies. A total of 28 shoulders were tested. Tests conducted include loading to failure and cyclic loading. One study found SSA to be biomechanically equivalent to DSA, and one found DSA to be superior. CONCLUSIONS: Based on limited cadaveric study, DSA are at least equivalent biomechanically to SSA, and may be superior. By using DSA, surgeons create repair constructs that are as strong as, or stronger than, those made with SSA, but with fewer anchors. This reduces the amount of holes drilled and implants placed in the glenoid, while also minimizing cost. CLINICAL RELEVANCE: Quantifying the benefit of additional sutures in a suture anchor can help optimize the quality of repair, time, and cost in arthroscopic shoulder repair.

Extensor mechanism disruptions are relatively uncommon injuries involving injury to the quadriceps tendon, patella, or patellar tendon. Patellar tendon avulsions from the tibial tubercle in adults are rare; as such, little technical information has been written regarding surgical management of this injury in the adult. Transosseous-equivalent repairs have been described in the management of several types of tendon ruptures, including rotator cuff and distal triceps tendon ruptures, but not previously in patellar injuries. We present a technique for repairing an avulsion injury of the patellar tendon from the tibial tubercle using suture anchors in a transosseous-equivalent manner. This technique for treating distal patellar tendon avulsion injuries likely increases contact area at the repair site while potentially improving fixation strength.

OBJECTIVE:Identify prognostic factors after salvage surgery for recurrent sinonasal malignancy (SNM). STUDY DESIGN/METHODS:Case series with chart review. SETTING/METHODS:University of Pittsburgh Medical Center. SUBJECTS/METHODS:Forty-two patients who underwent curative surgery for locally recurrent SNM ± adjuvant therapy from June 5, 2000, to December 19, 2012. Patients without follow-up were excluded. METHODS:Chart review with established prognostic indicators for primary malignancies. Statistical analysis included Kaplan-Meier log-rank test, Fisher's exact test, Student's t test, and Cox regression. RESULTS:Forty-two patients met inclusion criteria: 38.5% developed a second recurrence, and 21.4% had metastases following treatment. The average disease-free interval (DFI) was 26.9 months (range, 2-90 months). DFI was significantly affected by ethmoid versus nonethmoid site (P = .049), histology (P = .012), carotid artery involvement (P = .008), perineural extension (P = .006), and clival invasion (P = .015). The overall survival rates at 6 months, 12 months, and 5 years following surgery were 83.3%, 69%, and 47.6%, respectively. Survival was affected by histology (P = .014), stratified grade (P = .042), tumor extension into the orbit (P = .019), carotid artery (P = .001), perineural space (P = .028), and clivus (P = .022). Complications occurred in 28.6% of patients and were associated with histology (P = .04). Length of hospital stay related to treatment was affected by histology (P = .009), grade (P = .013), and postoperative complication (P < .001). The median percentage of time hospitalized was 8%, and 43% of patients who died within 12 months spent >10% of their remaining days in the hospital. CONCLUSION/CONCLUSIONS:High-risk histologic subtype (melanoma, sinonasal undifferentiated carcinoma, adenocarcinoma, neuroendocrine cancer, sarcoma, and squamous cell carcinoma), grade, and orbital and skull base involvement negatively affect survival and/or DFI for patients with local recurrence of SNM. Improved stratification of patients can be used to guide decision making for patients with recurrent SNM and to avoid inappropriate surgery.

The use of fluoroscopy has become commonplace in many orthopaedic surgery procedures. The benefits of fluoroscopy are not without risk of radiation to patient, surgeon, and operating room staff. There is a paucity of knowledge by the average orthopaedic resident in terms proper usage and safety. Personal protective equipment, proper positioning, effective communication with the radiology technician are just of few of the ways outlined in this article to decrease the amount of radiation exposure in the operating room. This knowledge ensures that the amount of radiation exposure is as low as reasonably achievable. Currently, in the United States, guidelines for teaching radiation safety in orthopaedic surgery residency training is non-existent. In Europe, studies have also exhibited a lack of standardized teaching on the basics of radiation safety in the operating room. This review article will outline the basics of fluoroscopy and educate the reader on how to safe fluoroscopic image utilization.

IMPORTANCE/OBJECTIVE:Salvage surgery for recurrent head and neck squamous cell carcinoma (HNSCC) carries substantial risks of morbidity and mortality. Risk factors for death within 1 year should be better defined. OBJECTIVES/OBJECTIVE:To report preoperative oncologic prognostic factors predictive of short-term (<1 year) survival after salvage surgery in patients with HNSCC, to assess whether preoperative age and comorbidity predicts 1-year mortality, and to report hospital courses after salvage surgery within 1 year. DESIGN, SETTING, AND PARTICIPANTS/METHODS:A retrospective medical record review of 191 patients with recurrent HNSCC treated with salvage surgery from January 1, 2003, through December 31, 2013, at a tertiary academic center. INTERVENTIONS/METHODS:Surgical salvage of HNSCC (larynx, oral cavity, oropharynx, or hypopharynx) with curative intent. MAIN OUTCOMES AND MEASURES/METHODS:Primary outcome was survival 1 year after salvage surgery. Secondary outcomes were length of inpatient hospital stay, days of admissions, and skilled nursing facility disposition within 1 year stratified by survival status. Presalvage Charlson-Age Comorbidity Index (CACI) was calculated. Associations among CACI, oncologic risk factors, and risk of death within 1 year after salvage surgery are investigated using multivariable analysis. RESULTS:Of 191 patients studied, 53 (27.7%) died within 1 year after salvage surgery. Patients who died within 1 year had more total inpatient admissions (P < .001), longer total length of stay (P < .001), and higher risk of discharge to a skilled nursing facility (P < .001) and spent 17.3% (interquartile range, 5.2-36.3) of their remaining days in the hospital. Independent risk factors for death within 1 year are CACI (relative risk [RR], 1.43; 95% CI, 1.16-1.76), primary T3 or T4 stage (RR, 2.34; 95% CI, 1.27-4.31), and disease-free interval of less than 6 months (RR, 5.61; 95% CI, 1.78-16.7). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Medical comorbidity and age as measured by the CACI, primary T3 or T4 stage, and short disease-free interval must be considered in selecting patients ideal for surgical salvage surgery for recurrent HNSCC. Patients with these risk factors should be more strongly considered for palliative measures.

PURPOSE: Cervical spondylotic myelopathy (CSM) is a condition resulting from cervical stenosis. Manifestations of CSM include paresthesia in the extremities, loss of fine motor skills, balance problems, and bowel and bladder dysfunction in advanced disease. Laminoplasty is one surgical treatment option. The goal of laminoplasty is to reposition the laminae to expand the spinal canal, allowing the spinal cord to migrate posteriorly. There are various laminoplasty techniques; the main ones being open-door laminoplasty and double-door laminoplasty. This manuscript demonstrates a double-door laminoplasty otherwise known as a "French-door" laminoplasty discusses the indications and outcomes of this procedure. METHODS: The double-door laminoplasty creates an opening in the midline of the spinous processes and a symmetrical expansion with hinges on both laminae. Bilateral troughs are drilled on each laminae using a bur, and opened liked a French-door, allowing the spinal cord to move posteriorly in the enlarged spinal canal. The space between the gapped laminae are then stabilized by allograft. RESULTS: This manuscript presents the case of a 56-year-old man with CSM caused by multilevel cervical stenosis. The patient had classic signs and symptoms of CSM including problems with fine motor skills and walking difficulty. The video demonstrates the spinal cord decompression achieved with the French-door technique from C4 to C6 with a dome laminectomy at C3. CONCLUSIONS: There are many surgical treatments for cervical stenosis including anterior cervical discectomy and fusions and posterior procedures such as laminoplasty or laminectomy and fusion. The indications and technical pearls for French-door laminoplasty are presented as an effective option for the treatment of multilevel cervical stenosis.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:To determine if training with a chicken wing model improves performance of endoscopic endonasal surgery (EES) with microvascular dissection. STUDY DESIGN/METHODS:Randomized experimental study. METHODS:A single-blinded randomized clinical trial of trainees with various levels of endoscopic experience was conducted to determine if prior training on a nonhuman model augments endoscopic skill and efficiency in a surrogate model for live surgery. Medical students, residents, and fellows were randomized to two groups: a control group that performed an endoscopic transantral internal maxillary artery dissection on a silicone-injected anatomical specimen, and an interventional group that underwent microvascular dissection training on a chicken wing model prior to performing the anatomic dissection on the cadaver specimen. Time to completion and quality of dissection were measured. RESULTS:A Mann-Whitney test demonstrated a significant improvement in time and quality outcomes respectively across all interventional groups, with the greatest improvements seen in participants with less endoscopic experience: medical students (P = .032, P = .008), residents and fellows (P = .016, P = .032). CONCLUSIONS:Prior training on the chicken wing model improves surgical performance in a surrogate model for live EES.

One of the key risk drivers at radioactive waste disposal facilities is radioiodine, especially 129I. As iodine mobility varies greatly with iodine speciation, experiments with 129I-contaminated aquifer sediments from the Savannah River Site located in Aiken, SC, were carried out to test iodine interactions with soils and aquifer sediments. Using tracer 125I- and stable 127I- additions, it was shown that such interactions were highly dependent on I- concentrations added to sediment suspensions, contact time with the sediment, and organic carbon (OC) content, resulting in an empirical particle-water partition coefficient (Kd) that was an inverse power function of the added I- concentration. However, Kd values of organically bound 127I were 3 orders of magnitude higher than those determined after 1-2 weeks of tracer equilibration, approaching those of OC. Under ambient conditions, organo-iodine (OI) was a major fraction (67%) of the total iodine in the dissolved phase and by implication of the particulate phase. As the total concentration of amended I- increased, the fraction of detectable dissolved OI decreased. This trend, attributed to OC becoming the limiting factor in the aquifer sediment explains why at elevated I-concentrations OI is often not detected.

We report nine new families of human medium reiteration frequency interspersed repetitive elements (MER elements). They were identified by computer-assisted analyses. Six of them were independently confirmed as repetitive families by DNA-DNA hybridization, and the number of elements for each of these families was estimated by plaque hybridization assay. The involvement of some of the reported MER elements in genetic rearrangements is demonstrated.