Faculty Bibliography

PURPOSE/OBJECTIVE:To correlate the histopathologic appearances of resected long head of the biceps tendon (LHBT) specimens following biceps tenodesis, with pre-operative MRI and arthroscopic findings, with attention to the radiologically normal biceps. MATERIAL AND METHODS/METHODS:Retrospective analysis of patients who had undergone preoperative MRI, subsequent arthroscopic subpectoral tenodesis for SLAP tears and histopathologic inspection of the excised sample between 2013 and 16. Those with a normal MRI appearance or mildly increased intrasubstance signal were independently analyzed by 2 blinded radiologists. A blinded orthopedic surgeon and pathologist reviewed all operative imaging and pathologic slides, respectively. RESULTS:Twenty-three LHBT resected samples were identified on MRI as either normal (Reader 1 n = 15; Reader 2 n = 14) or demonstrating low-grade increased signal (Reader 1 n = 8; Reader 2 n = 9). Of these, 86.9% demonstrated a histopathological abnormality. 50% of samples with histopathological abnormality demonstrated normal appearance on MRI. The most common reported histopathology finding was myxoid degeneration (73.9%) and fibrosis (52.2%). The most common arthroscopic abnormality was fraying (18.2%) and erythema (13.6%). Utilizing histopathology as the gold standard, the two radiologists demonstrated a sensitivity of 35.0% v 42.9%, specificity of 66.7% v 100%, PPV of 87.5% v 100%, and NPV of 13.3% v 14.3%. Corresponding arthroscopic inspection demonstrated a sensitivity of 31.6%, specificity of 66.6%, PPV 85.7% and NPV of 13.3%. There was moderate agreement between the two radiologists, κ = 0.534 (95% CI, 0.177 to 0.891), p = 0.01. CONCLUSION/CONCLUSIONS:Histopathological features of low grade tendinosis including mainly myxoid degeneration and fibrosis are frequently occult on MR imaging.

Meniscal tears are common injuries that may result in functionally limiting pain, swelling, and mechanical symptoms. The management of meniscal pathology has evolved as surgeons' understanding of the important role the menisci play in normal knee kinematics increases. Recent emphasis on partial meniscectomy, expanding indications for meniscal repair, and the increased use of meniscal allograft transplantation have helped improve the outcomes of patients with a meniscal tear who undergo treatment. Orthopaedic surgeons should understand meniscal function, pathology, and treatment approaches.

While yoga has been widely studied for its benefits to many health conditions, little research has been performed on the nature of musculoskeletal injuries occurring during yoga practice. Yoga is considered to be generally safe, however, injury can occur in nearly any part of the body-especially the neck, shoulders, lumbar spine, hamstrings, and knees. As broad interest in yoga grows, so will the number of patients presenting with yoga-related injuries. In this literature review, the prevalence, types of injuries, forms of yoga related with injury, specific poses (asanas) associated with injury, and preventive measures are discussed in order to familiarize practitioners with yoga-related injuries.

Orthobiologics are organic and synthetic materials that are used in and outside of the operating room to augment both bone and soft tissue healing. The orthobiologics portfolio has vastly expanded over the years, and it has become imperative for orthopedic surgeons to understand the role and function of this new class of biologic adjuvants. This review will highlight key components and product groups that may be relevant for the practicing orthopedic surgeon in any subspecialty. This by no means is an extensive list of the available products but provides an important overview of the most highlighted products available in the market today. Those discussed include, bone void fillers, extracelluar matrix (ECM) products, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). These are further categorized into their uses in several subspecialties including, traumatology, sports medicine, sports surgery, and spine surgery.

Meniscal tears are common injuries that may result in functionally limiting pain, swelling, and mechanical symptoms. The management of meniscal pathology has evolved as surgeons' understanding of the important role the menisci play in normal knee kinematics increases. Recent emphasis on partial meniscectomy, expanding indications for meniscal repair, and the increased use of meniscal allograft transplantation have helped improve the outcomes of patients with a meniscal tear who undergo treatment. Orthopaedic surgeons should understand meniscal function, pathology, and treatment approaches.

Management of proximal and distal biceps tendon pathology is evolving. The long head of the biceps tendon, if inflamed, may be a pain-producing structure. In appropriately indicated patients, a symptomatic long head of the biceps tendon can be surgically managed via tenotomy, tenodesis, and/or superior labrum anterior to posterior repair. In some patients, primary superior labrum anterior to posterior pathology can be managed via biceps tenodesis. Determining which procedure is most appropriate for and which technique and implant are preferred in a given patient with biceps tendon pathology is controversial. Less debate exists with regard to the timing of distal biceps tendon repair; however, considerable controversy exists with regard to selection of an appropriate surgical technique and implant. In addition, the treatment of patients with a chronic and/or retracted distal biceps tendon tear and patients in whom distal biceps tendon repair fails is extremely challenging. Orthopaedic surgeons should understand the anatomy of, nonsurgical and surgical treatment options for, and outcomes of patients with proximal or distal biceps tendon pathology.

Introduction/UNASSIGNED:Rupture of the distal biceps brachii results in significant weakness and limitation of function in those affected. Acute ruptures of the biceps tendon are generally best treated with early repair, ideally within 3weeks of injury. The preferred treatment of chronic ruptures is still uncertain. Case Report/UNASSIGNED:We present a case of a chronic distal biceps tendon rupture repaired with a novel, two-incision, minimally invasive anterior approach utilizing an Achilles tendon allograft and cortical button fixation, in a patient with a high demand occupation as a cabinet maker. Conclusion/UNASSIGNED:Numerous surgical techniques have been described for the repair or reconstruction of chronic distal biceps ruptures. Most described techniques have utilized an extensile anterior approach or an extensile anterior approach combined with another posterolateral incision. We believe that this minimally invasive approach allows for better cosmesis and quicker recovery and return to work in patients with high demand occupations.

PURPOSE OF REVIEW/OBJECTIVE:Accurate isolated PCL diagnosis continues to present a challenge. This article reviews the current literature regarding clinical and radiographic evaluation of PCL injuries. RECENT FINDINGS/RESULTS:A thorough history to understand the mechanism of injury should begin any evaluation. Several clinical tests have been shown to effectively assess PCL laxity, with the posterior drawer test possessing the highest sensitivity and specificity. Any thorough exam should compare the contralateral, uninjured leg. If a PCL or multi-ligament injury is suspected, plain radiographs should be performed to avoid missing a fracture or avulsion. An MRI represents the current gold standard for diagnosing ligament injuries in the knee and should always be obtained in these cases. Due to the significant incidence of nerve injuries (25%) and vascular injuries (18%) with knee dislocations, any suspicion of neurovascular compromise necessitates further studies. A combination of a thorough clinical history and examination, followed by appropriate imaging optimizes PCL and multi-ligament injury evaluation.

PURPOSE/OBJECTIVE:To utilize MRI to assess the relationship between BMI, peripheral soft tissue composition about the knee, and surgical outcomes in patients undergoing primary ACL reconstruction. It was hypothesized that a fatty periarticular soft tissue composition may be better than BMI at predicting poor outcomes after ACL reconstruction. METHODS:Fifty-eight patients who underwent primary acute ACL reconstruction were identified from the surgical database and their data were retrospectively reviewed. Patients were selected based on availability of 2-year IKDC outcome scores, BMI data, and preoperative MRI studies. To approximate peripheral soft tissue composition, novel measurements of axial MRI images were employed using PACS ROI measurement tool. Relationships were assessed between IKDC outcome scores and measures of body habitus including BMI, total knee area, knee fatty-connective tissue area, and fatty-connective tissue to bone size ratio. RESULTS:(range 18.5-36.9). Median IKDC score was 81.0 (range 46-100). BMI was correlated with total knee area (R = 0.72) and periarticular fat (R = 0.53). Neither continuous BMI (n.s.) nor total knee area (n.s.) was predictor of IKDC outcomes scores. Periarticular fatty-connective tissue trended towards predicting negative outcomes (n.s.). Periarticular fatty-connective tissue to bone size ratio was a significant negative predictor of IKDC scores (p = 0.03). Patients with more fat than bone on axial MRI (ratio > 1, N = 34) reported a lower mean IKDC score compared to patients with a ratio < 1 (N = 24) (77.2 vs. 87.7, p = 0.0028). The top quartile (N = 14) of these ratios reported a mean IKDC score of 68.9, compared to 87.3 of the bottom quartile (p = 0.0001). CONCLUSIONS:Periarticular soft tissue composition, as approximated by the novel MRI analysis of this study, is a better predictor of outcomes following ACL reconstruction than is BMI. This information can be utilized in guiding surgeon and patient expectations following surgery, either via a direct application of these measurements or heightened awareness of the importance of peripheral body habitus. LEVEL OF EVIDENCE/METHODS:III.