Faculty Bibliography

INTRODUCTION: Though outcomes following ACL reconstruction are largely positive, patients' post-operative recovery is highly variable, and is typically based off generalized timetables derived from population data. In an attempt to individualize prognostic estimates and establish how biomarker concentrations may change with injury, we sampled knee joint synovial fluid from patients with ACL tears with and without associated cartilage injuries and compared biomarker concentrations to samples obtained from the contralateral non-injured knee. Method: In an institutional review board approved study, 480 patients indicated for knee arthroscopy were consented and had samples drawn to form a synovial fluid database. If no injury history or symptoms were present in the contralateral knee, samples were drawn as well. For the current study, only patients that had confirmed ACL injury at the time of arthroscopy were included. Associated cartilage injury location, size and depth was documented. Synovial fluid samples were centrifuged, and the concentrations of 20 biomarkers were determined using a multiplex magnetic bead immunoassay. Concentrations were then compared between the three study groups (ACL tear with cartilage injury, ACL tears without cartilage injury, and healthy contralateral knees) using a Welch ANOVA test with pairwise comparisons. Results: The study included samples from 132 knees: 34 ACL tears without cartilage injury (mean age 34.0 years); 28 ACL tears with cartilage injury (mean age 36.3 years), and 72 contralateral knees (41.1 years). ANOVA testing demonstrated significant differences among groups for: MMP-3 (p>001); TIMP-1 (p=.001); TIMP-2 (p=.015); FGF-2 (p=.011); IL-6 (p=.001); and MlP-lb (p=001). Pairwise comparisons demonstrated no significant differences between ACL tears with, and without cartilage damage, but did show both types of ACL tears had significantly higher concentrations of MMP-3, TIMP-1, IL-6, and MlP-lb than contralaterals. ACL tears without cartilage damage had significantly lower concentrations of TIMP-2 and FGF-2 (13) than contralaterals (Table 1). Discussion: The course from surgery to symptomatic relief and functional improvement following ACL reconstruction is highly variable. Data from the current study demonstrated that cytokine concentrations are significantly different between ACL tears (+/- cartilage damage) and healthy knees. SIGNIFICANCE: These validated differences can help establish synovial fluid biomarker analysis as a method for injury stratification ultimately providing patient-specific prognostic data

The ulnar collateral ligament (UCL) of the elbow acts as the primary restraint to valgus force experienced in the late cocking and early acceleration phases of overhead throwing. If the UCL or dynamic flexor-pronator musculature is incompetent, elbow extension and valgus torque, as seen in throwing, can result in posteromedial impingement with subsequent chondromalacia and osteophyte formation. Before the first UCL reconstruction, performed by Frank Jobe in 1974, this injury was considered career ending in overhead athletes. Since the index procedure, further techniques have been developed to minimize dissection of the flexor-pronator mass and improve the biomechanical strength of graft fixation with the goal of increased return to athletic competition. We describe our technique-including pearls and pitfalls, as well as advantages and disadvantages-which combines the docking technique, through a flexor muscle-elevating approach with transposition of the ulnar nerve using a fascial sling. Harvest and preparation of a palmaris longus tendon autograft is also described.

Objectives: Introduction: Though outcomes following ACL reconstruction are largely positive, patients' postoperative recovery is highly variable, and is typically based off generalized timetables derived from population data. In an attempt to individualize prognostic estimates and establish how biomarker concentrations may change with injury, we sampled knee joint synovial fluid from patients with ACL tears with and without associated cartilage injuries and compared biomarker concentrations to samples obtained from the contralateral non-injured knee. Methods: 480 patients indicated for knee arthroscopy had samples drawn to form a synovial fluid database. If no injury history or symptoms were present in the contralateral knee, samples were drawn as well. For the current study, only patients that had confirmed ACL injury at the time of arthroscopy were included. Associated cartilage injury location, size and depth was documented. Synovial fluid samples were centrifuged, and the concentrations of 20 biomarkers were determined using a multiplex magnetic bead immunoassay. Concentrations were then compared between the three study groups (ACL tear with cartilage injury, ACL tears without cartilage injury, and healthy contralateral knees) using a Welch ANOVA test with pairwise comparisons. Results: The study included samples from 132 knees: 34 ACL tears without cartilage injury (mean age 34.0 years); 28 ACL tears with cartilage injury (mean age 36.3 years), and 72 contralateral knees (41.1 years). ANOVA testing demonstrated significant differences among groups for: MMP-3 (p>001); TIMP-1 (p=.001); TIMP-2 (p=.015); FGF-2 (p=.011); IL-6 (p=.001); and MIP-1b (p=.001). Pairwise comparisons demonstrated no significant differences between ACL tears with, and without cartilage damage, but did show both types of ACL tears had significantly higher concentrations of MMP-3, TIMP-1, IL-6, and MIP-1b than contralaterals. ACL tears without cartilage damage had significantly lower concentrations of TIMP-2 and FGF-2 (13) than contralaterals (Table 1). Conclusion: The course from surgery to symptomatic relief and functional improvement following ACL reconstruction is highly variable. Data from the current study demonstrated that cytokine concentrations are significantly different between ACL tears (+/- cartilage damage) and healthy knees. These validated differences can help establish synovial fluid biomarker analysis as a method for injury stratification ultimately providing patientspecific prognostic data. (Table Presented)

Objectives: Proper surgical planning requires accurate and reliable pre-operative patient information. The more comprehensive the data, the more the surgeon can tailor a general surgical technique to an individual patient's unique anatomy. A previous retrospective study demonstrated that three-dimensional magnetic resonance imaging more accurately characterized rotator cuff tears compared to two-dimensional images when checked against intraoperative pictures. The purpose of this study was to determine if three-dimensional MRI imaging would continue to be more accurate than two-dimensional imaging in a prospective study. Methods: Patients were prospectively included if they had a full-thickness primary rotator cuff tear on pre-operative MRI. Intra-op videos were taken from the posterior and lateral portals, with a grasper fully mobilizing the torn tendon in each view. 7 surgeons then reviewed the videos and independently characterized the shape of the tears into crescent, U-shaped tears, L-shaped tears, or massive tears. This was considered the gold-standard. Two musculoskeletal radiologists reviewed the corresponding MRI studies independently and blind to the arthroscopic findings and characterized the shape on the basis of the tear's retraction and size 2D MRI. The 3D reconstructions of each cuff tear were reviewed by each radiologist to characterize the shape. Statistical analysis included 95% confidence intervals and fleiss's kappa. Results: 37 patients were enrolled in the study. Among the 7 surgeons, agreement on cuff tear was 93% ( =.87). The accuracy for differentiating between crescent-shaped, longitudinal, and massive tears using measurements on 2D MRI was 73.4% for reader 1 and 71.2% for reader 2. The accuracy for tear shape characterization into crescent and longitudinal U- or L-shaped using 3D MRI was 92% for reader 1 and 94% for reader 2. When further characterizing the longitudinal tears as massive or not using 3D MRI, both readers had an accuracy of 83%. The overall accuracy of 3D MRI was 91%, significantly different (P=.07) from 2D MRI accuracy (70.4). Conclusion: Our study has demonstrated that 3D MR reconstructions of the rotator cuff improve the accuracy of characterizing rotator cuff tear shapes compared with current 2D MRI-based techniques. (Figure Presented)

The Latarjet procedure involves the transfer of the coracoid process with its soft tissue attachments, thereby providing both bony and soft tissue articular reinforcement for glenohumeral stabilization. Most studies show positive outcomes with this procedure and complications at rates as low as 1%, predominately secondary to technical error. We present a case of recurrent anterior instability after two attempts at soft tissue stabilization (arthroscopic labral repair followed by open inferior capsular shift) in which an open Latarjet procedure was performed followed by subsequent revision secondary to coracoid autograft fracture. The case presented specifically highlights the need to appropriately identify the "bony margins" of the coracoid prior to drilling to make certain that drill holes are not eccentrically placed.

Knee pain in young, active patients with meniscus-deficient knees and articular cartilage damage can present a challenge to treatment. Meniscal allograft transplantation (MAT) has shown good clinical results as treatment for meniscus deficiency; however, worse outcomes have been observed in patients with significant chondral damage. The development of chondral restorative techniques such as osteochondral allograft transplantation (OCA) has expanded the population of patients who may benefit from MAT. We present a case of proximal tibial osteochondral and lateral meniscal allograft transplant. This review includes a sample of patient examinations and imaging, followed by a detailed technical description of the case. The technique article concludes with a discussion on the niche combined MAT-OCA procedures occupy in the patient treatment realm.

INTRODUCTION: Ultrasonography offers a fast and inexpensive method to evaluate the rotator cuff in the office setting. However, the accuracy of ultrasound is highly user dependent. The purpose of this study is to investigate the learning curve of an orthopaedic surgeon in using ultrasound to diagnose rotator cuff tears. METHODS: A sports medicine fellowship trained orthopaedic surgeon was taught how to perform and interpret an ultrasound examination of the shoulder by a musculoskeletal radiologist. In this prospective study, subjects were patients who presented to the office with shoulder pain suspected to be consistent with rotator cuff pathology, either complete or partial tears. The surgeon was blinded to magnetic resonance imaging (MRI) results and performed the ultrasound after performing a physical exam. Based on ultrasound and exam, the surgeon assessed if the rotator cuff was intact (no tear) or torn (having a partial or full thickness tear). Results were compared to MRI findings and arthroscopic findings (when available), and accuracy was evaluated over time to determine overall accuracy and if significant learning and improvement in accuracy took place over the time period studied. RESULTS: Eighty patients were enrolled in the study; seventy-four had an MRI within 3 months of the ultrasound and were available for evaluation. Nineteen patients underwent ultrasound, MRI, and arthroscopy. Ultrasound was able to accurately diagnose the correct rotator cuff pathology (no tear, a partial thickness tear, or a full thickness tear) in 61% of patients. Ultrasound accurately diagnosed simply the presence or absence of a tear in 74% of patients. There was a general trend toward improved accuracy as the investigator gained experience, with accuracy rates of approximately 51% for the first 40 patients, and 69% for the last 40 patients evaluated, although this difference was not statistically significant (p = 0.154). DISCUSSION: Ultrasound imaging requires significant training and practice to provide a clinically useful level of diagnostic accuracy. The applicability of this procedure for diagnosing primary rotator cuff tears in an orthopaedic office setting may be limited by the time and volume required for the practitioner to approach the accuracy reported for diagnostic ultrasound and MRI in the literature.

In cases of chronic distal biceps ruptures, the combination of muscle atrophy, distal tendon retraction, and fibrosis makes primary anatomic reattachment of the tendon particularly challenging. To regain tendon length and avoid flexion contractures, reconstruction with graft augmentation has been proposed as an alternative for cases not amenable to primary repair. We describe our technique using an Achilles allograft through a modified Henry approach to reconstruct the distal biceps tendon to regain length as well as restore flexion and supination strength. With proper and detailed exposure, chronic distal biceps injuries can be reconstructed safely and efficaciously using an Achilles allograft.