Faculty Bibliography

Varus or valgus malalignment of the lower extremity can alter the load distribution across the knee and hasten the development of focal osteoarthritis. Although knee arthroplasty remains an effective option for end-stage arthritis, it is not typically recommended in the young, active patient. In the setting of painful unicompartmental cartilage injury in a mechanically malaligned limb, alignment correction by osteotomy has been shown to slow the progression of osteoarthritis and lessen pain. In this review, we will discuss the different options, indications, and techniques for osteotomies about the knee.

RATIONALE AND OBJECTIVES: The objectives of this study were to investigate the changes in compartment-specific subchondral bone marrow lipids of femoral-tibial bone in acute anterior cruciate ligament (ACL)-injured patients compared to that of healthy volunteers and patients with osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 2-3). MATERIALS AND METHODS: A total of 55 subjects were recruited in the study and subdivided into three subgroups: 17 healthy controls (4 females, 13 males; mean age = 41 +/- 16, age range 24-78 years), 17 patients with acute ACL injury (3 females, 14 males; mean age = 30 +/- 11, age range 18-61 years), and 21 patients with KL2-3 OA (12 females, 9 males; mean age = 65 +/- 12, age range 44-89 years). Routine clinical proton density-weighted fast spin echo images in sagittal (without fat saturation), axial, and coronal (fat saturation) planes were acquired on a 3 T clinical scanner for cartilage morphology using Whole-Organ Magnetic Resonance Imaging Score grading. A voxel of 10 x 10 x 10 mm3 was positioned in the medial and lateral compartments of the tibia and femur for proton magnetic resonance spectroscopy measurements using the single voxel stimulated echo acquisition mode pulse sequence. All proton magnetic resonance data were processed with Java-based magnetic resonance user interface. Wilcoxon rank sum test and mixed model two-way analysis of variance were performed to determine significant differences between different compartments and examine the effect of ACL injury, OA grade and compartment, and their interactions. RESULTS: The index of unsaturation in lateral tibial compartment in ACL-injured patients was significantly higher (P < .05) than all compartments except lateral femoral in patients with KL2-3 OA. Significantly lower values (P < .05) were also identified in saturated lipids at 2.03 ppm in all compartments in ACL-injured patients than those of all compartments in patients with KL2-3 OA. CONCLUSIONS: The preliminary results suggest that the indices of unsaturation in the lateral tibial compartment and the peaks of saturated lipids at 1.3 and 2.03 ppm in medial tibial compartment may be clinically useful to characterize subchondral bone marrow among healthy controls, acute ACL-injured patients, and patients with OA.

Tendon-to-bone healing is vital to the ultimate success of the various surgical procedures performed to repair injured tendons. Achieving tendon-to-bone healing that is functionally and biologically similar to native anatomy can be challenging because of the limited regeneration capacity of the tendon-bone interface. Orthopaedic basic-science research strategies aiming to augment tendon-to-bone healing include the use of osteoinductive growth factors, platelet-rich plasma, gene therapy, enveloping the grafts with periosteum, osteoconductive materials, cell-based therapies, biodegradable scaffolds, and biomimetic patches. Low-intensity pulsed ultrasound and extracorporeal shockwave treatment may affect tendon-to-bone healing by means of mechanical forces that stimulate biological cascades at the insertion site. Application of various loading methods and immobilization times influence the stress forces acting on the recently repaired tendon-to-bone attachment, which eventually may change the biological dynamics of the interface. Other approaches, such as the use of coated sutures and interference screws, aim to deliver biological factors while achieving mechanical stability by means of various fixators. Controlled Level-I human trials are required to confirm the promising results from in vitro or animal research studies elucidating the mechanisms underlying tendon-to-bone healing and to translate these results into clinical practice.

OBJECTIVE: To assess the ability of 3D MR shoulder reconstructions to accurately quantify glenoid bone loss in the clinical setting using findings at the time of arthroscopy as the gold standard. MATERIALS AND METHODS: Retrospective review of patients with MR shoulder studies that included 3D MR reconstructions (3D MR) produced using an axial Dixon 3D-T1W-FLASH sequence at our institution was conducted with the following inclusion criteria: history of anterior shoulder dislocation, arthroscopy (OR) performed within 6 months of the MRI, and an estimate of glenoid bone loss made in the OR using the bare-spot method. Two musculoskeletal radiologists produced estimates of bone loss along the glenoid width, measured in mm and %, on 3D MR using the best-fit circle method, which were then compared to the OR measurements. RESULTS: There were a total of 15 patients (13 men, two women; mean age, 28, range, 19-51 years). There was no significant difference, on average, between the MRI (mean 3.4 mm/12.6 %; range, 0-30 %) and OR (mean, 12.7 %; range, 0-30 %) measurements of glenoid bone loss (p = 0.767). A 95 % confidence interval for the mean absolute error extended from 0.45-2.21 %, implying that, when averaged over all patients, the true mean absolute error of the MRI measurements relative to the OR measurements is expected to be less than 2.21 %. Inter-reader agreement between the two readers had an IC of 0.92 and CC of 0.90 in terms of percentage of bone loss. CONCLUSIONS: 3D MR reconstructions of the shoulder can be used to accurately measure glenoid bone loss.

Objectives: Tenodesis of the long head of the biceps is one of many options to reduce pain caused by proximal long head insertional tendinopathy, tendon instability, or part of a superior labrum anterior-posterior lesion. This technique can be performed either as an open or arthroscopic procedure. The purpose of this study is to compare the relative incidence and demographics of patients who underwent either an arthroscopy or open biceps tenodesis procedure in New York State from 2002-2010. Methods: Retrospective review of patients who underwent open or arthroscopic biceps tenodesis surgery were identified from the New York State Statewide Planning and Research Commission (SPARCS) ambulatory surgery database, which includes all outpatient surgeries performed at hospitals, outpatient surgical centers, and rural clinics in New York State. Cases of open and arthroscopic biceps tenodesis were identified by unique Current Procedural Terminology codes (23430, 29828). Data from 2002 to 2010 were available for open procedures and from 2008 to 2010 for arthroscopic procedures. Chi-square test and student's t-test were used to analyze the data. Variables measured included incidence, age, gender, race, ethnicity, type of operating facility, and primary payor. Results: From 2002 to 2010 the incidence of biceps tenodesis rose over 600%. From 2008 to 2010 there were 2672 open biceps tenodesis procedures and 3289 arthroscopic biceps tenodesis procedures performed in New York State. The arthroscopic group contained significantly more women (33%) than the open group (25%, P<.0001). The average age arthroscopic patients was slightly higher (55.33 years) than that of open patients (54.45 years, P<.01). There was a significantly greater proportion of African- American patients in the arthroscopic group. Patients undergoing arthroscopic surgery were more likely to be treated at a hospital as opposed to a free standing clinic. The most common primary payor for open cases was worker's compensation at 22% of all cases. Of arthroscopic patients, 18% listed worker's compensation as the primary payor. Medicare patients accounted for 16% of open cases and 19% of arthroscopic patients (P<.001). Conclusion: Incidence of biceps tenodesis surgery has increased steadily from 2002 to 2010. There were 23% more arthroscopic procedures performed in 2010 than there were in 2008. Arthroscopic patients are more likely to be older, female, and African American. Arthroscopic biceps tenodeis, which require additional skill and training, were more likely to be performed in a hospital setting

BACKGROUND: Because current instrumentation makes it possible to perform an arthroscopic transosseous rotator cuff repair, we performed a biomechanical comparison of a double-row transosseous equivalent rotator cuff repair using suture anchors to an arthroscopic, transosseous rotator cuff repair to determine if they provided similar fixation stability. METHODS: Six pairs of shoulders were used. One of each pair had a standard double row, transosseous equivalent arthroscopic rotator cuff repair using a suture-bridge technique with suture anchors, and the other had an arthroscopic transosseous repair using an Xbox technique. The repairs were cycled at 150 N for 10,000 cycles with movement of the lateral cuff edge recorded and then tested to failure. RESULTS: The total cuff edge displacement at 10,000 cycles in the anchor group (transosseous equivalent repair) was 7.9 mm and 6.3 mm for the bone tunnel group (transosseous repair); these were not significantly different (p=0.19). The anchor group failed at an average of 309 N and the bone tunnel group at an average of 339 N (p=0.22). DISCUSSION: Biomechanical testing suggests that arthroscopic, transosseous rotator cuff repair using a Xbox suture configuration is similar in strength and stability to an arthroscopic transosseous equivalent suture-bridge repair. Both techniques demonstrated difficulty in maintaining the lateral position of the tendon.

Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.