Faculty Bibliography

BACKGROUND: Scapular notching is a unique complication of Grammont-style reverse total shoulder arthroplasty. While reverse total shoulder arthroplasty has revolutionized the treatment of pseudoparalysis secondary to cuff tear arthropathy, the implications of scapular notching with regard to patient function and implant stability remain unclear. QUESTIONS/PURPOSES: We reviewed literature to determine the etiology and incidence, radiographic progression and effect on implant stability, relationship with postoperative function, and risk factors for the development of scapular notching. METHODS: We reviewed PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE with the terms "reverse total shoulder arthroplasty" and "scapular notching." Inclusion criteria were a level of evidence of IV (or better). Twenty-four articles were selected after manual review. RESULTS: Scapular notching after reverse total shoulder arthroplasty is due to repetitive contact between the polyethylene of the humeral component and the inferior scapular neck during adduction, leading to erosion of the scapular neck, polyethylene wear, joint inflammation, and potential implant loosening. Scapular notching appears between 6 and 14 months postoperatively, with an incidence of 44% to 96%. Radiographic progression and effect on patient function remain controversial. Predictors of scapular notching include surgical approach, glenoid wear, preoperative diagnosis, infraspinatus muscle quality, cranial-caudal positioning, and tilt of the glenosphere. CONCLUSIONS: Improved understanding of the etiology and risk factors for scapular notching will lead to refinement in implant technology and surgical technique that may translate into improved patient function and implant longevity for Grammont-style reverse total shoulder arthroplasty.

BACKGROUND: Allograft tissue remains a valuable alternative for anterior cruciate ligament reconstruction. No study to date has correlated the effect of donor age to bone mineral density (BMD) in a large series of irradiated bone-patellar tendon-bone (BPTB) allograft tissue. Hypothesis/ PURPOSE: The authors attempted to correlate donor age with BMD in a large group of BPTB allograft specimens treated with low-dose gamma irradiation (1.0-1.3 Mrad) collected over a 4-year period. They hypothesized there would be no effect of donor age on the BMD of irradiated BPTB allografts. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 110 BPTB allograft specimens from 44 male and 66 female donors with a mean age of 46 years (range, 21-58 years) were analyzed. Bone mineral density data were obtained from both the patellar and tibial bone plugs of the BPTB complex. Statistical analyses were conducted using linear regression for correlations and 2-tailed Student t tests for comparisons between groups. RESULTS: The mean BMD of the patellar bone plug (0.471 g/cm(2)) was significantly greater than the mean BMD of the tibial bone plug (0.328 g/cm(2)) (P < .001). No correlation was identified between donor age and BMD for either the patella or tibial bone plugs (R(2) = .014 and .011, respectively). Both patellar and tibial BMD was significantly greater for the male grafts than the female ones. CONCLUSION: No correlation was found between donor age and BMD for irradiated BPTB allograft tissue. The patellar bone plugs were noted to have a greater BMD than the tibial bone plugs. Allograft tissue from male donors had higher BMD values than that harvested from female donors.

BACKGROUND: Recent studies have emphasized the importance of anatomic tunnel placement during anterior cruciate ligament (ACL) reconstruction in an effort to restore normal knee kinematics and stability. Secondary to the constraints imposed by a coupled drilling technique, the ability to achieve an anatomic femoral tunnel during transtibial hamstring ACL reconstruction may be limited. HYPOTHESIS: The size limitations imposed by the small-diameter tibial tunnel used in hamstring ACL reconstruction would preclude the ability to place an anatomic femoral tunnel. STUDY DESIGN: Descriptive laboratory study. METHODS: In a descriptive laboratory study, fresh-frozen human cadaveric knees fixed at 90 degrees of flexion were dissected to expose the centers of the native femoral and tibial ACL insertions. The geometry and location of each insertion were evaluated. Using a standardized starting point, tibial tunnels were drilled to the center of the tibial insertion using an 8-mm reamer. Next, a 6-mm over-the-top guide was used to position as close as possible to the anatomic femoral ACL insertion on the lateral wall, and femoral tunnels were drilled with the 8-mm reamer. For each tunnel, the location, geometry, and percentage overlap with the native insertion site were evaluated using a 3-dimensional laser scanner. RESULTS: The reamed tibial tunnel was central within the insertion site, occupying 40.4% +/- 2.0% of the native tibial insertion. Transtibial drilling resulted in femoral tunnels that were superior and posterior compared with the native femoral insertion. Thefemoral tunnel had a mean +/- SD overlap of 30.0% +/- 12.6% with the femoral insertion, with the center of the tunnel 7.6+/- 0.5 mm from the center of the native ACL femoral insertion. CONCLUSION: Based on our data using our specific starting point, during hamstring ACL reconstructions, the constraints imposed by a coupled drilling technique result in nonanatomic femoral tunnels that are superior and posterior to the native femoral insertion. CLINICAL RELEVANCE: Anatomic femoral tunnel placement during hamstring ACL reconstructions may not be possible using a coupled, transtibial drilling approach.

Treating glenohumeral arthritis in the young adult remains a significant challenge. There are a variety of etiologies that can lead to this condition, and the diagnosis is often not straightforward. With advances in both surgical techniques and biologic options, the treatment algorithm for patients with glenohumeral arthritis is constantly evolving. When nonsurgical treatment fails, there are a variety of possible surgical options, each with potential benefits. It is helpful to review the diagnostic challenges presented by these patients and understand the palliative, reparative, restorative, and reconstructive surgical options and their associated clinical outcomes, which provide a framework for clinical and surgical decision making.

CONTEXT: Lateral meniscus tears are a common entity seen in sports medicine. Although lateral-side knee pain is often the result of a meniscus injury, several extra-articular pathologies share signs and symptoms with a meniscus tear. It is critical for the clinician to be able to identify and understand extra-articular pathologies that can present similar to a lateral meniscus tear. EVIDENCE ACQUISITION: Data were collected through a thorough review of the literature conducted through a MEDLINE search for all relevant articles between 1980 and February 2010. STUDY TYPE: Clinical review. RESULTS: Common extra-articular pathologies that can mimic lateral meniscal tears include iliotibial band syndrome, proximal tibiofibular joint instability, snapping biceps femoris or popliteus tendons, and peroneal nerve compression syndrome or neuritis. The patient history, physical examination features, and radiographic findings can be used to separate these entities from the more common intra-articular knee pathologies. CONCLUSIONS: In treating patients who present with lateral-sided knee pain, clinicians should be able to recognize and treat extra-articular pathologies that can present in a similar fashion as lateral meniscus tears.

Spontaneous osteonecrosis of the knee (SPONK) and osteo necrosis in the postoperative knee (ONPK) are two clinical entities that have the potential to cause significant morbidity in affected patients. In addition to the knowledge of the patient population at risk and the classic presentation and imaging characteristics of SPONK and ONPK, the treating orthopaedic surgeon needs to maintain a high index of suspicion for these disorders since early diagnosis and treatment may allow for an improved clinical outcome. The following review presents the current knowledge regarding these two pathological processes of the knee.

Injuries to the articular cartilage of the knee are common. They alter the normal distribution of weightbearing forces and predispose patients to the development of degenerative joint disease. The management of focal chondral lesions continues to be problematic for the treating orthopaedic surgeon. Although many treatment options are currently available, none fulfill the criteria for an ideal repair solution: a hyaline repair tissue that completely fills the defect and integrates well with the surrounding normal cartilage. Autologous chondrocyte implantation (ACI) is a relatively new cell-based treatment method for full-thickness cartilage injuries that in recent years has increased in popularity, with early studies showing promising results. The current article reviews the nature of cartilage lesions in the knee and the treatment modalities utilized in their management, focusing on the role ACI plays in the surgical treatment of these complex injuries

Background Negative pressure wound dressings have revolutionized the treatment of open wounds by stimulating the formation of granulation tissue and hastening wound closure. We hypothesized that negative pressure therapy in the immediate postoperative period after total knee arthroplasty (TKA) in high-risk patients would also hasten the time to a dry wound. Methods This prospective, randomized trial compared the number of days to a dry wound after TKA with application of a negative pressure dressing compared with sterile gauze dressing in 51 patients undergoing 60 TKA surgeries (9 bilateral). Patients undergoing primary TKA who were obese (BMIZ30) and received enoxaparin were randomized to receive either a negative pressure dressing or sterile gauze for 48 hours postoperatively. The days to a dry wound, total weight of drainage, number of gauze dressings used, duration of hospital stay and infection rate were recorded. Results Twenty-four knees received negative pressure therapy and 36 knees had sterile gauze placed. There was no significant difference in the primary endpoint of days to a dry wound (4.3 days with negative pressure and 4.1 days with sterile gauze). There were two postoperative infections, one in each arm of the study. The study was stopped prematurely when 15 of 24 knees (63%) treated with the negative pressure wound dressing developed skin blisters. Conclusions Negative pressure wound therapy did not appear to hasten wound closure and was associated with blisters. There does not appear to be a benefit to the routine use of negative pressure wound dressings in the immediate postoperative TKA period. 2011 Wolters Kluwer Health | Lippincott Williams &Wilkins

The menisci have an essential function in force transmission across the knee. Injuries to the menisci are common. The indications for repair should be expanded, as the results of partial meniscectomy may deteriorate over time. Tears in younger, higher demand patients should be prepared to optimize the healing environment and be meticulously repaired, particularly in the setting of concurrent anterior cruciate ligament reconstruction. For complex, recurrent, or avascular zone tears, particularly when surgery is limited to meniscal work, consideration can be given to augmenting the repair with a fibrin clot or platelet rich plasma. Partial meniscectomy is a suitable option for lower demand or older patients. Meniscal allograft transplantation is a salvage procedure

Iliotibial band syndrome is a common overuse injury typically seen in runners, cyclists, and military recruits. Affected patients report lateral knee pain associated with repetitive motion activities. The diagnosis is usually made based on a characteristic history and physical examination, with imaging studies reserved for cases of recalcitrant disease to rule out other pathologic entities. Several etiologies have been proposed for iliotibial band syndrome, including friction of the iliotibial band against the lateral femoral epicondyle, compression of the fat and connective tissue deep to the iliotibial band, and chronic inflammation of the iliotibial band bursa. The mainstay of treatment is nonsurgical; however, in persistent or chronic cases, surgical management is indicated