Faculty Bibliography

The operative management of focal chondral lesions continues to be problematic for the treating orthopedic surgeon secondary to the limited regenerative capacity of articular cartilage. Although many treatment options are currently available, none fulfills the criteria for an ideal repair solution, including a hyaline repair tissue that completely fills the defect and integrates well with the surrounding normal cartilage. The microfracture technique is an often-utilized, first-line treatment modality for chondral lesions within the knee, resulting in the formation of a fibrocartilaginous repair tissue with inferior biochemical and biomechanical properties compared to normal hyaline cartilage. Although symptomatic improvement has been shown in the short term, concerns about the durability and longevity of the fibrocartilaginous repair have been raised. In response, a number of strategies and techniques for augmentation of the first-generation microfracture procedure have been introduced in an effort to improve repair tissue characteristics and reduce long-term deterioration. Recent experimental approaches utilize modern tissue-engineering technologies including local supplementation of chondrogenic growth factors, hyaluronic acid, or cytokine modulation. Other second-generation microfracture-based techniques use different types of scaffold-guided in situ chondroinduction. The current article presents a comprehensive overview of both the experimental and early clinical results of these developing microfracture augmentation techniques.

Tendinopathy of the long head of the biceps brachii encompasses a spectrum of pathology ranging from inflammatory tendinitis to degenerative tendinosis. Disorders of the long head of the biceps often occur in conjunction with other shoulder pathology. A thorough patient history, physical examination, and radiographic evaluation are necessary for diagnosis. Nonsurgical management, including rest, nonsteroidal anti-inflammatory drugs, physical therapy, and injections, is attempted first in patients with mild disease. Surgical management is indicated for refractory or severe disease. In addition to simple biceps tenotomy, a variety of tenodesis techniques has been described. Open biceps tenodesis has been used historically. However, promising results have recently been reported with arthroscopic tenodesis.

Originally defined as 'tenderness to palpation over the greater trochanter with the patient in the side-lying position,' greater trochanteric pain syndrome (GTPS) as a clinical entity, has expanded to include a number of disorders of the lateral, peritrochanteric space of the hip, including trochanteric bursitis, tears of the gluteus medius and minimus and external coxa saltans (snapping hip). Typically presenting with pain and reproducible tenderness in the region of the greater trochanter, buttock, or lateral thigh, GTPS is relatively common, reported to affect between 10% and 25% of the general population. Secondary to the relative paucity of information available on the diagnosis and management of components of GTPS, the presence of these pathologic entities may be underrecognized, leading to extensive workups and delays in appropriate treatment. This article aims to review the present understanding of the lesions that comprise GTPS, discussing the relevant anatomy, diagnostic workup and recommended treatment for trochanteric bursitis, gluteus medius and minimus tears, and external coxa saltans

Excision of the distal clavicle (DCE) is a commonly carried out surgical procedure used in the management of acromioclavicular joint pathology. Although successful outcomes after both open and arthroscopic distal clavicle excision occur in a high percentage of patients, treatment failures have been reported, creating a difficult clinical scenario for the treating orthopedic surgeon. The most common mode of failure after DCE is persistent pain and potential etiologies include under-resection, over-resection leading to joint instability, postoperative stiffness, heterotopic ossification, untreated concomitant shoulder pathology, and postoperative infection. Less common causes of failure include distal clavicle fracture, reossification or fusion across the acromioclavicular joint, suprascapular neuropathy, and psychiatric illness. Persistent symptoms and disability after distal clavicle excision require a careful assessment of these potential causes of treatment failure and the formulation of a treatment plan, which may include conservative care, revision surgery, or coracoclavicular ligament reconstruction. Although careful patient selection, preoperative planning, proper surgical technique, and appropriate rehabilitation during the index procedure can minimize the likelihood of poor outcome, this paper reviews the work-up and management of cases of failed distal clavicle excision

The diagnostic and therapeutic modalities utilized in the management of pelvic ring fractures depend on patient characteristics, mechanism of injury, and hemodynamic status at the time of presentation. Knowledge of the complex anatomy and biomechanics of pelvic stability may guide appropriate initial management strategies. Even with the development of specific treatment algorithms and advances in both diagnostic and operative techniques, fractures of the pelvis continue to cause significant morbidity and mortality. The current paper reviews the diagnosis and management of pelvic ring fractures, focusing on current concepts with respect to initial assessment and treatment protocols, including the identification of associated injuries and emergency methods of provisional pelvic stabilization

BACKGROUND: To date, repair of the lacertus in distal biceps tendon ruptures, recommended by some, has not been evaluated. The goal of these biomechanical experiments was to evaluate the degree to which its repair increases the strength of a distal biceps tendon repair. HYPOTHESIS: An intact or repaired lacertus fibrosus will increase the strength of a distal biceps tendon repair. STUDY DESIGN: Controlled laboratory study. METHODS: Four matched pairs of fresh-frozen human cadaveric upper extremities were prepared by isolating the lacertus fibrosus and the distal biceps tendon. The extremity was placed in a custom-built rig with the distal biceps brachii clamped and affixed to a stepper motor assembly. The distal biceps tendon was sharply removed directly from the radial tuberosity and repaired through a bony tunnel in all specimens. One side of each pair was randomized to also receive repair of the lacertus. The specimens were pulled at a constant rate until failure. RESULTS: The mean failure strength, defined as maximal strength to 15 mm of displacement, was higher in specimens with a repaired lacertus (250.2 N vs 158.2 N; P =.012), as was mean maximum strength (256.8 N v. 164.5 N; P =.0058). Mean stiffness was not significantly different (16.36 N/mm vs 13.8 N/mm; P =.58). All specimens failed due to fracture at the bony bridge. CONCLUSION: Repair of the lacertus strengthened distal biceps tendon repair in a controlled laboratory setting. CLINICAL RELEVANCE: Repair of the lacertus fibrosus as an adjunct to distal biceps tendon repair strengthens the repair in the laboratory setting. Clinical testing is needed to verify that this increased strength improves clinical results. Surgeons should be cautioned to protect the underlying neurovascular structures during repair of the lacertus fibrosus and to avoid an overly tight repair