Faculty Bibliography

OBJECTIVE:To determine the 50 most cited articles in orthopedic cartilage surgery and their characteristics. DESIGN/METHODS:A systematic review of the Science Citation Index Expanded was performed for articles related to cartilage surgery published in the 66 journals under the category "Orthopedics." The 50 most cited articles were determined, and the following characteristics were analyzed for each article: authors, journal and year of publication, number of citations, geographic origin, article type (basic science or clinical), article subtype by study design, and level of evidence. Citation density (total number of citations/years since publication) was also computed. RESULTS:The 50 most cited articles ranged from 989 to 172 citations, with citation density ranging from 71.5 to 4.1. The publication years spanned from 1968 to 2008, with the 2000s accounting for half (25) of the articles and the highest mean citation density (14.6). The 50 most cited articles were published in 11 journals. The majority of the articles (29) were clinical, with level IV representing the most common level of evidence (10). The remaining basic science articles were most commonly animal in vivo studies (14). Stronger level of evidence was correlated with overall number of citations (P = 0.044), citation density (P < 0.001), and year of publication (P = 0.003). CONCLUSIONS:Articles with stronger levels of evidence are more highly cited, with an increasing trend as evidence-based practice has been emphasized. This article list provides clinicians, researchers, and trainees with a group of "citation classics" in orthopedic cartilage surgery.

IMPORTANCE:Synovial cell sarcoma of the head and neck (SCSHN) is a rare tumor associated with significant morbidity and mortality. The literature regarding these tumors is limited to case series and case reports. We used data from the population-based US Surveillance, Epidemiology, and End Results (SEER) cancer registry to determine factors affecting both overall survival and disease-specific survival of patients with SCSHN. OBJECTIVE:To determine the clinicopathologic and therapeutic factors determining survival in patients with SCSHN. DESIGN, SETTING, AND PARTICIPANTS:The SEER registry was reviewed for patients with primary SCSHN from January 1, 1973, to January 1, 2011. MAIN OUTCOMES AND MEASURES:Overall survival (OS) and disease-specific survival. RESULTS:A total of 167 cases of SCSHN were identified. The mean (SD) age at diagnosis was 37.9 (17.3) years, and 100 (59.9%) of the patients were males. The monophasic spindle cell and biphasic variants were the most common histologic subtypes. Surgical resection and radiotherapy were performed in 150 (89.8%) and 108 (64.7%) of the cases, respectively. The median OS at 2, 5, and 10 years was 77%, 66%, and 53%, respectively. Univariate Kaplan-Meier survival analysis revealed that age, race, and tumor stage and size were associated with improved survival. Histologic subtype was not associated with significant differences in survival. Radiotherapy was associated with improved disease-specific survival (hazard ratio [HR], 0.29 [95% CI, 0.12-0.68]; P = .003), but surgical management was not associated with improved survival (HR, 0.52 [95% CI, 0.19-1.46]; P = .21). Multivariate Cox regression analysis revealed that size greater than 5 cm (adjusted HR, 3.60 [95% CI, 1.43-9.08]; P = .007) and stage at presentation (adjusted HR, 3.86 [95% CI, 2.01-7.44]; P < .001) were independent determinants of OS. In separate analysis of cohorts with tumors 5 cm or less and larger than 5 cm, stage at presentation was found to be a significant indicator of the probability of survival in both cohorts (adjusted HR, 3.10 [95% CI, 1.46-6.60]; P = .003 and 5.32 [95% CI, 1.49-18.98]; P = .01, respectively); surgical resection and radiotherapy were not associated with differential survival outcomes using this model. CONCLUSIONS AND RELEVANCE:Synovial cell sarcoma of the head and neck is rare. Independent significant determinants of survival include size (>5 cm) and stage at presentation. Histologic subtype of the tumor is not a significant indicator of the probability of survival. Surgical resection and radiotherapy were not independent determinants of survival.

Previously, we reported on the implantation of electrospun polycaprolactone (PCL) grafts for use in ACL tissue engineering in a small animal model. In the present study, we hypothesized that grafts fabricated from ultra-high molecular weight polycaprolactone (UHMWPCL) would have similarly favorable biologic properties but superior mechanical properties as compared to grafts fabricated from PCL. Two forms of polycaprolactone were obtained (UHMWPCL, MW = 500 kD, and PCL, MW = 80 kD) and electrospun into scaffolds that were used to perform ACL reconstruction in 7-8 week old male Lewis rats. The following groups were examined: UHMWPCL, PCL, flexor digitorum longus (FDL) allograft, native ACL, as well as sham surgery in which the ACL was transsected. At 16 weeks post-operatively, biomechanical testing, histology, and immunohistochemistry (IHC) were performed. Analysis of cellularity indicated that there was no significant difference among the UHMWPCL, PCL, and FDL allograft groups. Quantification of birefringence from picrosirius red staining demonstrated significantly more aligned collagen fibers in the allograft than the PCL group, but no difference between the UHMWPCL and allograft groups. The peak load to failure of the UHMWPCL grafts was significantly higher than PCL, and not significantly different from FDL allograft. This in vivo study establishes the superiority of the higher molecular weight version of polycaprolactone over PCL as a scaffold material for ACL reconstruction. By 16 weeks after implantation, the UHMWPCL grafts were not significantly different from the FDL allografts in terms of cellularity, peak load to failure, stiffness, and collagen fiber alignment. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:828-835, 2016.

OBJECTIVE:To describe the incidence and determinants of survival of patients with sinonasal undifferentiated carcinoma (SNUC) from 1973 to 2011 using the SEER database (Surveillance, Epidemiology, and End Results), with consideration of tumor stage based on the Kadish system. STUDY DESIGN/METHODS:Retrospective database analysis. SETTING/METHODS:Academic medical center. SUBJECTS AND METHODS/METHODS:The SEER registry was utilized to calculate survival trends for 328 patients with SNUC between 1973 and 2011. Patient data were then analyzed with respect to histopathology, age, sex, race, subsite, modified Kadish stage, tumor size, and treatments rendered. RESULTS:The cohort was composed of 61.9% males with median age of 60 years. The median overall survival (OS) was 1.9 years. Most tumors presented in the nasal cavity, maxillary sinus, and ethmoid sinus (29.3%, 27.4%, 21%, respectively); 43.7% of patients received both surgical and radiation therapy. OS at 2, 5, and 10 years was 43%, 30%, and 25%, respectively. On univariate analysis, age, Kadish stage, and tumor size were associated with worse OS and disease-specific survival (DSS), while surgery and radiation therapy were associated with improved OS and DSS (all P < .05). On multivariate analysis, radiation therapy and lower Kadish stage were associated with improved OS and DSS, while younger age was additionally associated with improved OS (all P < .05). CONCLUSION/CONCLUSIONS:SNUC is a rare but aggressive sinonasal malignancy. Tumor stage as determined by the Kadish system is associated with worse survival, with radiation therapy appearing to play a key role in therapeutic management.

PURPOSE/OBJECTIVE:To evaluate the utilization and charges related to physical therapy (PT) after rotator cuff repair in privately insured and Medicare patients and between arthroscopic and open/mini-open repair techniques. METHODS:The PearlDiver insurance database was queried for patients receiving postoperative PT using Current Procedural Terminology codes. Data were available from 2007 to 2011 for United Healthcare and from 2005 to 2011 for Medicare patients. Patients undergoing arthroscopic (CPT 29827) or open/mini-open approaches (CPT 23410, 23412, 23420) were identified in both populations. Utilization was determined by both the percentage of patients with at least one postoperative PT-related code and the average number of encounters per patient. Per-patient average charge was determined by dividing total charges within the billing period by the patient total. RESULTS:A total of 365,891 patients undergoing rotator cuff repair were identified. There was an increase in the number of arthroscopic repairs (+29.1%, P = .027, United Healthcare; +78.9%, P < .001, Medicare) and a decrease in the number of open/mini-open repairs (-18.2%, P = .038, United Healthcare; -18.2%, P < .001, Medicare) across the study period. At 6 months postoperatively, PT utilization was greater in the United Healthcare groups (82.9% arthroscopic, 81.0% open/mini-open) than in the Medicare groups (41.8% arthroscopic, 43.2% open/mini-open). Utilization-weighted per-patient average charge was comparable among all 4 groups, with slightly higher charges in the United Healthcare groups ($3,376 arthroscopic, $3,251 open/mini-open) compared with the Medicare groups ($2,940 arthroscopic, $2,807 open/mini-open). The United Healthcare groups had a greater number of utilization-weighted billed encounters (36.1 for open/mini-open, 9.5 for arthroscopic) than their Medicare counterparts (12.8 open/mini-open, 16.7 arthroscopic). CONCLUSIONS:Utilization of PT after rotator cuff repair is substantially higher in privately insured than in Medicare patients. Utilization rates appear to be comparable between surgical approaches. Per-patient costs were comparable irrespective of surgical approach and insurance modality. LEVEL OF EVIDENCE/METHODS:Level IV, economic.

OBJECTIVES/OBJECTIVE:To determine the epidemiology and prognostic indicators in patients with malignant peripheral nerve sheath tumors (MPNST) of the head and neck. MATERIALS AND METHODS/METHODS:The surveillance, epidemiology, and end results registry was reviewed for patients with head and neck MPNST from 1973 to 2011. Study variables included age, sex, race, tumor size, stage at presentation, and treatment modality. RESULTS:There were 374 cases of head and neck MPNST identified. Mean age at diagnosis was 50.7 y ears; 60.2% of patients were male and 82.6% were white. After diagnosis, 38.8% of patients underwent surgery and radiation therapy and 48.1% underwent surgery alone. Kaplan-Meier analysis demonstrated overall (OS) and disease-specific survival (DSS) of 51% and 67% at 5 years. Multivariate Cox regression analysis showed that age (p=0.030), stage (p=0.002), surgery (p=0.037), and size (p<0.001) were predictors of OS, while stage (p<0.001) and size (p<0.001) were predictors of DSS. For stage I/II cancers, surgery (p=0.011) and size (p=0.010) were predictors of OS, and size (p=0.001) predicted DSS. For stage III/IV cancers, both radiotherapy (p=0.024, p=0.009) and size (p=0.001, p=0.001) predicted OS and DSS. For tumors ⩽5 cm, stage (p=0.031) predicted DSS. For tumors >5 cm, male gender (p=0.005), stage (p=0.001), surgery (p=0.003), and radiotherapy (p=0.050) were determinants of OS, and male gender (p=0.022), stage (p<0.001), and radiotherapy (p=0.002) were determinants of DSS. CONCLUSION/CONCLUSIONS:Surgical resection confers survival benefit in patients with early stage MPNST, while radiotherapy improves survival in cases with metastatic disease. Surgery and radiotherapy are prognostically important in patients with tumors >5 cm.

Anterior cruciate ligament (ACL) rupture is a common ligamentous injury often necessitating surgery. Current surgical treatment options include ligament reconstruction with autograft or allograft, which have their inherent limitations. Thus, there is interest in a tissue-engineered substitute for use in ACL regeneration. However, there have been relatively few in vivo studies to date. In this study, an athymic rat model of ACL reconstruction was used to evaluate electrospun polycaprolactone (PCL) grafts, with and without the addition of basic fibroblast growth factor (bFGF) and human foreskin fibroblasts. We examined the regenerative potential of tissue-engineered ACL grafts using histology, immunohistochemistry, and mechanical testing up to 16 weeks postoperatively. Histology showed infiltration of the grafts with cells, and immunohistochemistry demonstrated aligned collagen deposition with minimal inflammatory reaction. Mechanical testing of the grafts demonstrated significantly higher mechanical properties than immediately postimplantation. Acellular grafts loaded with bFGF achieved 58.8% of the stiffness and 40.7% of the peak load of healthy native ACL. Grafts without bFGF achieved 31.3% of the stiffness and 28.2% of the peak load of healthy native ACL. In this in vivo rodent model study for ACL reconstruction, the histological and mechanical evaluation demonstrated excellent healing and regenerative potential of our electrospun PCL ligament graft.

IMPORTANCE/OBJECTIVE:Osteosarcoma of the jaws is rare and clinically distinct from osteosarcoma of the long bones of the body with different treatment and outcomes. The literature on these tumors is limited to case reports and small case series mostly from single institutions. We used data from the population-based national Surveillance, Epidemiology and End Results (SEER) cancer registry to determine the epidemiology and prognostic factors associated with osteosarcoma of the jaws. OBJECTIVE:To investigate the epidemiologic characteristics and prognostic factors for survival in patients diagnosed with osteosarcoma of the jaws. DESIGN, SETTING, AND PARTICIPANTS/METHODS:A retrospective, population-based cohort study of 541 patients in the SEER tumor registry diagnosed with osteosarcoma of the jaws from 1973 through 2011 were reviewed. EXPOSURES/METHODS:Patients had been treated with surgery, radiation, both, or neither. MAIN OUTCOMES AND MEASURES/METHODS:Overall and disease-specific survival. RESULTS:A total of 541 patients diagnosed with osteosarcoma of the jaws were identified (49.9% male and 50.1% female, with a mean age of 41.3 years). Kaplan-Meier analysis demonstrated an overall survival (OS) and disease-specific survival (DSS) of 53% and 62%, respectively, at 5 years and 35% and 54%, respectively, at 10 years. Multivariate Cox regression analysis revealed that independent predictors of OS and DSS included age at diagnosis (hazard ratio [HR], 1.03; 95% CI, 1.02-1.04 [P < .001] for OS; and HR, 1.03; 95% CI, 1.02-1.05 [P < .001] for DSS); stage at presentation (HR, 1.37; 95% CI, 1.10-1.71 [P = .006] for OS; and HR, 1.34; 95% CI, 1.01-1.76 [P = .04] for DSS); and surgical resection (HR, 0.31; 95% CI, 0.16-0.60 [P < .001] for OS; and HR, 0.22; 95% CI, 0.09-0.56 [P = .001] for DSS). Tumor size was not significant for OS (HR, 1.00; 95% CI, 1.00-1.01 [P = .11] but significant for DSS (HR, 1.01; 95% CI, 1.00-1.01 [P = .003]). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:To our knowledge, this is the largest study to date investigating prognostic factors for survival in patients diagnosed with osteosarcoma of the jaws. Determinants of survival include age at diagnosis, stage at presentation, tumor size, and surgical therapy. Radiation therapy was not associated with improved survival, reflecting the controversy surrounding its use in clinical literature.

Anterior cruciate ligament (ACL) rupture is a common ligamentous injury that often requires surgery because the ACL does not heal well without intervention. Current treatment strategies include ligament reconstruction with either autograft or allograft, which each have their associated limitations. Thus, there is interest in designing a tissue-engineered graft for use in ACL reconstruction. We describe the fabrication of an electrospun polymer graft for use in ACL tissue engineering. This polycaprolactone graft is biocompatible, biodegradable, porous, and is comprised of aligned fibers. Because an animal model is necessary to evaluate such a graft, this paper describes an intra-articular athymic rat model of ACL reconstruction that can be used to evaluate engineered grafts, including those seeded with xenogeneic cells. Representative histology and biomechanical testing results at 16 weeks postoperatively are presented, with grafts tested immediately post-implantation and contralateral native ACLs serving as controls. The present study provides a reproducible animal model with which to evaluate tissue engineered ACL grafts, and demonstrates the potential of a regenerative medicine approach to treatment of ACL rupture.