Faculty Bibliography

PURPOSE: To analyze orthopaedic resident case log data to report temporal trends in performing arthroscopic procedures and to assess variability in arthroscopic case volume among residents. METHODS: Accreditation Council for Graduate Medical Education orthopaedic surgery resident case logs were reviewed from 2007 to 2013. The mean number of wrist, elbow, shoulder, knee, and ankle arthroscopic procedures performed by graduating residents was analyzed. The median number of arthroscopic procedures reported by the 70th and 30th percentiles of graduating residents (by arthroscopic case volume) was also recorded. Temporal trends were assessed using a linear regression model. RESULTS: From 2007 to 2013, there were significant increases in the mean number of wrist (5.8 to 6.3; P = .038), elbow (2.5 to 3.2; P < .001), shoulder (93.5 to 133.8; P < .001), knee (170.6 to 185.1; P = .011), and ankle (5.8 to 7.4; P < .001) arthroscopies performed per resident. Residents in the 70th percentile of caseload performed significantly more wrist (7 v 2; P < .001), elbow (3.3 v 1; P < .001), shoulder (134.1 v 70.6; P < .001), knee (205 v 128.7; P < .001), and ankle (7.9 v 2.9; P < .001) arthroscopies than residents in the 30th percentile. CONCLUSIONS: Our findings indicate that arthroscopic caseload is increasing among orthopaedic residents. However, resident experience performing arthroscopic procedures is substantially disparate. Although the educational implications of this disparity are not well understood, our findings may aid in efforts to optimize arthroscopic training during orthopaedic residency.

Bone marrow edema of the knee occurs secondary to a myriad of causes. The hallmark of a bone marrow lesion (BML) is an area of decreased signal intensity on T1 weighted MRI with a corresponding area of increased signal intensity on a T2 weighted MRI. Recently, chronic bone marrow lesions have been correlated with knee pain and progression of osteoarthritis. These lesions have also been associated with other degenerative conditions such as meniscal tears, cartilage deterioration, subchondral cyst formation, mechanical malalignment, and ultimately progression to arthroplasty. Medical treatments, such as prostacyclin and bisphosphonate therapy, have shown promise. Alignment procedures, as well as core decompression and subchondroplasty, have been used as surgical treatments for chronic BMLs.

INTRODUCTION: Recurrent patellar instability can be a source of continued pain and functional limitation in the young, active patient population. Instability in the setting of an elevated tibial tubercle-trochlear groove (TT-TG) distance can be effectively managed with a tibial tubercle osteotomy. At the present time, clinical outcome data are limited with respect to this surgical approach to patellar instability. METHODS: A retrospective chart review was performed to identify all cases of tibial tubercle osteotomy for the management of patellar instability performed at our institution with at least 1 year of post-operative follow-up. Patient demographic information was collected along with relevant operative data. Each patient was evaluated post-operatively with their outcomes assessed utilising a visual analogue score of pain, patient satisfaction, Tegner Activity Scale and Kujala score. RESULTS: 31 patients (23 females and 8 males) with mean age of 27 years (17-43 years) and a mean BMI of 26.3kg/m(2) (19.6-35.8) at time of surgery who underwent a tibial tubercle osteotomy as treatment for recurrent patellar instability were identified. The cohort had a mean follow up of 4.4 years (1.5-11.8 years). The mean pre-operative TT-TG distance was 18mm (10-22mm). The mean VAS pain score demonstrated a significant improvement from 6.8 (95% CI 6.1-7.5) at baseline to 2.8 (95% CI 1.9-3.7) post-operatively (p<0.001). The Tegner score improved from 4.1 (95% CI 3.4-4.8) pre-operatively to 5.2 (95% CI 4.5-5.9) at the time of final follow up (p<0.04). The Kujala score for anterior knee pain improved postoperatively from 62 (95% CI 55.4-68.7) to 76.5 (95% CI 69.5-83.5) at final follow up (p<0.001). 26 of the 31 patients (83.8%) had good to excellent Kujala scores. 27 of 31 patients (87.1%) reported that they would undergo the procedure again if necessary. CONCLUSION: For the management of recurrent patellar instability in the setting of an increased tibial tubercle-trochlear groove distance, a corrective tibial tubercle osteotomy is an effective treatment modality to reliably prevent patellar instability while reducing pain and improving function in this cohort of young, active patients.

PURPOSE: To correlate the intraoperative concentrations of 20 synovial fluid biomarkers with preoperative symptoms, intraoperative findings, and postoperative outcomes in patients undergoing knee arthroscopy, with comparisons made to samples obtained from asymptomatic knees. METHODS: Synovial fluid samples were obtained from 81 patients undergoing knee arthroscopy meeting the inclusion criteria, which included 70 samples from operative knees and 32 samples from contralateral knees. Preoperatively, baseline data obtained from clinical questionnaires including a visual analog scale (VAS) score, the Lysholm score, and the Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form were recorded. Synovial fluid was collected from both the operative knee and asymptomatic contralateral knee. Synovial fluid was stored with a protease inhibitor at -80 degrees C until analysis. Intraoperative findings, procedures performed, and International Cartilage Repair Society (ICRS) cartilage status scores in all operative knees were documented. The concentrations of the following 20 biomarkers were measured using a multiplex magnetic bead immunoassay: matrix metalloproteinase (MMP) 3; MMP-13; tissue inhibitor of metalloproteinase (TIMP) 1; TIMP-2; TIMP-3; TIMP-4; fibroblast growth factor 2; eotaxin; interferon gamma; interleukin (IL) 10; platelet-derived growth factor BB; IL-1 receptor antagonist; IL-1beta; IL-6; monocyte chemotactic protein 1 (MCP-1); macrophage inflammatory protein 1alpha; macrophage inflammatory protein 1beta; RANTES (regulated upon activation, normal T cell expressed and secreted); tumor necrosis factor alpha; and vascular endothelial growth factor. Clinical outcome scores were obtained in 83% of patients at a mean of 17 months' follow-up postoperatively. Analysis of variance and Pearson correlation analysis were performed to determine statistical significance between preoperative data, intraoperative findings, postoperative outcomes, and synovial fluid biomarker concentrations compared with asymptomatic contralateral knees. RESULTS: Analysis was performed on 70 operative and 32 contralateral samples. There were strong positive correlations between ICRS score and age, symptom duration, VAS score, and Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form. A strong positive correlation was found between MCP-1 and IL-6 concentrations, intraoperative ICRS score, and continued pain at the time of final follow-up. MCP-1 and IL-6 were the strongest predictors of severe cartilage lesions, whereas IL-1 receptor antagonist was inversely related. MMP-3 levels were consistently elevated in all operative samples and directly correlated to increased preoperative VAS scores. RANTES, vascular endothelial growth factor, and platelet-derived growth factor BB were the strongest predictors of postoperative improvement at final follow-up regardless of injury and cartilage status. CONCLUSIONS: Synovial fluid biomarkers have the capacity to reflect the intra-articular environment before surgery and potentially predict postoperative clinical outcomes. Recognition of key molecular players may yield future therapeutic targets, and large clinical trials exploring these discoveries are anticipated. LEVEL OF EVIDENCE: Level III, therapeutic case-control study.

The purpose of the current study was to determine if the application of platelet-rich fibrin matrix could improve regeneration of the tendon-bone insertion site in a rat rotator cuff repair model. 25 Lewis syngeneic rats underwent bilateral tenotomy and repair of the supraspinatus tendon. 10 separate rats were used for PRFM harvest. All left (control) shoulders underwent transosseous rotator cuff repair, while all right (treatment) shoulders were repaired similarly with PRFM augmentation. 9 rats were sacrificed at 2-weeks and ten at 4-weeks for biomechanical testing. 3 separate rats were sacrificed at 2-weeks and 4-weeks each for histologic analysis of the insertion site. At 2 weeks, the experimental group repairs were significantly stronger in ultimate load to failure (P=0.01), stress (P=0.03), and stiffness (P=0.03). Differences in biomechanical testing were not found between the groups at 4 weeks. Histological analysis revealed less collagen organization and cartilage formation at the insertion site in the experimental group. Semiquantitative histologic analysis confirmed our qualitative assessment of the specimens. PRFM does not recapitulate the native enthesis, but rather induces an exuberant and disordered healing response that is characterized by fibrovascular scar tissue.

Objectives: The purpose of the present study was to determine when patients recover the ability to safely operate the brakes of an automobile following a right knee anterior cruciate ligament reconstruction (ACLR). Methods: A prospective case series of 27 patients who underwent a right knee ACLR, nine with a bone patellar tendon-bone (BPTB) autograft, nine patients who had hamstring (HS) tendon autograft and nine patients who had tibialis anterior (TA) tendon allograft for their reconstructions were tested in a validated computerized driving simulator. At 7-10 days, three weeks, and six weeks post operatively, patients were evaluated with respect to their brake reaction time (BRT), brake travel time (BTT), and total braking time (TBT). Each cohort was then compared with thirty healthy volunteers with similar demographics to establish normative mean values. Results: At 7-10 days post-operatively, all patients had statistically significant differences compared to controls for BRT, BTT, and TBT, regardless of the graft used for the reconstruction. By three weeks postoperatively, those reconstructed with TA allografts demonstrated a return to normal braking parameters with no statistically significant differences compared to controls between BRT, BTT, and TBT, whereas those with BPTB and HS autografts continued to have significant delays in their BTT and TBT with BPTB (p = 0.007, p = 0.009) and HS (p = 0.016, p = 0.015), respectively. By six weeks post-operatively, braking parameters for patients receiving an ACL reconstruction with a hamstring autograft returned to normal values while those treated with a BPTB autograft continued to demonstrate impairment in brake travel time and total braking time compared to controls; however, their brake reaction time had recovered to normative values. Conclusion: Patients who underwent a right knee ACL reconstruction with a TA allograft regained normal braking times by three weeks post-operatively and continued to improve through the six week postoperative time point. In contrast, those treated with a BPTB or HS autograft demonstrated impaired ability to operate motor vehicle brakes three weeks following surgery. While at six weeks, the braking ability of patients treated with hamstring autografts normalized, those receiving a BPTB autograft continued to demonstrate limitations in their brake travel time and total braking time. Patients should be counseled appropriately when discussing reconstruction options and when it is safe to resume driving

Objectives: The purpose of the current study is to investigate the functional strength outcomes of late distal biceps reconstruction using allograft tissue. Methods: Patients who underwent distal biceps reconstruction with allograft tissue between May 2007 and May 2013 were identified. Charts were retrospectively reviewed for post-operative complications, gross flexion and supination strength, and range of motion (ROM). Isokinetic strength and endurance in elbow flexion and forearm supination were measured in both arms. Tests were conducted using a dynamometer at 60o per second for isokinetic strength and 240o per second for endurance. Isometric strength testing was also measured for elbow flexion and forearm supination. Paired t tests were used for statistical analysis. Results: Ten patients with a mean age of 48 years (range 42 - 61 years) were included in the study. Distal biceps reconstruction was performed using an Achilles tendon allograft in 9 patients and a combination of tibialis anterior allograft and gracilis allograft in 1 patient. Of the reconstructions, 50% involved the dominant arm. Full ROM was observed in all patients at the time of their final follow up assessment. The mean followup for dynamometer strength testing was 34 months (range 13-81 months). No statistical differences were noted between data obtained from operative and contralateral extremities. The average peak torque of the operative limb (38.5+/- 5.9 Nm) was 91.7% of that of the contralateral limb (41.8+/-4.9 Nm) in flexion and 93.4% (operative, 5.7+/-1.3 Nm; contralateral, 6.1+/- 1.0 Nm) in supination. No significant differences were found in fatigue index between operative or contralateral limbs for flexion (operative, 34.1+/-17.1%; contralateral, 30.8+/-17.1%; p = 0.29) or supination (operative, 38.2+/-16.5%; contralateral, 42.1+/-11.9%; p = 0.65). The only complication observed was a transient PIN palsy in one patient which resolved by 3 months post-operatively. All patients reported postoperative cosmetic deformity but found their gross appearance acceptable. Conclusion: Late reconstruction for chronic distal biceps rupture using allograft tissue is a safe and effective solution for symptomatic patients with functional demands in forearm supination and elbow flexion. Dynamometer testing shows near normal return of strength and endurance of both elbow flexion and supination following the procedure

INTRODUCTION: Historically, venous thromboembolism (VTE) in the setting of elective knee arthroscopy has been considered rare. However, more recently, the rate of deep vein thrombosis (DVT) has been reported to be approxi - mately 10%. With increasing recognition of the potential for the development of thromboembolic events, several random - ized trials have evaluated the efficacy of chemoprophylaxis in reducing the risk of VTE following knee arthroscopy. However, all of these studies have evaluated the efficacy of low molecular weight heparins (LMWH), with reductions in the risk of DVT ranging from 65% to 93%, but with the potential side effect of bleeding. At the present time, there have been no randomized studies reported evaluating the utility of aspirin, an agent with a reportedly lower bleeding risk than LMWH, as pharmacologic prophylaxis against VTE after arthroscopic knee surgery. METHODS: In a single-center, randomized, single-blind prospective trial, the efficacy of aspirin as postopera - tive pharmacologic VTE prophylaxis was evaluated in a low risk population undergoing knee arthroscopy. One hundred seventy patients were randomized to a treatment group of 325 mg of aspirin daily for 14 days postoperatively (66 patients) or to the control group with no intervention (104 patients). Bilateral, whole leg, com - pression venous duplex ultrasonography was performed 10 to 14 days postoperatively to document the incidence of DVT. The primary endpoint of the current study was the development of DVT or pulmonary embolism (PE), and the secondary endpoint was the development of a postoperative complication. RESULTS: The study cohort was comprised of 104 males (61%) and 66 females (39%) with a mean age of 44.4 +/- 14.4 years (range: 18 to 75 years). Within both the aspirin treatment and control groups, the surgical procedures in - cluded meniscectomy, ACL reconstruction, chondroplasty, and meniscus repair. No cases of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE) were identi - fied in either arm of the study during the observation period. Twenty-three patients experienced a complication, including pain or swelling (9%), residual joint line tenderness (3%), arthrofibrosis (0.6%), and instability after a fall (0.6%). Three patients developed knee swelling, two of them in the aspirin group and one of whom required a knee aspiration. However, there was no difference in the development of complications between the two patient populations (p = 0.76, odds ratio [OR] 1.14, 95% confidence interval [CI] 0.5-2.56). CONCLUSIONS: With no cases of VTE identified in our pa - tient population, the use of aspirin in a low-risk population undergoing arthroscopic knee surgery is not warranted.

Bone marrow aspirate, prolotherapy, platelet-rich plasma,and autologous conditioned serum represent alternativetreatment options that have emerged to address variousmusculoskeletal ailments. We have reviewed the basicscience, physiology, and clinical evidence of each of thesemodalities and discovered that each treatment has its individualplace in the management of common orthopaedicpathologies. Bone marrow aspirates are successful intreating early arthritis and cartilage defects. Prolotherapyand platelet-rich plasma have demonstrated good efficacyin treating inflammatory processes and early arthritis. Finally,autologous conditioned serum (Orthokine) representsa promising treatment option for chronic joint arthritis. Theclinical evidence supporting these alternative treatmentmodalities is insufficient and further level 1 evidence isneeded before we can begin to employ these techniques inour daily orthopaedic practice.

Throughout the history of orthopaedics, our understandingof the function and necessity of the meniscus has significantlyevolved, and with it, our techniques of treating,repairing, preserving, and replacing it have progressed inparallel. Currently, it is known that a meniscus deficiencyis a predisposing factor to the development of degenerativechanges of the knee. Thus, it is incumbent upon the surgeonto preserve the meniscus to the extent that biology will allow.Unfortunately, circumstances arise when the meniscus cannotbe preserved, and young patients afflicted by irreparablemeniscus deficiency may be potential candidates for a meniscustransplant. Though its indications are limited and itsexecution technically complex, meniscal allograft transplanthas been shown to provide good subjective outcomes and isa potentially joint preserving surgery. This paper provides acomprehensive and historical review of the meniscus, a briefreview of meniscus anatomy and biomechanics, and commentaryon the role of meniscal allograft transplant for thetreatment of meniscal deficiency, including patient selection,graft selection and sizing, surgical technique, and outcomes.