Faculty Bibliography

Rotator cuff tears are a common pathologic entity, and rotator cuff repairs are a frequently performed procedure. Given the high rate of structural failure of repair, biological augmentation of repairs is increasingly important. Biological augmentation primarily enhances the healing response and secondarily provides a mechanical bridge for tension free repair. Understanding biology of tendons and tendon healing aids in determining an optimal environment for repair. The basic principles of rotator cuff repair are aimed at achieving high initial fixation strength of the repair, restoring the anatomic footprint of the cuff tendon, minimizing gap formation, and maintaining mechanical stability until biologic healing occurs. Methods of augmentation come in many different forms and can be categorized by cell type and mechanism of delivery. Cell types include individual growth factors, stem cells, or a combination of both. Vehicles range from in situ delivery, such as microfracture, direct injection, or scaffold materials that are biologic or synthetic.

OBJECT: Our objective was to use 7 T MRI to compare cartilage morphology (thickness) and collagen composition (T2 values) in cartilage repair patients and healthy controls. MATERIALS AND METHODS: We scanned the knees of 11 cartilage repair patients and 11 controls on a 7 T MRI scanner using a high-resolution, gradient-echo sequence to measure cartilage thickness and a multi-echo spin-echo sequence to measure cartilage T2 values. We used two-tailed t tests to compare cartilage thickness and T2 values in: repair tissue (RT) versus adjacent cartilage (AC); RT versus healthy control cartilage (HC); AC versus HC. RESULTS: Mean thickness in RT, AC, HC were: 2.2 +/- 1.4, 3.6 +/- 1.1, 3.3 +/- 0.7 mm. Differences in thickness between RT-AC (p = 0.01) and RT-HC (p = 0.02) were significant, but not AC-HC (p = 0.45). Mean T2 values in RT, AC, HC were: 51.6 +/- 7.6, 40.0 +/- 4.7, 45.9 +/- 3.7 ms. Differences in T2 values between RT-AC (p = 0.0005), RT-HC (p = 0.04), and AC-HC (p = 0.004) were significant. CONCLUSION: 7 T MRI allows detection of differences in morphology and collagen architecture in: (1) cartilage repair tissue compared to adjacent cartilage and (2) cartilage repair tissue compared to cartilage from healthy controls. Although cartilage adjacent to repair tissue may be normal in thickness, it can demonstrate altered collagen composition.

Soft tissue lesions are common to the prepatellar region, often due to acute or chronic trauma, and most frequently include prepatellar bursitis, lipomas, and ganglion cysts. We report a case of a posttraumatic prepatellar epidermal inclusion cyst to highlight the diagnostic complexities that can arise with soft tissue lesions in this location. On the basis of our case report, treating orthopaedic surgeons should consider the possibility of an epidermal inclusion cyst in patients who present with atypical anterior soft tissue masses with a history of trauma to the anterior knee.

BACKGROUND: Chronic ruptures of the distal biceps are often complicated by tendon retraction and fibrosis, precluding primary repair. Reconstruction with allograft augmentation has been proposed as an alternative for cases not amenable to primary repair. PURPOSE: To investigate the clinical outcomes of late distal biceps reconstruction using allograft tissue. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 20 patients who underwent distal biceps reconstruction with allograft tissue between May 2007 and May 2012 were identified. Charts were retrospectively reviewed for postoperative complications, gross flexion and supination strength, and range of motion. Subjective functional outcomes were assessed prospectively with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: Eighteen patients with adequate follow-up were included in the study. All had undergone late distal biceps reconstruction with allografts (Achilles [n = 15], semitendinosus [n = 1], gracilis [n = 1], or anterior tibialis [n = 1]) for symptomatic chronic ruptures of the distal biceps. At a mean office follow-up of 9.3 months (range, 4-14 months), all patients had full range of motion and mean gross strength of 4.7 of 5 (range, 4-5) in flexion and supination. After a mean out-of-office follow-up at 21 months (range, 7-68.8 months), the mean DASH score was 7.5 +/- 17.9, and the mean MEPS increased from 43.1 preoperatively to 94.2 postoperatively (P < .001). The only complication observed was transient posterior interosseous nerve palsy in 2 patients. Additionally, all but 1 patient reported a cosmetic deformity. However, all patients found it acceptable. CONCLUSION: Late reconstruction for chronic ruptures of the distal biceps using allograft tissue is a safe and effective solution for symptomatic patients with functional demands in forearm supination and elbow flexion. While there are several graft options, the literature supports good results with Achilles tendon allografts. Further studies are needed to evaluate the clinical outcomes of other allograft options.

Objective Structured Clinical Examinations (OSCEs) have been used extensively in medical schools and residency programs to evaluate various skills, including the six core competencies outlined by the Accreditation Council for Graduate Medical Education (ACGME). Orthopaedic surgery residency programs will be required by the ACGME to assess residents on core competencies in the Milestone Project. Thus, it is important that evaluations be made in a consistent, objective manner. Orthopaedic residency programs can also use simulation models in the examination to accurately and objectively assess residents' skills as they progress through training. The use of these models will become essential as resident work hours are decreased and opportunities to observe skills become more limited. In addition to providing a method to assess competency, OSCEs are a valuable tool for residents to develop and practice important clinical skills. Here, we describe a method for developing a successful OSCE for use in orthopaedic surgical resident training.

Patellofemoral chondral lesions are unique and difficult-to-treat entities often affecting a young and active patient population. Recent advances in our understanding of cartilage injuries, surgical techniques, and surgical technology have provided treatment options for symptomatic patients with lesions of the patellofemoral compartment. A number of surgical treatment options are available, including surgical microfracture, autologous or juvenile chondrocyte implantation, osteochondral autograft transfer, and osteochondral allograft implantation. Management decisions are based on a number of patient- and lesion-related factors in an effort to relieve pain, restore function, and preserve the patellofemoral articulation. The present article reviews the evaluation and management of cartilage injuries affecting the patellofemoral joint.

Despite advances in thromboprophylaxis, venous thromboembolism remains a significant problem in major orthopaedic surgery, associated with significant morbidity and high cost of treatment. Virchow's triad, as well as patient and procedural risk factors, put many orthopaedic surgery patients at high risk. Diagnosis is based on clinical suspicion in combination with imaging such as ultrasound. Options for prophylaxis include aspirin, warfarin, low-molecular weight heparins and direct inhibitors of coagulation factors. In this review, we discuss the latest American Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP) guidelines for prevention of venous thromboembolism and their implications for practice. 1940-7041 2013 Wolters Kluwer Health