Faculty Bibliography

OBJECTIVE: The purpose of this review is to gain insight into the latest methods of articular cartilage implantation (ACI) and to detail where they are in the Food and Drug Administration approval and regulatory process. DESIGN: A PubMed search was performed using the phrase "Autologous Chondrocyte Implantation" alone and with the words second generation and third generation. Additionally, clinicaltrials.gov was searched for the names of the seven specific procedures and the parent company websites were referenced. RESULTS: Two-Stage Techniques: BioCart II uses a FGF2v1 culture and a fibrinogen, thrombin matrix, whereas Hyalograft-C uses a Hyaff 11 matrix. MACI uses a collagen I/III matrix. Cartipatch consists of an agarose-alginate hydrogel. Neocart uses a high-pressure bioreactor for culturing with a type I collagen matrix. ChondroCelect makes use of a gene expression analysis to predict chondrocyte proliferation and has demonstrated significant clinical improvement, but failed to show superiority to microfracture in a phase III trial. One Step Technique: CAIS is an ACI procedure where harvested cartilage is minced and implanted into a matrix for defect filling. CONCLUSION: As full thickness defects in articular cartilage continue to pose a challenge to treat, new methods of repair are being researched. Later generation ACI has been developed to address the prevalence of fibrocartilage with microfracture and the complications associated with the periosteal flap of first generation ACI such as periosteal hypertrophy. The procedures and products reviewed here represent advances in tissue engineering, scaffolds and autologous chondrocyte culturing that may hold promise in our quest to alter the natural history of symptomatic chondral disease.

Chondral injury in the knee is a unique challenge to the orthopaedic surgeon. Given the high probability of progression to knee arthrosis, the treatment of symptomatic cartilage defects of the knee has become an important surgical intervention in young, active patients. The demand for an alternative to prosthetic resurfacing has driven the trend towards biologic resurfacing and joint preservation. Osteochondral allografts are composed of hyaline cartilage attached to subchondral bone and are suited for large osteochondral lesions. This allograft tissue must be harvested, processed, and stored appropriately to reduce the risks of graft failure and potential complications. With appropriate indications and surgical techniques, osteochondral allografts have been shown to have good long-term graft survival and patient outcomes.

Iatrogenic vascular injury during hip fracture surgery is a rare complication, with infrequent reports of injury during the procedure of cepahalo-medullary nailing. We describe a case report of injury to the superior gluteal artery which occurred during insertion of a nail for prophylactic fixation of an incomplete femur fracture secondary to alendronate use. We describe the anatomy of the arterial branches, the postoperative course, and the management strategy and hope this will increase awareness of these rare injuries.

Ice hockey is a fast paced sport with unique injury potential. A covering physician must be prepared to acutely manage injuries to the face, neck, and chest that are not common in orthopedic practice. Injuries about the face seen in ice hockey include facial fractures, lacerations, and eye and dental injuries. Neck trauma can result in lacerations and neurologic injury. Commotio cordis and sudden cardiac death are potentially fatal conditions seen in ice hockey. This review details the appropriate acute management of these conditions for the physician covering an ice hockey game. Knowledge of these conditions and appropriate rink-side management can be potentially life-saving.

Golf is a global sport enjoyed by an estimated 60 million people around the world. Despite the common misconception that the risk of injury during the play of golf is minimal, golfers are subject to a myriad of potential pathologies. While the majority of injuries in golf are attributable to overuse, acute traumatic injuries can also occur. As the body's direct link to the golf club, the upper extremities are especially prone to injury. A thorough appreciation of the risk factors and patterns of injury will afford accurate diagnosis, treatment, and prevention of further injury.

Objectives: Tenodesis of the long head of the biceps is one of many options to reduce pain caused by proximal long head insertional tendinopathy, tendon instability, or part of a superior labrum anterior-posterior lesion. This technique can be performed either as an open or arthroscopic procedure. The purpose of this study is to compare the relative incidence and demographics of patients who underwent either an arthroscopy or open biceps tenodesis procedure in New York State from 2002-2010. Methods: Retrospective review of patients who underwent open or arthroscopic biceps tenodesis surgery were identified from the New York State Statewide Planning and Research Commission (SPARCS) ambulatory surgery database, which includes all outpatient surgeries performed at hospitals, outpatient surgical centers, and rural clinics in New York State. Cases of open and arthroscopic biceps tenodesis were identified by unique Current Procedural Terminology codes (23430, 29828). Data from 2002 to 2010 were available for open procedures and from 2008 to 2010 for arthroscopic procedures. Chi-square test and student's t-test were used to analyze the data. Variables measured included incidence, age, gender, race, ethnicity, type of operating facility, and primary payor. Results: From 2002 to 2010 the incidence of biceps tenodesis rose over 600%. From 2008 to 2010 there were 2672 open biceps tenodesis procedures and 3289 arthroscopic biceps tenodesis procedures performed in New York State. The arthroscopic group contained significantly more women (33%) than the open group (25%, P<.0001). The average age arthroscopic patients was slightly higher (55.33 years) than that of open patients (54.45 years, P<.01). There was a significantly greater proportion of African- American patients in the arthroscopic group. Patients undergoing arthroscopic surgery were more likely to be treated at a hospital as opposed to a free standing clinic. The most common primary payor for open cases was worker's compensation at 22% of all cases. Of arthroscopic patients, 18% listed worker's compensation as the primary payor. Medicare patients accounted for 16% of open cases and 19% of arthroscopic patients (P<.001). Conclusion: Incidence of biceps tenodesis surgery has increased steadily from 2002 to 2010. There were 23% more arthroscopic procedures performed in 2010 than there were in 2008. Arthroscopic patients are more likely to be older, female, and African American. Arthroscopic biceps tenodeis, which require additional skill and training, were more likely to be performed in a hospital setting

OBJECTIVES: To evaluate cartilage repair and native tissue using a three-dimensional (3D), radial, ultra-short echo time (UTE) (23)Na MR sequence without and with an inversion recovery (IR) preparation pulse for fluid suppression at 7 Tesla (T). METHODS: This study had institutional review board approval. We recruited 11 consecutive patients (41.5 +/- 11.8 years) from an orthopaedic surgery practice who had undergone a knee cartilage restoration procedure. The subjects were examined postoperatively (median = 26 weeks) with 7-T MRI using: proton-T2 (TR/TE = 3,000 ms/60 ms); sodium UTE (TR/TE = 100 ms/0.4 ms); fluid-suppressed, sodium UTE adiabatic IR. Cartilage sodium concentrations in repair tissue ([Na(+)](R)), adjacent native cartilage ([Na(+)](N)), and native cartilage within the opposite, non-surgical compartment ([Na(+)](N2)) were calculated using external NaCl phantoms. RESULTS: For conventional sodium imaging, mean [Na(+)](R), [Na(+)](N), [Na(+)](N2) were 177.8 +/- 54.1 mM, 170.1 +/- 40.7 mM, 172.2 +/- 30 mM respectively. Differences in [Na(+)](R) versus [Na(+)](N) (P = 0.59) and [Na(+)](N) versus [Na(+)](N2) (P = 0.89) were not significant. For sodium IR imaging, mean [Na(+)](R), [Na(+)](N), [Na(+)](N2) were 108.9 +/- 29.8 mM, 204.6 +/- 34.7 mM, 249.9 +/- 44.6 mM respectively. Decreases in [Na(+)](R) versus [Na(+)](N) (P = 0.0.0000035) and [Na(+)](N) versus [Na(+)](N2) (P = 0.015) were significant. CONCLUSIONS: Sodium IR imaging at 7 T can suppress the signal from free sodium within synovial fluid. This may allow improved assessment of [Na(+)] within cartilage repair and native tissue. KEY POINTS : * NaIR magnetic resonance imaging can suppress signal from sodium within synovial fluid. * NaIR MRI thus allows assessment of sodium concentration within cartilage tissue alone. * This may facilitate more accurate assessment of repair tissue composition and quality.

Most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms postoperatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge. A thorough patient history, physical examination, and imaging studies (eg, plain radiography, MRI, magnetic resonance arthrography, ultrasonography) are required for diagnosis. Management is determined based on patient age, functional demands, rotator cuff competence, and the presence or absence of glenohumeral arthritis. Treatment options include revision repair, nonanatomic repair with or without biologic or synthetic augmentation, tendon transfer, and arthroplasty.