Faculty Bibliography

Arthroscopic treatment of meniscal pathology is one of the most common orthopaedic procedures in the United States, constituting 10-20% of all surgeries performed in many centers. This review summarizes the surgical indications and the actual operative techniques in arthroscopic meniscal repair

This study performed the first in vitro histological analysis of the effects of bipolar thermal energy on human meniscal tissue. Sixteen fresh human menisci were mounted on a cutting block and placed in a water bath simulating an arthroscopic environment. Each specimen was divided into four sections and randomized to one of four treatment options: 1. thermal ablation with a bipolar multielectrode 3 mm Covac wand (power 3 setting); 2. thermal ablation with a bipolar multielectrode 3 mm Covac wand (power setting 7); 3. resection with a scalpel blade; and 4. resection with a motorized 4.5 full-radius resector. Six micron sections were cut and stained with Hematoxylin and Eosin and Masson's trichrome stain. Menisci were evaluated for the contour of the cut edge: straight, jagged, frayed, or combined. The zone of thermal necrosis and zone of thermal alteration were determined by examining the differential staining of the connective tissue and measuring the affected area. Menisci treated with the bipolar thermal probe were noted to have a smoother contoured edge in comparison to motorized cutters. The zone of thermal penetration for the Arthrocare power setting 3 averaged 0.18 mm (range: 0.09 to 0.20; SD 0.04) and for Arthrocare power setting 7 averaged 0.33 mm (range: 0.26 to 0.36; SD 0.03). The difference in thermal penetration between Arthrocare power settings 3 and 7 was 0.15 mm. This was statistically significant at p < 0.0001 (95% CI: 0.11 to 0.19 mm). The zone of thermal penetration was non-existent for the shaver and scalpel groups. This study provides the first histological description of the effects of bipolar radiofrequency energy on meniscal tissue. It demonstrates that there is intra-substance thermal penetration and alteration of the meniscal tissue. Its clinical significance is unclear and further in vivo studies are needed to address its clinical applicability

Superior labral lesions and internal impingement are believed to be the primary cause of shoulder pathology in the overhead athlete, particularly the baseball player. Increased shoulder external rotation can lead to repetitive impingement of the rotator cuff and superior labrum resulting in a superior labrum anterior and posterior lesion and partial articular-sided rotator cuff tearing. Although the etiology for this phenomenon remains controversial, the end result remains the same: pathology in the rotator cuff and superior labrum. Isolated treatment of the pathology alone, without addressing the capsular laxity, results in lower return to play rates. Addressing the capsular laxity arthroscopically at the same time as the intra-articular pathology is necessary to give these athletes the best chance to return to their prior competitive level. Although short-term results are promising, long-term follow-up is necessary to determine the ultimate usefulness of this treatment philosophy

The treatment of anterior glenohumeral instability has been a topic of debate in the recent literature. Current surgical management of shoulder instability has included a variety of open and arthroscopic procedures. Open techniques for anterior reconstruction have been quite successful in preventing recurrent dislocations and continue to be the gold standard of care. In an attempt to address some of the disadvantages associated with open procedures, arthroscopic stabilization procedures have been developed. Arthroscopic capsuloligamentous repair presumably has clear advantages including better cosmesis, decreased perioperative morbidity, and a possible decrease in the loss of external rotation. Advances in arthroscopic instrumentation and improved arthroscopic techniques have increased the popularity of arthroscopic stabilization. The art of diagnosing the anatomic pathology associated with instability and proper patient selection continues to evolve. Most previous reports of arthroscopic stabilization have included small numbers of patients, variable patient pathology, and a variety of surgical techniques, making comparisons between stabilization procedures difficult. Arthroscopy can be valuable in both the confirmation of the degree and severity of the instability and to correct the pathoanatomy responsible for the instability

Recent advances in instrumentation and a growing understanding of the pathophysiology of osteoarthritis have led to increased use of arthroscopy for the management of degenerative arthritis of the knee. Techniques include lavage and debridement, abrasion arthroplasty, subchondral penetration procedures (drilling and microfracture), and laser/thermal chondroplasty. In most patients, short-term symptomatic relief can be expected with arthroscopic lavage and debridement. Greater symptomatic relief and more persistent pain relief can be achieved in patients who have acute onset of pain, mechanical disturbances from cartilage or meniscal fragments, normal lower extremity alignment, and minimal radiographic evidence of degenerative disease. Arthroscopic chondroplasty techniques provide unpredictable results. Concerns include the durability of the fibrocartilage repair tissue in subchondral penetration procedures and thermal damage to subchondral bone and adjacent normal articular cartilage in laser/thermal chondroplasty. Although recent prospective, randomized, double-blinded studies have demonstrated that outcomes after arthroscopic lavage or debridement were no better than placebo procedure for knee osteoarthritis, controversy still exists. With proper selection, patients with early degenerative arthritis and mechanical symptoms of locking or catching can benefit from arthroscopic surgery

This investigation compared the stability of 2 methods of fixation for acromioclavicular (AC) joint separations. A complete AC joint separation was simulated in 6 matched pairs of fresh-frozen human cadaveric shoulders. One specimen from each pair was repaired with two No. 5 nonabsorbable braided sutures passed around the base of the coracoid and the other with 2 suture anchors preloaded with the same suture material placed into the base of the coracoid process. The specimens were cyclically loaded for 10(4) cycles to simulate our early postoperative rehabilitation protocol for coracoclavicular repairs. Before cycling, the repairs had a mean superior laxity of 1.68 +/- 0.44 mm for the sutures alone and 1.23 +/- 0.31 mm for the suture anchors. After 10(4) cycles, the laxity was 1.32 +/- 0.59 mm and 1.33 +/- 0.94 mm, respectively. These differences were not statistically significant (P =.2). This study demonstrated that similar stability can be achieved for coracoclavicular fixation with suture anchors or with sutures placed around the base of the coracoid for the treatment of AC joint separations. The clinical relevance includes the following: (1) the potentially diminished risk of neurovascular injury with the use of suture anchors compared with the passage of sutures around the base of the coracoid and (2) the potentially reduced surgical time associated with the use of suture anchors

The lack of literature on residency selection criteria used by orthopaedic program directors has left medical students in the position of relying on rumor and anecdotal information as to what program directors value most highly when sorting through large candidate pools. The purpose of this study was to compare the perspectives on resident selection criteria solicited from orthopaedic program directors and residency applicants. A power analysis was done to determine adequate sample size. A 26-item questionnaire was mailed to 98 residency applicants who interviewed at our program and 156 orthopaedic program directors. The program directors were also asked to elaborate on those factors that were most important in their selection process. A two-tailed Student's t-test was employed to compare the two groups. Significance was set at p < 0.05. Statistically significant differences between applicant and program director ratings were found in 12 of the 26 questionnaire items. Applicants (n = 91) ranked the following criteria as most important: a letter of recommendation from an orthopaedic surgeon (8.6 on a scale of 1 to 10, 10 being most important), USMLE I score (7.7), and rank in medical school (7.6). The most important criteria for the directors (n = 109) were: the applicant performed a rotation at the director's program (7.9), USMLE I score (7.8), and rank in medical school (7.8). This study provides the most comprehensive empirical data to date as to the factors which orthopaedic program directors consider most important during the residency selection process. To our knowledge, this is the first study in the orthopaedic literature that compares the program directors 'and residency applicants' views on resident selection criteria. Significant differences were found between applicant and program director views on resident selection criteria

The effect of stem length, diameter, and mode of fixation on the motion and stress transfer of a cemented tibial tray were evaluated for in 12 cadaver knees. There was a significant decrease in motion of the tibial tray with increasing press-fit stem length (75-150 mm) and increasing stem diameter (10-14 mm). Cemented tibial stems showed significantly less tray motion than uncemented stems. The short cemented stems produced tray stability equivalent to long press-fit stems. Although there was a trend for increased proximal tibial stress shielding with the use of cement and longer, wider stems, the trend was not statistically significant. Modular, press-fit stems can achieve tray stability similar to a smaller cemented stem and can avoid the potential problems with cement