Dr. Seth L. Sherman is a third-generation team physician and surgeon. He is board certified and fellowship trained in Sports Medicine. Dr. Sherman is proud to serve as Orthopedic Surgeon for Stanford Cardinal Football and as the Sports Medicine fellowship director.
Dr. Sherman specializes in arthroscopic and minimally invasive surgical interventions for the knee and shoulder. He has subspecialty and research interests in knee joint preservation/cartilage restoration and the patellofemoral joint. As a tertiary care provider, Dr. Sherman offers non-surgical and salvage surgical solutions for active patients with complex problems and in cases where other surgeries have failed.
Dr. Sherman completed his residency training at the Hospital for Special Surgery in New York City and was trained by the team physicians for the NY Giants, Mets, and Knicks. During his sports medicine fellowship in Chicago , he served as assistant team physician for the Chicago Bulls and White Sox. Prior to joining the team at Stanford University in July 2019, he served as team physician for the Mizzou Tigers in the NCAA SEC conference.
Dr. Sherman is co-author on more than 100 peer reviewed articles/chapters and actively presents his research at national and international meetings. He is Chairman of the AAOS Sports Medicine/Arthroscopy committee and holds leadership positions in several other organizations (AOSSM, AANA, ISAKOS, ICRS). He is a member of the prestigious international ACL and Patellofemoral Study Groups.
He enjoys spending time with wife Sylvia and daughter Evie. He is an avid fresh and saltwater fly fisherman.
- Orthopaedic Surgery
- Knee Ligament Repair/Reconstruction (ACL, PCL, Posteromedial, Posterolateral, Anterolateral complex, Medial Patellofemoral Ligament)
- Knee Meniscus Repair/Replacement (all-inside repair, inside-out repair, outside-in repair, root repair, meniscus allograft transplantation)
- Knee Cartilage Restoration (osteochondral allograft, MACI procedure, DeNovo NT, OAT autograft, microfracture plus etc.)
- Knee Osteotomy (Tibial Tubercle Osteotomy/Fulkerson, High Tibial Osteotomy, Distal Femoral Osteotomy)
- Surgical Management of the Patellofemoral Joint
- Shoulder arthroscopy (rotator cuff tendonitis, rotator cuff tear, SLAP/biceps complex, AC arthritis/separation, subacromial bursitis, labral tear, shoulder instability)
- Open shoulder surgery (TSA, reverse TSA, open Latarjet, open distal tibial allograft)
- Surgical tendinopathy/tear (distal biceps, distal triceps, patella tendon, quad tendon, Achilles tendon, proximal hamstring, tennis elbow, golfer's elbow)
Associate Professor - Med Center Line, Orthopaedic Surgery
Board Certification: Sports Medicine, American Board of Orthopaedic Surgery (2015)
Board Certification: Orthopaedic Surgery, American Board of Orthopaedic Surgery (2013)
Fellowship: Rush University Medical Center GME Office (2011) IL
Residency: Hospital for Special Surgery Orthopaedic Surgery Residency (2010) NY
Medical Education: Weill Cornell Medical College (2005) NY
Microfracture Versus Adipose Derived Stem Cells for the Treatment of Articular Cartilage Defects
The purpose of this study is to compare two biologic methods for the treatment of articular cartilage defects in the knee. The first method, microfracture, is the standard of care and is routinely used to recruit cells from the subchondral bone marrow to the site of cartilage loss. The second method is the application of adipose-derived stem cells (ADSCs) to the defect site. In theory, ADSCs on a collagen scaffold should enable the delivery of more specific progenitor cells to the site of injury, resulting in better regeneration and integration of articular cartilage at the site of a defect as compared to the microfracture method.
Subchondroplasty® Knee RCT
This is a multi-center, prospective, single-blinded, two-arm study, randomized to include 134 subjects treated with Subchondroplasty (SCP) + Arthroscopy and 67 subjects with arthroscopy alone. The primary objective of this study is to demonstrate superiority of Subchondroplasty with arthroscopy compared to arthroscopy alone for treatment of Bone Marrow Lesions (BMLs) in the knee.
The Effect of Adipose-Derived Stem Cells for Knee Osteoarthritis
The purpose of this study is to compare the clinical and functional outcomes of patients with mild to moderate arthroscopically confirmed osteoarthritis between the following two groups: 1. Partial fat pad harvest with Adipose-Derived Stem Cell (ADSC) transplantation with standard arthroscopic treatment consisting of: partial meniscectomy, cartilage stabilization, loose body removal and selective synovectomy. 2. Standard arthroscopic treatment (above) with out cell transplant.
The Effect of Micro Fragmented Adipose Tissue (MFAT) on Knee Osteoarthritis
This is a non-surgical trial comparing the clinical and functional outcomes of patients with osteoarthritis treated with Intra-articular injection of Micro Fragmented Adipose Tissue versus conventional therapy of intra-articular injection of corticosteroid.
Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group.
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA
PURPOSE: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS and description of the RTS continuum, as well as to provide clinical guidance on RTS testing and decision-making.METHODS: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.RESULTS: Key points include that RTS is characterized by achievement of the pre-injury level of sport and involves a criteria-based progression from return to participation to return to sport, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along a RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries.CONCLUSION: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biologic assessment of healing and recovery.LEVEL OF EVIDENCE: IV.
View details for DOI 10.1007/s00167-020-06009-1
View details for PubMedID 32347344
- Failures of Realignment Osteotomy OPERATIVE TECHNIQUES IN SPORTS MEDICINE 2020; 28 (1)
Patellofemoral Cartilage Restoration: A Systematic Review and Meta-analysis of Clinical Outcomes.
The American journal of sports medicine
Many surgical options for treating patellofemoral (PF) cartilage lesions are available but with limited evidence comparing their results.To determine and compare outcomes of PF cartilage restoration techniques.Systematic review and meta-analysis.PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, and Cochrane Library databases. Inclusion criteria were clinical studies in the English language, patient-reported outcomes after PF cartilage restoration surgery, and >12 months' follow-up. Quality assessment was performed with the Coleman Methodology Score. Techniques were grouped as osteochondral allograft transplantation (OCA), osteochondral autograft transfer (OAT), chondrocyte cell-based therapy, bone marrow-based therapy, and scaffolds.A total of 59 articles were included. The mean Coleman Methodology Score was 71.8. There were 1937 lesions (1077 patellar, 390 trochlear, and 172 bipolar; 298 unspecified). The frequency of the procedures was as follows, in descending order: chondrocyte cell-based therapy (65.7%), bone marrow-based therapy (17.2%), OAT (8%), OCA (6.6%), and scaffolds (2.2%). When compared with the overall pooled lesion size (3.9 cm2; 95% CI, 3.5-4.3 cm2), scaffold (2.2 cm2; 95% CI, 1.8-2.5 cm2) and OAT (1.5 cm2; 95% CI, 1.1-1.9 cm2) lesions were smaller (P < .001), while chondrocyte cell-based therapy lesions were larger (4.7 cm2; 95% CI, 4.1-5.3 cm2; P = .039). Overall, the instability pool was 11.9%, and the anatomic risk factors pool was 32.1%. Statistically significant improvement was observed on at least 1 patient-reported outcome in chondrocyte cell-based therapy (83%), OAT (78%), OCA (71%), bone marrow-based therapy (64%), and scaffolds (50%). There were no significant differences between any group and the overall pooled change in International Knee Documentation Committee score (30.2; 95% CI, 27.4-32.9) and Lysholm score (25.2; 95% CI, 16.9-33.5). There were no significant differences between any group and the overall pooled rate in minor complication rate (7.6%; 95% CI, 4.7%-11.9%) and major complication rate (8.3%; 95% CI, 5.7%-12.0%); however, OCA had a significantly greater failure rate (22.7%; 95% CI, 14.6%-33.4%) as compared with the overall rate (6.8%; 95% CI, 4.7%-9.5%).PF cartilage restoration leads to improved clinical outcomes, with low rates of minor and major complications. There was no difference among techniques; however, failures were higher with OCA.
View details for DOI 10.1177/0363546519886853
View details for PubMedID 31899868
Relationship of the Medial Patellofemoral Ligament Origin on the Distal Femur to the Distal Femoral Physis: A Systematic Review.
The American journal of sports medicine
The relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis has been reported in multiple studies.To determine the distance from the MPFL central origin on the distal femur to the medial distal femoral physis in skeletally immature participants.Systematic review.A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched for studies investigating the anatomic origin of the MPFL on the distal femur and its relationship to the medial distal femoral physis in skeletally immature participants. Study methodological quality was analyzed with the Anatomical Quality Assessment tool, with studies categorized as low risk, high risk, or unclear risk of bias. Continuous variable data were reported as mean ± SD. Categorical variable data were reported as frequency with percentage.Seven articles were analyzed (298 femurs, 53.7% male patients; mean age, 11.7 ± 3.4 years). There was low risk of bias based on the Anatomical Quality Assessment tool. The distance from the MPFL origin to the distal femoral physis ranged from 3.7 mm proximal to the physis to 10.0 mm distal to the physis in individual studies. Six of 7 studies reported that the MPFL origin on the distal femur lies distal to the medial distal femoral physis in the majority of specimens. The MPFL originated distal to the medial distal femoral physis in 92.8% of participants at a mean distance of 6.9 ± 2.4 mm.The medial patellofemoral ligament originates distal to the medial distal femoral physis in the majority of cases at a mean proximal-to-distal distance of 7 mm distal to the physis. However, this is variable in the literature owing to study design and patient age and sex.
View details for DOI 10.1177/0363546520904685
View details for PubMedID 32109145
Meniscus Injuries: A Review of Rehabilitation and Return to Play.
Clinics in sports medicine
2020; 39 (1): 165–83
Meniscal injury potentiates a sequence of events that leads to degenerative changes and early osteoarthritis. It is therefore imperative to preserve the meniscus whenever possible. Given the expanding indications for meniscus repair, it is important to continually analyze and advance the understanding of rehabilitation and return to play following meniscal surgery. This article presents evidence-based rehabilitation and return-to-play guidelines as well as a brief review of return-to-play outcomes following isolated meniscus repair.
View details for DOI 10.1016/j.csm.2019.08.004
View details for PubMedID 31767104
- Patellofemoral Imaging and Analysis OPERATIVE TECHNIQUES IN SPORTS MEDICINE 2019; 27 (4)
Enhanced subchondroplasty treatment for post-traumatic cartilage and subchondral bone marrow lesions in a canine model.
Journal of orthopaedic research : official publication of the Orthopaedic Research Society
This study characterizes outcomes associated with subchondroplasty (SCP) versus SCP enhanced with platelet rich plasma (PRP) or bone marrow aspirate concentrate (BMC) treatment of impact-induced subchondral bone marrow lesions (BML) using a validated pre-clinical canine model. With IACUC approval, purpose-bred research hounds (n=24) underwent arthroscopic impact injury (40N) to both medial femoral condyles. At 3 months, functional assessments, arthroscopy, and MRI were performed. One knee in each dog (n=24; n=12 per endpoint) was randomly assigned to SCP with the other knee randomly assigned to SCP+PRP, SCP+BMC or sham injection (Control) (n=8 per group; n=4 per endpoint). Dogs were evaluated at 6 and 12 months after treatment using functional assessments, radiography, arthroscopy, and MRI and humanely euthanatized at 6 or 12 months after treatment for histologic assessments. At 6 months post-treatment, comfortable range-of-motion (CROM) was higher (p<0.04) in SCP+PRP and SCP+BMC knees compared to Controls. At 1 year post-treatment, %-Total Pressure Index was higher (p=0.036) in SCP+BMC compared to Controls, pain was lower (p<0.05) in SCP+BMC and SCP+PRP compared to SCP and Controls, and CROM was higher (p<0.05) in SCP+BMC and SCP+PRP compared to SCP and Controls. Knees treated with SCP+PRP and SCP+BMC had better (p<0.05) MRI grades than SCP and Controls. No statistically significant differences in arthroscopic or histologic pathology were noted. Clinical significance: Biologics added to SCP treatment may further enhance its beneficial effects by improving range-of-motion, pain severity, and limb loading through 1 year after treatment. However, these benefits must be considered alongside cost, logistics, and treatment availability. This article is protected by copyright. All rights reserved.
View details for DOI 10.1002/jor.24508
View details for PubMedID 31692048
Biomechanical Evaluation of Suture Anchor versus Transosseous Tunnel Patellar Tendon Repair Techniques.
The journal of knee surgery
2019; 32 (8): 825–32
The objective of this study is to compare the cyclic loading strength and ultimate failure load in suture anchor repair versus transosseous tunnel repair of patellar tendons using a cadaver model. Twelve cadaveric patella specimens were used (six matched pairs). Dual-energy X-ray absorptiometry (DXA) measurements were performed to ensure equal bone quality among groups. All right knees were assigned to the suture anchor repair group (n=6), whereas all left knees were assigned to the transosseous bone tunnel group (n=6). Suture type and repair configuration were equivalent. After the respective procedures were performed, each patella was mounted into a gripping jig. Tensile load was applied at a rate of 1Hz between magnitudes of 50 and 150N, 50 and 200N, 50 and 250N, and tensile load at a rate of 0.1 mm/s until failure. Failure was defined as a sharp deviation in the linear load versus displacement curve, and failure mode was recorded. DXA measurements demonstrated equivalence of bone quality between the two groups (p>0.05). During cyclic load testing, there was only a statistically significant difference between the groups with regard to cyclic loading at the 50 to 200N loading cycle (p=0.010). There was no statistically significant difference between the groups with regard to ultimate load to failure (p=0.43). Failure mode within the suture anchor cohort occurred through anchor pullout except for one, which failed through the tendon. All specimens within the transosseous cohort failed through the midsubstance of the tendon except for one, which failed through suture breakage. Suture anchor repair demonstrated a similar biomechanical profile regarding cyclic loading and ultimate load to failure when compared with "gold standard" transosseous tunnel patellar tendon repair with a trend toward less gapping in the suture anchor group. Using suture anchors for repair of the patella tendon has similar biomechanical properties to transpatellar tunnels but may provide other clinical advantages.
View details for DOI 10.1055/s-0038-1669790
View details for PubMedID 30189438
Optimizing Patellofemoral Cartilage Restoration and Instability With Tibial Tubercle Osteotomy
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
2019; 35 (8): 2255–56
Tibial tubercle osteotomy (TTO) is a procedure that may be used to address a wide array of patellofemoral joint pathology. The most common indications for TTO include (1) patellar instability, including either a lateralized force vector or abnormal patellar alta, and (2) patellar focal cartilage defects or chondromalacia. Customization of the TTO can effectively address the patellofemoral joint pathology by modifying patellar tracking in the trochlear groove and/or altering the contact pressures experienced by the patellofemoral cartilage. TTO may be most successful when performed in conjunction with soft-tissue stabilization and/or biological augmentation of chondral injuries. Specifically, isolated anteromedialization is recommended for focal, distal lateral patellar lesions; combined anteromedialization and cartilage restoration are recommended for medial, central, and/or panpatellar cartilage pathology; medialization with soft-tissue stabilization is recommended for a lateralized tubercle position (elevated tibial tubercle-trochlear groove distance); and distalization with soft-tissue stabilization is recommended for patella alta. Clinical studies have shown good to excellent results at long-term follow-up when a TTO is performed for patellar instability, whereas TTO performed for chondral defects has shown good to excellent outcomes that correlate strongly with the size and location of the chondral defect. With appropriate patient selection, TTO is a valuable tool for the treatment of patellofemoral joint pathology.
View details for DOI 10.1016/j.arthro.2019.05.013
View details for Web of Science ID 000478807600002
View details for PubMedID 31395155
Articular Cartilage Lesion Characteristic Reporting Is Highly Variable in Clinical Outcomes Studies of the Knee
2019; 10 (3): 299–304
The purpose of this study was to investigate the degree of standardized evaluation and reporting of cartilage lesion characteristics in high-impact clinical studies for symptomatic lesions of the knee. We hypothesized that there are significant inconsistencies in reporting these metrics across orthopedic literature.A total of 113 clinical studies on articular cartilage restoration of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2016. Full-text review was used to evaluate sources for details on study methodology and reporting on the following variables: primary procedure, location, size, grade, and morphology of cartilage lesions.All studies reported on the type of primary cartilage procedure and precise lesion location(s). Approximately 99.1% reported lesion morphology (chondral, osteochondral, mixed). For lesion size, 32.7% of articles did not report how size was measured and 11.5% did not report units. The lesion sizing method was variable, as 27.4% used preoperative magnetic resonance imaging to measure/report lesion size, 31.0% used arthroscopy, and 8.8% used both. The majority of studies (83.2%) used area to report size, and 5.3% used diameter. Formal grading was not reported in 17.7% of studies. Only 54.8% of studies reported depth when sizing osteochondral defects.Recent literature on cartilage restoration provides adequate information on surgical technique, lesion location, and morphology. However, there is wide variation and incomplete reporting on lesion size, depth, and grading. Future clinical studies should include these important data in a consistent manner to facilitate comparison among surgical techniques.
View details for DOI 10.1177/1947603518756464
View details for Web of Science ID 000472034600004
View details for PubMedID 29405742
View details for PubMedCentralID PMC6585291
Do neoprene sleeves and prophylactic knee braces affect neuromuscular control and cutting agility?
Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine
2019; 39: 23–31
OBJECTIVES: To evaluate the effects of neoprene sleeves (NSs) and prophylactic knee braces (PKBs) on neuromuscular control and cutting agility.DESIGN: Markerless motion-capture technology tracked subjects (1) without a brace as a control (2) with NSs and (3) with PKBs during single-leg drop vertical jump (SLDVJ), single-leg squat (SLS), Y-excursion, and cutting movements. Movements were recorded five times per bracing condition in three different sessions.SETTING: University laboratory.PARTICIPANTS: Ten healthy, active subjects (5 male, 5 female; age range, 22-26 years).MAIN OUTCOME MEASURES: Degrees of motion and time to completion.RESULTS: Use of NSs and PKBs reduced subjects' hip internal rotation in the loading phase of SLDVJ (p = 0.026, 0.02) and SLS (p = 0.005, <0.001), reduced knee flexion in the loading phase of SLDVJ (p = 0.038, <0.001), and reduced knee frontal plane abduction (FPA) with SLS (p = 0.015, 0.024) and Y-excursion (p = 0.002, 0.005) compared to control. Use of PKBs decreased subjects' hip internal rotation in the Y-excursion (p = 0.024) and reduced knee FPA in the SLDVJ loading phase (p = 0.014) compared to control. There was no difference in cutting agility for either group (p = 0.145, 0.347).CONCLUSION: Both NSs and PKBs positively impacted neuromuscular control without impacting cutting agility.
View details for DOI 10.1016/j.ptsp.2019.05.007
View details for PubMedID 31203143
Accurate Reporting of Concomitant Procedures Is Highly Variable in Studies Investigating Knee Cartilage Restoration.
OBJECTIVE: Successful clinical outcomes following cartilage restoration procedures are highly dependent on addressing concomitant pathology. The purpose of this study was to document methods for evaluating concomitant procedures of the knee when performed with articular cartilage restoration techniques, and to review their reported findings in high-impact clinical orthopedic studies. We hypothesized that there are substantial inconsistencies in reporting clinical outcomes associated with concomitant procedures relative to outcomes related to isolated cartilage repair.DESIGN: A total of 133 clinical studies on articular cartilage repair of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2017. Studies were included if they were primary research articles reporting clinical outcomes data following surgical treatment of articular cartilage lesions with a minimum sample size of 5 patients. Studies were excluded if they were review articles, meta-analyses, and articles reporting only nonclinical outcomes (e.g., imaging, histology). A full-text review was then used to evaluate details regarding study methodology and reporting on the following variables: primary cartilage repair procedure, and the utilization of concomitant procedures to address additional patient comorbidities, including malalignment, meniscus pathology, and ligamentous instability. Each study was additionally reviewed to document variation in clinical outcomes reporting in patients that had these comorbidities addressed at the time of surgery.RESULTS: All studies reported on the type of primary cartilage repair procedure, with autologous chondrocyte implantation (ACI) noted in 43% of studies, microfracture (MF) reported in 16.5%, osteochondral allograft (OCA) in 15%, and osteochondral autograft transplant (OAT) in 8.2%. Regarding concomitant pathology, anterior cruciate ligament (ACL) reconstruction (24.8%) and meniscus repair (23.3%) were the most commonly addressed patient comorbidities. A total of 56 studies (42.1%) excluded patients with malalignment, meniscus injury, and ligamentous instability. For studies that addressed concomitant pathology, 72.7% reported clinical outcomes separately from the cohort treated with only cartilage repair. A total of 16.5% of studies neither excluded nor addressed concomitant pathologies. There was a significant amount of variation in the patient reported outcome scores used among the studies, with the majority of studies reporting International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcomes Score (KOOS) in 47.2% and 43.6% of articles, respectively.CONCLUSIONS: In this study on knee cartilage restoration, recognition and management of concomitant pathology is inadequately reported in approximately 28% of studies. Only 30% of articles reported adequate treatment of concomitant ailments while scoring their outcomes using one of a potential 18 different scoring systems. These findings highlight the need for more standardized methods to be applied in future research with regard to inclusion, exclusion, and scoring concomitant pathologies with regard to treatment of cartilage defects in the knee.
View details for DOI 10.1177/1947603519841673
View details for PubMedID 30971096
Isolated Complete Rupture of the Biceps Femoris Insertion: A Surgical Repair Technique Manuscript
2019; 8 (4): E407–E411
Isolated rupture of the distal biceps femoris insertion is rare. Current literature offers limited case reports and outcome measures after surgical management. We describe a knotless suture anchor fixation technique for this tear pattern. At surgery, the retracted biceps tendon and insertion site is debrided to healthy tissue, FiberTape suture (Arthrex) is passed in a Kracków fashion through the tendon, and the 2 ends of the suture are brought down to a SwiveLock anchor (Arthrex) at the anatomic insertion. FiberWire sutures (Arthrex) from the anchor are brought over the remnant stump, completing the repair.
View details for DOI 10.1016/j.eats.2018.11.020
View details for Web of Science ID 000466921200009
View details for PubMedID 31080724
View details for PubMedCentralID PMC6506860
Relationship Between 2-Dimensional Frontal Plane Measures and the Knee Abduction Angle During the Drop Vertical Jump
JOURNAL OF SPORT REHABILITATION
2019; 28 (4): 399–402
Context: Knee abduction angle (KAA), as measured by 3-dimensional marker-based motion capture systems during jump-landing tasks, has been correlated with an elevated risk of anterior cruciate ligament injury in females. Due to the high cost and inefficiency of KAA measurement with marker-based motion capture, surrogate 2-dimensional frontal plane measures have gained attention for injury risk screening. The knee-to-ankle separation ratio (KASR) and medial knee position (MKP) have been suggested as potential frontal plane surrogate measures to the KAA, but investigations into their relationship to the KAA during a bilateral drop vertical jump task are limited. Objective: To investigate the relationship between KASR and MKP to the KAA during initial contact of the bilateral drop vertical jump. Design: Descriptive. Setting: Biomechanics laboratory. Participants: A total of 18 healthy female participants (mean age: 24.1 [3.88] y, mass: 65.18 [10.34] kg, and height: 1.63 [0.06] m). Intervention: Participants completed 5 successful drop vertical jump trials measured by a Vicon marker-based motion capture system and 2 AMTI force plates. Main Outcome Measure: For each jump, KAA of the tibia relative to the femur was measured at initial contact along with the KASR and MKP calculated from planar joint center data. The coefficient of determination (r2) was used to examine the relationship between the KASR and MKP to KAA. Results: A strong linear relationship was observed between MKP and KAA (r2 = .71), as well as between KASR and KAA (r2 = .72). Conclusions: Two-dimensional frontal plane measures show strong relationships to the KAA during the bilateral drop vertical jump.
View details for DOI 10.1123/jsr.2018-0017
View details for Web of Science ID 000470203900001
View details for PubMedID 30422040
The 50 Most-Cited Articles in Meniscal Allograft Transplantation Research: A Bibliometric Analysis
2019; 10 (2): 196–204
To identify the 50 most-cited articles in meniscal allograft transplantation (MAT) research and analyze their characteristics.In September 2017, the Scopus database was queried to identify the 50 most-cited articles in MAT research. Variables analyzed include number of citations, publication year, journal, institution, country of origin, article type, study design, and level of evidence. Citation density was calculated for each article. The correlation between citation density and publication year and the correlation between level of evidence and number of citations, citation density, and publication year were computed.The 50 most-cited articles were published in 12 journals between 1986 and 2011. The number of citations ranged from 59 to 290 (109.3 ± 48.6). Citation density ranged from 2.7 to 17.6 citations per year (7.0 ± 3.3). There was a positive correlation between citation density and publication year ( r = +0.489, P < 0.001). Overall, 56% of the articles were clinical and 44% were basic science. Of the 28 clinical articles, 61% were level IV or V evidence. Level of evidence was not significantly correlated with number of citations ( r = -0.059, P = 0.766), citation density ( r = +0.030, P = 0.880), or publication year ( r = -0.0009, P = 0.996).This analysis provides the orthopedic community with a readily accessible list of the classic citations in MAT research and provides insight into the historical development of this procedure. Although there was a moderate positive correlation between citation density and publication year, articles with stronger levels of evidence were not more frequently cited despite the increasing trend toward evidence-based practice.
View details for DOI 10.1177/1947603517749922
View details for Web of Science ID 000461640700006
View details for PubMedID 29291274
View details for PubMedCentralID PMC6425545
- Management of patellofemoral instability in the setting of multiligament knee injury ANNALS OF JOINT 2018; 3 (11)
Reconstruction of the medial patellotibial ligament results in favorable clinical outcomes: a systematic review
KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY
2018; 26 (10): 2920–33
The medial patellotibial ligament (MPTL), the medial patellofemoral ligament (MPFL), and the medial patellomeniscal ligament (MPML) support the stability of the patellofemoral joint. The purpose of this systematic review was to report the surgical techniques and clinical outcomes of the repair or reconstruction of the MPTL in isolation or concomitant with the MPFL and/or other procedures.A systematic review of the literature was conducted. Inclusion criteria were articles in the English language that reported clinical outcomes of the reconstruction of the MPTL in isolation or in combination with the MPFL and/or other procedures. Included articles were then cross-referenced to find additional journal articles not found in the initial search. The methodological quality of the articles was determined using the Coleman Methodology Score.Nineteen articles were included detailing the clinical outcomes of 403 knees. The surgical procedures described included hamstrings tenodesis with or without other major procedures, medial transfer of the medial patellar tendon with or without other major procedures and the reconstruction of the MPTL in association with the MPFL. Overall, good and excellent outcomes were achieved in > 75% of cohorts in most studies and redislocations were < 10%, with or without the association of the MPFL. An exception was one study that reported a high failure rate of 82%. Results were consistent across different techniques. The median CMS for the articles was 66 out of 100 (range 30-85).Across different techniques, the outcomes are good with low rates of recurrence, with one article reporting a high rate of recurrence. Quality of the articles is variable, from low to high. Randomized control trials are needed for a better understanding of the indications, surgical techniques, and clinical outcomes. This systematic review suggests that the reconstruction of the MPTL leads to favorable clinical outcomes and supports the role of the procedure as a valid surgical patellar stabilization procedure.IV: systematic review of level I-IV studies.
View details for DOI 10.1007/s00167-018-4833-6
View details for Web of Science ID 000444832000008
View details for PubMedID 29344696
Subchondroplasty for the treatment of post-traumatic bone marrow lesions of the medial femoral condyle in a pre-clinical canine model
JOURNAL OF ORTHOPAEDIC RESEARCH
2018; 36 (10): 2709–17
This study characterizes long-term outcomes associated with subchondroplasty (SCP) treatment for impact-induced subchondral bone marrow lesions (BML) using a validated pre-clinical canine model. With IACUC approval, purpose-bred research hounds (n = 16) underwent arthroscopic impact injury (40N) to both medial femoral condyles. At 3 months, functional assessments, arthroscopy, and MRI were performed and knees (n = 32) were randomly assigned to SCP (3 ml fluoroscopically guided percutaneous injection of AccuFill BSM into BML bone defects) or sham injection (Control). Dogs were assessed at 3, 6, 12, and 24 months after treatment using functional assessments, radiographic evaluation, arthroscopy, and MRI. Dogs were humanely euthanatized at 3, 6, 12, or 24 months after treatment for gross, microCT, and histologic assessments. All knees had focal articular cartilage defects with associated subchondral BMLs, as well as clinical dysfunction, 3 months after injury. At the 3 and 6 months, SCP knees showed more functional impairment than Control knees, however, these differences were not statistically significant. At 1- and 2-year post-treatment, function in SCP knees was better than in Control knees with range of motion being significantly (p < 0.05) better for SCP. Radiographic, arthroscopic, MRI, gross, microCT, and histologic findings matched the functional assessments well with Control being associated with better results at the two early time points and SCP being associated with better results at 1 and 2 years. Clinical significance: SCP treatment using calcium phosphate bone void filler was associated with an initial increase in pain and dysfunction followed by symptomatic benefits for up to 2 years after treatment for post-traumatic femoral condyle BMLs in a preclinical canine model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2709-2717, 2018.
View details for DOI 10.1002/jor.24046
View details for Web of Science ID 000449527800016
View details for PubMedID 29748965
- Evaluation of Novel Cartilage Treatment Options for Clinical Use OPERATIVE TECHNIQUES IN SPORTS MEDICINE 2018; 26 (3): 218–26
- Meniscus Allograft Transplantation OPERATIVE TECHNIQUES IN SPORTS MEDICINE 2018; 26 (3): 189–204
Radiologic and Histologic Evaluation of Proximal Bicep Pathology in Patients With Chronic Biceps Tendinopathy Undergoing Open Subpectoral Biceps Tenodesis
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
2018; 34 (6): 1790–96
To correlate preoperative magnetic resonance imaging (MRI) and intraoperative anatomic findings within the proximal long head biceps tendon to histologic evaluation of 3 separate zones of the tendon in patients with chronic biceps tendinopathy.Sixteen patients with chronic biceps tendinopathy were treated with open subpectoral biceps tenodesis. Preoperative MRI tendon grading was as follows: normal tendon, increased signal, tendon splitting, incomplete/complete tear. The removed portion of the biceps tendon was split into 3 segments: zone 1, 0-3.5 cm from the labral insertion; zone 2, 3.5-6.5 cm; and zone 3, 6.5-9 cm, and was histologically evaluated using the Bonar score. Tenosynovium adjacent to the tendon was assessed histologically using the Osteoarthritis Research Society International score. CD31, CD3, and CD79a immunohistochemistries were conducted to determine vascularization, T-cell infiltrates, and B-cell infiltrates, respectively. Analysis of variance and Pearson correlations were performed for statistical analysis.Preoperative MRI showed no significant differences in tendon appearance between zones 1-3. Intraoperative findings included nonspecific degenerative SLAP tears or mild/moderate biceps tenosynovitis in all cases. Significantly (P < .001) higher Bonar scores were noted for tendon in zones 1 (7.9 ± 1.8) and 2 (7.3 ± 1.5) compared with zone 3 (5.0 ± 1.1). Cell morphology scores in zone 1 (1.9 ± 0.4) and zone 2 (1.5 ± 0.6) were significantly higher than that in zone 3 (0.8 ± 0.3) (P < .05). Inflammatory tenosynovium showed weak correlation with tendon changes in zone 1 (r = 0.08), zone 2 (r = 0.03), or zone 3 (r = 0.1).In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. Severity of tendon histopathology was more pronounced in the proximal and mid-portions of the tendon.Proximal versus distal biceps tenodesis is a subject of frequent debate. This study contributes to the ongoing evaluation of the characteristics of the proximal biceps in this type of pathologic condition.
View details for DOI 10.1016/j.arthro.2018.01.021
View details for Web of Science ID 000433213900013
View details for PubMedID 29573932
Return to Play after Patellar Stabilization
CURRENT REVIEWS IN MUSCULOSKELETAL MEDICINE
2018; 11 (2): 280–84
The purpose of this review is to evaluate the existing literature regarding return to play (RTP) and return to prior performance (RPP) following patellar stabilization surgery. It will also discuss suggested guidelines regarding RTP, and finally, to encourage future patellofemoral instability research to report and publish results of RTP rates using standardized RTP guidelines.There is a lack of validation and universal adoption of standardized RTP guidelines. This has led to a dearth of high-quality studies on RTP and RPP after patellar stabilization. The best available studies to date would suggest high RTP rates (84%-100%), average RPP rates (33%-77%), and a highly variable timeframe for return (3-12 months). Patellofemoral instability can be a persistent and challenging problem, particularly in the young and active population for which it most often occurs. Much of the previous studies on patellofemoral instability evaluated success and failure as prevention of recurrent dislocation. However, prevention of recurrence alone may not be enough for many patients. The best available data on RTP and RPP following patellofemoral instability is based on lower quality of evidence studies, expert opinion, and published societal guidelines. Future research on this topic should include clinical validation of the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine (ISAKOS) RTP guidelines and reporting of outcomes based on these guidelines in patellofemoral instability publications.
View details for DOI 10.1007/s12178-018-9484-1
View details for Web of Science ID 000433204500014
View details for PubMedID 29750318
View details for PubMedCentralID PMC5970119
- Chondral and osteochondral lesions in the patellofemoral joint: when and how to manage ANNALS OF JOINT 2018; 3 (6)
Anterior Cruciate Ligament Injuries in Missouri High School Male and Female Soccer Athletes
LIPPINCOTT WILLIAMS & WILKINS. 2018: 575
View details for Web of Science ID 000456870502404
Distal Femoral Varus Osteotomy for the Management of Valgus Deformity of the Knee
JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
2018; 26 (9): 313–24
Distal femoral varus osteotomy is a well-described treatment option for patients with valgus malalignment associated with a variety of underlying conditions. This procedure may be the definitive treatment option in active patients with isolated lateral compartment osteoarthritis or posttraumatic arthritis. It may be a useful concomitant procedure in young patients with lateral meniscus deficiency, focal chondral defects, chronic medial collateral ligament insufficiency, and/or patellofemoral instability. Distal femoral varus osteotomy can be performed with medial closing wedge or lateral opening wedge techniques. Variable outcomes and complication rates have been reported. A framework for the use of distal femoral varus osteotomy can aid the orthopaedic surgeon in the evaluation and treatment of patients with symptomatic valgus malalignment.
View details for DOI 10.5435/JAAOS-D-16-00179
View details for Web of Science ID 000441215400006
View details for PubMedID 29629916
- Patellofemoral Cartilage Restoration: Indications, Techniques, and Outcomes Foreword JOURNAL OF KNEE SURGERY 2018; 31 (3): 205
Youth Baseball Pitching Mechanics: A Systematic Review
SPORTS HEALTH-A MULTIDISCIPLINARY APPROACH
2018; 10 (2): 133–40
Pitching injuries in youth baseball are increasing in incidence. Poor pitching mechanics in young throwers have not been sufficiently evaluated due to the lack of a basic biomechanical understanding of the "normal" youth pitching motion.To provide a greater understanding of the kinetics and kinematics of the youth baseball pitching motion.PubMed, MEDLINE, and SPORTDiscus databases were searched from database inception through February 2017.A total of 10 biomechanical studies describing youth pitching mechanics were included.Systematic review.Level 3.Manual extraction and compilation of demographic, methodology, kinetic, and kinematic variables from the included studies were completed.In studies of healthy youth baseball pitchers, progressive external rotation of the shoulder occurs throughout the start of the pitching motion, reaching a maximum of 166° to 178.2°, before internally rotating throughout the remainder of the cycle, reaching a minimum of 13.2° to 17°. Elbow valgus torque reaches the highest level (18 ± 4 N·m) just prior to maximum shoulder external rotation and decreases throughout the remainder of the pitch cycle. Stride length is 66% to 85% of pitcher height. In comparison with a fastball, a curveball demonstrates less elbow varus torque (31.6 ± 15.3 vs 34.8 ± 15.4 N·m).Multiple studies show that maximum elbow valgus torque occurs just prior to maximum shoulder external rotation. Forces on the elbow and shoulder are greater for the fastball than the curveball.
View details for DOI 10.1177/1941738117738189
View details for Web of Science ID 000429947700006
View details for PubMedID 29090988
View details for PubMedCentralID PMC5857730
In Vivo Toxicity of Local Anesthetics and Corticosteroids on Supraspinatus Tenocyte Cell Viability and Metabolism.
The Iowa orthopaedic journal
2018; 38: 107–12
Background: This study was conducted to evaluate the effects of commonly used injection medication combinations on supraspinatus tenocyte cell viability and tissue metabolism.Methods: Twenty adult dogs underwent ultrasound guided injection of the canine equivalent of the subacromial space, based on random assignment to one of four treatment groups (n=5/group): normal saline, 1.0% lidocaine/methylprednisolone, 1.0% lidocaine/triamcinolone or 0.0625% bupivacaine/triamcinolone. Full-thickness sections of supraspinatus tendon were harvested under aseptic conditions and evaluated on days 1 and 7 post-harvest for cell viability and tissue metabolism. Data were analyzed for significant differences among groups.Results: Tendons exposed to 1% lidocaine/ methylprednisolone had significantly lower cell viability at day 1 as compared to all other groups and control. All local anesthetic/ corticosteroid combination groups had decreased cell viability at day 7 when compared to the control group.Conclusions: This study demonstrated significant in vivo supraspinatus tenotoxicity following a single injection of combination local anesthetic/ corticosteroid when compared to saline controls.Level of Evidence: Level II.
View details for PubMedID 30104932
Overuse of Magnetic Resonance Imaging in the Diagnosis and Treatment of Moderate to Severe Osteoarthritis.
The Iowa orthopaedic journal
2018; 38: 33–37
Background: MRI in the evaluation of end-stage knee joint osteoarthritis (OA) is usually unnecessary when radiographic and clinical evidence of gonarthrosis is clear. The purpose of this study was to assess the prevalence of MRI scans ordered in patients with radiographically obvious gonarthrosis and to examine the characteristics of health care providers who ordered these imaging studies.Methods: We retrospectively identified 164 patients diagnosed with moderate to severe OA who were referred for total knee replacement (TKA) over a one-year period. The percentage of patients who had an MRI scan with or without X-ray, within the preceding 3 months prior to referral, were calculated. Subgroups were analyzed to identify characteristics that may influence the decision to order an MRI, including K-L grade, provider type, level of training, and practice location.Results: Of 145 patients, 19 (13.1%) presented with an MRI scan. Between the number of MRI scans ordered, there was a significant difference when comparing physicians versus non-physicians, with physicians ordering less MRI scans (p=0.018). There was a significant difference when comparing non-academic versus academic, with academic providers ordering less MRI scans (p=0.044). There was no significant difference with fellowship training or provider proximity to our academic institution.Conclusions: In this study, 13.1% of patients with radiographically obvious knee OA obtained an MRI prior to referral for TKA. Non-physicians and non-academic physicians were more likely to order MRI scans. Improved education for referring providers may be necessary to decrease overuse of MRI in the diagnosis of moderate to severe arthritis.Level of Evidence: Level II.
View details for PubMedID 30104922
Development and Validation of a Portable and Inexpensive Tool to Measure the Drop Vertical Jump Using the Microsoft Kinect V2
SPORTS HEALTH-A MULTIDISCIPLINARY APPROACH
2017; 9 (6): 537–44
Noncontact anterior cruciate ligament (ACL) injury in adolescent female athletes is an increasing problem. The knee-ankle separation ratio (KASR), calculated at initial contact (IC) and peak flexion (PF) during the drop vertical jump (DVJ), is a measure of dynamic knee valgus. The Microsoft Kinect V2 has shown promise as a reliable and valid marker-less motion capture device.The Kinect V2 will demonstrate good to excellent correlation between KASR results at IC and PF during the DVJ, as compared with a "gold standard" Vicon motion analysis system.Descriptive laboratory study.Level 2.Thirty-eight healthy volunteer subjects (20 male, 18 female) performed 5 DVJ trials, simultaneously measured by a Vicon MX-T40S system, 2 AMTI force platforms, and a Kinect V2 with customized software. A total of 190 jumps were completed. The KASR was calculated at IC and PF during the DVJ. The intraclass correlation coefficient (ICC) assessed the degree of KASR agreement between the Kinect and Vicon systems.The ICCs of the Kinect V2 and Vicon KASR at IC and PF were 0.84 and 0.95, respectively, showing excellent agreement between the 2 measures. The Kinect V2 successfully identified the KASR at PF and IC frames in 182 of 190 trials, demonstrating 95.8% reliability.The Kinect V2 demonstrated excellent ICC of the KASR at IC and PF during the DVJ when compared with the Vicon system. A customized Kinect V2 software program demonstrated good reliability in identifying the KASR at IC and PF during the DVJ.Reliable, valid, inexpensive, and efficient screening tools may improve the accessibility of motion analysis assessment of adolescent female athletes.
View details for DOI 10.1177/1941738117726323
View details for Web of Science ID 000418307700007
View details for PubMedID 28846505
View details for PubMedCentralID PMC5665114
Management of Anterior Cruciate Ligament Injury? What's In and What's Out?
INDIAN JOURNAL OF ORTHOPAEDICS
2017; 51 (5): 563–75
Sports medicine physicians have a keen clinical and research interest in the anterior cruciate ligament (ACL). The biomechanical, biologic, and clinical data researchers generate, help drive injury management and prevention practices globally. The current concepts in ACL injury and surgery are being shaped by technological advances, expansion in basic science research, resurging interest in ACL preservation, and expanding efforts regarding injury prevention. As new methods are being developed in this field, the primary goal of safely improving patient outcomes will be a unifying principle. With this review, we provide an overview of topics currently in controversy or debate, and we identify paradigm shifts in the understanding, management, and prevention of ACL tears.
View details for DOI 10.4103/ortho.IJOrtho_245_17
View details for Web of Science ID 000410233800011
View details for PubMedID 28966380
View details for PubMedCentralID PMC5609378
Osteochondral Autologous Transplantation
CLINICS IN SPORTS MEDICINE
2017; 36 (3): 489-+
Osteochondral autologous transplantation (OAT) is a treatment strategy for small and medium sized focal articular cartilage defects in the knee. This article reviews the indications, surgical techniques, outcomes, and limitations of OAT for the management of symptomatic chondral and osteochondral lesions in the knee joint.
View details for DOI 10.1016/j.csm.2017.02.006
View details for Web of Science ID 000404499200008
View details for PubMedID 28577708
Safety and efficacy of hyperosmolar irrigation solution in shoulder arthroscopy
JOURNAL OF SHOULDER AND ELBOW SURGERY
2017; 26 (5): 745–51
A hyperosmolar irrigation solution has been reported to be safe and have potential benefits for use during shoulder arthroscopy in an animal model study. In this study, the clinical effects of a hyperosmolar solution were compared with a standard isotonic solution when used for shoulder arthroscopy.A prospective, double-blind, randomized controlled trial was performed to compare isotonic (273 mOsm/L) and hyperosmolar (593 mOsm/L) irrigation solutions used for arthroscopic rotator cuff repair. Primary outcomes focused on the amount of periarticular fluid retention based on net weight gain, change in shoulder girth, and pain. All patients were tracked through standard postsurgical follow-up to ensure no additional complications arose. Patients were contacted at 1 year to assess American Shoulder and Elbow Surgeon score, visual analog scale pain score, and the Single Assessment Numeric Evaluation shoulder scores RESULTS: Fifty patients (n = 25/group) were enrolled and completed the study. No statistically significant differences were noted between cohorts in demographics or surgical variables. The hyperosmolar group experienced significantly less mean weight gain (1.6 ± 0.82 kg vs. 2.25 ± 0.77 kg; P = .005), significantly less change in shoulder girth (P < .05), and a significantly lower immediate postoperative visual analog scale pain score (P = .036). At 1 year postoperatively, the differences between groups for American Shoulder and Elbow Surgeons, visual analog scale pain, and Single Assessment Numeric Evaluation were not significant (P > .2).A hyperosmolar irrigation solution provides a safe and effective way to decrease periarticular fluid retention associated with arthroscopic rotator cuff surgery without any adverse long-term effects. Use of a hyperosmolar irrigation solution for shoulder arthroscopy has potential clinical benefits to surgeons and patients.
View details for DOI 10.1016/j.jse.2017.02.021
View details for Web of Science ID 000402464300010
View details for PubMedID 28318850
In vivo bone tunnel evaluation of nanoparticle-grafts using an ACL reconstruction rabbit model
JOURNAL OF BIOMEDICAL MATERIALS RESEARCH PART A
2017; 105 (4): 1071–82
Acellular human gracilis tendons conjugated with gold nanoparticles (AuNP) and hydroxyapatite nanoparticles (nano-HAp) were used as a graft in an anterior cruciate ligament (ACL) reconstruction rabbit model. The ACLs of 11 New Zealand rabbits were reconstructed using grafts conjugated without nanoparticles, with AuNP only, and with both AuNP and nano-HAp. Semi-quantitative histological scoring of bone tunnel portion of grafts was performed after 14 weeks. Bone tunnels were scored for graft degeneration, graft remodeling, percentage of new host fibrous connective, collateral connection, head-to-head connection, graft collagen fiber organization, new host fibrous connective tissue organization, and graft and interface vascularity. All grafts were intact at 14 weeks. Results of bone tunnel scoring indicate remodeling in all graft types with new organized host fibrous connective tissue, head-to-head connection to bone and mild inflammation associated with remodeling. Components of the 20 nm AuNP grafts have significantly more graft degeneration, more new host fibrous connective tissue, and more vascularity compared to crosslinked grafts. Comparison between femoral and tibial tunnel scores indicate more degeneration in femoral tunnels compared to tibial tunnels. Overall results indicated potentially enhanced remodeling from the use of 20 nm AuNP grafts. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 1071-1082, 2017.
View details for DOI 10.1002/jbm.a.36000
View details for Web of Science ID 000395008300012
View details for PubMedID 28076887
In vitro toxicity of local anaesthetics and corticosteroids on supraspinatus tenocyte viability and metabolism
JOURNAL OF ORTHOPAEDIC TRANSLATION
2017; 8: 20–24
The purpose of this study was to evaluate supraspinatus tenocyte viability and metabolism in explants exposed to various local anaesthetics and corticosteroids. Our hypothesis was that the tendons exposed to these common injectates would have significantly decreased cell viability and metabolism compared with controls.Supraspinatus tendon explants were obtained from dogs, placed in a culture media, and randomly assigned to one of the following groups: culture media only (control), 1% lidocaine, 0.5% lidocaine, 0.25% bupivacaine, 0.125% bupivacaine, 0.0625% bupivacaine, betamethasone acetate (5 mg), methylprednisolone acetate (40 mg), or triamcinolone acetonide (40 mg). Cell viability was determined on Days 1 and 7 after culture treatment using calcein AM (live cell) and Sytox Blue (dead cell) stains. Tissue metabolism was assessed on Days 1 and 7 using the resazurin blue metabolic assay. Significant differences were evaluated using a one-way analysis of variance with Tukey post hoc analysis.Compared with the controls, there were significant decreases in cell viability noted at Days 1 and 7 in tenocytes exposed to 1% lidocaine, betamethasone, and methylprednisolone. Significant decreases in cell metabolism were also noted at Days 1 and 7 in those groups. Treatment with 0.125% bupivacaine, 0.0625% bupivacaine, and triamcinolone demonstrated no decrease in cell viability or metabolism when compared with controls at any time point.This data confirms that peritendinous injection of commonly used local anaesthetics and corticosteroids results in significant supraspinatus tenotoxicity in vitro. Further in vivo studies are required before making definitive clinical recommendations.
View details for DOI 10.1016/j.jot.2016.08.002
View details for Web of Science ID 000391086500004
View details for PubMedID 30035090
View details for PubMedCentralID PMC5987053
Development of a Micronized Meniscus Extracellular Matrix Scaffold for Potential Augmentation of Meniscal Repair and Regeneration
TISSUE ENGINEERING PART C-METHODS
2016; 22 (12): 1059–70
Decellularized scaffolds composed of extracellular matrix (ECM) hold promise for repair and regeneration of the meniscus, given the potential for ECM-based biomaterials to aid in stem cell recruitment, infiltration, and differentiation. The objectives of this study were to decellularize canine menisci to fabricate a micronized, ECM-derived scaffold and to determine the cytocompatibility and repair potential of the scaffold ex vivo. Menisci were decellularized with a combination of physical agitation and chemical treatments. For scaffold fabrication, decellularized menisci were cryoground into a powder and the size and morphology of the ECM particles were evaluated using scanning electron microscopy. Histologic and biochemical analyses of the scaffold confirmed effective decellularization with loss of proteoglycan from the tissue but no significant reduction in collagen content. When washed effectively, the decellularized scaffold was cytocompatible to meniscal fibrochondrocytes, synoviocytes, and whole meniscal tissue based on the resazurin reduction assay and histologic evaluation. In an ex vivo model for meniscal repair, radial tears were augmented with the scaffold delivered with platelet-rich plasma as a carrier, and compared to nonaugmented (standard-of-care) suture techniques. Histologically, there was no evidence of cellular migration or proliferation noted in any of the untreated or standard-of-care treatment groups after 40 days of culture. Conversely, cellular infiltration and proliferation were noted in scaffold-augmented repairs. These data suggest the potential for the scaffold to promote cellular survival, migration, and proliferation ex vivo. Further investigations are necessary to examine the potential for the scaffold to induce cellular differentiation and functional meniscal fibrochondrogenesis.
View details for DOI 10.1089/ten.tec.2016.0276
View details for Web of Science ID 000391500100001
View details for PubMedID 27824291
OSTEOCHONDRAL ALLOGRAFTS IN SHOULDER SURGICAL PROCEDURES
2016; 4 (11)
The use of fresh osteochondral allografts has become popular in many joint-preserving orthopaedic procedures and shows early promising results within the shoulder. Distal tibial allograft contains a stout cartilaginous layer that appears to have highly congruent curvature and concavity to the glenoid, which makes for an optimal allograft option for instability. In the setting of large Hill-Sachs lesions, the use of a humeral-head osteochondral allograft is essential to restore geometry, stability, and mechanics of the native glenohumeral joint. One must be cautious with the treatment of glenoid chondral lesions with osteoarticular grafting procedures because of the depth of the glenoid compared with the depth of subchondral bone on the graft necessary to achieve a press fit, and advanced imaging is recommended when planning an operative intervention. Optimizing joint-preservation treatment with osteochondral allografts will rely on the long-term results of these procedures, and careful patient selection, preoperative discussion, and realistic expectations are necessary.
View details for DOI 10.2106/JBJS.RVW.16.00001
View details for Web of Science ID 000391034100003
View details for PubMedID 27922984
The 50 Most Cited Articles in Orthopedic Cartilage Surgery
2016; 7 (3): 238–47
To determine the 50 most cited articles in orthopedic cartilage surgery and their characteristics.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.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).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.
View details for DOI 10.1177/1947603515621997
View details for Web of Science ID 000384334800004
View details for PubMedID 27375839
View details for PubMedCentralID PMC4918068
Biomechanical Evaluation of Suture Anchor Versus Transosseous Tunnel Quadriceps Tendon Repair Techniques
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
2016; 32 (6): 1117–24
To evaluate the biomechanical fixation strength of suture anchor and transosseous tunnel repair of the quadriceps tendon in a standardized cadaveric repair model.Twelve "patella-only" specimens were used. Dual-energy X-ray absorptiometry measurement was performed to ensure equal bone quality amongst groups. Specimens were randomly assigned to either a suture anchor repair of quadriceps tendon group (n = 6) or a transosseous tunnel repair group (n = 6). Suture type and repair configuration were equivalent. After the respective procedures were performed, each patella was mounted into a gripping jig. Tensile load was applied at a rate of 0.1 mm/s up to 100 N after which cyclic loading was applied at a rate of 1 Hz between magnitudes of 50 to 150 N, 50 to 200 N, 50 to 250 N, and tensile load at a rate of 0.1 mm/s until failure. Outcome measures included load to failure, displacement at 1st 100 N load, and displacement after each 10th cycle of loading.The measured cyclic displacement to the first 100 N, 50 to 150 N, 50 to 200 N, and 50 to 250 N was significantly less for suture anchors than transosseous tunnels. There was no statistically significant difference in ultimate load to failure between the 2 groups (P = .40). Failure mode for all suture anchors except one was through the soft tissue. Failure mode for all transosseous specimens but one was pulling the repair through the transosseous tunnel.Suture anchor quadriceps tendon repairs had significantly decreased gapping during cyclic loading, but no statistically significant difference in ultimate load to failure when compared with transosseous tunnel repairs. Although suture anchor quadriceps tendon repair appears to be a biomechanically superior construct, a clinical study is needed to confirm this technique as a viable alternative to gold standard transosseous techniques.Although in vivo studies are needed, these results support the suture anchor technique as a viable alternative to transosseous repair of the quadriceps tendon.
View details for DOI 10.1016/j.arthro.2015.11.038
View details for Web of Science ID 000377563900026
View details for PubMedID 26895785
Two-Stage Revision Anterior Cruciate Ligament Reconstruction
2016; 39 (3): E456–E464
The number of primary anterior cruciate ligament (ACL) tears is rapidly increasing. In patients who wish to return to their preoperative level of function, specifically as it pertains to participation in sports, the gold standard of treatment following an ACL tear remains an anterior cruciate ligament (ACL) reconstruction. Despite a majority of good/excellent results following primary ACL reconstruction, there is a growing subset of patients with persistent or recurrent functional instability who require revision ACL reconstruction. Preoperative planning for revision ACL reconstruction requires a careful understanding of the root cause of ACL failure, including possible technical causes of primary ACL failure and the presence of combined knee pathology that was not addressed at the index ACL reconstruction. The decision to perform 2-stage revision ACL reconstruction is multifactorial and is reached by technical considerations that may make a 1-stage revision less optimal, including tunnel widening, arthrofibrosis, active infection, and others. Concomitant knee pathology such as meniscal deficiency, malalignment (including an increase in posterior tibial slope), chondral lesions, and other ligamentous laxity may also require a staged approach to treatment. This evidence-based review covers the indications for 2-stage revision ACL reconstruction, surgical techniques, evidence for and technique of bone grafting prior ACL tunnels, and outcomes of 2-stage revision stratified by initial cause of ACL reconstruction failure. With proper preoperative planning and an understanding of the cause of failure following the primary ACL reconstruction, revision ACL reconstruction can offer excellent outcomes in the motivated patient. [Orthopedics. 2016; 39(3):e456-e464.].
View details for DOI 10.3928/01477447-20160324-01
View details for Web of Science ID 000377519200010
View details for PubMedID 27045480
Development of a Novel Canine Model for Posttraumatic Osteoarthritis of the Knee
JOURNAL OF KNEE SURGERY
2016; 29 (3): 235–41
Translational models of posttraumatic osteoarthritis (PTOA) that accurately represent clinical pathology need to be developed. This study assessed a novel canine model for PTOA using impact injury. Impacts were delivered to the medial femoral condyle of dogs using a custom-designed impactor at 20, 40, or 60 MPa. Functional assessments and magnetic resonance imaging (MRI) were performed at 2 and 12 weeks, and arthroscopic and histologic assessments were performed at 12 weeks after injury. At 2 and 12 weeks, dogs had observable lameness, knee pain, effusion, loss in range of motion (ROM) and dysfunction in both hindlimbs with severity correlated strongly (r > 0.77) to impact level. At 12 weeks, function, pain, effusion, and ROM were significantly (p < 0.049) worse in knees impacted at 40 and 60 MPa compared with 20 MPa. MRI showed consistent cartilage and subchondral bone marrow lesions, and arthroscopy revealed synovitis and cartilage destruction in impacted knees, with increased severity for 40 and 60 MPa impacts. Histopathology was significantly (p = 0.049) more severe in 40 and 60 MPa and strongly correlated (r = 0.93) to impact level. This novel translational model appears to be valid for investigation of PTOA, including determination of temporal mechanisms of disease and preclinical testing for preventative and therapeutic strategies.
View details for DOI 10.1055/s-0035-1549026
View details for Web of Science ID 000373292400009
View details for PubMedID 25892003
Rethinking the Standard of Care in Treating Professional Athletes
CLINICS IN SPORTS MEDICINE
2016; 35 (2): 269-+
There is public discussion and debate about the role of the team physician in professional sports. There is uncertainty over whether a separate legal standard of care should apply when treating professional athletes. This article advocates a single standard of care for all patients. This article also proposes that it would be useful for team physicians to develop a consensus that there should be a health policy for professional athletes. This health policy should aspire that professional athletes can complete their career, while minimizing the risk of cognitive or physical injuries that affect later quality of life.
View details for DOI 10.1016/j.csm.2015.10.001
View details for Web of Science ID 000372375700009
View details for PubMedID 26832976
Nonligamentous Soft Tissue Pathology About the Knee: A Review
2016; 39 (1): 32–42
Knee pain is one of the most frequent complaints evaluated by orthopedic surgeons. It encompasses a broad range of pathology and can present in a variety of ways. Most of this pain can be attributed to essential structures of the knee, including the menisci, cruciate or collateral ligaments, and articular cartilage. However, there are underrecognized structures in and around the knee that can frequently be a cause of knee pathology and pain. Knee pain stemming from these structures may be missed or incorrectly diagnosed, and these patients often present for second and third opinions because of failure to diagnose and treat the underlying pathology. The synovial plica, suprapatellar pouch, lateral retinaculum, infrapatellar fat pad, and infrapatellar branch of the saphenous nerve are less common but still significant causes of knee pain. Although initial treatment involves various nonoperative modalities, operative treatment is often warranted. Operative and nonoperative management of these soft tissue structures may occur in isolation or with concomitant procedures, including knee ligament reconstruction, total knee arthroplasty, tibial tuberosity osteotomy, or lysis of adhesions. With proper recognition of the role of these structures in knee pain, the orthopedic surgeon can offer a valuable primary or adjunctive treatment option for patients with knee pain, especially those without localizing signs of meniscal, ligamentous, or cartilage damage.
View details for DOI 10.3928/01477447-20151218-06
View details for Web of Science ID 000377409200041
View details for PubMedID 26709560
In Vitro Toxicity of Local Anesthetics and Corticosteroids on Chondrocyte and Synoviocyte Viability and Metabolism
2015; 6 (4): 233–40
There is growing concern that intra-articular injection of local anesthetic and/or corticosteroids may cause significant morbidity, including potential toxicity to chondrocytes and synoviocytes, after even a single exposure. We demonstrate that full thickness canine chondral and synovial samples exposed to various local anesthetics and corticosteroids exhibit decreased loss of cell viability compared with prior in vitro studies using monolayer culture, due to the protective effects of intact extracellular matrix and cell heterogeneity.Full-thickness cartilage and synovial explants were obtained from canine cadavers and exposed in culture media to the following for 24 hours: 1% lidocaine, 0.5% lidocaine, 0.25% bupivacaine, 0.125% bupvacaine, 0.0625% bupivacaine, betamethasone acetate, methylprednisolone acetate, triamcinolone acetonide, or culture media only (control). Cell viability was determined on days 1 and 7 of culture using a microscopic live-dead and alamar blue metabolic assays.Complete loss of chondrocyte and synoviocyte viability was noted in the 1% and 0.5% lidocaine group, 0.25% and 0.125% bupivacaine group, betamethasone group, and methylprednisolone groups after 1 and 7 days of culture. Treatment with 0.0625% bupivacaine and triamcinolone demonstrated no decrease in cell viability or metabolism when compared to negative control.In this canine explant model, 1% and 0.5% lidocaine, 0.25% and 0.125% bupivacaine, betamethasone acetate, and methylpresdnisolone acetate were severely chondrotoxic and synoviotoxic after a single exposure, despite intact extracellular matrix. In contrast, chondrocytes and synoviocytes exposed to 0.0625% bupivacaine and triamcinolone remained viable after treatment. Further in vivo study is needed before definitive recommendations can be made.
View details for DOI 10.1177/1947603515594453
View details for Web of Science ID 000361156100005
View details for PubMedID 26425261
View details for PubMedCentralID PMC4568732
Return to Play Following Anterior Cruciate Ligament Reconstruction
JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
2015; 23 (5): 283–96
In athletes, significant advances in anterior cruciate ligament reconstruction techniques and rehabilitation have led to improved surgical outcomes and increased expectations for return to play. Although an expeditious return to sport has become an achievable and often realistic goal, the factors that most influence safe, timely, and successful return to play remain unknown. The literature offers mainly anecdotal evidence to guide the team physician in the decision-making process, with a paucity of criteria and consensus guidelines available to help determine return to sport. Attempts have been made to introduce criteria-based progression in the rehabilitation process, but validation of subjective and objective criteria has been difficult. Nevertheless, several pertinent factors in the preoperative, intraoperative, and postoperative periods may affect return to play following anterior cruciate ligament reconstruction. Further research is warranted to validate reliable, consensus guidelines with objective criteria to facilitate the return to play process.
View details for DOI 10.5435/JAAOS-D-13-00183
View details for Web of Science ID 000353467800005
View details for PubMedID 25911661
In Vivo Toxicity of Local Anesthetics and Corticosteroids on Chondrocyte and Synoviocyte Viability and Metabolism
2015; 6 (2): 106–12
Intra-articular injection of local anesthetic and/or corticosteroid is an adjunct treatment for arthritic and inflammatory orthopedic conditions. Despite potential benefits, there is growing concern that these medications may cause significant morbidity, including potential toxicity to intra-articular chondrocytes and synoviocytes.Twenty dogs underwent intra-articular injection of the shoulder joint using ultrasound guidance, with the following injectates (n = 5 each): negative control (saline), methylprednisolone/1.0% lidocaine, triamcinolone/1.0% lidocaine, and triamcinolone/0.0625% bupivacaine. The dogs were euthanized 24 hours postinjection for reasons unrelated to this study. Synovium/cartilage explants were harvested under sterile conditions and assessed immediately or cultured for 7 days. Synoviocyte and chondrocyte viability was determined on day 1 and day 7 using Calcien AM and Sytox Blue live/dead fluorescent stains, and cell metabolism determined on day 2 using the alamar blue additive test. Results were compared statistically.On day 1 synovium exposed to 1%L/M demonstrated a significant decrease in cell metabolism (P = 0.0107) and subjective synoviocyte viability scores (P = 0.013) compared with the negative control. Cartilage exposed to 1%L/M demonstrated decreased chondrocyte viability and cell metabolism versus all other groups, although not significantly. After 7 days of culture, cartilage viable cell density in the 1%L/M group was significantly (P ≤ 0.001) lower than the negative control. Subjective synoviocyte viability scores was significantly lower in the 1%L/M (P = 0.013), 1%L/T (P ≤ 0.001), and 0.0625%B/T groups (P = 0.006) compared with the negative control.This study suggests potential negative effects of combination local anesthetic/corticosteroid on intra-articular cell viability and cell metabolism. Further study is needed before determining definitive clinical recommendations.
View details for DOI 10.1177/1947603515571001
View details for Web of Science ID 000356631400005
View details for PubMedID 26069713
View details for PubMedCentralID PMC4462250
Quantifying the Economic Impact of Provider Volume Through Adverse Events The Case of Sports Medicine
ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE
2015; 3 (3): 2325967115574476
Procedures performed by surgeons with higher provider volumes offer advantages both to the individual patient and the health system, with studies documenting fewer adverse events, shorter surgical times, and decreased reoperation rates. With workforce requirements for surgeons growing, it is increasingly necessary to establish the most efficient structure of this workforce.Substantial economic savings are realized when procedures are performed by high-volume providers as compared with low-volume providers in the areas of readmission, prolonged admission, and subsequent surgery.Economic and decision analysis; Level of evidence, 2.This study utilized decision modeling to estimate the cost savings to high-volume providers in sports medicine. Simple decision models were constructed for 3 common procedures: anterior cruciate ligament (ACL) reconstruction, rotator cuff repair, and total shoulder arthroplasty. Outcome probabilities for adverse events (readmission, prolonged admission, and subsequent surgery) and costs were taken from the literature. A Monte Carlo simulation reflecting the incidence of these procedures in the United States was performed to estimate the total nationwide cost of these procedures, and the impact of both negative and positive policies on this cost were examined using sensitivity analysis.The costs per case attributable to adverse outcomes for ACL reconstruction (in 2010 US$) were $496, $781, and $868 for high-, medium-, and low-volume providers, respectively. For rotator cuff repair, these numbers were $523, $640, and $872, and for total shoulder arthroplasty, $1692, $1876, and $2021, respectively. Sensitivity analysis revealed that a 50% increase in the number of these 3 procedures performed by high-volume surgeons could save the health system $23.1 million. If all procedures were performed by high-volume surgeons, the health system could save $72 million.The hypothesis was accepted; higher provider volumes for surgeons do convey substantial societal economic benefits. Policies to incentivize and facilitate a greater portion of procedures being performed by high-volume surgeons may increase the efficiency of resource utilization in health care delivery.
View details for DOI 10.1177/2325967115574476
View details for Web of Science ID 000367979000008
View details for PubMedID 26665030
View details for PubMedCentralID PMC4622357
Anterior Ankle Arthroscopy Indications, Pitfalls, and Complications
FOOT AND ANKLE CLINICS
2015; 20 (1): 41–57
Anterior ankle arthroscopy is a useful, minimally invasive technique for diagnosing and treating ankle conditions. Arthroscopic treatment offers the benefit of decreased surgical morbidity, less postoperative pain, and earlier return to activities. Indications for anterior ankle arthroscopy continue to expand, including ankle instability, impingement, management of osteochondritis dissecans, synovectomy, and loose body removal. Anterior ankle arthroscopy has its own set of inherent risks and complications. Surgeons can decrease the risk of complications through mastery of ankle anatomy and biomechanics, and by careful preoperative planning and meticulous surgical technique.
View details for DOI 10.1016/j.fcl.2014.10.001
View details for Web of Science ID 000351810000005
View details for PubMedID 25726482
Managing and recognizing complications after treatment of acromioclavicular joint repair or reconstruction
CURRENT REVIEWS IN MUSCULOSKELETAL MEDICINE
2015; 8 (1): 75–82
Complications of the acromioclavicular joint injuries can occur as a result of the injury itself, conservative management, or surgical treatment. Fortunately, the majority of acromioclavicular surgeries utilizing modern techniques and instrumentation result in successful outcomes. However, clinical failures do occur with frequency. The ability to identify the causative factor of failures makes revision surgery more likely to be successful. The purposes of this review are to highlight common problems that can occur following acromioclavicular joint surgery and discuss techniques that can be utilized in revision surgery.
View details for DOI 10.1007/s12178-014-9255-6
View details for Web of Science ID 000219599300009
View details for PubMedID 25663435
View details for PubMedCentralID PMC4596186
Effects on Exposed Articular Cartilage During Open Surgical Procedures: A Comparison of Various Fluids in an Animal Model
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
2015; 31 (1): 113–17
The aim of this study was to assess the potential detrimental effects of the operating room environment on exposed healthy articular cartilage and to evaluate tissue hydration treatment strategies for preserving chondrocyte viability and extracellular matrix composition in this environment.With institutional Animal Care and Use Committee approval, femoral and tibial condyles (n = 36; 6 per specimen) were harvested from canine cadavers (n = 6) immediately after euthanasia and placed on a draped operating table under standard surgical lighting for a timed 2-hour period. Each condyle was randomly assigned to one of 6 groups (n = 6 per group): no-treatment control, hyaluronic acid (HA), saline sponge, saline drip, culture media (Dulbecco's modified Eagle's medium [DMEM]) sponge, or culture media drip. Full-thickness cartilage sections were collected from each specimen immediately after harvest (time 0) and immediately after 2-hour exposure (time 2H), and processed to determine chondrocyte viability, tissue water content, and extracellular matrix composition (glycosaminoglycan [GAG] and collagen content).Chondrocyte viability was significantly lower (P = .03) after the 2-hour exposure in the control group. HA, saline sponge, and saline drip treatment groups all had significantly higher (P < .043) chondrocyte viability compared with controls at time 2H. Water content was significantly lower (P < .01) after the 2-hour exposure in the control group. Further, the water content in the control group was significantly lower than all treatment groups at time 2H (P < .001). No significant differences in tissue collagen or GAG content were observed within groups between time points or among groups at either time point.Canine articular cartilage did not demonstrate any reduction in chondrocyte viability or tissue water content at 2 hours when treated with hyaluronic acid, saline drip, saline-soaked sponge, or DMEM-soaked sponge compared with untreated exposed cartilage.Surgeons should consider the use of a hydrating solution for the treatment of exposed articular cartilage during open joint surgery of 2 hours or longer duration.
View details for DOI 10.1016/j.arthro.2014.07.027
View details for Web of Science ID 000347032400024
View details for PubMedID 25260748
Does a Syrinx Matter for Return to Play in Contact Sports? A Case Report and Evidence-Based Review of Return-to-Play Criteria After Transient Quadriplegia
SPORTS HEALTH-A MULTIDISCIPLINARY APPROACH
2014; 6 (5): 440–45
Transient quadriplegia is a rare injury that can change the course of an athlete's career if misdiagnosed or managed inappropriately. The clinician should be well versed in the return-to-play criteria for this type of injury. Unfortunately, when an unknown preexisting syrinx is present in the athlete, there is less guidance on their ability to return to play. This case report and review of the current literature illustrates a National Collegiate Athletic Association (NCAA) Division I football player who suffered a transient quadriplegic event during a kickoff return that subsequently was found to have an incidental cervical syrinx on magnetic resonance imaging. The player was able to have a full neurologic recovery, but ultimately he was withheld from football.
View details for DOI 10.1177/1941738114544674
View details for Web of Science ID 000214873300011
View details for PubMedID 25177422
View details for PubMedCentralID PMC4137682
Tibial Tuberosity Osteotomy Indications, Techniques, and Outcomes
AMERICAN JOURNAL OF SPORTS MEDICINE
2014; 42 (8): 2006–17
Tibial tuberosity osteotomy (TTO) is a well-described treatment option for a broad range of patellofemoral joint disorders, including patellofemoral instability, patellar and trochlear focal chondral lesions, and patellofemoral arthritis. The purpose of this article is to review the evolution of the TTO procedure, from the original Hauser procedure to the current anteromedialization procedure, as well as discuss the pertinent anatomy and radiographs that accompany this procedure. The article highlights the surgical techniques for some of the more commonly performed TTO procedures and discusses the outcomes of the various TTO techniques. Complications, as well as clinical pearls to avoid these complications, are also included.
View details for DOI 10.1177/0363546513507423
View details for Web of Science ID 000341634900033
View details for PubMedID 24197613
Patellofemoral Anatomy and Biomechanics
CLINICS IN SPORTS MEDICINE
2014; 33 (3): 389-+
Patellofemoral disorders are common. There is a broad spectrum of disease, ranging from patellofemoral pain and instability to focal cartilage disease and arthritis. Regardless of the specific condition, abnormal anatomy and biomechanics are often the root cause of patellofemoral dysfunction. A thorough understanding of normal patellofemoral anatomy and biomechanics is critical for the treating physician. Recognizing and addressing abnormal anatomy will optimize patellofemoral biomechanics and may ultimately translate into clinical success.
View details for DOI 10.1016/j.csm.2014.03.008
View details for Web of Science ID 000339463400003
View details for PubMedID 24993406
Evidence-Based Approach of Treatment Options for Postoperative Knee Pain
PHYSICIAN AND SPORTSMEDICINE
2014; 42 (2): 58–70
Optimal pain management is critical after knee surgery to avoid adverse events and to improve surgical outcomes. Pain may affect surgical outcomes by contributing to limitations in range of motion, strength, and functional recovery. The causes of postoperative pain are multifactorial; therefore, an appropriate pain management strategy must take into account preoperative, intraoperative, and postoperative factors to create a comprehensive and individualized plan for the patient. Preoperative assessment includes management of patient expectations, recognition of conditions and early counseling for high-risk patients (ie, opioid dependence, psychiatric comorbidities), and use of preemptive analgesia techniques (ie, preoperative IV medications, peripheral nerve blocks, incisional field blocks). Intraoperative strategies include meticulous surgical technique, limiting the use of tourniquets (ie, duration and pressure), and using preventive analgesia methods (ie, postoperative field block, continuous nerve catheters, intra-articular injection). Postoperative analgesia may be facilitated by cryotherapy, early mobilization, bracing, and rehabilitation. Certain modalities (ie, continuous passive motion devices, transcutaneous electrical nerve stimulation units, iontophoresis) may be important adjuncts in the perioperative period as well. There may be an evolving role for alternative medicine strategies. Early recognition and treatment of exaggerated postoperative pain responses may mitigate the effects of complex regional pain syndrome or the development of chronic pain.
View details for DOI 10.3810/psm.2014.05.2058
View details for Web of Science ID 000343399000006
View details for PubMedID 24875973
Does ACL Reconstruction Alter Natural History? A Systematic Literature Review of Long-Term Outcomes
JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME
2014; 96A (4): 292–300
Anterior cruciate ligament (ACL) injury can lead to tibiofemoral instability, decreased functional outcomes, and degenerative joint disease. It is unknown whether ACL reconstruction alters this progression at long-term follow-up.A systematic literature review of the long-term results (minimum follow-up, more than ten years) after operative intra-articular reconstruction of ACL injuries and after nonoperative management was performed to compare (1) knee stability on physical examination, (2) functional and patient-based outcomes, (3) the need for further surgical intervention, and (4) radiographic outcomes. After application of selection criteria, forty patient cohorts with a mean of 13.9 ± 3.1 years of postoperative follow-up were identified. Twenty-seven cohorts containing 1585 patients had undergone reconstruction, and thirteen containing 685 patients had been treated nonoperatively.Comparison of operative and nonoperative cohorts revealed no significant differences in age, sex, body mass index, or rate of initial meniscal injury (p > 0.05 for all). Operative cohorts had significantly less need for further surgery (12.4% compared with 24.9% for nonoperative, p = 0.0176), less need for subsequent meniscal surgery (13.9% compared with 29.4%, p = 0.0017), and less decline in the Tegner score (-1.9 compared with -3.1, p = 0.0215). A difference in pivot-shift test results was observed (25.5% pivot-positive compared with 46.6% for nonoperative) but did not reach significance (p = 0.09). No significant differences were seen in outcome scores (Lysholm, International Knee Documentation Committee [IKDC], or final Tegner scores) or the rate of radiographically evident degenerative joint disease (p > 0.05 for all).At a mean of 13.9 ± 3.1 years after injury, the patients who underwent ACL reconstruction had fewer subsequent meniscal injuries, less need for further surgery, and significantly greater improvement in activity level as measured with the Tegner score. There were no significant differences in the Lysholm score, IKDC score, or development of radiographically evident osteoarthritis.
View details for DOI 10.2106/JBJS.L.01713
View details for Web of Science ID 000331431300005
View details for PubMedID 24553885
Fresh Osteochondral Allograft Transplantation for the Knee: Current Concepts
JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
2014; 22 (2): 121–33
Fresh osteochondral allograft (OCA) transplantation has been used to manage a wide spectrum of chondral and osteochondral knee disorders. Basic science and clinical studies support the safety and efficacy of the procedure. Transplantation of viable, mature hyaline cartilage into the affected area is an advantage of the procedure, which can be used to restore bone stock in complex or salvage scenarios. Indications for OCA transplantation in the knee include primary management of large chondral or osteochondral defects and salvage of previously failed cartilage repair. The procedure also can be used for complex biologic knee reconstruction in the setting of osteonecrosis, fracture malunion, or posttraumatic arthritis. Challenges associated with OCA transplantation include allograft storage and size matching, tissue availability, chondrocyte viability, the possibility of immunologic graft response, and a demanding surgical technique. Future research should focus on optimizing allograft viability and healing and refining current surgical indications and techniques.
View details for DOI 10.5435/JAAOS-22-02-121
View details for Web of Science ID 000349452200007
View details for PubMedID 24486758
Evaluation and Management of an Irreducible Posterolateral Knee Dislocation
JOURNAL OF KNEE SURGERY
2013; 26: S136–S141
Irreducible posterolateral knee dislocations are rare and complex injuries that are often difficult to treat. Prompt recognition and appropriate early management are vital to the successful long-term outcome for the patient. In this case report, we highlight a single patient presenting with an irreducible posterolateral knee dislocation following a high-energy trauma. Evaluation and management included careful history and physical examination, appropriate imaging studies, and formulation of an early operative plan, leading to a safe and successful knee reduction for this patient. We review the best available evidence to guide orthopedic surgeons in their evaluation and management of the irreducible knee dislocation.
View details for DOI 10.1055/s-0033-1341577
View details for Web of Science ID 000346581400030
View details for PubMedID 23512541
Return to High-Level Sport After Meniscal Allograft Transplantation
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
2013; 29 (3): 539–44
Our purpose was to determine the results of meniscal allograft transplantation (MAT) in high school and higher-level athletes, specifically with respect to return to their preinjury level of play.This is a retrospective case series of prospectively collected data from a single surgeon, evaluating athletes who underwent MAT. Each patient participated in either high school, collegiate, or professional athletics before injury, with a mean preinjury Tegner score of 8. In addition, patients were only included if one of their stated preoperative goals was to return to their previous level of activity. Patients completed preoperative and postoperative validated knee surveys (Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee score, Lysholm score, and Tegner score) and underwent physical examinations.The mean age of the 13 included patients was 19.8 years, with a mean follow-up of 3.3 years (range, 1.9 to 5.7 years). After MAT, 10 of 13 patients (77%) returned to sporting activity. The mean Knee Injury and Osteoarthritis Outcome Score for the sport subset was 76 (SD, 18), the mean International Knee Documentation Committee score was 77 (SD, 14), and the mean Lysholm score was 81 (SD, 13). Of the 13 patients, 3 (23%) required further surgery, comprising one revision MAT, one partial meniscectomy, and one meniscal repair.In this small retrospective series, 77% of high school and higher-level athletes with meniscal deficiency and symptomatic "post-meniscectomy syndrome" returned to their desired level of play after MAT. These athletes also had significant improvements in most outcome measures.Level IV, therapeutic case series.
View details for DOI 10.1016/j.arthro.2012.10.027
View details for Web of Science ID 000315584200023
View details for PubMedID 23375179
An Evidenced-Based Examination of the Epidemiology and Outcomes of Traumatic Rotator Cuff Tears
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
2013; 29 (2): 366–76
The purpose of this study was to systematically review the literature to better define the epidemiology, mechanism of injury, tear characteristics, outcomes, and healing of traumatic rotator cuff tears. A secondary goal was to determine if sufficient evidence exists to recommend early surgical repair in traumatic rotator cuff tears.An independent systematic review was conducted of evidence Levels I to IV. A literature search of PubMed, Medline, Embase, and Cochrane Collaboration of Systematic Reviews was conducted, with 3 reviewers assessing studies for inclusion, methodology of individual study, and extracted data.Nine studies met the inclusion and exclusion criteria. Average patient age was 54.7 (34 to 61) years, and reported mean time to surgical intervention, 66 days (3 to 48 weeks) from the time of injury. The most common mechanism of injury was fall onto an outstretched arm. Supraspinatus was involved in 84% of tears, and infraspinatus was torn in 39% of shoulders. Subscapularis tears were present in 78% of injuries. Tear size was <3 cm in 22%, 3 to 5 cm in 36%, and >5 cm in 42%. Average active forward elevation improved from 81° to 150° postoperatively. The weighted mean postoperative UCLA score was 30, and the Constant score was 77.Traumatic rotator cuff tears are more likely to occur in relatively young (age 54.7), largely male patients who suffer a fall or trauma to an abducted, externally rotated arm. These tears are typically large and involve the subscapularis, and repair results in acceptable results. However, insufficient data prevent a firm recommendation for early surgical repair.Level IV, systematic review Levels III and IV studies.
View details for DOI 10.1016/j.arthro.2012.06.024
View details for Web of Science ID 000314127100027
View details for PubMedID 23290186
Biomechanical Evaluation of Transosseous Rotator Cuff Repair Do Anchors Really Matter?
SAGE PUBLICATIONS INC. 2013: 283–90
Suture anchor fixation has become the preferred method for arthroscopic repairs of rotator cuff tears. Recently, newer arthroscopic repair techniques including transosseous-equivalent repairs with anchors or arthroscopic transosseous suture passage have been developed.To compare the initial biomechanical performance including ultimate load to failure and localized cyclic elongation between transosseous-equivalent repair with anchors (TOE), traditional transosseous repair with a curved bone tunnel (TO), and an arthroscopic transosseous repair technique utilizing a simple (AT) or X-box suture configuration (ATX).Controlled laboratory study.Twenty-eight human cadaveric shoulders were dissected to create an isolated supraspinatus tear and randomized into 1 of 4 repair groups (TOE, TO, AT, ATX). Tensile testing was conducted to simulate the anatomic position of the supraspinatus with the arm in 60° of abduction and involved an initial preload, cyclic loading, and pull to failure. Localized elongation during testing was measured using optical tracking. Data were statistically assessed using analysis of variance with a Tukey post hoc test for multiple comparisons.The TOE repair demonstrated a significantly higher mean ± SD failure load (558.4 ± 122.9 N) compared with the TO (325.3 ± 79.9 N), AT (291.7 ± 57.9 N), and ATX (388.5 ± 92.6 N) repairs (P < .05). There was also a significantly larger amount of first-cycle excursion in the AT group (8.19 ± 1.85 mm) compared with the TOE group (5.10 ± 0.89 mm). There was no significant difference between repair groups in stiffness during maximum load to failure or in normalized cyclic elongation. Failure modes were as follows: TOE, tendon (n = 4) and bone (n = 3); TO, suture (n = 6) and bone (n = 1); AT, tendon (n = 2) and bone (n = 3) and suture (n = 1); ATX, tendon (n = 7).This study demonstrates that anchorless repair techniques using transosseous sutures result in significantly lower failure loads than a repair model utilizing anchors in a TOE construct.Suture anchor repair appears to offer superior biomechanical properties to transosseous repairs regardless of tunnel or suture configuration.
View details for DOI 10.1177/0363546512469092
View details for Web of Science ID 000314307500009
View details for PubMedID 23239668
Recutting the distal femur to increase maximal knee extension during TKA causes coronal plane laxity in mid-flexion
2012; 19 (6): 875–79
The aim of this study was to quantify the effects of distal femoral cut height on maximal knee extension and coronal plane knee laxity.Seven fresh-frozen cadaver legs from hip-to-toe underwent a posterior stabilized TKA using a measured resection technique with a computer navigation system equipped with a robotic cutting guide. After the initial femoral resections were performed, the posterior joint capsule was sutured until a 10° flexion contracture was obtained with the trial components in place. Two distal femoral recuts of +2mm each were then subsequently made and the trials were reinserted. The navigation system was used to measure the maximum extension angle achieved and overall coronal plane laxity [in degrees] at maximum extension, 30°, 60° and 90° of flexion, when applying a standardized varus/valgus load of 9.8 [Nm] across the knee.For a 10 degree flexion contracture, performing the first distal recut of +2mm increased overall coronal plane laxity by approximately 4.0° at 30° of flexion (p=0.002) and 1.9° at 60° of flexion (p=0.126). Performing the second +2mm recut of the distal femur increased mid-flexion laxity by 6.4° (p<0.0001) at 30° and 4.0° at 60° of flexion (p=0.01), compared to the 9 mm baseline resection (control). Maximum knee extension increased from 10° of flexion to 6.4° (± 2.5° SD, p<0.005) and to 1.4° (± 1.8° SD, p<0.001) of flexion with each 2mm recut of the distal femur.Recutting the distal femur not only increases the maximum knee extension achieved but also increases coronal plane laxity in midflexion.
View details for DOI 10.1016/j.knee.2012.05.007
View details for Web of Science ID 000311329300027
View details for PubMedID 22727760
Long-term survivorship of a unicondylar knee replacement - A case report
2012; 19 (6): 944–47
Unicondylar knee arthroplasty (UKA) was introduced in the 1970s as a treatment option for isolated knee compartment gonarthrosis. Early results were discouraging secondary to poor patient selection, suboptimal surgical technique, and inferior prosthetic design. In recent years, there has been resurgence in the use of the UKA. Improvements in implant design, surgical technique, and patient selection have led to multiple studies demonstrating 94-98% survivorship of the implants at a 10 year follow-up. However, there still remains a paucity of evidence with regard to this treatment option for young, active patients. This case report presents the longest recorded follow-up (31 years) of a UKA in a young, active patient and it highlights that with appropriate patient selection and meticulous surgical technique, UKA may have a role as a long term treatment option in patients with isolated unicompartmental disease.
View details for DOI 10.1016/j.knee.2012.03.015
View details for Web of Science ID 000311329300040
View details for PubMedID 22533962
Graft Tensioning During Knee Ligament Reconstruction: Principles and Practice
JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
2012; 20 (10): 633–45
Failure to correctly tension grafts may overconstrain or underconstrain the knee, potentially predisposing the patient to deteriorating clinical and/or radiographic results over time. Knee ligament reconstruction requires a fundamental understanding of native anatomy, ligament biomechanics, and principles of graft tensioning. A successful strategy for graft tensioning takes into account the specific biomechanics of the ligament or ligaments in question, the mechanical properties of the graft selected, the chosen fixation method, the selected tensioning method (ie, manual or mechanical), and the overall goal of the reconstruction (ie, isometry versus anisometry).
View details for DOI 10.5435/JAAOS-20-10-633
View details for Web of Science ID 000309489400003
View details for PubMedID 23027693
Biomechanical Analysis of the Pectoralis Major Tendon and Comparison of Techniques for Tendo-osseous Repair
AMERICAN JOURNAL OF SPORTS MEDICINE
2012; 40 (8): 1887–94
Various described surgical techniques exist for the repair of pectoralis major ruptures at the tendo-osseous junction. It is unclear how these techniques restore the native properties of the pectoralis major tendon because its biomechanical properties have not been described.All repairs will have lower initial biomechanical profiles than the native attachment, and transosseous sutures will demonstrate improved initial biomechanical performance compared with anchors or buttons.Controlled laboratory study.Twenty-four fresh-frozen cadaveric shoulders were randomized to 4 equal groups, including 3 experimental repair groups and 1 control group of intact pectoralis major tendons. The characteristics of the native anatomic footprint were recorded, and the experimental groups underwent pectoralis detachment, followed by subsequent repair. The restoration of the anatomic footprint was recorded. All specimens were tested with cyclic loading and load-to-failure protocols with load, displacement, and optical marker data simultaneously collected.Under cyclic loading, the intact specimens demonstrated a significantly higher secant stiffness (74.8 ± 1.6 N/mm) than the repair groups (endosteal Pec Button [PB], 46.2 ± 6.4 N/mm; suture anchor [SA], 45.9 ± 8.7 N/mm; transosseous [TO], 44.2 ± 5.5 N/mm). Measured as a percentage change, the PB and SA groups showed a significantly higher initial excursion than the intact group (PB, 24.0% ± 11.7%; SA, 17.5% ± 6.9%; intact, 2.2% ± 1.0%), and the PB group demonstrated a significantly higher cyclic elongation than the intact group (PB, 7.5% ± 2.9%; intact, 1.5% ± 1.5%). Under load-to-failure testing, the intact group showed a significantly greater maximum load (1454.8 ± 795.7 N) and linear stiffness (221.0 ± 111.7 N/mm) than the 3 repair groups (PB, 353.5 ± 88.3 N and 63.5 ± 6.9 N/mm; SA, 292.0 ± 73.3 N and 77.0 ± 7.8 N/mm; TO, 359.2 ± 110.4 N and 64.5 ± 14.1 N/mm, respectively). All repair constructs failed via suture pulling through the tendon.The biomechanical characteristics of the transosseous repair, suture anchors, or Pec Button repair were inferior to those of the native pectoralis tendon. There was no significant difference in any of the biomechanical outcomes among the repair groups. Further refinement and evaluation of suture technique and configuration in pectoralis major repair should be considered.Transosseous repair, suture anchors, and endosteal Pec Buttons appear to confer similar biomechanical integrity for pectoralis major repair. Restricting early activities to thresholds below the identified failure loads seems prudent until soft tissue healing to bone is reliably achieved.
View details for DOI 10.1177/0363546512452849
View details for Web of Science ID 000307175700026
View details for PubMedID 22781500
A Review of Translational Animal Models for Knee Osteoarthritis
Knee osteoarthritis remains a tremendous public health concern, both in terms of health-related quality of life and financial burden of disease. Translational research is a critical step towards understanding and mitigating the long-term effects of this disease process. Animal models provide practical and clinically relevant ways to study both the natural history and response to treatment of knee osteoarthritis. Many factors including size, cost, and method of inducing osteoarthritis are important considerations for choosing an appropriate animal model. Smaller animals are useful because of their ease of use and cost, while larger animals are advantageous because of their anatomical similarity to humans. This evidence-based review will compare and contrast several different animal models for knee osteoarthritis. Our goal is to inform the clinician about current research models, in order to facilitate the transfer of knowledge from the "bench" to the "bedside."
View details for DOI 10.1155/2012/764621
View details for Web of Science ID 000215117300023
View details for PubMedID 23326663
View details for PubMedCentralID PMC3541554