- Sports Medicine
- Sports Injuries
- knee surgery
- Knee Injuries
- shoulder and elbow surgery
- hand surgery
- Ankle Injuries
- Orthopaedic Surgery
Clinical Professor, Orthopaedic Surgery
Head Team Physician, Medical Director, San Francisco 49ers (2014 - Present)
Team Physician, San Francisco Giants (2014 - Present)
Consutant Team Physician, San Francisco Giants (2012 - 2013)
Team Physician, Golden State Warriors (2011 - 2013)
Team Physician, San Francisco 49ers (2007 - Present)
Team Physician, Stanford Men's Basketball (2004 - 2007)
Program Director, Department of Orthopaedic Surgery (2002 - 2008)
Honors & Awards
San Francisco Magazine "Top Doctors", San Francisco Magazine (2018)
Rettig Award for Academic Excellence, National Football League Physician Society (2017)
San Francisco Magazine "Top Doctors", San Francisco Magazine (2017)
Certificate of Added Qualification (CAQ), Sports Medicine (2007)
Certificate of Added Qualification (CAQ), Hand Surgery (2004)
Teacher of the Year Award, Stanford Orthopaedic Surgery (2002)
Magna Cum Laude, Georgetown University School of Medicine (1995)
Alpha Omega Alpha Medical Honor Society, Georgetown University School of Medicine (1994)
Boards, Advisory Committees, Professional Organizations
Board Member, National Football League Physician Society (2017 - Present)
Fellowship: Stanford University Hand Surgery Fellowship (2001) CA
Residency: University of New Mexico Office of GME (2000) NM
Internship: University of New Mexico Office of GME (1996) NM
Medical Education: Georgetown University School of Medicine Registrar (1995) DC
Board Certification: American Board of Orthopaedic Surgery, Orthoped Surg/Sports Med (2007)
Board Certification: American Board of Orthopaedic Surgery, Orthopaedic Surgery (2003)
MD, Georgetown University, Medicine, Magna Cum Laude (1995)
Current Research and Scholarly Interests
ACL knee injury: Graft options in the athlete.
Athlete's shoulder: Dynamic open MRI evaluation of "peel-back" SLAP lesions of the shoulder.
Elbow MCL: Biomechanical comparison of two techniques for reconstruction of the elbow MCL with palmaris autograft.
Athlete's knee articular cartilage: Investigation of articular cartilage replacement techniques.
Elbow arthroscopy: Arthroscopy lab set up in Anatomy building (both wrist and elbow). Looking at lateral ligament complex of the elbow and its role in stability.
Rotator cuff: Rabbit study in which massive rotator cuff tears are simulated and grafted with either fascia lata alone, or fascia lata with a deltoid flap procedure. Histological and Biomechanical analysis of specimens at 3 and 6 months post-operatively.
Independent Studies (5)
- Directed Reading in Orthopedic Surgery
ORTHO 299 (Aut, Win, Spr, Sum)
- Early Clinical Experience in Orthopedic Surgery
ORTHO 280 (Aut, Win, Spr, Sum)
- Graduate Research
ORTHO 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
ORTHO 370 (Aut, Win, Spr, Sum)
- Undergraduate Research
ORTHO 199 (Aut, Win, Spr, Sum)
- Directed Reading in Orthopedic Surgery
Cartilage Subsurface Changes to Magnetic Resonance Imaging UTE-T2*2 Years After Anterior Cruciate Ligament Reconstruction Correlate With Walking Mechanics Associated With Knee Osteoarthritis
AMERICAN JOURNAL OF SPORTS MEDICINE
2018; 46 (3): 565–72
Anterior cruciate ligament (ACL) injury increases risk for posttraumatic knee osteoarthritis (OA). Quantitative ultrashort echo time enhanced T2* (UTE-T2*) mapping shows promise for early detection of potentially reversible subsurface cartilage abnormalities after ACL reconstruction (ACLR) but needs further validation against established clinical metrics of OA risk such as knee adduction moment (KAM) and mechanical alignment.Elevated UTE-T2* values in medial knee cartilage 2 years after ACLR correlate with varus alignment and higher KAM during walking.Cohort study (diagnosis); Level of evidence, 2.Twenty patients (mean age, 33.1 ± 10.5 years; 11 female) 2 years after ACLR underwent 3.0-T knee magnetic resonance imaging (MRI), radiography, and gait analysis, after which mechanical alignment was measured, KAM during walking was calculated, and UTE-T2* maps were generated. The mechanical axis and the first and second peaks of KAM (KAM1 and KAM2, respectively) were tested using linear regressions for correlations with deep UTE-T2* values in the central and posterior medial femoral condyle (cMFC and pMFC, respectively) and central medial tibial plateau (cMTP). UTE-T2* values from ACL-reconstructed patients were additionally compared with those of 14 uninjured participants (mean age, 30.9 ± 8.9 years; 6 female) using Mann-Whitney U and standard t tests.Central weightbearing medial compartment cartilage of ACL-reconstructed knees was intact on morphological MRI. Mean UTE-T2* values were elevated in both the cMFC and pMFC of ACL-reconstructed knees compared with those of uninjured knees ( P = .003 and P = .012, respectively). In ACL-reconstructed knees, UTE-T2* values of cMFC cartilage positively correlated with increasing varus alignment ( R = 0.568). Higher UTE-T2* values in cMFC and cMTP cartilage of ACL-reconstructed knees also correlated with greater KAM1 ( R = 0.452 and R = 0.463, respectively) and KAM2 ( R = 0.465 and R = 0.764, respectively) and with KAM2 in pMFC cartilage ( R = 0.602).Elevated deep UTE-T2* values of medial knee cartilage 2 years after ACLR correlate with 2 clinical markers of increased risk of medial knee OA. These results support the clinical utility of MRI UTE-T2* for early diagnosis of subsurface cartilage abnormalities. Longitudinal follow-up of larger cohorts is needed to determine the predictive and staging potential of UTE-T2* for posttraumatic OA.
View details for PubMedID 29293364
Video Analysis of Anterior Cruciate Ligament Tears in Professional American Football Athletes.
The American journal of sports medicine
2018; 46 (4): 862–68
Anterior cruciate ligament (ACL) injuries are prevalent in contact sports that feature cutting and pivoting, such as American football. These injuries typically require surgical treatment, can result in significant missed time from competition, and may have deleterious long-term effects on an athlete's playing career and health. While the majority of ACL tears in other sports have been shown to occur from a noncontact mechanism, it stands to reason that a significant number of ACL tears in American football would occur after contact, given the nature of the sport. Hypothesis/Purpose: The purpose was to describe the mechanism, playing situation, and lower extremity limb position associated with ACL injuries in professional American football players through video analysis to test the hypothesis that a majority of injuries occur via a contact mechanism.Case series; Level of evidence, 4.A retrospective cohort of National Football League (NFL) players with ACL injuries from 3 consecutive seasons (2013-2016) was populated by searching publicly available online databases and other traditional media sources. Of 156 ACL injuries identified, 77 occurred during the regular season and playoffs, with video analysis available for 69 injuries. The video of each injury was independently viewed by 2 reviewers to determine the nature of the injury (ie, whether it occurred via a noncontact mechanism), the position of the lower extremity, and the football activity at the time of injury. Playing surface, player position, and time that the injury occurred were also recorded.Contrary to our hypothesis, the majority of ACL injuries occurred via a noncontact mechanism (50 of 69, 72.5%), with the exception of injury to offensive linemen, who had a noncontact mechanism in only 20% of injuries. For noncontact injuries, the most common football activity at the time of injury was pivoting/cutting, and the most common position of the injured extremity included hip abduction/flexion, early knee flexion/abduction, and foot abduction/external rotation. There was no association between injury mechanism and time of injury or playing surface in this cohort.In this study of players in the NFL, the majority of ACL tears involved a noncontact mechanism, with the lower extremity exhibiting a dynamic valgus moment at the knee. These findings suggest that ACL injury prevention programs may reduce the risk of noncontact ACL tears in American football players.
View details for PubMedID 29466019
Tendon Excision Following Distal Semitendinosus Injury in the Elite Athlete: A Surgical Technique.
HSS journal : the musculoskeletal journal of Hospital for Special Surgery
2018; 14 (2): 181–85
Hamstring injuries can present in numerous forms, some of which can lead to persistent pain, loss of function, and delay in return to sport. Although most are treated conservatively, proximal and distal tendon avulsion injuries have become more commonly treated with surgery. Distal semitendinosus avulsion injuries have been largely reported in the elite athlete population. While conservative management has been utilized, failure in this group can significantly impact a future career.The purpose of the manuscript is to describe our approach of surgical tendon excision for distal semitendinosus injury in an elite athlete.We highlight a two-incision technique to isolate the avulsed tendon, followed by exteriorization and tendon excision. In addition, we provide insight on clinical and imaging findings to help guide management.This technique provides a reliable and effective surgical option for managing these rare injuries of the distal semitendinosus, along with outlining rehabilitation goals in the postoperative period.In this setting, we present a detailed surgical technique to excise the injured distal semitendinosus tendon to promote recovery and potentially allow for earlier return to play.
View details for PubMedID 29983661
Chondral Rib Fractures in Professional American Football: Two Cases and Current Practice Patterns Among NFL Team Physicians.
Orthopaedic journal of sports medicine
2016; 4 (2): 2325967115627623-?
Although a recognized and discussed injury, chondral rib fractures in professional American football have not been previously reported in the literature. There currently exists no consensus on how to identify and treat these injuries or the expected return to play for the athlete.To present 2 cases of chondral rib injuries in the National Football League (NFL) and discuss the current practice patterns for management of these injuries among the NFL team physicians.Case series; Level of evidence, 4.Two cases of NFL players with chondral rib injuries are presented. A survey regarding work-up and treatment of these injuries was completed by team physicians at the 2014 NFL Combine. Our experience in identifying and treating these injuries is presented in conjunction with a survey of NFL team physicians' experiences.Two cases of rib chondral injuries were diagnosed by computed tomography (CT) and treated with rest and protective splinting. Return to play was 2 to 4 weeks. NFL Combine survey results show that NFL team physicians see a mean of 4 costal cartilage injuries per 5-year period, or approximately 1 case per year per team. Seventy percent of team physicians use CT scanning and 43% use magnetic resonance imaging for diagnosis of these injuries. An anesthetic block is used acutely in 57% and only electively in subsequent games by 39%.A high index of suspicion is necessary to diagnose chondral rib injuries in American football. CT scan is most commonly used to confirm diagnosis. Return to play can take up to 2 to 4 weeks with a protective device, although anesthetic blocks can be used to potentially expedite return.Chondral rib injuries are common among NFL football players, while there is no literature to support proper diagnosis and treatment of these injuries or expected duration of recovery. These injuries are likely common in other contact sports and levels of competition as well. Our series combined with NFL team physician survey results can aid team physicians in identifying these injuries, obtaining useful imaging, and counseling players and coaches and the expected time of recovery.
View details for DOI 10.1177/2325967115627623
View details for PubMedID 26925425
Ultrasound-guided musculoskeletal interventions in American football: 18 years of experience.
AJR. American journal of roentgenology
2014; 203 (6): W674-83
Myotendinous strains, contusions, and hematomas are common injuries in American football. Along with ligament sprains and inflammatory disorders, musculoskeletal injuries often result in lost participation time. This article summarizes 18 years of experience with 128 ultrasound-guided drainages and injections in 69 football players with 88 injuries.When performed by an operator with sufficient expertise in diagnostic and procedural skills, ultrasound-guided musculoskeletal interventions are minimally invasive, are safe, and can play an integral role in injury management.
View details for DOI 10.2214/AJR.14.12678
View details for PubMedID 25415734
Prevalence of abnormal patellofemoral congruence in elite american football players and association with quadriceps isokinetic testing.
The journal of knee surgery
2014; 27 (1): 47-52
Abnormal patellofemoral joint alignment has been discussed as a potential risk factor for patellofemoral disorders and can impact the longevity of any elite athlete's career. The prevalence of abnormal patellofemoral congruence in elite American football athletes is similar to the general population and does not have a relationship with quadriceps isokinetic testing. A total of 125 athletes (220 knees) from the 2011 National Football League (NFL) Combine database who had radiographic and isokinetic studies were reviewed. Congruence angles (CA) and lateral patellofemoral angles (LPA) were calculated on a Merchant radiographic view. Isokinetic testing was used to determine quadriceps-to-hamstring strength (Q/H) ratio and side-to-side deficits. The relationships between abnormal CA and LPA with Q/H ratios, side-to-side deficits, and body mass index (BMI) were examined in separate logistic regression models. A Chi-square test was used to examine the association between CA and player position. Of all, 26.8% of the knees (95% CI: 21.1-33.2%) had an abnormal CA. Knees with normal CA (n = 161) did not significantly differ from those with an abnormal CA (n = 59) in Q/H ratios (mean: 0.699 vs. 0.728, p = 0.19) or side-to-side quadriceps deficits (mean: 4.0 vs. 1.24, p = 0.45). For each point increase in BMI, the odds ratio (OR) of abnormal congruence increased by 11.4% (p = 0.002). Of all the knees, 4.1% (95% CI: 1.9-7.6%) had an abnormal LPA, and this was not associated with Q/H ratios (p = 0.13). For each point increase in BMI, the odds of abnormal LPA increased by 16% (p = 0.036). CA abnormality had much higher odds of having an abnormal LPA (OR: 5.96, p = 0.014). We found that abnormal patellofemoral radiographic alignment in elite American football players is relatively common and there was no association with isokinetic testing.
View details for DOI 10.1055/s-0033-1348406
View details for PubMedID 23925950
ACL Reconstruction in Patients Aged 40 Years and Older A Systematic Review and Introduction of a New Methodology Score for ACL Studies
AMERICAN JOURNAL OF SPORTS MEDICINE
2013; 41 (9): 2181-2190
Treatment of the anterior cruciate ligament (ACL)-deficient knee in older patients remains a core debate.To perform a systematic review of studies that assessed outcomes in patients aged 40 years and older treated with ACL reconstruction and to provide a new methodological scoring system that is directed at critical assessment of studies evaluating ACL surgical outcomes: the ACL Methodology Score (AMS).Systematic review.A comprehensive literature search was performed from 1995 to 2012 using MEDLINE, EMBASE, and Scopus. Inclusion criteria for studies were primary ACL injury, patient age of 40 years and older, and mean follow-up of at least 21 months after reconstruction. Nineteen studies met the inclusion criteria from the 371 abstracts from MEDLINE and 880 abstracts from Scopus. Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, and Tegner activity scores), joint stability measures (Lachman test, pivot-shift test, and instrumented knee arthrometer assessment), graft type, complications, and reported chondral or meniscal injury were evaluated in this review. A new methodology scoring system was developed to be specific at critically analyzing ACL outcome studies and used to examine each study design.Nineteen studies describing 627 patients (632 knees; mean age, 49.0 years; range, 42.6-60.0 years) were included in the review. The mean time to surgery was 32.0 months (range, 2.9-88.0 months), with a mean follow-up of 40.2 months (range, 21.0-114.0 months). The IKDC, Lysholm, and Tegner scores and knee laxity assessment indicated favorable results in the studies that reported these outcomes. Patients did not demonstrate a significant difference between graft types and functional outcome scores or stability assessment. The mean AMS was 43.9 ± 7.2 (range, 33.5-57.5). The level of evidence rating did not positively correlate with the AMS, which suggests that the new AMS system may be able to detect errors in methodology or reporting that may not be taken into account by the classic level of evidence rating.Patients aged 40 years and older with an ACL injury can have satisfactory outcomes after reconstruction. However, the quality of currently available data is still limited, such that further well-designed studies are needed to determine long-term efficacy and to better inform our patients with regard to expected outcomes.
View details for DOI 10.1177/0363546513481947
View details for Web of Science ID 000325714200028
View details for PubMedID 23548805
Biomechanical Evaluation of a Novel Reverse Coracoacromial Ligament Reconstruction for Acromioclavicular Joint Separation
AMERICAN JOURNAL OF SPORTS MEDICINE
2012; 40 (2): 440-446
Enhancing anterior-posterior (AP) stability in acromioclavicular (AC) reconstruction may be advantageous.To compare the initial stability of AC reconstructions with and without augmentation by either (1) a novel "reverse" coracoacromial (CA) ligament transfer or (2) an intramedullary AC tendon graft.Reverse CA transfer will improve AP stability compared with isolated coracoclavicular (CC) reconstruction.Controlled laboratory study.Six matched pairs of cadaveric shoulders underwent distal clavicle resection and CC reconstruction. Displacement (mm) was measured during cyclic loading along AP (±25 N) and superior-inferior (SI; 10-N compression, 70-N tension) axes. Pairs were randomized to receive each augmentation and the same loading protocol applied.Reverse CA transfer (3.71 ± 1.3 mm, standard error of the mean [SEM]; P = .03) and intramedullary graft (3.41 ± 1.1 mm; P = .03) decreased AP translation compared with CC reconstruction alone. The SI displacement did not differ. Equivalence tests suggest no difference between augmentations in AP or SI restraint.Addition of either reverse CA transfer or intramedullary graft demonstrates improved AP restraint and provides similar SI stability compared with isolated CC reconstruction.Reverse CA ligament transfer may be a reasonable alternative to a free tendon graft to augment AP restraint in AC reconstruction.
View details for DOI 10.1177/0363546511426099
View details for PubMedID 22085727
New Frontiers for Cartilage Repair and Protection
2012; 3 (1): 77S-86S
Articular cartilage injury is common after athletic injury and remains a difficult treatment conundrum both for the surgeon and athlete. Although recent treatments for damage to articular cartilage have been successful in alleviating symptoms, more durable and complete, long-term articular surface restoration remains the unattained goal. In this article, we look at both new ways to prevent damage to articular surfaces as well as new techniques to recreate biomechanically sound and biochemically true articular surfaces once an athlete injures this surface. This goal should include reproducing hyaline cartilage with a well-integrated and flexible subchondral base and the normal zonal variability in the articular matrix.A number of nonoperative interventions have shown early promise in mitigating cartilage symptoms and in preclinical studies have shown evidence of chondroprotection. These include the use of glucosamine, chondroitin, and other neutraceuticals, viscosupplementation with hyaluronic acid, platelet-rich plasma, and pulsed electromagnetic fields. Newer surgical techniques, some already in clinical study, and others on the horizon offer opportunities to improve the surgical restoration of the hyaline matrix often disrupted in athletic injury. These include new scaffolds, single-stage cell techniques, the use of mesenchymal stem cells, and gene therapy.Although many of these treatments are in the preclinical and early clinical study phase, they offer the promise of better options to mitigate the sequelae of athletically induced cartilage.
View details for DOI 10.1177/1947603511411050
View details for Web of Science ID 000209218100013
View details for PubMedCentralID PMC4297164
Pectoralis Major Tendon Rupture: A Biomechanical Analysis of Repair Techniques
JOURNAL OF ORTHOPAEDIC RESEARCH
2011; 29 (11): 1783-1787
Rupture of the insertion of the pectoralis major muscle to the proximal humerus is becoming a common injury. Repair of these ruptures increases patient satisfaction, strength, and cosmesis, and shortens return to competitive sports. Several repair techniques have been described, but recently many surgeons are using suture anchors. The traditional repair technique uses transosseous sutures, but no study has biomechanically compared the strength of these two repair techniques in human cadavers. Twelve fresh-frozen human shoulder specimens were dissected. The pectoralis major tendon insertion was cut from the bone and repaired using one of the two repair techniques: specimens were randomly assigned to transosseous trough with suture tied over bone versus four suture anchors. The fixation constructs were pulled to failure at 4 mm/s on a materials testing system. The mean ultimate failure load of the transosseous repairs was 611 N and the mean ultimate failure load of the suture anchor repair was 620 N. The mean stiffness of the transosseous repair was 32 and 28 N/mm for the suture anchor group. We found no statistically significant difference between these two repair techniques.
View details for DOI 10.1002/jor.21438
View details for Web of Science ID 000295803900025
View details for PubMedID 21538507
An anatomic study of the coracoid process as it relates to bone transfer procedures
JOURNAL OF SHOULDER AND ELBOW SURGERY
2011; 20 (3): 497-501
The Latarjet and Bristow procedures address recurrent anterior shoulder instability in the context of a significant bony defect. However, the bony and soft tissue anatomy of the coracoid as they relate to coracoid transfer procedures has not yet been defined. The purpose of this study was to describe the soft tissue attachments of the coracoid as they relate to the bony anatomy and to define the average amount of bone available for use in coracoid transfer.Ten paired fresh frozen shoulders from deceased donors were dissected, exposing the coracoid, lateral clavicle, and acromion, along with the coracoid soft tissue attachments. The bony dimensions of the coracoid and the locations and sizes of the soft tissue footprints of the coracoid were measured.The mean maximum length of the coracoid available for transfer (ie, distance from the coracoid tip to the anterior border of the coracoclavicular ligament) was 28.5 mm. The mean distance from the coracoid tip to the anterior pectoralis minor was 4.6 mm, to the posterior pectoralis minor was 17.7 mm, to the anterior coracoacromial ligament was 7.8 mm, and to the posterior coracoacromial ligament was 25.7 mm.Average dimensions of the bony coracoid and average locations and sizes of coracoid soft tissue footprints are provided. This anatomic description of the coracoid bony anatomy and its soft tissue insertions allows surgeons to correlate the location of their coracoid osteotomy with the soft tissue implications of the coracoid transfer as the native anatomy is manipulated in these nonanatomic procedures.
View details for DOI 10.1016/j.jse.2010.08.015
View details for PubMedID 21106399
Arthroscopic repair of the scapholunate interosseous ligament.
Techniques in hand & upper extremity surgery
2010; 14 (4): 204-208
Scapholunate injuries are the most frequent of the intercarpal ligament injuries in the wrist. Current repair methods generally involve an open approach the dorsal capsule of the wrist. Arthroscopic repair of the dorsal portion of the scapholunate interosseus ligament would carry the advantages of less stiffness and would preserve the important dorsal capsular stabilizers. In the development of this technique, we first sought to determine the anatomic location and accessibility of the dorsal scapholunate ligament and the site in which a suture anchor would be placed. Ten fresh-frozen cadaver limbs were used. With the arthroscope in the 4 to 5 portal, the most dorsal portion of the SLIL was visualized in each specimen. K-wires were inserted through the 3 to 4 portal into the scaphoid adjacent to most distal portion of the dSLIL visualized. All limbs were dissected and the location of the wires relative to the prominence on the scaphoid directly adjacent to the central portion of the dSLIL was measured. The location of the prominence relative to the dSLIL was studied through magnified photography of a stained section of a cadaveric scaphoid. The mean distance of these wires distal to the center of the dSLIL is presented. Then the technique of arthroscopic repair of the dSLIL was developed using additional cadaveric wrist specimens. The technique is described.
View details for DOI 10.1097/BTH.0b013e3181df0a93
View details for PubMedID 21107214
Nerve Injuries About the Elbow
CLINICS IN SPORTS MEDICINE
2010; 29 (4): 655-?
The ulnar, radial, median, medial antebrachial cutaneous, and lateral antebrachial cutaneous nerves are subject to traction and compression in athletes who place forceful, repetitive stresses across their elbow joint. Throwing athletes are at greatest risk, and cubital tunnel syndrome (involving the ulnar nerve) is clearly the most common neuropathy about the elbow. The anatomy and innervation pattern of the nerve involved determines the characteristic of the neuropathy syndrome. The most important parts of the work-up are the history and physical examination as electrodiagnostic testing and imaging are often not reliable. In general, active rest is the first line of treatment. Tailoring the surgery and rehabilitation protocol according to the functional requirements of that athlete's sport(s) can help optimize the operative outcomes for recalcitrant cases.
View details for DOI 10.1016/j.csm.2010.06.001
View details for PubMedID 20883903
Articular Cartilage Injury in Athletes
2010; 1 (3): 165-179
Articular cartilage lesions in the athletic population are observed with increasing frequency and, due to limited intrinsic healing capacity, can lead to progressive pain and functional limitation over time. If left untreated, isolated cartilage lesions can lead to progressive chondropenia or global cartilage loss over time. A chondropenia curve is described to help predict the outcome of cartilage injury based on different lesion and patient characteristics. Nutriceuticals and chondroprotective agents are being investigated as tools to slow the development of chondropenia. Several operative techniques have been described for articular cartilage repair or replacement and, more recently, cartilage regeneration. Rehabilitation guidelines are being developed to meet the needs of these new techniques. Next-generation techniques are currently evaluated to optimize articular cartilage repair biology and to provide a repair cartilage tissue that can withstand the high mechanical loads experienced by the athlete with consistent long-term durability.
View details for DOI 10.1177/1947603509360210
View details for Web of Science ID 000209217000002
View details for PubMedCentralID PMC4297068
New developments in magnetic resonance imaging techniques for shoulder instability in athletes.
Open access journal of sports medicine
2010; 1: 137-142
Magnetic resonance (MR) imaging can be a very useful tool in the evaluation of instability in the athlete's shoulder. Technical options of MR imaging, such as arthrography, higher power magnets, and shoulder positioning, have enhanced MR evaluation of the shoulder. This update discusses the application of new MR techniques to a variety of shoulder instability patterns, including anterior instability, posterior instability, and atraumatic multidirectional instability. Specific applications of MR imaging in the postoperative patient is discussed. Finally, we describe the future directions of MR imaging in the setting of shoulder instability.
View details for PubMedID 24198551
Clinical Efficacy of the Microfracture Technique for Articular Cartilage Repair in the Knee An Evidence-Based Systematic Analysis
AMERICAN JOURNAL OF SPORTS MEDICINE
2009; 37 (10): 2053-2063
Despite the popularity of microfracture as a first-line treatment for articular cartilage defects in the knee, systematic information on its clinical efficacy for articular cartilage repair and long-term improvement of knee function is not available.Systematic analysis of the existing clinical literature of microfracture in the knee can improve the understanding of the advantages and limitations of this cartilage repair technique and can help to optimize its indications and clinical outcomes.Systematic review.A comprehensive literature search was performed using established search engines (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials) to identify original human studies of articular cartilage repair with microfracture. Modified Coleman Methodology Scores were used to analyze the quality of the existing studies. Clinical efficacy of articular cartilage repair was evaluated by systematic analysis of short- and long-term functional outcome scores, macroscopic and microscopic repair cartilage quality, and findings of postoperative magnetic resonance imaging.Twenty-eight studies describing 3122 patients were included in the review. The average follow-up was 41 months, with only 5 studies reporting follow-up of 5 years or more. Six studies were randomized controlled trials and the mean Coleman Methodology Score was 58 (range, 22-97). Microfracture effectively improved knee function in all studies during the first 24 months after microfracture, but the reports on durability of the initial functional improvement were conflicting. Several factors were identified that affected clinical outcome. Defect fill on magnetic resonance imaging was highly variable and correlated with functional outcome. Macroscopic repair cartilage quality positively affected long-term failure rate, while the influence of histologic repair tissue quality remained inconclusive.This systematic analysis shows that microfracture provides effective short-term functional improvement of knee function but insufficient data are available on its long-term results. Shortcomings of the technique include limited hyaline repair tissue, variable repair cartilage volume, and possible functional deterioration. The quality of the currently available data on micro-fracture is still limited by the variability of results and study designs. Further well-designed studies are needed to determine the long-term efficacy of microfracture and to define its specific clinical indications compared to other cartilage repair techniques.
View details for DOI 10.1177/0363546508328414
View details for Web of Science ID 000270272700022
View details for PubMedID 19251676
Arthroscopic Treatment of Triangular Fibrocartilage Wrist Injuries in the Athlete
34th Annual Meeting of the American-Orthopaedic-Society-for-Sports-Medicine
SAGE PUBLICATIONS INC. 2009: 291–97
Triangular fibrocartilage (TFC) injuries are an increasingly recognized cause of ulnar-sided wrist pain and can be particularly disabling in the competitive athlete. Previous studies show that arthroscopic debridement or repair can improve symptoms, but the results of arthroscopic treatment of TFC injuries in high-level athletes have not yet been reported.Arthroscopic debridement or repair of wrist TFC injury will allow a high rate of return to full function in the elite athlete.Case series; Level of evidence, 4.Between 2001 and 2005, 16 competitive athletes (mean age, 23.4 years) with wrist TFC injuries underwent arthroscopic surgery. Repair was performed in unstable tears, and all others underwent debridement alone. Presurgery and post-surgery mini-DASH (Disabilities of the Arm, Shoulder, and Hand) scores were recorded for each athlete through medical record review and clinical evaluation. The mean duration of follow-up was 32.8 months (range, 24-51 months).The TFC was repaired in 11 (68.8%) and debrided in 5 (31.3%) patients. The tear was ulnar-sided in 12 (75%), radial-sided in 2 (12.5%), combined radial-ulnar in 1, and central-sided in 1 patient. Mean mini-DASH scores improved from 47.3 (range, 25-65.9) to 0 (all patients) (P = .002), and the mean mini-DASH sports module improved from 79.7 (range, 68.8-100) to 1.95 (range, 0-18.8) (P = .002). Return to play averaged 3.3 months (range, 3-7 months). Associated conditions in the 2 patients unable to return to play at 3 months were distal radioulnar joint (DRUJ) instability with ulnar-carpal abutment (n = 1) and extensor carpi ulnaris (ECU) tendinosis (n = 1).Arthroscopic debridement or repair of wrist TFC injury provides predictable pain relief and return to play in competitive athletes. Return to play may be delayed in athletes with concomitant ulnar-sided wrist injuries.
View details for DOI 10.1177/0363546508325921
View details for PubMedID 19059892
An analysis of four ulnar collateral ligament reconstruction procedures with cyclic valgus loading
JOURNAL OF SHOULDER AND ELBOW SURGERY
2009; 18 (1): 58-63
We describe a new transolecranon fossa ulnar (TOFU) collateral ligament reconstruction technique and compare its response to cyclic valgus loading with the Jobe, Docking, and DANE procedures. TOFU is an arthroscopically assisted, modified all-interference screw technique. A cyclic valgus moment was applied to 32 intact and reconstructed, unembalmed elbows. Valgus angles were measured at 1, 10, 100, and 1000 cycles. At all cycles, there was no difference between intact and TOFU-treated elbows. TOFU resulted in significantly smaller angles than DANE at cycles 10, 100, and 1000; Docking at cycle 1000; and Jobe at cycles 10, 100, and 1000. The TOFU procedure shows superior resistance to valgus loading than DANE and Jobe by cycle 10, and Docking by cycle 1000. Further study is needed to evaluate the clinical value of the TOFU procedure as an arthroscopically assisted technique.
View details for DOI 10.1016/j.jse.2008.06.011
View details for PubMedID 19095176
Emerging Options for Treatment of Articular Cartilage Injury in the Athlete
CLINICS IN SPORTS MEDICINE
2009; 28 (1): 25-?
Articular cartilage injury is observed with increasing frequency in both elite and amateur athletes and results from the significant joint stress associated particularly with high-impact sports. The lack of spontaneous healing of these joint surface defects leads to progressive joint pain and mechanical symptoms with resulting functional impairment and limitation of athletic participation. Left untreated, articular cartilage defects can lead to chronic joint degeneration and athletic disability. Articular cartilage repair in athletes requires effective and durable joint surface restoration that can withstand the significant joint stresses generated during athletic activity. Several techniques for articular cartilage repair have been developed recently, which can successfully restore articular cartilage surfaces and allow for return to high-impact athletics after articular cartilage injury. Besides these existing techniques, new promising scientific concepts and techniques are emerging that incorporate modern tissue engineering technologies and promise further improvement for the treatment of these challenging injuries in the demanding athletic population.
View details for DOI 10.1016/j.csm.2008.09.001
View details for Web of Science ID 000262324200005
View details for PubMedID 19064163
- Articular Cartilage Injury in the Athlete Clin Sports Med 2009; 28 (1): 25-40
Tibial aperture bone disruption after retrograde versus antegrade tibial tunnel drilling: a cadaveric study
KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY
2008; 16 (9): 818-822
The purpose of this study is to compare the local microfracture effects of antegrade versus retrograde drilling of the tibial tunnel in ACL reconstruction. Arthroscopic ACL excision was performed on eight matched cadaveric knees. Arthroscopic guided tibial tunnel reaming was performed in either an antegrade (four) or retrograde (four) direction. A 3 x 3 cm section of proximal tibial surrounding the tibial aperture was removed with open dissection, and each section underwent micro-computed tomography analysis. Three musculoskeletal radiologists graded the specimens for bone aperture disruption and discrete fracture lines. Tibial aperture irregularity was seen in all four of the antegrade specimens (mean, Grade 1.5), and in none of the retrograde specimens. Discrete fracture lines were present in all four antegrade specimens (mean 10.13 mm depth; 8.95 mm length). No fracture lines were seen in the retrograde group. Retrograde drilling of the tibial tunnel in ACL reconstruction results in less microfracture trauma to the surrounding aperture bone. The use of retrograde drilling in ACL reconstruction may decrease synovialization of the graft-tissue interface when compared to antegrade drilling.
View details for DOI 10.1007/s00167-008-0554-6
View details for PubMedID 18516594
Surgical decompression of the quadrilateral space in overhead athletes
AMERICAN JOURNAL OF SPORTS MEDICINE
2008; 36 (3): 528-532
Quadrilateral space syndrome is an uncommon condition that can disable the overhead athlete. The authors describe 4 cases of quadrilateral space syndrome that may assist clinicians in recognition of this problem in patients with posterior shoulder pain.Quadrilateral space syndrome can present as posterior shoulder pain in the overhead athlete, and surgical decompression can relieve symptoms and allow full return to activity.Case series; Level of evidence, 4.Between 2004 and 2006, the authors performed surgical decompression of the quadrilateral space in 4 overhead athletes (4 shoulders; mean age, 24 years). They evaluated the clinical presentations, diagnostic tests, surgical procedures, and results of treatment. Mean follow-up was 24.5 months.All 4 patients underwent surgical decompression of the quadrilateral space. Fibrous bands entrapped the axillary nerve in 3 shoulders, and venous dilation was found in the fourth shoulder. All patients returned to full activity without pain or limitation of overhead function 12 weeks after surgery.Quadrilateral space syndrome is an uncommon cause of posterior shoulder pain that is easily overlooked and can severely limit overhead function in the athlete. Surgical decompression can predictably relieve pain and improve function in patients who do not respond to nonoperative regimens.
View details for DOI 10.1177/0363546507309675
View details for PubMedID 18055916
- Articular cartilage regeneration in the knee Current Opinions in Orthopaedics 2008; 19: 37-43
Deltoid flap combined with fascia lata autograft for rotator cuff defects: a histologic study
KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY
2007; 15 (9): 1144-1149
The purpose of this study was to compare the histological characteristics of an autogenous fascia lata graft alone and a fascia lata graft combined with a deltoid flap in the reconstruction of rotator cuff tears. Ten New Zealand white rabbits were divided into two groups. Infraspinatus tendon defects (1 x 1 cm) were created in each animal. Reconstruction consisted of either a fascia lata graft alone or a fascia lata graft combined with a distally based deltoid flap. At 3 months, tissue harvest and histological analysis was performed. Compared to the fascia lata graft alone, there was significantly increased remodeling activity and neovascularization in the group that included a deltoid flap. Also, there was pronounced interdigitation at the graft/flap interface in the latter group. A mutually beneficial relationship may exist when an autogenous fascial graft is combined with a functional deltoid flap for reconstructing large rotator cuff defects.
View details for DOI 10.1007/s00167-006-0281-9
View details for PubMedID 17279424
Abduction and external rotation in shoulder impingement: An open MR study on healthy volunteers - Initial experience
2007; 244 (3): 815-822
To prospectively evaluate rotator cuff contact with the glenoid in healthy volunteers placed in the unloaded and loaded abduction and external rotation (ABER) positions in an open magnetic resonance (MR) imager.The study was institutional review board approved and HIPAA compliant, and informed consent was received. Eight male volunteers with no history of shoulder pain or pathology were imaged in a 0.5-T open MR imager. Volunteers were imaged in an unloaded ABER position with the arm at 90 degrees abduction and in a loaded ABER position, with a 1-kg load that produced an average external rotation of 111 degrees+/-6 (standard deviation). Two radiologists graded rotator cuff contact on a three-point scale. Three-dimensional anatomic models generated from the MR images were used to measure distances. Minimum distances were computed between the tendon insertion sites and the glenoid, acromion, and coracoid for the loaded ABER position. Minimum distances were compared by using a paired Student t test.In the unloaded ABER position, contact was seen between the infraspinatus and supraspinatus tendons and the glenoid in all eight volunteers. In the loaded ABER position, contact was also observed between the infraspinatus and supraspinatus and the posterior and posterosuperior glenoid, respectively. Deformation of the infraspinatus on the glenoid was seen in four volunteers, whereas supraspinatus deformation was only seen in one volunteer. The minimum distance between the supraspinatus insertion and acromion in the loaded ABER position decreased significantly (P<.01). Supraspinatus tendon to glenoid and infraspinatus tendon to glenoid minimum distances also decreased significantly (P<.01).The unloaded and loaded ABER positions resulted in contact of the supraspinatus and infraspinatus with the glenoid in all volunteers. Distances between the rotator cuff insertion sites and the glenoid decreased in the loaded ABER position.
View details for DOI 10.1148/radiol.2443060998
View details for PubMedID 17690321
Two ulnar collateral ligament reconstruction methods: The docking technique versus bioabsorbable interference screw fixation - A biomechanical evaluation with cyclic loading
JOURNAL OF SHOULDER AND ELBOW SURGERY
2007; 16 (2): 224-228
We compared the effects of cyclic valgus loading on 2 techniques for reconstruction of the elbow ulnar collateral ligament (UCL): the docking procedure and the bioabsorbable interference screw procedure. A cyclic valgus load was applied to the 16 unembalmed elbows, and the valgus angle was measured at 1, 10, 100, and 1000 cycles. Testing was repeated after UCL palmaris tendon reconstruction via either the docking technique or bioabsorbable interference screw fixation. At cycle 1, the valgus angle was not different between treated and intact cases. At cycles 10 and 100, the valgus angle for the docking technique was significantly greater than that for both the intact cases and the interference screw technique. By the 1000th cycle, no difference was measured between the 2 techniques. In this study, bioabsorbable interference screw fixation resulted in less valgus angle widening in response to early cyclic valgus load as compared with the docking technique.
View details for DOI 10.1016/j.jse.2005.12.012
View details for PubMedID 17254812
Ligament and tendon injury to the elbow: clinical, surgical, and imaging features.
Topics in magnetic resonance imaging
2006; 17 (5): 327-336
Significant advances in the understanding of elbow anatomy, biomechanics, imaging, and surgical technique have been made over the last decade. Tendon injuries are often seen in athletes and physical laborers from repetitive eccentric overload. Ligament injuries are commonly seen in throwing athletes or after elbow dislocation. Magnetic resonance imaging has proven valuable for diagnosing and monitoring most of these soft tissue injuries, and effective surgical techniques have evolved to address them. This article describes typical clinical findings associated with ligament and tendon injuries in the elbow as well as common surgical therapies. The use of magnetic resonance imaging is highlighted throughout because this modality has revolutionized noninvasive evaluation of the elbow.
View details for PubMedID 17414994
Injury to the deep motor branch of the ulnar nerve during hook of hamate excision
2006; 29 (5): 456-458
View details for PubMedID 16729750
In vivo anatomy of the Neer and Hawkins sign positions for shoulder impingement
JOURNAL OF SHOULDER AND ELBOW SURGERY
2006; 15 (1): 40-49
The Neer and Hawkins impingement signs are commonly used to diagnose subacromial pathology, but the anatomy of these maneuvers has not been well elucidated in vivo. This 3-dimensional open magnetic resonance imaging study characterized shoulder anatomy and rotator cuff impingement in 8 normal volunteers placed in the Neer and Hawkins positions. Subacromial and intraarticular contact of the rotator cuff was graded, and minimum distances were computed between the tendon insertion sites and the glenoid, acromion, and coracoid. Both the Neer and Hawkins maneuvers significantly decreased the distance from the supraspinatus insertion to the acromion and posterior glenoid and from the subscapularis insertion to the anterior glenoid. However, the Hawkins position resulted in significantly greater subacromial space narrowing and subacromial rotator cuff contact than the Neer position. In the Hawkins position, subacromial contact of the supraspinatus and infraspinatus was observed in 7 of 8 and 5 of 8 subjects, respectively. In contrast, rotator cuff contact with the acromion did not occur in any subject in the Neer position. Intraarticular contact of the supraspinatus with the posterosuperior glenoid was observed in all subjects in both positions. Subscapularis contact with the anterior glenoid was also seen in 7 of 8 subjects in the Neer position and in all subjects in the Hawkins position. This extensive intraarticular contact suggests that internal impingement may play a role in the Neer and Hawkins signs.
View details for DOI 10.1016/j.jse.2005.04.007
View details for PubMedID 16414467
Acute compartment syndrome of the thigh in a football athlete - A case report and the role of the vacuum-assisted wound closure dressing
JOURNAL OF ORTHOPAEDIC TRAUMA
2005; 19 (10): 748-750
We present a case of compartment syndrome of the thigh due to blunt injury in a Division I American football player managed with fasciotomy and vacuum-assisted wound closure. This case report discusses the vacuum-assisted wound closure dressing as an alternative to more traditional closure techniques such as suture retention devices and split-thickness skin grafting. We feel that any surgeon involved in performing fasciotomies should be familiar with this increasingly used closure device and its potential complications.
View details for PubMedID 16314725
The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability
JOURNAL OF SHOULDER AND ELBOW SURGERY
2005; 14 (3): 298-301
This study evaluates the relative roles of the radial collateral ligament, the lateral ulnar collateral ligament, and the overlying musculature in posterolateral rotatory instability of the elbow. Fourteen cadaveric upper limbs underwent sequential arthroscopic sectioning of the lateral collateral ligament complex. After sectioning, arthroscopic and fluoroscopic evaluation of a lateral pivot shift test was done. Minimal instability was noted after the first section, but no difference between radial collateral or lateral ulnar collateral ligament sectioning was found. A greater degree of instability was seen between the first and second cut ( P = .0001), but no significant difference was seen between sectioning the 2 groups ( P = .61). Complete instability occurred only after sectioning the overlying musculature. On the basis of this study, injury to both the radial collateral and lateral ulnar collateral ligaments is necessary to cause significant posterolateral rotatory instability of the elbow. Furthermore, the overlying musculature plays an important role in overall stability.
View details for DOI 10.1016/j.jse.2004.08.003
View details for PubMedID 15889029
CT angiography in complex upper extremity reconstruction.
Journal of hand surgery (Edinburgh, Scotland)
2004; 29 (5): 465-469
Computed tomography angiography is a new technique that provides high-resolution, three-dimensional vascular imaging as well as excellent bone and soft tissue spatial relationships. The purpose of this study was to examine the use of computed tomography angiography in planning upper extremity reconstruction. Seventeen computed tomography angiograms were obtained in 14 patients over a 20-month period. All studies were obtained on an outpatient basis with contrast administered through a peripheral vein. All the studies demonstrated the pertinent anatomy and the intraoperative findings were as demonstrated in all cases. Information from two studies significantly altered pre-operative planning. The average charge for computed tomography angiography was 1,140 dollars, compared to 3,900 dollars for traditional angiography.
View details for PubMedID 15336751
- CT angiography in complex upper extremity reconstruction JOURNAL OF HAND SURGERY-BRITISH AND EUROPEAN VOLUME 2004; 29B (5): 465-469
Arthroscopic evaluation of scaphoid waist fracture stability and the role of the radioscaphocapitate ligament
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
2004; 20 (2): 152-157
The purpose of this article is to arthroscopically evaluate the effect of forearm rotation on scaphoid fracture displacement and the impact of intra-articular ligament sectioning.Controlled laboratory study.Scaphoid fracture stability is studied arthroscopically in 10 cadaveric upper limbs. Displacement of the osteotomized scaphoid with and without forearm rotation is arthroscopically evaluated before and after radioscaphocapitate (RSC) ligament sectioning.No rotation at the fracture site was identified in full pronation and full supination with the wrist immobilized. With the RSC ligament intact, no immobilization, and the wrist fully pronated, 25% of scaphoid fractures rotated less than 1 mm, 62.5% rotated 1 to 2 mm, and 12.5% rotated more than 2 mm. After sectioning the RSC ligament, the fully pronated wrist resulted in rotation of less than 1 mm in 75% and 1 to 2 mm in 25%. No rotation at the fracture site was seen with supination, with or without immobilization. No difference was found between loaded and unloaded trials.Based on this observational data, it appears safe to use a below-elbow thumb spica cast in the treatment of minimally displaced scaphoid waist fractures. Sectioning of the RSC ligament resulted in reduced amount of rotation at the scaphoid waist fracture; thus the RSC ligament may be a deforming force rather than a stabilizing force in scaphoid waist fractures. Arthroscopy may be a valuable tool in the study of the effect of ligament sectioning on fracture stability.
View details for DOI 10.1016/j.arthro.2003.11.023
View details for PubMedID 14760347
Central screw placement in percutaneous screw scaphoid fixation: a cadaveric comparison of proximal and distal techniques.
journal of hand surgery
2004; 29 (1): 74-79
Percutaneous screw fixation of acute minimally displaced scaphoid fractures is an attractive treatment alternative compared with cast immobilization and can be performed with either a distal/volar or proximal/dorsal approach. Central screw placement within the scaphoid appears to be an important factor for successful fixation. The purpose of this cadaveric study is to investigate whether the proximal or distal approach for percutaneous screw scaphoid fixation allows for more central placement of the screw.Twelve fresh frozen cadaveric upper limbs were studied, with 6 specimens assigned to scaphoid screw placement with a proximal approach and 6 matched specimens assigned to scaphoid screw placement with a distal approach. After screw placement, the scaphoid was sectioned evenly into quarters along the longitudinal proximal-distal axis. For each section, the distance from the center of the screw hole to the edges of the dorsal/volar/radial/ulnar axes was measured, and the means of the 2 groups were compared with a Hotelling's T(2) test to determine statistically significant central screw placement.A statistically significant difference was found between the mean location of the distal fixation group and the center of the scaphoid in the midwaist and distal pole of the scaphoid (p =.007 and.012, respectively) and between the mean location of the proximal and distal fixation groups in the distal pole of the scaphoid (p =.045).We find that the proximal/dorsal approach to the percutaneous screw fixation of scaphoid waist fractures allows for a more central placement in the distal pole, but there is no significant difference when it is used in the proximal or waist region. It remains unclear whether the more central screw placement afforded by the proximal approach might translate into an improved clinical outcome.
View details for PubMedID 14751108
Magnetic resonance imaging in diagnosis of chronic posterolateral rotatory instability of the elbow.
American journal of orthopedics (Belle Mead, N.J.)
2003; 32 (10): 501-503
Posterolateral rotatory instability of the elbow can be difficult to diagnose and requires a high degree of clinical suspicion. Cases of chronic posterolateral rotatory instability (symptoms present more than 1 year) may be an even more perplexing subgroup. This is a case report of a patient with a 30-year history of intermittent elbow instability. Clinical examination was equivocal, and magnetic resonance imaging was unable to define any ligamentous injury around the elbow. Examination under anesthesia and surgical findings were consistent with complete disruption of the lateral ulnar collateral ligament. The 12-month follow-up after surgical reconstruction showed complete resolution of symptoms. Posterolateral rotatory instability is a diagnosis largely made by examination under anesthesia. A thorough history and a high clinical suspicion are necessary to support the physician's decision to place the patient under anesthesia. Confirmation of a chronic tear of the lateral ulnar collateral ligament of the elbow with magnetic resonance imaging can be difficult and sometimes misleading.
View details for PubMedID 14620091
Improving resident work environment: Evaluation of a novel cooperative program
64th Annual Meeting of the Society-of-University-Surgeons
MOSBY-ELSEVIER. 2003: 158–63
Improving the resident work environment is a major concern for surgery faculty. This study evaluated the ability of a cooperative program with nurses and interns to decrease the number of nonurgent pages and consistently generate a 4-hour block of time at night without nonurgent pages.Multiple discussions with interns and with nurses on 2 nursing floors identified ways to improve nurse/resident communication. These included use of a notebook by nurses to record nonurgent issues and having on-call interns check with the night nurses after night shift report. For the week before and after institution of the program, interns logged each page received. Pretest and posttest data were compared by use of t testing.Interns logged fewer pages after intervention compared with preintervention (P <.01). In addition, the interns had a 4-hour block of time on call nights without pages more frequently during the posttest period (100% vs 25%, P <.01). The percent of necessary calls increased from 50% to 70% during day shifts (P <.01).A cooperative program that focused on decreasing nonurgent pages and maximizing efficient communication led to a decrease in the number of nonurgent pages received by interns and increased the number of call nights in which a 4-hour block of sleep or study time was generated, thereby improving residents' work environment.
View details for DOI 10.1067/msy.2003.266
View details for Web of Science ID 000185184900008
View details for PubMedID 12947313
The effect of pronation and supination on the minimally displaced scaphoid fracture
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
The amount of rotation that occurs at the scaphoid waist fracture site with pronation and supination of the forearm is studied in 10 upper extremities from cadavers. Two colinear metal markers were placed in the osteotomized scaphoid and a below-the-elbow cast was applied. Spiral volumetric computed tomography scanning of the scaphoid was done with multiplanar reformation to evaluate displacement of the metal markers. Four of the 10 specimens also were studied without any immobilization. The total magnitude of motion from pronation to supination averaged 0.2 mm in the specimens with a below-the-elbow thumb spica cast, and 2.4 mm in specimens without immobilization. The current study showed no significant rotation at the minimally displaced scaphoid waist fracture site during pronation and supination in a below-the-elbow cast. Furthermore, there is unacceptable rotation at the fracture site in the absence of a cast. Based on this study, a below-the-elbow thumb spica cast seems adequate for fracture immobilization; however, clinical correlation is needed.
View details for DOI 10.1097/01.blo.0000069886.31220.86
View details for PubMedID 12782882
Injury to the dorsal sensory branch of the ulnar nerve in the arthroscopic repair of ulnar-sided triangular fibrocartilage tears using an inside-out technique: a cadaver study.
journal of hand surgery
2002; 27 (5): 840-844
This anatomic study of the commonly described inside-out Tuohy needle technique was performed to better define the course of needle passage relative to the anatomic structures in this region including the dorsal sensory branch of the ulnar nerve (DBUN) and extensor carpi ulnaris (ECU) tendon. Ten fresh-frozen cadaver specimens had arthroscopic-guided passage of a Tuohy needle through the triangular fibrocartilage (TFC). Dissection of the ulnar side of the wrist was performed and various measurements were recorded. The average minimum distance between suture A (the suture closest to the nerve) and the DBUN was 1.9 mm. The average minimum distance between suture B and the DBUN was 2.7 mm. The distance between the 2 sutures at the level of the capsule averaged 6.2 mm. The distance between the DBUN and the ECU averaged 7.2 mm. In 5 of 10 specimens the sutures exited on opposite sides of the DBUN. The DBUN is variable in its course but in every case it passes in close proximity to the sutures that exit the ulnar side of the wrist in arthroscopic repair of ulnar-sided TFC tears.
View details for PubMedID 12239674
Long-term follow-up of surgical release of the A(1) pulley in childhood trigger thumb
JOURNAL OF PEDIATRIC ORTHOPAEDICS
2002; 22 (1): 41-43
Trigger thumb is an uncommon problem in infants and children. The authors reexamined 21 patients (30 thumbs) who underwent a release procedure, with an average follow-up of 181.3 months (15.1 years). Twenty-three percent of patients had a loss of interphalangeal motion and 17.6% had metacarpal phalangeal hyperextension, and this was unrelated to age at the time of surgery. There was no recurrence of triggering or nodules and no functional deficit. All seven patients who had a longitudinal incision had concerns about their scar appearance. It is the authors' belief that a transverse skin incision and surgical release of the A(1) pulley for trigger thumb in children is a successful procedure even when done after age 3, but interphalangeal motion loss and metacarpal phalangeal hyperextension may occur in the long term.
View details for Web of Science ID 000172965800010
View details for PubMedID 11744852
The role of plain films and computed tomography in the evaluation of scapular neck fractures
JOURNAL OF ORTHOPAEDIC TRAUMA
2002; 16 (1): 7-11
To assess the ability of plain films and computed tomography scans to show the pattern, displacement, and angulation of scapular neck fractures. To assess the ability of computed tomography to identify concomitant occult shoulder injuries.Masked retrospective radiographic review.Level I trauma center.Three orthopaedic surgeons (two attending physicians and one senior resident) and one musculoskeletal radiology attending physician reviewed the imaging studies of scapula neck fractures in twenty patients treated at our institution.Kappa analysis of agreement of fracture characteristics and benefits of computed tomography for scapular neck fractures.The mean weighted kappa coefficient for interobserver reliability of fracture displacement was 0.49 when the fractures were assessed by plain films alone, 0.15 when they were assessed by computed tomography scans alone, and 0.35 when they were assessed by plain films and computed tomography scans. The mean weighted kappa coefficients for fracture angulation were 0.30, 0.23, and 0.16, respectively. The mean simple kappa coefficients for fracture classification were 0.81, 0.20, and 0.33, respectively. Concomitant injury to the superior shoulder suspensory complex was seen in 57 percent of cases, including nine clavicle fractures, one coracoid fracture, and three acromion process fractures. The coracoid fracture and two of the acromion process fractures were minimally displaced and seen on computed tomography scans only.Scapular neck fracture displacement, angulation, and anatomic classification showed moderate interobserver reliability by plain films but were not enhanced by computed tomography. Computed tomography confused, rather than clarified, the assessment of these characteristics. Computed tomography may be useful to identify associated injuries to the superior shoulder suspensory complex, which can be missed by plain films alone. Routine computed tomography in patients with scapular neck fractures cannot be recommended based on this study. Computed tomography of scapular neck fractures may be useful in selected cases in which intraarticular extension is noted on plain films.
View details for PubMedID 11782625
Frostbite: an orthopedic perspective.
American journal of orthopedics (Belle Mead, N.J.)
1999; 28 (1): 21-26
Frostbite injury to the extremities has the potential for disastrous effects. This review provides information valuable to the orthopedic surgeon to aid in the evaluation and treatment of frostbite. The pathophysiology and predisposing factors that provide a basic understanding of the nature of frostbite are discussed. Accepted and experimental imaging studies and treatment options are also reviewed. An effort is made to give the orthopedic perspective on each issue, providing a valuable resource for all orthopedic surgeons involved in the care of the patient with frostbite.
View details for PubMedID 10048354