Friday, June 29, 2012

Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy

Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy

Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy

  1. LTC Brett D. Owens, MD
+ Author Affiliations
  1. *Department of Orthopaedics and Rehabilitation, William Beaumont Army Medical Center, Fort Bliss, Texas
  2. Orthopaedic Surgery Service, Keller Army Community Hospital, West Point, New York
  3. Study performed at John A. Feagin Jr. Sports Medicine Fellowship, Orthopedic Surgery Service, Keller Army Hospital, United States Military Academy, West Point, New York
  1. LTC Brett D. Owens, MD, Chief, Orthopaedic Surgery, John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, West Point, NY 10996 (e-mail: b.owens@us.army.mil).
  1. Presented at the 37th annual meeting of the AOSSM, San Diego, California, July 2011.

Abstract

Background: There is recent evidence that use of allograft tendons for anterior cruciate ligament (ACL) reconstruction in young patients may result in increased failure rates compared with autologous grafts.
Hypothesis: Allograft ACL reconstruction will result in higher failure rates in young athletes compared with autograft reconstruction.
Study Design: Cohort study; Level of evidence, 2.
Methods: A prospective cohort study of cadets at the United States Military Academy (USMA) was performed to assess performance of ACL reconstructions performed before entrance to service. Members of the classes of 2007 through 2013 who had undergone prior ACL reconstruction were identified through the Department of Defense Medical Evaluation Review Board reporting and waiver process and evaluated on the first day of matriculation. These participants were followed during their tenure at the academy with revision ACL reconstruction as the primary outcome measure of interest. Kaplan-Meier survival analysis was performed for all graft types using STATA with significance set as P < .05.
Results: A total of 120 cadets underwent 122 ACL reconstructions (2 bilateral) before matriculation and compose the prospective cohort. This cohort included 30 female and 90 male cadets. Of these 122 knees with prior ACL reconstructions, the grafts used were 61 bone–patellar tendon–bone (BTB), 45 hamstring, and 16 allograft. A total of 20 failures occurred among this cohort at an average of 545 days from matriculation. Of the failures requiring revision, 7 were BTB (11% of all BTB), 7 were allograft (44% of all allograft), and 6 were hamstring (13% of all hamstring). There was no significant difference in the graft failure between the BTB and hamstring autograft groups. In contrast, those who entered the USMA with an allograft were 7.7 times more likely to experience a subsequent graft failure during the follow-up period when compared with the BTB autograft group (hazard ratio = 7.74; 95% confidence interval [CI], 2.67-22.38; P < .001). When allografts were compared with all autografts combined, a similar increase failure was noted in the allograft group (hazard ratio = 6.71; 95% CI, 2.64-17.06; P < .001).
Conclusion: In this young active cohort, individuals having undergone an allograft ACL reconstruction were significantly more likely to experience clinical failure requiring revision reconstruction compared with those who underwent autologous graft reconstruction. The authors recommend the use of autograft in ACL reconstruction in young athletes.


MRI of the Shoulder: Rotator Cuff: Abstract and Introduction

MRI of the Shoulder: Rotator Cuff: Abstract and Introduction

Introduction

Linking the axial trunk and upper extremity, the shoulder joint plays an imperative role in most daily activities, allowing us to position our hands in space. Further, the joint acts as a small fulcrum for a long lever arm, predisposing the rotator cuff to injury, especially from the rapid accelerations and decelerations inherent to most sports and even some activities of daily living.
Shoulder anatomy and biomechanics, particularly those of the rotator cuff (RC), endow the glenohumeral joint with dynamic and static stability throughout a substantial range of motion. The interconnected supraspinatus, infraspinatus, teres minor, and subscapularis musculotendinous complexes constitute the rotator cuff and act as the shoulder's primary functional unit. Because of the rotator cuff's crucial role, RC pathology may lead to considerable limitations in daily routine, work, and leisure/sporting activities.
Shoulder magnetic resonance imaging (MRI) improves the sensitivity and specificity of diagnosing RC disorders, reduces unnecessary arthroscopic procedures, and provides important clinical information to guide patient management. This review will cover recent literature regarding RC anatomy and the clinical presentation, evaluation, and management of RC disease. We will discuss new observations about the strengths, inherent blind spots, and diagnostic effectiveness of shoulder MRI, and then outline the classification of rotator cuff MRI findings and their impact on patient management. Finally, we will present an effective search pattern approach to evaluate the rotator cuff on shoulder MRI examinations.

Wednesday, June 27, 2012

Etiology of PASTA tears in non-throwers requires specific strategy

Etiology of PASTA tears in non-throwers requires specific strategy | Orthopedics Today

Etiology of PASTA tears in non-throwers requires specific strategy

  • Orthopedics Today, June 2012
    Christopher S. Ahmad, MD
This article is the first in a two-part series on surgical techniques for partial thickness rotator cuff tears. This article will cover the partial articular-sided supraspinatus tendon avulsion or PASTA surgical repair performed on non-throwers. Part 2, appearing next month, will cover the repair strategy, rationale and surgical technique used in throwing athletes.
Partial rotator cuff tears can be bursal-sided, instrasubstance or articular-sided. Articular-sided tears predominate and have been coined PASTA tears or lesions. The etiology and pathogenesis of PASTA lesions differs among younger throwing athletes and older non-throwing patients. In addition, the demands and functional adaptations necessary for throwing necessitate a different repair strategy and surgical technique compared to non-throwers.
Symptomatic patients with suspected rotator cuff pathology require an MRI to accurately diagnose partial rotator cuff tears as well as any concomitant lesions, such as labral tears (Figure 1). Repair of partial rotator cuff tears is indicated when 3 months to 6 months of nonoperative treatment fails. Patient-related factors however, can lead to earlier operative treatment. Surgical technique options include rotator cuff debridement or rotator cuff repair. In addition, repair can be done open, mini-open or arthroscopically.
A partial thickness rotator cuff tear 
Figure 1. The arrow on this MRI indicates a partial thickness rotator cuff tear. Sometimes these occur in conjunction with other pathology, such as labral tears.
A partial thickness tear of the supraspinatus 
Figure 2. An arthroscopic view shows a partial thickness tear of the supraspinatus.
Images: Center for Shoulder, Elbow and Sports Medicine at Columbia University Medical Center

To complete or not complete

A central decision in treating partial thickness rotator tears is whether to complete the tear, converting it to a full thickness tear or perform a transtendon repair without detaching the intact rotator cuff.
Several concerns are associated with completing the partial tear with subsequent repair. First, the intentionally detached intact tendon increases the overall amount of tissue required for healing and may even increase tension on the repair. In addition, more anchors and suture passing are required to restore the anatomic footprint. In response to this, an arthroscopic in situ or transtendon repair technique has been developed. The transtendon technique requires penetration of the intact bursal side of the rotator cuff to facilitate anchor insertion and suture passing. As long as the bursal side is intact, with a transtendon repair the rotator cuff is preserved, fewer anchors are used and the excision of normal tissue is minimized or avoided entirely, retaining the normal anatomy. The main disadvantage of this procedure is it causes a small amount of damage to the intact tendon for anchor insertion and may retain abnormal tendinotic tissue.
I follow a general treatment guideline despite a lack of strong supporting evidence for this. If 25% of the cuff is torn, rotator cuff debridement is performed. If 50% of the cuff is torn, an in situ all-arthroscopic repair to the footprint is performed without completing the tear. If 75% or more of the cuff is torn, the tear is completed and an all-arthroscopic rotator cuff repair is considered, especially if the intact tendon appears tendinotic.

My surgical technique

I prefer to position the patient in the lateral decubitus position with the shoulder in abduction. Abducting the shoulder with a partial rotator cuff tear brings the tear into the region that is closer to the working portals. Portals include a standard posterior viewing portal, an anterior working portal and a lateral working portal. The anterior working portal is positioned more superior and lateral than typical of other procedures, and this helps facilitate access of instruments, such as shavers and graspers, to the rotator cuff tear.
The procedure begins with the camera introduced into the glenohumeral joint through the posterior portal, and a thorough diagnostic exam is performed prior to creating additional portals (Figure 2). Appreciating the complete pathology, such as combined labral tears, may influence portal placement. Evaluation of the undersurface of the rotator cuff proceeds from anterior to posterior. The arm may be abducted and adducted, and internally and externally rotated as needed. A spinal needle is used to confirm the desired position of the anterior portal. As stated earlier, often the best portal location is more superior and lateral than used in other shoulder arthroscopic procedures.
Next I do some debridement of the tear edges and in the process evaluate the extent of the partial thickness tear by looking at the footprint (Figure 3). Determining the size of the exposed footprint allows calculation of the extent of the partial thickness tear by considering the normal footprint size as between 12 mm and 14 mm.

Bursal side pathology

Performing a bursectomy before placing anchors in a transtendon fashion is essential because subacromial bursa can obscure the suture limbs and compromise knot tying later in the surgery. In addition, the bursal side of the rotator cuff should be inspected for damage which may affect the decision to perform a tear completion. A spinal needle is introduced percutaneously through the tear, and a suture is passed and retrieved out the anterior portal. The suture is then found on the bursal side with the camera in the subacromial space. If there is bursal side damage, its size should be added to the 50% of the footprint rule used on the articular side. The resultant sum will factor into how the tear is best treated.
The shaver is shown from the anterior portal 
Figure 3. The shaver is shown from the anterior portal. It is used to debride partial thickness tears and debride the insertional footprint.
The suture anchor penetrates an intact tendon 
Figure 4. The suture anchor penetrates an intact tendon for placement in the greater tuberosity footprint.
A double-loaded suture anchor in place 
Figure 5. Pictured is a double-loaded suture anchor in place during the procedure in a non-thrower.
A grasper is used to retrieve a suture limb 
Figure 6. A grasper is used to retrieve a suture limb out the anterior cannula.

Rotator cuff repair steps

A spinal needle is introduced again percutaneously, through the rotator cuff, and to the desired anchor placement location. Adducting the shoulder often helps get a better angle to the medial aspect of the footprint. The anchor is then inserted percutaneously and penetrates the rotator cuff and inserted into the bone (Figure 4). Damage to the rotator cuff during insertion can be minimized if the anchor is screwed in through the soft tissue of the rotator cuff.
After that, anchor placement suture passing is then performed (Figure 5). Several devices may be used, but I prefer a simple 18-gauge spinal needle to minimize trauma to the intact rotator cuff and will shuttle with a monofilament suture. One suture limb from the anchor is retrieved out the anterior working cannula (Figure 6). Working from anterior to posterior, a spinal needle is then used to penetrate the intact bursal cuff and then the articular-sided tear lamina (Figure 7). A monofilament suture is run through the needle and used to shuttle the anchor suture form the anterior cannula through the tear. This is repeated for all sutures of the double-loaded suture anchor (Figure 8). If the tear extends further posterior, additional anchors may be placed and the steps repeated. Tensioning the sutures will demonstrate the reduction of the torn rotator cuff.
The next step is going back into the subacromial space and tying the sutures, which is fairly easy to do having done the bursectomy earlier (Figure 9). The glenohumeral joint is re-visualized once more to inspect the repair (Figure 10).
A spinal need penetrates the rotator cuff and a monofilament suture is advanced 
Figure 7. A spinal need penetrates the rotator cuff and a monofilament suture is advanced for suture shuttling.
All four sutures after suture passing is completed 
Figure 8. All four sutures are depicted after suture passing is completed.
Sutures are tied in the subacromial space 
Figure 9. Sutures are tied in the subacromial space, which is much easier to carry out if a bursectomy was initially done.
The completed repair 
Figure 10. In this final view, the completed repair is seen from the intra-articular space.

Postoperative rehabilitation results

Postoperative rehabilitation following transtendon rotator cuff repair is similar to the standard arthroscopic rotator cuff repair rehabilitation protocol. The arm is placed in a sling with a small pillow. The sling is worn continuously for 4 weeks to 6 weeks, except during bathing and exercises. Active elbow flexion and extension are encouraged for the initial 6 weeks. At the 6-week mark, the program is progressed to active-assisted and active range of motion exercises with progressive stretching. Resistive exercises are added at 10 weeks. Progressive activities are incorporated as strength allows, and unrestricted activities are usually resumed 6 months to 12 months following surgery.
To date, numerous clinical reports support transtendon repair. Biomechanical research also supports transtendon repair. Our group performed a biomechanical study comparing the transtendon technique to the tear completion and repair technique. When subjected to cyclic loading, the transtendon repair had significantly less gapping and higher ultimate failure strength than the tear completion group. Based on clinical reports and biomechanical evidence, we recommend preserving the intact rotator cuff tendon.
References:
  • Gonzalez-Lomas G, Kippe MA, Brown GD, et al. In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears. J Shoulder Elbow Surg. 2008;17:722-728. Epub 2008 June 16.
  • Ide J, Maeda S, Takagi K. Arthroscopic transtendon repair of partial-thickness articular-side tears of the rotator cuff: Anatomical and clinical study. Am J Sports Med. 2005;33:1672-1679.
  • Lo IK, Burkhart SS. Transtendon arthroscopic repair of partial-thickness, articular surface tears of the rotator cuff. Arthroscopy. 2004;20:214-220.
  • Seo YJ, Yoo YS, Kim DY, et al. Trans-tendon arthroscopic repair for partial-thickness articular side tears of the rotator cuff. Knee Surg Sports Traumatol Arthrosc. 2011;19:1755-1759.
  • Shin SJ. A Comparison of two repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy. 2012; 28(1):25-33. Epub 2011 Oct. 14.
  • Snyder SJ. Arthroscopic treatment of partial articular surface tendon avulsions. Presented at the 2001 AAOS/AOSSM Comprehensive Sports Medicine: The athletic perspective to treatment, controversies and problem-solving. Lake Tahoe, Nev.

Study: Platelet-rich plasma not effective for treatment of Achilles tendinosis | Orthopedics

Study: Platelet-rich plasma not effective for treatment of Achilles tendinosis | Orthopedics

Study: Platelet-rich plasma not effective for treatment of Achilles tendinosis

  • June 25, 2012
SAN DIEGO – Platelet-rich plasma does not improve chronic non-insertional Achilles tendinosis, according to a researcher who presented at the American Orthopaedic Foot and Ankle Society Annual Meeting, here.
“Achilles tendionsis is a common condition and non-insertional is typically presented with painful swelling,” Gerard Bourke, MD, said.
Bourke and his colleagues conducted a prospective randomized controlled trial of 48 patients categorized into four groups: a group injected with a placebo into skin and tendon, a group injected with saline into the skin and tendon, a group injected with buffy coat blood platelets into skin and tendon and a group injected with whole blood into skin and tendon.
Patients and physicians were blinded to which injection patients would undergo. The researchers performed ultrasound-guided examinations of tendons and calculated Victorian Institute of Assessment of Sports Activity-Achilles (VISA-A) scores at injection time and at a 12-week follow-up. Radiologists assessed patients for alternate pathologies, such as partial tears or insertional tendinopathy.
The researchers found no improvement in the whole blood or platelets group compared to the placebo and saline groups.
“This was also found when the VISA-A score was disaggregated to the pain and function questions and analyzed separately,” the authors wrote in their study abstract.
“This study demonstrates no benefit of platelet-rich plasma for treatment of non-insertional Achilles tendinosis,” Bourke said.
Reference:
Bourke G. A prospective, randomized, controlled trial to assess the efficacy of whole blood or platelets in the treatment of chronic Achilles tendinosis. Presented at the American Orthopaedic Foot and Ankle Society 2012 Annual Meeting. June 21-23. San Diego.

Audio On Demand « CBS Philly-Great Sports Doc Elliot Leitman CBS Sports Radio

Audio On Demand « CBS Philly

My great friend and Sports Doc Elliot Leitman on CBS Sportstalk Philly, Listen and learn!!

Monday, June 25, 2012

Multivalent Ligand Displayed on Plant Virus Induces Rapid Onset of Bone Differentiation - Molecular Pharmaceutics (ACS Publications)

Multivalent Ligand Displayed on Plant Virus Induces Rapid Onset of Bone Differentiation - Molecular Pharmaceutics 

Multivalent Ligand Displayed on Plant Virus Induces Rapid Onset of Bone Differentiation

L. Andrew Lee, Sevan M. Muhammad, Quyen L. Nguyen, Pongkwan Sitasuwan, Gary Horvath, and Qian Wang*
Department of Chemistry and Biochemistry, University of South Carolina, 631 Sumter Street, Columbia, South Carolina 29208, United States
Mol. Pharmaceutics, Article ASAP
DOI: 10.1021/mp300042t
Publication Date (Web): May 30, 2012
Copyright © 2012 American Chemical Society
*University of South Carolina, Department of Chemistry and Biochemistry, 631 Sumter St., Columbia, SC 29208. E-mail: wang@mail.chem.sc.edu. Tel: 803-777-8436. Fax: 803-777-9521.

Abstract

Abstract Image


Viruses are monodispersed biomacromolecules with well-defined 3-D structures at the nanometer level. The relative ease to manipulate viral coat protein gene to display numerous functional groups affords an attractive feature for these nanomaterials, and the inability of plant viruses to infect mammalian hosts poses little or no cytotoxic concerns. As such, these nanosized molecular tools serve as powerful templates for many pharmacological applications ranging as multifunctional theranostic agents with tissue targeting motifs and imaging agents, potent vaccine scaffolds to induce cellular immunity and for probing cellular functions as synthetic biomaterials. The results herein show that combination of serum-free, chemically defined media with genetically modified plant virus induces rapid onset of key bone differentiation markers for bone marrow derived mesenchymal stem cells within two days. The xeno-free culture is often a key step toward development of ex vivo implants, and the early onset of osteocalcin, BMP-2 and calcium sequestration are some of the key molecular markers in the progression toward bone formation. The results herein will provide some key insights to engineering functional materials for rapid bone repair.

Keywords:

bionanoparticles; Tobacco mosaic virus; osteogenesis; multivalency; stem cell differentiation

Practice Patterns for Arthroscopy of Osteoarthritis of the Knee in the United States

Practice Patterns for Arthroscopy of Osteoarthritis of the Knee in the United States

Conclusion: Knee arthroscopy for patients with osteoarthritis among orthopaedic surgeons during their ABOS examination case collection period has decreased after the publication of a highly publicized article demonstrating a lack of efficacy of this procedure. Further study is needed to determine if this change occurred in the orthopaedic community at large or if practice patterns only changed for surgeons during their board collection periods.

Sunday, June 24, 2012

BloodCure: Regenokine featured on ABC's Nightline

BloodCure: Regenokine featured on ABC's Nightline

An interesting look at cutting edge treatments around the globe.  New biologic treatments are moving at light speed.

Saturday, June 16, 2012

All-arthroscopic Anatomic Repair of an Avulsed Popliteus Tendon in a Multiple Ligament–injured Knee | Orthopedics

All-arthroscopic Anatomic Repair of an Avulsed Popliteus Tendon in a Multiple Ligament–injured Knee | Orthopedics

Conclusion

All-arthroscopic repair of an avulsed popliteus tendon has multiple uses. It can be performed in the case of an isolated avulsion or when the popliteus tendon is the only injured posterolateral structure with a mild rotatory instability. This technique may, in some cases, be able to eliminate the need for an open incision and may decrease the risk of complications associated with capsulotomy in open procedures.

Outcomes of Arthroscopic Double-bundle PCL Reconstruction Using the LARS Artificial Ligament | Orthopedics

Outcomes of Arthroscopic Double-bundle PCL Reconstruction Using the LARS Artificial Ligament | Orthopedics

Using the LARS ligament for double-bundle reconstruction of the PCL avoids donor-site morbidity and disease transmission. The complication rate is low, and the results appear to be stable with time and comparable with those obtained with other grafts. The authors suggest that double-bundle PCL reconstruction with the LARS artificial ligament may be an alternative treatment option for reconstructing an anatomic PCL. A randomized, controlled study should be performed to further assess the value of using the LARS artificial ligament for double-bundle PCL reconstruction.

Wednesday, June 13, 2012

Clinical improvements seen with PRP for patellar tendinopathy | Orthopedics Today

Clinical improvements seen with PRP for patellar tendinopathy | Orthopedics Today

“We found that platelet-rich plasma (PRP) leads to clinically and statistically significant improvement in symptoms, pain, stability and function in patellar tendinopathy at 12 weeks,” Amy S. Wasterlain, BA, said during her presentation at the Arthroscopy Association of North America 2012 Annual Meeting. “Importantly, we also showed that PRP is both clinically and statistically significantly better than dry needling based on the Victorian Institute of Sports Assessment score of patella tendinopathy symptoms.”
Wasterlain and her colleagues conducted a randomized controlled trial of 17 patients with patellar tendinopathy. One group underwent dry needling with eccentric exercises and the other had dry needling with ultrasound-guided PRP injection and eccentric exercises. There were found no significant differences between the groups regarding demographics. The investigators followed patients at 3 weeks, 6 weeks, 9 weeks and 12 weeks. Outome measures included Tegner, Lysholm, Visual Analog Scale (VAS), Victorian Institute of Sport Assessment (VISA) and SF-12.
The PRP group improved 29 points on the VISA, which was 23 points more than the dry needling group demonstrating a clinically and statistically significant difference. The PRP group also should clinical and statistically significant improvements on the VAS scale. Although the Lysholm score improved by 29 points in the PRP group and 27 points in the dry needling group, Wasterlain noted that the difference was not statistically significant.
The Tegner activity scale improved 1.6 points in the PRP group, which was more than the dry needling group.
“These were clinically significant because the improvements were greater than one point, but these were not statistically significant,” Wasterlain said.
The researchers found a statistically significant improvement in the PRP group for the SF-12, but discovered no statistically significance differences between the groups for this measure.

More revisions seen with ACL reconstructions using allograft | Orthopedics

More revisions seen with ACL reconstructions using allograft | Orthopedics

Farrow and his colleagues conducted a retrospective chart review of 123 patients with a mean 4-year follow-up who underwent ACL reconstruction using tibialis anterior allograft (99 patients) or hamstring autograft (24 patients) between 2000 and 2008. The study included 67 men and 56 women with a mean age of 29 years. Exclusion criteria included patients undergoing revision ACL reconstructions or multiligament reconstruction.
The investigators found revision rates of 17% for the allograft group and 4.2% in the autograft group. The researchers found a 30% reoperation rate for patients younger than 25 years in the allograft group. They found no failures in patients younger than 25 years in the autograft group.
 “In competitive athletes, definitely no allograft,” Farrow said. “In patients 25 years to 50 years old, have them consider autograft. [In patients] greater than 50 years old, we are more willing to counsel about allograft reconstruction, and by all means, I do not use tibialis anterior [grafts].”