Carolyn M Hettrich

Hospital for Special Surgery, New York City, New York, United States

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Publications (20)47.3 Total impact

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    ABSTRACT: BACKGROUND:An initial anterior cruciate ligament (ACL) tear can be treated with surgical reconstruction or focused rehabilitation. The KANON (Knee Anterior cruciate ligament, NON-surgical versus surgical treatment) randomized controlled trial compared rehabilitation plus early ACL reconstruction (ACLR) to rehabilitation plus optional delayed ACLR and found no difference at 2 years by an intention-to-treat analysis of total Knee injury and Osteoarthritis Outcome Score (KOOS) results. PURPOSE:To compare the cost-effectiveness of early versus delayed ACLR. STUDY DESIGN:Economic and decision analysis; Level of evidence, 2. METHODS:A Markov decision model was constructed for a cost-utility analysis of early reconstruction (ER) versus rehabilitation plus optional delayed reconstruction (DR). Outcome probabilities and effectiveness were derived from 2 sources: the KANON study and the Multicenter Orthopaedic Outcomes Network (MOON) database. Collectively, these 2 sources provided data from 928 ACL-injured patients. Utilities were measured by the Short Form-6 dimensions (SF-6D). Costs were estimated from a societal perspective in 2012 US dollars. Costs and utilities were discounted in accordance with the United States Panel on Cost-Effectiveness in Health and Medicine. Effectiveness was expressed in quality-adjusted life-years (QALYs) gained. Principal outcome measures were average incremental costs, incremental effectiveness (as measured by QALYs), and net health benefits. Willingness to pay was set at $50,000, which is the currently accepted standard in the United States. RESULTS:In the base case, the ER group resulted in an incremental gain of 0.28 QALYs over the DR group, with a corresponding lower overall cost to society of $1572. Effectiveness gains were driven by the low utility of an unstable knee and the lower utility for the DR group. The cost of rehabilitation and the rate of additional surgery drove the increased cost of the DR group. The most sensitive variable was the rate of knee instability after initial rehabilitation. When the rate of instability falls to 51.5%, DR is less costly, and when the rate of instability falls below 18.0%, DR becomes the preferred cost-effective strategy. CONCLUSION:An economic analysis of the timing of ACLR using data exclusively from the KANON trial, MOON cohort, and national average reimbursement revealed that early ACLR was more effective (improved QALYs) at a lower cost than rehabilitation plus optional delayed ACLR. Therefore, early ACLR should be the preferred treatment strategy from a societal health system perspective.
    The American journal of sports medicine 05/2014; · 3.61 Impact Factor
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    ABSTRACT: BACKGROUND:Joint motion is commonly prescribed after tendon repair surgeries such as rotator cuff repairs; however, the ideal rehabilitation program to optimize tendon-to-bone healing is unknown. HYPOTHESES:(1) Delayed loading would result in a mechanically stronger and better organized tendon-to-bone interface compared with prolonged immobilization or immediate loading. (2) Low-magnitude load would lead to superior healing compared with high-magnitude load. STUDY DESIGN:Controlled laboratory study. METHODS:A total of 192 rats underwent unilateral patellar tendon detachment and repair followed by placement of a custom external fixator. Rats were assigned to immobilization, immediate postoperative loading, or delayed-onset loading (4- or 10-day delay). Loading was controlled using a specially designed motorized device to apply constant strain until 3 N (low load) or 6 N (high load) of axial tensile force was reached through the healing bone-tendon complex for 50 cycles per day. Rats were sacrificed at 4, 10, 21, or 28 days postoperatively for histomorphometric, immunohistochemical, radiographic, molecular, and biomechanical analyses. RESULTS:The load to failure was significantly higher in the immobilized group compared with the immediate and delayed loading groups (P < .05). Compared with loaded specimens, the immobilized specimens had significantly less fibrocartilage (at 4, 10, and 28 days), significantly better collagen fiber organization (at 4, 10, and 21 days), decreased expression of matrix metalloproteinase-13 (at 10, 21, and 28 days), and significantly fewer apoptotic cells (at 21 and 28 days). Micro-computed tomographic analyses showed that the 3-N immediate load group had significantly less total volume (P = .012), bone volume (P = .012), and bone mineral density (P = .023) for cortical bone, and the immobilized group had significantly more specimens with new bone formation at the enthesis (100%; P = .001). CONCLUSION:Immobilization results in a stronger tendon-bone complex, with less scar tissue and a more organized tendon-bone interface compared with all loading regimens in this study. CLINICAL RELEVANCE:Given the relatively high rate of failure after rotator cuff and other tendon-to-bone repairs, identification of optimal rehabilitation programs postoperatively is an important research goal.
    The American journal of sports medicine 04/2014; · 3.61 Impact Factor
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    ABSTRACT: To assess regional variations in the arterial and venous blood supply to the femoral head following displaced fracture of the femoral neck using dynamic contrast enhanced (DCE)-MRI quadrant analysis. A total of 27 subjects with displaced femoral neck fractures were enrolled in the study. Quadrant specific DCE-MRI perfusion analysis was performed on a 1.5 Tesla MRI scanner. Simultaneous imaging of control and displaced fractured hips was done for comparison. Quadrant specific decreases were found in the arterial (A (0.52 versus 0.27; P = 5.7E-13), Akep (1.0/min(-1) versus 0.41/min(-1) ; P = 1.3E-9) and venous (kel (0.05/min(-1) versus -0.02/min(-1) ; P = 5.1E-5) supply to the femoral head between control and injured sides using a two-factor analysis of variance test. The fractional perfusion (initial area under the curve) in the supero/inferolateral quadrants was 49% min/54% min, in the supero/inferomedial quadrants was 43% min/46% min and for the total femoral head was 39% min on the fracture versus control sides. Quadrant specific decreases in arterial and venous perfusion on the fracture side were observed when compared with control. J. Magn. Reson. Imaging 2013. © 2013 Wiley Periodicals, Inc.
    Journal of Magnetic Resonance Imaging 12/2013; · 2.57 Impact Factor
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    ABSTRACT: BACKGROUND:Subsequent surgeries have a profound effect on patient satisfaction and outcome after primary anterior cruciate ligament reconstruction (ACLR). There have been no prospective studies to date describing the rate and predictors (surgical and patient variables) of all subsequent knee surgeries at short-term and midterm follow-up along with analyses of surgical and patient variables that are associated with subsequent surgeries. PURPOSE:To report the rate and predictors of all subsequent surgeries at short-term and midterm follow-up along with associated patient variables. STUDY DESIGN:Case-control study; Level of evidence, 3. METHODS:A total of 980 patients (540 male) were prospectively enrolled in a Multicenter Orthopaedic Outcomes Network (MOON) cohort from January 2002 to December 2003. The 2- and 6-year follow-up information for subsequent procedures was obtained. Operative reports were obtained, and all procedures were categorized. RESULTS:One hundred eighty-five patients underwent a subsequent surgery on the ipsilateral leg (18.9%) and 100 on the contralateral knee (10.2%) at 6-year follow-up. On the ipsilateral knee, there was a 7.7% rate of ACL revisions, a 13.3% rate of cartilage procedures, a 5.4% rate of arthrofibrosis procedures, and a 2.4% rate of procedures related to hardware. For the contralateral knee, there was a 6.4% rate of primary ACL ruptures. Younger age at the index surgery and the use of allografts were predictors (risk factors) for subsequent surgery. Revision ACLR, female sex, body mass index, and surgical exposure were not significant predictors. CONCLUSION:At 6-year follow-up, 18.9% of patients who had undergone ACLR underwent subsequent surgeries on the ipsilateral knee. The rates between an ipsilateral ACLR graft versus a contralateral normal ACL tear were similar (7.7% vs 6.4%, respectively). Younger age and the use of allografts were risk factors for subsequent surgery.
    The American journal of sports medicine 05/2013; · 3.61 Impact Factor
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    ABSTRACT: Little is known of the cellular events that occur in native or repaired tendons as a result of immobilization after injury. To examine this issue, we compared (1) native tendons without immobilization, (2) native tendons with immobilization, and (3) surgically repaired tendons with immobilization. Eighty-one rats underwent either patellar tendon repair followed by immobilization or immobilization of the native tendon without repair. A custom external fixation device was used for immobilization. The tendon-bone insertion site was evaluated after two and four weeks of immobilization with use of histologic, radiographic, and biomechanical analyses. Immobilization of the native tendon led to a significant decrease in the load to failure (p < 0.01) and stiffness (p < 0.05) compared with the native tendon at both two and four weeks. The repaired/immobilized group had a significantly lower load to failure at two weeks compared with the native/immobilized group (p < 0.05); however, by four weeks, the repaired group was significantly stronger (p < 0.01). Micro-computerized tomography demonstrated no significant differences in bone microstructure at two weeks but demonstrated increased bone mineral density and bone volume fraction in the repaired/immobilized group at four weeks. There was significantly more MMP-13 (matrix metalloproteinase-13) staining in the native/immobilized specimens compared with the native specimens at both time points (p < 0.01). Immobilization had a significant detrimental effect on the bone-tendon complex. At two weeks there was a significant decrease in the mechanical properties of the native tendon, but the immobilized, native tendon remained significantly stronger than the repaired and immobilized tendon. However, four weeks of immobilization led to a significant loss of strength of the bone-tendon complex in the native tendon, such that it was significantly weaker than the repaired and immobilized tendon. Surgeons who manage patients with immobilization should be aware of the changes at the bone-tendon complex. Immobilization may have negative effects on the native bone-tendon complex.
    The Journal of Bone and Joint Surgery 05/2013; 95(10):925-30. · 3.23 Impact Factor
  • Carolyn M Hettrich, Bruce Browner
    Best practice & research. Clinical rheumatology 04/2012; 26(2):281-8. · 2.90 Impact Factor
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    ABSTRACT: To report on the use of a supplemental medial endosteal implant to prevent varus collapse and screw cutout in proximal humerus fractures treated with a laterally placed locking plate. Twenty-seven patients meeting study inclusion criteria were included in the study. Follow-up averaged 63.1 weeks (minimum 37 weeks and maximum 120 weeks). All patients were either older than 70 years or had sustained a proximal humerus fracture with medial comminution. Using the anterolateral acromial approach, a proximal humeral locking plate augmented with a medial endosteal implant (fibular allograft in 23 patients and semitubular plate in 4 patients) was used for fixation. Intraoperative fluoroscopic images and the most recent follow-up radiographs were used to measure the head-shaft angle and loss of height between the implant and the articular surface. Only 1 of 27 patients had significant loss of reduction with collapse of the fracture into varus (4.2 mm change). Ninety-six percent of patients maintained their original reduction with an average loss of height of 1.2 mm and an average change in shaft-head angle of 2.2 degrees. There were no implant failures or screw perforations of the articular surface and no radiographic or clinical evidence of AVN. Use of a medial endosteal implant as a supplement to a lateral locking plate is effective in maintaining operative reduction, preventing varus collapse, and implant failure in fractures with medial comminution and/or poor bone quality. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 02/2012; 26(4):212-5. · 1.78 Impact Factor
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    ABSTRACT: Successful rotator cuff tendon repair depends on secure tendon-to-bone healing. Recombinant human parathyroid hormone (rhPTH) has been shown in multiple studies to accelerate bone healing. Recent studies have also shown that rhPTH is chondrogenic by increasing chondrocyte recruitment and differentiation. We hypothesized that rhPTH would improve tendon-to-bone healing in a rat rotator cuff repair model. One hundred and fourteen Sprague Dawley rats underwent division and repair of the supraspinatus tendon. Fifty seven rats received daily subcutaneous injections of 10 µg/kg of rhPTH. Rats were sacrificed at 3, 7, 14, 28, and 56 days for histologic and immunohistochemical analysis. In addition, rats in each group were sacrificed at 14, 28, and 56 days for biomechanical testing and micro CT analysis. At 2 weeks the controls had a significantly higher load to failure than the rhPTH group. At 28 and 56 days there were no differences in load to failure. rhPTH specimens had significantly higher stiffness at 56 days. MicroCT analysis showed that the rhPTH group had significantly greater total mineral content at all time points, as well as significantly higher bone volume (BV) at 14 and 28 days. Histologically, the rhPTH specimens had more fibrocartilage, osteoblasts, and blood vessels at all timepoints, with significantly better collagen fiber orientation at 28 and 56 days. Although treatment with rhPTH resulted in an increase in bone and mineralized fibrocartilage formation, as well as better collagen fiber organization, this did not translate into improved biomechanical properties.
    Journal of Orthopaedic Research 11/2011; 30(5):769-74. · 2.88 Impact Factor
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    ABSTRACT: Treatment of displaced proximal humerus fractures remains challenging. The introduction of locking plates has renewed interest in treating these fractures with joint-preserving techniques rather than hemiarthroplasty, but high complication rates are still reported. Avascular necrosis is not solely dependent on the initial fracture pattern, but can also result from intraoperative and postoperative vascular insults. We describe a technique to minimize disruption of humeral head blood supply and maximize fracture fixation. A total of 34 patients with complex proximal humerus fractures were treated with a locking plate and endosteal implant through an anterolateral approach and followed for an average of 66 weeks to determine the rates of avascular necrosis. No patient suffered complete osteonecrosis (0%) and only one patient suffered partial necrosis (2.8%) of the humeral head. The length of the posteromedial hinge was not predictive of this complication. Use of the anterolateral approach and endosteal augment of a lateral locking plate can minimize avascular necrosis following proximal humerus fracture.
    Archives of Orthopaedic and Trauma Surgery 08/2011; 131(12):1617-22. · 1.36 Impact Factor
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    ABSTRACT: Current diagnostic strategies for detection of structural articular cartilage abnormalities, the earliest structural signs of osteoarthritis, often do not capture the condition until it is too far advanced for the most potential benefit of noninvasive interventions. To systematically review the literature relative to the following questions: (1) Is magnetic resonance imaging (MRI) a valid, sensitive, specific, accurate, and reliable instrument to identify knee articular cartilage abnormalities compared with arthroscopy? (2) Is MRI a sensitive tool that can be utilized to identify early cartilage degeneration? Systematic review. A systematic search was performed in November 2010 using PubMed MEDLINE (from 1966), CINAHL (from 1982), SPORTDiscus (from 1985), SCOPUS (from 1996), and EMBASE (from 1974) databases. Fourteen level I and 13 level II studies were identified that met inclusion criteria and provided information related to diagnostic performance of MRI compared with arthroscopic evaluation. The diagnostic performance of MRI demonstrated a large range of sensitivities, specificities, and accuracies. The sensitivity for identifying articular cartilage abnormalities in the knee joint was reported between 26% and 96%. Specificity and accuracy were reported between 50% and 100% and between 49% and 94%, respectively. The sensitivity, specificity, and accuracy for identifying early osteoarthritis were reported between 0% and 86%, 48% and 95%, and 5% and 94%, respectively. As a result of inconsistencies between imaging techniques and methodological shortcomings of many of the studies, a meta-analysis was not performed, and it was difficult to fully synthesize the information to state firm conclusions about the diagnostic performance of MRI. There is evidence in some MRI protocols that MRI is a relatively valid, sensitive, specific, accurate, and reliable clinical tool for identifying articular cartilage degeneration. Because of heterogeneity of MRI sequences, it is not possible to make definitive conclusions regarding its global clinical utility for guiding diagnosis and treatment strategies. Traumatic sports injuries to the knee may be significant precursor events to early onset of posttraumatic osteoarthritis. Magnetic resonance imaging may aid in early identification of structural injuries to articular cartilage as evidenced by articular cartilage degeneration grading.
    The American journal of sports medicine 07/2011; 39(7):1557-68. · 3.61 Impact Factor
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    ABSTRACT: Locking-plate technology has renewed interest in plate fixation for treating proximal humerus fractures. Complications associated with these devices, including loss of reduction, screw cutout, and intra-articular penetration, are frequent. Establishing a second column of support may reduce complications and improve clinical outcome scores. We asked whether addition of an endosteal cortical allograft strut, used as an augment to locking-plate fixation for displaced proximal humerus fractures, would reduce complications and improve clinical outcome scores. We retrospectively reviewed the charts and radiographs of 38 patients treated by this method. All patients were evaluated with serial radiographs, as well as the Disabilities of the Arm, Shoulder, and Hand and Constant-Murley scores. There were seven two-part, 19 three-part, and 12 four-part fractures. The minimum followup was 49 weeks (average, 75 weeks; range, 49-155 weeks). No patient had intra-articular screw penetration or cutout. No patient had complete osteonecrosis, but one had partial osteonecrosis. The reduction was lost in one patient. The mean Disabilities of the Arm, Shoulder, and Hand score was 15 (range, 0-66.4). The mean Constant-Murley score was 87 (range, 51-95). Low rates of complication and high clinical outcome scores can be achieved when treating complex proximal humerus fractures with locking-plate fixation and an endosteal strut augment. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 06/2011; 469(12):3300-6. · 2.79 Impact Factor
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    ABSTRACT: Nonunions of proximal humerus fractures can be disabling as a result of pain, deformity and instability, and are often found in geriatric patients with poor bone quality. There are relatively few studies examining the treatment of nonunions of the proximal third of the humerus and the ideal treatment and surgical approach remains unclear. This case series reports the successful use of the anterolateral acromial approach for treatment of the symptomatic proximal third humerus nonunions in a geriatric group of patients with clear challenges as a result of patient comorbidities and bone quality.
    International Journal of Shoulder Surgery 01/2011; 5(1):21-5.
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    ABSTRACT: Despite good clinical results after rotator cuff repair, follow-up studies show significant rates of failed healing. This may be because of excessive tension on the repaired tendon due to shoulder motion. We hypothesized that botulinum toxin A injections would result in improved attachment strength and collagen organization at the tendon-bone interface at early time points but may result in decreased mechanical properties at later time points because of the negative effects of stress deprivation. We performed division and repair of the supraspinatus tendon in 132 rats: 66 underwent repair alone and 66 received injections of botulinum toxin into the muscle before repair. Rats were killed at 4, 8, and 24 weeks and were evaluated by use of histologic, biomechanical, and micro-computed tomography analyses. At 4 and 24 weeks, there was no significant difference in load to failure between groups. At 8 weeks, the botulinum group had a significantly lower load to failure compared with controls (27.7 N vs 46.7 N, P < .01). The weight of the supraspinatus muscle was significantly decreased at 4 and 8 weeks in the botulinum group, but it recovered by 24 weeks. Micro-computed tomography analysis showed the botulinum group to have significantly less bone volume, total mineral content, and total mineral density at 8 weeks. Histologic analysis showed formation of a more normal tidemark and increased collagen fiber organization in the botulinum specimens at 4 weeks. Botulinum toxin A-treated specimens had increased collagen fiber organization at 4 weeks and decreased mechanical properties at later time points. The rapid healing of the rat rotator cuff likely makes it difficult to realize benefits from reduction in strain.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 12/2010; 20(5):688-97. · 1.93 Impact Factor
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    ABSTRACT: The current consensus in the literature is that the anterolateral branch of the anterior humeral circumflex artery provides the main blood supply to the humeral head. While the artery is disrupted in association with 80% of proximal humeral fractures, resultant osteonecrosis is infrequent. This inconsistency suggests a greater role for the posterior humeral circumflex artery than has been previously described. We hypothesized that the posterior humeral circumflex artery provides a greater percentage of perfusion to the humeral head than the anterior humeral circumflex artery does. In twenty-four fresh-frozen cadaver shoulders (twelve matched pairs), we cannulated the axillary artery proximal to the thoracoacromial branch and ligated the brachial artery in the forearm. In each pair, one shoulder served as a control with intact vasculature and, in the contralateral shoulder, either the anterior humeral circumflex artery or the posterior humeral circumflex artery was ligated. Gadolinium was injected through the cannulated axillary arteries, and magnetic resonance imaging was performed. After imaging, a urethane polymer was injected, and specimens were dissected. For volumetric analysis, the gadolinium uptake on the magnetic resonance imaging was quantified in each quadrant of the humeral head with use of a custom automated program. The gadolinium uptake was compared between the control and ligated sides and between the ligated anterior humeral circumflex artery and ligated posterior humeral circumflex artery groups. The posterior humeral circumflex artery provided 64% of the blood supply to the humeral head overall, whereas the anterior humeral circumflex artery supplied 36%. The posterior humeral circumflex artery also provided significantly more of the blood supply in three of the four quadrants of the humeral head. The finding that the posterior humeral circumflex artery provides 64% of the blood supply to the humeral head provides a possible explanation for the relatively low rates of osteonecrosis seen in association with displaced fractures of the proximal part of the humerus. In addition, protecting the posterior humeral circumflex artery during the surgical approach and fracture fixation may minimize loss of the blood supply to the humeral head.
    The Journal of Bone and Joint Surgery 04/2010; 92(4):943-8. · 3.23 Impact Factor
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    ABSTRACT: A technique of removing proximal humerus locking plates using an arthroscopic technique is described. Though technically demanding, benefits include smaller incisions, decreased risk of infection, and the ability to visualize and protect the axillary nerve throughout the course of the procedure. Furthermore, arthroscopy affords the surgeon with the ability to address concomitant intraarticular pathology at the time of surgery.
    Knee Surgery Sports Traumatology Arthroscopy 11/2009; 18(3):409-11. · 2.68 Impact Factor
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    Brandon Beamer, Carolyn Hettrich, Joseph Lane
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    ABSTRACT: Fractures require adequate stability and blood supply to heal. The vascular supply to long bones is compromised in a fracture, and the ability to heal hinges on the ability of new blood vessels to proliferate from surrounding vessels in a process known as angiogenesis. This process is largely driven by the growth factor, vascular endothelial growth factor (VEGF), whose levels are increased locally and systemically during fracture healing. VEGF is involved in many steps throughout the fracture healing cascade, from initially being concentrated in fracture hematoma, to the promotion of bone turnover during the final remodeling phase. This article reviews the current literature surrounding the role of VEGF and other growth factors in reestablishing vascular supply to fractured bone, as well as medications and surgical techniques that may inhibit this process.
    HSS Journal 09/2009; 6(1):85-94.
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    ABSTRACT: Recent studies have demonstrated a potentially critical role of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in the pathophysiology of rotator cuff tears. We hypothesize that local delivery of a MMP inhibitor after surgical repair of the rotator cuff will improve healing at the tendon-to-bone surface interface. Sixty-two male Sprague-Dawley rats underwent acute supraspinatus detachment and repair. In the control group (n=31), the supraspinatus was repaired to its anatomic footprint. In the experimental group (n=31), recombinant alpha-2-macroglobulin (A2M) protein, a universal MMP inhibitor, was applied at the tendon-bone interface with an identical surgical repair. Animals were sacrificed at 2 and 4 weeks for histomorphometry, immunohistochemistry, and biomechanical testing. Statistical comparisons were performed using unpaired t tests. Significance was set at P < .05. Significantly greater fibrocartilage was seen at the healing enthesis in the A2M-treated specimens compared with controls at 2 weeks (P < .05). Significantly greater collagen organization was observed in the A2M-treated animals compared with controls at 4 weeks (P < .01). A significant reduction in collagen degradation was observed at both 2 and 4 weeks in the experimental group (P < .05). Biomechanical testing revealed no significant differences in stiffness or ultimate load-to-failure. Local delivery of an MMP inhibitor is associated with distinct histologic differences at the tendon-to-bone interface after rotator cuff repair. Modulation of MMP activity after rotator cuff repair may offer a novel biologic pathway to augment tendon-to-bone healing after rotator cuff repair.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 09/2009; 19(3):384-91. · 1.93 Impact Factor
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    ABSTRACT: In spite of extensive accounts describing the blood supply to the femoral head, the prediction of avascular necrosis is elusive. Current opinion emphasises the contributions of the superior retinacular artery but may not explain the clinical outcome in many situations, including intramedullary nailing of the femur and resurfacing of the hip. We considered that significant additional contribution to the vascularity of the femoral head may exist. A total of 14 fresh-frozen hips were dissected and the medial circumflex femoral artery was cannulated in the femoral triangle. On the test side, this vessel was ligated, with the femoral head receiving its blood supply from the inferior vincular artery alone. Gadolinium contrast-enhanced MRI was then performed simultaneously on both control and test specimens. Polyurethane was injected, and gross dissection of the specimens was performed to confirm the extraosseous anatomy and the injection of contrast. The inferior vincular artery was found in every specimen and had a significant contribution to the vascularity of the femoral head. The head was divided into four quadrants: medial (0), superior (1), lateral (2) and inferior (3). In our study specimens the inferior vincular artery contributed a mean of 56% (25% to 90%) of blood flow in quadrant 0, 34% (14% to 80%) of quadrant 1, 37% (18% to 48%) of quadrant 2 and 68% (20% to 98%) in quadrant 3. Extensive intra-osseous anastomoses existed between the superior retinacular arteries, the inferior vincular artery and the subfoveal plexus.
    Journal of Bone and Joint Surgery - British Volume 02/2009; 91(1):131-7. · 2.69 Impact Factor
  • Carolyn M Hettrich, Dennis Crawford, Scott A Rodeo
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    ABSTRACT: The goal of all cartilage replacement techniques is the reformation of mature organized hyaline cartilage. However, currently cartilage repair techniques lead principally to production of fibrocartilage, which has material properties that are inferior to hyaline cartilage. Cell-based therapies such as autologous chondrocyte implantation hold promise for cartilage regeneration; however, these techniques still do not predictably result in hyaline cartilage formation. The newest, "third-generation techniques" have been developed to address the limitations of earlier techniques. These new procedures use 3 novel approaches: chondro-inductive or chondro-conductive matrix; use of allogeneic cells, both of which may allow a single-stage surgical approach; and techniques to mechanically condition the developing tissue before surgical application to improve the material properties and maturation of the implant. However, at this time there is very limited clinical data available on the nature and outcomes of these procedures.
    Sports medicine and arthroscopy review 01/2009; 16(4):230-5. · 1.16 Impact Factor
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    ABSTRACT: To assess the wound complications and reductions achieved in a cohort of patients with pilon fractures who were treated using a novel lateral approach. Retrospective review. Two level 1 trauma centers affiliated with academic institutions. All 44 fractures (in 43 patients) treated by the senior authors with open reduction and internal fixation (ORIF) using the lateral approach as the primary approach were included. Data regarding medical comorbidities, mechanism of injury, soft-tissue injury sustained during the injury, treatment, wound healing, and secondary surgeries were recorded. Fractures were classified using the AO/OTA system with most being type C3. Eighteen fractures were open injuries (10 type 3). Fracture reductions were scored using the criteria of Teeny and Wiss. Quality of articular reduction and soft-tissue healing. An anatomic or good fracture reduction was achieved in 41 fractures (93%), and a fair reduction was obtained in 3 fractures. Two patients were successfully treated for deep infection (4.5%), and 2 patients developed a wound dehiscence (4.5%). There were no amputations. Twelve patients underwent secondary surgeries (27%). Five of these were for symptomatic screw removal (related to the fibular hardware in all cases), and the sixth was for planned removal of a syndesmotic-type screw (13.6%). Four were for nonunion, representing 9% of all cases. The remaining secondary surgeries (2 cases) were performed for infection. Overall, 13.6% of patients underwent a secondary surgical procedure to address nonunion or infection. When applied in a staged fashion, the lateral surgical approach for pilon fractures provides excellent protection of the soft-tissue envelopes by creating thick flaps while allowing excellent visualization for reconstruction of the anterior and lateral distal tibia.
    Journal of Orthopaedic Trauma 10/2007; 21(8):530-7. · 1.75 Impact Factor

Publication Stats

205 Citations
47.30 Total Impact Points


  • 2009–2014
    • Hospital for Special Surgery
      • Department of Orthopaedic Surgery
      New York City, New York, United States
  • 2012–2013
    • University of Iowa
      • Department of Orthopaedics and Rehabilitation
      Iowa City, Iowa, United States
  • 2011
    • The Ohio State University
      • Sports Health and Performance Institute
      Columbus, OH, United States