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The Journal of Bone and Joint Surgery 12/2010; 92 Suppl 2:23-35. · 3.27 Impact Factor
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J.00769 J Bone Joint Surg Am. 01/2010; 92:23-35.
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ABSTRACT: Traditionally, arthroscopic management of shoulder instability has been reserved for patients with isolated Bankart lesions without any capsular laxity or injury. To date, there are no animal studies evaluating the healing potential of capsular plication and/or capsulo-labral repair. The purpose of this in vivo animal study was to determine if the histological capsular healing of an open capsular plication simulating an arthroscopic plication is equivalent to the more traditional open capsular shift involving cutting and advancing the capsule. Twenty-six skeletally mature sheep were randomized to either an open capsular plication simulating arthroscopic plication (n = 13), or an open traditional capsular shift (n = 13). A sham operation (n = 4) was also performed involving exposure to visualize the capsule. Normal non-operated control shoulders were also analyzed. A pathologist blinded to the treatment evaluated both hematoxylin and eosin (H&E) sections and polarized light microscopy. Qualitative scoring evaluated fibrosis, mucinous degeneration, fat necrosis, granuloma formation, vascularity, inflammatory infiltrate and hemosiderin (0 to 3 points). Both the capsular plication and open shift groups demonstrated healing by fibrosis at the site of surgical manipulation. There were no statistical differences in the capsular healing responses between the two groups with regard to fibrosis, granuloma formation and vascularity. The open shift group demonstrated significantly more mucinous degeneration (p = 0.038). Fat necrosis was present in 4/13 specimens in the open shift group and none in the capsular plication specimens. Both groups demonstrated disorganized collagen formation under polarized light microscopy. There were no differences between non-operated control specimens and sham surgery specimens. Our findings support the hypothesis that histologic capsular healing is equivalent between the plication group and the open shift group. In addition, the open shift group demonstrated significantly more changes indicative of tissue injury. This basic science model confirms capsular healing after simulated arthroscopic plication, providing support for arthroscopic capsular plication in practice.
The Iowa orthopaedic journal 01/2005; 25:95-101.
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ABSTRACT: Many patient-based knee-rating scales are available for the evaluation of athletic patients. However, there is little information on the measurement properties of these instruments and therefore no evidence to support the use of one questionnaire rather than another. The goal of the present study was to determine the reliability, validity, and responsiveness of four knee-rating scales commonly used for the evaluation of athletic patients: the Lysholm scale, the subjective components of the Cincinnati knee-rating system, the American Academy of Orthopaedic Surgeons sports knee-rating scale, and the Activities of Daily Living scale of the Knee Outcome Survey.
All patients in the study had a disorder of the knee and were active in sports (a Tegner score of 4 points). Forty-one patients who had a knee disorder that had stabilized and who were not receiving treatment were administered all four questionnaires at baseline and again at a mean of 5.2 days (range, two to fourteen days) later to test reliability. Forty-two patients were administered the scales at baseline and at a minimum of three months after treatment to test responsiveness. The responses of 133 patients at baseline were studied to test construct validity.
The reliability was high for all scales, with the intraclass correlation coefficient ranging from 0.88 to 0.95. As for construct validity, the correlations among the knee scales ranged from 0.70 to 0.85 and those between the knee scales and the physical component scale of the Short Form-36 (SF-36) and the patient and clinician severity ratings ranged from 0.59 to 0.77. Responsiveness, measured with the standardized response mean, ranged from 0.8 for the Cincinnati knee-rating system to 1.1 for the Activities of Daily Living scale.
All four scales satisfied our criteria for reliability, validity, and responsiveness, and all are acceptable for use in clinical research.
The Journal of Bone and Joint Surgery 11/2001; 83-A(10):1459-69. · 3.27 Impact Factor
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ABSTRACT: As the indications for shoulder arthroscopy continue to expand, so too does the need for complete access to the glenohumeral joint. Specific regions of the joint, including the axillary recess, are often times difficult to access using traditionally described posterior and anterior portals. In this article, we describe a technique for the placement of an accessory posterior portal into the inferior hemisphere of the glenohumeral joint, effectively in the 8 o'clock or 4 o'clock position. To demonstrate the safety and effectiveness of this portal, 6 cadaveric specimens were dissected after the placement of a standard and accessory posterior portal. The proximity of the posterior portals to the axillary and suprascapular nerves was analyzed. Measurements were made in simulated beach-chair and lateral decubitus positions. The authors show that the accessory posterior portal is safe to use and may prove useful to the surgeon who wishes to gain access to the inferior recesses of the glenohumeral joint.
Arthroscopy The Journal of Arthroscopic and Related Surgery 11/2001; 17(8):888-91. · 3.02 Impact Factor
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ABSTRACT: We report a clinically relevant anatomic variation of the tendon of the long head of biceps brachii muscle. The clinical and historically relevant data regarding an anatomic finding observed in 1 patient are reviewed. The clinical outcome of the patient's care was successful. Recognition of the described anatomic variant of the biceps tendon can aid the surgeon in focusing the treatment on the actual pathology and not on aberrant anatomy. Several anatomic variations in the origin of the long head of the biceps brachii have been observed. Some of these anomalies have been implicated as having a role in rotator cuff tendinopathy or in exposure for shoulder surgery. We are reporting the observation that the long head of the biceps tendon may have a mesotendon or be incorporated in the extra-articular side of the glenohumeral joint capsule, making arthroscopic visualization and assessment of the tendon difficult.
Arthroscopy The Journal of Arthroscopic and Related Surgery 10/2001; 17(7):E29. · 3.02 Impact Factor
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ABSTRACT: A review of the literature reveals that surgical treatment of coracoid impingement has heretofore involved open surgical decompression in all cases. Previously unreported, the authors describe an arthroscopic technique to treat coracoid impingement syndrome, demonstrate its feasibility, and cover the specific technical points that facilitate this procedure.
Arthroscopy The Journal of Arthroscopic and Related Surgery 10/2001; 17(7):784-7. · 3.02 Impact Factor
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ABSTRACT: The use of arthroscopic means to address shoulder instability has provided a technically advantageous way to approach Bankart lesions while posing complex questions regarding the specific indications for such an intervention. A successful outcome with arthroscopic Bankart repair is a function of proper surgical indication and patient selection. Several authors have evaluated the causes of failure and reasons for success with the Suretac device. The development of a bioabsorbable repair device at the authors' institution was precipitated by a desire to address and repair Bankart lesions arthroscopically while avoiding the frequent complications associated with the metal staple and the transglenoid suture technique. The Suretac represents the first generation of bioabsorbable transfixing devices. The initial objectives of the Suretac device were to adequately and dynamically tension soft tissue to bone, while providing a bioabsorption profile that mirrored the native healing response. The Suretac device is an appropriate surgical tool for arthroscopically repairing Bankart lesions in a carefully selected patient population.
Clinical Orthopaedics and Related Research 10/2001; · 2.53 Impact Factor
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ABSTRACT: Bone morphogenic protein-7 (BMP-7) supports ectopic cartilage and bone formation, is expressed in normal articular cartilage, and increases matrix synthesis in chondrocytes. Based on this knowledge, we hypothesized that an adenovirus (Ad) vector encoding human BMP-7 could be used to modify chondrocytes genetically to improve their capacity for cartilage repair. An adenovirus vector encoding BMP-7 (AdBMP-7) was constructed and its bioactivity confirmed by ectopic bone formation assay. AdBMP-7 modification of bovine chondrocytes induced expression of BMP-7 mRNA and bioactive protein, resulting in an increase in incorporation of 35SO4- into proteoglycan, 3H-proline uptake into protein, and the expression of the cartilage-specific matrix genes, aggrecan and type II collagen. An in vitro model of chondrocyte transplantation was used to demonstrate the feasibility of using genetically modified chondrocytes to enhance formation of cartilage-like tissue. When transplanted onto cartilage explants and maintained in vitro for 3 weeks, chondrocytes modified with AdBMP-7 formed 1.9-fold thicker tissue than chondrocytes modified with a control vector (P < 0.001). This tissue was positive for type II collagen and proteoglycan but negative for type X collagen and demonstrated a cartilage-like morphology. These observations suggest that Ad-mediated transfer of BMP-7 gene to chondrocytes enhances the chondrocyte-specific matrix synthesis and their capacity to form cartilage-like tissue, thus representing a strategy that may improve cell-based cartilage repair.
Journal of Orthopaedic Research 09/2001; 19(5):751-8. · 2.81 Impact Factor
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ABSTRACT: Patients' expectations of medical care are linked to their requests for treatment and to their assessments of outcome and satisfaction. Our goals were to measure patients" preoperative expectations of knee surgery and to develop and test patient-derived knee expectations surveys.
An initial sample of 377 patients (mean age, 54.6 18.2 years; 52% women) was enrolled in the survey-development phase. One hundred and sixty-one (43%) of these patients subsequently underwent total knee arthroplasty; seventy-five (20%), cruciate ligament repair; eighty-five (23%), meniscal surgery; and fifty-six (15%), surgery for another knee condition. Preoperatively, these patients were asked open-ended questions about their expectations of knee surgery. Their responses were grouped with use of qualitative research techniques to generate categories of expectations. Categories were transformed into specific questions and were formatted into two draft surveys, one for patients undergoing total knee arthroplasty and one for patients undergoing other surgical procedures on the knee. A second sample of 163 patients (mean age, 55.1 17.5 years; 49% women) was enrolled in the survey-testing phase, and they completed the draft surveys on two separate occasions to establish test-retest reliability. Items were selected for the final surveys if they were cited by 5% of the patients, if they represented important functional changes resulting from surgery, or if they represented potentially unrealistic expectations. All selected items fulfilled reliability criteria, defined as a kappa (or weighted kappa) value of 0.4, or were deemed to be clinically relevant by a panel of orthopaedic surgeons.
From the survey-development phase, a total of fifty-two categories of expectations were discerned; they included both anticipated items such as pain relief and improvement in walking ability and unanticipated items such as improving psychological well-being. Expectations varied by diagnosis and patient characteristics, including functional status. Two final surveys were generated: the seventeen-item Hospital for Special Surgery Knee Replacement Expectations Survey and the twenty-item Hospital for Special Surgery Knee Surgery Expectations Survey. Each required less than five minutes to complete.
Patients have multiple expectations of knee surgery in the areas of symptom relief and improvement of physical and psychosocial function, and these expectations vary according to the diagnosis. We developed two valid and reliable surveys that can be used preoperatively to direct patient education and shared decision-making and to provide a framework for setting reasonable goals. Reexamining patients' responses postoperatively could provide a way to assess fulfillment of expectations, which is a crucial patient-derived measure of outcome and satisfaction.
The Journal of Bone and Joint Surgery 08/2001; 83-A(7):1005-12. · 3.27 Impact Factor
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ABSTRACT: Nitric oxide (NO*) is a multifunctional messenger molecule generated by a family of enzymes called the nitric oxide synthases (NOSs). Although NOSs have been identified in skeletal muscle, specifically brain NOS (bNOS) and endothelial NOS (eNOS), their role has not been well clarified. The goals of this investigation were to (1) characterize the immunoreactivity, Ca(2+) dependence, and activity of NOS in human and rat skeletal muscle and (2) using a rat model, investigate the effect of chronic blockade of NOS on skeletal muscle structure and function. Our results showed that both human and rodent skeletal muscle had NOS activity. This NOS activity was similar to that of the endothelial and brain NOS isoforms in that it was calcium-dependent. However, Western blot analysis consistently showed that a polyclonal antibody raised against a peptide sequence of human inducible NOS (iNOS) reacted with a protein with a molecular weight (95 kDa) that was different from that of other NOS isoforms. RT-PCR analysis identified the mRNA expression of not only eNOS and bNOS but also iNOS in human and rat muscle. Inhibition of nitric oxide synthase in rats with N(omega)-nitro-L-arginine methyl ester (L-NAME) resulted in a progressive, severe reduction in walking speed (30-fold reduction in walking velocity at day 22, P < 0.001), muscle fiber cross-sectional area (40% reduction at day 22, P < 0.001), and muscle mass (40% reduction in dry weight at day 22, P < 0.01). Rats fed the same regimen of the enantiomer of L-NAME (d-NAME) had normal motor function, muscle fiber morphology, and muscle mass. Taken together, these results imply that there may be a novel nitric oxide synthase in muscle and that NO. generated from muscle may be important in muscle function.
Nitric Oxide 06/2001; 5(3):219-32. · 3.55 Impact Factor
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ABSTRACT: Microfracture (MFX) and Autologous Chondrocyte Implantation (ACI) have been utilized in an effort to promote the regeneration of articular cartilage in the knee. The purpose of this study is first, to determine which of these two treatments yields the best clinical results and, second, to determine whether the MR appearance of treated cartilage lesions correlates with clinical outcome. Thirty-five patients with isolated articular cartilage lesions of the medial femoral condyle (MFC) were treated either with ACI (17 patients) or with MFX (18 patients, 19 knees). Patients were evaluated clinically using the modified Cincinnati Knee Questionnaire and with a physical exam. MRs were graded using eight different criteria: an MR score of 100% represents normal cartilage. The average follow-up was 2,6 years for the ACI group and 2,8 years for the MFX group. The average size of the lesion was 472 mm2 for the ACI group and 326mm2 for the MFX group. The Cincinnati scores improves an average of 22% for the ACI patients and 42% for the MFX patients from preoperatively to postoperatively. The average MR score was 66% for the ACI group and 44% for the MFX group. Fifty-nine percent of the ACI patients required at least one additional procedure. This is the first clinical and MR comparison of ACI and MFX to treat full thickness cartilage lesions of the MFC. Clinical improvement was 2 times greater for the MFX patients compared to the ACI patients. The MR scores did not correlate with clinical outcome using our grading system.
Ortopedia, traumatologia, rehabilitacja 05/2001; 3(2):224-6.
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ABSTRACT: The purpose of this study is to better understand the function of the popliteomeniscal fasciculi and their relationship to the popliteus tendon and the lateral meniscus by describing these structures during embryonic development.
Anatomic dissection and histologic evaluation.
Twelve fresh-frozen lower extremity specimens (6 paired limbs) from second and third trimester human fetuses were obtained from spontaneous abortions. Each specimen was fixed in formalin and decalcified in 9.0% nitric oxide. The specimens were prepared by removal of all skin and most of the soft tissues before dissection of the lateral meniscus, parts of the posterolateral joint capsule, and the popliteus tendon and muscle. The right-side specimens were sectioned in the transverse plane, and the left-side specimens in the coronal plane. Histologic sections were prepared with H&E and Masson's trichrome stains. Light microscopy was used to evaluate the lateral meniscal attachment, with detailed attention to the popliteomeniscal fasciculi.
The close interrelationship of lateral meniscus and popliteus tendon, especially during embryologic development, does give a better understanding how the fasciculi stabilize the lateral meniscus and allow the popliteus tendon to function as a retractor of the lateral meniscus. The fasciculi consist of 3 layers including a dense collagen layer, a vascular layer, and a synovial or capsular layer.
During embryologic development, the fasciculi appeared to provide a vascular supply to the lateral meniscus adjacent to the popliteal hiatus where the meniscus is devoid of capsular attachments.
Arthroscopy The Journal of Arthroscopic and Related Surgery 01/2001; 17(1):14-8. · 3.02 Impact Factor
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ABSTRACT: This case report presents chondral damage associated with a resorbable meniscal repair implant. Although the devices may not have been inserted properly, surgeons using these implants should be aware of the potential severe chondral injury that may occur.
Arthroscopy The Journal of Arthroscopic and Related Surgery 11/2000; 16(7):749-53. · 3.02 Impact Factor
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ABSTRACT: Little is known about the biology of meniscal allograft transplantation in humans. In particular, little information is available about the phenotype of the cells that repopulate the allograft, whether an immune response is elicited against the graft, and whether the repopulating cells synthesize normal extracellular matrix components.
A small biopsy specimen of the meniscal allograft (twenty-eight menisci in twenty-five patients) and the adjacent synovial membrane (sixteen patients) was harvested during follow-up arthroscopy in patients who had undergone meniscal allograft transplantation at a mean of sixteen months earlier. Seventeen patients had undergone concomitant reconstruction of the anterior cruciate ligament with an allograft. Normal menisci (unimplanted allografts) and synovial specimens from age-matched controls were examined as well. All twenty-eight meniscal allografts were examined histologically. Immunohistochemical analysis was carried out on ten menisci and nine synovial specimens with use of monoclonal antibodies to class-I and class-II major histocompatibility complex antigens, CD-8, CD-11b, and CD-19 epitopes, as well as other epitopes, to demonstrate immunogenic macromolecules, cytotoxic T-lymphocytes, activated macrophages, and B-lymphocytes.
Most of the specimens demonstrated incomplete repopulation with viable cells. The repopulating cells stained positively with phenotype markers for both synovial cells and fibroblasts. Polarized light microscopy demonstrated evidence of active remodeling of the matrix. The cells in frozen, unimplanted menisci stained positively for class-I and class-II human leukocyte antigens, indicating immunogenicity at the time of transplantation. Overall, nine of twelve specimens contained immunoreactive cells (B-lymphocytes or cytotoxic T-cells) in the meniscus or synovial tissue. However, only a small number of these cells was present. There was no evidence of frank immunological rejection. The clinical outcome (success or failure of the transplant) was not related to the overall histological score or to the presence of an immune response in the meniscal or synovial biopsy specimen.
Human meniscal allograft transplants are repopulated with cells that appear to be derived from the synovial membrane; these cells appear to actively remodel the matrix. Although there is histological evidence of an immune response directed against the transplant, this response does not appear to affect the clinical outcome. The presence of histocompatibility antigens on the meniscal surface at the time of transplantation (even after freezing) indicates the potential for an immune response against the transplant.
Despite the absence of frank immunological rejection, a subtle immune reaction may affect the healing, incorporation, and revascularization of the graft. It is possible that the structural remodeling associated with cellular repopulation may render the meniscus more susceptible to injury.
The Journal of Bone and Joint Surgery 09/2000; 82-A(8):1071-82. · 3.27 Impact Factor
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ABSTRACT: Tissue engineering, a relatively new field of research, was born as a result of a search for solutions to the limited alternatives currently used to replace structure and function lost because of failure or loss of tissues throughout the body. The field merges advances in cell biology, growth factor therapy, and material design. It encourages creation of tissue-engineered menisci for repair and replacement therapy and offers a means for developing a better understanding of meniscal cell and matrix biology.
Orthopedic Clinics of North America 08/2000; 31(3):411-8. · 1.25 Impact Factor
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ABSTRACT: Repair or resection of meniscal injuries is one of the most common operative procedures in orthopedics today. A variety of techniques for reconstruction have been attempted and experts are still unsure which treatment of meniscal lesions is best. This article reviews different techniques of meniscal repair and some novel approaches that may be used for treatment of meniscal lesions in the coming years.
Orthopedic Clinics of North America 08/2000; 31(3):419-36. · 1.25 Impact Factor
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ABSTRACT: The efficacy of anterior cruciate ligament (ACL) reconstruction in the knee using hamstring tendon or patellar tendon grafts is thought to depend on the relative amounts of graft elongation, or creep, following postoperative rehabilitation. In this study, the creep responses of the tendinous portions of these two graft types were compared during 1 hour of cyclic loading to 200 N at 1 Hz. In the hamstring tendon grafts, strains were measured in both the tissue and in the length-augmentation tape to identify the relative contribution of this particular graft fixation to overall creep. Differences in tissue strain between graft types during cyclic loading were not statistically significant. For both types of grafts, overall graft length significantly increased after 3600 cycles while tissue creep was not significant. The greatest creep in the hamstring tendon grafts occurred at the tissue-tape interface, indicating a potential disadvantage of this composite graft construct.
The American journal of knee surgery 02/2000; 13(1):8-12.
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ABSTRACT: Brachial neuritis is a rare disorder of unknown etiology that causes pain and weakness of the shoulder and upper extremity. There have been many descriptions of the disorder in the literature. The classic symptoms begin with an acute onset of sharp pain in the shoulder girdle. As the pain subsides, weakness occurs. The diagnosis often is difficult to make in the acute setting. Diagnostic tests typically are not helpful, although electromyography may be useful. The treatment is chiefly supportive with analgesics initially followed by range of motion exercises. Full functional recovery is expected in most patients, although the interval may be protracted. Understanding the disorder of brachial neuritis and its course will assist in the diagnosis and treatment.
Clinical Orthopaedics and Related Research 11/1999; · 2.53 Impact Factor
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ABSTRACT: A method for measuring the expression of integrin subunits on the cell surface of knee ligament fibroblasts was developed with use of flow cytometry and immunofluorescence. The ligament cells exhibited uniform size and density, as shown by forward and side-scatter properties, and showed minimal nonspecific binding of isotype control antibodies compared with unstained cells. All cells expressed the alpha5 integrin subunit; lateral collateral ligament cells stained with antibody to alpha5 showed a mean fluorescence intensity 2-fold higher than that of medial collateral ligament cells, 1.5-fold higher than that of posterior cruciate ligament cells, and 3-fold higher than that of anterior cruciate ligament cells, indicating a greater expression of the alpha5 subunit by lateral collateral ligament cells than by medial collateral, posterior cruciate, and anterior cruciate ligament cells. All cells expressed the beta1 integrin subunit; the expression by posterior cruciate ligament cells was 3-fold higher than that by medial collateral ligament or lateral collateral ligament cells and 5-fold higher than that by anterior cruciate ligament cells. All cells expressed the beta3 integrin subunit; the expression by posterior cruciate ligament cells was 1.5, 3, and 4.5-fold greater than that by lateral collateral, anterior cruciate, and medial collateral ligament cells, respectively. Our data suggest there is a differential expression of integrin subunits in knee ligament fibroblasts, and this in part may explain differences in their attachment and adherence to extracellular matrix molecules.
Journal of Orthopaedic Research 10/1999; 17(5):748-54. · 2.81 Impact Factor
