[Show abstract][Hide abstract] ABSTRACT: Recent advances in diagnosis and instrumentation have facilitated the arthroscopic treatment of hip pathology. However, little has been reported on trends in the utilization of hip arthroscopy. The purpose of this study was to examine changes in the use of hip arthroscopy as reflected in the American Board of Orthopaedic Surgery (ABOS) database. We also surveyed directors of both sports and joint reconstruction fellowships to determine attitudes toward hip arthroscopy training.
The number of hip arthroscopy cases in the ABOS database during 1999 through 2009 was determined. A survey was devised to determine the type of hip arthroscopy training that was currently being offered at the fellowship level.
The number of hip arthroscopy procedures performed by ABOS candidates increased significantly from 0.02 cases per candidate in 1999 to 0.36 cases per candidate in 2009 (p < 0.0001). From 2003 through 2009, a significantly greater percentage of ABOS candidates with sports fellowship training (10.4%) than candidates without such training (2.9%) performed hip arthroscopy (p < 0.0001). During this same time period, candidates in the Northeast and Northwest performed the most hip arthroscopy procedures as a percentage of total procedures (p < 0.0001). Nearly half of the sports and joint reconstruction fellowships that included hip arthroscopy as a component of the training in 2010 had added it within the past three years. Fellows performed fewer than twenty hip arthroscopy cases per year in the majority of training programs.
The number of hip arthroscopy procedures performed by candidates taking Part II of the ABOS examination increased eighteenfold between 1999 and 2009. This increase is likely the result of several factors, including an increase in the number of programs offering training in hip arthroscopy.
The Journal of Bone and Joint Surgery 02/2012; 94(4):e23. DOI:10.2106/JBJS.J.01886 · 5.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent publications suggest that arthroscopic and open rotator cuff repairs have had comparable clinical results, although each technique has distinct advantages and disadvantages. National hospital and ambulatory surgery databases were reviewed to identify practice patterns for rotator cuff repair.
The rates of medical visits for rotator cuff pathology, and the rates of open and arthroscopic rotator cuff repair, were examined for the years 1996 and 2006 in the United States. The national incidence of rotator cuff repairs and related data were obtained from inpatient (National Hospital Discharge Survey, NHDS) and ambulatory surgery (National Survey of Ambulatory Surgery, NSAS) databases. These databases were queried with use of International Classification of Diseases, Ninth Revision (ICD-9) procedure codes for arthroscopic (ICD-9 codes 83.63 and 80.21) and open (code 83.63 without code 80.21) rotator cuff repair. We also examined where the surgery was performed (inpatient versus ambulatory surgery center) and characteristics of the patients, including age, sex, and comorbidities.
The unadjusted volume of all rotator cuff repairs increased 141% in the decade from 1996 to 2006. The unadjusted number of arthroscopic procedures increased by 600% while open repairs increased by only 34% during this time interval. There was a significant shift from inpatient to outpatient surgery (p < 0.001).
The increase in national rates of rotator cuff repair over the last decade has been dramatic, particularly for arthroscopic assisted repair.
The Journal of Bone and Joint Surgery 02/2012; 94(3):227-33. DOI:10.2106/JBJS.J.00739 · 5.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Meniscal root tears have attracted increasing interest in recent years. Fixation is an important factor for rehabilitation and avoidance of early failure. Suture fixations have been the most commonly used techniques. The current study aimed to evaluate the maximum failure load of the native meniscal roots (anteromedial, posteromedial, anterolateral, and posterolateral) and of 3 commonly used meniscal root fixation techniques (2 simple stitches, modified Kessler stitch, and loop stitch).
(1) There will be no difference in maximum failure load between the native meniscal roots. (2) The loop stitch will sustain the greatest maximum load to failure, followed by the modified Kessler stitch and the 2 simple stitches. (3) The maximum failure load of the native meniscal roots will not be restored by the tested fixation methods.
Controlled laboratory study.
The maximum failure load of the 4 human native meniscal roots was evaluated using 64 human meniscal roots. Additionally, the maximum failure load of the 3 fixation techniques was evaluated on 24 meniscal roots: (1) 2 simple stitches, (2) modified Kessler stitch, and (3) loop stitch using a suture shuttle.
The average maximum failure load of the native meniscal roots was 594 ± 241 N (anterolateral: 692 ± 304 N; posterolateral: 648 ± 140 N; anteromedial: 407 ± 180 N; posteromedial: 678 ± 200 N). The anteromedial root was significantly weaker than the posterolateral and posteromedial roots (P = .04 and P = .01, respectively). Regarding fixation techniques, the maximum failure load of the 2 simple stitches was 64.1 ± 22.5 N, the modified Kessler stitch was 142.6 ± 33.3 N, and the loop was 100.9 ± 41.6 N. None of the fixation techniques recreated the strength of the native roots.
The native anterolateral root was the strongest meniscal root, and the anteromedial root was the weakest meniscal root. Regarding primary fixation strength, the modified Kessler stitch was the strongest technique compared with the loop and the 2 simple stitches.
None of our tested fixation methods restored the strength of native meniscal roots. Thus, rehabilitation after meniscal root fixation should proceed cautiously.
The American Journal of Sports Medicine 07/2011; 39(10):2141-6. DOI:10.1177/0363546511413250 · 4.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several methods are available for fixing the femoral side of a hamstring autograft in ACL reconstruction and the best method is unclear. Biomechanical studies have shown varying results with regard to fixation failure.
We asked whether there were any differences with regard to graft failures and functional outcome measures with differing methods of femoral fixation of hamstring autografts in ACL reconstruction.
We systematically reviewed the literature using PubMed, MEDLINE, Scopus, and Cochrane Controlled Trial Register databases with regard to interference screw fixation (aperture fixation) versus noninterference screw fixation (fixation away from the joint line). A meta-analysis was performed of those studies reporting on surgical failures and postoperative International Knee Documentation Committee score. Eight studies met our inclusion criteria of Level I or II evidence.
Use of interference screws for femoral fixation resulted in a trend toward decreased risk of surgical failure (relative risk = 0.57; confidence interval, 0.1678-1.0918). When only Level I trials were evaluated, the same trend was noted toward a decreased risk of surgical failures using femoral interference screws (relative risk = 0.52; confidence interval, 0.1794-1.3122). There was no difference in postoperative International Knee Documentation Committee score with Level I and II studies (relative risk = 0.9940; confidence interval, 0.6230-1.5860) or only Level I studies (relative risk = 1.0380; confidence interval, 0.6381-1.6886).
The literature suggests a trend toward decreased surgical failures with femoral fixation at the joint line with an interference screw. However, there is no difference when postoperative functional outcomes are compared. Future studies are needed with standardized fixation methods and outcomes assessment to determine the importance of femoral fixation.
Clinical Orthopaedics and Related Research 11/2010; 469(4):1075-81. DOI:10.1007/s11999-010-1662-4 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aging is a major risk factor for tendon injury and impaired tendon healing, but the basis for these relationships remains poorly understood. Here we show that rat tendon- derived stem ⁄ progenitor cells (TSPCs) differ in both self-renewal and differentiation capability with age. The frequency of TSPCs in tendon tissues of aged animals is markedly reduced based on colony formation assays. Proliferation rate is decreased, cell cycle progression is delayed and cell fate patterns are also altered in aged TSPCs. In particular, expression of tendon lineage marker genes is reduced while adipocytic differentiation increased. Cited2, a multi-stimuli responsive transactivator involved in cell growth and senescence, is also downregulated in aged TSPCs while CD44, a matrix assembling and organizing protein implicated in tendon healing, is upregulated, suggesting that these genes participate in the control of TSPC function.
[Show abstract][Hide abstract] ABSTRACT: Femoroacetabular impingement is recognized as a cause of hip pain in young adults and as a precursor to osteoarthritis although many questions persist regarding its management. One in particular is when to resect a pincer lesion and how much to resect. Instability can result from overresection and persistent impingement can result from underresection.
We therefore determined the correlation between the change in center-edge (CE) angle and the amount of acetabular rim resection.
We performed open acetabular rim trimming on 10 cadaveric hips. Radiographs were performed before and after rim resection every millimeter from 1 to 5 mm and we determined the CE angle. We performed linear regression to establish any correlation of the CE angle with the amount of resection.
The CE angle could be predicted by -1.3X + 1.5 (R(2) = 0.99), in which X = the amount of resection for 1 to 3 mm of resection. The average CE angle before resection was 35° ± 8.8° (range, 19°-58°).
The CE angle changes in a predictable way with acetabular rim trimming with larger amounts of resection resulting in greater changes in the CE angle.
The ability to accurately plan the amount of acetabular rim resection in hip arthroscopy by knowing the exact change in CE angle with amount of rim removal may help prevent overresection or underresection in pincer trimming.
Clinical Orthopaedics and Related Research 09/2010; 469(4):1071-4. DOI:10.1007/s11999-010-1581-4 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The number of females participating in sports continues to increase. Adolescent and preadolescent females are at a risk injury to both their open growth plates as well as their joints. The purpose of this article is to review the common injuries seen with the most popular sports with females. Mt Sinai J Med 77:307-314, 2010. (c) 2010 Mount Sinai School of Medicine.
Mount Sinai Journal of Medicine A Journal of Translational and Personalized Medicine 05/2010; 77(3):307-14. DOI:10.1002/msj.20179 · 1.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of the study was to compare frequency of meniscal repair to partial meniscectomy in patients undergoing anterior cruciate ligament reconstruction using the American Board of Orthopaedic Surgeons (ABOS) database.
(1) Practice patterns are similar with respect to geographic region. (2) Surgeons with fellowship training perform more meniscal repairs compared with general orthopaedic practitioners. (3) Younger patients are more likely to be treated with meniscal repair at the time of anterior cruciate ligament reconstruction. (4) The frequency of meniscal repair in conjunction with anterior cruciate ligament reconstruction has increased over time.
Cross-sectional study; Level of evidence, 3.
Information was extracted from the ABOS database from 2002 orthopaedic surgeons who sat for the part II examination from 2003 to 2007. The database was queried for all patients who underwent anterior cruciate ligament reconstruction (Current Procedural Terminology [CPT] code 29888) without or with meniscectomy (CPT 29881) or meniscal repair (CPT 29882). Factors affecting meniscal surgery that were investigated included patient age, geographic region of practice, fellowship training, and declared subspecialty of the surgeon.
On average there were 52,000 cases per year registered in the ABOS database, approximately 1700 of whom underwent anterior cruciate ligament reconstruction. Meniscal repair was most frequently performed in the Southwest region (18.6%, P < .001) and least frequently in the Northwest region (11.3%, P < .001). Combined anterior cruciate ligament reconstruction and meniscal repair was performed significantly more often by fellowship-trained surgeons (17%) than by surgeons with other fellowship training (12%) or no fellowship training (12%, P < .001) and in patients younger than age 25 years (19%) compared with those age 40 years and older (8%, P <.001). Meniscal repair was performed in 13.9% of anterior cruciate ligament reconstructions in 2003 and in 16.4% of anterior cruciate ligament reconstructions in 2007 (P > .05).
Combined anterior cruciate ligament reconstruction with meniscal repair was more frequent for younger patients and by surgeons with sports fellowship training. Concomitant meniscal repair is performed by fellowship-trained surgeons in this study in only 18% of anterior cruciate ligament reconstructions.
The American Journal of Sports Medicine 05/2010; 38(5):918-23. DOI:10.1177/0363546509357900 · 4.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study was designed to investigate differences in recovery in male and female soccer athletes.
Soccer players with a history of concussion will perform worse on neurocognitive testing than players without a history of concussion. Furthermore, female athletes will demonstrate poorer performance on neurocognitive testing than male athletes.
Cohort study (prognosis): Level of evidence, 2.
Computer-based neuropsychological testing using reaction time, memory, and visual motor-speed composite scores of the ImPACT test battery was performed postconcussion in soccer players ranging in age from 8 to 24 years (N = 234; 141 females, 93 males). A multivariate analysis of variance was conducted to examine group differences in neurocognitive performance between male and female athletes with and without a history of concussion.
Soccer players with a history of at least 1 previous concussion performed significantly worse on ImPACT than those who had not sustained a prior concussion (F = 2.92, P =.03). In addition, female soccer players performed worse on neurocognitive testing (F = 2.72, P =.05) and also reported more symptoms (F = 20.1, P =.00001) than male soccer players. There was no significant difference in body mass index between male and female players (F =.04, P =.85).
A history of concussion and gender may account for significant differences in postconcussive neurocognitive test scores in soccer players and may play a role in determining recovery. These differences do not appear to reflect differences in mass between genders and may be related to other gender-specific factors that deserve further study.
The American Journal of Sports Medicine 06/2009; 37(9):1699-704. DOI:10.1177/0363546509332497 · 4.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As interest in double-bundle anterior cruciate ligament (ACL) reconstruction grows, we continue to refine our technique to perform the most anatomic reconstruction possible. Our experience has brought to our attention the potential mistakes that should be avoided when performing an anatomic double-bundle ACL reconstruction. These mistakes include (1) failure to visualize the femoral insertion completely, (2) use of the clock face to reference femoral tunnel positioning, (3) nonanatomic tunnel placement leading to graft impingement, (4) mismatching tibial and femoral tunnels, and (5) failure to restore the native tension pattern of the ACL. It is also important to recognize that a double-bundle ACL reconstruction is not necessarily equivalent to an anatomic double-bundle reconstruction. This article reviews potential mistakes in DB ACL reconstruction and describes our way of avoiding them.
[Show abstract][Hide abstract] ABSTRACT: This study investigated which variables influence patients' return to sports after operative fixation of an unstable ankle fracture.
Over a 5-year period, 488 patients underwent surgical repair of an unstable ankle fracture. 243 patients preoperatively identified themselves as participating in vigorous activity. Clinical evaluation, functional outcome scores, and radiographic findings were reviewed retrospectively.
At 3 months postoperatively, only 3% of all patients had returned to full sports. At 6 months, 14% of patients had returned, while at one year, only 24% of patients had returned. Younger age was predictive of return to sports by 3 months (p = 0.02), 6 months (p = 0.02) and 12 months (p = 0.0001). Males were more likely to return to sports at 6 (p = 0.001) and 12 months (p = 0.040). At 1 year, 88% of recreational athletes had returned to sports, while only 11.6% of competitive athletes had returned to sports (p = 0.043). At 12 months, bimalleolar injuries were more likely to return to sports than unimalleolar ankle fractures (p = 0.042). Furthermore, patients without an associated syndesmotic injury were more likely to return to athletic activities at 12 months (p = 0.011). A patient with an ASA of one or two was ten times more likely to return to sports versus a patient with an ASA of three or four (odds ratio > 10, p = 0.010).
Predictors of return to sporting activities at one year include younger age, male gender, no or mild systemic disease, and a less severe ankle fracture. Negative predictors include older age, female gender, and the presence of severe medical comorbidities.
[Show abstract][Hide abstract] ABSTRACT: Posterior cruciate ligament injuries occur much less frequently than anterior cruciate ligament injuries. We review the important physical examination and radiographic findings, as well as provide the indications for nonoperative and operative treatment.
Bulletin of the NYU hospital for joint diseases 02/2009; 67(1):45-51.
[Show abstract][Hide abstract] ABSTRACT: Recurrent patellar instability can result from osseous abnormalities, such as patella alta, a distance of >20 mm between the tibial tubercle and the trochlear groove, and trochlear dysplasia, or it can result from soft-tissue abnormalities, such as a torn medial patellofemoral ligament or a weakened vastus medialis obliquus. Nonoperative treatment includes physical therapy, focusing on strengthening of the gluteal muscles and the vastus medialis obliquus, and patellar taping or bracing. Acute medial-sided repair may be indicated when there is an osteochondral fracture fragment or a retinacular injury. The recent literature does not support the use of an isolated lateral release for the treatment of patellar instability. A patient with recurrent instability, with or without trochlear dysplasia, who has a normal tibial tubercle-trochlear groove distance and a normal patellar height may be a candidate for a reconstruction of the medial patellofemoral ligament with autograft or allograft. Distal realignment procedures are used in patients who have an increased tibial tubercle-trochlear groove distance or patella alta. The degree of anteriorization, distalization, and/or medialization depends on associated arthrosis of the lateral patellar facet and the presence of patella alta. Associated medial or proximal patellar chondrosis is a contraindication to distal realignment because of the potential to overload tissues that have already undergone degeneration.
The Journal of Bone and Joint Surgery 01/2009; 90(12):2751-62. DOI:10.2106/JBJS.H.00211 · 5.28 Impact Factor