Cathy Buyea

Which Method of Rotator Cuff Repair Leads to the Highest Rate of Structural Healing? A Systematic Review

Background The purpose of rotator cuff repair is to diminish pain and restore function, and this most predictably occurs when the tendon is demonstrated to heal. Recent improvements in repair methods have led to improved biomechanical performance, but this has not yet been demonstrated to result in higher healing rates. The purpose of our study was to determine whether different repair methods resulted in different rates of recurrent tearing after surgery. Hypotheses We hypothesized that (1) the rotator cuff repair method will not affect retear rate, and (2) the surgical approach will not affect the retear rate for a given repair method. Study Design Systematic review of the literature. Methods The literature was systematically searched to find articles reporting imaging study assessment of structural healing rates after rotator cuff repair, with data stratified according to tear size. Retear rates were compared for transosseous (TO), single-row suture anchor (SA), double-row suture anchor (DA), and suture bridge (SB) repair methods, as well as for open (O), miniopen (MO), and arthroscopic (A) approaches. Results Retear rates were available for 1252 repairs collected from 23 studies. Retear rates were significantly lower for double-row repairs when compared with TO or SA for all tears greater than 1 cm and ranged from 7% for tears less than 1 cm to 41% for tears greater than 5 cm, in comparison with retear rates for single-row techniques (TO and SA) of 17% to 69% for tears less than 1 cm and greater than 5 cm, respectively. There was no significant difference in retear rates between TO and SA repair methods or between arthroscopic and nonarthroscopic approaches for any tear size. Conclusion Double-row repair methods lead to significantly lower retear rates when compared with single-row methods for tears greater than 1 cm. Surgical approach has no significant effect on retear rate.

Current trends in anterior cruciate ligament reconstruction.

In 2006, a survey regarding anterior cruciate ligament (ACL) reconstruction was mailed to physician members of the American Orthopaedic Society for Sports Medicine. A total of 993 responses were received from 1747 possible respondents (57%). The number of ACL reconstructions per year ranged from 1 to 275 (mean=55). The most important factors in the timing of surgery were knee range of motion and effusion. Bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%). Five years earlier, BPTB grafts were more frequent and hamstring tendon and allografts were less frequent (63%, 25%, and 12%, respectively). A single-incision arthroscopic technique was used by 90%. Most allowed return to full activity at 5 to 6 months, with a trend toward earlier return for BPTB grafts; quadriceps strength was an important factor in the decision. There was limited experience (4%) with double-bundle and computer-assisted ACL reconstruction. Arthroscopic-assisted, single-incision reconstruction using a BPTB autograft fixed with metal interference screws remains the most common technique used for primary ACL reconstruction. In the past 5 years, the use of alternative graft sources and methods of fixation has increased. Consensus regarding the best graft type, fixation method, and postoperative protocol is still lacking.

Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series.

Donor site morbidity and complication rate using the reamer-irrigator-aspirator (RIA) system for intramedullary, non-structural autogenous bone graft harvesting were investigated in a retrospective chart and radiographic review at a University affiliated Level-1 Trauma Centre. 204 RIA procedures in 184 patients were performed between 1/1/2007 and 12/31/2010. RIA-indication was bone graft harvesting in 201 (98.5%), and intramedullary irrigation and debridement in 3 (1.5%) cases. Donor sites were: femur - antegrade 175, retrograde 4, tibia - antegrade 7, retrograde 18. Sixteen patients had undergone two RIA procedures, two had undergone three procedures, all using different donor sites. In 4 cases, same bone harvesting was done twice. Mean volume of bone graft harvested was 47 ± 22ml (20-85 ml). The complication rate was 1.96% (N=4). Operative revisions included 2 retrograde femoral nails for supracondylar femur fractures 6 and 41 days postoperatively (antegrade femoral RIA), 1 trochanteric entry femoral nail (subtrochanteric fracture) 17 days postoperatively (retrograde femoral RIA) and 1 prophylactic stabilization with a trochanteric entry femoral nail for intraoperative posterior femoral cortex penetration without fracture. In our centre, the RIA technique has a low donor site morbidity and has been successfully implemented for harvesting large volumes of nonstructural autogenous bone graft.

Is It Safe to Perform Aggressive Rehabilitation After Distal Biceps Tendon Repair Using the Modified 2-Incision Approach? A Biomechanical Study

Background Despite improved methods of fixation, there is still a delay in early active motion after distal biceps repair. Hypothesis Distal biceps repairs using the modified 2-incision technique can be treated with early motion, and there is no difference in the cyclic performance of Ethibond and Fiberwire when used for the repair. Study Design Controlled laboratory study. Methods Nine matched pairs of cadaveric elbows had release of the distal biceps followed by repair with either No. 5 Ethibond or Fiberwire through a bone tunnel. The repairs were cyclically loaded for 3000 cycles (1000 cycles from 10-50 N, 1000 cycles from 10-75 N, 1000 cycles from 10-100 N) followed by single-load displacement to failure in surviving specimens. Results There was no difference in the displacement or stiffness between surviving repairs at any point measured. Ethibond repairs survived significantly more cycles than did Fiberwire repairs, particularly at higher loads. Conclusion Distal biceps repair using the 2-incision technique with Ethibond should allow early active motion, but early active motion may not be possible with Fiberwire.

Use of audiotapes for patient education, medical record documentation, and informed consent in lower extremity reconstruction.

Since 1992, the authors have audiotaped each new patient visit and provided a copy of that tape to the patient. In addition, an office copy of the entire patient interaction is maintained in an office file. One hundred twelve patients seen over a 6-month period participated in a survey measuring their satisfaction with this procedure, and six attorneys were surveyed after listening to a representative tape. Ninety percent of patients had positive comments about receiving the tape. Seventy percent played the tape for others, most commonly their spouses. The attorneys concluded the patient was well served by this process, and there were no increased malpractice issues or exposure. The cost of providing patients with the tapes is minimal, and the high level of patient satisfaction and increased understanding offer a considerable benefit to patients and office staff.

3D bone microarchitecture modeling and fracture risk prediction

As prevalence and awareness of osteoporosis increase and treatments of proven efficacy become available, the demand for management of patients with the disease will also rise. It calls for innovative research on understanding of osteoporosis and fracture mechanisms, allowing early and more accurate prediction of bone disease progression. The most widely validated technique for the diagnosis of osteoporosis is Bone Mineral Density (BMD) measurement based on dual energy X-ray absorptiometry (DXA). However, a major limitation of BMD is that it incompletely reflects the variation in bone strength. In this paper we develop and evaluate a novel three-dimensional (3D) computational bone framework capable of providing: (1) Spatio-temporal 3D microstructure bone model; (2) Derived quantitative measures of 3D bone microarchitecture; (3) Analysis of BMD and bone strength; and (4) A state-of-the-art probabilistic approach to analyze bone fracture risk factors including demographic attributes and life styles. Beyond efficient 3D bone microstructure representation, quantitative assessment is considered not only for identifying critical elements in bone microstructure, but also ensuring effective predictioin of bone diseases in advance. The simulation network model of 3D bone microarchitecture and extensive empirical study on fracture risk improve our understanding of bone disease risk arising from the complex interplay of the human BMD assessment result with presence of major risk factors.

A virtual interactive navigation system for orthopaedic surgical interventions

Background and Objective: In the last decade, the field of medicine has ingressed into a new era of technological advancements, driven by an ever increasing demand to reduce patient costs and risks, improve patient safety, efficiency, and surgical outcomes. The need for alternative ways of training and surgery is stronger than ever. Virtual reality based training and surgery systems hold significant promise in this direction. However, development of realistic virtual surgery systems for invasive orthopaedic surgical procedures remains one of the most challenging problems in the field of virtual reality based surgery and training because of the involvement of complex musculoskeletal structures and surgical tools. In recent years, some advances have been made in this area but they have limited practical scope because of their support for small range of procedures and training scenarios. The tools developed so far are either restricted in their ability or follow non patient-centric approaches and hence, cannot be considered viable alternatives to the conventional techniques for invasive orthopaedic surgery and training. In this paper, we discuss the challenges and complexities associated with the development of a virtual reality based system for orthopaedic training and surgery, and present our image guidance based navigation system, developed as part of our ongoing research initiative to build a comprehensive tool for realistic virtual orthopedic surgery and training. Methods: Our image guidance based interactive navigation system provides a common interface for the assembly of different components crucial for a realistic virtual reality based training and surgery application. Presently, the system incorporates various features including rigid body registration, patient-specific three-dimensional model generation, two-dimensional and three-dimensional interactive visualizations, and real time intraoperative surgical guidance. In this paper, we outline the details of our present system along with its key features. Results: A preliminary version of our proposed virtual reality based orthopaedic training and surgery navigation system is presented. To demonstrate the applicability of our system, a sample application showing the anatomically detailed three -dimensional representations of a patients knee, derived from the pre-operative image scans, along with the corresponding two-dimensional image details is presented. To the best of our knowledge, this is the first attempt that constructs and integrates patient-specific, anatomically correct, and comprehensive three-dimensional models, with all possible soft tissue details, to provide patient-specific visualization and training capabilities. Preliminary feedback by the orthopaedic surgeons on the prototype of our system is very encouraging and pin points some additional features that can further strengthen the efficacy of our tool and its clinical adoption. Conclusion: A comprehensive virtual reality based navigation system for orthopaedic training and surgery is presented. The system utilizes patient-specific two-dimensional image modalities and provides corresponding two-dimensional and three-dimensional, interactive visualization capabilities along with realtime tracking of surgical instruments. The present system can be used as an effective tool for anatomy education, surgical planning, diagnosis, and real-time intra-operative surgical navigation. Additional components such as haptics and real-time tissue deformations are currently under development and will soon be integrated with this platform.