Sudheer Reddy

The Morbidity Associated With Osteochondral Harvest From Asymptomatic Knees for the Treatment of Osteochondral Lesions of the Talus

Background Mosaic autogenous osteochondral transplantation has been used to treat large osteochondral defects. Hypothesis There is potential, previously unrecognized donor-site morbidity associated with osteochondral harvest from asymptomatic knees for the treatment of talar osteochondral defect lesions. Study Design Case series; Level of evidence, 4. Methods Fifteen patients underwent mosaic osteochondral transplantation to treat a talar osteochondral defect lesion, with 11 patients available for follow-up. A Lysholm knee score was used to assess donor-site morbidity at a mean follow-up of 47 months (range, 7-77 months). Mean age was 29 years (range, 21-44 years). A single surgical team performed the mosaicplasties. Significance was determined using the Student t test. Results All patients had asymptomatic knees preoperatively. Mean postoperative Lysholm score was 81 (range, 49-100). By Lysholm criteria, 5 rated as excellent, 2 as good, and 4 as poor. No significant difference was detected in terms of the harvest method or the number of grafts obtained from those having an excellent rating versus those having a good/poor rating. Patients rated as good/poor cited knee instability in daily activities as the most common problem. One had knee pain and patellar instability after osteochondral harvest by lateral arthrotomy that required a subsequent lateral retinacular release and tibial tubercle osteotomy. Conclusion This study demonstrates that donor-site morbidity after osteochondral harvest can be significant. In this population, those who experienced a decline in knee function had problems performing activities of daily living. When performing these procedures, the authors recommend that surgeons consider these risks and discuss them with their patients.

Operative Treatment for Peroneal Tendon Disorders

Peroneal tendon disorders are rare, are frequently missed, and can be a source of lateral ankle pain. Magnetic resonance imaging is the standard method of radiographic evaluation of peroneal tendon disorders; however, diagnosis and treatment are based primarily on the history and physical examination. Peroneal tenosynovitis typically responds to conservative therapy, and operative treatment is reserved for refractory cases. Operative treatment is frequently required for peroneal tendon subluxation and consists of anatomic repair or reconstruction of the superior peroneal retinaculum with or without deepening of the retromalleolar groove. Operative treatment of peroneal tendon tears is based on the amount of remaining viable tendon. Primary repair and tubularization is indicated for tears involving <50% of the tendon, and tenodesis is indicated for tears involving >50% of the tendon.

After rotator cuff repair, stiffness—but not the loss in range of motion—increased transiently for immobilized shoulders in a rat model

Although rotator cuff repair is often successful at relieving pain, the repaired insertion site frequently fails. Mechanical properties of the repair improved when the shoulder was immobilized in an animal model, but joint stiffness and range of motion were not evaluated. The objective of this study was to measure rotational mechanics before and after shoulders were immobilized after cuff injury and repair, not immobilized after cuff injury and repair, and immobilized without injury and repair. Humeral rotation was significantly less 4 and 8 weeks after injury and repair but did not decrease significantly when the injured and repaired shoulder was immobilized. Rotational stiffness increased significantly 4 and 8 weeks after injury and repair and was significantly greater at 4, but not 8, weeks when the injured and repaired shoulders were immobilized. This study demonstrated that the increase in joint stiffness caused by immobilizing an injured and repaired shoulder was transient and, therefore, does not outweigh the long-term benefits of immobilization on improved tendon to bone healing.

Prophylactic Bracing Decreases Ankle Injuries in Collegiate Female Volleyball Players

Background Ankle injuries account for the highest percentage of injuries among female collegiate volleyball players. Since 1998, all female volleyball players at the authors’ institution have worn bilateral double-upright padded ankle braces at all times. Purpose To review the authors’ experience with this brace in preventing ankle injuries that result in a loss of play. Study Design Case series; Level of evidence, 4. Methods Injury data, preparticipation medical histories, and total exposure data were collected prospectively on all female volleyball players at the authors’ institution from 1998 to 2005. Injuries and exposures were defined based on established National Collegiate Athletic Association Injury Surveillance System criteria. Injury rate was calculated as the number of injuries per 1000 exposures. The National Collegiate Athletic Association female volleyball injury data from 1998 to 2005 were used for comparison. Results During the study period, there were a total of 13 500 exposures and 1 injury in our group yielding an injury rate of 0.07 per 1000 exposures. Nearly half of our athletes had a preparticipation history of ankle sprains, yet only 1 ankle injury occurred during all of our braced exposures. Conclusion There were 811 710 exposures and 797 injuries in the National Collegiate Athletic Association comparison group with an increased injury rate of 0.98 per 1000 exposures (P = .001). Prophylactic use of a double-upright ankle brace significantly reduced the ankle injury rate compared with that reported by the National Collegiate Athletic Association. From these data, it appears that the use of such a brace is an effective way to decrease the incidence of ankle injuries in this active but vulnerable group of athletes.

Correction of Moderate to Severe Coronal Plane Deformity with the STAR™ Ankle Prosthesis

Background: Prior studies have demonstrated a correlation between the degree of preoperative coronal plane deformity and failure following ankle replacement. We reviewed all of our patients who underwent ankle replacement utilizing the STAR™ prosthesis from 2000 to 2009 to evaluate the outcome of those with moderate (10 to 19 degrees) and severe (20 degrees or greater) coronal plane deformity. Materials and Methods: Out of 130 consecutive patients, 43 patients had at least 10 degrees of preoperative coronal plane deformity. Twenty-five ankles had 10 to 19 degrees degrees of deformity and 18 ankles had 20 degrees or greater deformity. Average age was 66 years. Average length of followup was 41 (range, 12 to 98) months. Results: Average talar preoperative deformity was 17.9 (range, 10 to 29) degrees, while average initial talar postoperative deformity was 3.5 (range, 0 to 12) degrees. Average final talar postoperative deformity was 4.7 (range, 0 to 14) degrees. Preoperative and final correction of deformity was statistically significant (p < 0.01), but there was no significant difference between initial and final postoperative correction. Overall, recurrence of the preoperative coronal plane deformity occurred in six of 43 patients (14%). All three patients who had deformities over 25 degrees developed recurrences. Correction of the coronal plane deformities was achieved by using intraoperative soft-tissue balancing, including deltoid ligament release in 12 patients and lateral ligament reconstruction in one patient. Deltoid ligament release was found to be necessary for all patients with greater than 18 degrees of varus plane deformity. Conclusion: Correction of moderate to severe coronal plane deformity with the STAR™ prosthesis was achievable with only soft-tissue balancing procedures with predictable results especially for deformities less than 25 degrees. Level of Evidence: IV, Retrospective Case Series

Effect of interleukin-10 overexpression on the properties of healing tendon in a murine patellar tendon model.

PURPOSE Interleukin-10 (IL-10) is a potent anti-inflammatory cytokine shown to inhibit scar formation in fetal wound healing. The role of IL-10 in adult tendon healing and scar formation, however, remains unknown. The objective of this study is to investigate the effect of IL-10 overexpression on the properties of adult healing tendon using a well-established murine model of tendon injury and a lentiviral-mediated method of IL-10 overexpression. METHODS A murine model of patellar tendon injury was used and animals divided into 3 groups. Mice received bilateral patellar tendon injections with a lentiviral vector containing an IL-10 transgene (n = 34) or no transgene (n = 34). Control mice (n = 34) received injections of sterile saline. All animals then were subjected to bilateral, central patellar tendon injuries 2 days after injection and were killed at 5, 10, 21, and 42 days after injury. IL-10 content was analyzed by immunohistochemistry (n = 4/group). Tendon healing was evaluated by histology (n = 4/group) and biomechanical analysis (n = 10/group). RESULTS Overexpression of IL-10 in patellar tendon was confirmed after injection of the lentiviral vector. IL-10 immunostaining was increased at day 10 in the IL-10 group relative to that in controls. Histologically, there was no significant difference in angular deviation between groups at day 21, but a trend toward decreased angular deviation in controls relative to that in empty vector group mice was seen at day 42. Biomechanically, the IL-10 group showed significantly increased maximum stress at day 42 relative to that in controls. Percent relaxation showed a trend toward an increase at day 10 and a significant increase at day 42 in the IL-10 group relative to that in controls. CONCLUSIONS This study demonstrates successful gene transfer of IL-10 into adult murine patellar tendon using a lentiviral vector. Although the effects of overexpression of IL-10 on adult tendon healing have not yet been fully elucidated, the current study may help to further clarify the mechanisms of tendon injury and repair.

Fixation Techniques for Split Anterior Tibialis Transfer in Spastic Equinovarus Feet

Equinovarus of the foot is the most common lower extremity deformity following traumatic brain injury. We evaluated outcomes of the split anterior tibialis tendon transfer (SPLATT) for correction of equinovarus in 47 patients with hemiplegic traumatic brain injury and specifically studied differences in outcomes with two tendon fixation techniques. Seventeen patients constituting Group I underwent fixation with one technique and 30 constituting Group II had another technique. Patients in both groups had appropriate procedures based on dynamic electromyography and gait analyses. Both groups were demographically comparable. All 47 feet were corrected to plantigrade position. Thirty-six of 47 patients became brace-free at final followup. There was a notable decrease in the use of ambulatory aids and ambulatory status improved in both groups. There were three fixation-related complications in Group I and none in Group II. Surgical correction of the spastic equinovarus with SPLATT, in the appropriate patient, with or without associated tendon procedures helps to achieve and maintain correction, improves the ambulatory status of the patient, and eliminates the need for bracing in as much as 77% of patients. We recommend the Group II construct owing to the considerably lower complication rate.Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The correction of pelvic obliquity in patients with cerebral palsy and neuromuscular scoliosis: is there a benefit of anterior release prior to posterior spinal arthrodesis?

Study Design. A retrospective study of 61 patients with cerebral palsy (CP) and neuromuscular scoliosis treated by either a combined anterior-posterior spinal arthrodesis or a posterior-only arthrodesis with the unit rod. Objectives. Compare coronal and sagittal plane radiographic outcomes in patients undergoing either a combined anterior-posterior spinal fusion (PSF) or a posterior-only fusion with the unit rod for neuromuscular scoliosis in patients with CP. Summary of Background Data. Although an anterior release before posterior spinal arthrodesis is commonly done for larger and stiffer neuromuscular curves, it is unclear whether or not an all-posterior construct produces similar correction in pelvic obliquity as that seen with an anterior-posterior spinal fusion. Methods. Sixty-one consecutive children with CP and scoliosis were treated at a single institution between 1991 and 2003 with PSF using the unit rod with an anterior release (group A: 19 patients; average = 14.4 years) or without an anterior release (group B: 42 patients; average = 13.7 years). Side-bending, AP, and lateral radiographs were used to assess various sagittal and coronal plane parameters at baseline, after surgery, and at 2 years. Results. Before surgery, group A had larger major curves (91°A vs. 72°B; P = 0.001), less flexible major curves (21% A vs. 40% B; P = 0.01), with greater pelvic obliquity (26°A vs. 19°B, P = 0.02) than group B. In the subset of patients with a more severe preoperative pelvic obliquity (>20°), percent correction in pelvic obliquity was equivalent between groups A (71%) and B (74%, P = 0.91). With respect to coronal and sagittal plane radiographic outcomes, there were no significant group differences in major curve correction (58% A vs. 60% B), but group A trended toward greater % correction from preop bending films. At most recent follow-up, there were no differences with respect to loss of curve correction (7.6 A vs. 8.1°B, P = 0.80). The rate of major complications was 26% for both groups, but group A patients had significantly longer operative times. Conclusion. We demonstrate that excellent correction in severe pelvic obliquity can be achieved in smaller, more flexible curves using an all-posterior PSF, and in larger, less flexible curves using an anterior release with PSF.

Cervical spine fracture-dislocation birth injury: prevention, recognition, and implications for the orthopaedic surgeon.

Spinal cord birth injury is rare, and orthopaedic surgeons infrequently encounter it. The injury is associated with hyperextension of the fetal head in utero and during delivery and with forceps-assisted breech vaginal deliveries. These cervical spinal cord injures may be complete or partial. They most commonly occur in the absence of bony injury, which can lead to diagnostic difficulties. Ultrasound and MRI studies are valuable diagnostic tools for identifying spinal cord injury in cases of hypotonic newborns with difficult deliveries. The authors report an unusual case of spinal cord birth injury with frank cervical fracture-dislocation following a difficult footling breech vaginal delivery. Early recognition of hyperextension of the fetal head in utero and planned cesarean section are important prevention methods. While this type of injury is rare, the pediatric orthopedic surgeon must understand its nature and severity to facilitate timely treatment.

Biomechanics - Part I

Biomechanics is the science of the action of forces, internal or external, on the living body. It includes the fields of statics, dynamics, and kinetics. This section will discuss some basic terminology used in biomechanics and also discuss the mechanical properties of some tissues and biomaterials that are important in orthopedic practice.