Tension, abduction, and surgical technique affect footprint compression after rotator cuff repair in an ovine model.

INTRODUCTION: Shoulder motion after rotator cuff repair may result in changes in tension and contact pressure at the repair site. Our goal was to determine how tension and motion affect a repair and what type of repair best tolerates these variables. METHODS: Rotator cuff tears were created ex vivo in 30 ovine shoulders divided into 5 groups: single-row repair, double-row repair, tension-band repair, suture bridge repair, and double-row tension-band repair. A pressure probe was passed through a hole created in the footprint to dynamically measure footprint pressure. The rotator cuffs were repaired, and contact pressure was measured with variable tension placed on the repaired tendon from 10 to 30 N and variable shoulder abduction from -10° to +10°. Repair strength was determined by use of a pull-to-failure test. RESULTS: Increasing tension on the repaired tendon resulted in an increase in contact pressure whereas increasing the abduction angle resulted in a decrease in contact pressure in all 5 groups. For all abduction and tension combinations, the suture-bridge and double-row tension band groups recorded the highest contact pressures (P < .05), followed by the tension-band, single-row, and double-row repairs. Load to failure was greatest for the 2 double-row techniques, followed by the tension-band, suture-bridge, and single-row repairs. DISCUSSION: Contact pressure increases as tension increases across the repair and decreases as the shoulder is abducted. The double-row tension-band rotator cuff repair showed the best combination of contact pressure and repair strength.

Treatment of tendinopathy: what works, what does not, and what is on the horizon.

UNLABELLED: Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear. LEVEL OF EVIDENCE: Level II, systematic review.

A comparison of digital cameras: features essential for the orthopaedic surgeon.

To make recommendations for the selection of digital imaging equipment and its use in the typical orthopaedic surgery practice, we investigated four digital cameras with maximal resolution ranging from 1.3-3.34 megapixels. We took images of a plain radiograph, a magnetic resonance image, a hand model, and a minifragment plate with all four digital cameras and a 35-mm film camera. Several variables were evaluated to determine their effect on image quality, including adjusting maximal camera resolution, using a flash, using a camera stand, and using a macromode. Images were graded on a 3-point scale on the computer desktop and as 5 x 7 inch prints by two blinded observers. A maximal camera resolution of 2.1 megapixels was required to make photograph-quality 5 x 7 inch prints of all subjects imaged. No difference in print quality was seen between images taken in the highest quality JPEG format and the uncompressed TIFF format. A macromode with closest focal length less than 5 inches was needed for imaging small subjects. The 1.3-megapixel camera was comparable with the higher resolution cameras for imaging radiographic studies and when viewing color images on the computer desktop.

Internet-based learning.

The Internet, with established and newly appearing websites, is becoming a more integral part of orthopaedic education every day. We review some of the well-known resources on the Internet (Orthogate, OrthoNet, American Academy of Orthopaedic Surgeons site, Orthopedic Hyperguide, WorldOrtho, Wheeless's Textbook of Orthopaedics, Orthoteers, AO North America site, University of Iowa Virtual Hospital texts, and South Australian Orthopaedic Registrars' Notebook) and reports the results of a survey of 35 orthopaedic surgery residents and 24 attending orthopaedic surgeons on the use of orthopaedic knowledge resources on the World Wide Web. The top three most commonly used online sites by the residents were Wheeless's Textbook of Orthopaedics, the American Academy of Orthopaedics Surgeons website, and Orthopedics Hyperguide. According to the survey, all 35 residents used online resources for learning, giving preference to online textbooks when looking for clinical information and online practice examinations when preparing for the in-training (OITE) or board examinations. Among the attending physicians, 19 (79%) used the Internet. Their most commonly used online sites were the American Academy of Orthopaedics Surgeons website, AO North America site, and Wheeless's Textbook of Orthopaedics. The attending physicians also preferred online textbooks to other online resources. Also provided in this article is a discussion of our idea for a future comprehensive, accurate, and constantly updated orthopaedic online resource that uses already available technology.

Total hip arthroplasty in skeletal dysplasias: patient selection, preoperative planning, and operative techniques.

Patients with substantial skeletal dysplasia and hip arthritis are poor candidates for noncustom total hip arthroplasty (THA) because of hip size and deformity. To determine the efficacy of THA via modified prostheses and surgical techniques in this population, the authors analyzed 9 consecutive THAs in 7 small-stature adults (mean height, 118.6 cm; mean weight, 47.5 kg). The Student t-test was used to test for significant (P < 0.05) differences in outcome variables. Seven hips received custom femoral components based on imaging studies. Five hips required extensive soft-tissue releases secondary to severe contractures. Follow-up radiographs (range, 24-56 months) showed adequate position of all prostheses and no loosening. Follow-up mean pain and function scores (Harris Hip Score and WOMAC Arthritis Index) showed significant improvement from preoperative levels.

Treatment of osteoarthritic cartilage lesions with osteochondral autograft transplantation.

Twenty-two osteochondral autograft transplantations were performed on two types of knees: those with isolated (group 1) and multiple (group 2) degenerative cartilage lesions. At minimum 24-month follow-up, group 1 had significantly better pain relief and function than group 2 based on the Western Ontario and McMaster Universities Osteoarthritis Index and pain scores (10-point visual analog scale). Osteochondral autograft transplantation may be effective in treating knees with isolated degenerative cartilage lesions but appears contraindicated in those with multiple lesions.

Postoperative fever after total knee arthroplasty: the role of cytokines.

Febrile temperatures commonly are seen after total knee arthroplasty, but their source and importance are unclear. The goal of the current study was to determine whether such fevers are part of the normal physiologic response to surgery mediated by inflammatory cytokines. In 20 patients who had total knee arthroplasty, serum and wound drain fluid samples were collected preoperatively and at 1, 6, 24, and 48 hours postoperatively; oral temperatures were measured postoperatively every 4 hours for 3 days. Concentrations of interleukin 1beta, interleukin 6, and tumor necrosis factor alpha in the samples were measured via enzyme-linked immunosorbent assays and compared in patients who did and did not have fevers develop (>or=38.5 degrees C). Gender, age, operative time, amount of blood loss or drain output, anesthesia type, drop in hematocrit, and transfusion administration were not associated with fever. Significant increases were seen postoperatively in drain fluid concentrations of interleukin 1beta and interleukin 6 and in serum concentrations of interleukin 6. Patients who were febrile had significantly higher drain and serum interleukin 6 concentrations than patients who were afebrile. These findings suggest that fevers seen after total knee arthroplasty are at least partly the result of surgical site inflammation and subsequent local and systemic release of the endogenous pyrogen interleukin 6.

A muscular lesion suggestive of focal myositis in a child with Proteus syndrome.

Proteus syndrome is a polymorphic hamartomatous disorder associated with a broad spectrum of rare congenital malformations. Many neoplasms have been linked to this condition, including lipomas, lymphangiomas, and hemangiomas. The authors describe a case of a congenital muscular lesion in a child with Proteus syndrome. This mass was painless but was growing out of proportion to her leg musculature. A magnetic resonance imaging scan and incisional biopsy showed findings consistent with focal myositis. The clinical, radiographic, and histologic characteristics of this previously undescribed lesion are discussed, with a brief review of the literature.