Thursday, August 4, 2005 SESSION I – TOTAL KNEE REPLACEMENT

Moderator: C. Lowry Barnes, MD

7:06 am – 7:13 am

Clinical Evaluation of a Knee Prosthesis Based on Medial-Pivot Kinematics

J. D. Blaha, MDWilliam J. Maloney, MD Robert Schmidt, MD Brad Penenberg, MD

Recent kinematic studies confi rm that the most appropriate model for human knee joint motion is a stable ball-in-socket joint on the medial side and a more mobile lateral side to allow axial rotation. A total knee prosthesis based on such medial-pivot kinematics has been designed and implanted.

Nine-hundred forty-three patients with an Advance® Medial Pivot total knee implant are included in a multi-center study. In each case, the patella was resurfaced. In 619 patients, the PCL was resected and in 294 patients the PCL was retained. (In 30 patients the status of the PCL was not reported.) Preoperatively the average ROM was 107º for the PCL sacrifi ced group and 111º for the PCL retained group. At 5 years ROM had increased to a mean value of 115º for the PCL sacrifi ced group and 114º for the PCL retained group. Radiographically, there were no progressive radiolucencies or measurable polyethylene wear reported at 5 years. Mid-term clinical results with the Advance® Medial Pivot knee design have shown excellent ROM and no signifi cant radiographic evidences of loosening or wear.

While continued follow-up and analysis of polyethylene wear and implant fi xation is continuing, the initial success of this design leads us to optimism for its long-term success.

Notes: Thursday, August 4, 2005 SESSION I – TOTAL KNEE REPLACEMENT

Moderator: C. Lowry Barnes, MD

7:14 am – 7:21 am

Total Knee Arthroplasty in Patients Younger Than 55 Years of Age with DJD Using a Modern Prosthesis: 10 to 15 Year Results

Amy R. Crowder, MD Gavan P. Duffy, MD

Introduction: Total Knee Arthoplasty has been shown to be effective in young patients. However, there is limited long-term follow-up data in patients with DJD. We report the 10- to 15-year results of Total Knee Arthroplasty using the PFC knee system in young patients with DJD.

Methods: 96 Consecutive Total Knee Arthroplasties in patients who were 55 years of age or younger at time of surgery. Patients were followed until death or for a minimum of 10 years, with average follow-up of 12 years (range 10-15 years). No knees were lost to follow-up. Pre-operative diagnoses were DJD in 88 patients and post-traumatic DJD in 8 patients. There were 48 men and 48 women.

Results: The knee function score improved from 34 points pre-operatively to 86 post-operatively. Pain scores improved from 36 to 92 post-operatively. There were 12 early reoperations, 3 manipulations under anesthesia, 1 for lysis of adhesion, 2 arthroscopies for debridement, 4 open debridements for arthrofi brosis, one hematoma evacuation, and one scar revision. At 10 years of follow-up, there were no revisions. At 10.4 years, there was one deep infection resulting in component removal without replacement. At an average of 12 years of follow-up (range 10.1-15 years) there were 11 revisions, including 7 replacements of distal inserts and 4 replacements of multiple components. Implant survival at 12 years is estimated at 87 percent.

Conclusion: At 10 years of follow-up implant survival was 100 percent and estimated to be 87 percent at an average follow-up of 12 years. Total Knee Arthroplasty using the PFC Knee System has excellent reliability and longevity in young patients with DJD.

Notes:

Moderator: C. Lowry Barnes, MD

7:22 am – 7:29 am

The Natural History of Venographic Deep Vein Thrombosis Following Total Joint Arthroplasty

Christopher T. Donaldson, MD Vincent D. Pellegrini, Jr., MD Daniel Farber, MD

C. McCollister Evarts, MD

3,169 total joint patients following clinical pathways (regional anesthesia, pre-discharge screening venography) were prospectively studied regarding DVT natural history and post-discharge warfarin venous thromboembolic disease (VTED) prevention effi cacy. Positive venograms received warfarin (target INR 1.5-2.0); thigh clots for 3 months and calf thrombi for 6 weeks. Negative venograms received no chemoprophylaxis. Clinical DVT, PE, and bleeding re-admissions were recorded for 1 year. Post-THA DVT prevalence was 14.7% (152/1032); 41.1% (333/810) after TKA. Overall re-admission rates for positive versus negative venograms were 0.4% (2/485) versus 1.8% (24/1357) respectively. VTED re-admission rates were twice greater after THA (2.2%; 19/880) than TKA (1.1%; 5/477). VTED re-admission rates of patients on warfarin versus those with negative screening venograms (no anticoagulation) were 0.1% vs. 1.8%, a statistically signifi cant difference. Selective anticoagulation based on routine DVT surveillance, even gold-standard venography, is a much less effective strategy than extended warfarin anticoagulation in post-arthroplasty patients.

Notes: Thursday, August 4, 2005 SESSION I – TOTAL KNEE REPLACEMENT

Moderator: C. Lowry Barnes, MD

7:30 am – 7:37 am

Ten Year Survival and Clinical Results of Constrained Components in Primary Total Knee Arthroplasty

Paul F. Lachiewicz, MD Elizabeth Soileau, RN

The use of constrained prostheses in primary total knee arthroplasty (TKA) is unusual. This is a study of the indications, clinical results and 10 year survival of these components. Fifty-four knees (44 patients) were prospectively followed and 42 knees (34 patients) had 5-16 years (mean 9) follow-up. The indications for the components were: valgus deformity with incompetent medial collateral ligament in 27 knees, severe fl exion contracture with inability to balance the knee in 12, and other in 3. Knees were evaluated by the Hospital for Special Surgery and Knee Society score systems. Statistical analysis included paired student t-test and survivorship analysis.

Of the entire cohort of 54 knees, there were only 2 failures: 1 tibial loosening revised at 3 years, 1 femoral loosening (no stem) revised at 1 year. Of the 42 knees with minimum 5 year follow-up, 12 knees were rated as excellent, 24 good, 3 as fair and 3 as poor. There was a signifi cant improvement in postoperative knee score, but not in the function score. The mean fl exion contracture preop was 17°, postop 1.7°; mean fl exion preop 93°, postop 97°. The 10 year survival with failure, defi ned as component revision for loosening, was 96% (CI 90.6-100%).

In diffi cult primary TKAs, there were 86% good or excellent results and a 10 year survival of 96% despite the increased constraint. The constrained condylar TKA remains indicated for knees with severe valgus deformity, incompetent MCL and severe fl exion contracture in which the knee cannot be properly balanced.

Notes: Thursday, August 4, 2005 SESSION I – TOTAL KNEE REPLACEMENT

Moderator: C. Lowry Barnes, MD

7:38 am – 7:45 am

Mini-Subvastus Approach for TKA

W. C. Schroer MDPaul J. Diesfeld, PA-C Mary A. Reedy, RN

Introduction: This paper compares the results of Total Knee Arhtroplasty (TKA) performed with a less invasive mini-subvastus approach to TKA performed with a traditional medial para-patellar approach.

Methods: Our initial 150 TKA utilizing a mini-subvas-tus surgical technique (MIS) were evaluated prospectively. This surgical technique avoids both the quadriceps tendonotomy and patella eversion. Skin incisions averaged 11cm. The results of the MIS group were compared with a control group of 150 consecutive TKA utilizing the a traditional medial para-patella arthrotomy. All 300 procedures were performed by a single surgeon, utilizing the same posterior stabilized cemented. Comparison of the two groups showed no differences in patient age, gender, Body Mass Index, knee deformity or surgical diagnosis.

Results: Range of motion was signifi cantly greater at 3, 6, 12 and 24 weeks post-op for the MIS group. Mean fl exion 110 for the MIS group versus 99 for the control group at three weeks, 118 vs. 108 at six weeks, 122 vs. 111 at twelve weeks, and 125 vs. 113 at 24 weeks post-op. Quadriceps strength returned quicker in the MIS patients with 83% (124 of 150) able to straight leg raise the day after surgery. No patients with the traditional approach demonstrated the ability to straight leg raise the day after surgery. Hospital length of stay decreased to 3.4 days for the MIS patients versus 4.0 for the control patients. Complication rates were similar between the two groups.

Discussion: Minimally invasive total knee surgery utilizing a mini-subvastus technique demonstrated improved range of motion and a more rapid return of quadriceps strength than we have previously seen in our traditional TKA patients. Hospital length of stay decreased in the MIS group and complication rates were not increased.

Notes: Thursday, August 4, 2005 SPECIAL FOCUS PRESENTATION

7:46 am – 7:53 am

Surface Replacement of the Hip— Are We Chasing Our Tails?

Riyaz H. Jinnah, MA, FRCS Shanon Poluski, FRCS(C)

In the late seventies and early eighties there was great hope that surface replacement would solve our problems in treating the young and active patient with gonarthrosis of the hip. Unfortunately the results of this procedure were far from satisfactory and by the mid eighties the procedure had essentially been abandoned. With the lessons learned from this era, modern bearing surfaces were developed which appear to have solved the problem of osteolysis secondary to polyethelene wear. The popularity of surface replacement is again on the rise and in the UK, 12% of all total hip replacements performed are of the surface variety. Advantages and results of this procedure as well as shortcomings will be discussed. There is no doubt that technically this is a more diffi cult option, and signifi cant training has to be embarked upon before proceeding down this route. We need to continue to be vigilant before fully embracing this procedure once again.

Notes: SYMPOSIUM I – COMPUTER VS. FREE-HAND CUTS IN TKR

Moderator: Thomas P. Vail, MD

8:28 am – 8:43 am

Computer Assisted Total Knee Arthroplasty

Mike Bolognesi, MD

During total knee arthroplasty, the surgeon has the opportunity to maximize clinical outcome by perfecting their surgical technique. Specifi cally, component alignment during the procedure must be optimized. Alignment errors in total knee arthroplasty (TKA) greater than three degrees, or outliers, can be associated with poorer outcomes and accelerated failure.

The use of computer-based systems during total knee arthroplasty has become more readily accepted and utilized during recent years. This is best evidenced by the increasing number of references in the orthopaedic literature to studies reporting on computer assisted techniques and early outcomes using these techniques. These systems can be generally grouped into three different types. There are image free navigation systems, image based navigation systems, and robotic systems.

The present study utilized an image free navigation system (Navitrack™ System-Optical Total Knee Replacement (TKR) CT-Less device, Orthosoft, Montreal, Quebec). There are several features about this computer navigation system that offer the surgeon possible advantages over standard instrumentation. The potential for improved accuracy with regard to component alignment and limb alignment may be provided when the system is used. This improved accuracy may allow the surgeon to avoid outliers.

This retrospective study compares alignment between fi fty TKAs performed using an imageless computer navigation system and fi fty TKAs using standard instrumentation. The same surgeon used a posterior referencing TKA system (Natural Knee™) in all cases. Our hypothesis was that computer navigation would improve component position while minimizing outliers, even for an experienced surgical team. Long-standing radiographs were collected at 6 weeks follow-up and measured for component orientation. When the navigation system was used 98% (49/50) of all femoral components and 100% (50/50) of all tibial components were placed within +/- 3º of the radiographic goal position. There was a decrease in the standard instrumentation group to 90% (45/50) and 92% (46/50) within ± 3º, respectively. There was a signifi cant difference in the standard deviations observed for the navigated cases and the conventional cases when femoral (p= 0.016) and tibial (p= 0.013) component position was considered. Average tourniquet time was 68 minutes in the navigated group and 57 minutes in the conventional group.

This system affords the surgeon the potential to reduce outliers with regard to component position without adding signifi cant operative time. In addition, violation of the intramedullary canal is avoided using this instrumentation. Navigation may lead to improved component survivorship in the long term and a reduction in complications associated with embolic phenomena occurring with intramedullary instruments.

Notes: SYMPOSIUM I – COMPUTER VS. FREE-HAND CUTS IN TKR

Moderator: Thomas P. Vail, MD

8:44 am – 8:59 am

Free Hand

Tom B. Volatile, MD

Notes: Thursday, August 4, 2005 SESSION II–PEDIATRICS/TRAUMA

Moderator: Mike LeCroy, MD

9:11 am – 9:18 am

Gunshot Wounds of the Femoral Shaft: Antegrade or Retrograde Nailing?

Thomas Jones, MD Maria del Carmen Guerrero, MD Albert M. Pendelton, BA Thomas Viehe, MD Lisa K. Cannada, MD

Penetrating trauma is increasing in urban areas. Gunshot wounds (GSW) of the femur are becoming a more common injury. With the increasing popularity of retrograde nailing, there are questions raised as to their appropriate indications. We compared retrograde versus antegrade nailing in the treatment of GSW to the femur. We identifi ed all femoral shaft fractures due to GSW over a 3 year period. 54 patients treated with retrograde and 20 patients with antegrade nail fi xation were included. 11.1% of retrograde fi xations were associated with post-operative infection, compared to zero in the antegrade cohort. Further, 9.3% of fractures with retrograde nails experienced >5 mm shortening compared to none in the antegrade group. Length of stay was greater in the retrograde group (5 days versus 4), but this did not reach statistical signifi cance. Our data suggests retrograde fi xation of femur fractures due to GSW is less desirable, and antegrade fi xation should be performed in most cases.

Notes:

Moderator: Mike LeCroy, MD

9:19 am – 9:26 am

An Analysis of Suboptimal Outcomes of Medial Malleolar Fractures in Skeletally Immature Children

Scott J. Luhman, MD Jon Oda, MD Perry L. Schoenecker, MD

J. Eric Gordon, MD

Introduction: Treatment of medial malleolar fractures in skeletally immature patients is usually predictable, however some injuries result in permanent pain and disability. The purpose of this study is to analyze the causes of suboptimal outcomes.

Methods: A database search identifi ed all skeletally immature patients with medial malleolar fractures, and only those having persistent ankle pain or needing secondary reconstructive procedures were included in the analysis.

Results: Twenty-six patients (11 female, 15 male) were identifi ed. Mean age was 10.1 years (range, 2-14 years). Nine patients were initially managed nonoperatively and 17 underwent operative management. Suboptimal outcomes could be attributed to 36 causes in the 26 patients: physeal arrest in 14 patients, malreductions in 12, osteochondral injury in 4, nonunions in 3, refracture in 2, talar AVN in 1, and litigation in 1. Of the 12 malreductions, 9 underwent operative management and all had articular step-off on postoperative radiographs. Fifty secondary operative procedures have been performed: epiphyseodeses in 12 patients, implant removal in 12, distal tibial osteotomies in 11, redo-ORIF in 6, ORIF for nonunion in 3, ankle arthroscopy in 2, and one each a tibial lengthening, tendoachilles lengthening, ankle arthrodesis, and osteoarticular allograft reconstruction. Persistent pain was reported at last fol-low-up in 12 patients.

Discussion: Malreductions of only 2 millimeters does not appear to be tolerated and the concept of “remodeling” likely does not apply to this fracture. We advocate accepting no more than 1 millimeter of step-off and, when operatively managed, recommend direct visualization of the fracture and minimizing iatrogenic damage to the physis.

Notes:

Moderator: Mike LeCroy, MD

9:27 am – 9:34 am

Prospective Randomized Trial Comparing IV Ketamine/Midazolam and Nitrous Oxide/Hematoma Block in the Management of Pediatric Forearm Fractures

Scott J. Luhmann, MD Jan D. Luhmann, MD Mario Schootman, PhD

Introduction: Emergency management of pediatric fractures requires effective sedation-analgesia. Although ketamine has been shown to be effective, adverse effects and prolonged recovery times may preclude it from being the ideal agent for emergency fracture reduction in children. The purpose of this study was to compare the efficacy and adverse effects of ketamine/midazolam

(K) versus nitrous oxide/hematoma block (N) for anal-gesia during forearm fracture reduction in children.

Methods: Children 4-18 years of age were randomized to receive intravenous ketamine (1 mg/kg)/midazolam (0.1mg/kg; max = 2.5 mg) or 50% nitrous oxide and a hematoma block with 2.5 mg/kg of 1% buffered lidocaine. All children received oral oxycodone 0.2 mg/kg (max = 15 mg) at least 45 minutes prior to fracture reduction. Videotapes were obtained before (baseline), during (intra) and after fracture reduction and later scored by a blinded observer using the Procedure Behavioral Checklist (PBCL). The primary outcome measure was the mean change from baseline to intra-pro-cedure PBCL score, with greater change from baseline indicating greater procedure distress. Other outcome measures of efficacy included recovery times and 10point VAS scores to assess patient and parent-report of distress and orthopaedic surgeon satisfaction with sedation. Adverse effects were assessed during the emergency visit and by telephone 1 day after fracture reduction. Data were analyzed using chi-square and t-tests.

Results: 102 children (mean age=9.0+3.0 years, 54%W, 60% M) were enrolled. There was no difference in age, race, gender, baseline pain and anxiety and baseline PBCL scores between K (55 subjects) and N (47 subjects). The mean change in PBCL score was significantly less for N (0.49 + 0.56) than K (2.1 + 0.44). Patients and parents reported less pain during fracture reduction in N. Recovery times were significantly shorter for N (mean = 15.8 + 10.4 minutes) compared to K

(83.3 + 32.1) and there was no difference in satisfaction ratings by the orthopaedic surgeon. 7% of K had O2 saturations <94%; 0% in N. Other adverse effects occurred in both groups, but significantly more often in K both during the emergency visit and at 1 day follow-up.

Conclusion: N experienced lower increases in intra-procedure distress from baseline than K during forearm fracture reduction in children. Both children and parents reported less pain during fracture reduction in N. There was no difference in orthopaedic surgeon satisfaction with sedation. Recovery times were shorter and adverse effects were fewer in N.

Notes:

9:35 am – 9:45 am

Management of Pediatric Femur Fractures

Mark Hammerberg, MD

A review will be presented of the current opinion regarding treatment of pediatric femur fractures, from spica casting to intramedullary nail fi xation.

Notes: Thursday, August 4, 2005 SPECIAL FOCUS PRESENTATION

9:46 am – 9:56 am

Management of Pediatric Elbow Fractures

L. Andrew Koman, MD

This presentation will discuss diagnosis and management of pediatric elbow fractures, emphasizing supracondylar fractures and lateral condyle fractures. It will detail potential risks and complications and how to avoid bad outcomes.

Notes: PRESIDENTIAL GUEST SPEAKER PRESENTATION

Thursday, August 4, 2005 Thursday, August 4, 2005
SYMPOSIUM II – LOCKING PLATE SYMPOSIUM II – LOCKING PLATE
VS. TRADITIONAL FIXATION FOR VS. TRADITIONAL FIXATION FOR
PERIARTICULAR FRACTURE FIXATION PERIARTICULAR FRACTURE FIXATION
Moderator: Steve Olson, MD Moderator: Steve Olson, MD
10:31 am – 10:46 am 10:47 am – 11:02 am
Locking Plate Traditional Fixation
Robert D. Zura, MD Langdon Hartsock, MD
Notes: Notes:

11:14 am – 11:44 am

Tissue Engineering in Orthopaedic Surgery

Gary G. Poehling, MD

Notes:

Thursday, August 4, 2005

PRESIDENTIAL GUEST SPEAKER AND DISTINGUISHED SOUTHERN ORTHOPAEDIST PRESENTATION

11:45 am – 12:05 pm

Non-Operative Management of the Elderly Patient with a Full Thickness Rotator Cuff Tear

Charles A. Rockwood, Jr., MD

Notes:

Friday, August 5, 2005 Friday, August 5, 2005
SYMPOSIUM III – TOTAL ANKLE SYMPOSIUM III – TOTAL ANKLE
ARTHROPLASTY VS. ANKLE FUSION FOR ARTHROPLASTY VS. ANKLE FUSION FOR
ANKLE OA ANKLE OA
Moderator: Lamar L. Fleming, MD Moderator: Lamar L. Fleming, MD
7:00 am – 7:15 am 7:16 am – 7:31 am
Total Ankle Arthroplasty Ankle Fusion
James A. Nunley, MD Robert S. Adelaar, MD
Notes: Notes:

Moderator: Robert S. Adelaar, MD

7:43 am – 7:50 am

First Metatarsophalangeal Joint Fusion with Precontoured Plate Fixation: A Promising New Technique

Matthew J. Hawkins, MD John J. Christoforetti, MD Rachelle Barimany, BS Matthew W. Martin, BS Paul S. Cooper, MD

Results of cone arthrodesis of the fi rst metatarsophalangeal joint using rigid precontoured plate fi xation has not been previously reported. The purpose of this study is to evaluate the effectiveness of this method using objective and patient outcomes-based standards. 32 cone arthrodeses in 29 patients with end-stage fi rst metatarsophalangeal joint arthrosis were retrospectively reviewed at 29 months average follow-up. Preoperative and postoperative AOFAS scores, clinical, and radiographic evaluations were analyzed. 24 female and 5 male patients were reviewed. 30/32 achieved clinical and radiographic fusion. Both failures occurred in patients with prior surgical intervention complicated by infection. Average AOFAS scores improved signifi cantly from 38 preoperatively to 71 postoperatively. 90% would choose the surgery again. Rigid precontoured plate fi xation can achieve a 97% fusion rate and statistically signifi cant outcomes based improvement. Further studies are needed to compare fi xation methods in a prospective, randomized fashion to elucidate the ideal technique.

Notes: Friday, August 5, 2005 SESSION III – FOOT AND ANKLE

Moderator: Robert S. Adelaar, MD

7:51 am – 7:58 am

Retrospective Analysis of Peroneal Groove Deepening in Patients with Chronic Peroneal Pain or Subluxation

Adam N. Wilson, MD Lew C. Schon, MD

This study retrospectively reviewed peroneal groove deepening using a periosteal bone fl ap in patients with a chronic history of peroneal pain. Six women and 10 men (mean age: 37.8 years), were referred for evaluation of ankle pain or instability following failed medical management. Patients presented on average 32.8 months following the development of symptoms including pain (100%), gait dysfunction (77.8%), instability (62.5%), tendon popping/snapping (56.3%), swelling (31.3%), and numbness (12.5%). Upon radiographic examination 42.9% of patients had no evidence of bony abnormalities. Magnetic resonance imaging performed on 56.3% of patients revealed tendonitis (55.6%) and ankle effusion (11.1%). Intraoperative fi ndings included shallow grooves (43.8%), tendonitis (31.3%), peroneal tears (25.0%), dislocated tendons (18.8%), and subluxable tendons (18.8%). No intraoperative complications occurred. Postoperatively patients were followed for 15 months. Patients reported signifi cant improvement in gait function (75.0%), stability on uneven terrain (67.5%), as well as decreased pain (93.8%) and denial of pain (37.5%). Peroneal tendon groove deepening using a periosteal bone fl ap is an effective surgical procedure for individuals with chronic peroneal pain and/or subluxation.

Notes:

SCIENTIFIC PROGRAM – FRIDAY

Moderator: Robert S. Adelaar, MD

7:59 am – 8:06 am

The Modifi ed Ludloff Proximal First Metatarsal Osteotomy for Surgical Correction of Hallux Valgus Deformity

Mark E. Easley, MD Hans-Jörg Trnka, MD

Introduction: Prospective Analysis of the modifi ed Ludloff osteotomy for surgical correction of hallux valgus deformity.

Methods: One-hundred nine feet in 99 patients (average age 53 years (range, 16-77), 89 females, 10 males) underwent modifi ed Ludloff osteotomies with DSTP at two institutions. Evaluation was prospective using the AOFAS forefoot-metatarsophalangeal-interphalangeal scoring system preoperatively and at latest follow-up. Weightbearing foot radiographs were analyzed according to AOFAS guidelines.

Results: Eighty-eight patients (97 feet) (89%) were available at an average followup of 36 months (range, 24-56 months). The average AOFAS score improved from 53 points to 87 points. Preoperatively, all patients complained of pain; at most recent followup 79 patients (90%) were asymptomatic. Radiographic evaluation suggested all osteotomies healed, but 17 cases (16%) demonstrated callus formation at the osteotomy site. Average age of patients with callus formation was 67 years. No cases of dorsifl exion malunion were observed. Average IMAs preoperatively and at latest follow-up were 17.8 degrees and 7.8 degrees, respectively; average HVAs were 41 degrees and 15 degrees, respectively. Tibial sesamoid position improved an average of 1.5 grades. Hallux varus was observed in 12 feet (11%). Three feet developed hallux rigidus (3%). Recurrence of hallux valgus was observed in 3 feet (3%). One deep infection and one cellulitis were managed effectively with satisfactory outcome.

Discussion and Conclusion: To our knowledge, this prospective, multicenter investigation comprises the largest cohort of patients undergoing a modifi ed Ludloff osteotomy. At intermediate follow-up, currently available outcome measures suggest that the results of this proximal fi rst metatarsal osteotomy are at least equal to those reported for other proximal fi rst metatarsal osteotomies utilized in correcting hallux valgus.

Notes:

Friday, August 5, 2005 Friday, August 5, 2005
SPECIAL FOCUS PRESENTATION SPECIAL FOCUS PRESENTATION
8:07 am – 8:17 am 8:18 am – 8:28 am
How I Evaluate and Fix Plantar Plate Disruption How I Evaluate and Treat Sesamoid Fractures
Mark E. Easley, MD Angus M. McBryde, Jr., MD
Notes: Notes:

SCIENTIFIC PROGRAM – FRIDAY

Moderator: Robert M. Peroutka, MD

9:06 am – 9:13 am

Preliminary Results with the Mayo Conservative Total Hip Arthroplasty

George W. Brindley, MD Timothy Dixon, MD

Objectives: The objective of this study is to evaluate the clinical and radiographic outcomes after Mayo Conservative Total Hip Arthroplasty.

Methods: From April 1999 through September 2002, 105 patients had 114 Mayo Conservative Total Hip Arthroplasties. Forty-fi ve patients were male and 60 were female. Average patient age at the time of surgery was 59 years. Eighty-nine of these patients (95 hips) were enrolled in a prospective industry-sponsored outcomes study that included pre- and post-operative health status assessments, specifi c hip function analysis, and radiographic evaluation. The remaining patients, though not enrolled in the outcomes study, were clinically and radiographically evaluated in a similar manner.

Results: Clinical and radiographic follow-up was less than 6 months for 16 patients, 12 to 24 months for 28 patients, 24 to 36 months for 36 patients, longer than 36 months for 24 patients, and 2 patients have died. Five patients had femoral component revision for symptomatic loosening (14 to 39 months after the index procedure).

The primary diagnosis was osteoarthritis in 74 patients and avascular necrosis in 30 patients. Preoperative Harris Hip Scores were 60 (range 20 to 70) and postoperative scores 92 (range 62 to 99). Surgical complications included canal perforation in 2 patients and calcar fracture in 4 patients. Postoperative complications included pulmonary embolus in 2 patients, deep infection in 3 patients, dislocation in 3 patients and early implant subsidence in 1 patient.

Two patients required femoral component revision after sustaining a periprosthetic femur fracture and 2 patients have evidence of prosthetic loosening but have not had component revision.

Conclusion: Since August 2003 all femoral implants have been implanted with hydroxyapatite coating with no radiographic evidence of implant loosening. The Mayo Conservative Femoral implant appears to function well, to have good biologic stability, and is very adaptable for limited incision surgery.

Notes:

Moderator: Robert M. Peroutka, MD

9:14 am – 9:21 am

Reduction in Early Post-Operative Dislocation Following THR

John M. Cuckler, MD

K. David Moore, MDAdolph Lombardi, MD Ed McPherson, MD Roger Emerson, MD

Introduction: The recent resurgence of metal-on-metal (MOM) total hip replacements (THR) has afforded the surgeon new options in femoral head diameters, not previously available. Reduction in the risk for dislocation and potential improvements in articular wear are the obvious advantages of large diameter femoral heads. We compared our dislocation experience in the fi rst 3 months after surgery among 5 surgeons using 38 vs. 28 mm diameter femoral heads.

Methods: The incidence of dislocation in the fi rst 3 months after surgery was examined among 616 patients receiving a 38mm MOM THR (M2A, Biomet) and compared with a group receiving 28mm MOM femoral heads. Effects of surgical approach on dislocation were also examined.

Results: The clinical experience among 616 38mm diameter femoral heads showed no dislocations within the fi rst 3 months after surgery, compared with 2.5% of 78 28mm diameter femoral heads with otherwise identical components (p<3.9 e-7). Type of surgical approach had no infl uence on the incidence of dislocation (p<0.006).

Discussion and Conclusions: Use of 38mm femoral heads appears to have the potential to substantially reduce the early risk of dislocation of the prosthetic hip arthroplasty when compared with conventional 28mm femoral heads.

Notes:

SCIENTIFIC PROGRAM – FRIDAY

Moderator: Robert M. Peroutka, MD

9:22 am – 9:29 am

Jumbo Porous Acetabular Components in Revision Arthroplasty: Results at 7 Years

Paul F. Lachiewicz, MD Elizabeth Soileau, BSN

With acetabular bone loss, there are several options for revision. One of the simplest is the use of extra-large or jumbo porous components. There are few longer-term reports of the results and complications of this technique.

One surgeon performed and prospectively followed 78 jumbo acetabular revisions (Mayo def. = 62 mm females, = 66 mm males). This represented 37% of all revisions. No cages were used. Multiple screws were used for fi xation. The mean patient age was 63 yrs and the mean follow-up time was 7.6 yrs. All hips had severe bone loss.

Overall, there were 3 acetabular failures (4%) requiring repeat revision, 2 removed for infection and 1 revised for fi ber-metal separation and femoral loosening. One other component has asymptomatic radiographic loosening for an acetabular success rate of 95%. The major complication was dislocation (10.2%) and two required surgery (liner exchange; femoral revision).

Jumbo acetabular components are a relatively simple solution for revision, with a high rate of success at mean

7.6 years follow-up. There is a high rate of dislocation, due to acetabular size — femoral head mismatch. Larger femoral heads are now used when jumbo reconstructions are performed.

Notes: Friday, August 5, 2005 SESSION IV – TOTAL HIP REPLACEMENT

Moderator: Robert M. Peroutka, MD

9:30 am – 9:37 am

Clinical Results of Alumina Ceramic-Ceramic Bearings in Total Hip Arthroplasty

Stephen S. Murphy, MD

Introduction: Wear, particulate debris, and resulting osteolysis are the primary long-term problems affecting total hip arthroplasty. The current study documents clinical results on alumina ceramic-ceramic bearings in young active patients.

Method: 296 total hips were preformed using ceramic bearings. Of these hips, 97 were evaluated at a minimum of 2 years. Mean age at surgery was 50.2 years. Follow up range was 2-7 years with a mean of 45 months. Patients were followed clinically and radiographically at yearly intervals.

Results: There were three implant-related revisions. There have been no dislocations, no fractures, no lysis.

Conclusion: Clinical Experience confi rms that ceramic bearings provide a reliable option for young and active patients.

Notes:

Moderator: Robert M. Peroutka, MD

9:38 am – 9:45 am

Percutaneously Assisted THA

Brad Penenberg, MD

Introduction: This study describes a soft tissue sparing technique for total hip arthroplasty used in association with a new approach to bone preparation and component implantation which can predictably and safely achieve precise component placement and more rapid return to function.

Methods: Between June and October 2002, 52 total hip arthroplasties were performed using a percutaneously assisted technique (PATH). In most a piriformis release only was carried out. External rotators and capsule were preserved. Cementless implants were used. Immediate weight bearing was permitted.

Results: Operating time ranged from 57 minutes to 2 hours. Blood loss 75 cc to 450 cc. 80% of patients performed unassisted straight leg raising within 48 hrs of surgery. 70% of patients used a cane between 1 and 7 days after surgery. 90% required no blood transfusion. Hospital stay was shortened by 50%. No dislocations or nerve injuries occurred.

Discussion/Conclusion: PATH technique permits safe and accurate component placement and improved recovery time.

Notes: Friday, August 5, 2005 SPECIAL FOCUS PRESENTATION

9:46 am – 9:56 am

Arthroscopic Lysis of Adhesions After Total Joint Replacement

Tom B. Volatile, MD

Notes:

SCIENTIFIC PROGRAM – FRIDAY

9:57 am – 10:07 am

The Latest on Femoral Head Resurfacing

Thomas P. Vail, MD

Hip resurfacing has a fascinating history that predates modern total hip replacement. Many early innovators including Charnley, McKee-Farrar, Wiles, Freeman, and Mueller conceived of a hip replacement that resurfaced the articular anatomy of the hip joint. While articular surface replacement of the hip is a procedure that has always made intuitive sense, technology has not always favored success. Early designs were made of acrylic, stainless steel, Tefl on, and polyethylene. Neither the metal on cartilage, nor the metal on polyethylene bearing has proven successful and predictable in clinical practice. Approximately 20% of the UCLA metal on poly resurfacing devices were revised due to bearing failure within four years.

Today’s hip resurfacing implants are not equivalent to their predecessors. Materials science and engineering have made it possible to manufacture extremely precise metal on metal articulations with larger diameter bearings. The sphericity, clearance, high carbon materials, instrumentation, and size options have led to the re-emergence of the hip resurfacing concept. The lubrication regime and consequently the wear of a metal on metal bearing are described by an equation called the lambda ratio. The ideal hard bearing has a fl uid fi lm between its surfaces, thus leading to very low wear. As described by this equation, a fl uid fi lm lubrication regime is more likely as the sphericity increases, the bearing diameter increases, and diametral clearance between the head and socket decrease. Thus, there will be some variance among resurfacing designs in terms of their wear profi le depending upon how closely they meet the optimal design prerequisites. From a clinical perspective, resurfacing offers potential advantages of bone conservation, joint stability, and a low wear bearing. Long term follow-up is not presently available.

Over the last 4.5 years we have performed close to 120 metal on metal hip resurfacings as part of an Investigational Device Study. We have recently reviewed our minimum 2 year experience. Hip resurfacing was performed in 45 hips (minimum follow-up 2 years). Patients were followed prospectively and compared to a contemporaneous cohort of 123 cementless THA. The resurfacing group was statistically better in both the total Harris hip and individual component scores. After controlling for age, the fl exion and activity level remained statistically superior in the resurfacing group. One patient (2.2%) in the resurfacing group (femoral neck fracture), and two patients (1.7%) in the THA group (1 femoral fracture, 1 infection) required reoperation.

*Class II Investigational device, not FDA approved. Dr Vail received research support from Wright Medical and is a designer of the ASRTM by DePuy.

Notes: SYMPOSIUM IV – ARTHROSCOPIC VS. OPEN REPAIR FOR ROTATOR CUFF TEARS

Moderator: Charles A. Rockwood, Jr., MD

10:21 am – 10:36 am

Arthroscopic

William Mallon, MD

Rotator Cuff Repairs

  • First reports in 1911 and 1912 by Ernest Amory Codman, MD

  • Neither fully repaired — suture à distance

  • He usually did an acromial osteotomy

  • 1934 — Codman reported his series of RCR in his classic book on shoulder surgery

  • 1970s — Neer furthered our knowledge of rotator cuff pathology

  • Described impingement

  • Described three phases of rotator cuff involvement

1980s — Shoulder Arthroscopy

  • Shoulder arthroscopy began to become a reality, following advances in knee arthroscopy

  • Most early shoulder surgery was joint débridement, and diagnostic only

  • Late 1980s, arthroscopic acromioplasty

  • Ca 1990, early attempts at instability repair

Early- to Mid-1990s — Shoulder Arthroscopy

  • Arthroscopic RCR is attempted. Lanny Johnson MD performs ARCR using metal staples with poor results

  • Pioneers of the technique

  • Steve Snyder (Los Angeles/SCOI)

  • Steve Burkhardt (San Antonio)

  • Rich Caspari (Richmond)

  • Buddy Savoie (Jackson, MS)

  • Jeff Abrams (Princeton, NJ)

My Own Early Experience

  • Late 1998 — 60ish female, very wealthy (lives near Carl) with RCT

  • I did an open RCR on her

  • She complained constantly about the pain and the appearance of the scar, but eventually did well

  • My impetus to learn ARCR

  • Began performing ARCR in late-1999

  • Always opened the repairs and examined them initially

  • Currently have done over 1,000 ARCR

  • It took me 2 years and almost 300 cases before I felt comfortable with this

  • Early — opened all repairs

  • Open repairs — did with all arthroscopic instruments to learn technique

  • Examined all ARCR by going back into the gleno-humeral joint

  • Examined all my open RCR by looking arthroscopically at gleno-humeral joint

  • Compared arthroscopic vs. hand-tied knots

  • Mid-2004 — did ARCR on that 60ish female from Chapel Hill on her opposite shoulder

  • She complained constantly about the pain and the appearance of the scar, but eventually did well

  • She did admit recovery was easier on the arthroscopic side

Arthroscopic RCR — Point-Counterpoint

    • Cannot see the RCT as well arthroscopically as open

    • • I would argue one can see it better as with knee arthroscopy vs. arthrotomy
    • Cannot tie arthroscopic knots as well

    • • I have compared these and I can assure you one can tie better arthroscopically
    • Simple sutures are not suffi cient to repair RCT

    • — need Mason-Allen/SCOI
      • We are now developing techniques to do horizontal mattress sutures and double-row technique may make this a moot point

      • Many more simple sutures are placed in arthroscopic repairs, which may make the necessity for complex stitches less necessary

    • Suture anchors are not suffi cient, must do bone tunnels

      • Maybe an argument in early days, but pull-out strength of suture anchors is now pretty strong

      • I have also done repairs through bone tunnels (using curved bone awls) and this is coming

      • In fact, Carl B sells a device that is making this possible

  • Can only repair small tears, cannot possibly repair large tears

SCIENTIFIC PROGRAM – FRIDAY

• I no longer ever open on large or massive tears that I cannot repair. I have now learned I cannot repair these any more better open than I can arthroscopically (echoed by many)

• High rate of failure in ARCR series — reference the famous Yamaguchi series

  • Actually, comparison studies have shown similar re-tear rates in open and arthroscopic RCR

  • No clinical difference in comparison studies

  • Yamaguchi series was only in large/massive tears and re-tear rate in these is huge in open repairs as well

My Own Comparison Series

  • 27 patients with bilateral RCR — one done open, one done arthroscopically

  • F/U — 7.8 years on open, 1.7 years on arthroscopic

  • ROM improvement similar in both shoulders

  • Strength improvement similar in both shoulders

  • Preference — 20 equal (no preference), 3 preferred open, 4 preferred arthroscopic

  • Ease of Recovery — 23 called recovery easier with arthroscopic, 4 said there was no difference

— nobody said open was easier

Arthroscopic RCR — Advantage

  • No disruption of deltoid muscle — remember the biomechanical camel’s back

  • Can address intra-articular pathology (minimal help, I think)

  • Studies have shown mini-open may have highest rates of stiffness

  • May start more aggressive PT earlier

Arthroscopic RCR — Learning

  • It is a diffi cult learning curve — took me 2 years with a large volume

  • But current technology is better and more ways to learn this currently

  • Orthopaedic Learning Center

  • Try some for awhile then go watch somebody (Jeff Abrams) — better than watching somebody before you start — you will be intimidated

  • Residents and fellows coming out now will be learning this technique and it will become common, as with arthroscopic ACL reconstruction

  • Open all your early repairs and examine them

  • Look at all your open repairs arthroscopically

  • Learn to use arthroscopic instruments on open repairs to help get familiar with them

Current Standard

  • Open RCR is an effective technique and I never impugn anybody using the open or mini-open technique

  • But arthroscopic RCR is now becoming equally effective and is likely the way of the future

Conclusion

  • “They’re wrong!”

  • “I’m right!”

  • “I win!”

Notes: SYMPOSIUM IV–ARTHROSCOPIC VS. OPEN REPAIR FOR ROTATOR CUFF TEARS

Moderator: Charles A. Rockwood, Jr., MD

10:37 am – 10:52 am

OPEN

Carl Basamania, MD

Notes:

Friday, August 5, 2005

11:25 am – 11:35 am

Orthopaedic Research and Education Foundation (OREF) Presentation

Mr. Gene Wurth

President and CEO

Notes:

SCIENTIFIC PROGRAM – FRIDAY

11:36 am – 11:51 am

American Academy of Orthopaedic Surgeons (AAOS) Presentation

James H. Beaty, MD

Second Vice President

Notes:

Friday, August 5, 2005

PRESIDENTIAL GUEST SPEAKER PRESENTATION

11:52 am – 12:28 pm

Refl ections on Graft Selection in ACL Reconstruction: The Case for Allograft

Gary G. Poehling, MD

Notes:

Moderator: Don D’Alessandro, MD

1:30 pm – 1:37 pm

Reverse Shoulder Prosthetic Replacement: Indications, Technique, and Early Outcomes

Eric MacLeod, MD Spero G. Karas, MD

Introduction: We discuss the early results of our fi rst 15 patients treated with reverse shoulder arthroplasty.

Materials: 15 RSP procedures (13F : 2M; age 75.1) were performed for rotator cuff arthropathy (RCA) (n=8) or a failed prosthetic replacement with rotator cuff defi ciency (n=7). Patients were assessed pre-opera-tively with VAS pain, range of motion, ASES, and SF36 outcomes tools.

Results: Nine patients were available for a minimum 6 month follow-up. Pre-operative pain (0-10 scale) averaged 8.7. Pre-operative forward elevation was 58.0 degrees. The mean pre-operative ASES score was 30.2. The mean pain score improved to 0.4. Post-operative elevation improved an average of 30 degrees. The mean post-op ASES score was 76.2. There were signifi cant improvements in multiple arms of the SF-36.

Discussion: Our early results indicate that reverse shoulder arthroplasty may be a viable option in patients with RCA or failed prosthetic replacement with rotator cuff insuffi ciency.

Notes: Saturday, August 6, 2005 SESSION V – SPORTS/SHOULDER

Moderator: Don D’Alessandro, MD

1:38 pm – 1:45 pm

The Effect of Low-Intensity Pulsed Ultrasound on Rotator Cuff Healing in a Sheep Model

Richard J. Hawkins, MD John M. Tokish, MD Theodore Schlegel, MD Simon Turner, BVSc†, MS Donna Wheeler, PhD Troy Trumble, DVM, MS

The purpose of this study is to evaluate the mechanical and histological effects of low-intensity pulsed ultrasound on rotator cuff repair in a sheep model.

A pre-hoc power analysis was performed. All sheep underwent a resection and subsequent reattachment of the infraspinatus tendon. Sheep were randomly assigned to either treatment with a low-intensity pulsed ultrasound device (US) or a control group. The treatment group received US for twenty minutes, twice daily. At twelve weeks postoperatively specimens underwent non-de-structive mechanical testing. The two groups were then randomly assigned to destructive mechanical testing or histologic analysis.

Rotator cuffs treated with US showed a 30% and 36% increase in failure and ultimate load-to-failure respectively at 12 weeks (p<0.05). Histologic scoring analysis revealed signifi cant improvements in the healing of the bone tendon interface and remodeling of the subchondral bone (p<0.05).

Our data suggest that healing and strength after rotator cuff may be signifi cantly enhanced by treatment with low-intensity pulsed ultrasound.

Notes:

SCIENTIFIC PROGRAM – SATURDAY

Moderator: Don D’Alessandro, MD

1:46 pm – 1:53 pm

Scapulothoracic Arthroscopy: Indications, Review of Literature, and Report of 24 Patients

David Cole, MD

T. Adam Ginn, MD Adam Smith, MD Gary Poehling, MD

Introduction: The purpose of this study was to evaluate the safety and effi cacy of arthroscopy of the scapulothoracic joint with bursectomy and endoscopic resection of the superomedial corner of the scapula with a long term follow-up review.

Methods: This study reports on a series of 24 patients who underwent arthroscopic debridement of the scapulothoracic joint with endoscopic partial resection for treatment of snapping scapula between 1993 and 2000. There was a mean age of 40.2. A chart review was conducted for evaluation at an average of 7.6 years post-op-eratively. Instruments administered included the Visual Analog pain Score (VAS), the ASES shoulder function index (SFI), and a specialized questionnaire.

Results: Of the 24 patients, 4 were unavailable for fol-low-up. Of the remaining 20 patients, 3 had bilateral procedures which were assessed as separate procedures for a total of 23 patients. At fi nal follow-up the average VAS was 2.5 and the average SFI was 73.7. 16 of 20 could return to their previous work, and all 20 could participate in their previous activities. 22 out of 23 patients were considered to have good or excellent results. Overall patient satisfaction with the procedure was high (22 of 23), and there were no complications. All patients surveyed would recommend the procedure to another patient, and 95% would undergo the procedure again. By subjective, patient reported analysis there was a statistical signifi cance (paired T test) in both improvement in pain and function.

Conclusions: We conclude that arthroscopy of the scapulothoracic joint with bursectomy and endoscopic resection of the superomedial scapula is a safe and effective treatment for snapping scapula.

Notes:

Moderator: Don D’Alessandro, MD

1:54 pm – 2:01 pm

Complications of Operatively Treated Proximal Humerus Fractures

Adam M. Smith, MD Rodrigo M. Mardones John W. Sperling, MD Robert H. Cofi eld, MD

Introduction: There is minimal information regarding complications following operatively treated proximal humerus fractures.

Methods: 116 shoulders had operative treatment of acute proximal humerus fractures (93 had osteosynthesis, and 23 had hemiarthroplasty). Patients were assessed for “acute” and “early” medical and surgical complications.

Results: In shoulders with osteosynthesis, the overall complication rate was 58% with twenty-two shoulders requiring further surgery. Initial fracture malpositioning and fracture displacement were encountered frequently. Fixed angle plates had lower rates of initial malpositioning and resultant malunion compared to other fi xation constructs. In shoulders undergoing hemiarthroplasty, the overall complication rate was 74% with most complications resulting from issues of tuberosity healing.

Discussion: Efforts at osteosynthesis should be directed to obtaining anatomic fracture fi xation that resists fracture displacement. Complications related to tuberosity reconstruction after hemiarthroplasty are common. A stabile shoulder with healed tuberosities should be the primary goal in the immediate and early phase of recovery.

Notes: Saturday, August 6, 2005 SESSION V–SPORTS/SHOULDER

Moderator: Don D’Alessandro, MD

2:02 pm – 2:09 pm

Fixation of Proximal Humerus Fractures Using a Spiral Blade Intramedullary Nail System Augmented with Norian SRS Cement

Michael S. Wildstein, MD Yuehei An, MD Michael Horan, BS Langdon Hartsock, MD

Introduction: Osteoporosis is responsible for 1.5 million fractures each year. Approximately 50% of women over the age of 50 and 33% of men over the age of 70 will have a fracture secondary to osteoporosis. Traditional internal fi xation of displaced proximal humerus fractures consisted of an intramedullary nail with screw fi xation. However, screw cutout from poor bone stock has been a signifi cant problem. The purpose of this study was to test the strength of the newly deveoped spiral blade intramedullary nail system (SBIN, Synthes, Paoli, PA) when augmented with the bioabsorbable bone cement, Norian (Norian Co, Cupertino, CA).

Methods: Twelve pairs of sawbones and twelve pairs of fresh frozen cadaveric humeral bones (range 55 — 82 years, average 69 years) were obtained. X-rays showed signifi cant osteopenic changes in the cadaveric bones. An osteotomy was made in each bone to reproduce a Neer two part humeral fracture. The fracture was reduced and the SBIN construct was inserted into the proximal humerus. In augmented specimens, the spiral blade was then removed and 10ml of Norian was injected into the void in the humeral head created by the spiral blade. The blade was then reinserted, the bones wrapped in moist towels and placed in an incubator at 37°C overnight. Each bone/SBIN construct underwent either torsional or cantilever testing using a hydraulic mechanical testing system (MiniBionix 858; MTS, Eden Prarie, MN). A specially designed component was used to convert the normally axially applied load into a torsional force, and a y-type adapter was utilized in the cantilever testing. The ultimate load to failure for each humerus was determined, with the machine run under

SCIENTIFIC PROGRAM – SATURDAY

displacement control at a rate of 25 mm/min. An identical procedure was followed for all humeri. Data were evaluated using paired students t-test.

Results: The ultimate load to failure of the Norian augmented and non-Norian augmented humeri were compared under cantilever and torsional stresses. In the torsional testing with 6 pairs of sawbones, the difference was statistically signifi cant (Cemented: 1035±338 N, non-cemented: 454±249 N, p = 0.00056). In the cadaveric humeri, there was an obvious trend of increased ultimate load sustained by the Norian augmented specimens (Cemented: 527±103 N, non-cemented: 342±126 N, p = 0.07). In the cantilever testing with 6 pairs of sawbones, the difference was statistically signifi cant (Cemented: 355± 23N, Non-cemented: 242± 74N, p = 0.015). In the cadaveric cantilever humeral tests, again, there was a statistically signifi cant difference between the norian augmented and non-augmented humeri (Cemented: 650± 206N, Non-cemented: 457± 186N, p = 0.049).

Discussion: The data indicates that that the SBIN system is an effective method for fi xation of Neer two part fractures of the proximal humerus. Particularly in osteoporotic bone in which traditional cancellous screws lack suffi cient purchase, Norian augmentation shows a clear trend in increasing load to failure. Unlike the extensive exposures necessary for plating, the limited approach with the SBIN system allows for the preservation of soft tissues. In addition, the stable fi xation makes early range of motion possible, which allows for bone remodeling and early callus formation. The addition of the spiral blade alone to the intramedullary construct yields an increase in surface area contact in the proximal humerus, allowing for a more stable fi xation compared with traditional humeral nails. When combined with the void fi lling bone cement, Norian, this study demonstrates increased strength in the fi xation of proximal humerus fractures. This fi xation modality may therefore be particularly useful in osteoporotic bone.

Notes:

Saturday, August 6, 2005 Saturday, August 6, 2005
SPECIAL FOCUS PRESENTATION PRESIDENTIAL ADDRESS
2:10 pm – 2:20 pm 2:32 pm – 3:02 pm
How and Why I Fix Clavicle Fractures Mentors and Heroes
Carl Basamania, MD Lamar L. Fleming, MD
Notes: Notes:

SCIENTIFIC PROGRAM – SATURDAY

SYMPOSIUM V – OPERATIVE VS. NONOPERATIVE MANAGEMENT OF TYPE III AC INJURY

Moderator: Charles A. Rockwood, Jr., MD

3:24 pm – 3:39 pm

Operative

Don D’Alessandro, MD

Notes:

Saturday, August 6, 2005

SYMPOSIUM V – OPERATIVE VS. NONOPERATIVE MANAGEMENT OF TYPE III AC INJURY

Moderator: Charles A. Rockwood, Jr., MD

3:40 pm – 3:55 pm

Non-Operative

Richard J. Hawkins, MD

This report will discuss the Powers and Bach survey in 1974 and Cox updated Power’s survey in 1992 that talk about orthopaedic sports medicine surgeons preferences regards treating grade III acromioclavicular dislocations. We will talk about the functional anatomy of the AC joint and the implications of such for non-operative management. Will discuss what happens when we don’t operate on acute grade III dislocations in terms of deformity, shoulder convalescents, early return to work and sport, little evidence of any strength deficients, secure complications, etc. Athletes will be discussed related to several publications as being very favorable. Also, we will talk about comparison of operative and non-opera-tive treatment in athletes and the preference and the outcomes by most to suggest non-operative treatment. The management of these will be discussed in terms of injecting the AC joints, return to play and implications of later surgery.

Notes: PRESIDENTIAL GUEST SPEAKER AND DISTINGUISHED SOUTHERN ORTHOPAEDIST PRESENTATION

4:07 pm – 4:27 pm

Traumatic Shoulder Dislocation in the Contact Athlete: Fix It!

Charles A. Rockwood, Jr., MD

Notes: Saturday, August 6, 2005 SESSION VI – SPINE/TUMOR

Moderator: William Ward, MD

4:28 pm – 4:35 pm

Management of Proximal Femoral Metastatic Disease with Resection and Endoprosthesic Replacement: Indications and Perioperative Complications

Christopher P. Cannon, MD Alan Yasko, MD Pat Lin, MD Valerae Lewis, MD

Introduction: The proximal femur is the most common appendicular skeletal site for bony metastases. Treatment with conventional internal fi xation, intramedullary nails or standard arthroplasties may be inadequate to address the extensive disease or failure of previous fi xation that is often encountered. Our institutional experience with proximal femoral replacements to deal with these scenarios is presented here.

Methods: Our Orthopaedic Oncology database was reviewed to identify all cases of metastatic disease (including multiple myeloma) of the proximal femur that was treated with a proximal femoral replacement. Oncologic diagnosis, surgical indications, methods of reconstruction, length of follow-up, oncologic outcome, perioperative complications, and additional operative procedures were identifi ed. Due to the nature of the disease, long-term follow-up was seldom available.

Results: 59 patients were treated with a proximal femoral replacement for metastatic disease. The most common oncologic diagnoses were metastatic cancer of the kidney, breast, lung, and prostate, as well as multiple myeloma. Indications for surgery were pathologic fracture with extensive disease in 24, impending fracture with extensive disease in 18, failed previous fi xation in 15, and solitary metastases in 2. The mean follow-up period was 14 months and ranged from 7 days to 123 months. 41 patients died of disease, 7 are alive with disease, 5 are alive with no evidence of disease, and 6 have been lost to follow-up. A total of 13 perioperative complications occurred in 10 patients and included 3 hip dislocations, 4 wound infections, 1 superfi cial wound dehiscence, 4 deep venous thromboses, and 1

SCIENTIFIC PROGRAM – SATURDAY

pulmonary embolism. The mean time to death averaged 15 months and ranged from 7 days to 117 months. Only 3 deaths occurred in the fi rst post-operative month, and none were related to the surgical event.

Discussion and Conclusion: Metastatic disease to the proximal femur is a relatively common occurrence and thus is managed by both general orthopaedic surgeons and orthopaedic oncologists. Extensive destruction of the proximal femur, with or without a pathologic fracture, can render treatment with more commonly used devices, such as intramedullary fi xation, sliding hip screws, or conventional short-stemmed arthroplasty, inadequate. Also, failure of any of the commonly used devices, especially sliding hip screws, commonly occurs and results in a large area of bony destruction and compromised fi xation. Proximal femoral replacements address these issues and provide stable fi xation, excellent pain relief, and improved mobility. Though this is a high-risk patient population given their underlying medical status and frequent chemotherapy and radiation, the overall complication rate is relatively low, and no perioperative deaths occurred. Thus, this procedure is a safe, viable option for both orthopaedic oncologists and general orthopaedists who manage patients with metastatic disease.

Notes: Saturday, August 6, 2005 SESSION VI–SPINE/TUMOR

Moderator: William Ward, MD

4:36 pm – 4:43 pm

Solitary Epipyseal Enchondromas

Benjamin K. Potter, MD Brett A. Freedman, MD Ronald A. Lehman, Jr., MD Scott B. Shawen, MD Timothy R. Kuklo, MD Mark J. Murphey, MD, AFIP

Enchondromas originating in the epiphyses or periarticular regions of long bones are rare, with fewer than 15 cases reported in the literature. We performed a review of 761 enchondromas seen over a 50-year period and excluded those of the hands, feet, or axial skeleton, as well as those which originated in the typical locations of the metaphysis or diaphysis. This produced a series of 33 patients having solitary lesions with radiographic and pathologic appearances consistent with enchondromas originating in the epiphyses of major long bones. There were 20 men and 13 women, mean age of 27 years (7-61). The most common locations were the humerus (36%) and femur (33%). 61% of lesions demonstrated metaphyseal extension including four of 11 patients with open physes. The majority of patients (70%) presented with complaints of pain, and 79% were amenable to surgical treatment by curettage, although 74% of lesions extended to subchondral bone. Although rare, epiphyseal enchondromas are an important diagnostic consideration in evaluating patients with radiolucent or chondroid epiphyseal lesions. Due to their proximity to the joint space, they appear to be more likely to cause pain and require surgical treatment than other enchondromatous lesions.

Notes:

Moderator: William Ward, MD

4:44 pm – 4:51 pm

Poor Correlation of Biopsy and Resection Diagnosis for Chondrosarcoma of Long Bones

Matthew J. Seidel, MD Alan W. Yasko, MD Valerae O. Lewis, MD Patrick P. Lin, MD Chrisopher Cannon, MD

Introduction: Chondrosarcoma is a heterogenous tumor. Biopsy may be misleading resulting in under-treat-ment. This study compares the biopsy diagnosis with the resection specimen diagnosis in long bones.

Methods: Ninety patients were evaluated. Biopsy versus resection specimen diagnosis was compared by high versus low-grade and by pathologic grade (I, IIa/b, III, dedifferentiated). This analysis was also performed for the following subgroups: anatomic site, needle versus open biopsy, and biopsy done in or out of our institution.

Results: Only 39.76% of the biopsies exactly matched the resection specimen pathologic grade and 65.56% of the biopsies correlated low and high-grade. Of all biopsies diagnosed as low-grade 22.03% were high-grade on fi nal diagnosis. No signifi cance difference existed between subgroups.

Discussion and Conclusion: Biopsies for chondrosarcoma are fraught with inaccuracy. The greatest utility of the biopsy may be to confi rm the existence of a cartilage tumor. The treating physician must be able to use the biopsy information in the context of the radiographs to treat patients appropriately.

Notes: Saturday, August 6, 2005 SESSION VI – SPINE/TUMOR

Moderator: William Ward, MD

4:52 pm – 4:59 pm

Biomechanical Features of Total Disc Arthroplasty Using a Canine Model

Brett A. Taylor, MD Gbolahan O. Okubadejo, MD Michael R. Talcott, DVM, DACLAM Toshihiro Imamura, MD

K.D. Riew, MD

Introduction: The objective of this study is to use a canine model to study the biomechanical properties of total disc arthroplasty as an alternative to arthrodesis.

Methods: 37 dogs underwent lumbar disc arthroplasty or fusion at L5-6 via a transperitoneal approach. Animals were sacrifi ced at 0 and 3 months. Analysis of axial rotation, fl exion-extension, and lateral bending at L5-6 level was done in vitro.

Results: For intact spine group (N=11), we obtained range of motion of 0.69º, 7.41º and 9.78º respectively. At time O, fusion group (N=6) had range of motion of 1.74º, 5.47º, and 4.93º, while TDR group (N=3) had ROM of 14.35º, 12.19º and 13.67º. At 3 months fusion group had ROM of 1.31º, 4.13º and 2.25º, while TDR group had ROM of 4.28º, 8.50º and 6.34º.

Discussion and Conclusion: The TDR group had more motion in every plane compared to the fusion group.

Notes:

SCIENTIFIC PROGRAM – SATURDAY

SYMPOSIUM VI – CERVICAL FUSION VS. ARTIFICIAL DISC FOR CERVICAL DDD WITH RADICULOPATHY

Moderator: William Richardson, MD

5:37 pm – 5:52 pm

Artifi cial Disc

John Heller, MD

Notes:

Saturday, August 6, 2005

SYMPOSIUM VI – CERVICAL FUSION VS. ARTIFICIAL DISC FOR CERVICAL DDD WITH RADICULOPATHY

Moderator: William Richardson, MD

5:53 pm – 6:08 pm

ACDF

John Kirkpatrick, MD

Anterior cervical discectomy and fusion (ACDF) is the “gold standard” for anterior surgical management of cervical degenerative disc disease with radiculopathy. Current indications for surgical management in radiculopathy include 1) radiculopathy unresponsive to non-operative treatment for 6-12 weeks, 2) progression of neurologic defi cit, and 3) signifi cant radicular pain with static defi cit. Patients with these indications must have imaging studies with anatomic fi ndings consistent with clinical symptoms and signs.

Surgical decompression of the nerve root(s) and/or spinal canal is the primary reason for performing the surgical procedure. Fusion was developed by Robinson and is commonly used to stabilize the spine and further aid in the resorption of osteophytes. Decades of success have followed with improved rates of fusion following modifi cations in the end plate preparation technique. Nonunion rates of <5% in single level fusions are expected using contemporary techniques. Complications from the fusion portion of the procedure are nonunion and graft site complications. Nonunion has been attributed to patient factors of smoking, multilevel fusion, and revision surgery.

Fusion technique is important to the success of the procedure. Following discectomy, the endplates should be prepared such that fl at surfaces are present with bleeding bone for accepting the bone graft. This can be done with either a curette or a high-speed burr. The bone graft of appropriate size is then gently impacted into position with the disc space distracted. The graft should be undersized in the sagittal plan to prevent intrusion into the spinal canal. The graft is generally countersunk into the disc space, although if a plate is added this is not necessary. An intra-operative radiograph is obtained to ensure appropriate placement of the graft.

Postoperative care includes the short term use of a drain and immobilization in an orthosis (if no plate used) or soft collar (if plate used) for 3-6 weeks.

Long-term studies have found that approximately 10% of patients have additional surgery due to spondylosis or herniation at an adjacent level. Hilibrand noted that the occurrence of adjacent segment disease with symptoms was 2.9% per year, with approximately 2/3 of symptomatic patients proceeding to surgical intervention. They believe that adjacent segment disease was from progressive spondylosis and not caused by the fusion itself.

This is in agreement with biomechanical studies showing that adjacent segments are not subjected to a disproportionate loading after cervical fusion.

Alternatives to fusion should be evaluated from several perspectives. Such alternative procedures should be directed at solving a well-defi ned problem with a logical rationale. Safety should be established in short term by evaluating surgical complications and in long term with clinical, radiographic, and retrieval studies with failure analysis. Safety should be compared with fusion and no difference found in incidence or severity of complications. Effectiveness should be compared to fusion in long-term clinical trials and be better than fusion. There should be a signifi cant benefi t noted in a signifi cant proportion of the population. Once safety and effectiveness are determined, then cost-benefi t analysis should be done to demonstrate whether added expense, if any, is resulting in adequate benefi t for our patients.

ACDF has set a high standard for clinical success. It may take many years and a high volume of patients to demonstrate superiority over a 92% overall success rate at 6 years follow-up.