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4James J. Irrgang, PhD, PT and Volker Musahl, MDImproving Outcomes for Multiple Ligament Knee Injuries
10John R. Fowler Jr., MDDiagnosing Carpal Tunnel Syndrome With Ultrasound: Better, Faster, and Cost-Effective
18Michael J. O’Malley, MDNew Frontiers in Hip and Knee Arthroplasty
14Carola van Eck, MD, PhDA Continuing Legacy of Pioneering Sports Medicine and ACL Research
24Gele B. Moloney, MDGeriatric Fractures: Causes, Complications, and Contributing Factors
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Founded in 1953 as a separate department
of the University of Pittsburgh School of
Medicine, the Department of Orthopaedic
Surgery is committed to delivering the
highest quality of diagnostic and therapeutic
patient care to both adults and children for
a diverse spectrum of orthopaedic disorders.
To this aim, the department seeks to meet
the needs of 21st century orthopaedic care
not only by integrating the latest biological
and technological advancements in
orthopaedic science, but equally by leading
the development of novel treatment
modalities through distinguished basic
science and clinical research programs.
In addition, the Department of Orthopaedic
Surgery seeks to be a leader in educating
the next generation of orthopaedic
surgeons through its residency and
fellowship training programs, which include
comprehensive, in-depth exposure to
all specialties of orthopaedic care and
advanced surgical experience.
Freddie H. Fu, MD, DSc (Hon), DPs (Hon)
Chairman
ABOUT THE DEPARTMENT OF ORTHOPAEDIC SURGERY
•AdultReconstructiveSurgery andMusculoskeletalOncology•Concussion•FootandAnkleSurgery•Hand,UpperExtremity, andMicrovascularSurgery•OrthopaedicTrauma•PediatricOrthopaedics•Research >Biomedical >ClinicalOutcomes >Computer-assistedSurgery >Kinematics >RegenerativeMedicine >StemCell•SpinalSurgery•SportsMedicineandShoulderSurgery
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Centers of Excellence
A Resource for You
UPMCPhysicianResourcesdeliversworld-classphysiciansandfreecontinuingmedicaleducationopportunities.Youcanviewpublicationsandphysicianpodcasts,andcompletefreecontinuingmedicaleducation,quicklyandeasily.FindoutmoreatUPMCPhysicianResources.com/Ortho.
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James J. Irrgang, PhD, PT
Volker Musahl, MD
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In2017,researchersfromtheDepartmentofOrthopaedicSurgerywereawardedamajornewgrant1(ContractNumber:W81XWH-17-0073)fromtheUnitedStatesDepartmentofDefense(DoD)tostudyanddetermineoptimaltimingforsurgeryandrehabilitationofmultipleligamentkneeinjuries(MLKIs).OfficiallytitledtheSurgical Timing and Rehabilitation (STaR) for Multiple Ligament Knee Injuries (MLKIs): A Multicenter Integrated Clinical Trial2,the$4.5millionrandomizedtrialisledbyco-principalinvestigatorsJames J. Irrgang, PhD, PT,professoranddirectorofclinicalresearchintheDepartmentofOrthopaedicSurgeryandchairmanoftheDepartmentofPhysicalTherapy,andVolker Musahl, MD,associateprofessorandchiefofsportsmedicine.
Currenthigh-levelevidenceisscarcetononexistentregardingwhenitisbesttoperformsurgeryandrehabilitationforcasesofmultipleligamentkneeinjuriestooptimizeoutcomesandreturnindividualswithanMLKIto,orascloseaspossibleto,theirpreinjurylevelofactivityandphysicalfunction.MostoftheguidingprinciplesusednowarebasedonACLreconstructionsurgery,whereearlysurgeryandearlyrehabilitationaftersurgeryisthestandardofcare.However,MLKIsareamuchbroader-spectrum,heterogeneousinjurywhenconsideringwhatandhowmanydifferentstructuresofthekneecouldbeaffected,andwhatkindofcorrectivesurgeryisrequiredtorepairthedamagedtissues.Theseserious,complex,multidimensionalinjuries,whilenotexceedinglycommoninoccurrence
(theincidenceinthegeneralpopulationisnotexactlyknownbutmaybeapproximately0.072per100patient-yearsincivilianswithorthopaedicinjuries3),arequitedevastatingintheirconsequences.Theseinjuriesareoftenaccompaniedbysignificantnerveandvasculartrauma,aswellasfracturesandinjurytosurroundingtendonsandstructures.MLKIsoftenaretheresultofhigh-energytraumaincidents,aswellashigh-impactsportssuchasfootballandotherstrenuousactivitiessuchasmilitarytraining.MLKIscarrywiththemarangeofpotentialpostsurgicalandrehabilitationcomplications.Theseincludepoorwoundhealing,arthrofibrosis,posttraumaticosteoarthritis,pain,andpersistentjointinstability,amongotherchallenges.
IMPROVING OUTCOMES FOR MULTIPLE LIGAMENT KNEE INJURIES
Pre- and post-reduction multiple ligament knee injury x-rays.
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Giventhesignificantresourcesintimeandcostsoftrainingandmaintainingtheiractivedutymembers,achievingbetteroutcomesforindividualswhosufferthistypeofinjuryisofsignificantconcernfortheDoD.Formilitarypersonnel,returntodutyatpreviouslevelsaftersustaininganMLKImaybeaslowas40percent.Inthecivilianpopulation,returntoworkatpreinjurylevelsisontheorderof80percent,however,thisisdependentonthetypeofworktheindividualdoes.Furthermore,thetimetoreturntopreinjuryactivitylevelhasnotbeenstudied.
This Study Will Address a Gap in the Literature
Whyisn’ttherecurrentlyagoodbodyofevidencetosupporttheoptimaltimingofsurgeryandrehabilitationfortheseinjuries?Dr.Musahlexplainsthatitcomesdowntotwomainfactorswiththeseparticularinjuries.“Ifyouexaminetheliterature,itisverydifficulttofindstudiesthatareprospectivebecauseoftheseverityofthisinjuryandconcomitantfactorssuchasvascularandnerveinjuries,openfractures,andheadandpoly-trauma.Thismakesitdifficulttorandomizepatientsinastudy.Thisiswhymostofthestudiesdonetodatehavebeensmallincohortsize,anduniversallyretrospectiveinnature.”
Thisalludestothesecondreasonforalackofclear-cutevidencefortimingoftreatment—therelativerarityoftheseinjuries.“Theonlywaythatyoucanhaveapowerfulenoughstudyofthisinjury,becauseoftherelativelylowincidencecoupledwiththefactthatwewillnecessarilyexcludemanypatientsfromthetrialbecauseofconcomitantinjuries,istodesignamulti-centertrial,”saysDr.Irrgang.
STaR Trial Participating Sites Site PI
UniversityofPittsburgh(LeadSite) JamesIrrgang,PhD
UniversityofPittsburgh-DCC CharityMoorePatterson,PhD
BrownUniversity BrettOwens,MD
HealthPartnersInstituteforEducationandResearch(Minneapolis,Minnesota)
JonathanCooper,DO
HospitalforSpecialSurgery(NewYork) AnilRanawat,MD
KellerCommunityArmyHospital(WestPoint,NewYork) MatthewPosner,MD
MayoClinic(Rochester,Minnesota) BruceLevy,MD
NovaScotiaHealthAuthority–QueenElizabethHealthSciencesCenter CathyCoady,MD
SanAntonioMilitaryMedicalCenter TravisBurns,MD
St.Michael’sHospital(Toronto) DanielWhelan,MD
TRIAOrthopaedicCenter(Bloomington,Minnesota) BradleyNelson,MD
TriplerArmyMedicalCenter(Honolulu,Hawaii) CraigBottoni,MD
UniversityofCincinnati BrianGrawe,MD
UniversityofConnecticut RobertArciero,MD
UniversityofKentuckyResearchFoundation DarrenJohnson,MD
UniversityofMichigan JohnGrant,MD
UniversityofMinnesota JeffMacalena,MD
UniversityofNewMexicoHealthSciencesCenter RobertSchenckJr.,MD
UniversityofTexasHealthSciencesCenteratHouston ChristopherHarner,MD
UniversityofVirginia MarkMiller,MD
UniversityofWashington(Seattle) AlbertGee,MD
UniversityofWesternOntario(London,Ontario) AlanGetgood,MD
WalterReedNationalMilitaryMedicalCenter(Bethesda,Maryland) JeffreyGiuliani,MD
WashingtonUniversity(St.Louis) MatthewMatava,MD
WilliamBeaumontArmyMedicalCenter(ElPaso,Texas) MarkPallis,MD
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WithapilotgrantfromtheDoDin2015,that’sexactlywhatDrs.IrrgangandMusahlaccomplished:developingtheprotocols,assemblingthesitesandnecessaryanalyticalresourcesincludinganonsitedatacenterandstatistician,andeventuallybuildingatrialframeworkthattheDoDhasnowfundedinfulltoattempttoshedthenecessarylightonhowbesttotreattheseinjuries.
Drs.IrrgangandMusahlhaveassembledacohortof24UnitedStatesArmedForcesentitiesandacademicmedicalcentersacrosstheUnitedStatesandCanadathatwillbeparticipatinginthetrialandenrollingpatients.Andrew Lynch, PhD, PT,assistantprofessorintheDepartmentofPhysicalTherapyattheUniversityofPittsburgh,isservingasthequalifiedclinicalinvestigatorforrehabilitationinthestudy.Dr.Musahlisservinginthatrolefromasurgicalperspective.Charity Moore Patterson, PhD,professorintheDepartmentofPhysicalTherapy,willserveasco-investigatorandleadbiostatisticianforthestudy.
Study Aims and Details
TheSTaRTrialiscomprisedoftwoseparatestudiesexaminingsubpopulationsofindividualswithanMLKIandrandomizingthemintoappropriatearmsofthestudybasedoninjurycriteria,timingofpresentation,andconcomitantinjuriesthatwouldrequireorprecludeearlysurgicaltreatment.
Thefirstaimofthestudyistodeterminethecombinedeffectsrelatedtothetimingofsurgeryandrehabilitationontheamountoftimeittakesforenrolledpatientstoreturntotheirpreinjurystatusandactivity.Individualspresentingfortreatmentwithinsixweeksofsurgerywhoarebetweentheagesof14and65willbeeligibleforthestudyandwillincludebothmilitarypersonnelandcivilianswhohaveamultipleligamentkneeinjury.Individualswithapasthistoryofkneereconstruction,orthosewhohaveassociatedvascularinjury,polytrauma,ortraumaticbraininjury,willbeexcludedfromparticipation.
Participantsinthefirststudywillberandomizedintooneoffourgroups:
•• Early•Surgery•and•Early•Rehabilitation
•• Early•Surgery•and•Delayed•Rehabilitation
•• Delayed•Surgery•and•Early•Rehabilitation
•• Delayed•Surgery•and•Delayed•Rehabilitation
“Ourhypothesisatthestartisthatearlysurgeryandearlyrehabilitation,andthecombinationthereof,willleadtobetteroutcomes,”saysDr.Musahl.“Earlysurgerysometimesenablesustorepairstructuresthatmaynotbepossibletorepairifthereisadelay,becauseofearlydegenerationorretractionfromconnectingtissues.Usingtissuegraftsandanatomicalreconstructionmayalsoaffordbenefitsinthisregard.Butwemayfind,too,thatinsomecasesorvariationsoftheinjury,patientsmaybenefitfromacourseofrehabilitationfirst—theconceptofpre-rehab—inessenceprimingthemusculoskeletalsystemforwhatistocomeaftersurgeryandduringthepostoperativerehabilitationphase,whichfortheseinjuriescanbeayearormoreinduration.”
Photo depicting a current rehabilitation patient with a previously dislocated knee and multiple ligament injury.
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Thesecondaimofthestudywillseektodeterminetheeffectsofthetimingofrehabilitationonthetimetoreturntoactivity.ParticipantsinthisaspectofthestudywillhavehadanMLKIforwhichthetimingofsurgerycannotberandomized.Thesepatientswillberandomizedintoeitherearlyordelayedrehabilitation.Participantsinthiscohortalsowillhavehadaninjurythatprecludestheirrandomizationintosurgery,orwhoforonereasonoranotherhaverefusedordeclinedrandomizationtosurgery.
Ontherehabilitationside,thereexistslittletonoevidenceatallabouthowbesttorehabilitatetheseinjuriesaftersurgery.“Theyarejustextensiveinjuriesrequiringdetailedsurgery.Typically,surgeonsareconcernedaboutprogressinganindividualtooquicklylesttheydisruptarepairorgraft.ThisiswhyIthinkmostindividualswithMLKIdoverylittleweightbearingandlimitedmotionforthefirstfourweekspostoperatively.However,whenyoureviewtheevidenceforACLreconstruction,itoverwhelminglyshowsbetteroutcomeswithearlyweightbearing,strengthening,andrangeofmotionexercises.Thequestionthenbecomes:Canyouapplythosesameprinciplestothesemoresignificantinjuriesandassociatedsurgeries?Theconcernisthatifwearetooaggressiveearlyonwithrehabilitation,itcoulddisruptwhatwasrepaired,resultinginakneethatistoolooseandunstable.
Ontheotherhand,ifwedelayrehabilitation,particularlycombinedwithearlysurgery,stiffnessandalackofrangeofmotionmayresult.Thisiswhatwearetryingtoanswerwiththeearlyversusdelayedrehabilitationquestion,”saysDr.Irrgang.
Auniqueaspectofthisstudyistheendoutcomemeasurebeingevaluated.“Wearereallyfocusedonthetimetoreturntoapreinjurylevelofactivity.Thiswillinclude,forexample,participationinmilitaryactivities,sportsactivities,andwork.Thishasneverreallybeenlookedatwithkneeinjuries,evenwithACLreconstruction.Wedon’thaveanysolidevidencetoanswerthisquestionoftiming,soweareveryexcitedtotryandquantifythisaspectinourstudy,”saysDr.Musahl.
Randomization Stratification
Multipleligamentkneeinjuriespresentonaspectrum.Theycanpresentanywherefromacompletetearorruptureoftwoligaments,theACLandMCLforexample,toacompletedislocationthatresultsintearsofallfourofthemainligamentswithaccompanyingdamagetocartilage,meniscus,andthelike.“Wethinkthereisabigdifferencebetweentearingonecruciateligamentandsomeotherligament,ortearingbothcruciateligamentswithorwithoutadditionaldamage,”saysDr.Irrgang.Toaccountforthisspectruminthestudy,randomizationofparticipantswillbestratifiedtohelpcontrolthevariabilityseenintheseinjuries.“Statisticalanalysisalsowillenterintothemodeloftheinjuryclassificationtohelpadjustforthesevariances.”
Laying the Groundwork for Future Research
Whilethisnewtrialisjustbeginning,withpatientrecruit-mentsettostartinthecomingmonths,Dr.Musahlseesmuchpotentialfortangential,evendepartment-wide,andnew,relatedavenuesofinvestigationinthefuture,suchashowbiologicapplicationsorinterventionsmayplayaroleandmodulateresponsestosurgeryandrehabilitationincasesofMLKI.
1 The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-14 is the awarding and administering acquisition office.
2 This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs, through the Peer Reviewed Orthopaedic Research Program, under Award No. W81XWH-17-2-0073. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.
“The only way you can have a powerful enough study of this injury is to design a multicenter trials.” James J. Irrgang, PhD, PT
Approximate Return to Duty/Work at previous levels after sustaining an MLKI
Military•Personnel 40%
Civilian•Populations 80%
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Our hypothesis is that early surgery and early rehabilitation, and the combination thereof, will lead to better outcomes.”Volker Musahl, MD
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HandandupperextremitysurgeonJohn R. Fowler Jr., MD,isnotonepronetoinflammatoryremarksfortheirownsake;however,hisadvocacyfortheuseofultrasound(US)isvocalandpassionate,specificallywhendiscussingthediagnosisofcarpaltunnelsyndrome(CTS)withUSversuswhathasbeenusedalmostexclusivelyinthepast—nerveconductionstudies(NCS).“Nerveconductionstudiesdefinitelyhavetheirplace,butthemoreresearchIconduct,themoreI’mconvinceditisnot,exceptinlimitedcircumstances,themostappropriatefirstlinediagnosticforCTS,”saysDr.Fowler.
Dr.Fowler’sworkoverthelast10yearsusing,studying,teaching,andadvocatingfortheuseofultrasoundimagingtodiagnosecarpaltunnelsyndromeisbasedintheevidenceasmuchasitisinhisunwaveringandvocalpassiontohelppatientsbyofferingthemalessinvasiveapproachtodiagnosetheircondition.“Lessinvasiveisalwaysgoodforanykindoftestasfaraspatientsareconcerned,butthetestshavetobereliable,predictable,repeatable,andaccurate,”saysDr.Fowler.MuchofDr.Fowler’sworkoverthelastdecadeandahalfhasbeentoprovethecaseforwideradoptionofultrasoundasafirst-linetestforcarpaltunnelsyndromethroughrigorousstudyandtraining.
Dr.FowlerfirstbecameinterestedintheuseofultrasoundwhileinresidencyatTempleUniversity.“Wewouldseepatientsinclinic,referthemfornerveconductiontesting,andhalformoreoftheseindividualswouldreturnwith-outhavinggottenthetest,duetoalackofappointment
optionsandassociatedcosts.Thediscomfortofthetestitselflikelyalsoplayedaroleinmanyofthesecases.Thisgotmethinkingaboutwhatalternativesandoptionsmightbeouttheretodiagnosethesepatients,”saysDr.Fowler.
FurtherworkasasurgicalfellowattheUniversityofPittsburghaffordedDr.Fowlertheabilitytouseultra-soundforallmannerofcases,allowinghimtogreatlyincreasehisknowledge,skill,andaccuracywiththetechniquebyconductingnearly1,000ultrasoundimagingproceduresduringhistraining.“ThisclinicalworkusingaportableUSmachineattheHandandUpperExtremityCenterreallybecametheimpetusandbasisformuchofmyearlyresearch.”
MostofDr.Fowler’sresearchtodatehasworkedtoconfirmandexpandonpastworkbyothersthatultra-soundisaveryaccuratetestforcarpaltunnelsyndrome.Intherightscenario,ultrasoundhasasimilar—ifnothigher—sensitivityandspecificitycomparedtonerveconductionstudies.“Afocusofmyresearchnowistofindwaystominimizetherateoffalsenegativesandfalsepositives,”saysDr.Fowler.PartofDr.Fowler’songoingstudiesinvolvesunderstandingwhetherornottheheight,weight,andBMIofindividualsmatterintermsoftheirnervesize.“Youwouldthinkthatthiswouldplayarole,however,whatwearefindingisthatthesizeoftheindividualhasverylittleinfluenceontheirmediannervesize,perhapsamillimeterorlessinmostcases.”
DIAGNOSING CARPAL TUNNEL SYNDROME WITH ULTRASOUND: BETTER, FASTER, AND COST-EFFECTIVE
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Recent Research: Comparing US and NCS in Carpal Tunnel Syndrome
In2016,Dr.Fowlerandcolleaguespublishedfindingsofastudy1designedtoassessthecorrelation,ifany,betweencross-sectionalareameasurementsofthemediannerveviaultrasoundimagingwiththemotor/sensorylatenciesofthenervemeasuredwithNCSinpatientswithsuspectedcarpaltunnelsyndrome.Thisblinded,prospectivestudyexamined87suspectedcasesofCTS.Dr.Fowler’sstudyshowedapositivecorrelationbetweenNCSandUS(91percent)instudyparticipants,aswellassimilarlevelsofsensitivityandspecificitybetweeneachtestingmodality(83percentand94percent,respectively).
OtherworkbyDr.Fowlerinvolvespre-andpostsurgicalcorrelationsbetweenfindingsindiagnostictests.“IfyoulookattheliteratureforNCS,youwillfindthatevenafterthesurgery,follow-uptestingdoesnotquiteshowareturntonormal,despitethepatientfeeling100percentbetterandbeingpainfree.We’renotsurewhythatis,butperhapswecancorrelatethosefindingsonultra-soundofthemediannerve,”saysDr.Fowler.Atpresent,Dr.Fowlerhasassembledadatabaseofmorethan500patientswhohavehadpreoperativeultrasound,with150ofthoseindividualshavinghadapostoperative,follow-upultrasound.Analysisisunderwaybetweenthesetwopatientcohortstoseeiftheimprovementsinapatient’snervecross-sectionalareascorrespondwiththeirsymptoms,orlackthereof.
Anotherstudyinprogressisexaminingifthereisaway,usingultrasound,topredicthowlongitwilltakepatientstorecoverdependingontheseverityoftheircarpaltunnelsyndrome.
Training a New Generation of Ultrasound Users
Dr.Fowlerisactivelyinvolvedwitheducation,specificallyrelatedtotheuseofultrasoundinorthopaedicsurgery,butmoregenerallyaswellwithmedicalstudents.Asassistantdeanformedicalstudentresearch,Dr.FowlerwasinstrumentalincreatinganewmusculoskeletaleducationalprogramforsecondyearmedicalstudentsattheUniversityofPittsburghincollaborationwithMaCalus V. Hogan, MD.
Additionally,forthelastseveralyears,Dr.FowlerandcolleagueTom Hughes, MD,haveconductedanultrasoundpre-courseattheannualmeetingoftheAmericanAssociationforHandSurgery.Thesix-hourcourseprovideseducationandtrainingonultrasoundfororthopaedicsurgeons,andisofferedasaseparateregistrationcourse.
SomeofDr.Fowler’seducationwithultrasoundimaginghasfedrecentresearchprojects.Publishedin2017,Dr.Fowler’spaper2inthejournalHand,alongwithcoauthorsJared Crasto, MD,andMichael Scott, MD,soughttoquantifytowhatdegreeandwithinwhattimeframeanindividualcouldbesuccessfullytrainedtouseultrasoundtodetectthesignsofcarpaltunnelsyndromeusingultrasoundandnervecross-sectionalareameasurements.“Surprisingly,thisstudyshowed,inasmallcohort,thatindividualsareabletolearnthetechniqueandmeasurethecorrectstructure—withrelativelyhighdegreesofsuccessandaccuracycomparedtotheirbaselinemeasurementspriortoinstructionandagainstthestudycontrols—inashortperiodoftime.”
Dr. Fowler discusses research findings with orthopaedic surgery resident Chinedu Nwasike, MD.
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Nerve conduction studies definitely have their place, but the more research I conduct, the more I’m convinced it is not, except in limited circumstances, the most appropriate first line diagnostic for CTS.”John R. Fowler Jr, MD
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Carola F. van Eck, MD, PhD,isoneofthenewestfacultymemberstohavejoinedthedepartmentinthesecondhalfof2017.Asportsmedicinespecialist,Dr.vanEck’straininginorthopaedicsurgeryincludedapost-doctoralresearchfellowshipinthedepartmentunderthementorshipofFreddieH.Fu,MD,followedbyherorthopaedicresidencytrainingattheUniversityofPittsburghfrom2011to2016.AftercompletinganorthopaedicsurgeryfellowshipattheCedars-SinaiKerlan-JobeInstituteinLosAngeles,California,Dr.vanEckreturnedtoPittsburghtojointhedepartment’simpressiverosteroffacultymemberswhocontinuetoshapeandguidethefieldoforthopaedicsurgerynationallyandinternationally.
Beyondherresearchinterests,whicharenumerousandincludeanemphasisonanteriorcruciateligament(ACL)reconstructiontechniquesandrepair(herPhDthesisexaminedthechanginganatomicACLreconstructionparadigm),andabusypracticeoftreatingsportsmedicinepatientsattheUPMCRooneySportsComplex,Dr.vanEckalsoservesastheteamphysicianforRobertMorrisUniversity(RMU)inPittsburgh,aswellasbeingateamphysicianforthePittsburghPassionwomen’sfootballteam.Dr.vanEckalsoplayedprofessionalwomen’sfootballherselffrom2008to2011whileworkingasapost-doctoralresearchfellowinPittsburgh.WithRMU,Dr.vanEckismostinvolvedwithfootball,andmen’sandwomen’sicehockey,lacrosse,andbasketball,althoughshetreatsandcoversathletesacrossallofRMU’s16DivisionINCAAsportsprograms.
Research Projects in the Pipeline
Dr.vanEckhasanextensiveresearchportfolio,co-authoring69peer-reviewedpublicationstodateandanother68abstracts.Sheiscurrentlyengagedinseveralnewprojectsincollaborationwiththedepart-ment’sOrthopaedicEngineeringandSportsMedicineLaboratory,whichisco-directedbyDepartmentChairmanFreddie H. Fu, MD,andPatrick Smolinski, PhD,fromtheUniversityofPittsburghDepartmentofMechanicalEngineeringandMaterialsScience.
Monica A. Linde-Rosen, MSIE, RN,isthetechnicalmanagerofthelab,andcontributestoandsupervisesallofitsactivitiesandinvestigations.Thislabhas,andcontinuestobe,ahotbedforresearchintoACLreconstructionandsurgicaltechniques,andrelatedbiomechanicalpropertiesandtissuebehavioroftheligamentitself.Eachyeararotatingassortmentofinternationalfellowscomestoworkatthelabandcontributetoitsongoingresearchprojects.
A CONTINUING LEGACY OF PIONEERING SPORTS MEDICINE AND ACL RESEARCH
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Notchplasty and Knee Biomechanics
Dr.vanEckandcollaboratorsinthelabhaveseveralnewprojectsinthepipelineandinprogressthatarefocusedonaspectsoftheACLandreconstructionandrepairtechniques.
“We are currently working on a grant application to examine the effect notchplasty has on knee biomechanics when performed in the setting of an ACL reconstruction.”NotchplastyisusedroutinelyinthesettingofACLreconstructiontoaidinvisualizationofthefemoralACLfootprinttoaccomplishanatomicgraftplacement,aswellastoavoidimpingementintheintercondylarnotchasthegrafthealspostoperatively.Thetechniqueremovesasmallportionofbonefromthelateralfemoralcondyle.“Wethinktheissueisthatthetechniqueleavesthepatientwithanalteredanatomy.Thetechniqueisnon-anatomicbydefinition,andweareinterestedinhowthiscouldpotentiallychangeaperson’sbiomechanics,”saysDr.vanEck.Thenewstudyinhumanswouldbebasedonananimalmodelversion1previouslypublishedbyDr.Fuandcolleaguesin2012.Thenewstudywouldassesschangesinkneebiomechanicsbasedonthesizeofthenotchplastyperformed.Dr.vanEckandcolleaguesplantoevaluatetwodifferentsizesandamountsofboneremovaltoassesshowthischangeinanatomywouldaffecttherepairandanypost-surgicalcomplications.
Repair Versus Reconstruction
Dr.vanEckandtheOrthopaedicEngineeringandSportsMedicineLaboratoryalsoareengagedinanotherstudyrelatedtotheACLregardingtheuseofinternalbracingofsurgicallyrepairedACLs.“There’sbeensomewhatofaresurgenceoflateinresearchintorepairofarupturedACLversusreconstructionwithagraft.Thisapproach,repairingthenativeligament,requirestheuseofsometypeofinternalbracingviaascaffoldorothertypeofrigidsuturematerialwhiletheACLheals,”saysDr.vanEck.Althoughthetechniqueisinclinicalpracticeinsomesettings,Dr.vanEckexplainsthatthereisreallyalackofqualityevidencefromabiomechanicalandclinicalperspectivetosupportwhetherornotthistypeofprocedureoughttoberoutinelyused,orperhapsconfinedwithinanarrowsetofclinicalindicators.“Thereareafewcasereportsandsmallretrospectiveexaminationsofthetechnique,butnothingconcreteexistsastotheefficacyandpossiblecomplicationsofthistypeofrepair,andwhatmethodologyortypeofbracingmaybebest,”saysDr.vanEck.
Thisstudy,inthedevelopmentphases,willevaluatethebiomechanicalpropertiesofaninternalbracingconstructinthesettingofACLandMCLrepairorreconstructiontodeterminewhetherandtowhatdegreetheconstructaidsinstabilizingthekneeaftertheligamentrepairisperformed.
“Oneofmyconcernsaboutthisapproachisifyou’reputtingsomethingintothekneejointthatismorerigidthanthenativeACLtotemporarilystabilizeit,thismayleadtooverconstrainingtheligament,therebyputtingabnormalforcesonthekneejoint.Weknowfromotherstudiesthatifyouoverconstraintheknee,itcanleadtoabnormalwearandosteoarthritis,”saysDr.vanEck.Theproceduremayalsoradicallychangeorincreasetheloadtofailurepointontheligamentbysignificantdegrees,theconsequencesofwhicharecompletelyunknownatthispoint.
ThereisalsothequestioninACLrepairorreconstructionastothedegreeofkneeflexionanglethesurgeonshouldtensionthedevice.Mostsurgeonsdoingrepairssuchastheseatpresentareusingthesameflexionangleaswouldbedoneinananatomicreconstruction.“Butthat’spurelyanecdotal.Wedonothavegoodevidencetosupportthatrightnow.Thesearethequestionswehopetoanswerwiththisstudy,”saysDr.vanEck.
OneofDr.vanEck’scollaboratorsonthisstudy,MonicaLinde-Rosen,suggeststhatafterthisinitialstudyconcludes,theteamoughttoconductaninvestigationinalivinganimalmodelthatlooksathowthesutureorbracingmaterialwithinthekneejointchangesovertime.Doesithaveanywearparticles,orresorbintothebody,anddoesitcauseaninflammatoryresponsewithintheknee?Theseareallsecondaryaspectsoftheprocedureforwhichthereisnoevidenceorunderstandingofthepotentiallong-termconsequences.
Radiological study of porcine knee used in notchplasty study.
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DR. VAN ECK SERVES AS TEAM PHYSICIAN FOR THE PITTSBURGH PASSION WOMEN'S PROFESSIONAL FOOTBALL
TEAM, AND ALSO SERVES AS A TEAM PHYSICIAN FOR ROBERT MORRIS UNIVERSITY. DR. VAN ECK HERSELF PLAYED
PROFESSIONAL WOMEN'S FOOTBALL FROM 2008 TO 2011 WHILE WORKING AS A POST-DOCTORAL RESEARCH
FELLOW IN PITTSBURGH.
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Michael J. O’Malley, MD,assistantprofessoroforthopaedicsurgery,isahipandkneereplacementsurgeryspecialistwhojoinedtheDepartmentofOrthopaedicSurgeryinSeptember2016.Dr.O’MalleycompletedhisfellowshiptrainingattheRothmanInstituteofThomasJeffersonUniversity,precededbyresidencytrainingattheUniversityofPittsburghandmedicalschoolatTempleUniversity.Dr.O’MalleytrainedundersomeofthemostrespectedandtalentedorthopaedicsurgeonsinthefieldwhileattheUniversityofPittsburgh.HecreditsDrs.LarryS.Crossett,BrianA.Klatt,andFreddieH.Fufortheirmentorshipandguidance,shapingthedirectionofhisclinicalpracticeandresearch,andultimatelybeingresponsibleforhisreturntothedepartmentasafacultymember.“Drs.CrossettandKlattinstilledinmetheirpassionandphilosophytowardjointreplacementandresearch,howpeople’slivescanbechangedwiththissurgery,andIhavecarriedthatforwardinmyapproachandfocusasasurgeonandresearcher,”saysDr.O’Malley.
Hip Arthroplasty–The Direct Anterior Approach
Dr.O’Malleyisaproponentandactiveuserofthedirectanteriorapproachtototalhiparthroplasty,havingtrainedextensivelyintheprocedureduringhisfellowshipattheRothmanInstitutewherehegainedaproficiencyinthetechniquethathascarriedforwardtohissurgicalpracticeinPittsburgh.“Thereareprosandconstothisapproach,muchastherearewithanytypeofsurgicalprocedure.Withthedirectanteriorapproach,thereislessdisruptiontomuscleattachments,specificallythehipabductors.Someoftheliteraturealsosuggestsfasterrecovery,lesspain,andaquickerdiscontinuationoftheuseofwalkingaids,"saysDr.O’Malley.Hipprecautionsaresomethingnottypicallyneededwiththedirectanteriorapproach.Withotherapproaches,therearepotentialdownsidessuchasincreasedinstabilityandtheneedtoviolatetheabductors.
Dr.O’MalleytrainedonthedirectanteriorapproachattheRothmanInstituteinacarefullycontrolledandrigorousmanner.“Ifyoulookattheresearch,thereisalearningcurvewiththedirectanteriorapproachof50to100casestoachieveproficiency.Myfocusfromthestarthasbeenonusingthistechniqueandthoroughlyunderstandinghowtobestconducttheprocedure.ThetrainingIdidasafellowallowedmetobeproficientinthetechniqueimmediatelyduringmypracticeatUPMC,andIbelievethishasbeentothebenefitofmypatients,"saysDr.O'Malley.
NEW FRONTIERS IN HIP AND KNEE ARTHROPLASTY
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BecauseofDr.O'Malley'strainingandproficiencywiththedirectanteriorapproach,morethan95percentofhiscasesoftotalhiparthroplasty(morethan200casessincejoiningthedepartment)aredoneinthismanner.OnlywhencertainanatomicalanomaliesexistinapatientwillDr.O'Malleyemployanalternatetechnique.
AnotheraspectofDr.O’Malley’sdirectanteriorapproachtohiparthroplastyismanifestinginworktodevelopaclinicalpathwayofsame-daydischargeforappropriatehiparthroplastypatients.Thispathwayisintheearlystagesofdevelopmentandmaybeofgreatbenefittothosepatientswhoareappropriatecandidates,aswellasthetheentireUPMCsystem.
“Several randomized studies by other groups have shown safety and efficacy of same-day discharge in hip arthroplasty. We are now currently evaluating this approach for our patients to determine if it is viable, safe, and effective.”
Periprosthetic Joint Infections and the Use of Sonication in Clearance and Culture
Periprostheticjointinfectionscontinuetobealeadingcauseoffailureandrevisionsurgeriesinhipandkneearthroplasty.Bacteriaandorganismsthatinvadeajointanddeviceareknowntoformabiofilmthatisresistanttotreatment,andclearingtheinfectionwhilethedeviceisstillinthepatientisgenerallynotaviableoption.Theuseofsonication,anultrasound-basedtechniqueforclearingadeviceofinfectiousagentsandsubsequentgatheringofmaterialsforculturing,isrelativelynewinthefieldoforthopaedicsurgery.Dr.O’Malleyandthedepart-mentwereearlyadoptersofthetechniquefrombothaclinicaluseandresearchstandpoint,andtheycontinuetheseeffortsinrecentlypublished1andongoingstudies.
Theprocessofsonicationquiteliterallyshakesthemicrobialagentsoffthedeviceinthelab.Forpatientsdeemedtohaveachronicinfectionwithadurationofmorethanthreeweeks,thestandardoftreatmententailsremovaloftheimplant,followedbytheplacementofatypeofantibiotic-ladenspacer,afterwhichthepatientisclosedandtheimplantissenttothelabforsonicationandculturing.Bacterial-ladenfluidsfromthesonicationprocessarealiquoted,centrifugedintopellets,andthenresuspendedandcultured.Patientstypicallyarestartedonintravenousantibioticsforadefinedperiodandthenretestedusingmultiplemeans.Patientssuccessfullyclearedofinfectionaretypicallyreimplantedaboutthreemonthsaftertheinitialremovalprocedure.
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ThetechniqueofsonicationhasbeenshowninresearchbyDr.O’Malleyandcolleaguestoproducepositiveculturesatamuchhigherratethanthetraditionalmeansofusingneedleaspirationoffluidfromthejoint.“With current methods, the success of cultures is approximately 67 percent. Our recent studies with sonication have yielded a positive culture rate of 95 percent in patients with active infections.Thetechniqueisprovingtohavehighsensitivityandspecificity.Knowingthebacteriaresponsiblefortheinfectioniscruciallyimportantfortreatmentandresultsinamuchmoreeffectiveandlong-termeradication.Thishasimportantconsequencesforthefield,”saysDr.O’Malley.
DR. O'MALLEY IS A PROPONENT AND ACTIVE USER OF THE DIRECT
ANTERIOR APPROACH TO TOTAL HIP ARTHROPLASTY. HE TRAINED
EXTENSIVELY IN THE PROCDURE DURING HIS FELLOWSHIP, AND
GAINED A PROFICIENCY IN THE TECHNIQUE THAT CARRIED FORWARD
IMMEDIATELY TO HIS SURGICAL PRACTICE AT UPMC.
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THE USE OF ROBOTIC PARTIAL KNEE ARTHROPLASTY
AFFORDS A SMALLER INCISION AND VIRTUALLY NO
INCIDENCE OF MALALIGNMENT.”“
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Dr.O’Malleyisalsoinvolvedinseveralotherperiprostheticjointinfection-relatedstudies,primarilywithBrian A. Klatt, MD,assistantprofessoroforthopaedicsurgery.Onestudy,amulticenterinvestigationattemptingtousenextgenerationPCRsequencingtoidentifythebacteriainaperiprostheticjointinfection,wouldeliminatetheneedforculturing.AsecondstudythatDr.O’MalleyandcolleaguesarecurrentlyinthemidstofresearchingisanevaluationofadiagnostictestfromCDDiagnosticscalledSynovasure®.“Essentially,whatthistestingdoesislookforamolecularmarkercalledalphadefensinasanindicatorofinfectionintheevaluationofsynovialfluid.Thereisalotofexcitementaboutthistestbecauseithasbeenshowntobebothsensitiveandspecific,andwecanobtainresultspriortosurgery.Ourstudywillcomparethistestandtheuseofsonicationtoseehowwellthetwocorrelate.Thisissuchinterestingandmeaningfulwork,becausewhiletheratesofperiprostheticjointinfectionarelow,whentheydohappen,theconsequencesaresevere,”saysDr.O’Malley.
Sleep Quality After Total Joint Arthroplasty
Dr.O’Malleyreceivedagrantin2017fromThePittsburghFoundationtostudysleepqualityanddisruptionpatternsinpatientsundergoingtotaljointarthroplasty.ThestudywillmonitorpatientsleepcyclesusingFitbit®devicesandquestionnairestodeterminewhetherpatientsleepisdisturbed.Theinterventioninthestudywillbeaplacebo-controlledtrialusingthenervemedicationgabapentin,whichisanatypicalpainmedicationwithsomesedatingsideeffects.Patientsenrolledinthestudywillreceiveeitheradoseof300mgofgabapentinorplacebo,atnightbeforebed,toseeiftheirsleepimproves.“Weknowsleepcanbedisruptedinthepost-surgicalperiod,anditisoneofthebiggestcomplaintsofpatients.Theyfeelgreatduringtheday,buttheirleghurtsatnightandtheirsleepisdisrupted.Gabapentin
hasbeenusedempirically,butthereisnorealevidencetosupportitsuseasatherapeuticagent.UsingtheFitbit®devicewillreallyhelpustoquantifyandqualifythesleepdisturbancesthatoccurintheseindividuals,andwiththedeviceswecanalsotrackandanalyzetheiractivitylevels,"saysDr.O’Malley.
Partial Robotic-Assisted Knee Arthroplasty
Dr.O’Malleyiscurrentlyusingarobotic-assistedplatformforhispartialkneereplacementsurgeries.Theroboticsystemusescomputer-controllednavigationtocontroltheburr,removingbonefromthejoint."Notallpatientsarecandidatesforthisapproach,butthosethataremaybeaffordedafasterrecoveryperiodandmorenormalpostoperativefeelingintheknee,"saysDr.O'Malley.
Anotherbenefitoftheroboticapproachisthatitallowsforamoreaccurateplacementoftheimplantwithrepeatableresults.“Byusingtheroboticapproach,”saysDr.O’Malley,“youendupwithasmallerincisionandvirtuallynoincidenceofmalalignment.”
The robotic system uses computer-controlled navigation to control the burr, removing bone from the joint in a precise manner.
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OrthopaedictraumasurgeonGele B. Moloney, MD,joinedtheDepartmentofOrthopaedicSurgeryinSeptember2016andcurrentlypracticesatUPMCMercy.Dr.Moloney’strainingincludedtheclinicalscientistresearchtrackresidencyatUPMCfrom2009to2014,followedbyanorthopaedicsurgerytraumafellowshipattheHospitalforSpecialSurgeryinNewYorkCity.Dr.MoloneyiscurrentlyanassistantprofessoroforthopaedicsurgeryandisthesiteprincipalinvestigatorfortheMajorExtremityTraumaResearchConsortium(METRC),alarge,multicentergroupconductingawiderangeofprospectivestudiesinorthopaedictrauma.Asanorthopaedictraumasurgeon,Dr.Moloneyseesallmannerandtypeofprimarytraumacasesandpost-traumaticreconstructiveprocedures.“Asanorthopaedictraumasurgeon,everycaseisdifferentandrequiresustotrytoveryquicklyunderstandpatientgoalsandthenoptimizeandindividualizetheircare,oftenwithouthavingtheluxuryofknowingthempriortothedayoftheirinjury.It’saconstantchallenge,andoneofthethingsthatdrewmeintothisareaoforthopaediccare,”saysDr.Moloney.
Geriatric Fracture Care and Management
Dr.MoloneyandIvan S. Tarkin, MD,chiefoftheDivisionofOrthopaedicTraumatology,havepreviouslystudiedandwrittenontheratesandcomplicationsassociatedwithgeriatricdistalfemurfractures.Theirfindingshighlightsomeofthechallengesincaringfortheseindividuals.Aretrospectivecohortstudyexaminedlocalandsystemiccomplicationsinacohortof176casesoflow-energydistalfemurfractureinelderlypatients.Atone-yearpost-surgicalfixation,25percentofthepatientsweredeceased.Oftheremainingindividuals,24percentdevelopedanonunionandwentontorequirefurthersurgery.Morethan80percentofpatientsweredischargedtoaskillednursingandrehabilitationfacility,and38percentofindividualshadatleastonepostoperativecomplication.
Hipfracturesingeriatricpatientshavegarneredalotofattentionintheliteratureandinthegeneralpopulation,andrightlyso.However,asDr.Moloneyexplains,theyarenottheonlytypeoffracturethatportendspatienthealthdeclinesandbadoutcomes.“Westartedtolookatpatientswithdistalfemurfracturesandfoundthat,whiletherearesimilaritiestohipfracturesintermsofmortality,distalfemurfracturepatientsaremuchmorelikelytorequiresecondarysurgeries,increasingtheburdenonboththepatientandthehealthcaresystemtryingtomanagethesechallengingcases,”saysDr.Moloney.
Pre- and Postoperative Distal Femur Nonunion X-rays.
Preoperative image (left) shows incomplete healing of the fracture. Postoperative image (right) is following secondary reconstruction with supplemental plating and the addition of a bone graft resulting in fracture union.
GERIATRIC FRACTURES: CAUSES, COMPLICATIONS, AND CONTRIBUTING FACTORS
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26 New Research: Geriatric Distal Femur Fracture and Malnutrition
AnewpathwayofresearchthatDr.Moloneyandherresearchcolleaguesinthetraumadivisionareinvestigatingistowhatextent,andtowhatdegree,patientnutritionandmalnutritionplayinimprovingoutcomesofgeriatricpatientsthatsufferadistalfemurfracture.Herteambegantolookatserummarkersofnutritioninthesepatients,primarilyalbuminlevels,andweresurprised
tofindalarminglyhighratesofdeficiency,pointingtosignificantratesofmalnutritioninpatients65andolderwithlow-energygroundlevelfallsandfemurfractures.Rightaway,theassociationswereclearthatindependentofotherfactors,malnutritionwasturningouttobealikelygoodpredictorofmortality,nonunion,andpostoperativeinfections.Dr.Moloneyandcolleagueshavemuchmoreinthewayoffindingswiththispatientcohortandsubmittedamanuscriptforpublicationthattheyhopetohavepublishedin2018.
“This line of investigation really coincides with a much bigger trend at UPMC related to the concept of prehabilitation and pre-surgical care, and how these concepts and associated interventions can help to optimize care of these patients. This kind of research and evolving approach to patient care can help us understand and modify care patterns and practice to achieve better outcomes.”Designing an Intervention Protocol
Comingoutoftheirresearchintomalnutritionanddistalfemurfractureisthenaturalquestion:Whatcanbedonefromaninterventionstandpointtomodifypatientrisk?Dr.Moloneyindicatesthatfromacorollarystandpoint,theylookedatyoungerpatientswithhigh-energytraumaandfracturestotheirankle.“Tibialpilonfracturesarenotoriouslybadinjuries.However,inpatientswiththisinjurywhowerereceivingnutritionalsupplementationinthehospital,specificallyaminoacid,vitamin,andproteinsupplementation,wewereseeinglowercomplicationratesandlowerreoperationrates.Thehypothesisisthatperhapswecanextrapolatethoseresultsandfindingstothisgeriatricpopulationofdistalfemurfracturesandseeifitcanimproveoutcomes,”saysDr.Moloney.Dr.Moloneyandcolleaguesareworkingonaninterventionthatwouldstartnutritionalsupplementationonthesamedayastheinjuryandprospectivelystudypatientoutcomes.
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Asmentionedpreviously,tibialpilonfracturesastheresultofhigh-energytraumaticeventsareexceptionallydifficultinjuriestorepairsurgicallyandachievelong-termsuccessfuloutcomes.NewresearchbyDr.Moloneyandcollaborators Ivan S. Tarkin, MD,andNicholas J. Greco, MD,isinvestigatingtheroleandabilityofnutritionalprehabilitationtostaveoffpost-surgicalcomplicationsandsuboptimaloutcomesinpatientswiththisinjury.
Dr.Moloneyandcolleagueshavesubmittedforpublicationtheirfindingsfromarecenttwo-yearstudythattrackedpatientoutcomesandcomplicationsfollowingtibialpilonfractureinacohortof90patients.Theirstudylookedatinfectionrates,andratesofnonuniontoseeifnutritionalsupplementationwasabletoshowapositiveeffectonlong-termoutcomes.Preliminaryfindingsarepromising,andmoreresearchwillneedtobeconducted,butthiscouldpointtowardandsupplytangentialevidenceforusingnutritionalsupplementationingeriatricdistalfemurfracturesinordertominimizecomplications.
New Research: Tibial Pilon Fracture Surgery and Nutritional Prehabilitation
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References and Further Reading
Improving Outcomes for Multiple Ligament Knee Injuries
References
1 SurgicalTimingandRehabilitation(STaR)forMultipleLigamentKneeInjuries(MLKIs):AMulticenterIntegratedClinicalTrial.PrincipalInvestigator:JamesJ.Irrgang.AwardNumber:W81XWH-17-2-0073.IntegratedClinicalTrialAward.
2TimingofSurgeryandRehabilitationtoOptimizeOutcomesforPatientsWithMultipleLigamentKneeInjuries:AMulti-centerClinicalTrial.PrincipalInvestigator:JamesJ.Irrgang.AwardNumber:W81XWH-15-1-0655.ClinicalTrialDevelopmentAward.
3 LynchAD,ChmielewskiT,BaileyL,StuartM,CooperJ,CoadyC,SgroiT,OwensJ,SchenckR,WhelanD,MusahlV,IrrgangJ.TheSTaRTrialInvestigators.CurrentConceptsandControversiesinRehabilitationAfterSurgeryforMultipleLigamentKneeInjury.Curr Rev Musculoskelet Med.2017;10:328-345.
Diagnosing Carpal Tunnel Syndrome With Ultrasound
References
1 PulikkottilBJ,SchubM,KadowTR,WangW,FowlerJR.CorrelatingMedianNerveCross-SectionalAreaWithNerveConductionStudies.J Hand Surg Am.2016;41(10):958-962.
2 CrastoJA,ScottME,FolwerJR.UltrasoundMeasurementoftheCross-SectionalAreaoftheMedianNerve:TheEffectofTeachingonMeasurementAccuracy.Hand.2017;Epubaheadofprint.
Further Reading
• FowlerJR,HirschD,KruseK.TheReliabilityofUltrasoundMeasurementsoftheMedianNerveattheCarpalTunnelInlet.J Hand Surg Am.2015;40(10):1992-1995.
• FowlerJR,etal.ComparisonofUltrasoundandElectro-diagnosticTestingforDiagnosisofCarpalTunnelSyndrome.J Bone Joint Surg Am.2014;96:e148(1-4).
• FowlerJR,GaughanJP,IlyasAM.TheSensitivityandSpecificityofUltrasoundfortheDiagnosisofCarpalTunnelSyndrome.AMeta-analysis.Clin Orthop Relat Res.2011;469:1089-1094.
• FowlerJR,MaltenfortMG,IlyasAM.UltrasoundasaFirstlineTestintheDiagnosisofCarpalTunnelSyndrome:ACost-effectivenessAnalysis.Clin Orthop Relat Res.2012;
• NerveConductionStudiesforCarpalTunnelSyndrome:GoldStandardorUnnecessaryEvil?Editorial.J Orthopaedics.2017;40(3):141-142.
A Continuing Legacy of Pioneering Sports Medicine and ACL Research
References
1 KeklikciK,YapiciC,KimD,Linde-RosenM,SmolinskiP,FuFH.TheEffectofNotchplastyinAnteriorCruciateLigamentReconstruction:ABiomechanicalStudyinthePorcineKnee.Knee Surg Sports Traumatol Arthrosc.2013;21(8):1915-1921.
Further Reading
• HusseinH,vanEckCF,CretnikA,DinevskiD,FuFH.IndividualizedAnteriorCruciateLigamentSurgery:AProspectiveStudyComparingAnatomicSingle-andDouble-BundleReconstruction.Am J Sports Med.2012;40(8):1781-1788.
• vanEckCF,SpinaIIINT,LeeJY.ANovelMRIClassificationSystemforCongenitalFunctionalLumbarSpinalStenosisPredictstheRiskforTandemCervicalSpinalStenosis.Eur Spine J.2017;26(2):368-373.
• SeabraP,vanEckCF,SáM,TorresJ.AreProfessionalHandballPlayersatRiskforDevelopingaGlenohumeralInternalRotationDeficitinTheirDominantArm?Physician Sportsmed.2017;4592:77-81.
• VanEckCF,FourmanMS,AbtahiAM,AlarconL,DonaldsonWF,LeeJY.RiskFactorsforFailureofNonoperativeTreatmentforUnilateralCervicalFacetFractures.Asian Spine J.2017;11(3):356-364.
• BanffyMB,vanEckCF,StantonM,ElAttracheNS.ASingle-TunnelTechniqueforCoracoclavicularandAcromioclavicularLigamentReconstruction.Arthrosc Tech.2017;6(3):e769-e775.
• VanEckCF,LimpisvastiO,ElAttracheNS.IsThereaRoleforInternalBracingandRepairoftheAnteriorCruciateLigament?ASystematicLiteratureReview.Am J Sports Med.2017;Epubaheadofprint.
New Frontiers in Hip and Knee Arthroplasty
References
1 RothenbergAC,WilsonAE,HayesJP,O'MalleyMJ,KlattBA.SonicationofArthroplastyImplantsImprovesAccuracyofPeriprostheticJointInfectionCultures.Clin Orthop Relat Res.2017Jul;475(7):1827-1836.
Geriatric Fractures: Causes, Complications, and Contributing Factors
Further Reading
• MoloneyGB,PanT,vanEckCF,PatelD,TarkinIS.GeriatricDistalFemurFracture:AreWeUnderstandingtheRateofLocalandSystemicComplications?Injury.2016;47(8):1732-1736.
• MoloneyGB,ToroJB,HelfetDL,WellmanDS.ProximalPeriprostheticFemurFractures:StrategiesforInternalFixation.Am J Orthop(BelleMeadNJ).2016;45(4):213-8.Review.
• HoellwarthJS,FourmanMS,CrossettL,GoodmanM,SiskaP,MoloneyGB,TarkinIS.EquivalentMortalityandComplicationRatesFollowingPeriprostheticDistalFemurFracturesManagedWithEitherLateralLockedPlatingoraDistalFemoralReplace-ment.Injury.2017;Epubaheadofprint.
UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE DEPARTMENT OF ORTHOPAEDIC SURGERYFreddieH.Fu,MD,DSc(Hon),DPs(Hon),Chairman
CLINICAL FACULTY
Adult Reconstruction LawrenceCrossett,MDBrianKlatt,MDMichaelO’Malley,MDAdolphYatesJr.,MD
Concussion Program MichaelCollins,PhDJonathanFrench,PsyDNathanKegel,PhDAliciaPuskar,PsyDAliciaSufrinko,PhDVanessaFazioSumrok,PhD
Foot and AnkleMaCalusV.Hogan,MDAlanYan,MD
General Orthopaedics – SurgicalDavidFowler,MD
General Orthopaedic and TraumaIvanTarkin,MDGaryGruen,MDGeleMoloney,MDPeterSiska,MDRashmiAgarwal,MDJustinArner,MDDanielMarch,MDAdamOlsen,MD
Hand and Upper Extremity RobertGoitz,MDJohnFowlerJr.MDRobertKaufmann,MD
Mercy DivisionLisaBlackrick,MDGeleMoloney,MD
Musculoskeletal Oncology RichardMcGoughIII,MDMarkGoodman,MDKurtWeiss,MD
Pediatric OrthopaedicsW.TimothyWard,MDPatrickBosch,MDOzgurDede,MDRobertGoitz,MDJanGrudziak,MD,PhDStephenMendelson,MDZ.DenizOlgun,MD
PodiatryPatrickBurns,DPMJeffreyManaway,DPM
Primary Care Sports MedicineJeanneDoperak,DOKelleyAnderson,DODavidEspinoza,MDAaronMares,MDMelissaMcLane,DOMarkSakr,DOThomasSisk,MD
Spine SurgeryWilliamDonaldsonIII,MDJoonLee,MDW.TimothyWard,MD
Sports MedicineVolkerMusahl,MDFreddieFu,MDBrysonLesniak,MDAlbertLin,MDStephenRabuck,MDMarkRodosky,MDCarolavanEck,MD,PhDDharmeshVyas,MD,PhD
UPMC Orthopaedic ServicesAndreaBadway,VicePresident
RESEARCH CENTERS
Center for Cellular and Molecular EngineeringRockyTuan,PhDPeterAlexander,PhDRiccardoGottardi,PhDHangLin,PhDThomasLozito,PhD
STEM CELL RESEARCH CENTER
Musculoskeletal Oncology LabKurtWeiss,MDRebeccaWatters,PhD
Growth & Regeneration LabMaCalusV.Hogan,MDHongshuaiLi,MD,PhD
Molecular Therapeutics LaboratoryBingWang,MD,PhD
RESEARCH LABS
Arthroplasty Design & Outcomes LabKennethUrish,MD,PhDDongzhuMa,MD,PhD
Biodynamics LabWilliamAnderst,PhD
Concussion Program LabMichaelCollins,PhDJonathanFrench,PsyDNathanKegel,PhDAnthonyKontos,PhDAliciaPuskar,PsyDVanessaFazioSumrok,PhD
Ferguson Laboratory for Ortho and Spine ResearchNamVo,PhDKevinBell,PhDJoonLee,MDGwendolynSowa,MD,PhDDongWang,PhD
Mechanobiology LabJamesH-CWang,PhDFengLi,MD,PhDJianyingZhang,PhD
Neuromuscular Research LabBradleyC.Nindl,PhD,FACSM
Ortho Engineering LabFreddieFu,MDPatrickSmolinski,PhD
Orthopaedic Robotics LabVolkerMusahl,MDRichardDebski,PhDKevinBell,PhD
Outcomes ResearchJamesIrrgang,PhD,PT,ATCChristineMcDonough,PT,PhD
CLINICAL AFFILIATED FACULTYD.KellyAgnew,MDMarshallBalk,MDMarkBaratz,MDJeffreyBaum,MDMichaelBowman,MDJamesBradley,MDCharlesBurkeIII,MDGlennButerbaugh,MDFranklinChou,MDPeterCohen,MDStephenConti,MDMichaelGaffney,MDTrentonGause,MDKraigGraham,MDYramGroff,MDWilliamHagberg,MDCarlHasselman,MDFredHeidenreich,MDThomasHughesJr.,MDJosephImbriglia,MDHarveyInsler,MDAlanKlein,MDAlexKline,MDJonLevy,MDCraigMauro,MDEdwardMcClainIII,MDDanaMears,MDMichaelMiller,MDThomasMuzzonigro,MD
CLINICAL AFFILIATED FACULTY (CONT’D)PeriklisPapapetropoulos,MDLoukiaPapatheodorou,MD,PhDSpiroPapas,MDNileshPatil,MDJohnPerri,MDAntonPlakseychuk,MD,PhDJoshuaPort,MDMichaelRytel,MDChristopherSchmidt,MDVivekSharma,MDVincentSilvaggio,MDPatrickSmith,MDDeanSotereanos,MDS.JoshuaSzabo,MDRobertWaltrip,MD
JOINT FACULTY/ADJUNCTAmeetAiyangar,PhDFabrisiaAmbrosio,PhDEricAnish,MDK.ChrisBeard,PhDJacquesChelly,MDConstanceChu,MDRichardDebski,PhDAnthonyDelitto,PhDAaronGrand,MDBethGusenoff,DMPJohnnyHuard,PhDScottLephart,PhDC.OwenLovejoy,PhDMarkLovell,PhDKentaroOnishi,DOH-C.Pape,MDAnthonyPardo,DVMJohnPayne,DVMMarcPhilippon,MDNaliniRao,MDCaraReddy,MDArmanSaparov,MD,PhDPatrickSmolinski,PhDGwendolynSowa,MD,PhDAlexSpiess,MDYasutakaTashiro,MD,PhDArvydasUsas,MD,PhDKiaWashington,MD
DEPARTMENT OF ORTHOPAEDIC SURGERY ACADEMIC ORGANIZATIONAL STRUCTURE
Freddie H. Fu, MDDavidSilverProfessorandChairman
Mark Baratz, MDViceChairmanforCommunityOutreach
William F. Donaldson III, MDExecutiveViceChairmanforClinicalServices
MaCalus V. Hogan, MDViceChairmanforEducationandResidencyDirector
James J. Irrgang, PhD, PT, ATCViceChairmanforClinicalOutcomesResearch
Joon Lee, MDAssociateResidencyDirector
Rocky Tuan, PhDExecutiveViceChairmanforOrthopaedicResearch
Nam V. Vo, PhDDeputyViceChairmanforOrthopaedicResearch
James H-C Wang, PhDViceChairmanforOrthopaedicResearch
W. Timothy Ward, MDViceChairmanforPediatricSurgery
Adolph Yates Jr., MDViceChairmanforQualityManagement
USNW505631TS/AS/MP5/18©2018UPMC
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