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Access Statistics 2011 | July-June | Issue 1


Original Research
Manjiri M Didolkar, Emily N Vinson

Basic Science
Tibial Plateau Cysts at the Meniscal Root Insertions: Incidence and Association

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:45-49]

Background: The purpose of this study is to identify a possible relationship between high T2-signal cyst-like foci in the tibial plateau at the meniscal root insertions and meniscal pathology.
Methods: Institutional review board approval was obtained for this retrospective study. HIPAA compliance was maintained throughout this study. Two radiologists reviewed 200 knee MRI examinations for tibial plateau cysts at the meniscal root insertion sites; meniscal tears and intrameniscal cysts were also noted. The knee MRI examinations were also evaluated for articular cartilage abnormalities of the medial and lateral tibial plateaus.
Results: Of the 200 knee examinations, 83(41.5%) demonstrated medial meniscal pathology and 47(23.5%) demonstrated lateral meniscal pathology. Twenty (10%) demonstrated cysts in at least one of the described locations; two knees had cysts in two separate locations. four (2%) examinations had cysts at the anterior horn medial meniscal insertion, and all four (100%) had medial meniscal pathology (p = 0.028). Eleven (5.5%) examinations demonstrated cysts at the posterior horn medial meniscal insertion, and eight (72.7%) had medial meniscal pathology (p = 0.031). five (2.5%) examinations demonstrated cysts at the anterior horn lateral meniscal insertion, and one (20%) had lateral meniscal pathology (p = 0.374). Two (1%) examinations demonstrated cysts at the posterior horn lateral meniscal insertion, and one (50%) had lateral meniscal pathology (p = 0.852).
Conclusion: Cysts at the meniscal insertions are often seen on knee MRI. Cysts located at the insertions of the medial meniscus have a statistically significant association with meniscal pathology.
Level of evidence: Level II, retrospective study with development of diagnostic criteria on the basis of consecutive patients.
Keywords: Tibial plateau cysts, Meniscal root.
How to Cite
Didolkar MM, Vinson EN. Tibial Plateau Cysts at the Meniscal Root Insertions: Incidence and Association. Duke Ortho J. 2010, 1, 1, 45-49


Original Research
Steven A Olson

The Bernese Periacetabular Osteotomy: A Review of Surgical Technique

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:21-26]

The Bernese periacetabular osteotomy (PAO) is a powerful technique in the treatment of hip dysplasia and related conditions of the hip. This technique is performed through a single anterior surgical approach. There are three steps in learning to perform the PAO. These include: mastering the surgical dissection required to perform the osteotomy, understanding the individual cuts that make up the PAO, and finally obtaining correction of the orientation of the acetabulum after the osteotomy is complete. The author's technique is reviewed in this work.
Keywords: Periacetabular osteotomy, Hip dysplasia.
How to Cite
Olson SA. The Bernese Periacetabular Osteotomy: A Review of Surgical Technique. Duke Ortho J. 2010, 1, 1, 21-26


Original Research
Christopher A Brown, Tyler S Watters, Richard C Mather III, Lori A Orlando, Michael P Bolognesi, Claude T Moorman III

Adult Reconstruction
Cost-Effectiveness Analysis of Unicompartmental Knee Arthroplasty and High Tibial Osteotomy for Treatment of Medial Compartmental Osteoarthritis

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:27-37]

Background: Interest in unicompartmental knee arthroplasty (UKA) has recently increased in the United States concomitantly with an increase in the prevalence of physiologically active patients presenting with medial compartment osteoarthritis. This study examined the cost-effectiveness of UKA compared with high tibial osteotomy (HTO) in patients with medial compartment osteoarthritis.
Methods: A Markov decision model was constructed with review of literature to conduct a cost-utility analysis of UKA as compared to HTO in a patient population aged 40 years at the time of surgical intervention. Utility values were assigned to health states annually based on the commonly accepted reference values of 1 being “full health” and 0 being “death”. These values are used to estimate quality-adjusted life years (QALYs). The Markov decision model was used to evaluate the total accumulated costs and effectiveness, measured in QALYs.
Results: The average cost of the UKA was cheaper by $842 and resulted in a significant incremental effectiveness gain compared to HTO (+ 0.96 QALY). UKA gained 20.05 QALY at a cost-effectiveness (C/E) ratio of $1048/QALY, whereas HTO gained 19.09 QALY at a C/E ratio of $1145/QALY.
Conclusion: Both UKA and HTO are cost-effective procedures but patients treated with UKA may experience an increased net health benefit over their lifetime.
Level of evidence: Economic and decision analysis level II.
Keywords: Unicompartmental, High tibial osteotomy, cost-effective arthroplasty.
How to Cite
Brown CA, Watters TS, Mather III RC, Orlando LA, Bolognesi MP, Moorman III CT. Cost-Effectiveness Analysis of Unicompartmental Knee Arthroplasty and High Tibial Osteotomy for Treatment of Medial Compartmental Osteoarthritis. Duke Ortho J. 2010, 1, 1, 27-37


Case Series
Robert A Magnussen, Christopher A Brown, J Todd Lawrence, Alison P Toth

Sports Medicine
Intra-articular Anakinra for the Treatment of Persistent Inflammation and Arthrofibrosis following Anterior Cruciate Ligament Reconstruction

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:51-56]

Purpose: Postoperative inflammation and arthrofibrosis remain difficult problems following ACL reconstruction. Interleukin-1 (IL-1) is a potent driver of intra-articular inflammation and arthrofibrosis following injury and surgery. Anakinra (Kineret, Amgen, Thousand Oaks, CA) is an IL-1 receptor antagonist. We hypothesize that postoperative intra-articular anakinra use decreases inflammation and subsequent arthrofibrosis, reducing the need for arthroscopic debridement and manipulation under anesthesia.
Methods: Four patients (ages 15-56) who were treated with anakinra for persistent postoperative inflammation and scarring within 4 months of ACL reconstruction were retrospectively reviewed. Anakinra was utilized when patients were unable to obtain full extension and at least 90° of flexion 1 month postoperatively in association with persistent effusions or decreased patellar mobility.
Results: Anakinra injection was performed between 36 and 97 days postsurgery. All four reported improvements in range of motion and decreased pain and effusions within 10 days of injection. One patient, who did not receive anakinra until more than 3 months postsurgery, required eventual arthroscopic debridement of a cyclops lesion but none of the patients required frank lysis of adhesions or manipulation under anesthesia. No adverse reactions to anakinra occurred.
Conclusion: Based on previous experience, we believe that all of these patients would have required arthroscopic debridement of scar tissue and manipulation under anesthesia to regain motion were not for the anakinra treatment. Clearly, the concept of IL-1 inhibition in the postoperative knee requires further research, but early results are promising for this unique treatment of a difficult clinical problem.
Keywords: Anakinra, Anterior cruciate ligament, Arthrofibrosis, Inflammation, Interleukin-1.
How to Cite
Magnussen RA, Brown CA, Lawrence JT, Toth AP. Intra-articular Anakinra for the Treatment of Persistent Inflammation and Arthrofibrosis following Anterior Cruciate Ligament Reconstruction. Duke Ortho J. 2010, 1, 1, 51-56


Original Research
William C Eward, Carter Lipton, Jonathan Barnwell, Thomas L Smith, Matthew Crowe, L Andrew Koman, David S Ruch

Hand and Upper Extremity
Nerve Conduit Enhancement with Vomeronasal Organ Improves Rat Sciatic Functional Index in a Segmental Nerve Defect Model

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:9-15]

Background: Segmental nerve loss presents a challenge to the reconstructive surgeon. The best regenerative results are obtained by using autologous interpositional nerve grafts. While this method can be successful, it necessitates a second surgical step, sacrifices donor nerve function and depends upon a finite supply of potential donor nerves. Collagen nerve conduits are commercially available for reconstruction of segmental nerve defects. However, no conduit-based reconstructive strategy has been as successful as autograft reconstruction. We hypothesized that collagen nerve conduits used to bridge a sciatic nerve defect may be enhanced by grafting with vomeronasal organ (VNO), owing to the unique capacity for regeneration of this mammalian olfactory tissue.
Methods: 21 rats underwent resection of a 1.0 cm segment of sciatic nerve. Seven rats underwent repair of the resultant nerve defect using a commercially available collagen nerve conduit (NeuraGen, Integra Life Sciences, Plainsboro NJ, USA). Seven rats underwent immediate repair of the nerve defect using the conduit filled with freshly harvested VNO allograft. An additional Seven rats underwent resection of a 4 mm segment of sciatic nerve and direct epineural repair. At 14 weeks postoperatively, all animals underwent walking track analysis. Toe prints were analyzed morphometrically to permit calculation of sciatic functional index (SFI). At 16 weeks postoperatively, rats were sacrificed and tissues were processed for histomorphometric analysis. This analysis included quantification of the number and diameter of myelinated axons as well as calculation of the axon density.
Results: All animals survived treatment without any serious surgical complications. All sciatic nerves were in continuity at sacrifice. All animals showed signs of sciatic denervation (decubitus ulcers, muscle atrophy) postoperatively. At 14 weeks, the mean sciatic functional index (SFI) was significantly higher in the VNO-enhanced group (p = 0.006) and the epineural repair (ER) groups (p = 0.004) than the conduit-only (CO) group. SFI was equivalent between VNO and ER groups (p = 0.338). Axon density was greater in the VNO (p = 0.013) and ER groups (p = 0.048) than in the CO group. Axon density was equivalent between the VNO and ER groups (p = 0.306).
Conclusions: In a rat sciatic nerve segmental defect model, modification of collagen nerve conduits to contain the pluripotent neuroepitheilial tissue vomeronasal organ (VNO) improves functional recovery and offers increased axon density relative to reconstruction with an empty conduit (CO).
Keywords: Nerve conduct, Vomeronasal organ, Segmental defect.
How to Cite
Eward WC, Lipton C, Barnwell J, Smith TL, Crowe M, Koman LA, Ruch DS. Nerve Conduit Enhancement with Vomeronasal Organ Improves Rat Sciatic Functional Index in a Segmental Nerve Defect Model. Duke Ortho J. 2010, 1, 1, 9-15


Case Report
William C Eward, Brian E Brigman, Vasilios Kontogeorgakos, Anand S Lagoo, Salutario Martinez

Orthopaedic Oncology
Extranodal Castleman Disease of the Extremities: A Case Report and Review of the Literature

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:57-63]


Original Research
Pier Francesco Indelli, John A Szivek, Andrew Schnepp, William A Grana

Basic Science
Load-Bearing at the Meniscofemoral Joint: An in vitro Study in the Canine Knee

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:39-43]

Background: The role of the menisci on tibial load transmission and stress distribution has been extensively studied, but few studies have focused on the meniscofemoral joint during physiologic weightbearing. The objective of this study was to determine the contact areas and local contact stresses at the meniscofemoral interface during physiologic range of motion and axial-loading in the canine knee and to determine the influence of a partial or total meniscectomy.
Methods: Both fresh-frozen knees of 3 hound-type canines were tested in a universal testing machine configured for an axial-load of 90- 120 N. Measurement of the contact area and the local contact stress were done at three different knee angles (30; 50; 70) and with both menisci intact, after partial meniscectomy, and after total meniscectomy. Pressure distribution was estimated by using pressure sensitive film inserted above the menisci.
Results: After partial meniscectomy, contact areas at 50° of knee flexion decreased approximately 25% on both femoral condyles, and local contact stress increased 30% on the medial femoral condyle but remained unchanged on the lateral. After total meniscectomy, contact areas at 50° of knee flexion decreased approximately 75% on both femoral condyles, and local contact stress increased approximately 60% on the medial compartment and 100% on the lateral compartment.
Conclusion: These data suggest that a conservative partial meniscectomy leaves the meniscus with an inferior weight distribution function; decreasing, but not canceling the protection on the femoral hyaline cartilage. A dramatic decrease of contact area followed by an increase of local contact stress was noted after a total meniscectomy. The clinical value of this study is to emphasize the biomechanical value of surgical procedures addressing the repair of damaged menisci.
Keywords: Meniscus, Load-bearing, Meniscofemoral, Stress.
How to Cite
Indelli PF, Szivek JA, Schnepp A, Grana WA. Load-Bearing at the Meniscofemoral Joint: An in vitro Study in the Canine Knee. Duke Ortho J. 2010, 1, 1, 39-43


Original Research
John D Hewitt, Craig T Haytmanek, Joshua N Tennant, Ryan C May, Selene G Parekh

Foot and Ankle
The Cost-Effectiveness of the TriMed Sidewinder Plate for the Treatment of Weber B Ankle Fractures

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:17-20]

Background: Ankle fractures are common injuries and many have indications for operative treatment. Newer plate designs have recently been introduced and have the potential to simplify and shorten the operative procedure. This study compares the cost of operative treatment of a lateral malleolar fracture between a novel plate design and a neutralization plate and lag screw approach.
Methods: A retrospective chart review was performed with institutional review board approval. All patients operatively treated for a Weber B lateral malleolar fracture were divided into two cohorts: an experimental group treated with a novel plate and a control group treated with a lag screw and neutralization plate. Cost of implants, operating room costs, and time to healing were compared between the two cohorts.
Results: The average implant cost for the novel plate design ($1,141) was significantly higher than that of the plate and lag screw construct ($208) (p < 0.0001). The average operating room costs were significantly lower for the experimental group ($4,410) compared to the control group ($6,037) (p < 0.01). The average time to union was significantly less in the experimental group (75 days) than in the control group (97 days) (p < 0.04).
Conclusions: Use of a novel plate design in this study was associated with decreased operating room costs and a quicker time to union compared to the use of a traditional construct. This may result from reduced amounts of dissection required to apply the novel plate and a more favorable biological environment for bone healing. The additional cost of new implant designs may be justified by quicker, simpler operative techniques, and enhanced healing.
Level of evidence: Therapeutic Level III.
Keywords: Ankle fractures, Cost-effectiveness, Sidewinder.
How to Cite
Hewitt JD, Haytmanek CT, Tennant JN, May RS, Parekh SG. The Cost-Effectiveness of the TriMed Sidewinder Plate for the Treatment of Weber B Ankle Fractures. Duke Ortho J. 2010, 1, 1, 17-20


Original Research
Marc J Richard, Daniel A Wartinbee, Michael Miller, Fraser J Leversedge, Jonathan Riboh, David S Ruch

Hand and Upper Extremity
Comparative Analysis of the Complication Profile following Palmar Plating versus External Fixation of Fractures of the Distal Radius

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:1-7]

Background: Much attention has been given recently to the complication profile of volar plate fixation of distal radial fractures. The purpose of this investigation was to compare complication rates among patients with distal radial fractures treated with volar plating versus those treated with external fixation.
Methods: Two parallel series of patients with comminuted intra-articular distal radius fractures were reviewed. 59 patients were treated with external fixation and 56 patients with volar plate fixation. Postoperative radiographs, range of motion, grip strength, DASH scores, and VAS pain questionnaires were analyzed, and complications were described.
Results: The external fixation group had a significantly higher overall complication rate (p = 0.021) than the volar plate fixation group. In the volar plate group, there were more tendon complications and median nerve pathology. Radial shortening was greater in the external fixation group when compared to the volar plate fixation group. DASH scores and VAS scores were significantly higher in the external fixation group. Clinically, the patients in the volar plate fixation group had significantly greater arcs of motion in pronation-supination (p < 0.0001) and flexion-extension (p = 0.002) with a trend towards better grip strength (p = 0.0062).
Conclusions: Volar plate fixation for fractures of the distal radius provides an overall decreased incidence of complications, significantly less radial shortening, and significantly greater postoperative wrist motion when compared to external fixation. Volar plate fixation is also associated with lower VAS scores when compared to external fixation as well as DASH scores that approach statistical significance.
Level of evidence: III (retrospective comparative study).
Keywords: Distal radius fracture, Palmar plating, External fixation, Complications, Comminuted.
How to Cite
Richard MJ, Wartinbee DA, Miller M, Leversedge FJ, Riboh J, Ruch DS. Comparative Analysis of the Complication Profile following Palmar Plating versus External Fixation of Fractures of the Distal Radius. Duke Ortho J. 2010, 1, 1, 1-7


Stephanie W Mayer, William C Eward

Letter from the Chief Editors

[Year:2011] [Month:July-June] [Volumn:1 ] [Number:1] [Pages:63] [Pages No:xvii]