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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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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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