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ORTHOPAEDIC JOURNAL

RESIDENT DIVISIONAL VISITING UPDATE: DEPARTMENT RESEARCH REPORTS PROFESSORS IVY MOUNTAIN SPOTLIGHT

CONTENTS University of Virginia Orthopaedics Journal | 2019

3 MESSAGE FROM THE CHAIR A. Bobby Chhabra, MD

4 UPDATE ON IVY MOUNTAIN A New Gold Standard: UVA Orthopaedics Facility Aims 54 to be ‘Best in the Country’ SPOTLIGHT Visiting Professors

9 76 DIVISIONAL CASE 55 2 MINUTE CONSULT REPORTS AND RESIDENT RESEARCH Test Your Knowledge TECHNICAL TRICKS DAY ABSTRACTS 10 Adult Reconstruction Groundbreaking Research and Advancements in 17 Foot & Ankle Orthopaedic Surgery 20 Hand & Upper Extremity 25 Oncology 77 26 Pediatrics 66 PHILANTHROPY 30 Prosthetics & Orthotics DEPARTMENT Help Make Great 32 Research SPOTLIGHT Orthopaedic Care 35 Spine Highlighting the at UVA Even Better Accomplishments, 41 Sports Medicine Recent Growth, and 46 Trauma Prominent Physicians in 52 Physician’s Assistants the Department 53 Residents & Fellows UVA Department of Orthopaedic Surgery

A. Bobby Chhabra, MD Chair of the Department | Lillian T. Pratt Distinguished Professor | David Harrison Distinguished Educator | President, UVA Physicians Group

ADULT RECONSTRUCTION RESEARCH Thomas E. Brown, MD George J. Christ, PhD Associate Professor Mary Muilenburg Stamp Professor James A. Browne, MD* Quanjun Cui, MD Alfred R. Shands Professor and Vice Chair for Clinical Operations Gwo-Jaw Wang Professor and Vice Chair for Research Quanjun Cui, MD Joe Hart, PhD Gwo-Jaw Wang Professor and Vice Chair for Research Associate Professor Joshua Li, MD, PhD FOOT AND ANKLE Associate Professor M. Truitt Cooper, MD Wendy Novicoff, PhD Associate Professor Professor Shepard Hurwitz, MD Shawn D. Russell, PhD Professor Emeritus Assistant Professor Joseph S. Park, MD* Associate Professor SPINE Venkat Perumal, MBBS Hamid Hassanzadeh, MD Assistant Professor Associate Professor Joshua Li, MD, PhD HAND AND UPPER EXTREMITY Associate Professor A. Bobby Chhabra, MD Francis H. Shen, MD* Lillian T. Pratt Distinguished Professor and Chair Warren G. Stamp Professor David Harrison Distinguished Educator Adam L. Shimer, MD A. Rashard Dacus, MD Associate Professor Associate Professor and Vice Chair for Diversity & Wellness Anuj Singla, MD D. Nicole Deal, MD* Assistant Professor Associate Professor Aaron M. Freilich, MD SPORTS MEDICINE Associate Professor Stephen F. Brockmeier, MD Associate Professor ONCOLOGY David R. Diduch, MD* Gregory Domson, MD Allen F. Voshell Professor Associate Professor F. Winston Gwathmey, MD Associate Professor and Residency Director PEDIATRICS Mark F. Abel, MD* Mark D. Miller, MD Charles J. Frankel Professor and Vice Chair for Faculty Development S. Ward Casscells Professor Keith R. Bachmann, MD Brian C. Werner, MD Assistant Professor and Associate Residency Director Assistant Professor Leigh Ann Lather, MD TRAUMA Associate Professor Ahmad Fashandi, MD Mark J. Romness, MD Instructor Associate Professor David B. Weiss, MD* Associate Professor PROSTHETICS & ORTHOTICS Seth R. Yarboro, MD Kevin King, CPO* Associate Professor and Quality Director Technical Director Michele Bryant Certified Orthotist and Assistant Director Mary Grant Certified Prosthetist * Division Head

This past July, I began my 7th year as the Chair of the Department of Orthopaedic Surgery at the University of Virginia. As many of you know, I have spent my entire career here at UVA beginning as a medical student in 1991. It is a tremendous honor to continue to build on the foundation of my predecessors, who helped create one of the top Orthopaedic programs in the country. The UVA Orthopaedic Journal was last published in 2000, my chief resident year. Since then, the department has changed dramatically, and we have experienced unprecedented growth. I am excited to share our progress in this second issue of a journal that will be published on a more frequent basis moving forward. UVA Orthopaedics is now the busiest surgical service at the UVA Medical Center, and we have increased our clinical footprint to include locations east and north of Charlottesville. We recorded 101,000 patient visits and performed 8,300 surgeries in fiscal year 2019 compared to 69,000 patient visits and 6,800 surgeries just seven years ago. Our faculty size has increased to 32 clinical faculty and 6 research faculty. We have 15 very talented Physician Assistants who help optimize our patient care and access. For the last two years, we have surpassed institutional quality metric and patient satisfaction goals and performed better than all other service lines at the UVA Medical Center. For six years in a row, UVA Orthopaedics has been ranked one of the top 100 Orthopaedic programs in the country in Becker’s Hospital Review and has been ranked in the top 10% of programs in the country in US News and World Report. We are in the midst of dramatic changes in how healthcare will be provided nationally, and this topic is a political hot button in upcoming elections. I am fortunate to have a group of faculty members who are resilient and determined to provide the best patient care possible despite the pressures of healthcare reform. I have challenged our faculty to continue to advance orthopaedic care while responding to increasing competition, declining reimbursement, and increasing focus on the cost, value, and quality measures of patient care. We are well-positioned to be one of the leading Orthopaedic programs in the country during this tumultuous and uncertain time. In addition to the changing clinical care paradigm, our educational model has changed substantially over the last several years. With duty hour restrictions and the need to improve surgical outcomes and patient safety, we have created innovative methods to educate our residents and fellows. We have successfully implemented a surgical simulation and cadaver dissection curriculum. Our Orthopaedic residency is one of the most competitive programs in the country and was recently ranked in the top 25 by Doximity. This year we received over 750 applications for our 5 intern positions. Our residency complement is still 25 total residents (5 residents/year), but we have expanded to 9 fellowship positions in 5 different specialties (Foot & Ankle, Hand, Adult Reconstruction, Spine, and Sports). Under the direction of our very talented residency and fellowship directors, we are continually modifying and improving our teaching methods and curriculum to ensure that we produce the most skilled Orthopaedic surgeons in the country. You, our loyal alumni, have allowed us to find ways to support these new educational endeavors with your generous donations. Coupled with changes in patient care and education, the usual mechanisms of research support are becoming less reliable. Despite this, we have continued to grow in the area of musculoskeletal research. Our Orthopaedic Clinical Trials division has flourished and is one of the most productive in the UVA Health System. We are recognized internationally for our contributions to tissue engineering advances for musculoskeletal disease. We opened a new state-of-the-art Human Performance and Motion Analysis laboratory last year. In the following pages, you will be introduced to our department by division and get a glimpse into our exciting future. You will learn about our clinical, educational, and research initiatives and get to know a few of us personally. There is also an update on the future home of UVA Orthopaedics: the Ivy Mountain Musculoskeletal Center that is under construction and will be completed in 2022. I am thankful for the great faculty, residents, fellows, physician assistants, and staff that I work with every day. I am grateful to our loyal alumni who continue to support our department in so many ways, including our educational and research endowments. I look forward to seeing many of you at our UVA Orthopaedic Alumni reception at the upcoming AAOS Annual meeting in Orlando, Florida in March.

Thank you again for your unwavering support of our department, and I hope our paths cross soon.

Sincerely, Bobby Chhabra

By Whitelaw Reid, University News Associate Office of University Communications

With exam rooms, operating rooms, surgery support and imaging services, a retail pharmacy, and food service, the Ivy Mountain Musculoskeletal Center will be a one-stop shop for orthopaedic and musculoskeletal care.

© 2019 BY THE RECTOR AND VISITORS OF THE UNIVERSITY OF VIRGINIA hen the University of Vir- ginia opened John Paul Jones Arena with a men’s W basketball game in 2006, legendary boxing announcer Michael Buf- fer (of “Let’s get ready to rumble!” fame) announced the starting lineup as fireworks exploded and the Cav Man mascot dramatically rappelled from the roof. ’Hoos in attendance beamed with pride over the new state-of-the-art building, which quickly was anointed by the college hoops world as one of the best facilities in View East the country. courtesy ZGF Architects Renderings Four years from now, Dr. Bobby Ch- habra believes the orthopaedic world will Chhabra said other benefits would be “We’ll be able to provide the most in- have a similar reaction when the UVA Ivy better communication between the phy- novative care and treatment technologies Mountain Musculoskeletal Center opens. sicians and providers, as well as improved for our patients at a more competitive In September, 2018, a beaming Chhab- synergy for patient care and clinical ortho- price.” ra—along with Dr. Rick Shannon, UVA paedic research. Shannon has called musculoskele- Health System’s executive vice president “No matter how many musculoskeletal tal and joint problems “the disease of the for health affairs—wielded a shovel in a problems you have, you will be able to get next century.” With many Baby Boomers groundbreaking ceremony for the $160 all of your care in one location,” Chhab- needing joint replacement, Chhabra said million project on Ivy Road near the U.S. ra said. “There will now be seamless care the prediction is already proving true. “If 29/U.S. 250 interchange. through the whole spectrum—from diag- you look at the trends, hip and knee re- “This facility,” Chhabra, chair of the nosis, treatment, to therapy. placement will be one of the most com- UVA Department of Orthopaedic Surgery, declared, “will be the best for musculoskeletal and orthopaedic care in the country.” Scheduled to open in 2022, Ivy Moun- tain will be one of only four similar facilities of its kind on the East Coast, joining the Hospital for Special Surgery in New York City, the Emory University Ortho- paedics & Spine Hospital in Georgia, and the University of Florida Orthopaedic and Sports Medicine Institute in Florida. With 90 exam rooms, six operating rooms, surgery support and imaging services, a retail pharmacy, and food service, the massive 195,000 square-foot facility will be the ultimate one-stop-shop for orthopaedic and musculoskeletal care. The center will unite all of UVA Ortho- paedics’ outpatient clinics, meaning patients who have sustained multiple injuries will no longer have to schlep around Charlottesville

to various specialists—a foot and ankle clinic System Health UVA Taylor, Kay by Photo The project has been a true labor of love for Dr. Bobby Chhabra, a “triple-’Hoo.” here, a hand clinic there—for their treatment.

6 | UVA ORTHOPAEDIC JOURNAL | 2019 | UVA’s Ivy Mountain View Southeast Musculoskeletal View West Center is scheduled to open in 2022.

Site Plan View of Lobby

mon surgeries in the world within the next “It’s been such a vision for him, and really, “The new medical center will provide decade,” he said. the whole orthopaedic department, to have a our student-athletes, and the community, And with a dedicated post-operative world-class facility,” Bennett said. “To see it an entirely new level of health care and joint replacement unit where patients can starting to come to fruition is really special.” convenience,” UVA Director of Athletics receive therapy right in their rooms while Chhabra, who helped start the UVA Carla Williams said. “It is a great mod- family members are present, Chhabra said Hand Center in 2010, said it’s definitely el of care where so many resources that they’ll now have the perfect place to do it. been a team effort. had previously been spread out around The project has been a true Grounds will be in one central labor of love for Chhabra, a Chhabra believes Ivy Mountain will give site. The concept and design “triple-’Hoo” who learned un- the University a leg up in recruiting the enhances multidisciplinary care der the legendary Dr. Frank and will greatly benefit patients McCue (the former doctor for best students and student-athletes. and their wellness needs.” UVA sports teams). He and his UVA Head Athletic Train- partners at UVA Orthopaedics er, Ethan Saliba, who has cared first dreamed up the idea 10 years ago and “It’s taken a village,” he said. “We’ve had for Wahoo athletes for 36 years, said Ivy Chhabra has spent the last two years nav- input from hundreds of people during the Mountain would be the new “gold stan- igating the project through the design and planning process, with the sole focus being, dard.” approval phase. ‘How do we provide the best care for our pa- “It will provide resources for the total UVA men’s basketball coach Tony Ben- tients and at the same time educate the next care of athletes—from the professional nett, whose players have relied on Chhabra generation of physicians and providers?’” to collegiate or high school level—along and his team for years, said Chhabra’s de- Located less than a mile from the UVA with those who are just interested in being termination to see the project through has sports complex, the facility will be of obvi- physically active,” Saliba said. “We are very been inspiring. ous benefit to Cavalier sports teams. fortunate to have this.”

| uvaortho.com | 7 Chhabra believes Ivy Mountain will give the University a leg up in recruiting the best students and student-athletes. “There’s nothing more important for a parent to know that their kid is getting the best health care possible, and this facility will not only be incredibly beautiful, incredibly advanced and innovative, but it will provide the parents of all our students real comfort in knowing their kids are getting the highest level of orthopaedic and musculoskeletal care in the country,” he said. For some UVA athletes, the one-stop nature of Ivy Mountain may feel similar to their current experience at JPJ, where they can practice, study, and eat all in the same place. “The state-of-the-art facilities all under one roof will just be incredible,” Bennett said. “When you combine that with what I believe are some of the best doctors and technicians—that’s when you start talking about world-class. I think that’s what we have here.” ■

Schematic Design Review BUILDING SECTION A

8 | UVA ORTHOPAEDIC JOURNAL | 2019 | UVA Orthopaedics BY DIVISION

The driving missions of our Department of Orthopaedic Surgery are to be national leaders in improving clinical care of orthopaedic conditions, in being innovators in educating residents who will become future leaders and to contribute impactful musculoskeletal research which will translate into the future treatments in our field. In pursuit of these goals, we strive always to provide state-of-the-art, comprehensive, but cost-effective care for all musculoskeletal, orthopaedic disorders. Our education curriculum is structured to evolve so as to provide updated, competency-based materials and a robust evaluation process. Researchers in Orthopaedics, endeavor to make significant and sequential advancements in the science of musculoskeletal medicine using a multidisciplinary, collaborative research approach which can inform the future practice of Orthopaedic Surgery.

Division heads denoted with an *

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Thomas E. Brown, MD James A. Browne, MD* Quanjun Cui, MD Associate Professor Vice Chair for Clinical Operations Gwo-Jaw Wang Professor and Alfred R. Shands Professor Vice Chair for Research

Dr. Thomas E. Brown is an Associate Profes- Dr. James A. Browne is the Alfred R. Shands Dr. Quanjun Cui is the G.J. Wang, MD, Pro- sor in the Adult Reconstruction Division at UVA. Associate Professor of Orthopaedic Surgery, Vice- fessor of Orthopaedic Surgery, and Vice-Chair He also serves as the Program Director for the Chair of Clinical Operations, and Division Head of for Research. He is a board-certified orthopaedic Adult Reconstruction (Joint Replacement) Fel- Adult Reconstruction at the University of Virginia. surgeon and specializes in total hip and knee lowship Program. Dr. Brown’s training began at He also serves as the physician co-lead of the replacement, osteonecrosis, surgical hip dislo- East Carolina, where he received both a Bache- Musculoskeletal Service Line. He was born and cations to treat femoro-acetabular impingement, lor’s and Master’s degree in Exercise Physiology. raised in Canada and moved to Virginia to pursue and computer-aided and minimally invasive Medical School training was completed at The his education at Washington and Lee University, surgery for total hip and knee arthroplasty. His Medical University of South Carolina, where he where he captained the Men’s Swim Team before research, focusing on stem cell and arthritis, is received the Thomas M. Savage Award for aca- graduating summa cum laude. He completed funded by the National Institute of Health (NIH). demic excellence. Residency training was com- medical school at Johns Hopkins, residency at Dr. Cui received his medical degree with hon- pleted at Geisinger Medical Center, followed by a Duke University, and Fellowship in Hip and Knee ors from Henan Medical University in China and short stint in private practice, before completing Arthroplasty at the Mayo Clinic, where he was then completed residency and fellowship training a Joint Replacement Fellowship at UVA. He was honored with the Mark B. Coventry Adult Recon- in Adult Reconstruction at the University of Virgin- then asked to stay on as faculty here at UVA upon structive Surgery Fellowship Award. ia School of Medicine. He also completed an AO completion of this Fellowship in 1999. His clinical interests and expertise include fellowship at the University of Bern in Switzerland. Dr. Brown’s clinical and research interests complex primary and revision hip and knee, and Dr. Cui has written over 130 papers and book have focused on complex hip and knee replace- he received the UVA Dean’s Clinical Excellence chapters and has edited 9 textbooks. He has ment, and he has been awarded the UVA School Award in 2014. Along with his clinical interests, served as a faculty member for several national/ of Medicine Master Clinician Award. Dr. Brown is he is actively involved with research encompass- international instruction courses, including AAOS an avid cyclist and enjoys spending time on the ing all aspects of hip and knee replacement, has instruction courses, Advances in Arthritis, Arthro- water with his wife, Janice, either in Maine or lo- published numerous peer-reviewed journal ar- plasty, and Trauma, and Advances in Surgical cally at Smith Mountain Lake. ticles and book chapters, and has been invited Technology. Dr. Cui also served as program chair to speak nationally and internationally on topics or faculty member at state and national/interna- related to joint replacement. tional meetings. He is a board member and re- He was awarded the Knee Society John Insall viewer for several prestigious journals, including Award in 2014 for his research examining obesity the Journal of Arthroplasty, the Journal of Bone and outcomes following total knee arthroplasty. and Joint Surgery, and the Journal of Orthopaedic He is currently an Associate Editor of the Journal Research. of Arthroplasty, serves on the Steering Commit- Dr. Cui has received numerous academic and tee of the American Joint Replacement Registry professional accolades, including the Hip Society (AJRR), is a Board Member of the American As- Otto Aufranc Award. He has been recognized as sociation of Hip and Knee Surgeons (AAHKS), is “America’s Top Orthopaedist” since 2009 and the Program Chair for the AAHKS Annual Meeting as one of “the Best Doctors in America” since in 2019, and was recently inducted into the Knee 2015. He is a Fellow of the American Academy Society. He and his wife, Amy, have two school- of Orthopaedic Surgeons, a member of the Or- age children. thopaedic Research Society, and a Fellow of the American Orthopaedic Association (AOA). He was the President of the Virginia Orthopaedic Society in 2017 and Vice President for North America of ARCO from 2015-2017. He is married to his medical school classmate, Ling, and has two grown children.

10 | UVA ORTHOPAEDIC JOURNAL | 2019 | ADULT RECONSTRUCTION

Fighting the Good Fight: trochanter, through the femoral neck, and into the subchondral lesion of the femo- Searching the Cure for Osteonecrosis ral head (Figure 1C). These tracts relieve the increased pressure and can potentially help to restore adequate blood flow to the Quanjun Cui, MD, and Nicholas Calabrese, PA other institutions to organize randomized femoral head, thereby allowing for healing multi-center clinical trials to assess the ef- and preservation of the joint. The injection University of Virginia, Department of Orthopaedic Surgery fectiveness of this therapy, the best possi- of concentrated bone marrow aspirates Charlottesville, VA ble source of cells, and the best method of (Figure 1D), containing autologous bone implantation to further improve results in marrow stem cells, through the CD tracts those with pre-collapse ONFH. can increase the population of active stem steonecrosis of the femoral Core decompression works by drilling cells present for osteogenesis. Once inject- head (ONFH) is a devastat- one or multiple tracts from the greater ed into the femoral head defect, these cells ing disease affecting young O patients at their most productive age (average 38 years old), where- by the femoral head is necrotic (dead), resulting in significant pain, eventual collapsed femoral head, and arthritis. Un- fortunately, there is no effective treatment for the disease. Patients with ONFH that is caught in the very early stages (before the femoral head collapses, ARCO Stages I-II) Figure 1A and B, are potential candidates for hip-preserving procedures, but the results of these treatments are mixed. In patients whose femoral heads have already collapsed (ARCO Stages III-IV), total hip arthroplasty remains the most reliable treatment, but the prostheses may not last for patients’ lifespan. Therefore, seeking effective joint-preserving therapy for early-stage disease is of paramount importance. The most promising interventions to date for pre-collapse ONFH is core decompression (CD) with the use of concentrated bone marrow aspirate to improve the healing potential of the disease. Dr. Quanjun Cui at the University of Virginia Medical Center is one of only a few experts in the nation who perform such a procedure, using bone-forming stem cells from bone marrow (Figure 2) Figure 1. ARCO stage I osteonecrosis of the femoral head. (A) Radiograph shows no significant changes of bone structure, but (B) MRI shows subchondral lesion. Core decompression was performed using 9 to treat this rare but devastating condi- mm trephine under the fluoroscopy (C) and the bone marrow aspirate concentrates were delivered to the tion. He is working with investigators at subchondral area through the core decompression tract (D).

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Radiographic Evaluation of Acetabular Cup Position in THA: How Good is the Current Literature?

James A. Browne, MD, and tified. Of the thirty-three studies, one Ian Cook Armstrong study obtained standing radiographs, four University of Virginia, studies obtained supine radiographs, one Department of Orthopaedic Surgery study obtained both standing and supine Charlottesville, VA radiographs, and twenty-seven studies did not clearly state whether the patient was standing or supine in the radiographs. ABSTRACT Within the entire group of studies, twen- Background: Acetabular component ority-two studies measured anteversion using entation affects the stability of the hip joint AP radiographs, nine studies measured and plays a role in determining the risk of anteversion using lateral radiographs, and dislocation after THA. A “safe zone” for two studies did not definitively state what cup orientation with anteversion of 15 + 10 position was used to measure anteversion. degrees and inclination of 40 + 10 degrees Upon examination of the studies for the use has long served as the standard goal for of standardized quality control methods in cup placement. Recent studies have called radiograph acquisition, it was found that into question the validity of said “safe zone” fourteen studies used standardized quality Figure 2. Bone marrow was aspirated from iliac crest (A) and then processed (B) to isolate/con- due to persistence of dislocation within the control methods, whereas nineteen studies centrate bone marrow stem cells for injection into range, and significant variability in cup ori- did not mention that any assessment of the the femoral head. entation measurements. It is known that radiographic quality was performed. different radiographic conditions, such as Conclusion: The existing body of liter- standing versus supine patient position, can ature has inconsistencies in the methodol- have been found to survive and proliferate affect pelvic tilt and alter measurements of ogy used in radiographic measurement of for up to 12 weeks. Although a contro- cup position. Standardized methods for acetabular component orientation in THA, versial topic, it has shown overall positive quality control of the images can impact the and there appears to be no consensus as to outcomes. accuracy of cup orientation measurements, how to assess cup position. Measurements Though molecular and cellular mech- as well. The objective of this literature re- may not be comparable across studies as anisms for bone formation by bone mar- view was to assess the quality and consis- the variations in radiograph acquisition row stem cells remain unclear, recent tency of published studies that attempt to reduce confidence in the accuracy and va- discoveries suggest that the regulation define desirable acetabular component ori- lidity of said measurements. of bone formation by the cells of the im- entation in total hip arthroplasty (THA). mune system is the leading mechanism. Methods: Relevant studies were sys- MATERIAL AND METHODS Supported by funds from National Insti- tematically reviewed in Medline’s PubMed Literature searches were conducted us- tute of Health (NIH), Dr. Cui’s research database. Studies were included if they dis- ing the National Library of Medicine’s team is working to determine which sub- cussed outcomes after THA and assessed PubMed database to identify relevant pub- sets of bone marrow stem cells, immune acetabular component orientation using lications studying adverse outcomes after cells and their cytokines, as well as natural the analysis of plain radiographs. THA and the role of acetabular component human antibodies correlate with optimal Results: Thirty-three unique studies orientation in said outcomes. The search bone healing. ■ that met the inclusion criteria were iden- terms used include total hip arthroplasty,

12 | UVA ORTHOPAEDIC JOURNAL | 2019 | ADULT RECONSTRUCTION

total hip areplacement, total hip prosthesis, tion used in post-operative radiographs, it variability of dislocating and non-dislo- dislocation, instability, cup orientation, ac- was found that one study obtained stand- cating hips for inclination or anteversion etabular component, anteversion, inclina- ing radiographs, four studies obtained in a series of 1,578 posterior approach tion, cup placement, cup positioning, and supine radiographs, one study obtained THAs.7 They rejected the existence of a safe zone (note that an asterisk was used at both standing and supine radiographs, and “safe zone” for dislocation, and instead the end of the term dislocation to include twenty-seven studies did not clearly state emphasized the multifactorial nature of all possible variations of the word). The whether the patient was standing or su- dislocation. Others have pointed out that search terms were searched for in all fields. pine in the radiographs. For the study by it is difficult to assess what angular rang- Before search, a list of known relevant pub- McCollum et al.,6, where both standing es of acetabular component orientation lications was created in to ensure that the and supine radiographs were obtained, the are recommended by the literature due to search results were focused, yet sufficiently standing radiograph was a lateral projec- broad and inclusive of the relevant studies. tion, while the supine radiograph was an Initial search results were reviewed by title, AP projection. and studies were selected for abstract re- Further review of the thirty-three This literature review is the first view if the title contained any mention of studies for type of projection used to of its nature to assess the quality outcomes after THA or acetabular compo- measure anteversion revealed that twen- and consistency of radiographic nent orientation in THA. Abstracts were ty-one studies measured anteversion methods used in the existing reviewed, and studies were chosen for full- using AP radiographs, nine studies literature that attempt to define text review if they discussed the relation- measured anteversion using lateral radio- target acetabular component ship between acetabular component orien- graphs, and three studies did not clearly orientation ranges. The existing body tation and outcomes after THA. Following state what projection was used to measure of literature has inconsistencies full-text review, studies were reviewed if anteversion. It was found that fourteen in the measurement of acetabular they discussed outcomes after THA and studies used standardized quality con- component orientation in THA and assessed acetabular component orientation trol methods, whereas nineteen studies there appears to be no consensus as using the analysis of plain radiographs. did not mention that any assessment of to how to assess cup position. The initial search yielded one-thousand radiographic quality was performed. The one-hundred and sixty unique titles. Title most common method for radiograph review narrowed the pool of studies to nine- quality control was centering the beam inconsistencies in experimental variables ty-two abstracts, and abstract review result- over the symphysis pubis. used in determining said “safe zones.” ed in thirty-six full-texts. Three studies were Yoon et al. found that choice of reference excluded during full-text review due to the DISCUSSION frame and the definitions for acetabular lack of analysis of plain radiographs. The Lewinnek “safe zone” is intended to cup orientation angles varied across the The studies were reviewed for clear, ex- provide a standard range for acetabular existing literature, leading to highly vari- plicit mention of radiographic conditions component placement that surgeons can able and incomparable target orientation used when obtaining postoperative radio- trust to consistently provide a low risk of values.8 More uncertainty in the literature graphs. These include supine vs. standing dislocation. However, it has been shown is likely if the radiographic methods used patient position, and radiograph projection repeatedly that many THAs with success- to assess acetabular component orienta- used for calculating anteversion (AP vs. ful cup placement within the “safe zone” tion vary significantly. lateral). The studies were reviewed for the result in dislocation. In a study of a co- A limitation of this literature review is use of a quality control method in radio- hort of 9,784 primary THAs, Abdel et al. that there is the possibility that relevant graph acquisition as well. found that sixty-five percent of dislocated, studies could have been wrongfully ex- posterior approach THAs were properly cluded from the review due to the exclu- RESULTS placed within the combined “safe zone.”3 sion criteria that was utilized. Though it is Thirty-three unique studies that met Such findings have led some to claim that not possible to entirely eliminate this risk the inclusion criteria were included in this there is no true “safe zone.” Timperley et from the methodology, we reviewed the review. Upon review of the patient posi- al. found no significant difference in the titles of 1,160 publications, a fairly large

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sample size, and included any ambiguously Revision of a Failed Metal-on- titled studies in the abstract review process. This gives us confidence that our method Metal Total Hip Arthroplasty with included the entirety of the relevant literature available to us. Incarcerated Components and In conclusion, this literature review is the first of its nature to assess the quality Acetabular Defect and consistency of radiographic methods to define a target range for acetabular com- Stephen J. Nelson, MD, Thomas E. Browne, MD ets, also known as trabecular metal cups, ponent orientation. The existing body of have become increasingly popular as they University of Virginia, literature has inconsistencies in the mea- Department of Orthopaedic Surgery have demonstrated improved rates of bone surement of acetabular component orien- Charlottesville, VA ingrowth and survivorship over other tech- tation in THA and there appears to be no niques (Grappiolo 2015). In order to treat consensus as to how to assess cup position. a wider variety of irregular bone defects, Measurements may not be comparable ABSTRACT modular augments are available to be used across studies as the variations in radio- Managing acetabular defects is one of the with porous metal sockets. These trabecular graph acquisition methodology reduce most challenging aspects of revision cases cups and modular augments allow for “off confidence in the accuracy and validity of in total hip arthroplasty. Trabecular met- the shelf ” customization for almost any ac- said measurements. ■ al technology and surgical ingenuity have etabular defect. provided solutions for these difficult prob- For large, irregular acetabular defects, REFERENCES lems. This case presents one such acetabu- treatment with augments can be quite 1. Jolles BM, Zangger P, Leyvraz PF. Factors predisposing lar defect successfully treated with a double difficult. For such select cases, the use of to dislocation after primary total hip arthroplasty: a mul- tivariate analysis. J Arthroplasty. 2002 Apr; 17(3):282-8. cup construct. a double-cup has recently been described

2. Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zim- (Webb 2017, Loppini 2018). Such a tech- merman JR. Dislocations after total hip-replacement ar- INTRODUCTION nique allows the bone defect to be filled throplasties. J Bone Joint Surg Am. 1978 Mar; 60(2):217-20. The incidence of total hip arthroplasty with a porous metal cup, providing an in- 3. Abdel MP, von Roth P, Jennings MT, Hanssen AD, (THA) revision procedures continues to terference fit for a second cup which ap- Pagnano MW. What Safe Zone? The Vast Majority of Dislocated THAs Are Within the Lewinnek Safe Zone increase and is expected to double by 2026 propriately restores the hip center of rota- for Acetabular Component Position. Clin Orthop Relat (Kurtz 2007). Despite many new implant tion and biomechanics. The case presented Res. 2016 Feb; 474(2):386-91. advancements, the frequency with which below details one such acetabular defect. 4. Au J, Perriman DM, Neeman TM, Smith PN. Standing primary hip arthroplasty is performed, or supine x-rays after total hip replacement—when is the CASE REPORT safe zone not safe? Hip Int. 2014 Dec 5; 24(6):616-23. particularly on younger patients, has yield-

5. Ackland MK, Bourne WB, Uhthoff HK. Antever- ed many new types of revision challenges. A 66 year old gentleman underwent an at- sion of the acetabular cup. Measurement of angle after Among the failure mechanisms for tempted right hip resurfacing at an outside total hip replacement. J Bone Joint Surg Br. 1986 May; THA, acetabular defects can be partic- hospital in 2006. The case was complicat- 68(3):409-13. ularly difficult to treat. The goals of such ed and required intraoperative conversion 6. McCollum DE, Gray WJ. Dislocation after total hip arthroplasty. Causes and prevention. Clin Orthop Relat Res. revision procedures are to provide stable from a hip resurfacing procedure to a large 1990 Dec; (261):159-70. initial fixation, to promote bone ingrowth, head metal-on-metal total hip arthroplas- 7. Timperley AJ, Biau D, Chew D, Whitehouse SL. Dislo- and to restore the native hip center of ro- ty. In 2016, he presented to UVA Ortho- cation after total hip replacement - there is no such thing tation. Depending upon the location and paedics complaining of bilateral hip pain. as a safe zone for socket placement with the posterior approach. Hip Int. 2016 Mar 23; 26(2):121-7. amount of pelvic bone stock available, Imaging at presentation demonstrated left

8. Yoon YS, Hodgson AJ, Tonetti J, Masri BA, Dun- a number of reconstructive options are hip arthritis and a failed metal-on-metal can CP. Resolving inconsistencies in defining the target available, including: bulk allograft, jumbo THA with a modular stem, a loose cup, orientation for the acetabular cup angles in total hip cup constructs, custom triflange implants, and a large acetabular defect (Figure 1). arthroplasty. Clin Biomech (Bristol, Avon). 2008 Mar; 23(3):253-9. cup-cage constructs, and, more recently, After undergoing a workup for infection, porous metal sockets. Porous metal sock- he first underwent an uncomplicated left

14 | UVA ORTHOPAEDIC JOURNAL | 2019 | ADULT RECONSTRUCTION

aled using available acetabular bone stock for the first cup, positioning it in such a way that it provided an interference fit for the second cup with the appropriate hip center of rotation. The remaining portion of the femoral stem was freed up utilizing flexible osteotomes. A metal cutting bur was used to create a notch into the stem so that it

Figure 3. Intraoperative radiograph demonstrating extended trochanteric osteotomy, cut femoral Due to the capacious acetabular Figure 1. AP pelvis radiograph from July 2016. stem, and trial acetabular cup placement with a defect, the proximal migration of the high hip center. femoral component, and the spin out of the loose cup, the hip was noted to be incarcerated and unable to be explanted from the acetabular cavity during the routine posterior hip approach.

could be disimpacted with a bone tamp. Once this was removed, the femoral shaft was reamed up in preparation for a mod- Figure 4. AP pelvis radiograph of final construct. Figure 2. AP pelvis radiograph from December ular taper-fluted stem (Stryker, Mahwah, 2016 NJ). The trial components were reduced unable to be mobilized. The stem was cut and intraoperative x-ray confirmed com- total hip arthroplasty in November 2016 and the proximal portion of the stem then ponent position. (Figure 2). After an uneventful recovery became mobile. However, even with this The trial components were removed from his left hip arthroplasty, the right hip mobilization the head was still incarcerated and cancellous allograft was packed in was addressed. within the acetabular cavity. Using a bone part of the acetabular defect followed by The patient underwent right hip revi- tamp, the proximal Morse taper of the fem- the impaction of the first trabecular metal sion in March 2017. Due to the capacious oral component was able to be disengaged cup. Multiple 6.5 mm screws were placed acetabular defect, the proximal migration from the incarcerated femoral head. through the trabecular metal shell. The of the femoral component, and the spin With the proximal stem removed, burs screw heads were covered with bone wax out of the loose cup, the hip was noted to and acetabular reamers were used to ex- from the internal cup and then polymeth- be incarcerated and unable to be explant- pand the acetabular introitus allowing re- ylmethacrylate was placed into the first cup, ed from the acetabular cavity during the moval of the metal on metal femoral head and the articulating shell was cemented routine posterior hip approach. Therefore, and cup. The bone stock and continuity of centrally into the first shell, while achiev- an extended trochanteric osteotomy was the pelvis were assessed and prep for ace- ing good host bone contact anteriorly and performed in situ in order to gain access tabular reconstruction was performed. Ini- posteriorly. The polyethylene liner was then to the implants. Despite mobilizing the tial reaming of available acetabular bone cemented into the articulating cup of the abductors and trochanter and freeing up stock yielded a high hip center and an united double cup construct, followed by the bone-prostheses interface with burrs expansile cavitary defect (Figure 3), there- final seating of the taper-fluted stem. The and osteotomes, the components were still fore a double cup reconstruction was tri- trochanteric osteotomy was repaired, and

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the wound closed. Patient was allowed common complication was dislocation 2018). Fleischman reviewed the femoral toe-touch weight-bearing with abduction (25%), however the hip average Harris Hip nerve palsy cases at a single institution and orthosis x 6 weeks. Postoperatively the pa- Score improved from 28.2 to 68.7 postop- found that motor strength recovery did not tient was noted to have a complete femoral eratively (P < .001). commence for a majority of patients until nerve palsy, which recovered over the next Loppini retrospectively reviewed 16 6 months postoperatively, however motor 6-9 months (Figure 4). double cup constructs performed at their weakness had resolved in 75% of patients institution for Paprosky III defects without by 33 months. Fortunately, our patient is discontinuity. The authors noted a 100% on a similar timeline for nerve symptom survivorship of their implants at a mean of resolution. In contrast to the majority of hip 34 months with an average improvement CONCLUSION revisions where the joint is able to in Harris Hip Score from 19.4 to 77.2 be dislocated allowing the femoral postoperatively (P < .001). Total hip revisions performed for acetab- stem and acetabular cup to be A number of metal-on-metal hips re- ular defects are challenging procedures. addressed separately, this particular quire revision for metallosis and pseudo- The acetabular defect case presented here case required a creative approach tumor. These were not of concern in this was particularly difficult due to compo- where in situ extended trochanteric scenario where acetabular failure and joint nent incarceration. Surgical creativity and osteotomy, cutting of the stem, dissociation were the primary reasons for new technology have provided innovative disengagement of the head within hip revision. solutions to these problems and fortu- the acetabulum, and reaming of the Removal of incarcerated components nately yielded a stable construct for this acetabular introitus were required to can be a major challenge in revision hip patient. ■ facilitate component removal. arthroplasty. Such cases require alternative and creative strategies to permit component REFERENCES removal. In contrast to the majority of hip 1. Fleischman AN, Rothman RH, Parvizi J. Femoral DISCUSSION Nerve Palsy Following Total Hip Arthroplasty: In- revisions where the joint is able to be dis- cidence and Course of Recovery. J Arthroplasty. 2018 The use of a porous trabecular metal hemi- located allowing the femoral stem and ace- Apr;33(4):1194-1199. spheric shell as an augment allows for an tabular cup to be addressed separately, this 2. Grappiolo G, Loppini M, Longo UG, Traverso F, Mazziotta G, Denaro V. Trabecular Metal augments for interference fit, with a large surface area for particular case required a creative approach the management of Paprosky Type III defects without bone ingrowth, while providing stability where in situ extended trochanteric osteot- pelvic discontinuity. J Arthroplasty. 2015 Jun;30(6):1024-9.

for an articular shell with the appropriate omy, cutting of the stem, disengagement of 3. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. J. Bone center of rotation. The utility and benefits the head within the acetabulum, and ream- Joint Surg Am. 2007 Apr; 89(4):780-5. of such double-cup constructs have recently ing of the acetabular introitus were required 4. Loppini M, Schiavi P, Rocca AD, Traverso F, Rocca FD, been described. to facilitate component removal. Mazziotta G, Astore F, Grappiolo G. Double-trabecular metal cup technique for the management of Paprosky Webb retrospectively reviewed 20 Though the stability of the patient’s hip type III defects without pelvic discontinuity. Hip Int. 2018 double-cup cases performed by a single construct was able to be restored, his case Nov;28(2_suppl):66-72. surgeon with a mean 2.4 year follow up was complicated by a femoral nerve palsy. 5. Webb JE, McGill RJ, Palumbo BT, Moschetti WE, Estok DM. The Double-Cup Construct: A Novel (Webb 2017). The authors noted that there This complication is relatively uncommon Treatment Strategy for the Management of Paprosky were no revisions for acetabular loosening after hip arthroplasty with a reported inci- IIIA and IIIB Acetabular Defects. J Arthroplasty. 2017 and no cases of aseptic loosening. The most dence in 0.17%-1.3% of cases (Fleischman Sep;32(9S):S225-S231.

16 | UVA ORTHOPAEDIC JOURNAL | 2019 | FOOT and ANKLE

M. Truitt Cooper, MD Shepard Hurwitz, MD Joseph S. Park, MD* Associate Professor Professor Emeritus Associate Professor

Dr. M. Truitt Cooper grew up on the east coast Dr. Shepard Hurwitz grew up in New Rochelle, Dr. Joseph S. Park was born in Brooklyn, NY, and of Florida and attended college at Washington and NY, and went to Columbia College, followed by grew up in the suburbs of Baltimore, MD. He Lee University, followed by medical school at the Columbia University College of Physicians & Sur- earned his undergraduate degree from the Uni- University of Virginia. He completed his Orthopae- geons for his BA and MD, respectively. He was versity of Pennsylvania in Philadelphia, where he dic Surgery Residency at Ohio State University. a college fencer on a team that won two NCAA graduated magna cum laude. He then graduated Following his residency, Dr. Cooper completed championships. Alpha Omega Alpha from the University of Virginia a Fellowship in Foot and Ankle Reconstruction un- Dr. Hurwitz spent two years in Charlottesville School of Medicine. Dr. Park then spent 5 years in der Michael Coughlin, MD, in Boise, Idaho. Initial- after medical school as a General Surgery Res- New York City, where he completed his Residen- ly, he joined a private practice group in Richmond, ident (1976-1978) and then completed an Or- cy in Orthopaedic Surgery at New York University VA. However, in 2014, he decided to return to the thopaedic Residency in New York City, at the New Langone Orthopedic Hospital. He then complet- University of Virginia to pursue a career in aca- York Orthopaedic Hospital. He completed one ed his Fellowship in Orthopaedic Foot and Ankle demics. Currently, Dr. Cooper serves as the Fel- year of adult and pediatric foot/ankle training at Surgery at Union Memorial Hospital in Baltimore, lowship Director for the Foot and Ankle Fellowship the Hospital for Special Surgery in New York City MD. He returned to the University of Virginia in at the University of Virginia, as well as the Medical then another year of biomechanics and fracture 2010 to join our Orthopaedic Surgery Faculty. Director for the Ambulatory Orthopaedic Clinics. surgery at New York Hospital/Hospital for Special Dr. Park, an Associate Professor in Orthopae- Dr. Cooper is an active member of the Amer- Surgery. He joined the UVA faculty in 1994 and dic Surgery, has been the Foot and Ankle Division ican Orthopaedic Foot and Ankle Society. He was the Chief of the Foot/Ankle Division of the Head at UVA since 2010 and serves as the Foot currently serves as Vice-Chair of the Physician department. and Ankle Consultant to the UVA Athletic Depart- Resource Committee and has served on the Dr. Hurwitz has been on numerous AAOS and ment. Through his research collaborations with the Post-Graduate Education Committee. He serves AOA committees as well as committees for the Biomedical and Mechanical Engineering Depart- on the editorial board for Foot and Ankle Specialist ORS, OTA, and AOFAS. He was a member-at-large ments at UVA, he has helped establish UVA and and as a reviewer for Foot and Ankle International. of the AOFAS Board of Directors (2005-2007), the Center for Applied Biomechanics as nationally In addition to maintaining an active clinical President of the Eastern Orthopaedic Association recognized leaders in biomechanical testing of or- practice focusing specifically on foot and ankle (2002-2003), and President of the Southeastern thopaedic implants. His peers voted him as one reconstruction, he has numerous research in- Fracture Symposium (2006-2008). He was on of the Best Doctors in America for 2015-2016 terests. These include total ankle arthroplasty, the ABOS Board of Directors (2005-2007) and and 2017-2018. He also received the UVA Dean’s midfoot injuries, and arthrodesis healing. He is was the Executive Director of the ABOS (2007- Award for Clinical Excellence in 2015. currently involved in multi-center clinical trials 2016). He was on the UVA Faculty Senate (2003- Dr. Park is a reviewer for the Journal of Bone involving total ankle replacement and bone graft 2006) and several SOM committees. and Joint Surgery as well as Foot and Ankle Ortho- substitutes for foot and ankle fusion procedures. Dr. Hurwitz is married to Margretta, and they paedics. He is the Associate Foot and Ankle Fel- Dr. Cooper is married with three children that have two daughters, Zoe and Leah. Zoe played lowship Director at UVA and is currently Chairman keep him and his wife very busy. He enjoys most varsity volleyball on an NC High School champi- of the Physician Resource Center Committee for outdoor activities, including mountain biking and onship team, and Leah is an outstanding field the American Orthopaedic Foot and Ankle Society trail running. hockey athlete who recently was named to a na- (AOFAS). In November of 2018, he traveled to Xia- tional travel team. Dr. Hurwitz volunteers in North men, China, where he was selected to represent Carolina as a physician to the athletic teams in the AOFAS at the 13th Annual Congress of the Carrboro and Chapel Hill, and he is the Admin- Chinese Orthopedic Association. istrator of the Surgical Skills Laboratory in the Dr. Park has helped establish and coordinate Department of Orthopaedic Surgery. His hobby is the Boar’s Head UVA Physician Speaker Series shooting clay pigeons and competing in skeet and and is an avid UVA Athletics fan. He and his wife, sporting clays events. He plays tennis occasional- Ann Marie, have 3 school-aged children (and 2 ly and enjoys fishing when he gets the chance to puppies). He is a member of the Boar’s Head go out on someone else’s boat. USTA tennis team and enjoys playing sports and spending time with his family.

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UVA Foot and Ankle Division

1 1 Joseph S. Park, MD , M. Truitt Cooper, MD , Resident Clerkship Director for the Foot Venkat Perumal, MBBS, MS1, and Ankle Division. Our PAs, Jim Short- Victor Shen2, PhD, Jason R. Kerrigan, PhD2, E. Meade Spratley, PhD3 en and Andrea White provide exceptional patient care and continuity of follow-up for Venkat Perumal, MBBS 1University of Virginia, our busy clinical practice. Assistant Professor Department of Orthopaedic Surgery, Our division is involved in multiple Charlottesville, VA clinical trials and biomechanical studies 2University of Virginia, focusing on ankle replacement, hindfoot ar- Dr. Venkat Perumal was born and grew up in In- Department of Mechanical and dia. He attended medical school and did his Resi- Aerospace Engineering, throdesis, tendon reconstruction, orthopae- dency in Orthopaedic Surgery in India. Charlottesville, VA dic implant performance and optimization, Dr. Perumal’s specialty is Foot and Ankle. He 3University of Virginia, as well as gait analysis for ankle replacement completed multiple fellowships, including one in Center for Applied Biomechanics, Pediatric Orthopaedic Surgery at Cincinnati Chil- patients. Many of our biomechanical stud- dren’s Hospital, one in Orthopaedic Trauma at the Charlottesville, VA ies have resulted in cross-Grounds collab- University of Louisville, and one in Adult Recon- orations with members of our Engineering struction and Foot and Ankle at UVA. Dr. Perumal joined the UVA Department of Orthopaedic Sur- he Orthopaedic Foot and Ankle Department, including Jason Kerrigan, gery’s faculty in April 2013. Division at the University of Vir- PhD, and Meade Spratley, PhD, from the He has a wife, Vanitha, and has two children. ginia has become a regional re- Center of Applied Biomechanics and Chris He spends his free time with family and enjoys ferral center for the comprehen- Li, PhD, from Mechanical Aerospace Engi- playing chess, camping, biking, hiking, attending T spiritual meetings, and volunteering in free medi- sive treatment of complex deformities and neering. Since 2017, when the University of cal camps and homeless shelters. athletic injuries to the foot and ankle. Our Virginia awarded our group an Engineering division is comprised of three Foot and An- in Medicine grant to develop a robotic gait kle Fellowship-trained attending surgeons, simulator, we have secured approximately as well as two experienced physician’s assis- $600,000 in external/industry funding for tants. Joseph Park, MD, serves as the Divi- lower extremity research projects. We will sion Head and is a team physician for the continue to cultivate these collaborative University of Virginia. Truitt Cooper, MD, endeavors, and hope to establish UVA as a is the Foot and Ankle Fellowship Director, leader in biomechanical testing for ortho- as well as the Medical Director for our out- paedic implants and procedures. patient clinics, and is a team physician for With Dr. Chris Li, we examined the James Madison University. Venkat Perum- performance of 1st tarso-metatarsal fusion al, MD, serves as the Medical Student and constructs in a sawbones foot model. In or-

Figure 1. DIC strain maps in the x and y direction are shown at the peak of the last load cycle.

18 | UVA ORTHOPAEDIC JOURNAL | 2019 | FOOT and ANKLE

der to better understand the dynamic properties of nitinol continuous compression implants and more traditional lag screw/ plate fixation, we utilized 3D digital image correlation to characterize the stress/strain of the arthrodesis construct under 3 point bending. We hypothesized that while stiffness of the joint would play a role in successful arthrodesis, residual displacement after loading might better indicate long- term stability of the implant construct. Paint was applied in a unique speckling pattern, and high resolution multi-planar video was utilized to illustrate the changing Gait Simulator Overview relationship between these individual reference points under 50 Newtons of load. This loading was repeated 100 times for each specimen, and we compared two arthrodesis constructs; three samples with a 4.0 mm lag screw and 4 hole locking T plate, and three samples with two nitinol compression staples implanted in an offset 90 degree configuration (dorsal and medial). The conclusions of our study showed that although the lag screw and locking plate construct resulted in less initial displacement compared to the compression staples (2.2 mm versus 3.2 mm respectively), after the conclusion of 100 cycles of loading, the Robotic Joint Characterization for TAR lag screw/locking plate construct had more residual plantar gapping of 0.8 mm versus 0.3 mm for the dual staple construct. Al- with 6 degrees of freedom, our group has acteristics of the mobile bearing implant, we though both implant constructs performed incorporated tendon actuators to more subjected the cadaveric ankle to loading in well under this simulated weight bearing closely replicate human gait by activat- dorsiflexion, plantarflexion, as well as -in cycling, the improved recovery of coming tendons during the appropriate time version and eversion to enable us to better pression after load for nitinol compression point during the gait cycle. This provides understand the response of the arthroplasty staples may facilitate an increase arthrod- our lower extremity research group with a construct and mobile bearing polyethylene esis rate for these challenging orthopaedic unique research tool that differentiates us to complex ambulation tasks such as nav- procedures. Currently, cadaveric testing is from every other biomechanical testing fa- igating hills and uneven surfaces. We hy- underway to better characterize the per- cility in the world. pothesized that the mobile bearing may de- formance of these implants for simulated In a preliminary mobile bearing ankle crease stress on the tibial and talar implant/ weight bearing in a fixed ankle walker. arthroplasty study, we demonstrated 3 di- bone interface due to its ability to rotate and With internal funding from UVA, we mensional motion analysis of the cadaveric translate within the ankle joint. Data anal- have developed a robotic gait simulator at ankle in the native condition, after ankle ar- ysis is currently underway, and additional the Center of Applied Biomechanics. Us- throplasty, and after ankle arthroplasty and studies to better understand ankle arthro- ing a Kuka robot with the ability to move subtalar arthrodesis. Given the unique char- plasty biomechanics are in preparation. ■

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A. Bobby Chhabra, MD A. Rashard Dacus, MD D. Nicole Deal, MD* Lillian T. Pratt Distinguished Professor and Chair Associate Professor and Vice Chair for Associate Professor David Harrison Distinguished Educator Diversity & Wellness

Dr. A. Bobby Chhabra is the Lillian T. Pratt Dis- Dr. Dacus joined the department in August of Dr. D. Nicole Deal is an Associate Professor with tinguished Professor and Chair of Orthopaedic 2007 after completing a Fellowship in Hand and tenure and the Division Head of Hand Surgery at Surgery and the David A. Harrison Distinguished Upper Extremity at the University of California, the University of Virginia. She is also the Co-Di- Educator, as well as Professor of Plastic Surgery San Diego. His practice encompasses hand rector or the UVA Hand Center and the Hand Fel- and Professor of Pediatrics at the University of trauma, nerve dysfunction in the upper extremi- lowship Director for the Plastic Surgery Depart- Virginia. He is also a team physician and the ty, joint replacement in the hand and elbow, and ment, where she also has an appointment. Dr. Hand and Upper Extremity Consultant for the reverse total shoulder arthroplasty, as well as Deal completed her undergraduate degree at the UVA Department of Athletics. He is currently the microvascular surgery of the hand and upper University of Virginia, medical school at the Med- President of the University of Virginia Physician’s extremity. ical University of South Carolina, and Residency Group and the School of Medicine Faculty Rep- He served as Residency Program Director from and Hand Fellowship at Wake Forest University. resentative to the UVA Health System Board and July 1, 2011, until June 30, 2019. Since 2008, In 2009, Dr. Deal was excited to join the Ortho- Board of Visitors. Dr. Dacus has been Assistant Team Physician for paedic Hand Faculty at the University of Virginia. Dr. Chhabra’s areas of expertise include hand, James Madison University Athletics and continues Since joining the faculty, Dr. Deal has received wrist, and elbow trauma and arthritis, with a par- in that capacity. On July 1, 2019, he assumed the many faculty achievement awards, including the ticular interest in sports injuries and congenital role of Vice-Chair for Diversity and Clinician Well- Dean’s Award for Clinical Excellence in 2013 hand surgery. ness for the Department of Orthopaedics. It is a and the Dean’s Award for Teaching Excellence in Dr. Chhabra is a nationally recognized edu- newly-created position, so that he will serve as the 2015, and was inducted into the Academy of Dis- cator. He has received the University of Virginia pioneer for possibilities for this role. tinguished Educators in 2016. Dr. Deal currently School of Medicine Dean’s Award for Excellence in Dr. Dacus serves on the Education Commit- serves as the Secretary/Treasurer for the Virginia Teaching, the University of Virginia Master Educa- tee for the American Association for Surgery of Orthopaedic Society and looks forward to serving tor Award, and the David A. Harrison Distinguished the Hand and serves as a reviewer for the Journal as the President for the 2020- 2021 term. Educator Award, the highest teaching honor at the of Hand Surgery. He is dedicated to the Charlot- Dr. Deal has authored 28 peer-reviewed jour- University of Virginia School of Medicine. In 2014, tesville community and serves on the Board of nal articles and 27 book chapters. Her research Dr. Chhabra was inducted into the Raven Society, Advisors for Big Brothers/Big Sisters of Central interests include nerve regeneration techniques, the most prestigious honorary society at the Uni- Virginia and the New Hill Board. He enjoys spend- and she has received 2 prestigious Coulter Foun- versity of Virginia. ing time with his wife and baby daughter and trav- dation grants for her collaboration with faculty Dr. Chhabra graduated from the Johns Hop- eling to new places. from the Department of Biology to develop novel kins University with a degree in biology before techniques to stimulate nerve growth. In addition, completing his medical education at the University she is the PI for a clinical study investigating the of Virginia School of Medicine. He completed his use of allografts for sensory deficits. residency training in Orthopaedic Surgery at the University of Virginia Health System. He received his fellowship training in Hand and Upper Extrem- ity, Microvascular, and Congenital Hand Surgery at the Hand Center of San Antonio and the Texas Scottish Rite Hospital. Dr. Chhabra has published over 60 peer-reviewed articles and 40 book chapters, has been the editor for 5 textbooks, given 150 national/international presentations, and has been invited as a Visiting Professor at 20 prestigious institutions.

20 | UVA ORTHOPAEDIC JOURNAL | 2019 | HAND and UPPER EXTREMITY

UVA Hand Highlights

The Hand Division is one of several academic medical centers contributing to a Nationwide Database on outcomes related to hand and digital replants following traumatic amputations.

The UVA hand division has 2 nationally recognized positions for hand Aaron M. Freilich, MD fellows in collaboration with the Department of Plastic Surgery. We receive Associate Professor more than 100 applications for these 2 positions and routinely match in the top 5 people on our rank list. Dr. Aaron M. Freilich is an Associate Professor of Orthopaedics in the Hand and Upper Extremity Recent publications from the hand center: Division with a joint appointment in the Depart- ment of Plastic Surgery. Dr. Freilich is the Ortho- paedic Hand Fellowship Director and serves as the 3rd Year Medical School Orthopaedic Clerk- niques have been proposed. The purpose of ship Director as well. Radial Head Fracture Fixation this paper is to detail and demonstrate the He began his education at the University of Using Tripod Technique With proper implementation of the tripod tech- Michigan, studying Economics and Cell and Mo- lecular Biology, and graduating with honors. He Headless Compression Screws nique using headless compression screws. received his MD in 2004 from the University of J Hand Surg Am. 2018 Jun;43(6):575. Marc D. Lipman, MD1, Trent M. Gause, MD1, Virginia. Dr. Freilich continued his training with 1 1 e1-575.e6. doi: 10.1016/j.jhsa.2018.03.009. a Residency in Orthopaedic Surgery at UVA and Victor A. Teran, MD , A. Bobby Chhabra, MD , 2 Epub 2018 Apr 27. then completed a Fellowship in Hand and Upper D. Nicole Deal, MD Extremity Surgery at Wake Forest Baptist Medical Center. He is a member of the AAOS and ASSH, 1Department of Orthopaedic Surgery, serving on several committees both locally and na- University of Virginia Health System, Patient-Related Risk Factors for tionally. He continues to serve as a member of the Charlottesville, VA Infection Following Open Carpal UVA Medical School Curriculum Committee as well. 2Department of Orthopaedic Surgery, Tunnel Release: An Analysis of Over Dr. Freilich treats hand, wrist, and elbow University of Virginia Health System, problems, with a particular interest in trauma Charlottesville, VA 450,000 Medicare Patients and microvascular reconstruction. He works closely with his plastics hand surgery colleagues Brian C. Werner, MD1, Victor A. Teran, MD1, in training plastic surgery residents and fellows 2 ABSTRACT D. Nicole Deal, MD and further developing a joint hand reconstructive service. His research interests are in edu- Radial head and neck fractures are one of 1Department of Orthopaedic Surgery, cation and simulation training and collaboration the most common elbow fractures, com- University of Virginia Health System, with the Center for Applied Biomechanics. He is Charlottesville, VA married with two children. He enjoys skiing, hik- prising 2% to 5% of all fractures, and 30% 2Department of Orthopaedic Surgery, ing, and spending time outdoors with his wife, of elbow fractures. Although uncomplicat- University of Virginia Health System, kids, and their 2 Labradoodles. ed Mason type I fractures can be managed Charlottesville, VA nonsurgically, Mason type II-IV fractures require additional intervention. Mason type II-III fractures with 3 or fewer fragments ABSTRACT are typically treated with open reduction Purpose: To establish the rate of postop- and internal fixation using 2 to 3 lag screws. erative infection after open carpal tunnel Transverse radial neck involvement or axial release (CTR) on a national level using an instability with screw-only fixation has his- administrative database and define relevant torically required the additional use of a mini patient-related risk factors associated with fragment T-plate or locking proximal radius its occurrence. plate. More recently, less invasive techniques Methods: The PearlDiver patient re- such as the cross-screw and tripod tech- cords database was used to query the 100%

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Medicare Standard Analytic Files retro- use and outline comparative costs. We also spectively from 2005 to 2012 for patients Bone Graft Substitutes: Current describe the future directions for this spe- undergoing open CTR using Current Pro- Concepts and Future Expectations cific aspect of reconstructive surgery with a cedural Terminology code 64721. Postop- focus on the role of bioactive glass. David C. Lobb, MD1, Brent R. DeGeorge, Jr., erative infection within 90 days of surgery J Hand Surg Am. 2019 Jan 28. pii: MD, PhD2, A. Bobby Chhabra, MD3 was assessed using both International S0363-5023(18)30766-4. doi: 10.1016/j. Classification of Diseases, Ninth Revision 1Department of Plastic and Maxillofacial jhsa.2018.10.032. [Epub ahead of print] codes for diagnoses of postoperative infec- Surgery, University of Virginia, tion or pyogenic arthritis of the wrist, and Charlottesville, VA Current Procedural Terminology codes for 2Department of Plastic and Maxillofacial Perioperative Narcotic Use and Carpal procedures for these indications, including Surgery, University of Virginia, Tunnel Release: Trends, Risk Factors, Charlottesville, VA either open or arthroscopic irrigation and and Complications 3Department of Orthopaedic Surgery, debridement. We used a multivariable University of Virginia, Charlottesville, VA Trent M. Gause, MD1, John J. Nunnery1, binomial logistic regression model that A. Bobby Chhabra, MD1, Brian C. Werner, MD1 allows for assessment of the independent ABSTRACT effect of a variable while controlling for 1Department of Orthopaedic Surgery, remaining variables to evaluate which pa- Owing to its osteoinductive and osteo- University of Virginia, Charlottesville, VA tient demographics and medical comor- conductive properties and the presence of bidities were associated with an increased osteogenic cells, freshly harvested autol- risk for postoperative infection. Adjusted ogous bone graft is the gold standard for ABSTRACT odds ratios and 95% confidence intervals skeletal reconstruction where there is in- Background: The goals of the study were were calculated for each risk factor, with adequate native bone. Whereas these char- to: (1) evaluate trends in preoperative and P < .05 considered statistically significant. acteristics are difficult to replicate, engi- prolonged postoperative narcotic use in Results: A total of 454,987 patients met neered, commercially available bone graft carpal tunnel release (CTR); (2) char- all inclusion and exclusion criteria. Of these substitutes aim to achieve a comparable acterize risks for prolonged narcotic use; patients, 1,466 developed a postoperative osseoregenerative profile. This work fur- and (3) evaluate narcotic use as an inde- infection, corresponding to an infection rate nishes the reader with an understanding pendent risk factor for complications fol- of 0.32%. Independent positive risk factors of the predominant classes of bone graft lowing CTR. for infection included younger age, male sex, substitutes available for reconstruction of Methods: A query of a large insurance obesity (body mass index of 30 to 40), mor- database from 2007-2016 was conducted. bid obesity (body mass index greater than Patients undergoing open or endoscopic 40), tobacco use, alcohol use, and numerous CTR were included. Revision surgeries or medical comorbidities including diabetes, We review bone graft substitutes patients undergoing median nerve repair inflammatory arthritis, peripheral vascular with respect to their mechanisms at the forearm, upper extremity fascioto- disease, chronic liver disease, chronic kidney of action, their advantages and mies, or with distal radius fractures were disease, chronic lung disease, and depression. disadvantages, and their indications excluded. Preoperative use was defined as Conclusions: The current study rein- and contraindications. narcotic use between 1 to 4 months prior forced conventional wisdom regarding the to CTR. A narcotic prescription between the overall low infection rate after CTR and 1 and 4 months after surgery was consid- revealed numerous patient-related risk fac- upper extremity bone defects following ered prolonged postoperative use. Demo- tors that are independently associated with trauma or oncological surgery. We review graphics, comorbidities, and other risk fac- an increased risk of infection after open bone graft substitutes with respect to their tors for prolonged postoperative use were CTR in patients enrolled in Medicare. mechanisms of action, their advantages assessed using a regression analysis. Sub- J Hand Surg Am. 2018 Mar;43(3): and disadvantages, and their indications group analysis was performed according to 214-219. doi: 10.1016/j.jhsa.2017.09.017. and contraindications. We provide exam- the number of preoperative narcotic pre- Epub 2017 Oct 18. ples of bone graft substitutes in clinical scriptions. Narcotic use as a risk factor for

22 | UVA ORTHOPAEDIC JOURNAL | 2019 | HAND and UPPER EXTREMITY

complications, including chronic regional curred over time, continues to be com- entities and define both the arthroscopic pain syndrome (CRPS) and revision CTR, monly performed and has provided pa- findings and correlated MRI findings in was assessed. tients with their desired pain relief and each of these states. Results: In total, 66,077 patients were return of function. The complications of Sports Med Arthrosc Rev. 2017 included. A decrease in prescribing of primary surgery, although relatively rare, Dec;25(4):e18-e30. doi: 10.1097/ perioperative narcotics was noted. Risk can present in various clinical ways. An JSA.0000000000000172. factors for prolonged narcotic use included understanding of the underlying anatomy, preoperative narcotic use, drug and sub- pathology of coexisting conditions, and stance use, lumbago, and depression. Pre- specific techniques used in the primary Smoking Increases Postoperative operative narcotics were associated with surgery is required to make the best rec- Complications After Distal Radius increased emergency room visits, read- ommendation for a patient with residual Fracture Fixation: A Review of 417 missions, CRPS, and infection. Prolonged pain following primary CMC arthroplas- Patients From a Level I Trauma Center postoperative narcotic use was linked to ty. The purpose of this review is to provide Daniel E. Hess, MD, S. Evan Carstensen, MD, CRPS and revision surgery. insights into the history of CMC arthro- Spencer Moore, A. Rashard Dacus, MD Conclusions: Preoperative narcotic plasty and reasons for failure and to offer use is strongly associated with prolonged an algorithmic treatment approach for the Department of Orthopaedic Surgery, postoperative use. Both preoperative and clinical problem of persistent postopera- University of Virginia, Charlottesville prolonged postoperative prescriptions nar- tive symptoms. cotic use correlated with increased risk of J Hand Surg Am. 2018 Sep;43(9): complications. Preoperative narcotic use is 844-852. doi: 10.1016/j.jhsa.2018.03.052. ABSTRACT associated with a higher risk of postopera- Epub 2018 Jun 20. Background: Unstable distal radius frac- tive CRPS. tures that undergo surgical stabilization Hand (N Y). 2018 Aug have varying complication rates in the lit- 1:1558944718792276. doi: MRI and Arthroscopic erature. Smoking is known to affect bone 10.1177/1558944718792276. Correlation of the Wrist healing and implant fixation rates but has [Epub ahead of print] never been definitively shown to affect Nicolas C. Nacey, MD1, Jeffrey D. Boatright, postoperative outcomes of surgically man- MD2, Aaron M. Freilich, MD2 aged distal radius fractures. Failed Thumb Carpometacarpal Methods: A retrospective review was 1Department of Radiology, Arthroplasty: Common Etiologies and performed of patients with surgically treat- University of Virginia, Charlottesville, VA Surgical Options for Revision 2Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA Daniel E. Hess, MD1, Patricia Drace, MD1, Michael J. Franco, MD2, Smoking is known to affect bone A. Bobby Chhabra, MD3 ABSTRACT healing and implant fixation rates 1Department of Orthopaedic Surgery, Since its introduction in 1979, the prac- but has never been definitively University of Virginia, Charlottesville, VA tice of and indications for wrist arthros- shown to affect postoperative 2Department of Plastic and Reconstructive copy in the diagnosis and treatment of outcomes of surgically managed Surgery, Cooper University Hospital, pathologic conditions in the wrist contin- distal radius fractures. Camden, NJ ues to grow. Magnetic resonance imaging 3Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (MRI) is another commonly used tool to noninvasively examine the anatomy and ed distal radius fractures at a Level 1 Trau- pathology of the wrist joint. Here, we re- ma Center who had at least 6 weeks of fol- ABSTRACT view the normal wrist anatomy as seen ar- low-up over a 5-year period. Charts were Carpometacarpal (CMC) arthroplasty throscopically and through MRI. We then reviewed for basic demographic informa- surgery, although modifications have oc- examine the various common pathologic tion, comorbidities, details about the oper-

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ative procedure, and early complications. ABSTRACT scribe the mean distance from the radial Notable physical examination findings were Multiple surgical procedures have been artery to 2 major landmarks used during noted, such as wrist stiffness and distal radi- described to treat first carpometacarpal surgical treatment and provide insight to us tenderness to palpation. Statistical analy- (CMC) arthritis. Although the superi- surgeons who perform these CMC recon- sis was performed to compare the smoking ority of one procedure over the others struction procedures to decrease the risk and nonsmoking groups. To control for con- of intraoperative radial artery injury. founding differences, a hierarchical multi- Orthopedics. 2018 Jul 1;41(4):e541-e544. variable regression analysis was performed. doi: 10.3928/01477447-20180511-05. Results: Four hundred seventeen pa- The authors describe the mean Epub 2018 May 18. tients were included in the study, and distance from the radial artery to 24.6% were current smokers at the time of 2 major landmarks used during surgery. The overall complication rate for surgical treatment and provide smokers was 9.8% compared with 5.6% in insight to surgeons who perform nonsmokers. The smoking cohort showed these CMC reconstruction significantly higher rates of hardware re- procedures to decrease the risk of moval, nonunion, revision procedures, intraoperative radial artery injury. wrist stiffness, and distal radius tenderness. When controlling for the confounding variables of diabetes and obesity, smokers continues to be a controversial topic, they still had significantly higher rates of the all approach the trapezium and require same complications. careful attention to the surrounding struc- Conclusion: Patients who smoke tures. One potential complication is inju- have a statistically significant higher rate ry to the radial artery, which lies in close of postoperative distal radius tenderness, proximity to the trapezium and is often wrist stiffness, nonunion, hardware remov- encountered during surgical approach. al, and revision procedures compared with Using cadaveric specimens, the authors those who do not smoke in a review of 417 dissected to identify and isolate the radi- total patients undergoing surgical fixation al artery as it travels in the forearm, wrist, for distal radius fractures. and hand while being careful not to dis- Hand (N Y). 2018 Nov turb its native course. The authors then 22:1558944718810882. doi: measured the shortest distance interval 10.1177/1558944718810882. from the radial artery to the first CMC Figure 1. Wrist fracture simulator [Epub ahead of print] joint and from the radial artery to the sca- photrapeziotrapezoidal joint. Descriptive statistics were calculated from these mea- RESIDENT EDUCATION A Cadaveric Study of the Mean surements and averaged over the various Distal Radius Fracture Reduction Distance of the Radial Artery specimens. The mean distance of the ra- Simulator as a Teaching Adjuvant for During the Approach to the First dial artery to the closest segment of the Junior Orthopaedic Residents Carpometacarpal Joint volar CMC joint was 11.6±2.5 mm. The The educational mission included both di- mean distance of the radial artery to the dactics and a physical reduction simulator Baris Yildirim, MD, Daniel E. Hess, MD, closest segment of the volar scaphotra- for incoming residents in managing distal Jesse B. Seamon, MD, Matthew L. Lyons, MD, A. Rashard Dacus, MD peziotrapezoidal joint was 1.6±1.8 mm. A radius fracture consults. The 3-D printed precise understanding of nearby anatomy wrist fracture simulator led to improved is paramount to a successful surgical treat- resident comfort with reduction tech- Department of Orthopaedic Surgery, ment for first CMC arthritis and to avoid niques prior to attempts in the emergency University of Virginia, Charlottesville, VA iatrogenic complications. The authors de- department (Figure 1). ■

24 | UVA ORTHOPAEDIC JOURNAL | 2019 | ONCOLOGY

Orthopaedic Oncology

he Orthopaedic Oncology Division serves patients in the treatment of both benign and malignant tumors of the extremities, pelvis, and shoulders. This area includes tumors that originate T in the soft tissues and bone and tumors that have traveled from Gregory Domson, MD other organs to bone. Dr. Domson has years of experience in treating these Associate Professor rare and complicated conditions in children and adults and divides his time between UVA and MCV in Richmond.

Dr. Domson specializes in orthopedic oncology, caring for patients from all over the state of Vir- ginia with benign and malignant, bone and soft tissue tumors of the extremities and pelvis. He treats both pediatric and adult patients. While he works one day a week at UVa and has for 10 years, he lives in Richmond and works full time at VCU as a musculoskeletal tumor specialist as well as program director for the orthopedic residency program. Dr. Domson was an Echols Scholar at UVa, graduating in 1996, before moving on to Eastern Virginia medical school, where he graduated in 2000. He finished his orthopedic residency at VCU in 2005 and completed a musculoskeletal tumor fellowship at the University of Florida in 2006. He received a master’s in adult education from VCU in 2013, and most of his current research focuses on resident training and education. He is a fellow of the American Academy of Orthopedics, a fellow of the American Orthopedic Association, and a member of the Musculoskele- tal Tumor Society.

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Mark F. Abel, MD* Keith R. Bachmann, MD Mark J. Romness, MD Charles J. Frankel Professor and Assistant Professor and Associate Professor Vice Chair for Faculty Development Associate Residency Director

Dr. Mark F. Abel, Charles Frankel Professor of Or- Dr. Keith R. Bachmann was born in Newark, Ohio, Dr. Mark J. Romness is an Associate Professor thopaedic Surgery and Professor of Pediatrics, is but moved to Richmond, Virginia, with his family of the Department of Orthopaedic Surgery with the Division Head of Pediatric Orthopaedics. He before elementary school. He then attended the a secondary appointment in the Department of has a diverse practice covering fractures, limb de- University of Virginia as an undergrad, where he Pediatrics. The dual appointment highlights his formities, and spinal deformities. He has a nation- met his wife, Anne. Dr. Bachmann went back to commitment to Pediatric Orthopaedics and the al reputation for the management of spinal defor- Richmond for medical school at MCV and then unique care that children encompass compared mities in children, including scoliosis. Through moved to Cleveland for his residency at the Cleve- to adults. His clinical and academic expertise his research and involvement in national study land Clinic. He completed his Fellowship in Pedi- includes children with special needs such as ce- groups, he has been instrumental in improving atric Orthopaedics and Scoliosis Surgery at Rady rebral palsy and spina bifida, which incorporates the non-operative treatment of scoliosis through Children’s Hospital in San Diego. Dr. Bachmann his other interests of extremity problems such as bracing and casting. In addition, he has worked began working at the University of Virginia upon hip, knee, and foot disorders. Rare disorders of collaboratively with surgeons from multiple major completion of his fellowship in August 2016. His childhood, such as osteogenesis imperfecta, con- children’s centers to improve the care pathways practice includes musculoskeletal surgery for genital pseudarthrosis of the tibia, and genetics and surgical techniques for children with spinal children, especially those with spinal deformity. syndromes, are additional areas of interest and deformities, including those with cerebral palsy Locally, Dr. Bachmann serves on the UVA expertise. and other neuromuscular conditions. Dr. Abel has Children’s Surgical Performance Improvement Dr. Romness has served on the Board of Di- also done extensive research on movement pat- Committee. He is active in the Virginia Orthope- rectors for the American Academy for Cerebral terns in children with cerebral palsy and studied dic Society, and moderates panels and serves Palsy and Developmental Medicine, been Presi- the effects of orthopaedic surgical procedures to on committees through the Pediatric Orthopedic dent of the Virginia Orthopaedic Society, and is a address these disorders. Society of North America (POSNA) and the Sco- long-standing member of the Pediatric Orthopae- Dr. Abel attended Tulane University Medical liosis Research Society (SRS). Dr. Bachmann is dic Society of North America. Within the Ortho- School, then completed an internship in Gener- a member of the Harms Study Group, which is paedic Department, Dr. Romness serves as the al Surgery at Washington University, St. Louis, working to further scoliosis care through longitu- Medical Director for Prosthetics and Orthotics, followed by Orthopaedic Surgical training at the dinal outcomes collection. His research focuses a member of the Resident Advocacy Committee, University of California, San Diego, including a on patient outcomes and working to improve the and Medical Student Clinical Supervisor. He is Fellowship in Pediatric Orthopaedic Surgery at metrics used to measure these outcomes. He is also an Associate Medical Director of the Motion the San Diego Rady Children’s Hospital. also interested in the long-term effect and the Analysis and Motor Performance Lab, which is in- Dr. Abel served in the Navy at the Portsmouth need for surgical treatment for spinal disorders. ternationally recognized for clinical evaluations of Naval Hospital for 4 years and then came to the Outside of work, Dr. Bachmann and his wife patients with cerebral palsy. UVA Health System in 1993, where he has prac- like to travel, preferably to destinations with scu- Dr. Romness grew up in Arlington, Virginia, ticed for over 25 years. He has served in numer- ba diving. They have two sons, a couple of dogs, and has been in practice for more than 25 years, ous leadership roles, including Chair of the De- and a cat. Dr. Bachmann tries to stay involved joining the University of Virginia in 2004 after partment of Orthopaedic Surgery between 2002 with mountain biking, golf, and scuba diving. He is practicing at children’s hospitals in Connecticut and 2003 and from August of 2008 through a fan of the University of Virginia collegiate sports, and Fairfax, Virginia. He received his undergrad- August 2013. He has been involved in commit- and Cleveland-based professional sports teams. uate education from the College of William and tees overseeing quality and strategy. Currently, Mary and then completed medical school and his he serves as the Vice-Chair for Faculty Develop- orthopaedic residency at Northwestern Universi- ment in the Department of Orthopaedics. He has ty. He spent one year at the Royal Children’s Hos- published over 87 peer-reviewed articles and nu- pital in Melbourne, Australia for his Fellowship in merous book chapters on pediatric orthopaedic Pediatric Orthopaedics. He is married to Christine topics. He has been listed among Connolly’s Best Romness and they have three grown children. Doctors in America for 13 consecutive years. Dr. Abel enjoys reading, music, and outdoor activities. He has 2 grown sons with his spouse, Jean, of 35 years.

26 | UVA ORTHOPAEDIC JOURNAL | 2019 | PEDIATRICS

What’s New in Pediatric Orthopaedics

Mark F. Abel, MD, Keith R. Bachmann, MD, to 5 cm of lengthening without the Leigh Ann Lather, MD, Mark J. Romness, MD need for general anesthetic. The law of Leigh Ann Lather, MD diminishing returns still applies with University of Virginia, Department of Ortho- Associate Professor MAGEC. After 7-9 lengthening ten- paedic Surgery, Charlottesville, VA sile resistance of the tissues restricts the

Dr. Leigh Ann Lather was born in Minneapolis, ability of the rod to lengthen. CARE OF CHILDREN WITH MN, and grew up in Iowa, New Jersey, and En- • Vertebral Body Tethering: Early trials gland. She majored in Psychology at Duke Univer- SPINAL DEFORMITIES suggest that tethering the anterior spi- sity and graduated with Honors from UNC Chapel Introduction: Major advances in the man- nal column using vertebral body screws Hill School of Medicine. Dr. Lather specializes in general orthopae- agement of children with spinal defor- in the apical vertebra and intercon- dic care for children ages newborn through 18 mities have occurred over the last several nected with a polyethylene cable across years. She originally trained as a pediatrician decades. Our involvement with multi-cen- the convexity of the curve can lead to and completed her residency and served as Chief Resident at UVA before entering private practice ter data collection efforts and research has slowing of curve enlargement and even pediatrics in rural NC for 13 years. She returned provided collective input leading to evi- correction in some cases. Current indi- to UVA in 2012 to complete Fellowship in Non-Op- dence-based changes in care pathways and cations are for children with a skeletal erative Pediatric Orthopaedics/Musculoskeletal surgical treatments. age of 8 to 10 years and curves of great- Medicine and then joined the orthopaedic faculty. Dr. Lather sees patients three days per week at er than 50 degrees. ADOLESCENT IDIOPATHIC SCOLIOSIS: UVA Children’s Hospital Clinics and one day each week at UVA Zion Crossroads. She teaches medi- • BRAIST study - a prospective cohort cal students and residents from the Departments study looking at efficacy of bracing. of Orthopaedics, Pediatrics, Family Medicine, and The validation of the CP:CHILD, PM&R, as well as her colleagues in practice who Finding (NEJM 2013): Bracing re- a health-related QOL survey, has care for children in this region and nationwide. duced the risk of reaching surgical greatly facilitated our understanding Dr. Lather serves as the Medical Leader of threshold; TLSO - 28% versus 52% the 4th floor Women’s and Children’s Hospital of the impact the spinal surgery has of observation group reached surgical Clinics. She is also involved nationally with a on this population. network of other non-operative pediatric orthope- threshold (>50 degree). dists at large pediatric teaching hospitals across • Further research shows highest risk: the US. She is proud to be actively engaged in the open triradiate, thoracic curves. Mini- NEUROMUSCULAR SCOLIOSIS: LEARNING evolution of this new specialty that fills a growing FROM THE PROSPECTIVE CEREBRAL need in pediatric medical care. mum brace time to improve outcome is PALSY SPINAL DEFORMITY STUDY When she is not working, she wants to be 18 hours/day for patients with a curve with her children, family, and friends. She loves >25 degrees and these characteristics. • Scoliosis is common in severely impaired hiking in the Blue Ridge, reading books that are patients with cerebral palsy. Up to 70% entirely fictional, and practicing Nia and yoga. She EARLY ONSET SCOLIOSIS: AGE-BASED also needlepoints, happily carrying on a tradition of patients in the most severe groups among the women of her mother’s family. TREATMENT APPROACHES (GMFCS IV & V) will develop signif- • Casting children between 1-3 years of icant scoliosis which can detrimentally age can slow progression and even im- affect sitting, pulmonary function, and prove curve size. GI function, and can cause pain. • Improved outcomes associated with • The validation of the CP:CHILD, a earlier age of first cast and greater in- health-related QOL survey, has great- cast correction (>50% correction). ly facilitated our understanding of the • Growth rod constructs have been re- impact the spinal surgery has on this placed by MAGEC, which allows up population.

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Sequential treatment of infantile Scoliosis: Casting from 14 months until 30 months of age, then insertion of MAGEC rods to allow serial distraction

CP: Child Questionaire – Prospectsive CP Spine Study – Consistent surgical teams reduce Pre-Post Comparison at 24 Months complications; Pre-op Mean Post-op Mean of Diff. P Value – The vast majority of patients with (SD) Mean (SD) (95% Cl) CP can have multi-modal spinal Personal Care & ADLs 39.5 (15.8) 44.5 (17.6) 5.1 0.013 (n = 89) (1.1, 9.0) cord monitoring intraoperatively; Positioning, Transfers & 35.5 (17.3) 44.1 (17.9) 8.6 <0.001 – Antibiotic powder may reduce in- Mobillity (n = 86) (4.8, 12.4) fection rates; Comfort, Emotions 72.9 (21.9) 80.4 (19.7) 7.5 0.003 – Early, day-of-surgery extubation is Behaviour (n = 74) (2.6, 12.5) the most important factor in reduc- Communication & 53.2 (29.5) 55.1 (28.6) 1.9 0.365 Social Interaction (n = 93) (-2.2, 5.9) ing length of stay. Health (n = 94) 55.1 (20.0) 60.6 (19.7) 5.5 0.008 (1.4, 9.4) LIMB LENGTHENING UPDATE: Overal QoL (n = 93) 63.0 (26.2) 69.2 (24.6) 6.2 0.033 USE OF THE PRECISE NAIL (0.5, 12.0) • Externally controlled intramedullary Total Score (N = 90) 50.7 (14.8) 56.8 (15.9) 6.1 <0.001 (3.1, 9.0) device to change the length of a bone. • Similar mechanism to MAGEC rod Patient related outcome of 22 patients with cerebral palsy undergoing spinal surgery. used in spine. • Nail can be controlled for lengthening and shortening so it is more adjustable • Spinal deformity surgery is a major in- of spinal surgery in this population and there are fewer problems with too tervention and historically major com- with the goals of understanding the rapid lengthening or overlengthening plications requiring hospitalizations change in QOL and improving care compared to prior lengthening nails and additional surgery occur in up to pathways. such as the ISKD. 20% of patients. • What we have learned: • Requires correction of angular or rota- • Therefore, since 2008 we have partici- – Intra-op use of tranexamic acid re- tional deformity before use so osteoto- pated in research to assess the impact duces blood loss; my needs to include that correction.

28 | UVA ORTHOPAEDIC JOURNAL | 2019 |

PEDIATRICS

Yaszay B, Sponseller PD, Bartley CE, Shah SA, Asghar J, Abel MF, Miyanji F, Newton PO.; Spine Deform. 2019 May;7(3):489-493.

Brace Success as Related to Curve Type, Compliance, and Maturity in Adolescents with Idiopathic Scoliosis: Com- mentary on an article by Rachel M. Thompson, MD, et al.: “Brace Success Is Related to Curve Type in Patients with Adolescent Idiopathic Scoliosis.” Abel MF.; J Bone Joint Surg Am. 2017 Jun 7;99(11):e59.

Patient-reported Outcomes Following Surgical Interven- tion for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis. Aghdasi B, Bachmann KR, Clark D, Koldenhoven R, Sultan M, George J, Singla A, Abel MF.; Clin Spine Surg. 2019 Mar 28.

Are antifibrinolytics helpful in decreasing blood loss and transfusions during spinal fusion surgery in children with cerebral palsy scoliosis? Dhawale AA, Shah SA, Sponseller PD, Bastrom T, Neiss G, Yorgova P, Newton PO, Yaszay B, Abel MF, Shufflebarger H, Gabos PG, Dabney KW, Miller F. Spine (Phila Pa 1976). 2012 Apr 20;37(9):E549-55.

FACTORS RELATED TO LENGTH OF STAY AFTER SPINAL DEFORMITY CORRECTION IN PATIENTS WITH CEREBRAL PALSY: Keith 15 year old male with angular and length deformity. Had unsuccessful attempt at medial growth tether, so Bachmann, MD; Wendy Novicoff, PhD; Kendra Jackson, had15 year old male with angular and length deformity. Had unsuccessful attempt at medial acute fixator-assisted angular correction and then lengthening with the PRECICE nail. BS, Mark Abel, MD; 72nd Annual Meeting, American Academy of Cerebral Palsy & Developmental Medicine; growth tether, so had acute fixator-assisted angular correction and then lengthening October, 2018. with the PRECICE nail. • Less pain, easier to do physical therapy, Effects of bracing in adolescents with idiopathic scoliosis. Weinstein SL, Dolan LA, Wright JG, Dobbs MB.; N Engl and better cosmetic appearance after J Med. 2013 Oct 17;369(16):1512-21. Nail cannot be used across an treatment than external fixators. Anterior Spinal Growth Tethering for Skeletally Imma- REFERENCESopen physis so it is not useful in • The nail has FDA clearance for mag- ture Patients with Scoliosis: A Retrospective Look Two to younger children, but that may be netic resonance imaging (MRI) under Four Years Postoperatively. Newton PO, Kluck DG, Saito Miller DJ, Flynn JJM, Pasha S, Yaszay B, Parent S, Asghar J, Abel MF, Pahys JM, Samdani A, W, Yaszay B, Bartley CE, Bastrom TP.; J Bone Joint Surg a reason to postpone lengthening certain conditions, but removal once Am. 2018 Oct 3;100(19):1691-1697. Hwang until SW, Narayanan older. UG, Sponseller PD, Cahill PJ; Harms Study Group. Improving ■ Health- related Quality of Life for Patients With Nonambulatory healed Cerebral is usually Palsy: recommended. Who Stands to Gain Magnetically controlled growing rods in the treatment From Scoliosis Surgery? J Pediatr Orthop. 2019 Jul 12. of early-onset scoliosis: a note of caution. Rushton PRP, BIBLIOGRAPHY Siddique I, Crawford R, Birch N, Gibson MJ, Hut- ton MJ. Bone Joint J. 2017 Jun;99-B(6):708-713. doi: Improving Health-related Quality of Life for Patients Hollenbeck • Can SM, be Yaszay used for B, bone Sponseller transport PD, to Bartley close CE, Shah SA, Asghar J, Abel MF, Miyanji F, 10.1302/0301-620X.99B6.BJJ-2016-1102.R2. Review Newton PO. The Pros and Cons of Operating Early Versus LatWith Nonambulatorye in the Progression of Cerebral Cerebral Palsy: Who Stands to a defect. Gain From Scoliosis Surgery? Miller DJ, Flynn JJM, Pasha PRECICE Intramedullary Limb Lengthening System: A Palsy Scoliosis. Spine Deform. 2019 May;7(3):489-493 • Nail cannot be used across an open S, Yaszay B, Parent S, Asghar J, Abel MF, Pahys JM, Sam- Review of Clinical Effectiveness. Young C, Adcock L. Ot- dani A, Hwang SW, Narayanan UG, Sponseller PD, Cahill tawa (ON): Canadian Agency for Drugs and Technologies Abel MF. Brace Success as Related to Curve Type, Compliance, and Maturity in Adolescents with physis so it is not useful in younger PJ; Harms Study Group. J Pediatr Orthop. 2019 Jul 12. in Health; 2017 Dec 7. Available from: https://www.ncbi. children, but that may be a reason to nlm.nih.gov/books/NBK526298/ Idiopathic Scoliosis: Commentary on an article by The Rachel Pros and M. Cons Thompson, of Operating MD, Early eVersust al.: Late "Brace in the postpone lengthening until older. Progression of Cerebral Palsy Scoliosis. Hollenbeck SM,

| For referrals, call 434-924-2301 | uvaortho.com | 29 PROSTHETICS & ORTHOTICS

Kevin King, CPO* Michele E. Bryant, MS, ATC, CO Mary Grant, CP Technical Director Assistant Technical Director Certified Prosthetist

Kevin is a graduate of Mount Union College in Alli- Michele grew up in Maryland and started her Mary was born and raised in Abingdon, a small ance, Ohio, with a Bachelor of Science in Biology college career at High Point University, where she town in Southwest Virginia. After graduation, in in 1996. He has been employed full time in the graduated with a B.S. in Sports Medicine and 1976, she attended Madison College, where she field of Prosthetics and Orthotics since 1996. He became a Certified Athletic Trainer. She worked earned a B.S. degree in Biology. She then worked attended Northwestern University in 1999 for his for the University of Tennessee Athletic Training at UVA in Physical and Occupational therapy for Orthotic and Prosthetic Certification. He spent the Department while earning her Master’s Degree a few years before leaving to go to Northwest- first 7 years of his professional career at the Cleve- in Exercise Science/Biomechanics. Michele en- ern University in Chicago to earn her certificate land Clinic Foundation, working first as a Prosthetic/ joyed working with the team specialists on lower in Prosthetics. She worked in Charlottesville at a Orthotic technician, then as a Certified Orthotist, extremity biomechanics and bracing, and she P&O facility while she did her apprenticeship and and finally as a Certified Prosthetist/Orthotist. Kev- went on to earn a degree in Orthotics from North- completed all the exams required for Certifica- in joined the faculty of the University of Virginia in western University. After completing her Orthotics tion. She received her Certification in Prosthetics 2003 in the UVA Orthopedics Division of Prosthet- Residency at the Cleveland Clinic, Michele went in 1980 and has been working in the field since ics and Orthotics. In 2008 he was appointed as on to work at the University of North Carolina Hos- that time. She has been a practitioner and super- Assistant Technical Director for the Division of Pros- pital as a Certified Orthotist. visor at the University of Virginia Prosthetics and thetics and Orthotics at UVA, and in March of 2017, Michele joined UVA Prosthetics & Orthotics in Orthotics Division since 1995. Kevin was appointed as the Technical Director for 2014 and became the Assistant Technical Direc- Mary is certified through the American Board the Division of Prosthetics and Orthotics. tor in 2017. Michele is a resident mentor for the for Certification in Prosthetics and Orthotics. She Kevin has a keen interest in Computer-Aided profession and enjoys educating students and is also a member of AOPA and ACPOC, two of Design and Manufacturing for the prosthetics and patients. her field’s national organizations. Locally, Mary orthotics field and has used this technology at UVA In her free time, Michele enjoys exercising, helped to organize and start “Limbs on the Go,” to help improve orthotic management of scoliosis crafting, reading, creating Halloween costumes, a support group for amputees in Central Virginia and plagiocephaly for the Division of P&O. He has spending time outside at the beach, in the moun- that has been helping amputees and their fami- most recently used this technology to develop tech- tains, and at the local parks with her husband lies for over 23 years. She has also been active niques for improved prosthetic fittings and repeat- and their dog. with Adventure Camp (a camp for kids with limb able outcomes. loss) for almost 22 years, serving as president of He is a long-standing member of both the As- the board for much of that time. sociation of Children’s Prosthetic and Orthotic Clin- Mary lives in Charlottesville and enjoys gar- ics ACPOC and the American Academy of Prosthe- dening, traveling, hiking, and spending time with tist/Orthotists AAOP. He has served in the Spinal, friends and family. Cranial, and CAD societies of AAOP over the years (currently active in the CAD society). Kevin volunteers extensively in the community and has served as both a soccer coach and an adaptive ski instructor. He has spent the past 16 seasons volunteering at Wintergreen Adaptive Sports teaching skiing to people with disabilities and holds a Level 2 Adaptive and Telemark Instructor credential through the Professional Ski Instructors of America. Every day he embraces the WAS slogan “from the top of the mountain, all we see is possibility.” Kevin enjoys spending time with his wife of 24 years and their 3 children. They all enjoy camping, hiking, skiing, and attending sporting events.

30 | UVA ORTHOPAEDIC JOURNAL | 2019 | PROSTHETICS & ORTHOTICS

Current Trends in Prosthetics and Orthotics at UVA

he University of Virginia Ortho- provides very accurate digital imaging Microprocessor controlled Prosthetic pedics Department has a state- for devices that require precision fit for Knees and ankles for above knee amputees of-the-art Prosthetics and Or- proper function 1. We specialize in multiple styles and T thotics Division that has made programming options for microproces- significant advancements in patient care. Comprehensive custom upper extremity, sor knees for above knee amputees in- Below are services that set us apart from lower extremity, and spinal orthotic care cluding C-Leg, Rheo Knee, Plie Knee, our competition: with state of the are in-house fabrication Genium, and X3 and Microproccesor 1. ABC certified technicians on staff en- ankles including the redesigned Pro- Scoliosis management via TLSO using sure high level of control and precision prio ankle. digital imaging and Computer Aided over our custom fabricated devices Design (CAD) technology 2. State of the art computer aided design Custom designed 3D printed prosthet- 1. We were a national pioneer in sco- and computer aided manufacture ma- ic covers for above and below knee am- liosis management using CAD and chinery ensure precision and repeat- putees digital imaging which is accurate to ability in the fabrication process 1. Designed through advanced 3D imag- within .5 mm ing and 3D printing 2. We developed CAD scanning and Custom upper and lower extremity pros- 2. Ability to add personal touch to the de- modifying protocols that are unique to thetic devices utilizing CAD technology sign, shape, and covering the field and differentiate us from our accurate to within .5 mm. competition 1. Digital scans offer significant preci- Custom myoelectric and body powered sion and accuracy and modification upper limb, partial hand, and finger pros- options that are not possible with plas- thetic options ter molds 1. We offer high end myoelectric partial We specialize in multiple styles 2. This technology offers the possibility of hand options including iDigits and and programming options for high level prosthetic care at our remote Naked Prosthetics microprocessor knees for above sites and real-time transfer of work files 2. iLimb Ultra, BeBionic, Michelangelo knee amputees including C-Leg, to our central fabrication site expedit- hand, etc offerings Rheo Knee, Plie Knee, Genium, ing the fabrication process 3. High definition custom functionally and X3 and Microproccesor aesthetic prosthetic options ankles including the redesigned Custom elevated vacuum above knee and Proprio ankle. below knee prosthetic sockets Team approach to patient care in re- 1. Considered to be one of the most effec- al-time which is not possible in a private tive solutions, we offer elevate vacuum, practice Cranial remolding via using CAD tech- suspension options to our prosthetic 1. We directly communicate with our nology patients physician and therapist partners to as- 1. We were the first facility in our area to 2. We are trained to fabricate and fit sure the ideal orthotic and prosthetic start using digital imaging and CAD elevated vacuum suspensions for our designs to fit the patient’s conditions. technology for helmet management prosthesis. Over the years we have 2. Our collaboration with the medical of plagiocephaly, brachycephaly, and refine our options for prosthetic fit- team is a unique advantage to our pa- scaphocephaly ting and suspension in order to offer tients, especially those with challenging 2. We designed our own scanning meth- unparalleled care for amputees in our conditions requiring innovative pros- ods accurate to within .5 mm which region thetic and orthotic solutions. ■

| For referrals, call 434-243-4670 | uvaortho.com | 31 RESEARCH

George J. Christ, PhD Quanjun Cui, MD Joe Hart, PhD Mary Muilenburg Stamp Professor Gwo-Jaw Wang Professor and Associate Professor Vice Chair for Research

Dr. Christ is a Professor of Biomedical Engineering and Dr. Quanjun Cui is the G.J. Wang MD Professor of Joe Hart, PhD, was born and raised in Stamford, Orthopaedic Surgery and holds the Mary Muilenburg Orthopaedic Surgery, Vice Chair for Research. He CT, and studied Athletic Training and Sports Med- Stamp Chair in Orthopaedic Research, where he is is a board-certified orthopaedic surgeon and spe- icine at Marietta College (BS as a Pioneer), West Director of Basic and Translational Research in Ortho- cializes in adult reconstruction performing primary Virginia University (MS as a Mountaineer), and paedics. He is Co-Director of the Center for Advanced and revision total hip and total knee replacement the University of Virginia (PhD as a Cavalier). He Biomanufacturing. He is the Past Chairman of the Di- surgery. Dr. Cui has written over 130 papers and has been with UVA Orthopaedics since 2005 as vision of Systems and Integrative Pharmacology of the book chapters on orthopedic surgery and related a post-doctoral research associate and research American Society of Pharmacology and Experimental researches. He edited 9 textbooks. His research is faculty, primarily serving the Sports Medicine Di- Therapeutics (ASPET), and Past President of the North funded by the National Institute of Health (NIH), fo- vision’s clinical research programs. In 2014, he Carolina Tissue Engineering and Regenerative Medi- cusing on stem cell therapy and arthritis. was appointed as the Clinical Research Director cine (NCTERM) group. He was inducted into AIMBE in Dr. Cui and his research team have been for the department and had been serving all di- 2017. He serves on the Executive Committee of the working on stem cell-based therapy and tissue visions’ clinical research programs ever since. In Division for Integrative Systems, Translational and Clin- engineering for the treatment of fractures and os- that time, he developed a Clinical Trials Division ical Pharmacology of ASPET. He is a member of the teonecrosis for years. His cutting-edge research to support the growing clinical research program Regenerative Rehabilitation Consortium Leadership has been published in prestigious journals and in UVA Orthopaedics. The Clinical Trials Division Council and serves on the Leadership Advisory Council widely cited by other investigators. One of his now has 5 full-time clinical research coordinators, for ARMI/BioFabUSA. He received the Ray Fuller Award current projects entitled “Inhibition of MSC1 stem 3 part-time research assistants, and 2 faculty and Lecture (ASPET, 2018). He serves on the Editorial cells and T cells to endorse bone healing” is sup- members to support almost 100 active clinical Board of five journals and is an ad-hoc reviewer for 2 ported by NIH, the goal of this study is to improve research protocols. dozen others. Dr. Christ has authored more than 225 bone-forming potential of mesenchymal stem Dr. Hart specializes in movement biomechan- scientific publications and is co-editor of a book on cells (MSCs) via inhibition of the TLR4 signaling ics, neuromuscular function, physical activity, and integrative smooth muscle physiology and another on in MSCs and the activity of T cells to achieve long-term outcomes in patients with ACL recon- regenerative pharmacology. consistent and reliable outcomes. Dr. Cui and his structed knees. He is one of 4 faculty directors of Dr. Christ has served on both national and collaborators will use natural antibodies to inhibit the Exercise and Sport Injury Laboratory housed international committees related to his expertise MSC1 stem cells and T cells from enhancing the in the Kinesiology Department at UVA, which regu- in muscle physiology, and on NIH study sections bone-forming ability of MSCs. larly collaborates with UVA Orthopaedics. Together in the NIDDK, NICHD, NCRR, NAIAD, NIAMS, and The other project entitled “A novel inflamma- they have developed a performance testing pro- NHLBI. He has chaired working groups for both the tion is targeting Tc-99m probe for osteoarthritis gram for ACL reconstructed patients to help inform NIH and the WHO and is co-inventor on more than imaging” is also supported by NIH. The goal of post-operative rehabilitation and return to physi- 26 patents (national and international) either is- this study was to develop a novel approach for cal activity decision making. They have over 500 sued or pending. Dr. Christ is also spearheading the diagnosis of early osteoarthritis using an in- patients in their database and regularly perform several MSK-applicable translational research flammation specific peptide cFLFLF labeled with analyses to understand better factors related to programs to develop novel regenerative medicine Tc-99m. Dr. Cui’s research team has established patient outcomes. Dr. Hart serves the Journal of treatments for orthopaedic patients, in particu- an anterior cruciate ligament transection (ACLT) Athletic Training as Associate Editor and the NATA lar, volumetric muscle loss injuries. He leads a model of osteoarthritis (OA) in rat and mouse Foundation Board of Directors as Vice President DOD-funded multi-institutional program for the knee joints and examined the activity of inflam- of External Affairs. He is a NATA and ACSM Fellow development of a tissue-engineered muscle re- matory cells during OA development. The study and member of the ORS and AOSSM. pair (TEMR) technology platform for the treatment has demonstrated that the peptide cFLFLF could He enjoys spending time with his wife, Jen- of Wounded Warriors and collaborates in another serve as an inflammation targeting molecule, nifer (who is a Physician Assistant with UVA Or- NIH and DOD funded translational multi-institu- which has great potential to be used for devel- thopaedics), his 3 children, and other family and tional effort as part of the C-DOCTOR consortium. oping optical and radioactive probes to improve friends. He truly enjoys being a part of the local Funding from the DOD and Keratin Biosciences diagnosis and therapeutic evaluation of inflam- Charlottesville community and the wonderful lo- also supports the evaluation of a proprietary hy- mation-related joint diseases such as OA. cal sights, food, and culture. He also loves trav- drogel for the treatment of lower extremity traumat- eling and sports,…especially beating Mark Miller ic injuries. at golf.

32 | UVA ORTHOPAEDIC JOURNAL | 2019 | RESEARCH

Joshua Li, MD, PhD Wendy Novicoff, Ph.D. Shawn D. Russell, PhD Associate Professor Professor Assistant Professor

Dr. Joshua Li was born and grew up in China. Wendy Novicoff, PhD, is a Professor of Orthopae- Shawn D. Russell, PhD, is the Director of the Mo- He attended Xi’an Medical University for his MD dic Surgery and Public Health Sciences at the Uni- tion Analysis and Motor Performance Laboratory and PhD training. He came to the United States versity of Virginia School of Medicine. She grew at the University of Virginia, and oversees the day- in 1999. up in Omaha, Nebraska, and came to the East to-day research operations of the laboratory and Dr. Li has held dual appointments as an Coast for college, receiving her undergraduate guides data collection and analysis. Associate Professor in the Department of Or- degree at Duke University and her graduate de- He has been conducting research using thopaedic Surgery and the Department of Bio- grees from the University of Virginia. motion analysis for the last 18 years. This work medical Engineering at the University of Virgin- Wendy works with many groups at the Uni- has included the detection of motion events and ia since 2017. He completed an Orthopaedic versity of Virginia, including serving as Faculty for the quantification of the kinetics and kinematics Surgery Residency at the University of Virginia. the Data Science Institute (soon to be the School associated with tasks including simple typically He followed his internship and residency with a of Data Science), as the Education Director for developed walking, pathological walking with and comprehensive Spine Surgery Fellowship at the the Be Safe Program (the patient safety program without assistive devices, scaling rock climbing world-renowned Columbia Spine Hospital. Dr. Li at UVA), as the Lead Evaluator for UVA’s Clinical walls, and predictive modeling of human move- has advanced expertise in a wide range of spinal and Translational Science Award Program, and ments. In addition, his work is developing meth- procedures, from microscope-assisted cervical as Program Director for a new master’s program ods for detection, measurement, and recognition artificial disc replacement to the most complex in interdisciplinary healthcare leadership. She is of human movement in out-of-lab environments spinal reconstruction for scoliosis. His clinical in- also a faculty member for the American College of using state-of-the-art IMU technology. terests include degenerative disorders of the cer- Healthcare Executives (ACHE), where she teach- More recently, he has begun developing mod- vical, thoracic, and lumbar spine (herniated disc, es performance improvement techniques. els and methods for the analysis of gait function spinal stenosis, etc.); spinal deformities (scoli- Her research interests include health ser- in Lewis rats used in preclinical trials. These osis, kyphosis, flatback syndrome, etc.); spinal vices research and outcomes evaluation, with methods have enabled him to begin quantifying tumors; metastatic spine disease; spine trauma; concentrations in patient decision-making, out- the effects of musculoskeletal injury and applied minimally invasive spine surgery; robotic-assist- comes after major surgery, comparative effective- therapeutics on the movement function quality of ed spine surgery; and motion-sparing technology ness, and the use of evidence-based medicine. their gait characteristics. (artificial disc replacement). She has also done extensive work in the areas of Dr. Li has developed a renowned laborato- health system quality and performance improve- ry focusing on intervertebral disc degeneration ment, including work on the refinement of mea- pathology and treatment with stem cells, nano- surement systems and reporting mechanisms technology, and gene therapy. He has been the and standardization of clinical practices. She is recipient of over 20 grants as the Principal In- a certified Lean Sensei, a certified Change Agent, vestigator, including four NIH (National Institute and a certified Six Sigma Master Black Belt. She of Health R03, R21, and R01) grants. He serves has published more than 100 peer-reviewed ar- as a committee member for the Orthopaedic ticles. Research Society and the North American Spine She is very involved in local theater, serving Society. He has been on various grant review on the Boards of the Four County Players and panels, including NIH, NASA, MTF, and AO-Inter- the Virginia Theatre Association, and performing national. in several shows each year. Wendy lives in Char- He is married to Dr. Li Jin. He likes traveling lottesville with her husband, Bob Davis, and their with his wife and plays badminton. He has also very fluffy cat, Katrina. led an exercise group practicing Falun Dafa in Charlottesville for a decade.

| uvaortho.com | 33 RESEARCH

Researchers Developing Drug Delivery Patches to Manage Pain Without Addiction Risk

by Fariss Samarrai, System’s expertise in orthopaedics and pain University News Associate, management—and the engineering of very Office of University Communications thin and flexible sensors and circuits. “We want to relieve pain for patients verybody occasionally experienc- while also reducing the use of potentially

es pain. Generally, pain is man- addictive opioids,” orthopaedic surgeon Dr. Communications University Addison, Dan by Photo ageable with over-the-counter Joshua Li said. “Our goal is to help patients Mechanical engineer Baoxing Xu, left, Jin Li, a medications, or no medication effectively participate in managing their researcher in orthopaedic surgery, and Dr. Joshua E Li, an orthopaedic surgeon, are developing an at all. But when pain is acute and severe, pain without fear of becoming dependent innovative patch that will bypass the bloodstream such as after an injury or surgery, stronger on medications.” by delivering medication directly to the site of pain. pain medication may be required. And for Li is a spine surgeon who also conducts chronic pain, such as from neck and back pain research. He works daily to alleviate with temperature sensors and micro-heat- disorders, the long-term use of opioids to his patients’ lower back pain before, during, ers that would create a warm, soothing ef- subdue pain can become addictive. and after surgery, and is well aware of the fect that also alleviates pain. Relief would Most narcotics are administered orally opioid addiction problem in the U.S. and come within about 15 minutes. or by injection, which means these drugs the need to keep patients comfortable “We already have experience developing travel through the bloodstream, affecting without creating dependency. very thin, skin-like sensors and micro-heat- the entire body, not only the pain site. This Li is working with mechanical engineer ers,” Xu said. “This new device would bring can cause side effects such as gastrointesti- Baoxing Xu, an expert at developing skin together several technologies working as nal problems, sleeplessness, low blood pres- sensors and devices that precisely control the one to manage the flow of medication.” sure, and even liver damage. It also can lead flow of microfluids, including medications, The team proposes to add a button or to physical dependency. and with Jin Li, a researcher in orthopaedic other control mechanism to their patch About 39.5 million adults complain of surgery. Together they are taking the con- that would allow patients to manipulate daily pain, and at least 2 million people in the cept of a commercially available product— the release of medication based on pain United States are addicted to prescription lidocaine pain relief patches—to a new level. level, while never having to worry about pain medications. In 2015, more than 33,000 Lidocaine is a non-addictive pain kill- overdosing or developing an addiction. people died by opioid overdose, many as il- er that works topically by blocking pain “This device would allow us to treat licit users who were first exposed to opioid sensors below the skin. Current lidocaine back pain directly at the site of the pain in drugs for the treatment of acute or chronic patches release medication to a pain site a controlled manner while bypassing the pain. There must be a better way. through skin absorption. But there is no bloodstream and the liver,” Li said. “We Three University of Virginia researchers control over when or how much medicine think this could be the solution patients are working toward an innovative solution is released, and the skin does not effectively need to manage their pain safely.” for treating lower back pain after surgery and absorb some of it. The researchers currently are planning for chronic back pain. They are developing The UVA researchers believe they have fundamental efficacy studies and believe drug delivery patches that would be worn on found a way to improve on these patches in their technology could be ready for use in the skin, like a bandage, to deliver non-ad- a big way by incorporating dissolvable and clinical trials within about five years. ■ dictive pain medicine directly to the site of minimally invasive microneedles below the pain, rather than systemically via pills or in- surface of the patch to painlessly release This project is funded by a seed grant from jections. The work builds on the UVA Health controllable flows of medicine, combined UVA Center for Engineering in Medicine.

34 | UVA ORTHOPAEDIC JOURNAL | 2019 | SPINE

Hamid Hassanzadeh, MD Joshua Li, MD, PhD Francis H. Shen, MD* Associate Professor Associate Professor Warren G. Stamp Professor

Dr. Hamid Hassanzadeh joined the UVA Spine Dr. Joshua Li was born and grew up in China. Dr. Francis H. Shen is the Warren G. Stamp En- Center in 2014 after an Orthopaedic Surgery He attended Xi’an Medical University for his MD dowed Professor of Orthopaedic Surgery, Profes- Residency at Johns Hopkins Hospital and fellow- and PhD training. He came to the United States sor of Pediatrics, Head of the Division of Spine, ship training in Spine Surgery at Rush University in 1999. and Co-Director of the Spine Center. He earned Medical Center. His clinical interests and exper- Dr. Li has held dual appointments as an Asso- his biomedical engineering degree from the Uni- tise include complex spinal deformity and the use ciate Professor in the Department of Orthopaedic versity of Michigan and completed his orthopae- of minimally invasive surgery. He is an Associate Surgery and the Department of Biomedical Engi- dic residency training at the University of Virginia. Professor and Director of the Spine Fellowship neering at the University of Virginia since 2017. He completed fellowship training in Spine at Rush Program and Co-Director of the UVA Spine Center. He completed an Orthopaedic Surgery Residen- University, Pediatric Spinal Deformity training at Dr. Hassanzadeh is an award-winning re- cy at the University of Virginia. He followed his Shriners Hospitals for Children in Chicago and an searcher published in more than 100 peer-re- internship and residency with a comprehensive Orthopaedic Research Fellowship at the Univer- viewed journals and has written over 40 textbook Spine Surgery Fellowship at the world-renowned sity of Virginia. He was selected as a Scoliosis chapters. He also leads the Spine Division’s Columbia Spine Hospital. Dr. Li has advanced Research Society Traveling Fellow and as a North Clinical Trial Program with several active phase expertise in a wide range of spinal procedures, American Spine Society Traveling Fellow. II/III trials. Dr. Hassanzadeh is actively involved from microscope-assisted cervical artificial disc His clinical practice includes the manage- in researching the potential for decreasing com- replacement to the most complex spinal re- ment of degenerative conditions, spinal defor- plications during large reconstructive spine sur- construction for scoliosis. His clinical interests mity, trauma, tumors, and spine infections. He geries by taking appropriate preventive measures include degenerative disorders of the cervical, utilizes open surgical techniques but specializ- and by combining open and minimally invasive thoracic, and lumbar spine (herniated disc, spi- es in cutting-edge minimally invasive surgery, techniques. He regularly shares his expertise nal stenosis, etc.); spinal deformities (scoliosis, image-guided spine surgery, and microsurgery. with fellow providers through continuing medical kyphosis, flatback syndrome, etc.); spinal tumors; He performed the first robotic-assisted spine education courses and presentations at national metastatic spine disease; spine trauma; minimal- surgery and the first robotic-assisted computer and international conferences. ly invasive spine surgery; robotic-assisted spine image-guided surgery at UVA. He has been rec- In his free time, he enjoys playing guitar and surgery; and motion-sparing technology (artificial ognized as a Top Doctor by US News and World spending time with his wife, Julia, and his two disc replacement). Report and Castle Connolly Top Physicians and daughters, Stella and Emma. Dr. Li has developed a renowned laboratory has been profiled by Becker’s Spine Review. He focusing on intervertebral disc degeneration pa- has developed several novel surgical techniques. thology and treatment with stem cells, nanotech- His research is focused on improving the fu- nology, and gene therapy. He has been the recipi- ture of patient care by applying tissue engineering ent of over 20 grants as the Principal Investigator, principles to solve clinically relevant problems. He including four NIH (National Institute of Health is the Director of the American Academy of Or- R03, R21, and R01) grants. He serves as a com- thopaedic Surgeon Board Review Course, Board mittee member for the Orthopaedic Research So- Examiner for the American Board of Orthopaedic ciety and the North American Spine Society. He Surgeons, and Editorial Board Member for the has been on various grant review panels, includ- Spine Journal, SPINE, European Spine Journal, ing NIH, NASA, MTF, and AO-International. and SpineLine. He has served on the AOSpine He is married to Dr. Li Jin. He likes traveling Foundation Board and the Cervical Spine Society with his wife and plays badminton. He has also Executive Board and is an International Meeting led an exercise group practicing Falun Dafa in on Advanced Spine Techniques Program mem- Charlottesville for a decade. bers. He is a multiple-time award recipient for Outstanding Basic Science Paper and Outstand- ing Clinical Paper in the Spine Journal. He has received over 20 Young Investigator Awards, Career Development Grants, and Foundation Awards.

| For referrals, call 434-924-BONE (2663), Option 5 | uvaortho.com | 35 SPINE

Adam L. Shimer, MD Anuj Singla, MD Associate Professor Assistant Professor

Dr. Adam L. Shimer is an Associate Professor of Dr. Anuj Singla was born and grew up in India. He Orthopaedic Spine Surgery at the University of attended medical school and completed his Res- Virginia. Dr. Shimer is the Spine Doctor for the idency in Orthopaedics in India. He completed University of Virginia and James Madison Univer- fellowships in Pediatric Spine and Orthopaedics/ sity Athletics. Neurosurgical Spine at LSU, Shriner’s Hospital, Dr. Shimer’s training started with college at and UVA. UVA, followed by medical school at UVA and Or- He is a comprehensive spine surgeon with thopaedic Residency at the University of Pitts- a current practice, including both pediatric and burgh Medical Center. He completed an Ortho- adult spine surgery. Dr. Singla joined UVA as a paedic Research Fellowship at UPMC focused on Fellow in 2013 and has been a part of the fac- cellular- and gene-based therapy for interverte- ulty since 2014. He is a reviewer/editorial board bral disc repair and regeneration. After his Ortho- member for top spine journals. He is also an ac- paedic Spine Fellowship at the Rothman Institute tive member of many committees with the Scolio- at Thomas Jefferson Hospital in Philadelphia, he sis Research Society. joined the faculty in 2009. His practice is focused Dr. Singla’s clinical and research interests in- on complete care of neoplastic, infectious, trau- clude early-onset scoliosis, fusion-less deformity matic, degenerative, and deformity conditions of correction, and patient outcome after spinal sur- the spine. geries. He has been married to his wife, Priya, for He has extensive experience with and par- about ten years, and they have two kids. ticular interest in treating complex cervical spine pathology. His other research interests include value base spine care, and patient reported outcome measurements and complications of spinal surgery. Dr. Shimer is also the Orthopae- dic Inpatient Unit Medical Director. He is a member of the Cervical Spine Research Society, the American Academy of Orthopaedic Surgeons, the North American Spine Society, and the Vir- ginia Orthopaedics Society.

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UPDATE: What’s New at UVA CERVICAL SPINE Anterior cervical discectomy and fusion Orthopaedic Spine and posterior cervical laminectomy and fusion remain very reliable and durable procedures for the treatment of cervical Francis H. Shen, MD umes over the last 5 years. Perhaps most radiculopathy and myelopathy. However, importantly, this growth has allowed us to adjacent segment arthritis and stenosis re- University of Virginia, Department of Orthopaedic Surgery, expand the care that we can provide for main a real clinical concern, especially in Charlottesville, VA our patients and has given us the ability our young patients. As a result, total cervi- to see not only routine but also complex cal disc replacement (Figure 1) and poste- pathologies from our referring physicians. rior laminoplasties have gained interest as SPINE DIVISION What follows is just a small peek into motion-preserving, non-fusion procedures, The Division of Spine Surgery has grown some of the surgical procedures that are and we are now one of the few institutions steadily over the last 5 years. We now have now being routinely performed by our in the region performing them routinely 5 board-certified spine surgeons and 2 surgeons. with excellent results. physician assistants covering the whole range of both operative and nonopera- DEFORMITY tive pathologies. As a result of our faculty Spinal deformity can be one of the growth, we have expanded the number of most technically challenging surgeries that Altered spinal anatomy combined outreach sites, and now see patients not our team manages. Altered spinal anatomy with the complex reconstructions only at the Spine Center at UVA, but also combined with the complex reconstruc- required makes these some of the at Zion’s Crossroads and Culpeper. This tions required makes these some of the most difficult surgical cases to expansion has resulted in a substantial in- most challenging surgical cases to address, address, but also some of the most crease in both availability for patient ac- but also some of the most rewarding. For rewarding. cess and office visits, and surgical case vol- over a decade, we have been developing and using the most cutting-edge technology to address these challenging cases. We developed the technique of Dual Con- struct (Figure 2) to help address implant failure. More recently, our surgeons performed several “firsts,” including the first computer-navigated pedicle screw in the region, the first robotic-assisted pedicle screw in the region, and the first fully navigated robotic case in the region (Figure 3). The ability to apply these techniques to se- lective cases has dramatically improved patient care and can shorten patient recovery.

TUMOR Primary or metastatic tumors of the spine and vertebral column can be some of the Figure 1A, B. JH is a 39-y.o. right-hand dominant male, who had right arm and right-sided neck pain for over most difficult conditions for patients, their one year with biceps and wrist extension weakness. MRI confirmed a C5-6 herniated disc. He had failed families, and our surgical team to experi- conservative measures, and with associated weakness in a young patient surgery was discussed. In the attempt to reduce the risk of adjacent segment disease, he underwent a C5/6 total cervical disc replacement ence. Many cases are managed medically (Figure 1A, B). He has regained full strength and normal sensation after the surgery. with systemic or radiation therapies. How-

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Figure 2A-D. J.R. is a 62-y.o female with progressive adult deformity who underwent multiple surgeries with good initial results at an outside institution, but developed pseudarthrosis and implant fracture (Figure 2A, B). She was referred to our institution for definitive care. She underwent multilevel osteotomy with multi-point fixation and reconstruction utilizing the Dual Construct technique developed at our institution (Figure 2C, D) with a good long-term result.

Figure 3A-D. M.M. is a 22-y.o. male with idiopathic scoliosis that presented to our institution with increasing curve (Figure 3A, B) and progressive back pain. He failed extensive conservative measures. He underwent wide releases and posterior spinal fusion with excellent correction. The ability to utilize computer-navigated, robot-assisted screw fixation allowed for improved accuracy and reduced radiation exposure (Figure 3C, D). Our group was the first to perform robotic-assisted and computer-navigated surgery at UVA and in the region.

ever, frequently, our team is involved in resections to reduce morbidity (Figure 4). TRAUMA helping resect tumors to restore or main- In other cases, large tumor resections will As a Level I spine trauma center in the area, tain neurologic stability or to re-establish leave significant bony voids that require the University of Virginia receives a wide spinal biomechanics. In some cases, we complex spinal reconstructions that are range of complex fractures. One area that is are now utilizing navigated instruments frequently unique to the surgical resection traditionally challenging to gain stability to to perform precise intra-operative bony performed (Figure 5). allow for more rapid mobilization is com-

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Figure 4A-C. C.C. is a 12-y.o. male with increasing mid-thoracic pain present at rest and waking him from sleep. CT scan confirmed an osteoid osteoma, with a large reactive rim on MRI with gadolinium (Figure 4A, arrowheads). Due to the location adjacent to the thoracic spinal cord (Figure 4B, single arrow), the interventional and musculoskeletal radiologist did not feel that a percutaneous radiofrequency ablation would be a safe option for him. Uti- lizing intraoperative CT scan and live real-time computer-navigated burr, the osteoid osteoma was localized and resected without extensive removal of the bony and ligamentous elements (Figure 4C, arrow). Therefore, a resection was performed without instrumentation. He had complete relief of pain Figure 5A-D. T.O. is a 60-y.o female diagnosed with primary liposarcoma of immediately post op and has returned to school and all sporting activities the rigth psoas and pelvis (Figure 5A, B). The patient had progression of tu- without restrictions. mor burden despite medical oncological therapy. There were no metastases identified on staging, and no further nonoperative options available for the treatment of the lesion. After extensive discussion with patient and family, surgical resection was decided upon. Patient underwent a single stage posterior and anterior en bloc resection with hemipelvectomy and right lower limb amputation. Surgical resection with margins was achieved, and patient underwent complex spinopelvic reconstruction (Figure 5 C,D). Surgical pathology confirmed good margins. As a result, patient did not need to undergo chemotherapy. At recent follow-up, patient is now ambulating unassisted with a walker and independent with ADLs.

plex sacropelvic fractures with lumbopelvic those needs. Fortunately, not all patholo- dissociation. In these cases, we have devel- gies require a large surgical intervention, Traditionally performed by an oped and utilized a multi-pelvic fixation and as a result, in selected cases, the Or- interventional radiologist and/or (Figure 6) to allow for complex reduction thopaedic Spine Division is now able to pain management specialist, techniques to achieve better anatomic re- offer our patients more limited alternatives our team’s ability to now provide duction and a more immediate rigid fixation to larger spine procedures, such as cement these procedures allows us to to allow for more immediate mobilization. augmentation for spinal fractures, neuro- deliver a more streamlined modulation therapy/spinal cord stimula- process, comprehensive care, NEUROMODULATION AND tors, and spinal injections. Traditionally and improved continuity of care INTERVENTIONAL SPINE PROCEDURES performed by an interventional radiologist for our patients. As the needs of our patients have expand- and pain management specialist, our team’s ed, our division has also expanded to match ability to now provide these procedures

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Figure 6. M.K. is a 37-y.o. male in high energy motor vehicle accident with prolonged extrica- tion, transferred to UVA for definitive polytrauma care of polytrauma patient. Code initiated with chest compressions upon arrival and taken to OR for emergent ex-lap and abdominal packing (Figure 6A) due to extensive intraabdominal vascular extravasation. CT scan confirmed vertical and rotationally unstable pelvis (Figure 6B, C). Patient underwent multidirectional pelvic stabilization to allow for multi-planar reduction of the pelvis fracture (Figure D-F).

Figure 7. Current treatment for herniated disc with acute radiculopathy can involve multiple providers and a prolonged treatment algorithm that can culminate in an invasive injection within the spinal canal (top pathway). In the current investigation, a peripheral intravenous injection with a site-specific targeted therapy could be delivered at the time of symptomatic flare (bottom pathway).

allows us to deliver a more streamlined have undergone cervical spine decom- support our division’s basic science proj- process, comprehensive care, and improved pressions. Most recently, UVA completed ects. One novel project focuses on treat- continuity of care for our patients. the largest enrollment in an international ing lumbar radiculopathy by delivering a study of over 50 hospital sites across the systemic, injectable, anti-inflammatory CLINICAL AND BASIC SCIENCE globe, investigating the potential for vac- nanoparticle via a peptide specifically RESEARCH cine therapy in the prophylaxis against targeted at active neutrophils and macro- In the last 5 years, our clinical and basic Methicillin-resistant Staphylococcus au- phages localizing at the site of disc herni- science research has exploded. There are reus (MRSA) related surgical infections. ations. This translational study is the first now over a dozen active clinical trials in Our basic science research remains in the of its kind and would dramatically alter place, ranging from an investigation of top tiers in the nation with several mil- the current paradigm of patient care for the role of external spinal fusion devices lion dollars in federal funding from the the management of lumbar radiculopathy to analyzing gait patterns of patients who National Institute of Health (NIH) to (Figure 7). ■

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Stephen F. Brockmeier, MD David R. Diduch, MD* F. Winston Gwathmey, MD Associate Professor Allen F. Voshell Professor of Sports Medicine Associate Professor and Residency Director

Dr. Stephen F. Brockmeier is an Associate Pro- Dr. David R. Diduch is the Allen F. Voshell Profes- Dr. F. Winston Gwathmey is the son of an ortho- fessor of Orthopaedic Surgery in the Division of sor and Division Head of Sports Medicine at the paedic hand surgeon, Dr. Gwathmey grew up in Sports Medicine at the University of Virginia. He University of Virginia. He is also the former Vice- Norfolk, VA and received his undergraduate de- is Director of the UVA Sports Medicine Fellowship Chair of the department. Dr. Diduch is the Head gree from the University of Virginia. He received and Team Physician for UVA Athletics, with prima- Orthopaedic Team Physician for UVA Athletics and his medical degree from Eastern Virginia Medi- ry coverage for the UVA Football, Men’s Soccer, has primary coverage for men’s basketball, foot- cal School and returned to UVA for residency. He and Men’s Lacrosse teams. ball, and women’s soccer teams. then completed a Sports Medicine and Shoulder A long-time Hoo, Dr. Brockmeier completed Dr. Diduch’s training started with college at Fellowship in Boston at Massachusetts General his undergraduate degree here at UVA in 1997. UNC, followed by medical school at Harvard and Hospital and pursued additional hip arthroscopy This was followed by medical school and Ortho- Orthopaedic Residency at UVA. After his Sports training with Dr. Thomas Byrd in Nashville, TN. paedic Residency at Georgetown University. After Fellowship in New York at the Insall-Scott-Kelly In- Dr. Gwathmey returned to UVA as a faculty residency, Dr. Brockmeier spent a year at the stitute, he joined the faculty in 1995. His practice member in 2013 and currently is an Associate renowned Hospital for Special Surgery in New is split between knee and shoulder surgery and Professor in the Division of Sports Medicine with York, where he completed a Fellowship in Sports the care of injured athletes. a special interest in arthroscopic techniques Medicine and Shoulder Reconstructive Surgery. A major area of clinical and research focus around the hip. He established the Hip Arthros- Prior to coming back to UVA as a faculty mem- for him involves taking care of patients with pa- copy Program at UVA and currently performs up- ber in 2010, Dr. Brockmeier spent three years in tella instability. He has extensive experience with wards of 200 hip arthroscopic surgeries per year. practice in Charlotte, NC, where he was the team treating complex patella instability problems with He is the Orthopaedic Residency Program Direc- physician for the NBA Charlotte Bobcats. cutting edge techniques, including tibial tubercle tor and active in the medical student curriculum His current practice at UVA focuses on sports osteotomy, MPFL reconstruction, and limb realign- as well. He has won multiple teaching awards medicine, knee and shoulder arthroscopy and ment. He is one of very few surgeons in the U.S. including, the Mulholland Teaching Award, the reconstructive surgery, and the care of athletes performing deepening trochleoplasty procedures Charles W. Miller Resident Teaching Award, and and active individuals. He subspecializes in knee for trochlear dysplasia and patella instability. His the Dean’s Award for Excellence in Medical Stu- ligament, meniscus, and cartilage repair surgery, other research interests include post-ACL surgery dent Teaching. as well as ACL reconstruction, and has become a return-to-play decision making, articular cartilage Dr. Gwathmey is the Medical Director of the regional expert in complex shoulder reconstruc- and meniscal repair, and novel knee unloading Sports Medicine Clinic. He is also one of the tion, management of shoulder instability, rotator devices for early arthritis. team physicians for both UVA and JMU Athletics. cuff surgery, as well as total shoulder arthroplasty He has received the UVA School of Medicine He is active in the American Orthopaedic Society and reverse shoulder arthroplasty. Master Clinician Award, served as chair of numer- for Sports Medicine and the Arthroscopy Asso- His current research focuses on management ous committees for AOSSM as well as the Council ciation of North America, serving as faculty at of shoulder instability in the contact athlete, re- of Delegates, served as President of the Virginia annual meetings and in surgical skills courses turn to play strategies after ACL reconstruction, Orthopaedic Society, and has been inducted into throughout the year. biologic options for rotator cuff repair, and cutting the Herodicus Society. He has been married to Outside of work, Dr. Gwathmey enjoys time edge and novel techniques in shoulder replace- his wife, Lynn, for over 30 years and has 3 grown with his wife, Kelly (a neurologist at VCU), and two ment surgery. He received the Dean’s Award for boys, all of whom graduated from UVA. kids, Cate and Robert. He enjoys cheering on the Clinical Excellence at UVA, was selected for the UVA and JMU athletic programs. prestigious AOSSM Traveling Fellowship to Europe in 2014, and is the current chair of the Education Committee for AOSSM. He is an active member of ASES, is the Vice President of the ACESS group, and was recently inducted into the Herodicus So- ciety. He lives in Charlottesville with his wife, Kris- tin, and their three children, Ben, Jack, and Paige.

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Mark D. Miller, MD Brian C. Werner, MD S. Ward Casscells Professor Assistant Professor

Dr. Mark D. Miller is the S. Ward Casscells Profes- Dr. Brian C. Werner is an Assistant Professor in sor of Orthopaedic Surgery and former Division the UVA Department of Orthopaedic Surgery. Head of Sports Medicine at the University of Vir- He completed a Fellowship in Sports Medicine ginia. He is a retired Colonel in the US Air Force. and Shoulder Surgery at the Hospital for Special He is a Distinguished Graduate (top 3%) of the Surgery, where he was a team physician for the US Air Force Academy and the Uniformed Ser- New York Giants and the New York Red Bulls. Dr. vices University of the Health Sciences (USUHS). Werner currently serves as the Head Orthopae- Dr. Miller completed his Residency in Orthopae- dic Team Physician for James Madison University dic Surgery at Wilford Hall USAF Medical Center Athletics, where he provides primary coverage in San Antonio, Texas, and a Fellowship in Sports for all sports, including the 2016 FCS national Medicine and Shoulder Surgery at the prestigious championship football team, men’s and women’s University of Pittsburgh. He served as a surgeon basketball, men’s and women’s soccer, and the and team physician at the Air Force Academy and 2018 national champion women’s lacrosse team, as Chief of Sports Medicine and Deputy Chair- among others. Board-certified in orthopaedic sur- man at Wilford Hall before coming to the Universi- gery, he specializes in sports medicine and shoul- ty of Virginia. He served as Head Team Physician der surgery. This includes both arthroscopic and for James Madison University for 15 years. open reconstructive surgery of the shoulder and Dr. Miller has authored over 200 articles and knee. He focuses on all sports and athletic inju- has authored and edited almost 40 textbooks. ries and has a particular clinical interest in shoul- He has served in numerous leadership positions der replacement and ligament reconstruction of for the American Orthopaedic Society for Sports the knee. Medicine (AOSSM) and currently serves as Sec- Dr. Werner has a significant interest in both retary on the Board of Directors. He has received clinical and basic science research, has published the AOSSM George Rovere Award for Education, over 180 peer-reviewed papers on a wide variety the USUHS Distinguished Service Award, and the of orthopaedic topics, and has presented his re- Virginia Orthopaedic Society Lifetime Achieve- search both regionally and nationally over 300 ment Award. times. He has won numerous national awards for Mark Miller is a highly sought after speak- his research. His current research interests in- er and has organized numerous Instructional clude clinical outcomes after knee and shoulder Course Lectures, served as a Visiting Professor surgery, biomechanical studies in the knee and at multiple prestigious programs, and founded shoulder, shoulder arthroplasty, and cartilage in- and directed the most successful review course jury and repair. in orthopaedics, the Miller Review Course, estab- Dr. Werner has numerous national leadership lished almost 25 years ago. roles, and serves on the Research Committee Dr. Miller’s research interests include com- for the American Orthopaedic Society for Sports plex knee to include multiple ligament injuries, Medicine, Education Committee for the American revision ACL, articular cartilage injuries, and me- Academy of Orthopaedic Surgeons, and the Ab- niscal repair and transplantation. He is married to stract Review Committee for the American Shoul- Ann Etchison and has four grown children. der and Elbow Surgeons Society. Outside of orthopaedics, Dr. Werner enjoys spending time with his wife and two boys, Benja- min and Wyatt. He is an avid runner and has run numerous marathons and continues to train for both marathon and half marathon distances. He also enjoys golf.

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Revision Anterior ONE-STAGE REVISION Obviously, most patients and, for that Cruciate Ligament (ACL) matter, surgeons prefer a one-stage approach. Our experience5 and that of oth- Reconstruction Research ers6 suggests that a one-stage revision can be successful if the tunnel is less than 14 mm in diameter, and the planned revision Mark D. Miller, MD The problem of tunnel osteolysis in the tunnel does not substantially overlap the setting of revision ACL reconstruction is previous tunnels. We have described a University of Virginia, Department of Orthopaedic Surgery, being increasingly recognized, and this is technique for one-stage revision ACL us- 7 Charlottesville, VA the focus of our current research. Two eti- ing bone dowel allografts that allows suc- ologies of osteolysis have been proposed: cessful revision provided the criteria not- the windshield wiper effect and the bungee ed above is met and provided that the new evision ACL reconstruction cord effect.3 Both are more common with tunnels compromise less than 50% of the presents a series of challenges suspensory (cortical) fixation. We have dowel (Figure 1). Others have described for even the most experienced noted increased osteolysis with allograft a similar technique using calcium-phos- R sports medicine knee surgeon. use (maybe related to processing) and on phate to fill the previous tunnels.8 Factors that may lead to ACL recon- the tibial side (likely an effect of gravity). struction failure can be grouped into three The real challenge with osteolysis is de- TWO-STAGE REVISION termining the optimum way to address For larger and/or converging tunnels, a it during revision ACL reconstruction. two-stage approach is required. The pre- Although tunnel Osteolysis can Although tunnel osteolysis can be appre- vious tunnel is serially reamed until all be appreciated on plain radiographs ciated on plain radiographs and magnetic fibrous tissue is removed. Dowels, which and magnetic resonance imaging resonance imaging (MRI), we have found are cannulated and available up to size 18 (MRI), we have found that computed that computed tomography (CT) is the x 34 mm, can then be inserted with a can- tomography (CT) is the best way best way to characterize tunnel osteolysis. nulated tamp using a press-fit technique. to characterize tunnel Osteolysis. The extent and location of osteolysis helps A CT scan is repeated at approximately determine whether it can be addressed in four months after the first stage proce- a one- versus a two-stage ACL revision.4 dure to assess healing (Figure 2). Our re- broad categories: technical errors, repeat search has demonstrated that integration trauma, and biologic failure.1 Technical errors include aberrant tunnel placement, hardware failure, missed concurrent injuries, failure to address excessive tibial slope, and a variety of other factors. Re- peat trauma to include overly aggressive physical therapy is often over-diagnosed, but does occur. Biologic failure is perhaps the most poorly understood cause of unsuccessful ACL reconstruction. We are all aware that graft selection is an important factor in ACL success, and allograft use, especially in young patients, is associated with alarmingly higher ACL failure rates.2 Biologic failure also includes infection and tunnel osteolysis. Figure 1. One Stage Revision ACL

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of these bone dowels equals the results of filling with autogenous iliac crest grafting.9 Biopsy of these dowels has shown good integration at four months and creeping substitution at one year (Figure 3). More recently, we have studied tunnel osteolysis and filling using 3-dimensional CT scanning. The preliminary results (Figure 4) are encouraging.

FUTURE STUDIES We are continuing our studies of both one- and two-stage revision ACL recon- Figure 2. CT Scan demonstrating bone dowel healing at 4 months post op structions with a clinical study and a randomized controlled study comparing bone dowels with calcium phosphate cement. We hope to report the results of these studies soon. ■

REFERENCES 1. Johnson DL, Harner CD, Maday M, Fu FH. Revision ACL Surgery. In Fu FH, Harner CD, Vince KG 9eds) Knee Surgery. Baltimore, Williams and Wilkins 877-896, 1994.

2. Pallis M, Svoboda SJ, Cameron KL, et al. Survival comparison of allograft and autograft anterior cruciate ligament reconstruction at the United States Military Acade- my. Am J Sports Med 2012; 40:1242-1246.

3. Maak TG, Wickiewicz TL, Warren RF. Tunnel widen- ing in Revision Anterior Cruciate Ligament Reconstruc- tion. J Am Acad Orthop Surg; 2010 18:695-706

4. Richter DL, Werner BC, Miller MD. Surgical Pearls in Figure 3. Histology demonstrating healing of bone dowels. A. Four month biopsy shows cement lines Revision ACL Surgery. When must I stage? Clin Sports between the host bone and allograft bone dowel. B. One year biopsy demonstrating repopulation of the Med 2017; 36: 173-87. graft with host cells (creeping substitution).

5. Buyukdogan K, Laidlaw MS, Miller MD. Two-Stage Revision ACL using Allograft Bone Dowels. Arthroscopy Techniques 2017; 4:e12972-1302.

6. Chahla JJ, Dean CS, Cram TR, et al. Two-Stage Re- vision Anterior Cruciate Ligament Reconstruction: Bone Grafting Technique Using an Allograft Bone Matrix. Ar- throscopy Techniques 2016; 5: e189-195.

7. Werner BC, Gilmore CJ, Haman JC, et al. Revision Anterior Cruciate Ligament Reconstruction: Results of a Single-stage Approach Using Allograft Dowel Bone Grafting for Femoral Defects. J Am Acad Orthop Surg 2016 24: 581-7.

8. Bonner K, Griffith J. Arthroscopy Techniques, In Press.

9. Uchida R, Toritsuka Y, Mae T, Kusano M, Ohzo- no K. Healing of tibial bone tunnels after bone grafting for staged revision anterior cruciate ligament surgery: A prospective computed tomography analysis. The Knee. 2016;23(5):830-6. Figure 4. 3-Dimensional CT Scan of bone void and filling.

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Engineering Approach to sidered irreversible and correlate directly with clinical outcomes. Rotator Cuff Atrophy Dr. Brian Werner has teamed up with Dr. George Christ and Dr. Thomas Barker to develop a tissue-engineering approach to 1 2 Brian C. Werner, MD , George Christ, PhD , Despite the known association be- address rotator cuff atrophy. The goals of their Thomas Barker, PhD2, Juliana Amaral tween muscle fibrosis, fatty infiltration in-vivo study are to develop a tissue-engi- Passipieri, PhD2, Sarah Dyer, Graduate student2, Zoe Roecker, BSE3 and rotator cuff atrophy with poor clinical neering muscle repair (TEMR) implant that outcomes and failure after rotator cuff re- can reverse rotator cuff atrophy in a rat rota- 1University of Virginia, Department of pair, much less research has been devoted tor cuff repair model. To date, Drs. Werner Orthopaedic Surgery Charlottesville, VA; to improving muscle quality and function and Christ have made promising progress. 2 University of Virginia, School of and reducing atrophy following repair of The TEMR constructs have been developed Engineering, Charlottesville, VA; 3University chronicFigure tears.1 .Even TEMR technology has been optimized in vitro and is ready for implantat with successful surgi- and optimized (Figure 1 A-B). A rat rotator ion in vivo (A). of Virginia Medical Student, Biomedical Figure 1. TEMR technology has been optimized in vitro and is ready for implantation in vivo (A). cal repair,Actin staining shows cell alignment on the BAM after preconditi defined by a healed tendon-bone cuff model which demonstrates profoundoning in the bioreactor su- Engineering, Charlottesville, VA Actin staining shows cell alignment on the BAM after preconditioning in the bioreactor interface on imaging, the degenerative praspinatus atrophy has been developed and changes in the muscle are generally con- optimized as well (Figure 2 A-D). ■ Figure 1. TEMR technology has been optimized in vitro and is ready for implantation in vivo (A). otator cuff tears are the most com- Actin staining shows cell alignment on the BAM after preconditioning in the bioreactor mon musculoskeletal injury in the shoulder, making rotator cuff repair R a common procedure. Even with recent advances in repair techniques, there remains a high incidence of healing failure. Numerous factors have been correlated with failure to heal after rotator cuff repair, including patient- and surgeon-related variables.

As rotator cuff repair techniques have improved, failure of the tendon to heal is less FigureFigure 1 . TEMR2 .technology Rotator cuff atrophy rat model. Atrophy of the supraspinatus develops 4 weeks after has been optimized in vitro and is ready for implantation in vivo (A). Actin likely to occur from weak fixation. More likely stainingdetachment and can be demonstrated in gross specimens, Figure showsFigure 2 cell. 2Rotator cuff atrophy rat model. Atrophy of the supraspinatus develops 4 weeks after . alignmentRotator cuff atrophy rat model. Atrophy of the supraspinatus d on the BAM after preconditioning in the bioreactor MRI and in weight testing.evelops 4 weeks after causes of failure include biologic factors such detachment and can be demonstrated in gross specimens, detachment and can be demonstrated in gross specimens, MRI and in weight testing.MRI and in weight testing. as lack of vascularity to the repaired tendon, Atrophied Atrophied fatty infiltration or atrophy of the muscle, in- SSP AtrophiedSSP muscle 4- trinsic degeneration of the tendon, fibrosis or muscle 4SSP- weeks muscleweeks 4- post-injurypost-injury Contralateral Contralateral decreased bone quality at the repair site. weeks control Atrophied control Atrophied post-injury Contralateral Substantial research has been devoted SSP muscle control 4 weeksAtrophiedSSP muscle to improving healing rates and clinical out- Humeral post4 -weeksinjury HumeralHead SSP muscle comes after rotator cuff repair. The majority 4post weeks-injury HumeralHead post-injury of these investigations focus on improving Head bone-tendon healing through a variety of approaches, including an assortment of methods of footprint preparation, the use of platelet rich plasma, mesenchymal stem cells or growth factors, improving the bio-

mechanical qualities of the repaired tissue through the use of biologic scaffolds or augmentation techniques and improvement of Figure 2. Rotator cuff atrophy rat model. Atrophy of the supraspinatus develops 4 weeks after detach- bone quality at the repaired enthesis. ment and can be demonstrated in gross specimens, MRI and in weight testing.

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Ahmad Fashandi, MD David B. Weiss, MD* Seth R. Yarboro, MD Instructor Associate Professor Associate Professor and Quality Director

Dr. Ahmad Fashandi is a Clinical Instructor in the Dr. David B. Weiss attended Johns Hopkins Uni- Dr. Seth Yarboro is a North Carolina native who has Orthopaedic Trauma Division. He is a born and versity in Baltimore, MD, for his undergraduate been an orthopaedic surgeon at UVA since 2012. raised Virginian, having grown up in the Washing- studies majoring in Biomedical Engineering to fa- He specializes in fracture care of both acute and ton, D.C., suburbs before moving to Charlottesville cilitate his future career as an orthopaedic trau- chronic injuries, as well as pathology involving soft for higher education. He attended college as well ma surgeon involved with re-engineering humans tissue and infection. His approach to surgery uti- as medical school and completed an Orthopaedic instead of bridges and machines. Dr. Weiss at- lizes both traditional as well as minimally invasive Residency at UVA. Following training, he contin- tended Georgetown University for medical school and computer-assisted surgical techniques. ued with the faculty in the Orthopaedic Trauma and then completed a surgical internship at the Dr. Yarboro attended medical school at the Division at UVA. University of Michigan. He then spent three years University of North Carolina at Chapel Hill, where His practice focuses on trauma of both the as an active duty Air Force flight surgeon sta- he also completed his Orthopaedic Residency upper and lower extremity as well as the pelvis. tioned at McConnell AFB in Wichita, KS. training. Dr. Yarboro then went on to complete Or- He treats a wide range of patients, from ado- After serving in the Air Force, Dr. Weiss re- thopaedic Trauma Fellowships at UNC Hospital, lescents to geriatric populations. His research turned to the University of Michigan to finish an an AOTrauma Fellowship in Hannover, Germany, interests include lower extremity imaging tech- Orthopaedic Surgery Residency and then com- and a Fellowship in Orthopaedic Trauma and niques, complex trauma to the foot/tibia/femur, pleted a one-year Fellowship in Orthopaedic Computer-Assisted Surgery in Ulm, Germany. and post-traumatic gait analysis. Dr. Fashandi is Trauma at Harborview Hospital in Seattle, WA. At UVA, Dr. Yarboro is an active research- married to Dr. Anna Fashandi and is the father of He spent the next five years as the Director of er with a variety of interests, including infection two young girls. Orthopaedic Trauma at St Joseph Mercy Hospi- treatment and prevention, ankle syndesmosis tal in Ann Arbor, MI, and joined the University of injuries, advanced intraoperative imaging, and Virginia in 2010 as the Division Head of Ortho- quality outcomes after surgery. He has contrib- paedic Trauma. His areas of clinical focus include uted to multiple publications and book chapters. complex fractures of the proximal and distal tibia He is also involved with the AO Technical Con- and malformed or unhealed fractures of the hips, gress (AOTK) in their Computer-Assisted and Im- legs, and feet. age-Guided Expert Group (CIEG), where technolo- Dr. Weiss is heavily involved with the ed- gy is used to advance the field of surgery. ucation of medical students and orthopaedic Dr. Yarboro currently serves as the Patient residents at the local and national level with our Safety and Quality Officer for the Department of specialty organization, the Orthopaedic Trauma Orthopaedics. This work involves organizing regular Association, the Academy of Orthopaedic Sur- conferences within the department for case review geons, and the AOTrauma foundation. He serves and education, optimizing quality measures and on education and patient safety committees for reporting, and representing the department within these organizations and has been honored with the institution regarding quality-related policy. several education and teaching awards in addi- He has a specific interest in orthopaedic tion to being selected as a Best Doctor for the last education, working routinely with residents in seven years and selected as one of the top 19 conferences and surgical training. He also works Traumatologists in North America in 2015. regularly with the Orthopaedic Trauma Associa- Dr. Weiss enjoys trail running, biking, flying tion (OTA), participating in their resident fracture (general aviation), and military history. He is mar- course. Additionally, he has served as a program ried with three boys currently ages 10, 12, and chair for educational meetings ranging from the 13 years old. Keeping up with their activities is a local to the national level. second full-time job. Dr. Yarboro performs surgeries at the UVA Main Hospital and sees patients at the UVA Orthopaedic Clinic in Fontaine Research Park, Office Building 545. He regularly sees new patients through physician referrals and direct patient requests.

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Improving Quality of Care for Geriatric Hip Fractures at UVA

Seth R. Yarboro, MD, David Weiss, MD Fracture Society (IGFS). This certification recognizes programs that undertake an University of Virginia, interdisciplinary approach to the manage- Department of Orthopaedic Surgery ment of fractures in our elderly population. Charlottesville, VA An interdisciplinary clinical pathway was created to standardize care and move the ip (or proximal femur) frac- patient through the system as effectively tures are commonly treated at and efficiently as possible. By measuring many hospitals, and the inci- and optimizing performance in several H dence of this type of fracture different clinical areas, we can ensure the is increasing as our population, on aver- highest level of quality of care is delivered. age, gets older. Specifically, fragility hip Adherence to the IGFS guidelines assists fractures, or broken bones that occur in in ensuring patients receive the same high elderly patients, can be challenging, espe- standard of care with minimal variability cially when there are other medical issues from case-to-case. The ultimate goal is to present. The impact the fractures have on improve outcomes and to best help patients mobility and quality of life can complicate and their families navigate the difficult situ- decisions for treatment. These fractures ation caused by geriatric fractures. To be recognized as a premier certified program from IGFS, a program must exceed The University of Virginia is proud national quality and outcome benchmarks of their accomplishment and recent established for geriatric fracture care. These recertification as the only institution goals are achieved through co-management in the state of Virginia whose hip of patients—meaning that surgeons and fracture program is certified by the medical doctors work side-by-side in pro- International Geriatric Fracture viding specialty care. In other situations, one Society (IGFS). of the two parties might work as a consultant or secondary physician instead of shar- ing caregiving duties equally. Other mem- as well as working on independence with have a substantial impact in terms of cost bers of the interdisciplinary team include hygiene, such as brushing teeth. By min- and lifestyle for patients and their families, physical and occupational therapists, nurses, imizing downtime after the fracture and and they represent one of the major chal- care coordinators, case managers, and social having the patient work intensively with lenges in caring for an aging population. workers, among others. therapy, we can determine the patient’s re- Therefore, it is very important we optimize Some of the criteria evaluated when habilitation and discharge needs and allow and standardize our approach for geriatric deciding IGFS certification include time families to know what to expect after the fractures. from admission until surgery, mortality hospital stay. The University of Virginia is proud of rates, readmission rates, and general bone With a clear pathway for patients who their accomplishment, and recent recerti- health care and education. have hip fractures, we can give them the fication as the only institution in the state Examples of typical patient care are best chance of a successful outcome and of Virginia, whose hip fracture program shown below, where this patient is mobi- help them regain as much mobility and in- is certified by the International Geriatric lizing with therapy shortly after surgery, dependence as possible. ■

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Anteroposterior (AP) View of Of these deformities, detecting malrotation with conventional fluoroscopy is the the Knee Does Not Reliably Replace most challenging. Despite attempts to restore the anatomic alignment, rotational the Lateral View During Evaluation malalignment remains a common complication, reported in up to 27% of cases1-4. of Femoral Torsion Evaluation of normal anatomy has proven that a wide range of femoral torsion exists in healthy, uninjured popu- Michael M. Hadeed, MD, fracture participated in the study. Each par- lations. Variations in proximal femoral Ahmad H. Fashandi, MD, ticipant had their bilateral lower extremi- anteversion between individuals of >10o Wendy Novicoff, PhD, Seth R. Yarboro, MD ties imaged utilizing anteroposterior imag- has been found without clinical implica- ing compared to the gold standard lateral tion. Side-to-side differences in antever- University of Virginia, Department of Orthopaedic Surgery views for establishing rotational alignment sion have also been noted in healthy in- Charlottesville, VA of the femur with conventional fluoroscopy. dividuals with an average of 4 degrees of Data were compared between repetitions variation, and 95% of patients within 11 of a single limb, a single patient’s two legs, degrees of the contralateral extremity.9,10 ABSTRACT and between patients. Intra- and inter-rater In evaluating postoperative patients, mal- Background: Femoral shaft fractures in reliability were measured. rotation has been defined as >10o of varia- the adult patient are a common injury Results: Overall, strong intraclass re- tion from a patient’s native anatomy while that almost always require operative fix- liability and reproducibility of the mea- >15o has shown clinical and functional sig- ation. Restoration of anatomic torsion at surements was achieved. Side-to-side and nificance.3 While appropriate torsion may the fracture site is a critical step. Several intra-patient variability in the relative po- be determined based on fracture reduc- accepted methods use the morphology of sition of the patella to the femur was iden- tion in spiral or long oblique patterns, this the femur, such as the lesser trochanter tified, with up to a 14-degree difference method may not be reliable in transverse, profile technique, to determine anatomic between limbs noted. short oblique, segmental, or comminuted torsion. Recently, the anteroposterior (AP) Discussion: The use of AP imaging fractures. As such, appropriately evalu- view of the knee has been used to simpli- alone does not reliably replace the later- ating and reestablishing native anatomy fy the procedure, yet this method has not al view for the evaluation of femoral tor- through secondary methods is required. been validated. This potentially introduc- sion. Circumstances were using the AP es variability as the anteroposterior view view will provide erroneous results were uses landmarks outside of the femur. The identified. Due to side-to-side differenc- The use of AP imaging alone does purpose of this study was to1 assess the re- es, the AP technique cannot be recom- not reliably replace the lateral view producibility of anteroposterior view of the mended to determine anatomic torsion in for evaluation of femoral torsion. knee,2 compare the side-to-side variability femoral shaft fractures. The conventional of a patella-centered view compared to the technique using overlapping posterior perfect lateral view of the distal femur, and3 condyles on the lateral view of the knee Several methods have been described to determine whether the anteroposterior remains an important part of determining to evaluate intraoperative femoral torsion view is adequate for evaluating femoral femoral torsion. at the time of fracture fixation. Clinical torsion in femoral shaft fractures. Keywords: Femur fracture; torsion; mal- examination of range of motion and lower Hypothesis: It is hypothesized that us- union; fluoroscopy; intraoperative imaging extremity alignment, cortical thickness at ing a reference point outside of the femur the fracture site, evaluation of anteversion may lead to inaccurate assessment of fem- INTRODUCTION on lateral imaging, lesser trochanteric pro- oral torsion. When fixing a femoral shaft fracture, it is files, and greater trochanter-head contact Patients and Methods: Fifteen pa- critical to restore the anatomy in all three methods have all been described as tech- tients without a history of lower extremity planes—length, angulation, and rotation. niques or adjuncts to determining appro-

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priate rotation.5-8 The latter three methods require the surgeon to obtain a perfect lateral view of the knee on the uninjured side prior to draping, as well as intraoperative lateral imaging of the injured extremity. This task may be challenging or cumbersome if the extremities are at the same level, or the fractured extremity must be manipulated. This difficulty with positioning the injured limb and maneuvering the fluoroscope has led some surgeons to use an anteroposterior (AP) view of the knee with the patella-centered relative to the distal femur as the basis for determining equal Figure 1. The patella is centered over the tibia spines, then the cross-table lateral view is obtained. femoral torsion, thus avoiding the need PACS software is used to determine distance between condyles on the AP view (left), and the lateral is for a lateral fluoroscopic view. However, measured for posterior condyle offset (right). this method has never been validated for utility and reliability. The purpose of this study was to (1) assess the reproducibil- tral rotation, and the process was repeat- The reliability of data was assessed us- ity of anteroposterior view of the knee, ed to obtain 5 sets of such images from ing Cronbach’s alpha and the intraclass cor- (2) compare the side-to-side variability of each extremity. Imaging was obtained relation coefficient (ICC (2,1)). Cronbach’s a patella-centered view compared to the with a marker ball and with consistent alpha can be interpreted as a measure of perfect lateral view of the distal femur, and positioning of the fluoroscope to maintain internal consistency of these measurements (3) to determine whether the anteroposte- magnification and allow for comparison. or as a measure of the generalizability of rior view is adequate for evaluating femo- If indicated due to an inability of the ex- this group of measurements to measure- ral torsion in femoral shaft fractures. The aminer to determine which condyle (me- ments in a larger population.11,12 The intra- lateral view is used as the gold standard dial or lateral femoral condyle) was more class correlation coefficient (the same raters for comparison. posterior on a given lateral image, addi- measured each subject, and each rater was tional oblique imaging was obtained, and considered representative of a larger popu- MATERIALS AND METHODS the more posterior condyle was noted on lation of similar raters) was also calculated After obtaining institutional review board the datasheet. to provide a composite value for both in- approval, 15 healthy subjects without a his- Images were measured using standard tra-rater and inter-rater reliability.13 tory of lower extremity fracture were con- imaging software (PACS) to determine sented for participation in this study. degrees of rotation from perfect lateral of RESULTS Patients were placed supine on a stan- the distal femur based on condylar over- Cronbach’s alpha and intraclass correla- dard operating room table to simulate lap on a lateral image. The distance was tions were considered good (above 0.80) intraoperative conditions. The extremity standardized with a marker ball to allow or excellent (above 0.90) for all compar- being evaluated was imaged at the level of conversion from the pixels measured to isons (Table 1).14 Both Cronbach alpha the knee with an AP fluoroscopic image the distance in centimeters and finally to values and ICC values were higher in the rotated, so the patella was located between degrees of rotation (Figure 1). These data left-side measures compared to the right- the tibial spines (Figure 1). While main- were compared between a given set of five side measures; the lowest Cronbach alpha taining the lower extremity in this posi- repetitions on a single limb, compared and ICC were observed in the side-to-side tion, the fluoroscope was rotated 90o, and between a given patient’s two limbs, and measurements. a cross-table lateral image was obtained. compared between patients to determine Table 2 shows the actual side-to-side The extremity was then released to neu- the reliability of measurements. difference for each of the subjects. The av-

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Table 1. Statistical analysis of data from participant imaging erage side-to-side difference between legs on individual patients was 6.2 degrees, Description of Measurement Cronbach’s Alpha ICC with a standard deviation of 1.6. The larg- Right side – offset pixels 0.970 0.864 est value was 14 degrees with a standard Right side – offset centimeters 0.977 0.895 deviation of 3.3. Right side – offset degrees 0.983 0.919 Left side – offset pixels 0.988 0.942 DISCUSSION Left side – offset centimeters 0.985 0.930 Left side – offset degrees 0.988 0.941 Reestablishing appropriate rotational Side-to-side differences 0.954 0.806 alignment of a femoral shaft fracture can be both difficult and cumbersome. Cur- rent gold standard techniques rely on obtaining orthogonal views of the uninjured Table 2. Side-to-side difference between legs of individual subjects extremity while also obtaining orthogo- Subject Number Average Side-to-Side Standard Deviation nal intraoperative imaging of the injured Difference (Femoral Version) limb. These orthogonal images allow di- 1 4.7° ±3.1 rect assessment of femoral morphology. 2 2.6° ±1.6 Imaging in a single plane would simplify 3 14.0° ±3.3 the procedure and increase intraoperative 4 2.0° ±1.5 efficiency, which is beneficial to patients. 5 8.6° ±2.3 However, imaging in a single plane relies 6 6.4° ±1.6 on landmarks outside of the femur, in- 7 7.5° ±0.9 cluding the patella and tibial spines. De- 8 7.9° ±0.9 9 1.4° ±1.2 spite use by some surgeons, this method 10 8.3° ±1.1 has not been empirically evaluated and 11 4.4° ±1.9 compared to the gold standard, and it is 12 8.9° ±0.7 unknown how those additional variables 13 3.4° ±0.7 might change the reliability and repro- 14 11.0° ±1.9 ducibility of the technique. 15 1.2° ±0.9 This study evaluated the use of intraoperative anteroposterior imaging alone for establishing rotation of a femoral shaft fracture undergoing intramedullary cohort was 14 degrees. Given that stud- cal history of knee or lower extremity pro- fixation. For this to be used in clinical ies have shown clinical significance when cedures were all noted to have a reproduc- practice, the measurements must be re- malrotation of >15 degrees occurs, a sig- ible side-to-side rotational profile within producible, and the femoral torsion must nificant margin of error to this magnitude 5 degrees. However, as noted by outliers be adequately represented on the AP im- is unacceptable. in this series of patients, soft tissue proce- aging alone. This study demonstrated that Utilization of the patella as a marker of dures about the knee can greatly influence an AP image of the distal femur with the position implicates soft tissues about the the relative alignment of the patella and patella centered over the tibial spines is knee that may be impacted by surgical or distal femur. As such, the key to utilizing a reproducible intraoperative measure. degenerative changes in addition to vari- a technique of anteroposterior imaging However, unlike techniques that rely on ability in anatomy. The subject that had alone intraoperatively is establishing its the perfect lateral radiograph, AP imag- the largest side-to-side difference previ- applicability to each patient scenario pri- ing of the distal femur does not provide ously underwent bilateral primary ACL or to its use (Table 3.) When significant a reliable side-to-side guide to reestablish reconstructions, and subsequent revision variability is noted, the gold standard of femoral torsion for all participants. The ACL reconstruction on one extremity. intraoperative perfect lateral imaging is maximum side-to-side difference in this Participants in this series without a surgi- recommended.

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Table 3. Steps to verify side-to-side similarity when using single plane fluoroscopy REFERENCES

Steps to verify side-to-side similarity when using single plane fluoroscopy 1. Yang KH, Han DY, Jahng JS, Shin DE, Park JH. Pre- vention of malrotation deformity in femoral shaft fracture. Uninjured Limb J Orthop Trauma. 1998;12(8):558-562.

• AP of the knee with the patella centered over the tibial spines (save all images) 2. Lindsey JD, Krieg JC. Femoral malrotation follow- • Rotate the fluoroscope 90o and obtain a lateral view ing intramedullary nail fixation. J Am Acad Orthop Surg. 2011;19(1):17-26. doi: 19/1/17 [pii]. • Move the fluoroscope proximally and obtain an AP image of the proximal femur to use for the lesser trochanteric profile (if side-to-side is equivalent) 3. Braten M, Terjesen T, Rossvoll I. Torsional deformity after intramedullary nailing of femoral shaft fractures. Injured Limb measurement of anteversion angles in 110 patients. J Bone • Move to the injured limb and take an AP of the uninjured knee with the patella centered over the Joint Surg Br. 1993;75(5):799-803. tibial spines 4. Jaarsma RL, Verdonschot N, van der Venne R, van Kamp- • Rotate the fluoroscope 90o and obtain a lateral view en A. Avoiding rotational malalignment after fractures of the femur by using the profile of the lesser trochanter: An in vitro study. Arch Orthop Trauma Surg. 2005;125(3):184-187. If the two lateral views (injured versus uninjured) are evaluated and deemed to have a matching doi: 10.1007/s00402-004-0790-2 [doi]. condylar overlap, the usage of anteroposterior imaging alone intraoperatively is deemed to be a 5. Ettinger M, Maslaris A, Kenawey M, et al. A prelim- viable tool. inary clinical evaluation of the “greater trochanter-head contact point” method for the intraoperative torsional control of femoral fractures. J Orthop Sci. 2012;17(6):717- 721. doi: 10.1007/s00776-012-0277-x [doi]. This study has several limitations. and found to be consistent between sides, 6. Fang C, Gibson W, Lau TW, Fang B, Wong TM, Leung F. Important tips and numbers on using the cortical step and di- Foremost is the sample size, both of the the AP view does appear to be a repro- ameter difference sign in assessing femoral rotation--should entire cohort and the subset of patients ducible measure. In this instance, the AP we abandon the technique? Injury. 2015;46(7):1393-1399. with previous ligamentous/soft tissue distal femur may be a more efficient view doi: 10.1016/j.injury.2015.04.009 [doi]. procedures about the knee. Of interest to than the lateral for comparing proximal 7. Jaarsma RL, Verdonschot N, van der Venne R, van Kamp- en A. Avoiding rotational malalignment after fractures of future study would be the evaluation of pa- and distal femur appearance when con- the femur by using the profile of the lesser trochanter: An in tients with no previous history of soft tis- firming appropriate femoral torsion intra- vitro study. Arch Orthop Trauma Surg. 2005;125(3):184-187. sue procedures about the knee compared operatively. ■ doi: 10.1007/s00402-004-0790-2 [doi]. to a cohort of patients having had cruciate, 8. Tung T, Tufescu T. The cortical step sign fails to pre- FUNDING, DISCLOSURES, vent malrotation of a nailed femoral shaft fracture: A collateral, or patellofemoral ligament pro- case report. Case Rep Orthop. 2014;2014:301723. doi: cedures. Data from this study imply a sig- CONTRIBUTION OF COAUTHORS 10.1155/2014/301723 [doi]. nificant influence of these interventions on • There were no sources of funding for 9. Pfeifer T, Mahlo R, Franzreb M, et al. Computed to- the relative positioning of the patella and this project mography in the determination of leg geometry. In Vivo. 1995;9(3):257-261. distal femur and as such, is a relationship • The authors have nothing to disclose 10. Waidelich HA, Strecker W, Schneider E. Computed that warrants evaluation. • Author contributions: tomographic torsion-angle and length measurement of – Michael M Hadeed, data acquisi- the lower extremity. the methods, normal values and ra- CONCLUSION tion, manuscript preparation diation load. Rofo. 1992;157(3):245-251. doi: 10.1055/s- 2008-1033007 [doi]. Based on these data, we cannot recom- – Ahmad H Fashandi, data acquisi- 11. Cronbach L. Essentials in psychological testing. Vol 3rd mend routine use of AP views with the tion, manuscript preparation Edition. 3rd Edition ed. Harper and Row; 1970. patella centered over the tibial eminence – Wendy Novicoff, statistical analysis, 12. Nunnally J. The assessment of reliability. In: Psychomet- to reliably match the distal femur position manuscript revisions ric theory. McGraw-Hill; 1994:260.

when determining femoral torsion. How- – Seth R Yarboro, conception and de- 13. Muller R, Buttner P. A critical discussion of intraclass cor- ever, if AP and lateral views of a patient’s sign of the study, data acquisition, relation coefficients. Stat Med. 1994;13(23-24):2465-2476. bilateral lower extremities are compared manuscript revisions 14. Lavrakas P. Encyclopedia of survey research methods. Thousand Oaks, CA: SAGE Publications; 2008.

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PHYSICIAN ASSISTANTS

Nick Calabrese, PA-C Traci Mahoney, PA-C Chad Wilson, PA-C Jim Shorten, PA-C Andrea White, PA-C Adult Reconstruction Adult Reconstruction Adult Reconstruction Foot & Ankle Foot & Ankle

Kelsey Parente, PA-C Amy Radigan, PA-C Emily Feiner, PA-C Nikki Ralston, PA-C Rose Tyger, PA-C Hand and Upper Extremity Hand and Upper Extremity Pediatrics Spine Spine

Claire Denny, PA-C Jen Hart, PA-C Michelle Post, PA-C Jodi Wells, PA-C Jacquelyn Wilson, PA-C Sports Sports Sports Trauma Trauma

FELLOWS 2019-2020

Matthew Harb, MD John Taliaferro, MD Mike Casale, MD Sheriff Akinleye, MD Patrick O’Callaghan, MD Adult Reconstruction Adult Reconstruction Foot & Ankle Hand and Upper Extremity Hand and Upper Extremity

Manminder Bhatia, DO Chris Bankhead, MD Courtney Quinn, MD Jordan Walters, MD Spine Sports Sports Sports

52 | UVA ORTHOPAEDIC JOURNAL | 2019 | RESIDENTS

RESIDENTS 2019-2020

Victor Anciano, MD Suraj Bolarinwa, MD Aaron Casp, MD Mike Hadeed, MD Harrison Mahon, MD Chief Chief Chief Chief Chief

Dennis Chen, MD Trent Gause, MD Max Hoggard, MD Michelle Kew, MD Eric Larson, MD PGY4 PGY4 PGY4 PGY4 PGY4

Francis Bustos, MD Matt Deasey, MD Emanuel Haug, MD Nicole Quinlan, MD Baris Yildirim, MD PGY3 PGY3 PGY-3 PGY3 PGY3

Ian Backlund, MD James Burgess, MD Zach Burnett, MD Tim Lancaster, MD David Noble, MD PGY2 PGY2 PGY2 PGY2 PGY2

Cara Thorne, MD Alyssa Althoff, MD Neil Blanchard, MD Pearson Gean, MD Thomas Moran, MD PGY2 INTERN INTERN INTERN INTERN

| uvaortho.com | 53 SPOTLIGHT: Visiting Professors

• August 29, 2018 – Dr. Rahman Kandil – • June 23, 2016 – Dr. Darren Johnson, 2019 StoneSprings Orthopaedics Sports Medicine, University of Kentucky • July 18, 2018 – Dr. Robin Queen, (Chief Resident Graduation Visiting Research VP – Virginia Tech Professor) • June 23, 2018 – Dr. Sig Hansen, • April 20, 2016 – Dr. Jay Lieberman, Harborview Medical Center Adult Reconstruction, University of • May 23, 2018 – Dr. Lynne Jones, Southern California Research VP, Johns Hopkins University – • April 13, 2016 – Dr. Donald LaLonde, “Teamwork: From Bench to Bedside. My Hand Surgery / Plastic Surgery, St. Experience with Total Joint Replacement” John, Canada (Morgan-McCue Visiting (from left) A. Bobby Chhabra, MD, UVA Ortho, • May 16, 2018 – Dr. John France, Chan Professor) Evan Carstensen, MD, UVA Ortho, Bayan Spine VP, West Virginia University • February 17, 2016 – Dr. Marty Boyer, Aghdasi, MD, UVA Ortho, Glenn Gaston, MD, OrthoCarolina, Kevin Laroche, MD, UVA Ortho, • April 18, 2018 – Dr. Nicholas Vedder, Hand and Upper Extremity Surgery, Hakan Pehlivan, MD, UVA Ortho, Dan Hess, MD, Morgan-McCue VP, University of Washington University, St. Louis UVA Ortho, A. Rashard Dacus, MD, UVA Ortho. Washington • January 20, 2016 – Dr. Gus Mazzocca, • March 21, 2018 – Dr. Robert Arciero, Sports Medicine, University of • August 21, 2019 – Dr. Dean Taylor, Sports Medicine, University of Connecticut Sports VP – Duke University Connecticut • July 17, 2019 – Dr. Di Chen, Research • February 21, 2018 – Dr. Bob Zura, VP – Rush University Trauma, Louisiana State University • June 21,2019 – Dr. Glenn Gaston, (Richard Whitehill Visiting Professor) Graduation VP – OrthoCarolina • January 17, 2018 – Dr. James Nunley, • April 17, 2019 – Dr. Sanj Kakar, Morgan- Foot and Ankle, Duke University McCue VP – Mayo Clinic • March 20, 2019 – Dr. John France, Chan Spine VP – West Virginia University 2017 • February 20, 2019 – Dr. Bob Ostrum, • November 1, 2017 – Brian Shaw, A. Bobby Chhabra, MD, UVA Ortho, (left) and Trauma, University of North Carolina Pediatric Orthopaedics, Children’s Dean Taylor, MD, Duke Health (right) • January 23, 2019 – Dr. Regis O’Keefe, Hospital of Colorado (Mark and Jean Research VP, Washington University, Abel Visiting Professor) St. Louis, MO • September 20, 2017 – Dr. Ginger Holt, 2015 • January 16, 2019 – Dr. Asheesh Bedi, Oncology, Vanderbilt University • December 16, 2015 – Dr. Mark Easley, Sports Medicine, University of Michigan • June 23, 2017 – Dr. Peter Stern, Hand Foot and Ankle, Duke University and Upper Extremity, Cincinnati (Chief • November 4, 2015 – Dr. James Resident Graduation Visiting Professor) Sanders, Pediatric Orthopaedics, 2018 • May 17, 2017 – Dr. Frank Phillips, Spine University of Rochester (Mark and Jean • November 21, 2018 – Dr. Keith Surgery, Rush University (Donald Chan Abel Visiting Professor) Wapner, Foot & Ankle VP – University of Spine Visiting Professor) • August 19, 2015 – Dr. John McCormick, Pennsylvania • April 19, 2017 – Dr. Reid Abrams, Hand Spine Surgery, Private Practice in • October 31, 2018 – Dr. Hank Chambers and Upper Extremity, UC-San Diego Savannah, GA – UC San Diego – Mark and Jean Abel (McCue-Morgan Visiting Professor) • June 19, 2015 – Dr. Thomas Byrd, Visiting Professor • March 22, 2017 – Dr. James Andrews, Sports Medicine and Hip Arthroscopy, Sports Medicine, American Sports Nashville Sports Medicine (Chief Medicine Institute (Richard Whitehill Resident Graduation Visiting Professor) Visiting Professor) • May 13, 2015 – Dr. Geof Baer, Sports • February 22, 2017 – Dr. Michael Medicine, University of Wisconsin Meneghini, Adult Reconstruction, • February 25, 2015 – Dr. Jeff Dugas, Indiana University Sports Medicine, American Sports Medicine Institute • April 15, 2015 – Dr. David Ruch, Hand 2016 and Upper Extremity, Duke University (from left) Jeremy Rush, MD, UVA Ortho, Stephen • December 14, 2016 – Dr. Michael (Morgan-McCue Visiting Professor) Brockmeier, MD, UVA Ortho, Brian Werner, MD, Coughlin, Foot and Ankle, • February 18, 2015 – Dr. Robert UVA Ortho, Eric Carson, MD, (was at UVA Ortho Saint Alphonsus, Boise, ID Trousdale, Adult Reconstruction, at time of photo; now at VA St. Louis Health Care • November 2, 2016 – Dr. John Blanco, Mayo Clinic System) A. Bobby Chhabra, MD, Asheesh Bedi, Pediatric Orthopaedics, Hospital for MD, University of Michigan, Judd Smith, MD, Special Surgery (Mark and Jean Abel David Diduch, MD, F. Winston Gwathmey, MD, Visiting Professor) Mark Miller, MD, John Awowale, MD

54 | UVA ORTHOPAEDIC JOURNAL | 2019 | RESIDENT RESEARCH DAY ABSTRACTS

The Impact of Meniscus Treatment niscus treatment at the time of ACLR surgery. The hypothesis is that weight-bearing on Functional Outcomes 6 Months restrictions after meniscal repair would hinder functional recovery. After Anterior Cruciate Ligament Methods: ACLR patients at the time of point of return to activity (5-7-month Reconstruction post-ACLR) and healthy controls completed patient-reported outcomes (IKDC, KOOS, and Tegner Activity Scale), and Aaron J. Casp, MD, Marvin K. Smith, MD, via repair or partial meniscectomy. Per- underwent bilateral isokinetic (90°/sec) Stephan Bodkin, M.Ed., Sterling Tran, MD, sistent muscle weakness, impaired func- and isometric (90°) strength tests of the Frank Winston Gwathmey, MD, Eric W. Carson, MD, Brian C. Werner, MD, tion, and poor patient-reported outcomes knee extensor and flexor groups. Outcomes Mark D. Miller, MD, David R. Diduch, MD, are a concern for patients early after recon- were recorded in a single session as part of Stephen F. Brockmeier, MD, struction and impact a timely and success- a return-to-sport test battery. Strength was Joseph M. Hart, PhD ful return to unrestricted physical activity expressed as torque normalized to mass without re-injury. However, little is known (Nm/kg), and limb-symmetry was ex- University of Virginia, about the effect of weight-bearing restric- pressed as a ratio of involved: uninvolved Department of Orthopaedic Surgery Charlottesville, VA tions and range of motion limitations af- torque. ACLR patients were stratified into ter meniscus repair on short term ACLR meniscal subgroups dependent on me- recovery and return-to-play assessment. niscal involvement at the time of ACLR: Objectives: Anterior cruciate ligament The purpose of this study was to compare Isolated ACLR (ACLR), ACLR+Menis- (ACL) tears are often associated with me- strength, jumping performance, and pa- cectomy (ACLR-MS), ACLR+Meniscal niscal injury. Meniscus tears are treated at tient-reported outcomes between isolated Repair (ACLR-MR). One-way ANOVAs the time of ACL reconstruction (ACLR) ACLR patients and those undergoing me- with post-hoc Tukey’s test for equal vari- ances was used to assess differences in subjective knee function as well as quadriceps Table 1. Patient Demographics Based on Meniscal Treatment Type and hamstring strength between groups. ACLR ACLR+MS ACLR+MR Healthy P-value Results: A total of 306 participants, n 50 44 71 140 including 165 ACLR patients and 141 Age (years) 22.9±10.1 25.0±12.5 20.3±7.0 21.4±3.5 .008a healthy controls, were recruited for partic- Sex (F:M) 31:19:00 23:21 33:38:00 82:59:00 n.s. ipation. The average time post-operatively Height (cm) 171.2±10.2 170.4±10.7 173.3±10.2 171.9±18.0 n.s. Mass (kg) 70.6±15.1 75.7±19.1 77.1±19.3 70.0±12.5 .008b was 5.96±0.47 months. Meniscal group Graft Type stratification resulted in: ACLR: n=50, BTB 33 25 42 – n.s. ACLR+MS: n=44, and ACLR+MR: HS 17 19 29 – n.s. n=71. Heathy controls demonstrated Time Post Surgery 6.0±.42 6.1±.53 5.9±.47 – n.s. higher subjective knee function than all (months) meniscal subgroups (p<.001); however, Tegner Activity Level 8.1±1.6 8.4±1.6 8.6±1.2 – – there were no differences between any of (Pre-Injury) the meniscal subgroups on the IKDC or Tegner Activity Level 5.7±1.8 6.0±1.6 6.0±2.0 7.8±1.7 <0.001c (Current) any KOOS subscales. Healthy controls IKDC (%) 80.2±12.7 83.4±9.1 78.6±14.8 97.0±5.0 <0.001d demonstrated significantly higher unilateral peak extensor torque (2.08 ±.56 Nm/ kg) and limb symmetry (98±.12%) than a Healthy participants are significantly younger than ACLR+MS patients b Healthy participants have significantly lower mass than ACLR+MR patients all meniscal subgroups (p<.001). There c Healthy participants have a significantly greater current activity level than all ACLR groups were no differences in unilateral or limb d Healthy participants have a significantly greater IKDC score than all ACLR groups symmetry measures of peak knee extensor

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torque between ACLR (1.45±.46 Nm/kg, Motion and Strength Analysis 68±19%), ACLR+MS (1.48±.48 Nm/kg, 68±19%), and ACLR+MR (1.58±.52 Nm/ of Scapholunate Ligament kg, 71±20%) patients (all p-values>.05). There were no differences in unilateral Reconstruction Using a Two-Tine or limb symmetry measures of peak knee flexor torque between any subgroups (all Staple in a Novel Cadaver Model p-values>.05). Conclusion: At 6 months follow- 1 1 ing ACLR, patients remain weaker and Daniel E. Hess, MD , Anthony J. Archual, MD , staple across SL interval. Data were col- Emily Dooley, BS2, Hans Prakash, BS3, more symptomatic compared to healthy lected using Vicon software (Vicon Mo- Shawn D. Russell, PhD2, controls. Meniscus treatment during sur- Aaron M. Freilich, MD1, A. Rashard Dacus, MD1 tion Systems Inc, Los Angeles, CA) and processed for modeling in MSC.Adams 1University of Virginia, (MSC Software, Newport Beach, CA) Department of Orthopaedic Surgery with LifeModeler plug-in. Specimens Charlottesville, VA with SL staple in place were then loaded 2University of Virginia, with the higher of 1000N or 200% subject Motion Analysis and Motor Performance Lab, Charlottesville, VA body weight using MTS tensile strength 3University of Virginia, School of Medicine, machine the (MTS Systems Corporation, Charlottesville, VA Eden Prairie, MN) and analyzed for moment of structural failure. Results: The eight sample arms used Introduction: The scapholunate ligament came from 2 male and 2 female subjects (SLL) is vital for maintaining normal with an average age of 76.3 years (range wrist kinematics. Numerous strategies for 62-89 years) and average the weight of repairing or reconstructing the SLL after 170lbs (range 100-208lbs). Motion cap- an acute injury have been described in the ture data demonstrated that, compared literature, but no single technique domi- with an intact SLL, motion between the Figure 1. Comparison of knee flexor and extensor nates, as each has significant drawbacks, scaphoid and lunate is increased with divi- strength and symmetry across meniscal treat- including mandatory second procedures, sion of the SLL and reduced with K-wire ment groups pin site infections, and wrist stiffness. Re- fixation. With the two-tine staple in place, cently, the use of two- and four-tine sta- SL motion and kinematics were similar ples has emerged as a promising method to prior to SLL division. Under axial load gery—whether it was meniscus repair or for SLL reconstruction. We, therefore, with staple fixation in place, 3 specimens meniscectomy—did not influence the ob- sought to compare SLL fixation tech- demonstrated scaphoid fractures, 2 speci- jective strength and functional test results. niques, including traditional Kirshner wire mens demonstrated distal radius fractures, These findings suggest that the postoper- (K-wire) fixation technique and two-tine and 3 specimens proceeded through test- ative weight-bearing and range-of-mo- staple fixation. ing without failure. There were no hard- tion restrictions associated with meniscus Materials and Methods: We used ware failures or deformation of the staple. repair do not result in early functional eight fresh cadaver arms with normal Conclusion: This study illustrates a differences in strength symmetry between SL intervals, the kinematics between the novel technique for assessing carpal kine- ACLR and ACLR+MR patients at the scaphoid and lunate were assessed using matics using motion capture technology. It time of return to sport. Such results may motion capture cameras in four distinct also demonstrates that the two-tine staple provide further insights for postoperative states: a) SLL intact, b) SLL divided, c) system provides adequate fixation strength rehabilitation and inform intraoperative K-wire fixation across SL interval and with motion more similar to the native decision-making. ■ scaphocapitate interval, and d) two-tine SLL than K-wire fixation. ■

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Do Local Anesthetic Arthroscopic number of pills consumed was recorded at the two-week follow-up. Portal Injections Decrease Pain Results: There was no difference in preoperative VAS scores amongst the 3 groups (3.0 After Knee Arthroscopy? vs. 3.1 vs. 3.5) (P = 0.56). There was a significant difference in VAS scores at 1 hour postoperatively between groups 1 and 3 (3.1 vs. Ian Dempsey, MD, MBA, Marc Lipman, MD, The purpose of this study was to evaluate 4.4) (P = 0.013) with a trend towards signifi- Abdurrahman Kandil, MD; Brian C. Werner, MD, the effect of local anesthetic during knee ar- cance between groups 2 and 3 (3.5 vs. 4.4) (P David R. Diduch, MD, Eric W. Carson, MD throscopy in improving postoperative pain. = 0.059). There was a significant difference in Methods: A prospective, randomized, VAS scores at 4 hours postoperatively between University of Virginia, Department of Orthopaedic Surgery, controlled, non-blinded study was con- groups 1 and 3 (2.9 vs. 4.3) (P = 0.001) and be- Charlottesville, VA ducted. 277 consecutive patients undergo- tween groups 2 and 3 (3.0 vs. 4.3) (P = 0.003). ing simple knee arthroscopy by two fellow- There was a trend toward decreased narcotic ship-trained surgeons were prospectively use in the first 2 postoperative days, but the Background: Knee arthroscopy is one of randomized to one of three groups, which overall number of narcotic pills consumed was the most common orthopaedic procedures received either 20 cc of 0.5% bupiva- the same by 2 weeks postoperatively. performed in the United States. With a caine(group 1), 20 cc of 0.25% bupivacaine Conclusions: The Use of local anes- continued trend toward performance-driven (group 2), or 20 cc of normal saline (group thetic at the time of knee arthroscopy was outcomes that rely on patient satisfaction, it 3). Baseline demographics, including Ly- found to result in a significant reduction in is of interest to the surgeon and of benefit sholm Knee Scores, were obtained. Pain patient-reported pain scores at 1 hour and to the patient to minimize pain after knee was assessed using VAS scores preopera- 4 hours postoperatively in this prospective, arthroscopy. Additionally, in light of the tively, 1 hour postoperatively, 4 hours, 24 randomized controlled study. These results current narcotic crisis in the United States, hours, 48 hours, and at the 2 week follow suggest routine use of local anesthetic as a multimodal analgesia has become an area up. A standardized number of narcotic pills multimodal analgesic regimen is reason- of focus during routine orthopaedic pro- were given in the form of 40 total pills of able for routine knee arthroscopy. ■ cedures. This includes local anesthetics like hydrocodone-acetaminophen 5-325 mg. bupivacaine that have become a mainstay for Daily pill counts were self-reported by pa- Level of evidence: Level I, randomized targeted analgesia around surgical incisions. tients for the first week, and then the total controlled trial

Biomechanical Analysis of the Deep The position of catcher is a demanding position that requires prolonged time squat- Squatting Position in Baseball Catchers ting with deep knee flexion. Some catchers wear posterior leg pads, called Knee Sav- With and Without Knee Saver™ Pads er™ pads (Easton, Van Nuys, CA) with the goal of reducing stress across the knee joint. However, the actual ergonomic ben- 1 2 J. Beamer Carr, MD , Emily Dooley, BS , Objectives: Overuse injuries continue to efits of Knee Saver™ pads have never been 2 1 Shawn D. Russell, PhD , Eric W. Carson, MD increase at alarming rates in youth sports. quantified to our knowledge. This study Prevention of overuse injuries is an im- has two main objectives: 1University of Virginia, Department of Orthopaedic Surgery, portant focus in managing young athletes. 1) To analyze the biomechanics of a Charlottesville, VA In particular, overuse upper extremity inju- catcher’s deep squat with and without Knee 2University of Virginia, ries are a major focus in youth baseball and Saver™ pads; and 2) to quantify the per- Motion Analysis and Motor Performance softball. However, little attention has been centage of body weight absorbed by each Lab, Charlottesville, VA paid to lower extremity overuse injuries. Knee Saver™ pad during a deep squat.

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Methods: Subjects were analyzed at our for each leg in every stance with and without The ankle, knee, and hip flexion values from institution’s motion analysis lab using reflec- Knee Savers™ were averaged and compared the load cell trials did not differ signifi- tive tape marker balls and ten infrared motion using a paired student’s t-test with a p-value cantly from the values obtained from Knee sensing cameras. Each catcher performed a of 0.05 set for significance. The force trans- Saver™ trials, suggesting that our load cell series of two squats with and without Knee mitted through each load cell model was cal- model recreated similar squatting mechan- Savers™. Each squat was performed three culated as a percentage of total body weight. ics to the Knee Saver™ pads. times and held for three seconds. The first Results: A total of 4 male baseball Conclusions: Knee Saver™ pads did squat performed was the “sign” stance, which catchers with an average age of 16.8 years not significantly reduce the knee flexion -an was the normal stance while giving a sign to (range 14-19 years) were analyzed. For both gles in the two most commonly performed the pitcher. The second squat was the “receiv- stances, Knee Saver™ pads increased the squats for a catcher. Based on our load cell ing” stance, which was the normal deep squat average ankle flexion angle while reducing model, Knee Saver™ pads received a com- for catching a pitch without a runner on base. the average knee and hip flexion angle in bined 45.1% of a catcher’s body weight Lastly, each catcher performed at least three each leg, yet these values were not signifi- during a normal receiving squat. “receiving” squats while wearing our load cell cant except for left hip flexion in the sign Therefore, any ergonomic value is likely Knee Saver™ pad model in order to calcu- stance. The greatest difference in knee flex- attributable to force redistribution as op- late the force transmitted through a Knee ion was observed in the right knee during posed to alteration of squatting mechanics. Saver™ pad. Data was collected using Vicon the sign stance, which resulted in a 4.3 angle It is possible that Knee Saver™ pads may software (Vicon Motion Systems Inc, Los difference (p=0.18). On average, each catch- help reduce overuse injuries to the knee Angeles, CA) and then subsequently pro- er loaded 22.1% body weight (range 18.4%- by reducing the force across the knee joint cessed for modeling in MSC.Adams (MSC 25.6%) through the right Knee Saver™ without altering squatting mechanics. Fur- Software, Newport Beach, CA) with LifeM- pad and 23.0% body weight (range 18.9%- ther studies are needed to better elucidate odeler plug-in. For each squat, ankle, knee, 25.8%) through the left Knee Saver™ pad possible benefits of Knee Saver™ pads in and hip flexion angles were calculated. Values while squatting with the load cell model. overuse injury prevention. ■

Is It Safe to Weight Bear Immediately described above. The purpose of this study was to determine whether weight-bearing After Intramedullary Nailing of after intramedullary nailing of extra-articular distal tibia fractures is safe. The specific Extra-Articular Distal Tibia Fractures? aims include 1) to determine if the construct can withstand simulated weight-bearing, 2) to determine how much the fracture will Michael M. Hadeed, MD, Hans Prakash, BS, construct or an intramedullary nail with in- displace during simulated weight-bearing, David B. Weiss, MD terlocking bolts. In isthmic tibia fractures, 3) to determine whether that displacement University of Virginia, one benefit of intramedullary nailing is the occurs early or late in the loading period, and Department of Orthopaedic Surgery safety of immediate weight-bearing post 4) to determine the rate of displacement. Charlottesville, VA operatively. This can lead to improved heal- Methods: A biomechanical model of ing, a decreased period of convalescence, and distal metaphyseal tibia fractures was creat- Disclosures: This study was funded by a potentially lower the risks of venous throm- ed using fourth generation composite bone grant from AO Trauma North America and boembolism and muscle atrophy. Outside of models. Three fracture patterns were test- material support was provided by Smith and Nephew the isthmus, there is concern that immediate ed: a spiral fracture (AO/OTA 43A1.1), an weight-bearing after fixation with an in- oblique fracture (AO/OTA 43A1.2), and a tramedullary nail may lead to fracture dis- fracture with a zone of comminution (AO/ Introduction: Extra-articular distal tibia placement. If shown to be safe, immediate OTA 43A3.2). The models were fixed with fractures are often treated with reduction weight-bearing after extra-articular distal intramedullary nails with three distal in- and fixation with either a plate and screw tibia fractures may lead to the same benefits terlocking bolts and then cyclically loaded.

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Loading was done in compression at 3000N of 1.22 degrees. Most of the displacement oc- caused minor displacement. The amount at 1 Hz for a total of 70,000 cycles. Displace- curred in the first 2,500 cycles, and the rate of of displacement was well under the typical ment (shortening, coronal angulation, sagittal displacement declined over time. The oblique thresholds which define a malunion. Most angulation) was measured at regular intervals. fracture model shortened an average of of the displacement occurred immediate- Results: The spiral and oblique fracture 0.18mm, developed an average coronal angu- ly, and the rate of displacement decreased patterns were able to withstand simulated lation of 2.36 degrees, and developed an aver- over time. Based on these data, immediate weight-bearing. The comminuted model had age sagittal angulation of 2.56 degrees. Similar weight-bearing after reduction and fixation early implant failure with breaking of the dis- to the spiral model, most of the displacement of an extra-articular distal tibia fracture tal interlocking bolts. The spiral fracture mod- occurred in the first 2,500 cycles, and the rate with an intramedullary nail and three dis- el shortened an average of 0.27mm, developed of displacement declined over time. tal interlocking bolts is safe, and it can be an average coronal angulation of 2 degrees, Conclusions: For spiral and oblique recommended for patient care in the right and developed an average sagittal angulation fracture patterns, simulated weight-bearing clinical scenario. ■

Ioban™ Suction Dressing Showed No for NPWT. Both NPWT dressings were applied with 75 mmHg, which is also an accept- Untoward Complications When Used ed pressure. At the end of the 48 hour period, a clinical photograph was taken of the wound, on Kocher-Langenbeck Incisions for and a second photograph was taken at the first 2 week post-op appointment. All wounds Acetabulum Fractures were closed with staples. Data categories that were collected included patient demographics, medical comorbidities, injury comorbidities, Cody Evans, MD, and Seth R. Yarboro, MD regarding its safety. To address this lack of length of stay, estimated blood loss from sur- understanding, we created a randomized tri- gery, type of VTE chemoprophylaxis utilized, University of Virginia, Department of Orthopaedic Surgery al to compare the short-term postoperative duration of surgery, time from injury to sur- Charlottesville, VA complication rates and safety profiles among gery, and acetabulum fracture pattern. The three types of dressings in patients with ac- wounds were monitored for postoperative etabulum fractures being addressed with a complications, including seroma formation, Introduction: Incisional negative pressure Kocher-Langenbeck incision. cellulitis, suture abscess, or overt surgical site wound therapy (INPWT) has been shown Methods: Trauma patients admitted to dehiscence and deep infection. The occurrence to be effective in reducing the incidence of the University of Virginia Medical Center of any postoperative wound complication was postoperative wound infection following sur- with posterior column, posterior wall, and/or the primary outcome measure. All patients gery to address tibial pilon, tibial plateau, and posterior wall acetabulum fractures amenable had follow-up to at least the 6 week postoper- calcaneus fractures. Every significant study to fixation through a Kocher-Langenbeck in- ative mark. Given the low incidence of com- to date has utilized the proprietary prod- cision were prospectively identified and que- plications, we sought to compare the dressings ucts from KCI, such as the V.A.C. Ulta or ried for participation in this study, after IRB with regards to wound appearance. The clini- Prevena. Despite being effective in reducing approval was granted. Participants were ran- cal photographs from each postop point were wound complications, the cost of these prod- domly assigned to one of three surgical dress- de-identified and placed into a PowerPoint ucts to patients and the healthcare system ing types using a random number generator. file. A trauma surgeon, operating room nurse, can be large. We have previously adminis- The three dressing types were: NPWT using resident, and medical student at our institu- tered NPWT using a less expensive dressing a KCI V.A.C. Ultra, NPWT using the afore- tion then compared the wounds and ranked made from gauze bandage, Ioban™, and wall mentioned in-house dressing, or a standard the wounds in order of appearance, from most suction tubing. Despite the presumptive ef- adhesive dressing. The selected dressing was appealing to least. Observers were provided a fectiveness and safety of this dressing based applied at the end of the surgery and remained validated grading system previously used in on anecdotal evaluation, concerns were raised in place for 48 hours, as is standard practice hernia surgery and encouraged to reference

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the grading system when ranking the wounds. complications treated with a course of oral the Ioban™ NPWT dressing was inferior or The final rank orders were analyzed to look for antibiotic, and both of these patients were caused any unforeseen safety problems with clustering of the dressing types and for inter- in the adhesive gauze treatment group. One regards to wounds. Given that no wound observer agreement. of these patients was diabetic and a smoker. complications were experienced within this Results: Over the course of twelve The second patient developed post-opera- group, and that photographs corresponding months, there were 26 patients who enrolled tive pulmonary embolisms and was treated to the Ioban™ group were competitive in the in the study and were randomized. The num- with therapeutic strength anticoagulation. ranking portion of the study, this dressing is ber of patients assigned to the Ioban™, adhe- There were no wound complications in ei- a safe option with which to treat high-risk sive, and KCI groups were 12, 7, and 13, re- ther of the NPWT groups. wounds in the future, such as tibial pilon, pla- spectively. Twenty of 26 patients (77%) were Discussion: Overall the rate of wound teau, and calcaneus fractures. We feel that a male. Average age was 40 years. The average complication was very low, which is corrob- randomized trial comparing dressings among EBL was 700 milliliters. Average duration orated in other studies evaluating acetabulum these patients would be valuable in determin- was two hours twenty-four minutes. All pa- fractures. The low number of events makes ing if this dressing type is safe and efficacious tients were treated with enoxaparin for VTE detecting superiority of any one dressing over in those wounds. If that is the case, then the chemoprophylaxis. Average BMI was 28.4. another difficult, however the primary goal of less-expensive Ioban™ dressing may be a more Two patients experienced superficial wound the study was to determine whether or not cost-effective dressing to use in the future. ■

Dialysis Dependence and Treatment using ICD-9 and CPT codes including in-hospital death, emergency room visits, Modality Impact Complication Rates hospital readmission, infection, and revision surgery. Statistical comparisons were com- Following Shoulder Arthroplasty pleted with a logistic regression analysis controlling for additional comorbidities. Results: The incidence of SA in dial- Jourdan M. Cancienne, MD, and SA in hemodialysis (HD) and perito- ysis-dependent patients significantly in- Stephen F. Brockmeier, MD, neal dialysis (PD) patients; 2) to compare creased over the study period (p < 0.0001). James A. Browne, MD, Michelle E. Kew, MD, Brian C. Werner, MD adverse events after THA, TKA, and SA in Compared to matched controls, dialysis de- HD and PD patients; 3) to compare adverse pendence at the time of SA was associated University of Virginia, events after THA, TKA, and SA in HD and with increased rates of in-hospital death (OR Department of Orthopaedic Surgery PD patients with matched controls without 7.60, p < 0.0001), emergency room visits (OR Charlottesville, VA dialysis dependence; and 4) to determine the 4.16, p < 0.0001), hospital admission (OR incidence of dialysis-dependent patients un- 1.63, p < 0.0001), and infection within one Background: While abundant literature has dergoing SA. year (OR 1.90, p = 0.009) (Table 1). Com- cited dialysis-dependence as an indepen- Methods: Dialysis-dependent patients pared to matched SA patients on HD, PD dent risk factor for increased complications undergoing THA, TKA, and SA were iden- patients had lower rates of in-hospital death following total hip (THA) and total knee tified in a national insurance database and (OR 0.40; p = 0.008) and hospital readmis- arthroplasty (TKA), no studies have distin- compared to a control cohort without dial- sion (OR 0.43, p = 0.047), as well as a lower guished if the modality of treatment has an ysis dependence, matched in a 3:1 ratio by incidence of infection (OR 0.30, p = 0.018) effect on these complications. Furthermore, age, sex, year of procedure, obesity, tobacco and revision surgery (OR 0.23, p = 0.037). no current studies have demonstrated if di- use, alcohol abuse, and diabetes mellitus. A Compared to controls, SA patients on PD alysis carries similar risks for similar com- subgroup analysis was performed compar- had similar rates of in-hospital death (p = plications following shoulder arthroplas- ing patients using PD with a group of pa- 0.342), readmission (p = 0.888), infection ty (SA). Therefore, the goal of the present tients using HD that were matched in a 1:1 (p = 0.789), and revision surgery (p = 0.701) study was fourfold: 1) to compare peripros- ratio using the same demographic variables. (Table 2). When comparing TKA patients thetic joint infection rates after THA, TKA, Complications were assessed for all cohorts on PD to matched HD controls, PD patients

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experienced significantly lower periprosthetic rates (OR 0.30, p = 0.006). When comparing is highly influenced by the type of dialysis. infection rates (OR 0.67, p = 0.026) and sim- THA patients on PD to matched non-dialy- Whereas patients on HD have a significant- ilar rates of other measured complications. sis controls, there were no differences in rates ly higher risk of infection, patients on PD do When comparing TKA patients on PD to of periprosthetic joint infection (p = 0.382), not appear to have this same risk when com- matched non-dialysis controls, there were readmission within 30 days (p = 0.276), and pared to non-dialysis-dependent patients. To no differences in periprosthetic infection (p revision THA (p = 0.593) (Table 4). our knowledge, this is the only study to date = 0.395) or revision TKA (0.478) (Table 3). Conclusions: Although there is a sig- to distinguish patients by the type of dialy- Similarly, when comparing THA patients on nificantly increased risk of postoperative sis and suggests the type of dialysis should PD to matched HD controls, there was also complications in dialysis-dependent patients be used to assess risk when considering hip, significantly lower periprosthetic infection who undergo SA, THA, and TKA, this risk knee, and shoulder arthroplasty. ■

Table 1. Comparison of Adverse Events and Complications after Shoulder Arthroplasty Complication Dialysis Matched Controls Comparison (Dialysis v Control) N % N % OR 95% CI P In-Hospital Death (1 yr) 78 6.37% 31 0.84% 7.60 [4.69-12.31] < 0.0001 ER Visit (30 d) 166 13.55% 98 2.67% 4.16 [3.11-5.56] < 0.0001 Admission to Hosp (30 d) 121 9.88% 205 5.58% 1.63 [1.25-2.13] < 0.0001 Infection (1 yr) 37 3.02% 46 1.25% 1.90 [1.40-2.58] 0.009 Revision 52 4.24% 75 2.04% 1.48 [0.97-2.26] 0.067

Table 2. Comparison of Adverse Events and Complications after Shoulder Arthroplasty Complication Peritoneal Dial. Hemodialysis Controls Comparison (PD v HD) Comparison (PD v Control) N % N % N % OR 95% CI P OR 95% CI P In-Hospital Death (1 yr) 7 5.38% 13 10.00% 5 1.28% 0.40 [0.22-0.74] 0.008 4.87 [1.24-19.16] 0.342 ER Visit (30 d) 23 17.69% 23 17.69% 10 2.56% 0.94 [0.49-1.82] 0.855 6.88 [2.91-16.26] < 0.0001 Admission to Hosp (30 d) 10 7.69% 20 15.38% 23 5.90% 0.43 [0.19-0.99] 0.047 1.06 [0.46-2.46] 0.888 Infection (1 yr) 2 1.54% 6 4.62% 7 1.79% 0.30 [0.11-0.79] 0.018 0.79 [0.14-4.47] 0.789 Revision (1 yr) 3 2.31% 8 6.15% 6 1.54% 0.23 [0.06-0.81] 0.037 1.36 [0.28-6.63] 0.701

Table 3. Comparison of Adverse Events and Complications after TKA Complication Peritoneal Dial. Hemodialysis Controls Comparison (PD v HD) Comparison (PD v Control) N % N % N % OR 95% CI P OR 95% CI P In-Hospital Death (1 yr) 30 5.65% 28 5.27% 12 0.75% 1.13 [0.65-1.96] 0.487 6.16 [3.04-12.46] < 0.0001 ER Visit (30 d) 72 13.56% 75 14.12% 113 7.09% 0.98 [0.69-1.39] 0.910 3.15 [2.18-4.55] < 0.0001 Admission to Hosp (30 d) 45 8.47% 43 8.10% 70 4.39% 1.03 [0.66-1.60] 0.896 2.01 [1.38-2.93] < 0.0001 Infection (1 yr) 18 3.39% 32 6.03% 42 2.64% 0.67 [0.49-0.93] 0.026 1.28 [0.73-2.24] 0.395 Stiffness (1 yr) 4 0.75% 7 1.32% 49 3.08% 0.57 [0.16-1.98] 0.379 0.32 [0.11-0.91] 0.012 Revision TKA (1 yr) 16 3.01% 21 3.95% 41 2.57% 0.79 [0.41-1.52] 0.483 1.24 [0.68-2.28] 0.478

Table 4. Comparison of Adverse Events and Complications after THA Complication Peritoneal Dial. Hemodialysis Matched Controls Comparison (PD v HD) Comparison (PD v Control) N % N % N % OR 95% CI P OR 95% CI P In-Hospital Death (1 yr) 37 6.47% 37 6.47% 15 0.87% 1.11 [0.68-1.80] 0.675 7.22 [3.58-14.55] < 0.0001 ER Visit (30 d) 96 16.78% 110 19.23% 85 4.95% 0.88 [0.65-1.20] 0.436 3.23 [2.32-4.50] < 0.0001 Admission to Hosp (30 d) 38 6.64% 38 6.64% 86 5.01% 1.04 [0.65-1.68] 0.857 1.26 [0.83-1.92] 0.276 Infection (1 yr) 9 1.57% 24 4.20% 38 2.21% 0.30 [0.12-0.71] 0.006 0.68 [0.36-1.29] 0.382 Dislocation (1 yr) 23 4.02% 26 4.55% 32 1.86% 0.99 [0.55-1.77] 0.966 2.00 [1.11-3.59] 0.020 Revision THA (1 yr) 18 3.15% 22 3.85% 42 2.45% 0.77 [0.41-1.47] 0.433 1.17 [0.65-2.10] 0.593

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Rate of Conversion to Surgery gone fluoroscopically guided facet cyst rupture at the authors’ institution were included and Risk Factors Analysis in the study. The procedures were performed in a fluoroscopy suite with a fixed C-arm Following Fluoroscopically unit, with the patient in a prone position. Af- ter sterile preparation and local analgesia, the Guided Facet Cyst Rupture inferior recess of the facet joint was targeted using fluoroscopy in the anteroposterior and ipsilateral oblique positions using a 22-gauge 1 Michael M. Hadeed, MD , of these cysts can vary widely, and studies needle. A small amount, approximately 1 cc, 1 2 Jose George, BS , Andrew Hill, MD , ™ 1 have shown results ranging from 0.5% to of Omnipaque iodinated contrast was in- Wendy Novicoff, PhD , 3,4 Nicolas C. Nacey, MD2, Adam L. Shimer, MD1 7.3%. These facet cysts have a wide range jected to demonstrate placement within the of clinical and radiographic findings. Stud- facet joint. A mixture of 0.5 cc (20mg) of De- 1University of Virginia, ies have examined the level, size, rim char- po-Medrol™ or 0.5 cc (20 mg) of Kenalog™ Department of Orthopaedic Surgery, acteristics, and contents of cysts in order to along with 0.5 cc of preservative free 0.25% Charlottesville, VA better understand possible pathogenesis.5,6 Bupivacaine™ was injected into the joint, ei- 2University of Virginia, It is thought that these variables may relate ther before or after cyst rupture depending Department of Radiology, Charlottesville, VA to the differences in efficacy of treatment. on operator preference. Additional fluid was There are several treatment options for injected into the facet joint to pressure the symptomatic facet cysts. Non-operative cyst and induce rupture. Fluoroscopy imag- Introduction: Juxta-articular cysts, which management can include intraarticular es were obtained to demonstrate location of are composed of ganglion and synovial steroid injections or fluoroscopically guid- contrast after attempted cyst rupture. cysts, arise from periarticular tissue and can ed percutaneous rupture, whereas operative Several variables were chosen based on occur in any joint. Cysts that are lined with management includes direct decompres- either prior literature or theoretical asso- synovium and communicate with the joint sion and cyst excision with possible fusion.7 ciation with failure of percutaneous man- are characterized as true synovial cysts while While studies currently report the efficacy agement (Table 1). The clinical variables cysts without a synovial lining that do not of percutaneous treatment of facet cysts to examined included sex, age, number of co- communicate with the facet joint are known be between 20 and 39%, further research morbidities, laterality (unilateral or bilater- as ganglion cysts.1 While ganglion and facet to identify clinical and radiographic fac- al), type of symptoms (pain, motor deficit, cysts can look alike externally, there are his- tors associated with failure of percutaneous sensory deficit), and whether the pain was tologic and pathologic differences. Synovial treatment is needed.8-12 predominantly leg, back, or combined. The facet cysts are thought to originate from The aim of this retrospective review is radiographic variables examined included instability of the facet which leads to herni- to evaluate the rate of conversion to sur- cyst signal, rim signal, presence of spondy- ation of the synovial membrane either due gery following percutaneous cyst rupture lolisthesis, presence of canal stenosis, pres- to tissue laxity, as seen in younger women, and to examine clinical, radiographic, and ence of facet joint fluid, bilateral fluid, facet or degenerative joint disease, as seen in old- procedural variables that might be asso- bone edema, bone erosion, cyst opacifica- er patients.2 Additional etiologies of facet ciated with that conversion. Ultimately, if tion, cyst size, and cyst shape. The proce- cysts could be due to myxoid degeneration specific clinical and radiographic risk fac- dural variables examined included the pain or increased production of hyaluronic acid. tors can be elucidated, it may be possible to score change from immediately pre and Regardless of the etiology, herniation of the more effectively and efficiently counsel and post procedure, cyst contrast filling, and synovial membrane can lead to spinal cord treat patients. successful cyst rupture. Finally, post proce- or nerve root compression. Materials and Methods: A retrospec- dure MRIs that were obtained within the Facet cysts are a common finding on tive review was completed for all patients first year after attempted cyst rupture were magnetic resonance imaging (MRI) when who underwent fluoroscopically guided facet evaluated to determine the decrease in cyst evaluating a patient with back pain and ra- cyst rupture from 2010-2016 at an academic size and the relationship with decrease in dicular symptoms. The reported prevalence medical center. All patients who had under- cyst size and conversion to surgery.

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Table 1. Data Variables Collected Table 2. Clinical Variable Results

Surgery No Surgery p-Value Sex Sex Age Males 17.6% 82.4% 0.310 Number of comorbidities Females 35.7% 64.3% Clinical BMI Age 62.6 ± 10.7 57.6 ± 12.4 0.187 Laterality of symptoms Number of Comorbidities 7.23 ± 3.54 4.50 ± 3.70 0.030 BMI (Body Mass Index) 27.54 ± 3.43 28.34 ± 5.16 0.545 Symptoms Laterality of Symptoms Pain location Bilateral 28.5% 71.5% 1 Unilateral 28.9% 71.1% Cyst signal Symptom Type Rim signal Motor 25.0% 75.0% 0.472 Spondylolisthesis Sensory 38.4% 61.6% Pain Location Canal stenosis Back & Leg 28.9% 71.1% Facet joint fluid 1 Leg Only 28.5% 71.5% Radiographic Bilateral fluid Facet bone edema Bone erosion excluded because they had no clinical notes had an average of 7.23 comorbidities and Cyst opacification or because no MRI was available for re- patients that did not have surgery had an Cyst size view. Clinical, radiographic, and procedur- average of 4.50 comorbidities (p = 0.030). Cyst shape al variables for 45 patients were recorded Failure of cyst rupture did trend towards and examined (Table 1). The average post significance for later conversion to surgery procedural follow-up for this cohort of pa- (p = 0.08). No other clinical, radiographic, Decrease in pain score tients was 1.4 years. or procedural variables were associated with ≥50% improvement Twenty-nine percent (95%CI = 15.7%, conversion to surgery in this cohort. Procedural pain score same or worse 42.2%) (13/45) of patients eventually un- Thirteen patients had a post procedure cyst contrast filling derwent a surgical procedure to address MRI within 1 year of the attempted fluo- successful rupture their facet cyst. The average interval to sur- roscopic cyst rupture. These were complet- gery was 95 days (median = 50 ± 105) after ed based on various indications from their attempted cyst rupture. Of those that had treating physicians. Nine out of the 13 pa- a surgical intervention, 38% (5/13) had a tients did have a greater than 50% decrease The primary outcome was rate of con- decompression and fusion while 62% had in size of their cyst (Table 5). This was not version to surgery. For those that converted decompression alone. a direct correlation with successful cyst to surgery, the rate of decompression and The variables in Table 1 were analyzed rupture. Of those nine, only one eventually fusion compared to decompression alone to evaluate for an association with future converted to surgery. was recorded. Secondary outcomes included conversion to surgery after percutaneous Discussion: Despite these reported clinical, radiographic, procedural, and follow management of facet cysts. The results for outcomes in the literature, it is unknown up MRI variable analysis to determine if the clinical variables are listed in Table 2, which patients that undergo fluoroscopic there were risk factors associated with con- the results for the radiographic variables facet cyst rupture end up converting to sur- version to surgery. Categorical variables were are listed in Table 3, and the results for the gery. If clinical, radiographic, or procedural analyzed using Fisher’s exact test as an alter- procedural variables are listed in Table 4. variables could be determined as predic- native to the Chi-square test and continuous Of the variables examined in this cohort, tors of future surgical intervention, then it variables were analyzed using a T-test. the number of comorbidities did have a sig- would be possible to better counsel patients. Results: Forty-nine patients met the nificant association with later conversion to Furthermore, if it was known who would inclusion criteria for the study. Four were surgery. Patients that underwent surgery convert to surgery, it may be possible to skip

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Table 3. Radiographic Variable Results unnecessary procedures and more definitively treat patients from initial presenta- Surgery No Surgery p-Value tion. Although some studies have evaluated Cyst Signal Low T1/High T2 certain variables in isolation, a thorough 30% 70% High T1/Low T2 100% 0% evaluation has not previously been reported. 0.320 Low T1/Low T2 100% 0% The meta-analysis done by Shuang et High T1/High T2 0% 100% al.9 showed 38.6% of the 544 patients that Rim Signal had satisfactory results with percutane- Low T1 22% 78% ous procedures had to eventually undergo 0.094 Intermediate/High T1 55.5% 45.5% surgery to achieve long-lasting relief of Spondylolisthesis symptoms. More recent studies done by Present 29.4% 70.6% Eshraghi et al. in 2016 and Lutz et al. in 1 Absent 28.5% 71.5% 2017 reported surgery rates of 20% (6/30) Canal Stenosis 11,12 and 31% (11/35) respectively. The cur- Present 30.4% 69.6% 1 rent study results of 29% fit well within the Absent 27.2% 72.8% rates of surgery that have already been re- Facet Joint Fluid ported. With so many studies demonstrat- Present 16.6% 83.4% 0.459 ing the success of percutaneous manage- Absent 33.3% 66.7% ment for lumbar facet cysts, it appears to Laterality of Fluid be viable as an initial method of treatment. Unilateral 23.1% 76.9% 0.340 Percutaneous management carries less risk Bilateral 36.8% 63.2% than surgical management and would be Facet Bone Edema especially useful in higher risk patients that Present 42.8% 57.2% 0.394 might not be ideal surgical candidates. Absent 26.3% 73.7% Out of the clinical factors from Table 1, Bone Erosion only the number of comorbidities was shown Present 0% 100% 1 to have a significant association with the fu- Absent 30.2% 69.8% ture need for surgical conversion. None of Cyst Opacification Opaque 30% 70% the other clinical variables had any signifi- 1 cant association with need for surgical con- Non-Opaque 20% 80% version after percutaneous management of Cyst Size 13.69mm ± 2.98 11.9mm ± 5.43 0.270 facet cysts. Our results for the association Cyst Shape between patient sex and age match up with Round 20% 80% the study conducted by Allen et al. who also Oval 33.3% 66.7% 0.763 Irregular 25% 75% found no significance between a successful outcome and patient age or sex.13 It would be difficult to use the comorbidity finding to change treatment decisions. Patients with proach for treatment of facet cysts in higher to have a decreased need for surgery. Cam- an increased number of comorbidities are, risk patients. This association could, however, bron et al. looked at the T2 signal intensity generally, considered more high-risk sur- be useful for patient education and counsel- and found that a T2 hyperintense cyst was gical candidates. While surgery is current- ing for the future need of a surgery in order less likely to have need for future surgery.10 ly the most effective management method to treat facet cysts. While the reason for the difference between as shown in the prospective study done by None of the radiographic variables test- T2 hyperintense versus intermediate to low Schulz et al.14 it makes sense that non-sur- ed correlated with conversion to surgery. intensity cysts is unclear, Cambron et al. sug- gical and lower risk approaches should be Prior to the statistical analysis, we were ex- gested that hyperintense cysts could contain attempted prior to a higher risk surgical ap- pecting cysts with a T2 hyperintense signal a larger amount of fluid while also having

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Table 4. Procedural Variable Results REFERENCES Surgery No Surgery p-Value 1. Nojiri H, Sakuma Y, Uta S. Degenerative intraspinal cyst Mean Decrease in Pain Score 2.5 ± 2.8 1.4 ± 2.6 0.243 of the cervical spine. Orthop Rev (Pavia). 2009;1(2):e17. doi:10.4081/or.2009.e17. doi: or.2009.e17 [pii]. ≥50% Improvement in Pain Scores 38.4% 34.3% 1.0 2. Jackson DE, Jr, Atlas SW, Mani JR, Norman D. Intraspinal Same or Worse Pain Score 38.4% 37.5% 1.0 synovial cysts: MR imaging. Radiology. 1989;170(2):527-530. Cyst Contrast Filling 92.3% 87.5% 1.0 doi: 10.1148/radiology.170.2.2911681 [doi].

Successful Cyst Rupture 53.8% 81.2% 0.08 3. Doyle AJ, Merrilees M. Synovial cysts of the lumbar facet joints in a symptomatic population: Prevalence on magnetic resonance imaging. Spine (Phila Pa 1976). 2004;29(8):874- Table 5. Follow-Up MRI Results 878. doi: 00007632-200404150-00010 [pii]. Successful No Rupture p-Value 4. Eyster EF, Scott WR. Lumbar synovial cysts: Report of Rupture eleven cases. Neurosurgery. 1989;24(1):112-115. ≥50% Decrease in Cyst Size 75% 60% 1.0 5. Apostolaki E, Davies AM, Evans N, Cassar-Pullicino VN. Surgery No Surgery MR imaging of lumbar facet joint synovial cysts. Eur Radiol. Of those with ≥50% Decrease in Cyst Size 87% 13% 0.22 2000;10(4):615-623. Accessed 1/14/2018 11:34:16 AM. doi: 10.1007/s003300050973 [doi].

6. Kusakabe T, Kasama F, Aizawa T, Sato T, Kokubun S. Facet less calcifications which could account for The main limitation of this study is cyst in the lumbar spine: Radiological and histopatholog- ical findings and possible pathogenesis. J Neurosurg Spine. greater rates of success after percutane- sample size. Because of the small popula- 2006;5(5):398-403. doi: 10.3171/spi.2006.5.5.398 [doi]. ous management. When compared to our tion studied, we were unable to complete 7. Amoretti N, Huwart L, Foti P, et al. Symptomatic lumbar study, while the patient demographics (62% a robust analysis of the various clinical and facet joint cysts treated by CT-guided intracystic and in- female) and location of lumbar cysts (60% radiographic outcomes that were obtained. tra-articular steroid injections. Eur Radiol. 2012;22(12):2836- 2840. doi: 10.1007/s00330-012-2533-z [doi]. L4-L5) are similar in both studies, Cam- If a thorough clinical and radiologic evalu- 8. Campbell RJ, Mobbs RJ, Phan K. Percutaneous resolu- bron et al. has a much larger sample size at ation of a larger population is completed, it tion of lumbar facet joint cysts as an alternative treatment to 110 patients. The difference in sample size may reveal more insight into which patients surgery: A meta-analysis. J Spine Surg. 2016;2(1):85-86. doi: and increased power could account for the eventually convert to surgery. Future areas jss-02-01-085 [pii]. results seen in Cambron’s study. of research could include a multicenter 9. Shuang F, Hou SX, Zhu JL, Ren DF, Cao Z, Tang JG. Percutaneous resolution of lumbar facet joint cysts as an al- Of the procedural variables tested, only study which would be able to recruit more ternative treatment to surgery: A meta-analysis. PLoS One. failure of cyst rupture trended toward sig- patients. Additionally, this was a retrospec- 2014;9(11):e111695. doi:10.1371/journal.pone.0111695. doi: PONE-D-14-21679 [pii]. nificance for later conversion to surgery. This tive review, which carries the limitation of makes intuitive sense; however, the conver- the data available in the medical record. 10. Cambron SC, McIntyre JJ, Guerin SJ, Li Z, Pastel DA. Lumbar facet joint synovial cysts: Does T2 signal intensi- sion to surgery rate for those who failed was Facet cysts have been recognized as a ty predict outcomes after percutaneous rupture? AJNR Am still only 50%. Ultimately, further data is cause of spinal stenosis, but their optimal J Neuroradiol. 2013;34(8):1661-1664. doi: 10.3174/ajnr. A3441 [doi]. needed to help discern how important this treatment is unknown. Typically, non-opera- variable is to further conversion to surgery. tive interventions are attempted prior to sur- 11. Eshraghi Y, Desai V, Cajigal Cajigal C, Tabbaa K. Outcome of percutaneous lumbar synovial cyst rupture Finally, the follow-up MRI evaluation gery, which often includes fluoroscopically in patients with lumbar radiculopathy. Pain Physician. did have some interesting findings. A de- guided facet cyst rupture. However, there is 2016;19(7):E1019-25. crease in cyst size was seen in 70% of the a significant percentage of patients in which 12. Lutz GE, Nicoletti MR, Cyril GE, et al. Percutaneous rupture of zygapophyseal joint synovial cysts: A prospective patients who had a follow-up MRI. Of this treatment fails to provide durable relief, assessment of nonsurgical management. PM R. 2017. doi: these patients, only 66% were noted to have and eventually, patients undergo a surgical S1934-1482(17)31202-9 [pii]. had a successful cyst rupture, which shows intervention. This study shows that there is a 13. Allen TL, Tatli Y, Lutz GE. Fluoroscopic percutane- that there is potential for a decrease in cyst large percentage of patients in whom percu- ous lumbar zygapophyseal joint cyst rupture: A clinical outcome study. Spine J. 2009;9(5):387-395. doi:10.1016/j. size despite the failure of cyst rupture. Of taneous management is successful, which is spinee.2008.08.008 [doi]. those that had a decrease in cyst size of at consistent with previously published reports. 14. Schulz C, Danz B, Waldeck S, Kunz U, Mauer UM. Per- least 50%, only one patient converted to At this time, we would recommend continu- cutaneous CT-guided destruction versus microsurgical resec- surgery. While this was not statistically ing to attempt fluoroscopic guided facet cyst tion of lumbar juxtafacet cysts. Orthopade. 2011;40(7):600- 606. doi:2 0710.1007/s00132-011-1744-3 [doi]. significant, it was likely limited due to the rupture in all patients with appropriate post small sample size of follow-up MRIs. procedural clinical monitoring. ■

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2018 Best Bedside That philosophy works. Dr. Ch- Manner Award habra’s orthopaedic program at the Congratulations to our UVA Ortho University of Virginia was named Faculty who have been recognized the best program in the state of with the 2018 Best Bedside Manner Virginia and the 33rd best in the Award in Our Health: Charlottesville country by US News & World Report. and Shenandoah Valley Magazine. “You can only accomplish that if you have a team that works well togeth- • SPORTS MEDICINE er,” Chhabra said. First Place – Eric Carson Dr. Chhabra came to Charlot- • SPORTS MEDICINE tesville in 1991 to attend medical Honorable Mention – school. He co-founded the Universi- Steve Brockmeier ty of Virginia Hand Center, holds the • ORTHOPAEDIC SURGERY title of Lillian T. Pratt Distinguished First Place – Winston Gwathmey Professor and Chair of Orthopaedic • ORTHOPAEDIC SURGERY Surgery, is a Professor of Plastic Honorable Mention – David Weiss Surgery, and has now been recog- • HAND SURGERY nized as Best Boss of Charlottes- Photo by Jackson Smith Jackson by Photo Second Place – Bobby Chhabra ville, among many other accom- Dr. Bobby Chhabra • HAND SURGERY plishments. “But,” he said, “I don’t do this Third Place – Nicole Deal Mountain Orthopaedic Outpatient that possible. During my time here, work for the accolades. I do it be- Care Facility, noting at the build- I’ve had the opportunity to partici- cause I’m passionate about working’s groundbreaking ceremony that pate in almost every committee at ing with a dedicated team of ex- “the facility will be the best for mus- the School of Medicine and Medical ceptional people that consistently Doctor Hoo – culoskeletal and orthopaedic care Center. I’ve learned a lot about this strives to provide the very best care Best Boss – Dr. Chhabra in the country.” institution, and I have seen it from we can for all our patients.” by Richard Albas so many perspectives. I’ve had oth- Charlottesville Daily Progress Q: From caring for patients from er opportunities offered to me, but our community and beyond to what’s kept me here at UVA are the An individual can achieve success, your extensive involvement with people and the collegial relation- Catching up with and a team can achieve miracles. the Health System and School of ships, and the ability to do what I Dr. Bobby Chhabra, Dr. Bobby Chhabra, Chair of Or- Medicine, your dedication to the am passionate about every day. Chair of the Department thopaedic Surgery at the University University of Virginia is evident. Additionally, UVA blessed me of Orthopaedic Surgery of Virginia, knows what it takes to Why UVA? What makes UVA so with great mentors during my med- at UVA be successful: listen to your team, special? ical school training, orthopaedic Pulse, UVA Health System be open to ideas, and above all, residency, and throughout my time share the same vision. I came to UVA in 1991, and I am as a junior faculty member. These Dr. Bobby Chhabra is a ‘Hoo Dr. Chhabra was voted best proud to be a triple ‘Hoo. The envi- meaningful relationships have re- through-and-through. In addition boss in Charlottesville in this year’s ronment here, from both an educa- ally inspired me in my clinical and to being a member of the Universi- Readers’ Choice, and he’s honored tion and patient care standpoint, is academic practice. These mentors ty of Virginia School of Medicine’s with that distinction. “It’s fantastic truly exceptional. I’m from Virginia have challenged me to be a better Class of 1995, Chhabra serves as to get this kind of recognition,” he and have raised my family here. My educator and leader, and without the Lillian T. Pratt Distinguished said. “That is very special to me.” wife, an endocrinologist in the com- their support, guidance, and en- Professor and Chair of Orthopaedic He is also quick to point out that be- munity, did her residency and fel- couragement, I do not think I would Surgery, and the David A. Harrison ing a successful leader is the result lowship at UVA, and she is a Darden be where I am today. Distinguished Educator. He is also of having a great team. School of Business graduate. UVA is a Professor of Plastic Surgery at “In the Department of Ortho- just a special place, and Charlottes- Q: What kind of growth have you UVA, the Hand and Upper Extremi- paedic Surgery alone, I lead a team ville a special city. seen in the Orthopaedics and ty Consultant for UVA Athletics, and of over 300 people. That includes I’ve been in department leader- Musculoskeletal Programs at the President of the UVA Physicians the surgeons, nurses, physician’s ship for 11 years now, and I can at- UVA during your time here? What Group. You can hear him every assistants, and administrative staff. test to how a collegial environment kind of growth do you see in the Thursday on ESPN Radio/Newsra- I value them equally, and I listen to drives interactions and collabora- next decade? dio WINA’s Best Seat in the House all of them,” he said. “I got to know tions that advance our patient care Injury Report, when he discusses them personally, and I learn what and academic missions. Simply put, The musculoskeletal specialty is everything from UVA player updates they are passionate about. By re- we’re a family and we help each oth- one of the fastest growing special- to the latest in the NFL and NBA. specting each other and everyone’s er. It’s a great environment for fac- ties in the country and the world. Most recently, Chhabra has been contribution, we can provide the ulty, staff, and for our trainees, and Similarly, joint replacement is al- the champion for the future Ivy best care possible for our patients.” UVA and Charlottesville help make ready a common procedure, but it

66 | UVA ORTHOPAEDIC JOURNAL | 2019 | DEPARTMENT SPOTLIGHT

will be one of the most common pro- we take ideas that require basic the room with the patient. Therapy Q: A fun fact, or one thing most cedures in the next decade or two. science investigation, and we work can be done in the room and the people don’t know about you? The growth of the musculo- to translate them into clinical use, patient will receive the highest level skeletal specialty at UVA has sur- evaluate their outcomes, and make of nursing care. When they’re ready I’m very passionate about sports. passed even that of the national sure these advances results in bet- to go home, they’ll have appropriate My wife, kids, and I spend a lot of trend. In just the past six to sev- ter rehabilitation and the return to instructions for pain management time watching and going to sporting en years, we’ve doubled the size everyday activities. and their rehabilitation. It’ll be a events, and I’m a diehard UVA and of the Orthopaedic Department. And patients are noticing our very collaborative and focused Washington, D.C., sports fan. But When I joined the faculty in 2002, efforts and advances. They’re trav- service, and will include experts in what really drives me, and what is I was the ninth faculty member in eling from farther away specifically every aspect of joint replacement. incredibly rewarding for me, is ed- the department. Now, we have 30 for the care they will receive at UVA. That’s the key thing about 23-hour ucating my patients and the com- orthopaedic surgeons. We’re the busiest spine trauma joint replacement—you need a spe- munity on orthopaedics, and more This tremendous growth has center in the state, and our sports cialized program and a specialized specifically on injuries related to been mirrored by an increasing medicine program has a very large team. From the minute you come in athletic or recreational activities. need for orthopaedic care globally. reach. Also, many of us have unique to when you leave, it’s a very unique This desire to share this knowl- People are staying active later in specialties, or we are experts in program for our area. The entire edge with others led me to the radio life, and they are just generally par- certain procedures. Patients from spectrum of care will be provided show I host every Thursday along- ticipating in recreational activities around the country come to UVA within a very specialized center. side Jay James, the Best Seat in the and athletics much more. Orthopaedics for consultation and House Injury Report. We talk about The growth has been remark- care because many of us are de- Q: How has philanthropy impact- what sports injuries mean and able in both patient volume and signing new techniques and proce- ed your work and your patients when you can expect to see ath- technology. Procedures such as hip dures and improving outcomes. during your career? letes to return to play. We actually and knee replacements used to re- won an Associated Press Award last quire long inpatient recovery stays. Q: One of the many incredible The philanthropic support of grate- year for the show, and it’s our third Now, because of advances in surgi- care opportunities the Ivy Moun- ful patients and loyal alumni has year broadcasting it together. cal and anesthesia techniques, as tain Orthopaedic Outpatient Care been tremendous during my time So here’s what most people well as implant technology, many Facility will provide is 23-hour at UVA. Alumni have helped create don’t know—an ultimate goal of patients undergoing those proce- joint replacement. Can you walk endowed chairs, which allow me to mine is to one day be on ESPN TV dures go home the very same day us through how that will work? support the work of my researchers or Radio. I’d love to be the official without a compromise in their over- and clinicians. I’ve also had several injury consultant for ESPN. I joke all outcome. So there has been a A 23-hour procedure is considered current faculty members and alum- around about it, but now with the dramatic change in post-operative outpatient because there is no ad- ni contribute to research endow- success of my weekly show, it would care and rehabilitation, even from mission to the hospital. Our new fa- ments for fellows and residents. be a dream come true for me to go the time when I was a resident. cility will include a joint replacement The training and education they re- national with ESPN someday. center, where a patient can be ceived here inspires them to set the Q: This growth you’ve seen and evaluated and receive non-invasive stage for the next generations with experienced firsthand—is ortho- treatment before surgery becomes their support. These endowments paedic research spurring it? And an option. The center will be a allow our residents and fellows to National ‘100 Great if so, how? one-stop shop—therapy if needed, travel to meetings, share their re- Orthopaedics Programs’ imaging and x-rays, and conserva- search projects, and receive a more List Features UVA Absolutely. I can certainly speak for tive treatment options like bracing. comprehensive and forward-think- by Eric Swensen, UVA Health System the UVA Musculoskeletal Research This is all before we even have the ing medical foundation. Division—we’re figuring out how to conversation about surgery, as out- Support for research is incred- For the fifth consecutive year, Beck- use growth factors and other bio- patient joint replacement surgery ibly crucial because, as in many er’s Hospital Review has named logics to improve healing across requires a clear understanding of fields, if you don’t focus on devel- University of Virginia Orthopaedics several musculoskeletal tissues, the process and expectations by oping new treatments, your care be- at UVA Medical Center to its list of such as bone, ligament, tendons, the patient. comes stagnant, which means that 100 hospitals and health systems and nerves. Our research program If joint replacement is the you’re not doing the best for the pa- with great orthopaedics programs. is completely focused on clinical course of treatment, the next step tients you care for. Especially in an “The hospitals featured on translation. Our priority is to trans- is the operating room. The Joint Re- academic environment like UVA’s, Becker’s Healthcare’s 100 hospi- late all research to clinical applica- placement Center operating rooms that’s one of our missions—to pro- tals and health systems with great tions. We have a very robust clinical will be specifically built for joint re- vide the best patient care thanks to orthopaedic programs list for 2018 trials program. We utilize safe new placement, and they will be home new discoveries that happen across have earned recognition for quality techniques and new technologies— to trained staff who specifically do Grounds through collaboration. of care and patient satisfaction for all while evaluating to make sure joint replacement every day. The best doctors are lifelong orthopaedic and spine surgery,” that patient outcomes are the best Following surgery, the facility learners, and the best patient care wrote the editors of the national that they can be. Our efforts include will have a specialized post-oper- comes from constant learning. Re- healthcare publication in introducing the whole spectrum of research— ative unit where family can stay in search plays a huge role in that. this year’s list. “Many of the ortho-

| uvaortho.com | 67 DEPARTMENT SPOTLIGHT

paedic programs highlighted have culoskeletal Center, which will con- learned from the growing network MB: Our existing facilities have rich histories of innovation and have solidate multiple outpatient ortho- of surgeons who trained at UVA? served us well, but we are grow- won grants to research musculoskel- paedic clinics to a single location. ing at a rapid pace and we have etal treatments. The centers include The 195,000 square-foot facility Michael Boblitz: I have been for- exhausted our space capacity. We robust nonoperative services and will include six outpatient operating tunate to work with many fine or- currently have orthopaedic clinics provide care to professional and rooms, advanced imaging, physical thopaedic surgeons during their in different locations including a elite athletes in their communities.” and occupational therapy, and 95 training who have become leaders separate Hand Center, Spine Cen- Becker’s highlighted the role of exam rooms. across the country, including our ter, and Pediatric Orthopaedics the UVA Sports Medicine Team in The center will also include current Chair. For instance, the Clinic. Our different locations in caring for UVA student-athletes, as same-day joint replacements and Head of Hospital for Special Sur- town make it difficult to provide ef- well as the more than 1,000 joint open in February 2022. Although gery in New York City is a former ficient care. This is an opportunity replacement surgeries—many done the project has just begun the build- UVA medical student and several for us to bring everyone together using minimally invasive techniques— ing phase, COO and Lecturer at UVA former residents are Chairs of aca- in one location and provide care and 1,500 spine surgeries performed Orthopaedic Surgery Michael H. demic departments or are success- more efficiently and at a lower cost. each year at UVA. The publication also Boblitz, the man helping the Chair ful leaders in private practice or We will have six operating rooms highlighted health insurer Blue Cross of Orthopaedics to drive this new their specialty societies. It is great and will be able to do outpatient Blue Shield designating UVA as a Blue facility, has spent more than four to see these surgeons grow, but for total joint replacements and many Distinction Center for its expertise in decades shaping and growing the the future we would love to have sports surgeries and allow patients knee and hip replacements. Orthopaedics Program at UVA. more diversity within our depart- to stay 23 hours for recovery in our “This honor from Becker’s Hos- He was previously instrumen- ment. That is a challenge for us and new facility. pital Review highlights both the tal in opening the McCue Center across the country in Orthopaedics. Our goal is to provide outstand- high quality and the wide range of at UVA in 1991, a sports medi- We try to recruit women and un- ing care with a seamless process. orthopaedic care we provide here cine and football athletic building derrepresented minorities in every at UVA,” said Bobby Chhabra, MD, named for Frank McCue, MD, a pio- orthopaedic residency and fellow- Q: You have experience as an oc- chair of the UVA Department of neer in sports medicine. One of Dr. ship class, as they add tremendous cupational therapist as well, fo- Orthopaedic Surgery. “Providing ex- McCue’s fellows, James Andrews, value to our program. But it is a cused on hand surgery and upper cellent care to our patients is a true MD, has become renowned for his challenge to recruit to a small city. extremity injuries. Could you talk team effort, and I want to thank ev- treatment of professional athletes We are not as large as Atlanta, New about your early career and how eryone at UVA Health System that and his campaign against youth York City, or D.C., but we do have a it has shaped your current philos- works together with our department sports injuries. wonderful environment and com- ophy of care? to serve our patients.” Mr. Boblitz also played a big role munity in Charlottesville. We are a “I am so pleased to see our in negotiating a multiyear contract cosmopolitan city and we have peo- MB: I graduated from Virginia Com- orthopaedics team recognized for for UVA to provide sports medicine ple from all over the world who go to monwealth University as an occupa- their outstanding care and service services to Harrisonburg, VA-based school here and teach here. tional therapist and two weeks later to our patients,” said Pamela M. James Madison University, which it I went into basic training in San An- Sutton-Wallace, Chief Executive Of- has done since 2003. UVA Ortho- Q: What makes the department tonio at Brooke Army Medical Cen- ficer of UVA Medical Center. “Their paedics provides care for both UVA unique? ter as a second lieutenant. I was ability to find innovative ways to and JMU Athletics, several small attached to the 1st Infantry and care for our patients will only be en- colleges, and 10 high schools. MB: Our department is unique 24th Infantry divisions and spent hanced following the construction In partnership with Bobby Ch- because we have to compete re- time at Fort Riley, Kansas. The 1st of our new musculoskeletal center habra, MD, Chair of the Orthopaedics gionally and nationally. If you don’t Infantry Division was rotating in and on Ivy Road here in Charlottesville.” Department, Mr. Boblitz is excited to compete nationally it’s harder to out of Vietnam and the 24th Infan- grow the department and continue recruit quality residents, fellows, try Division was rotating in and out the UVA Health System’s legacy of at- and faculty. One of the frustrations of Germany because of the Berlin tracting diverse orthopaedic surgeon of being [in] an academic environ- crisis. Our 300-bed hospital often faculty, residents, and fellows who ment, unlike in private practice, is it had 1,000 patients from Vietnam Q&A with Michael Boblitz provide world-class care. takes longer to get projects started, that we were treating, and I worked The philosophy that drove 40+ Here, Mr. Boblitz discusses his planned, approved, and built. The with other clinicians to take care of years of success at University of career and the new UVA Musculo- new Musculoskeletal Center has gunshot wounds, burns, and other Virginia Health System’s skeletal Center and shares his best been a 10-year effort from inception traumatic injuries. Orthopaedic Department & a advice for aspiring leaders. of the vision to beginning construc- Even when I arrived at UVA to new Musculoskeletal Center tion, but it’s something we’ve want- teach and perform research, I kept by Laura Dyrda, Becker’s Spine Q: Since you joined UVA in 1977 ed to do for quite a while so that we up my certifications that allowed Review as a research assistant, you’ve can provide the highest level of in- me to continue to care for hand and been able to work with ortho- novative care for our patients. upper extremity injuries. I’ve been Earlier this fall, Charlottesville-based paedic surgeons as residents able to do a variety of things in my University of Virginia Health System and fellows who are now spread Q: Why did you decide to build a role, which is one of the reasons I began construction on a new Mus- across the country. What have you new facility? stayed here at UVA for so long. We

68 | UVA ORTHOPAEDIC JOURNAL | 2019 | DEPARTMENT SPOTLIGHT

have built an exceptional team here, and we still have a lot of work to do. When Deasey graduated from the UVA men’s basketball team. and we’re unique because we have We want this center to be high-tech high school, his next goal was to Dave Leitao was hired to lead the had no turnover of faculty in over 10 but with a feeling of warmth and attend college and later to go to team’s final season in U-Hall, which years; two surgeons retired, but we comfort. We expect the project to medical school. He had several is currently being demolished to have been able to build a collegial, be done in the fall of 2021 and schools on his short list, but after make way for an athletic precinct transparent, team-oriented envi- opened early 2022. visiting UVA, he never looked back. near the John Paul Jones Arena. ronment. Any faculty member can He started his first year in the fall Before the 2005 season become and look at the performance Q: What has changed since you of 2003. gan, Leitao hosted a one-night try- of themselves and their colleagues. first joined the department? “I came to UVA thinking I was out for walk-on players. This was We make an effort to compensate done with basketball,” he says. “I Deasey’s shot to join the team. our staff and faculty appropriately MB: For the first few years, I was was like, ‘I’m just going to go be a He and 11 other hopefuls came to and reward them for what they do heavily involved in research. One of student and go to medical school.’” U-Hall to try to impress the coach- in all areas of our mission (clinical the first Chairs of the department, Deasey filled his schedule with es. The trial started with a warmup, care, research, and education). I Dr. Warren Stamp, obtained permis- an ambitious course load and bal- free-throw shooting, full-court drills, think that’s one of the reasons we sion to do total joint replacements anced homework with friends and full- and half-court shooting, and are successful. Nobody is perfect, here and we developed a joint re- his ongoing relationship with Lind- running between each. but we have been able to get our placement program. Since then, say. She had a car, so she would “I was exhausted 15 minutes group to work together and accom- we’ve had a very active research drive down from Pennsylvania to in,” Deasey says. “I was in pretty plish a great deal. arm and developed the depart- visit him on the weekends. good shape, but I hadn’t been play- ment with the idea of translational A couple years into his college ing Division I college basketball.” Q: How did you recruit and select research being a key aspect of the career, Deasey befriended a fellow At the end of practice, Deasey the right people to build your de- program. Taking a clinical issue former high-school athlete. The received positive feedback from partment? people are concerned about, bring- two had a common intertest in the the coaches. To keep the momen- ing it to the lab to find a solution and sports where they used to shine, tum going, the following week, he MB: I hired people who are smarter then implementing it in the clinical and the duo started working out to- and scholarship player Sean Sin- than me and I take very good care environment is critical in advancing gether after class. His friend set his gletary, whose No. 44 jersey is of them. We have a good team of our patient care. people who look after each other. It has been an honor to be a It’s almost like a family. I have a faculty member in the UVA School CFO who has worked here for 35 of Medicine and having a leader- years and many of our staff mem- ship role in Orthopaedic Surgery all bers have been here for decades. these years. I hope to continue to I feel that I’ve been the glue that contribute as long as I can. holds the department together as leaders and Chairs change. One of my key roles has been managing expectations. You have topflight UVA Helped Matt Deasey surgeons who are well-respected Live Two Dreams: around the country and we want Basketball and Medicine to make sure they have the tools to by Amy Hughes, UVA Health System do everything they can to provide quality care. If there are patient Matt Deasey, MD, says being an or- complaints, I’m heavily involved in thopaedic surgeon is a lot like play- that with my boss. ing basketball. Well, sort of. Now in his second year of his Orthopaedic Q: With the new building, how are Surgery Residency at UVA, he’s had Photo by Kay Taylor, UVA Health System Health UVA Taylor, Kay by Photo you employing your core compe- many lessons along the way, most Dr. Matt Deasey tencies of team building and man- notably as a Virginia men’s basket- aging people to get the job done? ball player. Deasey attended Episcopal sights on making the UVA wrestling now retired, reconnected for work- MB: Dr. Chhabra and I have been Academy near his hometown of team, so Deasey thought, “I’ll go outs at U-Hall. Deasey and Single- overseeing the whole project from Wynnewood, Pennsylvania, a sub- play basketball.” Although he hadn’t tary grew up as basketball rivals conception and working with the urb of Philadelphia. He was a bas- played basketball in two years, he at neighboring middle and high leaders of the hospital, health ketball star, point guard, and team felt stronger than ever before. schools in Philadelphia. system, and University. We have captain. He went to prom with his Soon, Deasey received a a large group of people who have high-school sweetheart, Lindsay, JOINING THE TEAM phone call from the coaching team. input in the building concept and and he “was in love with her from It was 2005, and Pete Gillen had In that moment, he joined the Vir- overall project. It’s been a challenge that point on.” stepped down as head coach for ginia Cavaliers roster. “My strategy

| uvaortho.com | 69 DEPARTMENT SPOTLIGHT

of leaving it all on the floor worked,” ed to his past, and teaching helped That game time comes at a They have a four-year-old daugh- Deasey says. him prepare for his future. price—a price of a demanding ter named Maggie who has been As a member of the team, he “I got to study for the MCATs schedule, little sleep, and scarce cheering “Go Hoos, go!” since she describes the experience as “thrill- [Medical College Admission Test] by family time. Deasey recently worked was 14 months old. ing. It’s something I’ve been wanting learning how to teach private-school two-and-a-half months of nights to do since I was seven years old.” kids chemistry, because I didn’t consecutively. On those shifts, “It’s GO HOOS! He was fulfilling his dreams and learn it while I was on the basket- you against the world,” he starts, Deasey has had little contact with pushing his physical limits. Practice ball team,” Deasey laughs. “A par- then stops with a chuckle. “It’s you the basketball team since he’s was 35-40 hours per week on the ent of one of my students was a on behalf of all the orthopaedic pa- been back in town. Quite frankly, he court, plus additional time lifting surgeon and Dean of the Medical tients in the hospital and everyone hasn’t had the time between a work- weights in the gym. School at Temple. He said, ‘It’s not that gets hurt in Central Virginia.” day that goes beyond dusk to dawn “It was awesome just to get to too late. If you want to go back and On those long nights, Deasey and a family at home. However, he warm up before the games,” Dea- be a doctor, you should go be a doc- had plenty of time to doubt his choic- is an avid fan and has had a few be- sey says. “That was a time when I tor.’ So, I applied to one place, and es or second guess the path he took. hind-the-scenes experiences. knew I would get shots. So, I was that was it.” But he never let the negativity creep This year, he thinks the team always the first person out of the Deasey left high-school sci- in. “Moments when I feel frustrated can win the NCAA tournament (they locker room. …It was amazing to go ence and enrolled in the Lewis Katz or tired or wonder why I am doing did, in fact, win). and play in these arenas where I School of Medicine at Temple Uni- this, I think about the fact that this is “I love the way they play,” he had been glued to the TV growing versity. He didn’t know until much something I really wanted, I worked says. “I like Ty Jerome. He has up watching my heroes play. To get later, but in the middle of one of his hard to get,” he says. “I’m grateful amazing poise. I wish that I had a to go and play in Cameron, to play long nights of his first year, Lindsay that UVA gave me a chance.” 10th of his poise on the ball. … The at the dome at UNC, to go play at (then his wife!) wrote a prediction on Bobby Chhabra, MD, Chairman way he and Kyle Guy work off each Maples Pavilion at Stanford was a piece of paper that Deasey would of Orthopaedic Surgery, was once other and find each other; it shows. amazing.” be an orthopaedic surgeon at UVA. a resident at UVA himself. Now as “I love Mamadi Diakite. [Diakite In a video lingering on the in- “Not a joke, not exaggerating— Chair, the culture he has created for and Deasey share the same num- ternet from Deasey’s days on the she put it in an envelope,” Deasey his own team is what drew Deasey ber: 25.] So, I hope he does well court, you get a glimpse into Dea- says. back to UVA. and starts selling those jerseys. sey’s personality—likeable, humble, And here he is. “Dr. Chhabra is an inspirational He’s the guy who I think will contin- hardworking—all things that have Chairman,” Deasey says. “I think ue to emerge throughout this year led him on the path to becoming an BACK TO CHARLOTTESVILLE he is similar to Coach [Tony] Ben- and has the potential to become orthopaedic surgeon. Deasey is currently in the middle of nett [men’s basketball coach] in a pro and make millions of dollars “I had been playing pickup, his second year of Orthopaedic Sur- that they are both people who care just because of his untapped skills but now I was playing with guys gery Residency at UVA. He calls it deeply about what kind of person is on the ball. He shows flashes of it. who were amazing,” Deasey says. “grueling” but also “rewarding.” part of their team.” Same thing with [Jay] Huff. He can “That’s something I am grateful for He brings all his experiences Deasey appreciates being cho- shoot from deep, he can stretch the now because that was the perfect into his residency, especially his sen for the team once again. He defense, take away the rim protec- preparation for being a resident: time as a Virginia Cavalier basket- feels at home in Charlottesville and tor, and then punish people. His You are not as good as those who ball player. “It’s remarkably similar would like to stick around this time. quote before the blue-white scrim- have been doing it for two years or to being on the team,” he says. “I “I’m naturally better at surgery mage last year was amazing. His five years or 25 years.” improved more in a year of playing than I was at defending elite ath- quote was, ‘Dunk everything,’ which At the end of the 2005-2006 here than I did in four years of high letes,” Deasey laughs. “I want to he said with a wry smile, but he’s season, Deasey’s basketball expe- school. And I think that’s true of ev- keep doing this, and I’m grateful doing it now.” rience came to an end. He played ery year of residency; you improve that I get to do it here.” Basketball and orthopaedic sur- six games, and Leitao’s team relied more than you did in all of medical For now, Deasey can look for- gery have shaped much of Deasey’s on him heavily in practice. school. It’s amazing. You can’t help ward to working alongside his UVA life up to this point. The common “We participated in practice,” but get better because you work at colleagues for at least a few more thread between both has been UVA. Deasey says, “and during five-on- it so much.” years. If we want to know where “The orthopaedic program here five drills, we played.” Halfway through his five-year Deasey will end up after that, per- is similar to the basketball program residency, Deasey is spending more haps we should ask Lindsay to put here because it just keeps getting THE REAL WORLD time in the operating room. another prediction for the future in better,” he says. “My goal is to be Deasey graduated from UVA in “We get to do a lot of surgery an envelope. good enough to be here.” 2007 and headed back home as a second year,” he says. “Intern Deasey and Lindsay married in Deasey keeps choosing UVA, to Pennsylvania and to Lindsay. year, first year you do a lot of watch- 2010. She is a philanthropic con- and UVA keeps choosing him. He He worked in a cardiothoracic re- ing, a lot of learning, which I think sultant working to eradicate polio. hopes to be in Charlottesville for the search lab for nine months, then is appropriate. It’s a lot like being a Deasey is thankful for all the sacri- long term, and he hopes Maggie will became a high-school science walk-on—you don’t get to do a lot of fices she’s made so he can pursue get the chance to grow up cheering teacher and basketball coach. games, but now you get a bit more his dreams of being a doctor and on the team for which her dad once Coaching helped him stay connect- game time.” says he “can’t do it without her.” played. Go Hoos! ■

The University of Virginia Department of Orthopaedics has no financial or other conflict of 70 | UVA ORTHOPAEDIC JOURNAL | 2019 | interest with the advertisers herein. We, in no way, endorse or recommend these products. MOVE FREELY. MOVE FORWARD. From treating common sports injuries to performing complex surgical procedures, we make a difference in our patients’ lives by seeing healthcare differently. Never relying on what is; always pushing for what can be. Stronger movement. Superior momentum. Healthier lives. Because when we work together as a team, we can make anything possible.

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SHOULDER SHOULDER KNEE PREOPERATIVE APPLICATION APPLICATIONS PLANNING (For Primary & Revision)

12-0000466_2019_US_UVA Ortho Journal_May20_ExactechGPS_Print_Ad_8.5x11.indd 1 5/24/19 3:58 PM PRECISION NOW COMES STANDARD This is just the beginning. Two distinct, prospective, consecutive series, single-surgeon studies comparing patients undergoing conventional jig-based total knee replacement versus Mako Total Knee The world’s only navigation for surgery (40 patients1 and 30 patients2 in each cohort), concluded that Mako Total Knee knee and shoulder arthroplasty. with Triathlon was associated with: Less Less Less Less Less bone need time to need for post- and for opiate hospital in-patient operative soft analgesics1 discharge1 physical pain1 tissue (p<0.001) (26% therapy (p<0.001) damage2 reduction sessions1 (p<0.05) in LOS) (p<0.001)

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References: 1. Haddad, F.S., et al. Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty. The Bone & Joint Journal, July 2018. 2. Haddad, F.S., et al. Iatrogenic Bone and Soft Tissue Trauma in Robotic-Arm Assisted Total Knee Arthroplasty Compared With Conventional Jig-Based Total Knee Arthroplasty: A Prospective Cohort Study and Validation of a New Classification System. J Arthroplasty. 2018 Aug;33(8):2496-2501. Epub 2018 Mar 27.

SHOULDER Professor Fares S. Haddad is a consultant of Stryker. However, Dr. Haddad and the authors of these publications did not receive financial or in-kind compensation for the SHOULDER KNEE research or publications. PREOPERATIVE APPLICATION APPLICATIONS A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. PLANNING Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information (For Primary & Revision) presented is intended to demonstrate the breadth of Stryker’s product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any of Stryker’s products. The products depicted are CE marked according to the Medical Device Directive 93/42/EEC. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your sales representative if you have questions about the availability of products in your area. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Stryker, Mako. All other trademarks are trademarks of their respective owners or holders. www.NoCapitalNav.com MAKTKA-AD-4_19014 © Stryker 2018 ©2019 Exactech, Inc. 0519 | For referrals, call 434-XXX-XXXX | uvaortho.com | 75

12-0000466_2019_US_UVA Ortho Journal_May20_ExactechGPS_Print_Ad_8.5x11.indd 1 5/24/19 3:58 PM 4494 Mako data ad for Bone and Joint Journal v1.indd 1 4/10/19 11:55 AM 2 MINUTE CONSULT

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discussed. What is the next best step?

she will likely increase load in the RLE while recovering. recovering. while RLE the in load increase likely will she

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: : ANSWER

76 | UVA ORTHOPAEDIC JOURNAL | 2019 | PHILANTHROPY

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