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James Herndon, MD, MBA
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First Session
Moderator: James Herndon, MD
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| Christopher Forthman, MD |
Jesse Jupiter, MD |
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Acute Traumatic Elbow Instability Patterns and Characteristics
Christopher Forthman, MD
Advisor: David Ring, MD
Discussor: Jesse Jupiter, MD
Elbow fractures and instability can be broken down into several different patterns. Does the recognition of one of these patterns help one to predict the bone and ligamentous injury characteristics? As well, in these types of fracture dislocations is it necessary to repair the medial collateral ligament (MCL)? Dr. Forthman looked at 51 fracture dislocations and 4 simple dislocations to help answer these questions. Additionally he provided a detailed review of the types of fracture patterns, the anatomy of the fracture and the operative protocol for the fixation of these injuries. Ultimately it was determined that knowledge and correct identification of the fracture pattern would yield great information about the structures involved. What is more, it was found that the MCL didn’t need to be repaired to ensure stability of the elbow joint.
Dr. Jupiter noted that the elbow is a unique and poorly understood joint, leading to some pessimism on the part of many surgeons with respect to these injuries. He noted that this study added greatly to the understanding of both the treatment as well as outcome of these fractures. He did question whether the knowledge gained about the fracture pattern in the OR had influenced their classification of the fractures, and suggested the need for intra- and inter-observer reliability assessments. Dr. Forthman noted that the fractures were classified solely on their radiological basis and agreed that further validation of their methods would be needed before wider acceptance.
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| Erik Spayde, MD |
Mark Vrahas, MD |
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A Biomechanical Evaluation of Z-Fiber Technology in Fracture Fixation
Erik Spayde, MD
Advisor: Paul Glazar, MD
Discussor: Mark Vrahas, MD
Current methods of fracture fixation suffer from three major difficulties: traumatic insertion, large screw “footprints”, and limited points of fixation. Dr. Spayde proposed a novel technique using z-fiber technology to help overcome some of these hurdles. Z-fiber technology has already been put to great use in both the aerospace and automotive industries on account of its decreased incidence of delamination and increased strength. It is possible to fit multiple materials with z-fibers thereby obtaining these benefits. In this work Dr. Spayde looked at finite element analysis, biomechanical assays of pullout strength and cadaveric tests to compare z-fiber plates with conventional DCP plates. It was ultimately shown that z-fibers were stronger, had higher pullout strength and increased load capacity prior to failure, thus making them a possible technology to be employed in new plate design.
Dr. Vrahas observed that this was an excellent proof of concept paper but that there were still several questions that needed answering prior to human trials. For example, it is unclear how easy plate removal would be with several points of fixation. Dr. Spayde surmised that the same technology used for plate insertion could possibly be used for extraction, but agreed that more work would be needed and was forthcoming.
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| Raj Ahluwalia, MD |
Thomas Thornhill, MD |
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Lesser Tuberosity Osteotomy in Total Shoulder Arthroplasty
Raj Ahluwalia, MD
Advisor: Peter Millett, MD
Discussor: Thomas S. Thornhill, MD
Total shoulder arthroplasties routinely involve taking down the subscapularis muscle from its insertion on the lesser tuberosity. However, between 60 and 65% of patients complain of some form of subscapularis dysfunction postoperatively. As well, between 3-11% have an actual subscapularis rupture, making this a difficult problem. Dr. Ahluwalia proposed that rather than releasing the soft tissue around the subscapularis or separating the muscle at it’s attachment, that one perform a lesser tuberosity osteotomy (LTO) – an idea that grew out of conversations between Dr. Christan Gerber and Drs. Warner and Millett. In this study a comparison was made between the biomechanical strength and the clinical outcomes of the various methods. He found that the LTO had decreased displacement and greater load to failure than other techniques. Moreover, after an analysis of 76 LTO’s he found normal function in 92.5% and rupture in only 1.3%, significantly better results than reported in the literature.
Dr. Thornhill observed that the authors relied on fiberwire sutures for their osteotomy fixation and noted that fiberwire has polyethylene at its core. He questioned whether using this type of construct could lead to particle debris and loosening. Dr. Millett felt it unlikely given the distance of the sutures and knots from the joint itself.
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