The Functional Outcome of Operative Treatment of Ununited Fractures of the Humeral Diaphysis in Elderly Patients.

David Ring, MD
Advisor: Jesse B. Jupiter, MD
Discussor: Gregory Altman, MD

          Focusing on the distinct population of elderly patients with painful, unstable nonunions of the humeral shaft, Dr. David Ring presented the surgical outcomes of 22 consecutive patients treated with open reduction and internal fixation and autogenous bone grafting. Using the Enforced Social Dependency Scale and the Disabilities of the Arm, Shoulder, and Hand outcomes instruments as measures of functional outcome, he demonstrated dramatic improvements in function following operative treatment. While fixation of osteoporotic bone can present a formidable challenge, the data in this series demonstrated that when specific techniques intended for the fixation of osteoporotic bone are used (including long plates, blade plates, and enhancements of screw fixation such as Schuhli washers, 6.5 millimeter cancellous screws, or cement) a high rate of union (91%) with no failure of fixation is attainable. Dr. Gregory Altman emphasized that this study applies to a subset of humeral nonunions in elderly patients that are severely disabling - nonunions that are mobile, unstable, and painful - and that patients with stable nonunions occasionally function well with a supportive brace alone. Dr. Buckwalter agreed that this study was a good example of the usefulness of outcomes instruments, but lamented the fact that population norms do not, as of yet, exist for the instruments used.

Current State of Orthopaedic Education: The Role of Multimedia

Jeffrey Guy, MD
Advisor: Robert Leffert, MD
Discussor: Mark Koris, MD

          Dr. Jeffrey Guy chronicled the development of the new internet home page for the Harvard Combined Orthopaedic Surgery Residency Program. During his real-time demonstration of the resources and capabilities already available on the 'Harvard Orthoweb,' Dr. Guy described the potential role of multimedia and internet technology in promoting resident education and furthering uniting Harvard-affiliated hospitals and institutions. A major part of his project will be the development of an intranet of educational resources and databases available to Harvard Staff and Residents. Dr. Mark Koris praised Dr. Guy's work and promoted the idea of using electronic media to develop educational resources.

Bone Mineral Density is Reduced in Vertebrae Instrumented for Adolescent Idiopathic Scoliosis

Hieu Ball, MD
Advisor: Brian D. Snyder, MD PhD
Discussor: M. Timothy Hresko, MD

          Dr. Hieu Ball used a proprietary computer algorithm for calculating bone mineral density of the spine using DEXA in the presence of internal fixation devices. In a short-term, prospective study of 8 patients with average of two-year follow-up and a long-term retrospective analysis of 15 patients with 17-year average follow-up, he demonstrated significant decreases in bone mineral density of vertebral bodies when the posterior elements had been fused. Density was not decreased in vertebrae adjacent to the fused area. Dr. Timothy Hresko was enthusiastic about the computer algorithms that make it possible to measure bone density adjacent to internal fixation device, but questioned the clinical importance of decreased bone density anteriorly when the posterior structures have been fused.

Surgical Treatment of Congential Kyphosis

Young-Jo Kim, MD
Advisor: M.Timothy Hresko, MD
Discussor: Paul Glazer, MD

          Though rare, congenital kyphosis is a progressive disease often resulting in cardiopulmonary dysfunction and paraplegia. Dr. Young-Jo Kim presented a retrospective analysis of 26 patients treated at The Children's Hospital for congenital kyphosis with greater than two year follow-up. Dr. Kim found that posterior fusion is a safe form of treatment in children less than three years old, with significant correction of deformity that may continue to improve over time. Combined anterior and posterior arthrodesis was safer in children less than three years of age. Psuedoarthrosis and neurological complications were more common in older children. Dr. Paul Glazer raised the importance of further analysis to measure functional outcomes in addition to successful fusion, and to further delineate the indications for a combined anterior and posterior procedure in the older child with congenital kyphosis.

The Role of Macrophages, Osteopontin, and Vascular Endothelial Growth Factor in Early Fracture Healing

Richard Illgen, MD
Advisor: James Kasser, MD
Discussor: Peter Hauschka, PhD

          Dr. Richard Illgen used a mouse model of fracture healing to study the role of macrophages and growth factors in the reparative process. Using techniques of enzyme-linked immunosorbent assay, immunohistochemistry, and tissue culture, he demonstrated that two macrophage gene products, osteopontin and vascular endothelial growth factor, play roles in angiogenesis and the stimulation of osteoprogenitor cells in the early phases of fracture healing. Dr. Peter Hauschka outlined the direction of further studies that will be needed to confirm and elaborate on these findings. Dr. Joseph Buckwalter was enthusiastic about the findings, but cautioned that when a few cells or growth factors are studied in isolation, we must reserve judgement about the relative importance of these elements in the overall process.

Preoperative Disease Severity and Postoperative Outcome in Patients Undergoing Total Joint Replacement

Sigurd Berven, MD
Advisor: Clement B. Sledge, MD
Discussor: Harry Rubash, MD

          During his research block at the Nuffield Orthopaedic Centre in Great Britain, Dr. Sigurd Berven collected outcomes data on patients scheduled for elective total knee arthroplasty using the SF-36 and WOMAC instruments. He observed differences in pre-operative disease severity between patients taken care of under the National Health Service and those cared for in private practice. After careful multifactorial analysis of other risk factors, he interpreted these differences in pre-operative disease severity as an index of access to care. Patients in the National Health Service cohort had more pain and more limited functional capabilities at the time of surgery, and had to wait an average of 134 weeks for surgery, compared to 6 weeks for private patents. There was no demonstrable difference in recovery or clinical outcome. Dr. Harry Rubash suggested that other differences between the two cohorts of patients may account for the worse preoperative status in NHS patients, such as different levels of pain tolerance and distinct cultural attitudes towards medical care. Dr. Buckwalter was very impressed with the paper and emphasized the importance of this kind of quantitative analysis of orthopaedic practice.

Arthroscopic Capsular Release for Refractory Frozen Shoulder, Outcome at Six Months to Four Years

Kenneth R. Sabbag, MD
Advisor: Gary S. Perlmutter, MD
Discussor: Robert Leffert, MD

          Addressing the complex problem of the frozen shoulder that is refractory to nonoperative treatment, Dr. Kenneth Sabbag presented the results of arthroscopic capsular release. In his retrospective review of 98 shoulders treated by arthroscopic release with average follow-up of two years, he demonstrated significant improvement in range of motion as well as function, as assessed by the Constant and Murley, American of Shoulder and Elbow Surgeons, and Subjective Activity scores. His talk also touched on the use of indwelling interscalene catheters, but it remains unclear if these add substantial benefit. Patients receiving Worker's Compensation had less improvement than other patients undergoing the same procedure. Dr. Robert Leffert led a discussion of the appropriate timing of arthroscopic capsular release in the treatment of the frozen shoulder and the use of interscalene catheters - both controversial topics.

Spine Fractures in Children and Adolescents: Mechanism of Injury, Anatomic Site, Neurologic Injury, & Precipitating Activity

Paul Benoit, MD
Advisor: John Emans, MD
Discussor: John Hall, MD

          Dr. Paul Benoit presented a survey of The Children's HospitalÕs experience with 197 spine fractures in 148 children and adolescents between 1982 and 1995. Unorganized sports, particularly diving, were a more common source of cervical spine fractures than organized sports such as football. The analysis of lumbar flexion-distraction injuries yielded some interesting data. While it is commonly believed that so-called Chance fractures that occur through bone will heal with external immobilization, three of five patients so treated developed a pseudoarthrosis and a fourth had loss of reduction. Dr. Benoit concluded that routine operative treatment may need to be considered. Dr. John Hall led the discussion of this thesis and noted that these conclusions are contrary to traditional teaching and merit further study. He raised the question of whether new preventative measures, such as automobile shoulder belts, have affected the incidence or severity of these flexion-distraction injuries.

A Comparison of the Bryan-Morrey and the Triceps Dividing Approach to Open Reduction of Complex Distal Humeral Fractures in Adolescents: Cybex Evaluation of Triceps Function and Elbow Motion

Leonard Remia, MD
Advisor: Peter Waters, MD
Discussor: James R. Kasser, MD

          Dr. Leonard Remia analyzed pediatric-aged patients in whom a Bryan-Morrey type exposure was used to repair an intra-articular fracture of the distal humerus. Using the Mayo performance index to grade the functional result and Cybex muscle testing to quantify muscle performance, he noted that the exposures led to comparable results. Dr. James Kasser discussed his interest and prior work on this topic and emphasized the benefits of the triceps elevating, Bryan-Morrey exposure.

The Use of Computer Generated Surface Signatures to Determine Metatarsal Rotation in Adult Hallux Valgus

Christopher Chiodo, MD
Advisor: Michael Wilson, MD
Discussor: William Tomford, MD

          Dr. Christopher Chiodo presented a novel means of analyzing rotational deformity in long bones using surface signature technology, in which CT images of tubular bones are 'unwrapped' about their long axes. Applying this technique to adult hallux valgus, he generated data that suggest that there is no first metatarsal pronation deformity in this disease. Dr. William Tomford, emphasized the importance of recognizing concomitant hindfoot deformity as a potential cause for apparent rotation in hallux valgus. Dr. Buckwalter noted that his partner in Iowa had studied first metatarsal rotation in hallux valgus and believes that rotation does occur--he joked that he will enjoy the process of confronting his partner with Dr. Chiodo's manuscript, which proves him wrong.

PRGB: A Novel Inhibitor of Angiogenesis Detected in Cartilage

Valerae O. Lewis, MD
Advisor: Lawrence Weissbach, MD
Discussor: Marcia Moses, PhD

          Dr. Valerae Lewis described the identification, purification, and functional analysis of the Plasminogen Related Gene B (PRGB) product, a nine kD protein produced by chondrocytes that shares greater than 90% gene sequence homology to the preactivation peptide (PAP) domain of plasminogen. After using genetic and molecular biology techniques to produce and purify the PRGB protein, Lewis demonstrated that it inhibits angiogenesis in vitro. She also presented data from a mouse model suggesting that PRGB can inhibit tumor growth by greater than 80%. Dr. Marcia Moses applauded Lewis for her mastery of a number of molecular biology techniques and the rigor of her studies, and challenged her to identify the mechanism of this protein in inhibiting tumor growth. Dr. Buckwalter was impressed with the amount of work required to complete this thesis and congratulated Dr. Lewis on her excellent work.

AWARDS