William A. Grana MD, MPH - Professor and Department Head

"The Effectiveness of Synvisc Therapy for Arthritis of the Knee"
William A. Grana, MD, MPH, Robert E. Hunter, MD

Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

This proposed study intends to determine the functional status of patients following a single three-injection course of Hylan GF-20 (Synvisc) (dose range 2cc) for treatment of oseoarthritis of the knee. Outcome results will add to the knowledge base as it relates to the efficacy of Synvisc and the utility of injections relative to risk and cost. One hundred subjects who are between the ages of 30 and 80 with radiographic grade 3 and 4 osteoarthritis of the knee will be recruited from the Orthopaedic Surgery outpatient clinic. Subjects will receive a series of 3 injections administered 1 week apart. If patients request both extremities be injected, the contralateral joint will be injected one week following the first. Subjects will undergo baseline evaluation, including health status and knee function, and will be asked to complete a series of questions about pain and function using a standard assessment instrument at 3 months and 6 months post injection. The validated outcome instrument is the Musculoskeletal Function Assessment Instrument (MFA46A), a 46-question health status instrument developed at the University of Washington (Journal of Orthopaedic Research, March 1996 and JBJS, September 1997). It is hypothesized that results may show the duration of relief of pain following the injections is not worth the risk and cost of the injections.

"A Longitudinal Study of Shoulder and Elbow Injuries Among Professional Baseball Players"
William A. Grana, M.D., MPH

Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

The purpose of the present study is two-fold: (1) to describe the characteristics, frequency, treatment, and outcome of shoulder and elbow injuries in the pitching arm of professional baseball pitchers, and (2) to determine relationships that may exist between injuries sustained in the two pitching joints. The null hypothesis is that an injury of one joint (i.e., the shoulder or the elbow of the pitching arm) does not cause injury in the other joint to be more likely. For the past three Spring Training sessions shoulder and elbow injuries of 124 pitchers from the Chicago White Sox Professional Baseball Association have been surveyed as part of the organization's standard practice of securing past medical history. The current study purports to administer the same survey (in person, by telephone, or by mail) to the 124 pitchers who have completed the survey in the past three Spring Training sessions (i.e., since March 2003) as well as to the additional 30-35 pitchers that will be brought into the organization each year for the next three Spring Training sessions (i.e., 2006 through 2008 Spring Training). The survey ascertains the date, circumstances, treatment, and outcome of shoulder and elbow injuries sustained in the past as well as in the previous baseball season. In the event that a pitcher is (or has been) released from the Chicago White Sox organization, an attempt will be made to ascertain responses to survey questions by telephone. If telephone contact cannot be made, the survey will be mailed out to the pitcher(s) for response. Information from these pre-season surveys will be analyzed in the context of prior survey data obtained since March 2003 (when applicable). Group data will be analyzed yearly using descriptivestatistics (e.g., frequency distribution) to provide a description of specific characteristics of this population: demographic information, experience, injury type, surgical treatments, and recurrence of injury. Nonparametric techniques (e.g., Chi Square) will be used to ascertain relationships between primary variables (e.g., shoulder injuries, elbow injuries) that may occur longitudinally over time.

"Infection Rate of ACL Reconstructions Using Allograft vs. Autograft"
William Grana, MD
(See entry under Brett Haywood, MD, William Grana, MD and Robert Hunter, MD)

"Allograft Infection Rates in ACL Reconstruction"
Robert E. Hunter, MD1, William A. Grana, MD, MPH1
William Allen, MD2, David Greenberg, MD2.

1Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona
2Department of Orthopaedic Surgery, The University of Missouri-Columbia School of Medicine,
Columbia , Missouri

The purpose of this multicenter study is to determine the infection rate for primary (first time) AnteriorCruciate Ligament (ACL) reconstruction surgery using allograft (human donor) tissue. Two-thousand subjects will be assessed across all sites. We have proposed to recruit 100 subjects locally. Of the 100 subjects, 50 will undergo ACL reconstruction using allograft (human donor) tissue and serve as the treatment subjects while 50 will undergo ACL reconstruction using autograft tissue (self-tissue) and serve as controls. The determination of this type of control group was deemed preferential to avoid the possibility of donor infectivity. The tissue selection will be based on surgeon preference.and the standard of care surgical reconstruction will apply to all subjects. Statisticians will determine the infection rate and significance using standard means (total number of infections/total number of cases). Although autograft tissue has been the gold standard for ACL reconstruction, there are many potential advantages for use of allograft tissue, including reduced donor site morbidity, shorter operative time, availability of larger grafts, smaller incisions, and a lower incidence of post-operative arthofibrosis. The knowledge of infection rates following the use of allograft tissue compared to infection rates after the use of autograft tissue in ACL reconstructive surgery will aid in clinical decision making.

"A Multicenter, Randomized, Pilot Study to Evaluate the Safety and Performance of The Small Intestine Submucosa (SIS) Meniscal Implant Device in Subjects Undergoing Partial Meniscectomy"
Robert E. Hunter, MD

Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

This multicenter, randomized, feasibility device study is sponsored by DePuy Biologics and will involve a total of 30 subjects across 4 sites (up to 10 locally) ages 18-55. The study is designed to evaluate the safety and performance of the SIS Meniscal Implant to regrow meniscal-like tissue in subjects undergoing partial meniscectomy due to an isolated primary tear in the posterior 50% of the medial meniscus. Additionally, outcome measures will help to identify meaningful endpoints and information for use in the design of a larger pivotal study. The utility of using MRI to quantify tissue regrowth at six months will be assessed and functional outcome measurements will be derived from the International Cartilage Repair Society (ICRS), the Koos Knee Survey, the Tegner Activity Level Scale, and the Visual Analogue Scale. Subjects receiving the implant will undergo a prescribed rehabilitation plan whereas those receiving a partial meniscectomy alone will undergo the standard of care rehabilitiation program tailored to each subject. Subjects will be randomized by study site to undergo either a partial meniscectomy or implantation of the SIS Meniscal Implant Device. Pre-clinical studies using the SIS implant, primarily in canine animal models, have shown robust new tissue regeneraton when the SIS implant was grafted into a defect with vascular access. In animal models SIS has been successfully used as a scaffold for in vivo tissue regeneraton and/or tissue remodeling. The model used in this pilot clinical study allows for access to the vascular supply and provides a source of cells capable of migrating onto the SIS implant. Past history has shown the amount of tissue removed during meniscectomy to be linked to the extent and speed of degeneration. Therefore, the study implant, composed of porcine small intestinal tissue, is hoped to regenerate functional meniscal tissue at a faster rate than human donor tissue and reduce the contact stress on the articular cartilage surface. It is expected that this, in turn, will potentially prevent degeneration of the knee joint or decrease the subjects' long-term risk of degenerative changes to the knee associated with partial meniscectomy alone. To date there is no data to effectively correlate the amount and quality of the regenerated tissue necessary to prevent further degeneration of the knee. This will be the first clinical study evaluating porcine small intestinal submucosa (SIS) grafts when a meniscal repair or regeneration is indicated. If results find that 15-20% of tissue has regenerated insubjects receiving the implant within six months of surgery, a larger multicenter clinical trial will be proposed.

THE PHOSPHATONIN SECRETED FRIZZLED-RELATED PROTEIN-4: TISSUE EXPRESSION AND REGULATION BY 1,25(OH)2D3

+*Jones, M D; *Kolek O I; *Thurston R D; *Barthel T K; *Uno J K; *Kiela PR; *Ghishan F K
*University of Arizona, Tucson AZ
mjones@u.arizona.edu

Introduction: Although both phosphate (Pi) and calcium are essential for normal bone mineralization, significantly less is known about the regulation of Pi. sFRP-4 has recently been suggested to be a phosphatonin. This study sought to characterize the tissue expression of sFRP-4, specifically its expression in bone, and to characterize any regulation of sFRP-4 mRNA expression by 1,25(OH)2D3.

Results: sFRP-4 mRNA is endogeneously expressed in various mouse tissues. sFRP-4 mRNA expression in bone (calvaria and tibia) is present at a significantly higher level than mRNA expression in kidney, brain, spleen, jejunum and liver (n=3, *p<0.0001). 1,25(OH2)D3 decreases sFRP-4 mRNA expression in UMR-106 osteoblast-like cells. Real-time PCR analysis of UMR-106 mRNA revealed that 1,25(OH)2D3 treatment decreases sFRP-4 mRNA expression by approximately 33% (Figure 2, n=7, *p<0.05).

Protein translation is required for the 1,25(OH2)D3 mediated decrease in sFRP-4 mRNA expression Cyclohexamide reversed the decrease in sFRP-4 mRNA expression evident with 1,25(OH)2D3 alone

Discussion: The physiologic role of sFRP-4 is uncertain. As an antagonist of the Wnt signaling pathway, it may be involved in development and carcinogenesis. It is likely that there are alternative functions of sFRP-4, including phosphate regulation and bone mineralization. The importance of sFRP-4 in bone homeostasis is supported by the high levels of mRNA expression in bone as compared to other tissues. The phosphatonins FGF23 and MEPE have previously been reported to be regulated by 1,25(OH)2D3; this study shows that sFRP-4 is also regulated by 1,25(OH)2D3, with a decrease in sFRP-4 mRNA expression after treatment with 1,25(OH)2D3. These data support the hypothesis that sFRP-4 has similarities to the other phosphatonins, and suggest further study of the regulation of sFRP-4 expression by 1,25(OH)2D3.

"Development of rt-PCR Identification of Chondrocytes and STEM Cells"
Laurel Cox (with the guidance of David Margolis)

Cartilage cells(chondrocytes) in arthritis patients do not divide. Since it is likely that a successful engineered cartilage tissue will require large numbers of cells, strategies for cell proliferation that involve either, de-differentiating chondrocytes into fibroblasts, then expanding them and finally re-differentiating them, or collecting stem cells, expanding them and then differentiating them into chondrocytes will be explored. Chemical and mechanical means are now being used to encourage cell differentiation in both these cell populations in cell culture. Success of conversion of cells from fibroblast to chondrocytes or from fat-derived stem cells will be examined using rt-PCR to detect RNA expression levels and protein concentrations assays.

"Development of Techniques of Identifying and Differentiation
Fat Derived Stem Cells into Chondrocytes"
Devin Wiley (with the guidance of Christopher Hall)

Successful engineered cartilage tissue will require large numbers of cells. Since cartilage cells in arthritis patients do not divide another potential source of cells could be Stem cells derived from the patient's adipose(fat) tissue. A technique for collecting Stem cells from fat has been developed but a method of positively identifying Stem cells is needed. rt-PCR will be used to detect RNA expression levels to identify Stem cells. Using combinations of proteins these cells will be differentiated into chondrocytes. Then rt-PCR will again be used to detect RNA expression levels and to examine proteins produced by the cells.

"Gene Expression in Osteoblasts Transfected with Calibindin-D28k"
Derek Moore (with the guidance of David Margolis)

The aim of this study is to characterize the role of Calbindin-D28k in osteoblast cells. Calbindin-D28k is an intracellular calcium binding protein that acts as a calcium buffer and a calcium signaling molecule. Calbindin-D28k is expressed in neuronal tissue, the kidneys, and in cells that produce calcified tissues (odontoblasts in teeth and osteoblasts in bone). Recent studies in our lab using Calbindin-D28k knockout mice have demonstrated that the function of this protein in normal bone is to limit bone mass, and animals that do not express Calbindin-D28k have thicker bones that fail at higher loads. This finding is exciting because limiting Calbindin-D28k expression in a patient may improve bone quality. In order to ascertain how Calbindin-D28k expression in osteoblasts is able to limit bone mass, a cell line over-expressing Calbindin-D28k has been created and will be used in this experiment to determine how increasing the levels of Calbindin-D28k changes gene expression. The expression levels of genes related to detecting bone strain and producing extra-cellular matrix will be characterized in static and loaded cell cultures. This analysis is expected to yield insight into the mechanism by which Calbindin-D28k may alter osteoblast function. An understanding of this mechanism is important as it may demonstrate target molecules that Calbindin-D28k interacts with and will be useful to evaluate drug targets in the treatment of osteoporosis.

"Western Blot analysis of Canine Collagen Expression"
Danielle Salazar (with the guidance of Christopher Hall)

It is well known that cartilage derived cells undergo a phenotypic change when subjected to a standard cell culture environment. Some aspects of this de-differentiation, such as the induction of cell proliferation, are advantageous to the production of a tissue engineered cartilage and some consequences, such as decreased production of characteristic matrix molecules, are disadvantageous to that end. With a better understanding of the process of de-differentiation in cartilage derived cells, a more deliberate approach could be taken in the tissue engineering process enabling a selection of the optimum environment for the cells used to make engineered tissue. The goal of this project is to evaluate the expression of matrix proteins in de-differentiating cartilage derived cells in vitro to gain a more detailed understanding of the consequences with regard to the creation of a tissue engineered cartilage. A previously developed Western Blot protocol will enable the analysis of protein expression. Western Blot will be used for analysis of protein expression of collagen I and II in cartilage derived cells. Ultimately these results will be compared with PCR results to determine how gene expression levels correlate with protein production. Such an analysis may also yield helpful information about the process of cartilage loss during the onset of osteoarthritis. The long-term goal of this experiment is to find an effective way to repair articular cartilage in patients with focal defects rather then replacing joints with metal and plastic implants. The development of a cartilage tissue-engineered construct will provide a long-term solution to arthritic joints without a loss of proprioception that typically results from total joint replacement.

"Acquisition of K9 Stifle Joint Loads Using a Portable Telemetry System"
Ivan Plascencia (with the guidance of Dr. John Szivek and Vivek Nandakumar)

Focal cartilage defects can lead to progressive joint degeneration and osteoarthritis. Current repair procedures have had limited success in treating these cartilage defects. Recently cartilage engineering techniques that utilize resorbable scaffolds to support the newly generated tissues have shown great promise in resurfacing damaged joints. Scaffolds allow for a solid bone/cartilage interface as bone readily grows into the scaffold and can be constructed to incorporate growth factors that encourage both bone and cartilage growth. Also, strain gauge sensors can be placed onto the scaffold to measure deformation and subsequently derive joint pressures. These joint pressures can be used to determine key biological triggers that affect cartilage cell proliferation and cartilage matrix maintenance. Also, direct measurement of loads during patient activity and rehabilitation will establish exercise regimens to encourage faster and more complete healing of focal defects. The overall goal of this research is to develop an implantable load monitoring system, which can be used to measure joint loading during various activities and rehabilitative therapies following focal defect repair. The aim of this project is to create a USB bus probe to allow for telemetric monitoring of an implanted "sensate" scaffold using a Macintosh G4 laptop computer running a Unix based operating system. Currently, telemetric data is being received through a serial port on a G3 laptop running a Macintosh specific operating system which can easily crash during data acquisition. To verify the accuracy of the measurements collected with the new system, results will be compared with data acquired with the G3 based system. Developed code will facilitate accurate monitoring of loads during gait and accurate assessment of peak loads and peak loading rates without having to reboot systems when the custom data acquisition software fails.

"In Vivo Characterization of Joint Loading"
Omar Silva (with the guidance of Cody Bliss)

The aim of this study is to accurately characterize and evaluate the in vivo loading patterns observed in the canine stifle under several conditions using an implanted strain gauged scaffold. Characterizing joint loading environments can establish loading patterns that are responsible for tissue destruction (cartilage) and tissue formation (bone). An understanding of these loading conditions can be used to prevent the onset of diseases such as osteoarthritis and osteoporosis. In addition, the loading conditions responsible for tissue function can be correlated to loading conditions that occur during routine activities such as running or stair climbing to determine safe activities that allow for optimal tissue function. The long-term goal of this project is to effectively use tissue engineering to treat arthritis and provide an alternative to artificial joint replacement. Developing a strain gauged scaffold to anchor the tissue-engineered cartilage is essential to the success of the project. Using the scaffold to assess loading condition present in the joint during activities is advantageous to designing better tissue-engineering techniques as well as developing a monitoring system to warn patients of excessive loads that may damage tissue-engineered cartilage. The specific short-term goals of this project are the in vivo evaluation of joint loading under a variety of conditions using an implantable scaffold in a canine model. To test the sensitivity and range of the scaffold system, a method will be designed to comfortably add weight to the hindquarters of each test animal to simulate gait with accurately defined load changes. Staircase and treadmill training techniques will be developed and used to evaluate load measurements during gait. Data will be analyzed according to previously developed parameters and established criteria; comparison analysis will be performed on data between different testing conditions and test animals. In addition, a method in which video data is analyzed to reproducibly assess step length and joint angles will be developed.

"Histomorphometry of Bone Ingrowth into Scaffold"
Chris Geffre in University of Arizona Medical School, MD/PhD program
(with the guidance of Dr. Szivek)

Engineered tissues grown on the surfaces of scaffolds for implantation will benefit from rapid stabilization of the scaffold so that the engineered tissues can begin to heal and bond to existing tissues. A scaffold with sensors has been developed for a dog stifle model to study the effects of in vivo loading on tissue engineered cartilage. The goal of this project is to quantify the rate of bone ingrowth into this newly developed, hydroxyapatite (HA) and tricalcium phosphate (TCP) particle coated porous scaffold design. Histology, histomorphometry and back scatter electron microscopy are being used to characterize the response of bone to these scaffolds. Results to date show that in the 3 month time period used for this study, significant bone ingrowth occurs into the pores of the scaffold. It also appears that this continues up to 6 months. Proteins which accelerate bone ingrowth are also being evaluated using these techniques.

"Genis Bone Graft Materials Testing"
Jose Ochoa from University of Chicago Medical School, MD program
(with the guidance of Dr. Szivek)

Calcium containing fillers have been used as bone repair materials and implant attachment vehicles in order to avoid the need to collect autograft from patients and to avoid the risks associated with the use of allograft. In particular, there has been extensive work done on calcium phosphate ceramics such as hydroxyapatite and tricalcium phosphate. Recently, proteins have been utilized in conjunction with these calcium based materials in order to make them osteoinductive and to increase the rate of bone formation and healing. Preliminary testing of a new formulation of calcium bone repair material developed by Genis indicates that this material is osteoinductive without the use of proteins and that it accelerates bone formation. The purpose of this study is to more conclusively evaluate the extent to which this new material accelerates the bone formation process.

This bone repair material can be formed into a paste in the operating room. A small animal model will be used to establish the extent to which it accelerates bone healing. A rat femoral defect model will be used. A single defect will be drilled in the lateral aspect of the rat femur in a series of test animals. Controls will be used to establish that the defects will not spontaneously fill with bone in the three week healing period. Test animals will be divided into three groups with different formulatio ns of repair materials in two of the three groups. The third group will act as a control in which holes will be unfilled.

"Development of Techniques to Induce Cell Stratification"
Jason Davis in University of Arizona Medical School, MD program
(with the guidance of David Margolis)

Although recent years have brought progress in the development of chondrocyte cell cultures which yield collagen matrix molecules, strategies which create cell and matrix molecule stratification are just now being explored. Native cartilage is highly stratified and cells and matrix within each tissue layer are oriented in different directions. The goal of this study is to evaluate cell and tissue stratification techniques such as tension loading, shear loading and compression loading. Preliminary evidence suggests that one of or a combination of these techniques will lead to cell and subsequently tissue stratification. Once a method of reproducibly stratifying one layer of cells and tissue has been established, techniques for layered stratification of two layers will be investigated.

"A K9 Stifle Testing Procedure Allowing Simultaneous Collection of Cartilage Surface Pressures, Sub-surface Loads and Surface Bone Strains; An In Vitro and In Vivo Study Supporting the Development of Scaffolds"
Cody Bliss in the Biomedical Engineering Ph.D. Program, U of A

Determining pressure in healthy joints is imperative to the understanding and development of a functional cartilage tissue-covered scaffold for joint resurfacing. The construction of a tissue covered scaffold will be guided by bone strain and joint load measurements from implanted strain gauged scaffolds. Orientation of the gauges on the scaffold have been studied to correlate measurements with joint pressure. Bench top experiments have served as a predictor of preferred gauge placement and orientation and the feasibility of collecting meaningful in vivo measurements. Reliability and consistency of the strain gauge measurement technique is being demonstrated by comparison of in vivo and cadaver bone test results. In addition, the influence of sensors and telemetry on the ingrowth of bone into the scaffolds is being established. The results of these studies are guiding the next steps in cartilage covered scaffold preparation.

"Fabrication and Characterization of Complex PBT scaffold systems"
Brandi Tellis in the Biomedical Engineering Masters Program, U of A

One promising potential treatment for focal cartilage defects in young patients is the replacement of lost cartilage with tissue engineered cartilage grown on a biodegradable polymer scaffold and implanted into the affected joint. Studies of the ideal characteristics of a scaffold are underway and include; 1. an interconnected pore network that enables tissue in-growth and the transport of nutrients and wastes, 2. a degradation rate that matches the rate of tissue replacement as closely as possible, 3. mechanical properties such that seeded cells are protected from overloading while growing into a 3D matrix, and 4. surface chemistry that encourages cell attachment, proliferation, and differentiation. This project has involved the use of computer aided drawing and rapid prototyping technology to allow the design and building of 3D, porous scaffolds of various geometries out of polybutylene terephthalate. Characterization of these scaffolds has included determining their mechanical properties with various coatings before and after implantation.

"Palm Software Development for Portable Strain Measurement"
Vivek S Nandakumar in the Electrical Engineering Masters Program, U of A

There is great potential value in being able to monitor tissue engineered cartilage after it has been implanted into a patient. In fact it would be ideal if the patient could monitor their own tissue to prevent overload during exercise. Currently an animal model has allowed the development of implantable transmitters but the receiver systems include a unit with a converter board attached to a laptop computer via a serial port connector. In order to make this system more portable a miniature receiver coupled with a Palm device is being developed. This will make the receiver system much more portable. A portable receiver of this type worn by the patient will allow monitoring of exercise activities. A Palm based software package has been written for this receiver system. In addition to allowing real time monitoring of loads on tissues, the Palm software will provide the ability to retransmit data to a PC for additional analysis. Other hand held computer platforms are also being evaluated after noting that the Palm platform is slow and has a small memory.

"In Vivo Strain Gauging of Mouse Femora"
David Margolis, in University of Arizona Medical School, MD/PhD program

In order to better understand bone remodeling in normal and disease states a mouse model has been developed. A series of mice have received micro-miniature CPC-coated strain gauges on their femora during surgery. TGF-ß1 was used on the surface of the CPC coatings in one group of mice to determine whether a significant increase in the rate of bone bonding was possible relative to that noted in bones gauged with unenhanced gauges. After six weeks mice were sacrificed and their femora explanted for mechanical testing. Immediately prior to sacrifice, mice were injected with technetium (99mTc) methylene diphosphate (MDP) and imaged with a dual µCT/SPECT imager to compare bone formation rate (BFR) using the dual imaging method. Following mechanical testing bones were embedded in poly-methylmethacrylate and the bone formation rate was characterized using histology and histomorphometry. BFR determined by the two techniques showed that TGF-ß1 does accelerate bone formation.

The next step in this study will be implanting of wired micro-miniature strain gauges into mice. A wiring and CPC coating technique have been developed and gauges are currently being prepared for surgery. A surgical technique for placement of the wired gauges onto the femora of mice and a method of measuring the strains from their bones is now being developed.

"ACL Suture Tensioning Study"
Eric Robinson, in University of Arizona Medical School, MD program

Suture tensioning during ACL repair can be performed using a tensioning device or simply by hand. Preliminary testing using a bench top model suggested that a specific approach was superior to the other techniques tested. Additional study of this problem using cadaver tissue is warranted in order to completely evaluate these techniques.

"Second Metatarsal Stress Fracture After Kirschner Wire Cortical Penetration During Hammer Toe Correction: Three Case Reports"
Kevin Casey, MD and Bradley Brainard, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

Kirschner wire fixation is used in foot surgery for correction of hammer toe deformities, preservation of joint alignment after reduction, and for fixation of fractures. Some previously described complications with use of this technique are: wire breakage or bending, pin tract infections, pin migration, nerve injury, and digital ischemia. We describe three cases of stress fracture of the second metatarsal after hammer toe correction which to our knowledge has not been reported previously. We recommend the use of fluoroscopy to centralize the pin and reduce cortical penetration. Stress fractures occurring by this mechanism can be effectively treated nonoperatively with activity restrictions and protective immobilization.

"MRI Characterization of the Pulley System of the Thumb"
Nathan Enoki, MD, Mihra Taljanovic, MD, and Joseph Sheppard, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

Previous studies of the thumb have revealed significant gross and radiographic variations in pulley system anatomy. In this study, cadaveric thumb specimens will be carefully dissected then imaged using magnetic resonance imaging (MRI) to radiographically characterize the anatomy of the pulley system of the thumb. The similarities and differences between specimens will be noted. This study will help to develop a better understanding of the previously reported anatomic variability of this complex structure, and the implications of this variability with MRI findings will be examined.

"Infection Rate of ACL Reconstructions Using Allograft vs. Autograft"
Brett Haywood, MD, William Grana, MD and Robert Hunter, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

Multicenter prospective study looking at the infection rate of ACL reconstructions using allograft vs autograft.

"Retrograde Nailing of the Supracondylar and Intercondylar Fractures of the Distal Femur: The Role of the Locking End Cap"
Brett Haywood, MD and John Ruth, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

Background: Retrograde intramedullary nail fixation of supracondylar femur fractures is an effective treatment modality. Certain retrograde nail systems allow placement of a distal end cap which locks into the distal interlocking screw and creates a fixed angle device. The purpose of this study is to analyze the relative stiffness of retrograde nails with the end cap in place.

Methods: Ten pair of composite femora were randomized and were implanted with Zimmer retrograde nails. One half of the femora had retrograde nails with the end cap in place and the other half had retrograde nails without the end cap. A transverse osteotomy was made in each femur at the diaphysis - metaphysis junction to simulate a supracondylar femur fracture. Each composite femur was placed under varus, valgus, torsional, and axial loads in the MTS. The femora were not loaded until failure.

Results: At the current moment, results are pending.

"Long-Term Follow-Up of Total Shoulder Arthroplasty Custom Glenoid Components"
Carter Kiesau, MD and Joseph Sheppard, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

Many of the problems with the long-term success of total shoulder arthroplasty has been dependent on the glenoid component. In an attempt to obtain better fixation and overall outcome, custom glenoid components have been attempted.

We are currently designing a study to evaluate the long-term outcomes of about 10 patients who received custom glenoid components as part of their total shoulder arthroplasty. After locating them, we will gather information about their history, progress, functionality, and obtain current radiographs. This information will be used to assess the overall outcome of this small cohort of patients receiving a custom glenoid component.

"Methods of Determination of Femoral Component Alignment in Computer Assisted Total Knee Arthroplasty"
Kim Lindberg, MD and Mark Clatworthy, MD, FRACS
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

"Complication Rates in Hip Fractures: A Comparison of Reported Data Between a Hospital's Medical Information Service and an Orthopaedic Surgery Department's Peer Review System"
Samuel L. Mortimer, MD and William Grana, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

Purpose: To compare complication rates reported by a medical information service and an orthopaedic department peer review service.

Information was obtained through the hospital's medical information service, specifically looking at the total number of hip fractures and their associated complications. The number of complications was gathered and compared to the complications reported by the peer review system. This data is currently undergoing statistical analysis and will hopefully be helpful in determining if there is a difference between reporting services and what the significance of this is.

"Radiographic and Clinical Outcome After Symphyseal Plate Fixation of Pelvic Ring Injury"
Jordan Smith, MD and John Ruth, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

The study objective is to assess correlation between radiographic and clinical outcome after anterior fixation following pelvic ring injury and to compare overall outcome after pelvic ring injury compared to age-matched controls.

"Telemedicine, Orthopaedics and The Emergency Room: A Rational, Available, Competent and Compliant Solution to Non-emergent ED Consultations"
Jordan Smith, MD and Joseph E. Sheppard, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

To increase competent, rational, and compliant solutions to non-emergent Emergency Medicine (ED) consultations, a proposal for telemedicine ED consultations is being undertaken. Such a proposal is deemed necessary because of lost revenue within the Orthopaedic Surgery department, difficulty ascertaining the precise nature of an injury when Orthopaedic consults are sought, limited communicationbetween ED personnel and Orthopaedic Surgeons at the time of referral, and inadequate documentation for use by the Orthopaedic surgeon. The current setting in the ED at The Arizona Health Sciences Center (AHSC) represents an ideal paradigm for the practical use of telemedicine in the Department of Orthopaedic Surgery. The purpose of this feasibility proposal is threefold: (1) to provide a detailed characterization of all Orthopaedic consultations sought in the ED over a 3 to 6 month period, (2) to calculate lost revenues as a manifestation of the services sought, and (3) to canvas current faculty and residents in the ED and Orthopaedic Surgery departments to determine feasibility and acceptance of an orthopaedic teleconsultation service with the ED to permit real time attending participation from a remote site. There will be two phases to the proposal. Phase I is a prospective, contemporaneous analysis of all consultations sought by the ED at AHSC from the Department of Orthopaedic Surgery. This data will be collected over a 90-day period. During this time, a questionnaire will be completed by all ED and Orthopaedic Surgery residents and attendings involved in emergency care to ascertain the level of acceptance for a change in the current system to one which utilizes teleconsultation services with the attending on call from a remote site. Depending on the analysis of data from Phase I, Phase II would consist of the implementation of the teleconsultation service within the department of Orthopaedic Surgery at AHSC. After a 2-month trial period, the same data collected in Phase I will be obtained to compare the two systems of service and a decision will be made whether or not to continue. If this system of service proves beneficial from both an economic and patient care standpoint, Phase III will involve an application of this technology to provide teleconsultation for patients with orthopaedic problems at the Emergency Room at University Physicians Healthcare at Kino campus.

"Case Report on Lateral Condyle Abscess/Osteomyelitis 2 Years After Closed Reduction and Percutaneous Pinning of a Supracondylar Humerus Fracture in a 7 Year Old Child"
Nick Webber, MD
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

A 7 year old male presented to three emergency rooms with left elbow pain 3 years after having a type 2 supracondylar humerus fracture closed reduced and pinned. The patient was sent home 2 times after being seen with elbow pain of unknown etiology. He was seen by his original orthopaedic surgeon, who checked serum esr, crp, and wbc which came back within normal levels. After obtaining a bone scan and MRI, an abscess was discovered located in the lateral humeral condyle. The abscess was drained and patient treated with IV antibiotics.

"Knee Injuries in Tennis Athletes"
Stacey D. McClure, MD, Robert E. Hunter, MD, William A. Grana, MD, MPH
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

Tennis is a sport which requires a high degree of agility and speed. Rapid cutting, pivoting, acceleration and deceleration movements are essential to play. These movements are precisely the reason other sports such as basketball, football, and soccer have a high incidence of injury to the major ligaments of the knee. Up to 800 tennis athletes from local high school, college, and intramural teams ages 14+ will be surveyed in this study to determine the incidence of major knee injuries during tennis play. The results of the survey will be discussed in the context of training programs and knee injury prevention.

"Clinical Outcomes of Meniscus Repair"
Scot A. Cordray, MD, Robert E. Hunter, MD, William A. Grana, MD, MPH
Department of Orthopaedic Surgery, The University of Arizona Health Sciences Center ,
Tucson, Arizona

The objective of this study is to evaluate the subjective clinical outcomes of those patients who have undergone meniscus repair. The information obtained will be helpful in judging the clinical success of repair from the patient's perspective. The research design is a retrospective chart review of those patients who have undergone a meniscus repair. The inclusive age range for consideration is 16-65 years of age. Demographic data as well as injury and operative details will be taken from the patient charts. Subjective knee outcome surveys, as well as consent and HIPAA forms, will then be mailed to the patients and returned after completion. The Lysholm Knee Rating System and the Knee Outcome Score will be the standard outcome measurement surveys used for this study. These surveys focus on knee specific symptoms, performance, and limitations and they provide a specific score based on the patient's responses.