fall 2003

o r t h o p a e d i c i n s i g h t s

THE CLEVELAND CLINICFOUNDATION

The Cleveland Clinic’s Orthopaedic Re-search Center was established in 2001 totap into the intellectual synergy that haslong existed between the departments of Orthopaedic Surgery and BiomedicalEngineering. Developed under the lead-ership of Joseph P. Iannotti, M.D., Ph.D.,chairman of Orthopaedic Surgery, thecenter melds clinicians’ research interestsand strengths with those of tissue engi-neering, biomechanical and musculo-skeletal research scientists.

This rich collaboration was enhancedin September 2002 when Peter Cavanagh,Ph.D., a distinguished researcher ofhuman biomechanics, kinesiology and locomotion from Pennsylvania State University, was named chairman of theDepartment of Biomedical Engineering.The Orthopaedic Research Center nowhas more than 30 principal investigatorsengaged in over 100 peer-reviewed clini-cal and basic science projects focusing on every aspect of the musculoskeletalsystem.

They say that the accelerated pace of scientific discovery and innovation isapparent in the development of new tech-niques such as the Merlot bone anchorfor minimally invasive endoscopic sacralfixation. Conceived by Cleveland Clinic

orthopaedic surgeon Isador Lieberman,M.D., the Merlot bone anchor’s double-helix design minimizes tissue damageduring insertion while increasing thespinal implant’s holding power (pull-

out and toggle resistance). This novel design is currently under full-scale devel-opment by DePuy-Acromed, a Johnson & Johnson Company, which licensed thetechnology from The Cleveland Clinic.

Welcome to this new issue of Orthopaedic Insights. We are pleased to have the oppor-tunity to share the latest developments in the Department of Orthopaedic Surgery atThe Cleveland Clinic with you.

Over the past several years, Orthopaedic Surgery has grown at The Cleveland Clinic. We currently have a full-time clinical staff of 57 physicians — including 45 ortho-paedic surgeons, seven podiatrists and five nonoperative primary care physicians — offering care at nine different sites in Northeastern Ohio. Last year, we registered130,000 outpatient visits and completed 11,989 surgical procedures for patients from around the world.

As you may know, U.S.News & World Report has ranked our department fifth inAmerica for five years in a row.

Research is an important part of our mission. In 2001, we created an OrthopaedicResearch Center to consolidate all of our investigative efforts. Today, it has grown to include 33 basic science researchers working on a vast range of musculoskeletal prob-lems. Funding for our basic research program totaled $8 million in 2002, with an addi-tional half-million or more in annual extramural funding for clinical research studies.

We support a broad program in continuing medical education. In 2002, we sponsored five CME symposia on sports medicine, upper extremity problems and spine disorders at locations throughout the United States.

In the coming year, our Orthopaedic Research Center will host clinical and basic science conferences in state-of-the-art facilities within the new Cleveland Clinic Inter-continental Hotel and MBNA Conference Center, located right here on our campus. In addition, we will co-sponsor conferences on joint replacement in Las Vegas and Orlando. (Please refer to the Orthopaedic CME calendar on page 13 for details on upcoming events.)

Orthopaedic Surgery is slated to play an important role in the new Cleveland ClinicLerner College of Medicine of Case Western Reserve University. The first class of 32 students is scheduled for admission in 2004. Our department’s unique six-year curricu-lum is designed to educate and mentor students for careers in academic medicine andclinical investigation. Research training will be a significant part of the curriculum, andour department will be encouraging and educating students in musculoskeletal careand research.

Finally, in 2002 our department published nearly 100 book chapters, review articlesand original peer-reviewed manuscripts. (See back page for highlights of scientific articles and book chapters authored by Cleveland Clinic orthopaedic surgeons and biomedical engineers in the past 12 months.)

We also began producing a consumer newsletter, The Cleveland Clinic Arthritis Advisor, in collaboration with an independent publishing house.

This marks the third year of publication for Orthopaedic Insights. It is our sincerehope that you find the content useful and informative. Should you have suggestions for a future topic, or comments about anything you’ve read, I hope that you’ll call me. I welcome your feedback and look forward to hearing from you.

Dr. Joseph Iannotti, chairman of the Department of Orthopaedic Surgery, is co-chairman of the Orthopaedic Research Center and a member of the Section of Handand Upper Extremity Surgery. He can be reached at 216/445-5151 or 800/553-5056,ext. 55151.

Dr. Lieberman leveraged the Bio-medical Engineering Department’s de-sign and prototype fabrication skills withthe Spine Research Laboratory’s in vitroexperimentation capabilities to demon-strate the new anchor’s effectiveness.The Medical Device Innovations Groupwithin Biomedical Engineering assisted in technical refinements.

“Three-dimensional computer draw-ings of the Merlot anchor were created,and the strength of the new design wascomputed using finite element simula-tions,”explains Dr. Cavanagh. “Once the preferred design was selected, the Prototype Laboratory fabricated stainlesssteel functional prototypes. The effective-ness of implanting the Merlot anchor,particularly in soft, potentially diseasedcancellous bone, was then tested in theSpine Research Laboratory.”

Dr. Iannotti adds that “the develop-ment of the Merlot bone anchor repre-sents a significant advance in posteriorsacral fixation, and highlights the uniqueopportunity we have in the OrthopaedicResearch Center to advance patient carethrough clinical and scientific teamwork.”

Orthopaedic Research Center Reaps Rewards of Collaboration

The Cleveland Clinic Department of Orthopaedic Surgery – A Year in Review: 2002 – 2003From Chairman Joseph P. Iannotti, M.D., Ph.D.

The Orthopaedic Research Center is a joint enterprise between the Department of OrthopaedicSurgery, chaired by Joseph Iannotti, M.D., Ph.D. (left), and the Department of Biomedical Engineer-ing, chaired by Peter Cavanagh, Ph.D. (right).

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A physician’s newsletter from the Department of Orthopaedic Surgery

The success of adjuvant chemotherapyhas helped to change our surgical philos-ophy toward childhood sarcomas. Today,skeletal reconstructions for both osteo-genic sarcoma and Ewing’s sarcoma haveto last longer and function better.

Forty years ago, through-the-boneamputation or proximal joint disarticula-tion was the treatment of choice for chil-dren and adolescents with sarcomas. Evenwith radical ablative surgery, results weredismal: Five-year survival was 20 percentfor osteogenic sarcoma, and less than 10percent for Ewing’s sarcoma.

Since that era, adjuvant chemother-apy has made a dramatic difference inprognosis. Today, more than 70 percent of osteogenic sarcoma patients live fiveyears or more free of metastatic disease,with similarly improved survival amongEwing’s sarcoma patients.

Limb-sparing resection and recon-struction have become increasingly im-portant means of achieving local controlsince the 1960s, when Ewing’s sarcomawas treated with whole-bone radiationtherapy.

The past four decades have seenmany advances in endoprosthesis designand allograft procurement. In 1977, weestablished a bone bank at The ClevelandClinic to facilitate procurement of mas-sive allografts for skeletal reconstruction.A year later, we instituted a program forendoprosthetic skeletal reconstructionfor sarcoma patients.

Since then, hundreds of patients ofall ages have undergone skeletal recon-struction with either an endoprosthesis— now the most common approach —or a massive allograft.

Successful limb-sparing surgery depends on the surgeon’s ability to re-construct the limb, whether it be thefemur, tibia or humerus. In selecting areconstruction technique, function and

implant durability, as well as age, tumorlocation, disease and activity level, arecrucial considerations.

In the young sarcoma patient, thelimitations and advantages of endopros-theses vs. allografts must be weighed carefully. Limb-sparing surgery is mademore difficult by the need to equalize leglengths in a growing child or adolescent.In the skeletally mature adolescent, leglengths are equalized at the time of sur-gery. In patients nearing skeletal maturity,the involved leg is made overly long.Epiphysiodesis is performed on the uninvolved leg when leg lengths equalizewith growth.

In children under 10, the anticipatedleg-length discrepancy is so great thatpast surgical options were limited to amputation or a Van Ness rotation plasty.An endoprosthesis now available allowsfor surgical lengthening of the implantas the child grows. The child undergoes a limited surgery once or twice a year to expand the prosthesis. Once growth is complete, a permanent modular prosthesis is exchanged for the original expanding device.

Customized or modular endopros-theses are used with increasing frequencyfor skeletal reconstruction after tumor resection. Endoprostheses offer many advantages over allografts, including ex-cellent fit and function, without concernsabout disease transmission. Patients re-cover more quickly, with early restorationof function, and periprosthetic fracturerates are low. Most importantly for chil-dren, relatively low infection and compli-cation rates allow them to return to theiradjuvant chemotherapy protocol as earlyas possible.

Aseptic loosening and late breakageare considered the greatest drawbacks toendoprostheses. However, advances indesign and the addition of a porous coat-

Limb-Sparing Reconstructions for Childhood SarcomasMust Now Function Better, LongerBy Kenneth E. Marks, M.D.

ing at the prosthesis-bone junction havesignificantly reduced such occurrences.Nonetheless, late failure and revision areto be expected when endoprostheses areimplanted in patients younger than 50.

Allografts are more prone to failurewhen osteochondral joint grafts areused. Causes include fracture; less often,infection; and arthritis. Healing and return to full activity are more gradualwith allografts than with endoprosthe-ses. Allografts are incorporated as boneremodeling occurs, usually within two to three years of surgery. Implantlongevity is important for the younger,active patient.

However, allografts offer superiorlong-term function and are preferredover endoprostheses for the following indications:

• proximal tibia reconstruction, whereconnecting an allograft with host tis-sue provides optimal reconstructionof the extensor mechanism;

• distal radius reconstruction, typi-cally performed using an allograft incombination with wrist fusion;

• rotator cuff reconstruction at theproximal humerus, where implant-ing an allograft-prosthetic compos-ite yields the best results in terms offunction and longevity;

• reconstruction following wide resec-tion of a tumor occurring in the diaphysis of a bone;

• knee fusion, which is accomplishedby implanting an allograft and a stabilizing intramedullary rod; and

• filling large acetabular defects, par-ticularly for active patients in goodhealth who respond to anticancertreatment.

Dr. Kenneth Marks heads the Sectionof Musculoskeletal Oncology. Specializing in the treatment of musculoskeletal tumors and in joint replacement, he can be reached at 216/444-2637 or800/553-5056, ext. 42637.

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The Center is also dedicated to thetraining of a new generation of clinicianscientists. The Orthopaedic Surgery Department’s six-year orthopaedic residency program—one of few in thenation— has a special concentration in basic research.

The curriculum features a full yeardevoted to basic science research in thelaboratory, learning from such highlyskilled investigators as Kathleen Derwin,Ph.D., a specialist in tendon and ligamentmechanobiology, and tissue engineering.

“Designing a replacement tendonwith long-term biological and mechani-cal function has proven an elusive goal,”says the bioengineer.“One attractivestrategy is using natural extracellular matrices, which can be augmented withcells and soluble factors involved in cellu-lar signaling systems.

“Conceptually, these matrices couldprovide temporary functional supportsince they possess inherent biologic prop-erties that favorably influence cell behav-

ior and tissue development, and are biocompatible, bioresorbable and im-munologically safe.”

A tendon tissue-engineering labora-tory team is investigating the hypothesisthat natural extracellular matrices, withand without cell augmentation, providethe best outcome for tendon regenera-tion. Their studies are aimed at under-standing the interactions between naturalscaffolds, cells and signaling systems, andeventually, targeting specific treatmentstrategies.

One extracellular matrix showingpromise in musculoskeletal applicationsis small intestinal submucosa (SIS).Porcine-derived SIS has been FDA-approved for human use in soft-tissue reinforcement (DePuy Orthopaedics’Restore Orthobiologic Implant).

Two Cleveland Clinic orthopaedicsurgery fellows recently participated in a study evaluating SIS as a flexor-tendongraft in a canine model. The SIS graftsdemonstrated a biologically favorable

response in that they were associated withhost-cell infiltration, neovascularizationand deposition of organized neotissue.

However, the grafts were scarred to the surrounding tissues along theirlength. Thus, they concluded that forflexor-tendon reconstruction, SIS matrices may require additional tissue engineering, such as coating with anti-adhesive molecules, to achieve adequatemechanical function.

Ongoing research focuses on the effect of mechanical conditioning on attachment, infiltration and phenotypicexpression of cell-seeded scaffolds such as SIS in an in vitro bioreactor system.These scaffolds are analyzed for specifichistological, biochemical and biome-chanical properties that indicate neo-tendinous quality.

Another orthopaedic surgery resident is studying in vitro mechanical conditioning in a commercially avail-able human dermis bioscaffold, aug-mented with mesenchymal stem cells

Orthopaedic Research Center Reaps Rewards of Collaborationcontinued from front page

or primary tendon cells (LifeCell Corporation’s AlloDerm).

“These studies provide insight intocritical aspects of tendon tissue-engineer-ing — scaffolds, cells and mechanical signals — that will direct our strategiesfor treatment and regeneration of injuredtendons,” says Dr. Cavanagh.

In addition to providing graduatemedical education, Orthopaedic Re-search Center members travel extensivelyto report on collaborative research. Theysponsor scientific symposia on a local,national and international scale, and host a seminar and lecture series thatdraws clinicians and basic scientists toThe Cleveland Clinic from throughoutthe world.

To speak with Dr. Joseph Iannotti,please call 216/445-5151 or 800/553-5056, ext. 55151. To speak with Dr. PeterCavanagh, please call 216/445-6980 or800/553-5056, ext. 56980.

Expandable prosthesis in the proximal left femur after resection for Ewing’s sarcoma.

Treatment on clinical trials is the hallmark of pediatric oncology. The National Cancer Institute recently called attention to the problem of poor access for adolescents withcancer to pediatric clinical trials. Teenagers with osteogenic sarcoma represent a groupof patients in whom we can begin to reverse this trend.

Cure rates for childhood cancer have increased dramatically, largely through clinical trials designed to identify prognostic factors that can be used to determinehigh- and low-risk patients, and alter therapy accordingly.

Risk factor analysis, including molecular genetic evidence — largely in leukemiasand neuroblastoma, due to diligent tumor banking and scientific investigations in cooperative groups — will be applied to osteogenic sarcoma in the upcoming genera-tion of clinical trials.

At the inception of the Children’s Cancer Group in 1960, the five-year event-freesurvival for osteogenic sarcoma was 20 percent. The addition of adjuvant chemothera-py — high-dose methotrexate, cisplatin, doxorubicin and ifosfamide — for the primarytreatment of osteosarcoma has increased event-free survival in those with clinicallynonmetastatic disease to more than 70 percent.

Preoperative chemotherapy has made limb salvage operations possible for morethan 80 percent of patients.

Neoadjuvant chemotherapy, followed by surgery, has allowed for an assessment of early response to therapy — the only well-documented predictor of long-term out-come. Children and adolescents with a good response to chemotherapy, defined in various studies as more than 90 to 98 percent of histologically measured necrosis, have a disease-free survival of more than 80 percent.

However, standard responders continue to have disease-free survival of 40 to 60percent. Clinical trials have proceeded to attempt intensification of therapy for thisgroup. While one study showed a benefit from the addition of ifosfamide and etopo-side to standard therapy, current trials are being designed to further optimize outcomesfor this group without increasing toxicity.

Up to this point, therapeutic complications have mainly been ototoxicity and cardiotoxicity. The most recently completed clinical trial, still awaiting maturity of data,evaluated the addition of the biologic agent MTP-PE. This agent activates monocytesand macrophages to become cytotoxic, and has shown antitumor activity in sponta-neous canine osteosarcoma.

Further studies with other biologic agents, such as IL-2 and interferon gamma, are under discussion, as are clinical trials using the cardioprotectant dexrazoxane.

Approximately 15 to 20 percent of osteosarcoma patients present with metastaticdisease, with the majority of metastases found in the lung. Their event-free survival is less than 25 percent. Children with metastatic pediatric osteosarcoma require an in-novative approach. Their poor prognosis justifies the exploration of targeted therapy.

Several recently identified potential molecular markers of prognosis are being studied in newly diagnosed osteosarcoma patients.

Among these is the overexpression of the HER2 gene seen in 42 percent of meta-static osteosarcoma patients. This marker was found to correlate with poor outcomesand poor response to standard chemotherapy. An antibody to the HER2 protein,trastuzumab (Herceptin) was developed to capitalize on this target. The currently open Children’s Oncology Group clinical trial for metastatic osteosarcoma employs a strategy that combines this antibody with conventional chemotherapeutic agents.

Cooperative group trials clearly benefit children with cancer. We hope that bothchildren and adolescents with osteosarcoma continue to benefit from this approach.

Dr. Joanne Hilden, chair of the Department of Pediatric Hematology/Oncology atThe Children’s Hospital at The Cleveland Clinic, is happy to consult with orthopaedicsurgeons about pediatric musculoskeletal cancer patients. To speak with her, physiciansmay call 216/444-8407; to schedule appointments for patients with Dr. Hilden or herstaff, please call 216/444-5517 or 800/553-5056, ext. 45517.

At The Children’s Hospital at The Cleveland Clinic,more than 100 pediatric specialists and subspe-cialists, including hematologists and oncologists, provide expert care to patients. By participating in the Children’s Oncology Group and other clini-cal trials, The Children’s Hospital offers pediatriccancer patients access to more than 100 nationaltrials at any given time.

Pediatric and Adolescent Osteogenic Sarcoma:Improved Outcomes on Clinical TrialsBy Joanne Hilden, M.D.

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This pediatric osteosarcoma, shown on AP X-ray and MRI, was success-fully treated with chemotherapy,resection and rotating-hinge distalfemoral replacement.

The Cleveland Clinic Department of OrthopaedicSurgery has a long history of excellence and innovation in medical and surgical care for thosewith musculoskeletal injuries and diseases. Forthe past several years, U.S.News & World Reporthas consistently ranked the Department of Or-thopaedic Surgery among the nation’s top fiveorthopaedic programs in a survey combiningphysician polling with mortality rates and otherdata. The Cleveland Clinic Foundation has beendesignated as one of the top five hospitals inAmerica since 1998 by U.S.News.

One of America’s Best

Interbody fusion cages are used widely to promote spine fusion in the treatmentof degenerative disease, trauma and de-formity. We undertook a study of clini-cally failed orthopaedic spinal implantsin order to expand our understanding of biocompatibility, and mechanisms of implant failure and success.

Many surgeons use iliac crest auto-graft within these cages, but harvestingautograft is associated with donor sitecomplications in at least 10 to 30 percentof patients. To avoid this morbidity, os-teoinductive and osteoconductive mate-rials — including recombinant humanosteogenic protein-1, bone morpho-genetic protein-2, demineralized bonematrix and hydroxyapatite — have beentested in preclinical studies and haveshown evidence of efficacy in generatingintervertebral arthrodesis.

Interbody cages vary in size, shape,composition and flexibility. Most designsare hollow to permit filling with bonegraft or bone-graft substitute materials.Lateral holes —of varying size and distri-bution — allow for potential vascular ingrowth and bone graft remodeling,facilitating fusion between adjacent vertebral bodies.

In spite of widespread use, there hasbeen little histologic documentation of

interbody cage contents from the humanspine. We analyzed 102 retrieved cages —made of carbon-fiber-reinforced poly-mer, titanium mesh and other materials— from 66 cases, submitted by 36 sur-geons at 33 different centers. The cages,mainly removed due to failed fusion cage malposition or migration, were insitu for two to 87 months (21 months on average).

We visually estimated the approxi-mate areas occupied by viable bone,necrotic bone, fibrocartilage, hyaline cartilage, fibrous tissue and bone-graftsubstitute, and expressed this as a per-centage of available volume. Particles of debris were estimated by a semiquanti-tative scoring system.

Most cages showed evidence of vas-cular ingrowth and histologically viablebone, almost certainly representing in-corporating bone graft. Average viablebone area was approximately 44 percent(0-80), a figure that did not correlate significantly with duration in situ or cage design.

In some cages, cortical bone graftfragments were associated with minimalnew bone formation, while small piecesof cancellous bone showed greater evi-dence of bone-graft incorporation.Previous basic science studies havedemonstrated greater bone formationwith cancellous vs. cortical bone grafts.Our observations suggest that segmentsof cortical bone graft may be less effectivethan cancellous bone from the iliac crest.

Several types of bone graft substi-tutes were present in the cages. We recog-nized residual demineralized bone matrixin seven cages, but found a small focus of endochondral bone formation in onlyone cage. Hydroxyapatite granules hadbeen packed without bone graft in onecage. This cage developed about 50 per-cent bone apposition to the hydroxyap-atite and about 20 percent viable bone by volume.

Hydroxyapatite granules had beeninserted with bone graft into anothercage, but the retrieved device showed no bone apposition and essentially no viable bone.

Particles of debris were present in 66 cages, but there was no histologic evi-dence of associated bone resorption. Thecages contained a relatively high propor-tion of fibrocartilage (up to 70 percent of available volume). The fibrocartilagewas predominantly of intervertebral discorigin. Bands of fibrocartilage connectingbone trabeculae also were present, espe-cially in relatively long titanium meshcages that had been placed vertically inthe cervical spine. The distribution ofthese bands suggests that the cages mayhave experienced bending and/or com-pressive load.

Hyaline cartilage occupied more

than 5 percent of the available area in 31 cages and was not associated withbone formation. It had the histologic appearance of articular cartilage, pre-sumably derived from the vertebral end plate or facets, and was probablypacked into cages along with local auto-graft, or entered through lateral holesduring cage insertion.

Five cages contained elastic fibers,probably originating from fragments of ligamentum flavum or a similar struc-ture. Another cage had fibers of unknownforeign material.

The results of this human retrievalstudy emphasize differences in the qualityof bone graft preparations from differentsites. Careful selection and use of graftsubstitute materials, and proper im-plant site preparation, are critical inspine fusion.

To speak with Dr. Isador Lieberman,a spine surgeon in the Department ofOrthopaedic Surgery, please call 216/445-2743. To reach Drs. Thomas Bauer orDaisuke Togawa, members of the depart-ments of Orthopaedic Surgery andAnatomic Pathology, please call Dr. Bauer’soffice at 216/444-6830. To contact Dr.Edward Benzel, neurosurgeon and directorof the Cleveland Clinic Spine Institute,please call 216/445-5514. The ClevelandClinic’s toll-free number for physicians is 800/553-5056.

Histological Evaluation of Clinically Failed Human Interbody CagesBy Daisuke Togawa, M.D., Ph.D., Thomas W. Bauer, M.D., Ph.D., Isador H. Lieberman, B.Sc., M.D., and Edward C. Benzel, M.D.

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Photomicrograph of histo-logic sections through cen-ter of retrieved BAK cage.

Small islands of necroticbone (NB), presumablyrepresenting residual bonegraft, are surrounded by ex-tensive viable bone (VB);osteoid is present.

Demineralized bone matrix(DBM) was not associatedwith new bone formation.Here, fibrous tissue sur-rounds fragments of DBM.

Higher magnification showsnew bone formation (B) as-sociated with surface of hy-droxyapatite granules (HA).

We hoped to improve our understanding of bio-compatibility, and implant failure and success.

Several cages contained relatively large amounts of cortical bone graft(CBG), with minimal new bone formation.

Avulsion of the distal biceps from its insertion at the bicipital tuberosity is becomingmore frequent, largely as a result of our aging, yet active population. For most patients, anatomic reinsertion provides results superior to nonoperative treatment and brachialis tenodesis.

Repair techniques have evolved over the years in response to complications andtechnical difficulties attributed to the surgical approach and the means of fixation. At present, the modified two-incision technique is utilized most commonly. Though the safety and efficacy of this procedure have been well-documented, heterotopic ossification with cross-union of the radius and ulna remains a potentially devastatingcomplication of the procedure.

In order to diminish this risk and to allow for earlier functional rehabilitation, wenow utilize a single-incision technique that employs a directed surgical approach andsuture-anchor fixation. A series of 32 Cleveland Clinic patients treated in this mannerachieved full, active elbow motion within six weeks. One year postoperatively, supina-tion strength was 7 percent less and elbow flexion strength 8 percent less than the contralateral arm.

Twenty of these 32 patients were assessed with the Disabilities of the Arm, Shoulder, and Hand outcome questionnaire before surgery and at least one year afterward. The scores improved significantly.

The technique for distal biceps repair favored at The Cleveland Clinic utilizes a 3-cm longitudinal incision along the medial border of the brachialis, beginning 1 cm distal to the elbow flexion crease. The vulnerable lateral antebrachial cutaneous nerve is quickly encountered and protected.

The interval between the brachialis and the pronator teres is developed with theforearm fully supinated to protect the posterior interosseous nerve. Frequently, a leashof vessels is present and must be ligated. To avoid nerve injury, right-angle retractors are utilized rather than self-retaining or Homan retractors.

The radial tuberosity is located by palpation at the distal, ulnar border of thesupinator. The bursa and tendon remnants leading to the previous site of tendon insertion are excised. The cortex of the tuberosity is abraded between the locations destined for suture-anchor placement.

The ruptured biceps tendon is retrieved in the distal arm, just superficial to the brachialis fascia. Degenerative tissue is sharply debrided from the tendon stump.

Two 3.5-mm Mite Super anchors, preloaded with #2 Ethibond suture, are each loaded with another #2 Fiberwire suture. One anchor is placed proximally and one distally along the posterior border of the radial tuberosity while the forearm is hypersupinated.

One limb of the Fiberwire from each suture is woven through the biceps tendon using a Krackow stitch and then tied proximally. One limb of the Ethibond from eachanchor is sewn through the tendon using a Bunnell stitch and tied proximally. The tendon is guided to the tuberosity as tension is placed on the remaining suture ends in an alternating fashion.

Tying the Fiberwire, and then the Ethibond ends, secures the biceps to the preparedcortex. Although elbow extension to –35˚ is desirable after the repair, the biceps musclerelaxes over time, making development of a flexion contracture unlikely. The tourniquetis deflated prior to closure, to avoid development of a hematoma. The elbow is splintedin 90° of flexion and neutral rotation.

Five to seven days after surgery, the therapist initiates passive flexion and supina-tion, and active pronation and extension to –45˚. A static long-arm splint is utilized forfour to six weeks. Protected active flexion and supination are started four weeks aftersurgery, and the patient is slowly progressed. Except for isolated biceps curls, full use is allowed by six months postoperatively.

Dr. Thomas Hunt, head of the Section of Hand Surgery, can be reached at 216/445-6426 or 800/553-5056, ext. 56426.

Distal Biceps Tenodesis: Single-Incision Technique AdvocatedBy Thomas R. Hunt III, M.D.

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Our preferred incision for the anterior single-incision approach.

Anterior surface of radius isvisualized with supinatorproximal and radial afterdissection between brachio-radialis and pronator, andligation of arterial leash.Note close proximity of lat-eral antebrachial cutaneousand median nerves. Arongeur is used to removetendon remnant andsheath.

Krackow stitch is placedfirst (one limb from eachsuture anchor). Remain-ing suture is then placedusing Bunnell stitch.

Sequentially tying re-maining sutures fromeach anchor, tendonstump is advanced andsecured to anatomic insertion site.

A directed surgical approach and suture-anchorfixation through a single incision reduces com-plications and speeds rehabilitation.

muscle; directional observation of signalflow from one region to another; or esti-mation of signal sources from scalp EEGon a 3-D brain model.

Compared with fMRI, EEG data pro-vide greater time resolution and probablygreater reproducibility of results, largelybecause they directly measure corticalelectrical activity.

In the future, fMRI signals, EEG,EMG and motor performance (such asforce or movement) will be investigatedsimultaneously. This should offer insightsinto central and peripheral mechanismsof sensorimotor control over joint move-ment and stability in injury, surgery andrecovery. Brain and muscle activationpatterns will be studied longitudinally to evaluate the effects of surgical proce-dures, and the efficacy of rehabilitation.All of these insights will be important in developing more effective medical interventions.

Orthopaedic surgery is beginning tomerge with biomedical engineering andneuroscience to offer a more completeunderstanding of the mechanisms under-lying injury or disease-related functionaldeterioration, and functional recoveryafter treatment.

Orthopaedic surgery related to sub-cortical neuromuscular and musculo-skeletal systems frequently focuses on the spinal cord and peripheral nervecomponents of the sensorimotor controlmechanisms involved in limb movement.Sophisticated electroencephalography,electromyography and functional mag-netic resonance imaging (fMRI) of corti-cally mediated musculoskeletal controlmechanisms, in conjunction with peri-pheral components, may improve ourunderstanding of normal and pathologicanatomy and physiology.

Brain activation of voluntary move-ment has traditionally been examined via invasive single-cell recordings intrained animals, subdural EEG record-ings in patients undergoing neurologicalsurgery, or positron emission tomogra-phy, which examines regional blood flowchanges in the brain. Although thesetechniques are still used, their applicationfor clinical evaluation is limited by theirinvasiveness, limited sampling areas insingle-cell and subdural recordings, andpoor resolution in PET.

Advances in noninvasive fMRI andmultichannel scalp EEG recordings nowallow for repeated evaluations with excel-lent resolution of central nervous systemreorganization/adaptations due to injuryor rehabilitation.

Functional MRI signals result fromthe so-called blood oxygen level-depend-ent (BOLD) effect. Increased neural ac-tivity in a cortical region augments localblood flow and volume. On the otherhand, oxygen consumption increasesonly slightly or not at all, reducing the

relative content of deoxyhemoglobin inthe affected brain region.

Because deoxyhemoglobin is para-magnetic, it produces microscopic mag-netic inhomogeneities that increase thedephasing, or desynchronization, of spin-ning hydrogen protons. A decrease in the quantity of deoxyhemoglobin reducesthe rate of signal decay, causing a relativefMRI signal increase (compared to thecontrol condition) in the area where un-coupling of changes in blood flow andoxygen consumption occurs.

Besides its noninvasive feature, fMRIoffers such advantages as high spatial resolution (1 to 2 mm) and flexibility of signal presentation (two- or three-dimensional, at any plane). FunctionalMRI can also map activation patterns,recruitment and fatigue in target muscles.

This unique 3-D perspective is notseen with traditional EMG or MRI. Forexample, selective activation of the flexordigitorum profundus can be observed,and the activated muscle can be tracedalong the forearm, when the distal inter-phalangeal joints of the fingers alone are moved.

Brain function is also increasinglystudied via scalp EEG, which records integrated electrical signals of corticalneurons.

There have been two major advancesin scalp EEG. One is a dramatic increase in the number of electrodes used for datacollection, which improves spatial resolu-tion of the EEG signal. The largest numberof channels used has been 512, although32 to 128 channels are used most often for mapping brain electrical signals.

The other advance is the increasingsophistication of data analysis software.New software packages allow for co-regis-tration of EEG data with MRI or fMRI;data analysis in both time and frequencydomains; signal correlation among differ-ent cortical regions or between brain and

The Center for Research on the DiabeticFoot, based in the Department of Bio-medical Engineering within the Cleve-land Clinic’s Lerner Research Institute,was established to study all aspects ofdiabetic foot disease. The center is part ofThe Clinic’s new comprehensive DiabeticFoot Care Program.

Our research on new approaches towound healing, high-technology foot-wear solutions, alternate methods ofdrug delivery to patients with footwounds, and Charcot fractures may be of particular interest to orthopaedic sur-geons dealing with diabetic foot disease.

To explore new approaches towound healing, we are pursuing a basicunderstanding of the molecular biologyof the process. A molecular dermatolo-gist associated with our center has devel-oped a model that allows for in vitrostudy of gene expression in any relevantagent. Clinically, this may lead to a tar-geted approach to wound healing by

Functional MRI, EMG and EEG Shed New Light on Neural Control of Limb MovementBy Guang H. Yue, Ph.D., and Peter J. Evans, M.D., Ph.D.

enhancing the expression of factors responsible for delayed healing.

In another study, a radiation oncolo-gist investigator is proposing to targetgrowth-factor molecules, tagged withmagnetic microspheres, to their deliverysite in foot ulcers by means of a magneticwound dressing.

In hopes of developing new footwearsolutions for diabetic patients, we areusing finite element models of the foot-shoe interface to predict stresses on plan-tar tissue. This approach should elucidatethe general rules underlying geometryand material properties of footwear intervention.

We also have an interest in “intelli-gent footwear” that can warn the subjectof dangerously high plantar pressures,and perhaps modify the shoe-foot inter-face accordingly.

In addition, we hope to learn moreabout the etiopathogenesis of Charcot’sneuroarthropathy. At the present time,

the factors that lead to this devastatingcomplication of diabetes are poorly un-derstood, and treatment consists simplyof immobilization. The combined effortsof the many bone biology experts in theBiomedical Engineering Departmentmay finally shed light on this importantcondition.

Other research under way in theCenter for the Diabetic Foot involves:

• MRI imaging of the foot gait andmovement problems in those withdiabetic neuropathy

• mechanical characteristics of skinand bone in diabetes

• pressure-distribution measurementunder the foot

• robotic approaches to the study offoot mechanics, and

• foot complications among African-Americans.Our new, multidisciplinary Diabetic

Foot Care Program integrates a variety ofclinical and research activities into one

Cleveland Clinic’s Center for Research on the Diabetic Foot EstablishedBy Peter R. Cavanagh, Ph.D.

6

Dr. Guang Yue, who directs the NeuralControl of Movement Laboratory in theDepartment of Biomedical Engineering at the Cleveland Clinic Lerner Research Institute, can be reached at 216/445-9336or 800/553-5056, ext. 59336. Dr. PeterEvans, of the Section of Hand and UpperExtremity Surgery as well as the Lerner Research Institute, directs the ClevelandClinic’s Peripheral Nerve Center. He can be reached at 216/ 444-7973 or 800/553-5056, ext. 47973.

Supplementary motor area(SMA) activation duringthumb flexion (left) and exten-sion (right), with functionalimage overlaid onto 3-Danatomical image. A larger vol-ume of SMA was activated dur-ing extension than flexion.Most motor cortex activationoccurred within brain surfaceand cannot be viewed. (Colorbar indicates z score of statisti-cal comparisons.)

Functional MRI study of mus-cle activation in female whonever exercises (upper row) andwell-trained male (lower row).Green = low muscle activation;red = high-intensity activation.Anatomical images are at left.Functional images in middleresult from small number ofelbow flexions against a load,and at right from exercisingelbow flexors to exhaustion.

(Most red pixels in middle result fromblood flow artifacts. Pixel size = 1mm.)

Peak plantar pressure during walk-ing from a diabetic patient with el-evated pressure under the hallux.Such patient data are collected rou-tinely in the Cleveland Clinic’s Di-abetic Foot Clinic.

A study we conducted in collaboration with the Cleveland Museum of Natural

History may help to predict which patients are at risk for the development of hallux

valgus deformity and to direct the course of treatment.

Certain anatomical differences in shape, size, and position of the hallux are

known to contribute to the development of hallux valgus. Attempts to quantify

differences in position through the measurement of a number of angles — including

the distal and proximal metatarsal articular angles — have been controversial. The

method of measurement, validity and usefulness of these angles have all been called

into question.

However, data concerning differences in shape and size, and other anatomical

configurations of the hallux metatarsal, are scarce in the literature. Thus, we decided

to investigate anatomic variations of the first metatarsal bone, including its dimen-

sions and the angulations of its articular surfaces, in a large diverse sample represen-

tative of the general population.

Fortunately, we were able to access the Hamman-Todd Osteological Collection

at the Museum of Natural History, which contains 3,100 human skeletons collected

between 1893 and 1938. This autopsied skeletal collection attracts researchers in

the fields of anthropology, forensics and medicine from around the globe. It is espe-

cially valuable to forensic and medical researchers because the age, sex, race and

cause of death for each specimen are known.

Thus, researchers have been able to investigate such areas as anomalies of

the thoracic bodies in individuals with Scheuermann’s kyphosis; sex, race, age and

height from skeletal remains; anatomical differences among sexes and races; and

skeletal changes caused by various disease processes.

In our study, we used 478 bones from 239 specimens within the Hamman-

Todd Osteological Collection to record:

• distal metatarsal articular angle (DMAA)

• surface shape

• proximal metatarsal articular angle (PMAA)

• height

• width at the mid-region of the shaft, and

• existence of a joint between the bases of the first and second metatarsals.

We attempted to correlate these anatomic measurements with the specimens’

weight, height, sex, race and age. Using a specially designed computer program,

the DMAA and PMAA were measured in relation to the shaft of the first metatarsal

bone, from a digital picture.

We found that males and African-Americans had longer and wider metatarsals

than females and Caucasians. A joint was present between the first and second

bases in 25 percent of the specimens.

The DMAA ranged from 30° of lateral deviation to –14° of medial deviation,

with an overall average of 8.2°. It increased 1.2° to 3° with every 10-year increment

in age for both the right and left bones (p<0.013 and <0.001, respectively). The

average increase from 20 to 60 years of age was 4.45°.

The PMAA (normally medially deviated, as reported in the literature) ranged

from 12.7° of medial deviation to –13.8° of lateral deviation, with an overall aver-

age of 0°. Medial deviation of this angle was increased among African-Americans

and in wider shafts. Lateral deviation of the PMAA was significant when a joint

was present between the bases of the first and second metatarsals (p<0.001).

Of clinical importance were the findings that the DMAA had a wider range

than reported in the literature and that it increased with age. This might influence

the choice of treatment. Although noting an increased DMAA is important in

adolescence, it may also be important in the older population when determining

surgical treatment for a hallux valgus deformity.

In addition, lateral deviation of the PMAA — which was common when an

articulation was present between the first and second metatarsals — could predis-

pose to a varus first metatarsal as well as a hallux valgus deformity. This elevated

PMAA may need to be addressed surgically and should be looked for, especially

in an individual with a 1-2 metatarsal joint.

Dr. Brian Donley, of the Section of Foot and Ankle Surgery, has a strong interest

in research and in the treatment of fractures and bunions, reconstruction after

foot and ankle trauma, acquired deformities including flat feet, and arthritis

and sports injuries in the foot and ankle. He can be reached at 216/445-2570

or 800/553-5056, ext. 52570. Dr. James Sferra, head of the Section of Foot and

Ankle Surgery, specializes in all aspects of foot and ankle reconstruction. He can

be reached at 216/445-8507 or 800/553-5056, ext. 58507.

Using “Old Bones”to Discover New Information About the Anatomy of the First MetatarsalBy Brian Donley, M.D., and James J. Sferra, M.D.

comprehensive agenda. This programwill serve as an excellent setting for clini-cal and translational research, allowing usto collect plantar pressure measurements,quantitative information on wound heal-ing, and data from computerized medicalrecords.

Through the same program, we will offer symposia on preventive diabetic foot care to health care providersthroughout the United States, and in2004 will host a research symposium expected to attract investigators fromaround the world. (See our OrthopaedicCME Calendar on page 13.)

Our Diabetic Foot Clinics, estab-lished in April 2003 at our main campusand family health centers throughoutGreater Cleveland, offer patients access to the program’s many specialists. Theseinclude orthopaedic foot and ankle surgeons, vascular surgery and vascularmedicine specialists, dermatologists,infectious disease specialists, physical

7

medicine and rehabilitation (includingprosthetics and orthotics) specialists,podiatrists and internists.

Dr. Peter Cavanagh is chairman ofthe Department of Biomedical Engineeringand academic director of the ClevelandClinic Diabetic Foot Care Program. He has been involved in the study of diabeticfoot complications for a number of years,including a term as chair of the American Diabetes Association Council on Foot Care.Dr. Cavanagh works closely with JosephIannotti, M.D., Ph.D., chairman of the Department of Orthopaedic Surgery (seearticle on our cover), and with the foot and ankle surgeons, and podiatrists, in the Department of Orthopaedic Surgery.

To refer patients to the Diabetic Foot CareProgram, call 888/931-FOOT (3668).

This digital caliper was used to measuremetatarsal length.

Dr. Brian Donley (right) and Bruce Latimer, Ph.D., executive director of the Cleveland Mu-seum of Natural History (left), with a portion of the Hamman-Todd Osteological Collection,containing 3,100 human skeletons collected between 1893 and 1938.

While progress has been made in detect-ing “SLAP” lesions by clinical exam andMRI arthrography, diagnosis remains achallenge to treating physicians. Denot-ing injury to the “Superior glenoidLabrum from Anterior to Posterior,”SLAP lesions typically cause patients todevelop pain and a popping or clicking of the shoulder with elevation, adductionor internal rotation. However, the physi-cal exam can often be equivocal.

The labrum, a fibrocartilagenousstructure, helps to deepen the socket ofthe glenoid. Loss of superior labral stabil-ity reduces the ability to withstand infe-rior translation of the humeral head onthe glenoid. The ability to withstand external rotation forces, thereby placinggreater stress on the inferior gleno-humeral ligament and increasing pa-tients’ susceptibility to anterior instability,also occurs. The long head of the bicepsserves as a humeral-head depressor andin the abducted position helps to limit internal rotation.

The most common injuries are dueto compression or traction. Compres-sion, where the superior labrum isdriven cephalad by the humeral head,occurs from a fall on an outstretchedarm. The typical traction injury mecha-nism involves a sudden eccentric loadto the biceps tendon, such as catching a falling object.

Four types of SLAP lesions can de-velop: Type I, where the superior labrumis frayed and degenerated, but the bicepsanchor is intact; Type II, where the supe-rior labrum and biceps anchor are de-tached from the insertion on the superiorglenoid, allowing the complex to archaway from the glenoid neck; Type III,where the superior labrum has a bucket-handle tear, but the remaining biceps tendon and labral rim attachment are intact; and Type IV, where a bucket-handle tear of superior labrum extendsinto the biceps anchor, and the torn bi-ceps tendon and labral flap are displacedinto the joint.

A careful history — with attention to mechanism of injury, description ofpain and popping or grinding, and loss of range of motion and strength — willlead one in the direction of a SLAP injury.

Cleveland Clinic Sports Health: A Resource for the Injured Elite Athlete

SLAP Lesions of the Shoulder: A Diagnostic ChallengeBy James S. Williams, M.D., and Richard D. Parker, M.D.

8

On physical exam, patients oftenhave scapular winging, popping/grind-ing, loss of range of motion, increased inferior translation and impingementsigns. While no test is specific for SLAPlesions, O’Brien’s tests, which attempt to compress the superior labral/bicepscomplex between the glenoid andhumeral head, can be helpful.

MRI arthrography is currently thebest form of imaging to confirm SLAP lesions. Bright signal has been noted inthe biceps labral anchor, superior glenoidlabrum, superior glenoid fossa, or dis-placement of the labrum inferior and glenoid labral cyst with SLAP lesions.

Nonoperative treatments such asNSAIDS, rehabilitation and avoidance of provoking activities can help to dimin-ish symptoms, but seldom give completerelief. Operative treatment in the form of arthroscopic debridement or fixationprovides more definitive relief.

Surgical treatment for SLAP lesionscenters on:

• simple arthroscopic debridement forType I;

• arthroscopic fixation for Type II:The superior glenoid is debrided tobleeding bone, while the labrum isfixed anteriorly and posteriorly withsuture anchors or tacs;

• arthroscopic debridement of buckethandle labral tear for Type III;

• arthroscopic debridement for TypeIV lesions less than 30 percent of bi-ceps width, and biceps tendon re-lease or tendonesis for lesions over30 percent of biceps width.

For Type II, III or IV lesions, additionalcapsulorrhaphy, in the form of rotatorcuff internal closure, suture or thermaltightening (depending upon results ofexam under anesthesia and degree ofassociated capsule and ligamentous injury) may be necessary.

Rehabilitation requires protection,followed by global shoulder strengthen-ing. Range-of-motion and strengtheningexercises are required following simpleSLAP lesion debridement. Six weeks ofrehabilitation are required after repair of Type II or IV lesions, with daily passiverange-of-motion exercises followed bygradual strengthening exercises.

Dr. James Williams, medical director of Cleveland Clinic Orthopaedics at EuclidHospital, specializes in sports medicine,knee and shoulder surgery and arthroscopy,as well as cartilage repair/transplantation.He can be reached at 216/692-7770.Dr. Richard Parker, head of the Clinic’sSection of Sports Medicine, specializes in arthroscopy, knee and shoulder surgery.He can be reached at 216/444-2992 or800/553-5056, ext. 42992.

MR arthrogram reveals Type II SLAPlesion (arrow).

Initial appearance of Type II SLAPlesion prior to probing.

Probing reveals detachment superiorly.

Appearance after arthroscopic repairwith suture anchors.

The NBA star had a problem: Should he play or should he go? His team was dependingon the player (name withheld due to confidentiality) to help win some big games.

Unfortunately, persistent tendinitis produced sharp, shooting pains in his tibiotalarjoint when he dribbled hard. His team’s doctor advised him to rest, and told him thatsurgery was an option. However, he would miss some crucial playing time.

The player didn’t want to let his team down, and was sure his coaches and man-agement wanted him out on the floor. Missing playing time also might decrease his value on the market. Frustrated, he sought a second opinion from a source unconnect-ed to the team: Cleveland Clinic Sports Health.

Director John Bergfeld, M.D., an orthopaedic surgeon, examined the hoopster. He took a thorough history, and reviewed X-rays, and prior workups and treatments,then ordered new X-rays, an MRI, a CT and other imaging tests.

His recommendation: decompression and partial synovectomy. Without surgery,the ankle injury would progessively worsen.

“When we suggested surgery, the player seemed relieved,” Dr. Bergfeld says. “But the final decision was one that he, his family and his business manager had to make. We told him he would have to bite the bullet and miss four months of the season.”

At Cleveland Clinic Sports Health, Dr. Bergfeld coordinates clinical care with agroup of medical and surgical specialists who understand the athlete. Foot and anklespecialist Brian Donley, M.D., with Dr. Bergfeld assisting, performed the decompression

Dr. John Bergfeld, director of Medical Affairs for Cleveland Clinic Sports Health and team physicianfor the Cleveland Browns since 1976, notes that evaluation by a third party not only alleviates an injured player’s concerns, but helps team management understand what’s at stake for the athlete.

Treatment for first-time shoulder disloca-tion varies, depending on chronicity, age,traumatic vs. atraumatic injury, degree of joint laxity and severity of injury.

For young patients with first-timedislocations of the glenohumeral joint,acute operative treatment provides amore predictable outcome, with highersuccess and patient satisfaction rates thannonoperative treatment. In contrast, olderfirst-time dislocators without rotator cuffinjury often do well with rehabilitation.

The shoulder is the most mobilejoint in the body, relying on a complex interaction between dynamic stabilizers(muscles) and static stabilizers (bone,ligaments, capsule and labrum). There is tremendous individual variation inshoulder laxity.

Subluxation and dislocation are two pathologic processes responsible forshoulder instability, or symptomatic ex-cessive translation of the humeral headon the glenoid. In subluxation, thehumeral head slides partially out of theglenoid; in dislocation, the humeral headcomes completely out of the glenoid.

Anterior instability accounts for 95percent of all shoulder instability. Trau-matic anterior instability is seen moreoften in young athletes playing contactsports. Multidirectional instability — inferior plus anterior being the mostcommon — is more common amongathletes using repetitive overhead move-ments, such as swimmers.

Subtle forms of instability (repetitivesubluxation) produce pain, weakness,occasional numbness and a sense of theshoulder shifting in the socket. The physi-cal exam typically demonstrates weak-ness, scapular winging and greatertranslation of the humeral head on the glenoid in the injured shoulder.

Dislocations can be transient and reduce on their own, but often require reduction in an emergency room. Themechanism of injury is typically excessiveforce to an abducted externally rotatedarm, such as an arm tackle in football.After reduction, patients demonstratepersistent apprehension to motions that

simulate the position of their arm at thetime of injury.

Those with less severe forms of sub-luxation will often respond to a goodphysical therapy program, emphasizingrotator-cuff and scapular-stabilizerstrengthening exercises. Athletes have to be consistent with these exercises year-round or risk symptom recurrence.Should they fail conservative measures,arthroscopic or open repair of the injuredcapsule, ligaments and/or labrum will be necessary.

The treatment of traumatic disloca-tions often varies by age. The younger thepatient, the greater the chance of redislo-cating. The redislocation rate for teen-agers is over 90 percent. For those aged 40 and older, the redislocation rate ismuch lower, but the chance of associatedrotator cuff tear is very high.

MRI arthrography is most helpful inthe traumatic dislocator group, providinginformation not only about the anteriorlabral injury (Bankart lesion), but alsoabout the rotator cuff in older patients.Older patients without rotator cuff in-juries do well with rehabilitation, althoughyounger first-time dislocators do not.

Because of their high recurrencerate, arthroscopic or open fixation ofthe anterior labrum back to the glenoidusing suture anchors or bioabsorbabletacs has gained popularity for young athletes playing contact sports. Successrates for preventing redislocation are inthe 90 percent range with surgery, com-pared to 10 percent without surgery.

Dr. Richard Parker, head of the Section of Sports Medicine, specializes in arthroscopy, and knee and shoulder surgery. He can be reached at 216/ 444-2992 or 800/553-5056, ext. 42992.Dr. James Williams, medical director ofCleveland Clinic Orthopaedics at EuclidHospital, specializes in sports medicine,knee and shoulder surgery and arthroscopy,as well as cartilage repair/ transplantation.He can be reached at 216/692-7770.

Consider Age and Other Factors in Treating First-Time Shoulder DislocationBy Richard D. Parker, M.D., and James S. Williams, M.D.

9

MR arthrogram demonstratesacute Bankart lesion (arrow;avulsion of inferior glenohumeralligament from anterior inferiorglenoid).

Arthroscopic visualization ofBankart lesion in right shoulder,from 2 o’clock to 7 o’clock. Sutureanchor fixation and slow method-ical rehabilitation are in order.Left: Before arthroscopic stabiliza-tion . Lower left: after arthroscopicstabilization.

and partial synovectomy to relieve the player’s tendinitis. A foot cast was prescribed for three weeks, and a rocker-bottom boot for three more, to allow for ambulation and ankle mobility.

At that point, proprioceptive, peroneal strengthening and heel-cord stretching exercises were prescribed by Cleveland Clinic Sports Health physical therapists tostrengthen (and preserve range of motion) in the ankle. After two more months ofphysical therapy, the player rejoined his team in time for an exciting playoff run.

Dr. Bergfeld and his team of knee, ankle, shoulder, elbow and hand specialists have been called on for such second opinions by more than 100 professional or semi-professional athletes over the last five years. These include figure skaters, hockey play-ers, football players, golfers, tennis players and soccer players from around the world, as well as elite athletes at the high school and college levels.

Some of the common injuries they see in these athletes besides tendinitis are anterior cruciate ligament tears, torn rotator cuffs, cervical spine fractures, transientparaplegia, ligamentous injuries to the elbow and cardiac problems, especially rhythmdisorders. Retired sports figures also seek help at The Clinic for conditions such as post-traumatic arthritis, spinal stenosis, degenerative arthritic problems and cardiovasculardisorders, says Dr. Bergfeld.

Richard D. Parker, M.D., head of the Orthopaedic Surgery Department’s Section ofSports Medicine, notes that “99 percent of all team physicians have the athlete’s best interests in mind. However, because of the physician’s relationship with management,

players are often gratified to get a neutral opinion from a party with no financial interest.” Dr. Bergfeld adds, “Evaluation by a third party away from their intense professional

environment can help to alleviate an athlete’s concerns. But that goes both ways. An objective evaluation also helps team management understand what is at stake for the athlete.”

Bob Kain, president and co-chief executive officer of IMG, a Cleveland-based sportsmanagement company representing hundreds of professional athletes, agrees. “Part of our job is protecting our athletes,” he says. “When they get hurt, it’s understandablethat they want a second opinion from someone not connected to the team or to anysponsorship deals they may have lined up.”

Mr. Kain likes the continuum of care provided at The Cleveland Clinic, where thesame team of health care professionals handles the athlete’s diagnosis, surgery and rehabilitation. “That helps prevent athletes from coming back too fast and possibly re-injuring themselves,” he notes. “A multispecialty hospital is a great resource.”

Cleveland Clinic sports medicine specialists work closely with orthopaedic surgerycolleagues also experienced in dealing with elite athletes. For non-sports-related problems, they consult with other specialists among the 120 disciplines represented at The Cleveland Clinic. For consultations or second opinions on the full range of sports injuries, please call 877/440-TEAM (8326).

One of the challenges facing orthopaedicsurgeons is control of pain following sur-gical procedures. Pre-emptive analgesiausing an indwelling epidural catheter canachieve “painless total knee replacement.”

Total knee arthroplasty has becomeincreasingly common. More than 300,000total knee arthroplasties are now per-formed annually in the United States.

Pain is one of the major concerns for these patients and their health careproviders. Severe pain, reported by 60percent of patients following total kneearthroplasty, interferes with rehabilita-tion, and leads to stiffness and dissatisfac-tion with outcome. This can createapprehension about surgery in patients,as well as the community at large.

Postoperative pain relief can beachieved after total knee arthroplasty by a variety of techniques, including in-travenous patient-controlled analgesia(IVPCA), oral pain medication, femoralnerve blocks and epidural analgesia.

Conventional IVPCA accomplishesthe goal of postoperative pain control.However, by affecting the brain — distantfrom the source of the pain — systemiceffects include sedation, GI disturbancesand respiratory depression. Patients self-administer narcotics in response to painperception, so pain is not prevented.Severe pain is often experienced in theearly postoperative period as the spinalwears off.

There is increasing interest in alter-native techniques, such as indwellingepidural catheters, to provide steadier,more effective analgesia and avoid theepisodic, excruciating pain that requiresaggressive treatment. This analgesic effectcan be considered pre-emptive, prevent-ing pain before it even occurs.

Analgesia using an indwellingepidural catheter offers several advan-tages. It can be the sole method ofproviding anesthesia as well as postopera-tive pain management, or it can be usedin conjunction with a spinal anesthetic or general anesthesia.

A functioning epidural catheter prevents the “wind-up”phenomenon ofsevere pain in the recovery room, whichrecruits additional pain pathways andcauses hyperpolarization of the dorsalcolumn, making subsequent pain controlmore difficult to achieve.

With proper dosing, sensory fibersare blocked before motor fibers, allowingthe patient to move the knee during physical therapy without associated pain.This can speed rehabilitation and lead toshorter hospital stays.

In a randomized study of patientsundergoing total knee arthroplasty at TheCleveland Clinic, 381 individuals were assigned to either spinal or epidural anes-thesia. Pain scores were obtained at restand during physical therapy. There was a significant decrease in pain reported by

those patients with an epidural cathetercompared to those who had IVPCA followed by oral pain medicine.

No complications occurred thatcould be attributed to the epiduralcatheter, which was left in place for up to seven days. Epidural analgesia also had a beneficial effect with regard tothrombophlebitis. This is important,because patients with indwelling epiduralcatheters are not given low-molecular-weight heparin for thromboprophylaxis,due to the rare but calamitous occurrenceof an expanding epidural hematoma.

It has been well-established that regional anesthesia is superior to generalanesthesia in rates of deep vein thrombo-sis. This is due to increased peripheralblood flow, an effect that is prolongedwith indwelling epidural catheters. In addition, platelet aggregation is directlyinhibited by local anesthetics, which areabsorbed into the circulation from theepidural infusion.

The patient comfort produced by an epidural catheter also results in de-creased sympathetic tone, associated witha lower tendency toward DVT formation.In our study, there was no difference inthe DVT rate between the two groups as assessed by duplex ultrasound, eventhough patients who received spinalanesthetics were treated prophylacticallywith enoxaparin, while those with anepidural were not.

The long-term health consequences ofobesity in childhood include diabetes, hy-pertension, gall bladder disease and sleepapnea. Slipped capital femoral epiphysis(SCFE) — in which dysfunction of theproximal femoral growth plate allows theproximal femoral epiphyses to slide offthe underlying metaphysis — is a com-mon orthopaedic consequence of obesityin children.

Epidemiological studies of SCFEdemonstrate that more than half the children with this disorder are over the95th percentile in weight and the 97thpercentile in height for their age. SCFE is also more common among African-American children and lower socioeco-nomic groups, observations which may

simply reflect the increased risk of obesityin these subpopulations.

In addition to increased body mass,delayed skeletal maturation has also beenfound in children with SCFE.

Although the etiology of SCFE is unknown, the combination of increasedmechanical stress resulting from obesity,along with the relative weakness in thegrowth plate associated with delayedskeletal maturation, have been suggestedas ultimate causes.

In light of the central role played bythyroid hormone in regulating skeletalmaturation at the growth plate, it is notsurprising that even normal-weight chil-dren with hypothyroidism are known tobe at increased risk of SCFE.

Advances in the understanding ofadipogenesis and lipid metabolism at themolecular level reveal the existence of afamily of nuclear hormone receptors thatlink nutritional signals to the control of gene expression. These receptors areinduced or activated in response to ahigh-fat diet.

These molecules, termed peroxisomeproliferator-activated receptors (PPARs),are also expressed in bone and cartilage,and may interfere with thyroid hormonereceptor (TR)-mediated gene transcrip-tion in cells in which the receptors are co-expressed.

Given that peroxisomal function isrequired for normal endochondral ossifi-cation, and that thyroid hormone plays acentral role in regulating skeletal matura-tion at the growth plate, it is reasonable to ask whether cross-talk exists betweenTR- and PPAR-mediated gene transcrip-tion in growth plate chondrocytes.

Preceding observations of the con-vergence of signaling pathways for the receptors suggest that obesity may inducethe expression of PPAR isoforms ingrowth plate chondrocytes. These iso-forms may then interfere with normalthyroid hormone-mediated regulation of skeletal maturation.

The delay in maturation at thegrowth plate, combined with mechanicalstress from the increased body weight,may combine to cause the failure of nor-mal growth plate function that allows the proximal femoral epiphysis to slip.

SCFE in obese euthyroid children,who represent the most common subsetof patients with this disorder, may there-fore be caused in part by a “functional hypothyroidism.”This would result frominhibition of TR-mediated gene tran-scription by PPARs, despite normal circulating levels of thyroid hormone.

Our laboratory is testing the hypoth-esis that PPARs are inducible repressorsof TR-mediated gene transcription in

Painless Total Knee Arthroplasty Employs IndwellingEpidural Catheter for Pre-Emptive AnalgesiaBy Peter J. Brooks, M.D.

In surgery, pain is considered the“fourth vital sign,”and effective painmanagement is an important goal. It isour responsibility as orthopaedic sur-geons to prevent pain, anxiety, fear ofsurgery and difficult rehabilitation fol-lowing knee arthroplasty. The use of anindwelling epidural catheter for “painlesstotal knee replacement”can result ingreater satisfaction for both the patientand the health care team.

Dr. Peter Brooks specializes in totaljoint replacement, especially of the hipand knee, and maintains an active inter-est in arthroscopy of the knee. He can be reached at 216/444-4284 or 800/553-5056, ext. 44284.

Research Points to “Functional Hypothyroidism”as Link Between Obesity and SCFEBy R. Tracy Ballock,M.D.

growth plate chondrocytes. If our hy-pothesis is confirmed, these data will provide a firm biological foundation for returning to the bedside for clinicalstudies of potential PPAR activation inobese euthyroid children with slippedcapital femoral epiphyses.

Dr. Tracy Ballock, head of the Sectionof Pediatric Orthopaedic Surgery, directs a laboratory supported by a $1.2 million,four-year NIH grant. In his clinical prac-tice, Dr. Ballock focuses on hip dysplasia,clubfoot deformity, leg-length discrepancyand other pediatric orthopaedic disorders.To reach Dr. Ballock, please call 216/444-5775 or 800/553-5056, ext. 45775.

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Dr. Peter Brooks believes use of epiduralcatheters produces greater satisfaction for bothpatient and health care team.

Dr. Tracy Ballock, head of the Section ofPediatric Orthopaedic Surgery, is also active in basic research.

Frog lateral radiograph of child’s hip demon-strates a slipped capital femoral epiphysis.The epiphysis of the femoral head is slippingposteriorly on the femoral neck, through thegrowth plate.

It has become a cliché to state that the advent of new technology has “dramatically

changed” an orthopaedic procedure and its results. Clearly, total hip implants have

changed significantly in the past 25 years, yet we continue to compare the results of

total hip arthroplasty with the Charnley prosthesis. Therefore, when we look at spinal

surgery in adolescents, we have to look not only at length of stay, and whether or not

the rods are titanium. We need to be sure that we are using the best approach, not

just the newest.

Having said that, adolescent idiopathic scoliosis surgery really has gone through

a revolution in the past 10 years; we appear to be doing a better job on all fronts be-

cause of changes in instrumentation and philosophy. The resurgence of interest in

the anterior approach to curve correction is largely due to advances in implant design

and technology.

The chief goals of scoliosis surgery — to halt curve progression and fuse the

affected segment of the spine — remain the same. Segmental fixation has essentially

eliminated postoperative casting and bracing in the large majority of cases.

The main advantage of the anterior approach to curve correction is that it allows

us, in most cases, to fuse a shorter segment of the spine while achieving an equal, if

not greater, correction than the posterior approach. Fusion of vertebral bodies is typical-

ly rapid and reliable, and future procedures to the posterior lumbar spine (especially

lumbar puncture and epidural anesthesia) are not affected.

Although anterior spinal instrumentation has been available for more than 30

years, the unreliability of some implants, and the need for postoperative immobilization,

limited both applicability and enthusiasm for their use. Today’s implant systems are ex-

ceptionally stable and strong, allowing powerful corrective forces to be applied to the

curve. Their stability allows for a brace-free postoperative course and independent

ambulation, usually by the third postoperative day.

The anterior approach is indicated for treatment of curves both of the lumbar and

thoracic spine, as well as thoracolumbar curves. The King II and III curve, previously in

the pure domain of the posterior approach, can now be managed through an anterior

approach via thoracotomy, or in some cases, thoracoscopy. Thoracolumbar curves are

approached through a thoracoabdominal approach, facilitating exposure above and

below the diaphragm.

Fixation in the anterior portion of the spine is achieved through screws placed

transversely through the vertebral body at each level. The screw, in turn, is affixed to

a rod that varies in diameter from 4.5 mm to 6.5 mm. Many spinal surgeons prefer

to use titanium implants anteriorly so as not to affect future MRI compatibility.

Two screws per vertebral body and a dual rod construct are frequently used for

thoracolumbar curves, while a single rod construct is more typical for pure thoracic

applications.

Hospital stay following instrumented anterior fusion is essentially the same as

for posterior fusion. Return to school is typically at the three- to four-week mark, and

athletic activities are restricted until the vertebral bodies demonstrate good radiograph-

ic consolidation — usually at six to eight months.

While much remains to be studied when comparing anterior to posterior fusion

using current technology, early data certainly indicate that correction of the curvature

is comparable, if not superior, to traditional posterior instrumentation. Clearly, the

number of levels requiring fusion is less with the anterior approach.

Internal thoracoplasty, resulting in markedly improved cosmetic appearance, is

easily performed during the procedure. This provides an abundant supply of autoge-

nous grafting material, sparing the expense of allograft bone and the morbidity of

obtaining bone from the iliac crest.

While not all curves are currently appropriate for a pure anterior approach, it is

an excellent tool in our expanding surgical armamentarium for the treatment of spinal

deformities.

Dr. Thomas Kuivila, of the Section of Pediatric Orthopaedics, specializes in

scoliosis surgery, and pediatric and adolescent trauma surgery. He can be reached

at 216/444-2741 or 800/553-5056, ext. 42741.

11

Anterior Spinal Fusion for Pediatric and Adolescent Spinal Deformity:Shorter Fusions, Greater CorrectionsBy Thomas E. Kuivila, M.D.

PA scoliosis view of 14-year-old boy with right thoraciccurve of 59 °.

Postoperative view following anterior instrumented fusionfrom T11 to L3 (dual screw androds construct). Cages were usedto prevent collapse into kyphosis.

PA view of 14-year-old girl withleft thoracolumbar curve of 42°.

Postoperative view after an-terior thoracic fusion fromT6 to T12. Cages at T10-T12 and T11-T12 preventdisc space collapse and junc-tional kyphosis.

Advances in implant design and instrumenta-tion have sparked renewed interest in the anterior approach.

Cervical laminaplasty, or posterior decompression of the spinal cord without removal ofthe lamina, avoids some of the risks and complications associated with laminectomy formany patients with cervical myelopathy.

Cervical myelopathy — in which cervical spinal cord compression produces a syn-drome characterized by progressive neurological dysfunction — may in full-blown formcause gait disturbance, extremity weakness, and bladder and bowel dysfunction. Objec-tive neurological findings include long-tract signs such as spasticity, hyperreflexia andclonus. Abnormal neurological signs, such as a Babinski response and Hoffman sign,may also be present.

The etiology of cervical myelopathy is diverse, but common causes include spinalcord compression due to disc herniation or age-related degenerative changes (cervicalspondylotic myelopathy or CSM).

When cervical myelopathy has a compressive cause, surgical decompression is thetreatment. Its goals are to reduce the potential for progression and further clinical dete-rioration, and to allow for some improvement in function. However, decompression —whether performed posteriorly or anteriorly — has its risks.

Anterior decompression involves either anterior cervical discectomy and fusion formyelopathy from disc herniation, or multilevel corpectomy and fusion for more diffusedisease. Potential risks associated with multilevel anterior corpectomy include:

• neural injury from insertion of a Kerrison rongeur into a severely compressed spinal canal

• esophageal injury• dysphagia from esophageal retraction• dysphonia from injury to the recurrent laryngeal nerve and • vertebral artery injury from extreme lateral decompression.

Dysphagia following lengthy anterior decompression is more common than previ-ously believed, and may be particularly problematic in elderly patients by interferingwith nutrition.

Posterior decompression — traditionally involving cervical laminectomy, or removalof one or more lamina to decompress the central and foraminal canal — avoids many of the risks associated with anterior surgery. However, laminectomy has several draw-backs, including potential neurological deterioration from insertion of surgical instru-ments into a severely stenotic spinal canal, and risks of kyphotic deformity, particularlyin young patients, unless laminectomy is accompanied by posterior instrumented fusion. This is due to loss of the protective and stabilizing functions of the posteriorbony and ligamentous structures.

In 1938, Japanese surgeons introduced cervical laminaplasty as an alternative tolaminectomy for posterior cervical decompression for CSM due to ossification of theposterior longitudinal ligament (OPLL).

Cervical laminaplasty has since been advocated for cervical spondylosis due to other etiologies. Laminaplasty, involving posterior decompression without removal ofthe lamina, expands the spinal canal by “hinging” the lamina open (see illustrations).Because it permits the spinal cord to gently displace posteriorly, it depends upon having a lordotic posture; cervical kyphosis is a contraindication to laminaplasty.

The advantages of laminaplasty for spinal canal decompression include:• avoiding risks associated with anterior surgery • preserving the protective and stabilizing function of the lamina • eliminating the need for fusion because spinal stability is not compromised and• the ability to decompress cervical nerve roots on the open side by facetectomy.

Disadvantages include reduced range-of-motion and increased risk of neck pain,and potential injury to the C5 nerve root. This is thought to be a traction injury due tothe increased posterior excursion of the C5 root as the spinal cord displaces posteriorlyfollowing laminaplasty.

The primary technical problem associated with laminaplasty is inadvertent closureof the hinged lamina. Various techniques have been reported for keeping the hinged“door” of the lamina open. The most widely used is Hirabayashi’s method, in which a suture placed around the facet capsule at each level on the hinged side of the lami-naplasty is passed through the supraspinous and infraspinous ligaments, and thenaround the spinous process.

Other techniques and modifications devised to keep the hinge door open and expand the spinal canal all share the same characteristic: preservation of the lamina and posterior ligamentous structures.

In cases of CSM in which cervical lordosis is present, decompression may be safelyaccomplished by either anterior corpectomy and fusion, or by posterior cervical lamina-plasty. If cervical lordosis is not present, however, laminaplasty is contraindicated, anddecompression must be accomplished anteriorly.

Dr. Gordon Bell, head of the Section of Spine Surgery within the Department of Orthopaedic Surgery, is also vice chairman of the department, and a member of theCleveland Clinic Spine Institute. He may be reached at 216/444-8126 or 800/553-5056,ext. 48126.

12

Cervical Laminaplasty: FewerRisks for Selected Patients withCervical MyelopathyBy Gordon R. Bell, M.D. Posterior view of cervical spine

shows intended site of full-thickness osteotomy (solid redline) and intended site of par-tial (greenstick) osteotomy(dotted red line). Laminaplastytypically extends from C3through C7.

Axial view shows full-thicknesscut through left hemilaminaand partial-thickness cutthrough right hemilamina toallow opening on left side andhinging on right side.

Posterior view shows opening of laminaplasty on left sidethrough full-thickness os-teotomy, and hinging of lami-naplasty on right throughpartial-thickness cut.

Axial view post-laminaplastyshows lamina opened on leftside with laminaplasty “door”hinged through partial-thick-ness cut on right. Suture placedthrough right facet joint cap-sule and tied around spinousprocess keeps “door” open; suchsutures are placed at each levelincluded in laminaplasty.

The first Cleveland Clinic Bone Summit, “The Clinical Science of Skeletal Repair, Maintenance and Regeneration,” slated for May 13 to 15, 2004, will explore innova-tive yet practical means of local and systemic repair, augmentation and regeneration of bone tissue. Cell-based therapeutic strategies — including methods of targetingspecific cell populations and cellular processes using customized implant materials,bone morphogenetic proteins (MBPS), PTH, bisphosphonates and statins — will be addressed.

An internationally renowned faculty will lead participants in an exploration of con-temporary biological concepts and technologies essential to the design and assessmentof rational, efficient clinical strategies for bone tissue-engineering and maintenance ofskeletal health. These include: stem cell biology, stem cell kinetics, growth factor andcytokine action and delivery, implant and biomatrix design, cell-matrix interaction,strategies for intraoperative stem cell isolation, manipulation and transplantation, the role of in vivo mass transport and mechanobiology in tissue-engineered grafts, and skeletal health.

Quantitative assessment of stem cell kinetics, bone mass and structural organiza-tion will be defined and applied in the context of contemporary clinical and research

settings. Clinically oriented sessions will focus on fractures and fracture non-union,bone-grafting for spinal fusion, skeletal reconstruction, surgical treatment of bone deficiency, and systemic prevention and treatment of osteoporosis.

Speaking at the landmark summit will be innovators and intellectual leaders in thefields of orthopaedics, neurosurgery, ENT, oral surgery, rheumatology, endocrinology,radiology, pathology, bone-tissue engineering and bone biology. Experts in the fields of bone biology and skeletal therapeutics will provide plenary overviews and lead dis-cussions on basic research and clinical paper presentations.

The summit is sponsored by the Cleveland Clinic’s Department of OrthopaedicSurgery, Department of Biomedical Engineering, Orthopaedic Research Center, Centerfor Osteoporosis and Metabolic Bone Disease, and Center for Women’s Health. Thevenue is the state-of-the-art InterContinental Hotel and MBNA Conference Center at the Cleveland Clinic main campus. A banquet and guest lecture by curator and an-thropologist Bruce Latimer, Ph.D., will be held in the “Dinosaur Hall” of the ClevelandMuseum of Natural History in nearby University Circle, the cultural center of Cleveland.

For more information, visit the Bone Summit Web Site atclevelandclinicmeded.com/summit/bone/index.htm, or e-mail or call Eleanora Voelkel at voelkee@ccf.org or 800/553-5056, ext. 52028.

Cleveland Clinic OrthopaedicCME Calendar Physicians are welcome to attend the following upcoming clinical and basic science symposia:

Sept. 17-18, 2003The Fifth International Bone Fluid Flow Workshop W.O. Walker Rehabilitation Center

Oct. 11-14, 2003Hyaluronan 2003: The International Conference Cleveland Clinic InterContinental Hotel and MBNA Conference Center

Nov. 15, 2003Optimizing Diabetic Foot Care: A Workshop in Collaboration with Penn State UniversityCleveland Clinic InterContinental Hotel and MBNA Conference Center

May 23-26, 2004Current Concepts in Joint Replacement Rio Suites Hotel & Casino, Las Vegas(Co-sponsored by The Cleveland Clinic and by Current Concepts Institute)

May 13-15, 2004Cleveland Clinic Bone Summit 2004:The Clinical Science of Skeletal Repair, Maintenance and Regeneration Cleveland Clinic InterContinental Hotel and MBNA Conference Center

Oct. 7-9, 20032003 Cleveland Clinic Medical Innovation Summit:From Boardroom to Patient Bedside - The Need for Speed Cleveland Clinic InterContinental Hotel and MBNA Conference Center

Oct. 14-16, 2004Lower-Extremity Complications of Diabetes: An International Research Summit Cleveland Clinic InterContinental Hotel and MBNA Conference Center

Dec. 15-18, 2004Current Concepts in Joint ReplacementHyatt Regency Grand Cypress, Orlando, Florida (Co-sponsored by The Cleveland Clinic and by Current Concepts Institute)

For more information, call the Department of Continuing Education at 216/444-5696 or 800/762-8173, or visit www.clevelandclinicmeded.com. For details on The Fifth International Bone Fluid Flow Workshop, con-tact Eleanora Voelkel at voelkee@ccf.org or 800/553-5056, ext. 52028.For details on the Current Concepts in Joint Replacement events, visit www.ccjr.com/intro.

13

Cleveland Clinic Bone Summit 2004

State-of-the-Art Conference Facilities

The new 35,000-square-foot MBNAConference Center, in the InterConti-nental Hotel on the Cleveland Cliniccampus, will be home to many up-coming CME symposia. Its 500-seatamphitheater, interconnected to eightbreakout rooms, is furnished withstate-of-the-art audiovisual and sound systems. Each amphitheater seat isequipped with high-speed Internet access and an audience response sys-tem for instantaneous polling. A linkto Cleveland Clinic operating theatersallows participants to view proceduresand question surgeons in real time.

Clinical and basic science abstracts may be submitted for oral or poster presentation by Feb. 25, 2004.

Alfred J. Cianflocco, M.D.Office: 216/692-7771

Specialty Interests: Neck and back problems,sportsmedicine and general medical orthopaedics

Wayne Daum, M.D.Office: 440/899-5600

Specialty Interests:Nonoperative adult orthopaedics,hip disease,low back pain,sacroiliac pain,and evidence-based medicine

Alan W. Davis, M.D.Office: 440/899-5600

Specialty Interest: Foot andankle surgery

Brian Davis, Ph.D.Office: 216/444-1055

Specialty Interests:Gait analysis,orthopaedic biomechanics,biomedical instrumentation and diabeticfoot ulceration

Kathleen Derwin, Ph.D.Office: 216/445-5982

Specialty Interests:Tendon and ligament biomechanics,andbiology/tissue engineering

Robert J. Dimeff, M.D.Office: 216/444-2185

Specialty Interests:Anabolicsteroid and nutritional supplement use among athletes,and exercise- induced medical disorders

Brian G. Donley, M.D.Office: 216/445-2570

Specialty Interest: Foot andankle surgery

Peter Evans, M.D., Ph.D.Office: 216/444-7973

Specialty Interests: Elbow,hand and shoulder surgery,arthroscopic hand and upperextremity surgery,and peripheral nerve regenera-tion and transplantation

Avrum I. Froimson, M.D.Office: 440/460-8333

Specialty Interests: Surgery of the hand,wrist and elbow

Mark I. Froimson, M.D.Office: 440/460-8333

Specialty Interests: Hip and knee replacement andarthroscopy

A. Seth Greenwald, D.Phil. Office: 216/523-7004

Specialty Interests:Biomechanics and biomaterials of artificial implants

Alan R. Gurd, M.D.Office: 216/444-2616

Specialty Interests:Pediatric orthopaedics,scoliosis,cerebral palsy and spina bifida

James O. Hall, D.P.M.Office: 216/444-9230

Specialty Interests: Generalpodiatric conditions,diabeticfoot care, infections of thefoot,and forefoot surgery

Vincent Hascall, Ph.D.Orthopaedic Research CenterOffice: 216/445-5676

Specialty Interests:Connective tissue biology and role of hyaluronan in inflammation

Christopher Herbert, D.P.M. Office: 440/985-3113

Specialty Interest: Podiatry

Thomas R. Hunt III, M.D.Head,Section of Hand SurgeryOffice: 216/445-6426

Specialty Interests:Adult and pediatric hand,wrist,forearm and elbow surgery;complex reconstruction andarthroscopy of the wrist;reconstruction of arthritic andcongenital deformities; frac-tures and fracture malunions

Susan Joy, M.D.Office: 216/986-4000

Specialty Interest:Sports medicine

Michael J. Joyce, M.D.Office: 216/444-4282

Specialty Interests:Trauma,oncology, total joint replacement and musculoskeletal tissue-banking

Ulf Knothe, M.D., Dr. med.Office: 216/445-6513

Specialty Interests:Adult reconstruction,hip and knee replacement,and orthopaedic research

John A. Bergfeld, M.D.Director,Medical Affairs,Cleveland Clinic Sports HealthOffice: 216/444-2618

Specialty Interests: Sportsmedicine,knee joint disorders and replacement,and traumatic injuries related to sports activity

Allan M. Boike, D.P.M.Office: 216/444-2614

Specialty Interests: Bunionsurgery,forefoot surgery andgeneral podiatric conditions

Lester S. Borden, M.D.Head,Section of Adult ReconstructionOffice: 216/444-2627

Specialty Interests:Primary and revision totaljoint replacement of the hip and knee

Georgeanne Botek, D.P.M.Office: 216/445-8152

Specialty Interests: Diabeticfoot care, forefoot surgery(elective,reconstructive andtrauma),rheumatoid foot,geriatric foot,and musculo-skeletal foot and ankle pathology

John J. Brems, M.D.Head,Section of Shoulderand Elbow SurgeryOffice: 216/444-8361

Specialty Interests: Surgery of the shoulder and elbow,joint replacement and arthritis surgery

Peter J. Brooks, M.D.Office: 216/444-4284

Specialty Interests: Total joint replacement and revision surgery

Anthony Calabro Jr., Ph.D.Office: 216/445-3273

Specialty Interests:Carbohydrate chemistry,especially glycosaminogly-can biology,and tissue- engineering studies ofenvironmental factorsaffecting cartilage metabo-lism and differentiation

John E. Cann, D.P.M.Office: 440/985-3113

Specialty Interest: Podiatry

Peter Cavanagh, Ph.D. Chairman,Department ofBiomedical EngineeringOffice: 216/445-6980

Specialty Interests: Humanbiomechanics,kinesiologyand locomotion,focusing onlower-extremity complica-tions of diabetes and bonemineral loss during long-term space flight

Joseph P. Iannotti, M.D., Ph.D.Chairman,Department ofOrthopaedic SurgeryOffice: 216/445-5151

Specialty Interests: Shoulderdisorders, including sportsinjuries; arthroscopic surgery; complex and revision surgery of the shoulder; shoulder bio- mechanics; and tendon tissue engineering

Thomas E. Anderson, M.D.Office: 216/444-2581

Specialty Interests:Sports medicine and upperextremity surgery,excludingthe hand

Jack T. Andrish, M.D.Office: 216/444-2629

Specialty Interests: Pediatricorthopaedics,scoliosis andsports medicine

Suneel Apte, M.B.B.S., D.Phil.Office: 216/445-3278

Specialty Interests:Connective tissue biology andorthopaedic research

R. Tracy Ballock, M.D.Head,Section of Pediatric Orthopaedic SurgeryOffice: 216/444-5775

Specialty Interests: Pediatricorthopaedics,orthopaedic research and skeletal development

Wael K. Barsoum, M.D. Office: 440/899-5600

Specialty Interests: Hip,knee,elbow and shoulder recon-struction and replacement;hip,knee and shoulderarthroscopy

Thomas W. Bauer, M.D.,Ph.D.Office: 216/444-6830

Specialty Interests:Orthopaedic pathology,metabolic bone disease,surgical pathology and biomaterials

George H. Belhobek, M.D.Office: 216/444-6584

Specialty Interests:Sports medicine radiology,arthrography,orthopaediconcology,musculoskeletalMRI and radiology of joint replacements

Gordon R. Bell, M.D.Head,Section of SpineSurgery; vice chairman,Department of OrthopaedicSurgeryOffice: 216/444-8126

Specialty Interests: Spinal surgery,adult reconstructivesurgery and fractures

14

staff directory

Melissa Knothe Tate, Ph.D.Office: 216/445-3223

Specialty Interests:Mechanobiology of the musculoskeletal system,cellular and biofluid mechan-ics,and physiological and en-gineering models for implantdesign

Michael C. Kolczun II, M.D.Office: 440/985-3113

Specialty Interests:Total joint replacement and sports medicine

Viktor E. Krebs, M.D.Office: 216/445-3834

Specialty Interests: Total jointreplacement,revision totaljoint replacement and hiparthroscopy

Thomas E. Kuivila, M.D.Director,Residency ProgramOffice: 216/444-2741

Specialty Interests: Pediatricand adolescent orthopaedics,scoliosis surgery,Ilizarov tech-niques and pediatric trauma

Jeffrey Lawton, M.D.Office: 216/445-6915

Specialty Interests: Hand,wrist, forearm and elbow surgery, including congenital upper extremity difference and traumatic reconstruc-tions,athletic injuries,carpal tunnel and repetitive injuries,and arthritis

Veronique Lefebvre, Ph.D.Office: 216/445-0762

Specialty Interests:Skeletogenesis,transcriptional regulation,cell differentiation,developmental biology and molecular genetics

Isador H. Lieberman, M.D.Office: 216/445-2743

Specialty Interests:Orthopaedic spine surgery,minimally invasive surgery,scoliosis,spine tumors,andosteoporosis and spine fractures

Kenneth E. Marks, M.D.Office: 216/444-2637

Specialty Interests:Musculoskeletal tumors and joint replacement

Mary Blair Matejczyk, M.D.Office: 216/444-2608

Specialty Interests: Joint replacement surgery of the hip and knee,and ortho-paedic problems in the elderly

David B. Shapiro, M.D.Office: 440/985-3113

Specialty Interest: Surgery of the hand and wrist

Antonie van den Bogert,Ph.D.Office: 216/445-6980

Specialty Interests:Biomechanics, joint injuriesand motor control

James H. Walker, M.D.Office: 216/986-4000

Specialty Interests: Total jointreplacement and trauma

Michael Walker, M.D.Office: 216/444-3603

Specialty Interests:Conservative care of backpain,and nonoperative care of degenerative joint diseaseand sports injuries

Garron G. Weiker, M.D.Office: 216/986-4000

Specialty Interests: Sportsmedicine,and gymnastics and dance injuries

Glenn E. Whitted, M.D.Office: 440/985-3113

Specialty Interests: Total joint replacement and sportsmedicine

James S. Williams Jr., M.D.Office: 216/692-7770

Specialty Interests: Sportsmedicine,knee and shouldersurgery,arthroscopy and cartilage repair/ transplantation

Guang Yue, Ph.D.Office: 216/445-9336

Specialty Interests:Neural control of the hand and fingers,skeletal musclephysiology and biomechan-ics,neuroimaging,humanmotor control,and neuraladaptations in injuries and diseases

Daniel J. Single, M.D. Office: 440/985-3113

Specialty Interest:General orthopaedics

Paul S. Treuhaft, M.D.Office: 440/985-3113

Specialty Interests:General orthopaedics andjoint replacement

Cahir McDevitt, Ph.D.Office: 216/444-5859

Specialty Interests:Biochemistry of connectivetissues in aging and osteoarthritis, intervertebraldisc diseases,biochemistry of adhesion proteins,and proteoglycans and collagens

Patrick J. McKee, D.P.M.Office: 216/445-5161

Specialty Interests: Foot and ankle trauma,painful heel conditions,forefoot deformities and general preventive care

Robert F. McLain, M.D.Office: 216/444-2744

Specialty Interests: Back andneck surgery,reconstructionand lower disc surgery

Ronald Midura, Ph.D.Office: 216/445-3212

Specialty Interests: Bone mineral production,bone and cartilage biochemistry in aging and disease,and hormonal control of the connective tissue matrix

Anthony Miniaci, M.D.Director,Cleveland ClinicSports Health Office: 216/444-2625

Specialty Interest:Sports medicine

Michael E. Moore, M.D.Office: 440/519-6819

Specialty Interest:General orthopaedics

George F. Muschler, M.D.Office: 216/444-5338

Specialty Interests:Musculoskeletal oncology,adult reconstructive ortho-paedic surgery,fracturenonunions,and research in bone healing and bone-grafting materials

R. Douglas Orr, M.D. Office: 440/899-5516

Specialty Interests: Spine surgery,spinal deformity andspinal tumors

Richard D. Parker, M.D.Head,Section of Sports MedicineOffice: 216/444-2992

Specialty Interests: Sportsmedicine,arthroscopy,andknee and shoulder surgery

David W. Piraino, M.D.Office: 216/444-4845

Specialty Interests:Arthrography,bone biopsies,MRI,musculo-skeletal radiology and three-dimensional image processing

Kimerly Powell, Ph.D.Office: 216/445-9364

Specialty Interests:Medical image post- processing,microscopy and high-resolution micro-CT imaging

Michael P. Recht, M.D.Office: 216/444-2285

Specialty Interests:Musculoskeletal radiologyand MRI

Bradford J. Richmond, M.D.Office: 216/444-3931

Specialty Interests: Bone densitometry,arthrography,bone biopsies,CT,MRI andmusculoskeletal radiology

Jonathan L. Schaffer, M.D.Office: 216/444-8960

Specialty Interests:Adult reconstructive surgery and orthopaedic research

Jean P. Schils, M.D.Office: 216/444-0775

Specialty Interest:Musculoskeletal radiology

William H. Seitz Jr., M.D.Office: 216/839-3700

Specialty Interests:Management of all upper extremity problems,includingshoulder,elbow,wrist andhand,from congenital,arthritic,traumatic,neuro-logic and acquired conditions

Alfred Serna, M.D.Office: 440/985-3113

Specialty Interests: Sportsmedicine and total joint replacement

James J. Sferra, M.D.Head,Section of Foot and Ankle SurgeryOffice: 216/445-8507

Specialty Interest:All aspects of foot and ankle reconstruction

Maria Siemionow, M.D.,Ph.D.Office: 216/444-2405

Specialty Interests:Microsurgery,hand surgery,peripheral surgery,transplantation and micro-circulation research

15

9500 Euclid Avenue W/14Cleveland,Ohio 44195

in this issue:Histologic Study of Failed Interbody Fusion Cages. . . . . . . . . . . . . . . 4

“Old Bones” Reveal New Information . . . . . . . . . . . 7

An Objective Resource for the Elite Athlete. . . . . . . . . 8

Pre-Emptive Analgesia in Total Knee Replacement. . . . . . . . . . . . . . 10

Functional Hypothyroidism: Cause of SCFE in Obese Children?. . . . . . . . . . . 10

Bulk RateU.S. Postage

PAIDCleveland, OhioPermit No. 4184

Orthopaedic Insights is a publicationof the Cleveland Clinic Department of Orthopaedic Surgery.

Joseph P.Iannotti,M.D.,Ph.D.Chairman,Department ofOrthopaedic Surgery

Kenneth Marks,M.D.,Editor-in-Chief

Editorial Board:Gordon Bell,M.D.John Brems,M.D.Brian Donley,M.D.Mark Froimson,M.D.Thomas Hunt,M.D.Melissa Knothe Tate,Ph.D.Thomas Kuivila,M.D.Richard Parker,M.D.

Yen Izanec,Marketing ManagerCora Liderbach,EditorDoug Crouch,Graphic Designer

The Cleveland Clinic Foundation is an independ-ent,not-for-profit multispecialty academic medical center,recognized as a National ReferralCenter and an international health resource.It is dedicated to providing quality specializedcare and includes an outpatient Clinic,a Hospitalwith 956 staffed beds,an Education Division and a Research Institute.

www.clevelandclinic.org/ortho

To refer a patient, call 216/444-BONE or 800/553-5056 ext. 42663.

THE CLEVELAND CLINICFOUNDATION

Following is a sampling of thenearly 70 scientific journal arti-cles and textbook chapters pub-lished during the past 12 monthsby members of the ClevelandClinic’s departments of Or-thopaedic Surgery and Biomed-ical Engineering:

Antoniou J, Tsai A, Baker D,Schumacher R, Williams GR, Iannotti JP. Milwaukee shoulder:correlating possible etiologicvariables. Clin Orthop 2003Feb;(407):79-85.

Bauer TW. Particles and periim-plant bone resorption. Clin Or-thop 2002 Dec;(405):138-143.

Botek G. Fungal nail infection:assessing the new treatment options. Cleve Clin J Med 2003Feb;70(2):110-118.

Buchler P, Ramaniraka NA, Rako-tomanana LR, Iannotti JP, FarronA. A finite element model of the shoulder: application to thecomparison of normal and os-teoarthritic joints. Clin Biomech(Bristol, Avon) 2002 Nov-Dec;17(9-10):630-639.

Calabro A, Oken MM, HascallVC, Masellis AM. Characteriza-tion of hyaluronan synthase ex-pression and hyaluronansynthesis in bone marrow mes-enchymal progenitor cells: pre-dominant expression of HAS1mRNA and up-regulatedhyaluronan synthesis in bonemarrow cells derived from multi-ple myeloma patients. Blood2002 Oct 1;100(7):2578-2585.

Carvalho RS, Bumann A, Schaf-fer JL, Gerstenfeld LC. Predomi-nant integrin ligands expressedby osteoblasts show preferentialregulation in response to bothcell adhesion and mechanicalperturbation. J Cell Biochem2002;84(3):497-508.

Cavanagh PR, Boulton AJM,Sheehan P, Ulbrecht JS, CaputoGM, Armstrong DG. Therapeuticfootwear in patients with dia-betes. JAMA 2002 Sep11;288(10):1231-1233.

Donley BG, Vaughn RA,Stephenson KA, Richardson EG.Keller resection arthroplasty fortreatment of hallux valgus defor-mity: Increased correction withfibular sesamoidectomy. FootAnkle Int 2002 Aug;23(8):699-703.

Goldberg JR, Gilbert JL, Jacobs JJ,Bauer TW, Paprosky W, LeurgansS. A multicenter retrieval study of

the taper interfaces of modularhip prostheses. Clin Orthop2002 Aug;(401):149-161.

Graham SM, Parker RD. Anteri-or cruciate ligament reconstruc-tion using hamstring tendongrafts. Clin Orthop 2002Sep;(402):64-75.

Hunt TR, 3rd. What is the appro-priate treatment for Dupuytrencontracture? Cleve Clin J Med2003 Feb;70(2):96-97.

Iannotti JP, Antoniou J, WilliamsGR, Ramsey ML. Iliotibial bandreconstruction for treatment ofglenohumeral instability associ-ated with irreparable capsulardeficiency. J Shoulder ElbowSurg 2002 Nov-Dec;11(6):618-623.

Iannotti JP, Norris TR. Influenceof preoperative factors on out-come of shoulder arthroplastyfor glenohumeral osteoarthritis.J Bone Joint Surg Am 2003 Feb;85A(2):251-258.

Joseph TA, Defranco MJ, WeikerGG. Delayed repair of a pec-toralis major tendon rupturewith allograft: a case report. JShoulder Elbow Surg 2003 Jan-Feb;12(1):101-104.

Joseph TA, Williams JS, Jr.,Brems JJ. Laser capsulorrhaphyfor multidirectional instability ofthe shoulder: an outcomesstudy and proposed classifica-tion system. Am J Sports Med2003 Jan-Feb;31(1):26-35.

Krebs VE. The role of hiparthroscopy in the treatment ofsynovial disorders and loosebodies. Clin Orthop 2003Jan;(406):48-59.

Lieberman IH. A retrospectiveview of seven specifically select-ed cases of patients with osteo-porotic compression fracturesand concomitant radiculopathy.J Spinal Disord Tech 2002Dec;15(6):468.

Lieberman IH. Re: Verlaan JJ,Van Helden WH, Oner FC, et al.Balloon vertebroplasty with cal-cium phosphate cement for di-rect restoration of traumaticthoraco-lumbar vertebral frac-tures. Spine 2002;27:543-548.Spine 2002 Oct 15;27(20):2300-1; discussion 2300-1.

Mason JB, McCarthy JC, O’Don-nell J, Barsoum W, Mayor MB,Busconi BD, Krebs VE, OwensBD. Hip arthroscopy: surgical approach, positioning, and

distraction. Clin Orthop 2003Jan;(406):29-37.

Mata A, Boehm C, FleischmanAJ, Muschler G, Roy S. Growthof connective tissue progenitorcells on microtextured polydi-methylsiloxane surfaces. J Bio-med Mater Res 2002 Dec15;62(4):499-506.

Mata A, Boehm C, FleischmanAJ, Muschler G, Roy S. Analysisof connective tissue progenitorcell behavior on polydimethyl-siloxane smooth and channelmicro-textures. Biomedical Mi-crodevices 2002 Dec;4(4):267-275.

Matsen FA, 3rd., Iannotti JP,Rockwood CA, Jr. Humeral fixa-tion by press-fitting of a taperedmetaphyseal stem: a prospectiveradiographic study. J Bone JointSurg Am 2003 Feb;85A(2):304-308.

May MM, Lawton JN, Blazar PE.Ulnar styloid fractures associat-ed with distal radius fractures:Incidence and implications fordistal radioulnar joint instability.J Hand Surg [Am] 2002 Nov;27(6):965-971.

McDevitt CA, Mukherjee S,Kambic H, Parker R. Emergingconcepts of the cell biology ofthe meniscus. Curr Opin Orthop2002 Oct;13(5):345-350.

McLain RF, Ferrara L, Kabins M.Pedicle morphometry in the up-per thoracic spine: limits to safescrew placement in older pa-tients. Spine 2002 Nov 15;27(22):2467-2471.

Muschler GF, Nitto H, Matsuku-ra Y, Boehm C, Valdevit A, Kambic H, Davros W, Powell K,Easley K. Spine fusion using cell matrix composites enrichedin bone marrow-derived cells.Clin Orthop 2003 Feb;(407):102-118.

Nicholls MA, Lawton JN,Lawrence SJ. Radiologic casestudy. Radial shaft fracture, an-terior interosseous nerve injury,and the presence of a foreignbody within the soft tissues ofthe proximal forearm. Orthope-dics 2003 Jan;26(1):26,111-112.

Nishikawa T, Kurosaka M,Yoshiya S, Lundin TM, GrabinerMD. Effects of prophylactic an-kle supports on pronation dur-ing gait. Int Orthop 2002Dec;26(6):381-385.

Publication Highlights:A Sampling of Publications From Cleveland Clinic Orthopaedic Surgeons and Biomedical Engineering Specialists

Owings TM, Grabiner MD. Motorcontrol of the vastus medialisoblique and vastus lateralis mus-cles is disrupted during eccentriccontractions in subjects withpatellofemoral pain. Am J SportsMed 2002 Jul-Aug;30(4):483-487.

Phillips FM, Pfeifer BA, LiebermanIH, Kerr EJ, 3rd., Choi IS, PazianosAG. Minimally invasive treat-ments of osteoporotic vertebralcompression fractures: vertebro-plasty and kyphoplasty. InstrCourse Lect 2003;52:559-567.

Phillips FM, Wetzel FT, LiebermanI, Campbell-Hupp M. An in vivocomparison of the potential forextravertebral cement leak aftervertebroplasty and kyphoplasty.Spine 2002 Oct 1;27(19):2173-2178.

Ritzman TF, Parker RD. Thermalcapsulorrhaphy of the shoulder.Curr Opin Orthop 2002 Aug;13(4):288-291.

Soslowsky LJ, Thomopoulos S, Es-mail A, Flanagan CL, Iannotti JP,Williamson JD, 3rd., CarpenterJE. Rotator cuff tendinosis in ananimal model: role of extrinsicand overuse factors. Ann BiomedEng 2002 Sep;30(8):1057-1063.

Steck R, Niederer P, Knothe TateML. A finite element analysis forthe prediction of load-inducedfluid flow and mechanochemicaltransduction in bone. J Theor Biol2003 Jan 21;220(2):249-259.

Takikawa S, Bauer TW, Kambic H,Togawa D. Comparative evalua-tion of the osteoinductivity oftwo formulations of human dem-ineralized bone matrix. J BiomedMater Res 2003 Apr 1; 65A(1):37-42.

Tami AE, Nasser P, Verborgt O,Schaffler MB, Knothe Tate ML.The role of interstitial fluid flow inthe remodeling response to fa-tigue loading. J Bone Miner Res2002 Nov;17(11):2030-2037.

Togawa D, Bauer TW, LiebermanIH, Lowery GL, Takikawa S. His-tology of tissues within retrievedhuman titanium mesh cages.Spine 2003 Feb 1;28(3):246-253.

Toole BP, Hascall VC. Hyaluronanand tumor growth. Am J Pathol2002 Sep;161(3):745-747.