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Orthopaedic Surgeon
22 years of experience
Video profile
Accepting new patients

Education ?

Medical School Score Rankings
University of Michigan Medical School (1988) *
  • Currently 4 of 4 apples
Top 25%
Residency
University of MI Hospitals (1993) *
Orthopaedic Surgery
Fellowship
AO International Trauma Fellowship (1992) *
Orthopaedic Trauma
* This information was reported to Vitals by the doctor or doctor's office.

Awards & Distinctions ?

Associations
American Academy of Orthopaedic Surgeons
American Association of Hip and Knee Surgeons
American Board of Orthopaedic Surgery
American Society for Dermatologic Surgery
Aboutstryker.com

Affiliations ?

Dr. Markel is affiliated with 7 hospitals.

Hospital Affilations

Score

Rankings

  • Providence Hospital and Medical Center *
    Orthopaedic Surgery
    16001 W 9 Mile Rd, Southfield, MI 48075
    • Currently 4 of 4 crosses
    Top 25%
  • Saint Joseph Mercy Saline Hospital
    400 W Russell St, Saline, MI 48176
    • Currently 4 of 4 crosses
    Top 25%
  • St John Detroit Riverview Hospital
    Orthopaedic Surgery
    7733 E Jefferson Ave, Detroit, MI 48214
    • Currently 3 of 4 crosses
    Top 50%
  • DMC - Sinai-Grace Hospital
    Orthopaedic Surgery
    6071 W Outer Dr, Detroit, MI 48235
    • Currently 1 of 4 crosses
  • St. Joseph Mercy Hospital Ann Arbor
  • St. Joseph Ann Arbor Hospital
  • Providence Park Hospital
    47601 Grand River Ave, Novi, MI 48374
  • Publications & Research

    Dr. Markel has contributed to 44 publications.
    Title Novel Angle Measurements for Assessment of Shoulder Location Using the Scapular Y Radiograph.
    Date September 2011
    Journal Orthopedics
    Excerpt

    Shoulder dislocation is an injury with potential long-term consequences that requires prompt diagnosis and treatment. Patient positioning and imperfect radiographic views may result in discomfort, added examination time, and problematic diagnosis. The scapular Y radiograph has been shown to be useful in diagnosing shoulder dislocation but is not considered sufficient in isolation. Using a synthetic bone shoulder model, we propose a novel technique wherein osseous landmarks are used to form angles that significantly improved diagnostic accuracy for shoulder dislocation, even in significantly rotated and otherwise indeterminate scapular Y radiographs.

    Title Constrained Acetabular Liners Cemented into Cages During Total Hip Revision Arthroplasty.
    Date December 2010
    Journal The Journal of Arthroplasty
    Excerpt

    The combination of acetabular bone loss and hip instability is challenging. Sixteen patients underwent revision total hip arthroplasty using constrained acetabular liners cemented into cages. The average follow-up was 28 months (range, 24-60 months). Clinical evaluation was obtained using the Harris hip score along with radiographic data. At latest follow-up, 13 patients were available for evaluation. Although the average postoperative Harris hip score was 62 points, which was better than the preoperative score of 27 points, the overall radiographic failure rate was 23%. The combination of poor acetabular bone stock and altered stresses from the increased constraint likely led to the poor outcome. We would only recommend use of a cemented, constrained acetabular liner in combination with a protrusio cage as a bail out or salvage procedure.

    Title Venous Thromboembolism: Management by American Association of Hip and Knee Surgeons.
    Date April 2010
    Journal The Journal of Arthroplasty
    Excerpt

    A 2008 survey of American Association of Hip and Knee Surgeons membership explored current venous thromboembolism (VTE) protocols for lower-extremity total joint surgery. Fifty-three percent reported a change in VTE-related practices in the last 5 years. More than 70% reported that their primary hospital now mandates VTE prophylaxis. Although 74% of their primary hospitals recognized the American College of Chest Physicians guidelines, 68% of surgeons felt the American Academy of Orthopaedic Surgeons guidelines were more relevant to their practice. Respondents believe low molecular weight heparin to be the most efficacious but aspirin to be the easiest to use and has the lowest risks of bleeding and wound drainage. Warfarin was the most used in hospital prophylaxis, and 90% of respondents targeted an international normalized ratio of 1.6 to 2.5. Practice patterns continue to evolve, and there remains no consensus on specific treatment protocols or preferences.

    Title The Effect of Neutron Radiation on Conventional and Highly Cross-linked Ultrahigh-molecular-weight Polyethylene Wear.
    Date October 2008
    Journal The Journal of Arthroplasty
    Excerpt

    The effects of a sarcoma therapy dose level neutron radiation on oxidation and wear were compared between conventional (N2\Vac, Stryker Orthopedics, Mahwah, NJ) and highly cross-linked (Crossfire, Stryker Orthopedics) ultrahigh-molecular-weight polyethylene acetabular liners. Liners were exposed to 15 Gy, a typical sarcoma treatment dose. Wear testing was conducted on a hip simulator. Transvinylene and oxidation indices were measured to determine if significant radiolytic reactions and oxidation occurred after the neutron beam exposure. The neutron bombardment produced further oxidation in both N2\Vac and Crossfire liners. Surprisingly, neutron radiation caused 62% increase in wear for N2\Vac but 0% change for the Crossfire acetabular liners. This study suggested that when joint implants are exposed to neutron beam radiation therapy, the conventional polyethylene liner is at risk for rapid wear.

    Title Macrophage Depletion Diminishes Implant-wear-induced Inflammatory Osteolysis in a Mouse Model.
    Date June 2008
    Journal Journal of Biomedical Materials Research. Part A
    Excerpt

    The purpose of this study was to determine whether macrophage depletion using clodronate liposomes diminishes wear-debris-induced inflammatory osteolysis in a murine osteolysis model. Ultra high molecular weight polyethylene (UHMWPE) particles were introduced into established air pouches on BALB/c mice, followed by implantation of calvaria bone from syngeneic littermates. Macrophages were depleted by the intraperitoneal injection of clodronate liposome (2 mg) 2 days before bone implantation and re-injection every 3 days (1 mg) until the sacrifice of the mice. Mice without clodronate liposome therapy or treated with empty liposome as well as mice injected with saline alone were included in this study as controls. Pouch tissues were collected 14 days after bone implantation for molecular and histology analysis. Our findings indicated that (1) macrophage depletion in clodronate-liposome-treated mice was achieved, as illustrated by F4/80 immunostaining in both pouch and spleen tissues; (2) clodronate-liposome treatment significantly reduced UHMWPE-induced tissue inflammation, with diminished pouch membrane thickness, reduced inflammatory cellular infiltration, and lowered interleukin 1beta (IL-1beta) and tumor necrosis factor alpha (TNFalpha) expression; (3) clodronate-liposome treatment markedly reduced the number of TRAP(+) cells in pouch tissues and protected against bone collagen depletion. In conclusion, this study demonstrates that macrophage depletion using clodronate-liposome reduces UHMWPE particle-induced inflammatory osteolysis. This observation supports the hypothesis that macrophages contribute to the severity of UHMWPE particles induced inflammatory osteolysis, and suggest that macrophage depletion represents a viable therapeutic approach to the prevention and treatment of patients with aseptic loosening.

    Title Observational Study on Intrathecal and Peridural Changes After Routine Spinal and Epidural Anesthesia in Patients Undergoing Total Joint Arthroplasty.
    Date January 2008
    Journal The Journal of Arthroplasty
    Excerpt

    Epidural bleeding from spinal anesthetics or epidural catheter placement is concerning, especially when anticoagulants are used. Little is known of the natural changes that occur subdurally or epidurally after each of these procedures. To describe the natural history and occurrence of bleeding that may result from these anesthetics with anticoagulants, we studied 16 joint arthroplasty patients who underwent spinal magnetic resonance imaging postoperatively. Seven patients had an epidural catheter, 7 had a straight spinal injection, and 2 had a general anesthetic. All patients received 5 mg of warfarin postoperatively, with dosing to an international normalized ratio of 2.0. Magnetic resonance imaging readings were blinded. No magnetic resonance image demonstrated peridural inflammation or hemorrhage. No difference was observed between the anesthetics. Warfarin did not cause abnormal bleeding. Based on these observations, one should consider bleeding or peridural inflammation to be abnormal after spinal or epidural anesthesia.

    Title A Randomized Prospective Study Evaluating the Effect of Patellar Eversion on the Early Functional Outcomes in Primary Total Knee Arthroplasty.
    Date September 2007
    Journal The Journal of Arthroplasty
    Excerpt

    A prospective, randomized, blinded study was designed to investigate the impact of patellar eversion on early quadriceps function after total knee arthroplasty. One hundred twenty-two consecutive patients were randomized by 2 surgeons to receive one of 2 different surgical approaches. Surgeon A randomized patients to receive a mid-vastus split with or without patellar eversion. Surgeon B randomized patients to receive a median parapatellar arthrotomy or a mid-vastus split, both without patellar eversion. For surgeon A, a significantly earlier return of straight leg raise was noted when patellar eversion was avoided. Significant correlation existed between an earlier return of straight leg raise and decreased length of stay. Avoiding patellar eversion enhanced the return of quadriceps function and led to a decreased length of stay in the hospital.

    Title Assessment of Acetabular Version by Plain Radiograph.
    Date May 2007
    Journal American Journal of Orthopedics (belle Mead, N.j.)
    Excerpt

    Radiographs are routinely used to assess the condition and position of the acetabular component. The condition of the cement mantle, or the ingrowth potential, is usually easily recognized. Component-bone position can be assessed by using the method of Ranawat or by measuring abduction angles. Assessment of the version of an acetabular component is often overlooked. This angle or position is important relative to instability, impingement, and motion abnormality. The opening angle or version can be implied from a true acetabular or cross-table lateral radiograph, but good-quality views are often difficult to obtain on an outpatient basis. Using the simple technique presented here, clinicians can assess the acetabular component for version on the basis of plain anteroposterior pelvis and hip radiographs.

    Title Success of Clinical Pathways for Total Joint Arthroplasty in a Community Hospital.
    Date May 2007
    Journal Clinical Orthopaedics and Related Research
    Excerpt

    Clinical pathways for total joint arthroplasty have been implemented successfully during the past decade. We report the results of pathway use for primary elective total hip and total knee arthroplasty in a community teaching hospital. We evaluated pathway efficacy using patient data forms and the hospital's financial database. Before instituting the pathway, the average length of stay was 4.41 days for patients having total hip arthroplasty and 3.92 days for patients having total knee arthroplasty. The average length of stay for patients having total hip arthroplasty decreased to 3.24 days and to 2.98 days for patients having total knee arthroplasty. Press Ganey Survey results showed high patient satisfaction rates before and after pathway initiation. Pathway implementation did not lead to increased complication rates or readmissions. Despite higher expected increases in the overall healthcare cost during the time of implementation (3 years), direct cost increases were limited to 3.48%. The key elements contributing to pathway success included preoperative patient education, standardized orders derived from evidence-based medicine, and a nurse practitioner who championed the pathway and ensured compliance. We recommend clinical pathways for patients having total joint arthroplasties to reduce length of stay, facilitate effective resource use, and preserve quality of care without compromising patient satisfaction or safety.

    Title Blockade of Vascular Endothelial Growth Factor Activity Suppresses Wear Debris-induced Inflammatory Osteolysis.
    Date March 2007
    Journal The Journal of Rheumatology
    Excerpt

    OBJECTIVE: Aseptic loosening is a common complication of total joint replacement in humans. Our study examined the hypothesis that wear debris may influence vascular endothelial grow factor (VEGF) expression, and that blocking VEGF bioactivity might improve wear debris-induced inflammatory osteolysis in a mouse model. METHODS: Ultra high molecular weight polyethylene (UHMWPE) particles were introduced into established air pouches on BALB/c mice, followed by implantation of calvaria bone from syngeneic littermates. Mice were treated with recombinant VEGF, or VEGF inhibitor (VEGF R2/Fc chimera) or vehicle control, and mice without UHMWPE stimulation were also included. Pouch tissues were harvested 2 weeks after bone implantation for molecular and histological analyses. RESULTS: Exposure of UHMWPE particles increased VEGF expression at both mRNA and protein levels in pouch tissues. Immunostaining revealed intense VEGF staining predominantly in UHMWPE deposit foci surrounded by inflammatory cells. VEGF inhibitor treatment strongly attenuated tissue inflammation (cellular infiltration, membrane proliferation, and expression of interleukin 1beta and tumor necrosis factor-alpha in UHMWPE-stimulated pouch tissues). Further, VEGF inhibitor treatment caused a significant reduction in the number of TRAP+ cells, and effectively prevented UHMWPE particle-induced bone resorption of implanted calvaria (assessed by extent of collagen depletion and frequency of bone erosions). CONCLUSION: The observation that VEGF inhibitor treatment prevented UHMWPE particle-induced inflammatory osteolysis opens new possibilities for treatment of aseptic loosening, especially at an early stage.

    Title Inflammatory and Immunological Responses to Hyaluronan Preparations. Study of a Murine Biocompatibility Model.
    Date February 2007
    Journal The Journal of Bone and Joint Surgery. American Volume
    Excerpt

    BACKGROUND: Intra-articular injection of hyaluronan preparations is a popular treatment for osteoarthritis of the knee. Recently, clinical reports have described acute inflammatory reactions in joints following these injections. The purpose of this study was to use a murine pouch model to study the local inflammatory and possibly immunological effects of three commercially available hyaluronan-derived products. METHODS: Each of three different hyaluronan products (Synvisc, Hyalgan, and Supartz) was injected into air pouches established in groups of BALB/c mice. A positive control group (with particle-induced inflammation) and a negative control group (injected with saline solution) were also included. After fourteen days, the mice were killed and the air pouches were explanted and prepared for histological evaluation of the local inflammatory reaction. The antibody response was measured with use of ELISA (enzyme-linked immunosorbent assay) of serum samples obtained after the mice were killed. RESULTS: Histological analysis revealed a significant increase in total membrane cellularity (p < 0.001 to p < 0.03) after the use of all hyaluronan preparations. The increased cellularity was attributed to an inflammatory cell influx, rather than accumulation of fibroblasts, and elevated lymphocyte counts were observed in membranes stimulated by Synvisc (hylan G-F 20). The ELISA data revealed an antibody response to the Synvisc preparation. This immunological response was directed against a non-hyaluronan portion of the product, as indicated by the lack of cross-reactivity with the other hyaluronan products. CONCLUSIONS: These findings demonstrate that all three hyaluronan preparations, as currently manufactured, can cause an inflammatory soft-tissue reaction, but only the non-hyaluronan portion of the Synvisc product created an immunological response. It appears likely that this component may be the target of adverse responses in patients.

    Title The Effect of Posterior Tibial Slope on Range of Motion After Total Knee Arthroplasty.
    Date January 2007
    Journal The Journal of Arthroplasty
    Excerpt

    Posterior slope has been theorized as advantageous to range of motion (ROM) after total knee arthroplasty. This study was undertaken to assess the accuracy of a 0 degrees and a 5 degrees posterior sloped intramedullary (IM) cutting guide and the effect of the posterior tibial slope on postoperative ROM. Thirty-one consecutive patients underwent total knee arthroplasty using a cutting block and intramedullary cutting guide designed to impart a 0 degrees posterior tibial slope (group 1). A 5 degrees tibia cutting block was used in 30 subsequent patients (group 2). The posterior slope measurement represented the angle between a line drawn parallel to the articular surface and a line drawn perpendicular to the long axis of the tibia on a lateral radiograph. Mean postoperative tibial slope measured 1.8 degrees for group 1 and 5.5 degrees for group 2. There was no significant difference between groups for postoperative flexion or improvement of Hospital for Special Surgery score. The tibial cutting guides accurately achieved the intended posterior slope, but increasing posterior slope did not result in a significant increase in ROM or Hospital for Special Surgery functional score.

    Title Association Between Uhmwpe Particle-induced Inflammatory Osteoclastogenesis and Expression of Rankl, Vegf, and Flt-1 in Vivo.
    Date November 2006
    Journal Biomaterials
    Excerpt

    Wear debris-induced vascularized granulomatous periprosthetic tissue may augment the progress of prosthetic loosening, a major clinical problem after total joint replacement. The purpose of this study is to investigate the association of ultra-high-molecular-weight polyethylene (UHMWPE) particle-induced inflammatory osteoclastogenesis and expression of RANK/RANKL and VEGF/VEGF receptors (Flt-1 and Flk-1) using a mouse osteolysis model. UHMWPE particles were introduced into established air pouches on BALB/c mice, followed by implantation of calvaria bone from syngeneic littermates. Mice were injected with either recombinant VEGF or VEGF inhibitor (VEGF R2/F(c) Chimera). Mice without drug treatment, as well as mice injected with saline alone were included. Each group contains 10 mice. Pouch tissues were harvested 2 weeks after bone implantation for histological and molecular analysis. UHMWPE stimulation significantly increased VEGF gene expression, and exerted a lower enhancement effect on the gene expression of Flt-1 and Flk-1. UHMWPE-stimulated VEGF production was markedly reduced by VEGF inhibitor treatment. Immunofluorescent staining indicated that pouch tissue macrophages were the main source of both VEGF and Flt-1 production. A positive association was observed between tissue inflammation and the levels of VEGF and Flt-1 gene transcripts. Both RANK and RANKL gene transcripts were significantly increased by UHMWPE stimulation, which was subsequently reduced by VEGF inhibitor treatment (p<0.05). VEGF treatment increased TRAP(+) cells in pouches either with or without UHMWPE particle stimulation, and VEGF inhibitor treatment caused a significant reduction in the number of TRAP(+) cells in UHMWPE-containing pouches. This study suggests that VEGF has a role in the regulation of RANK/RANKL-mediated osteoclastogenesis, and warrant future investigations to elucidate the role of VEGF signaling in the pathogenesis of prosthetic loosening.

    Title Computer Assisted Navigation in Total Knee Arthroplasty: Comparison with Conventional Methods.
    Date April 2006
    Journal The Journal of Arthroplasty
    Excerpt

    The success of knee arthroplasty is dependent on many factors. Postoperative extremity and component alignment are important determinants of outcome and longevity. Malalignment (>3 degrees ) results in higher failure rates. Computer-assisted navigation devices were developed to improve implant positioning. This study evaluated the early outcomes of a high-volume fellowship-trained surgeon relative to component positioning and limb alignment using an image-free navigation system. The navigation group consisted of 116 consecutive patients, and the conventional group consisted of 51 consecutive patients. The postoperative mechanical axis was within 3 degrees of neutral mechanical alignment in 95% of the navigation cases vs 84% of the conventional cases (P < .02). The range of the alignment and component position measurements narrowed, and the undesired outliers decreased. Accuracy was improved with navigation. Navigation was a viable device to improve the outcome of total knee arthroplasty relative to limb and component alignment.

    Title Unicompartmental Knee Arthroplasty: Troubleshooting Implant Positioning and Technical Failures.
    Date September 2005
    Journal The Journal of Knee Surgery
    Excerpt

    Improvements to implant design and the advent of minimally invasive surgery have increased the popularity of unicompartmental knee arthroplasty. Minimally invasive techniques for implant placement can augment the unicompartmental knee arthroplasty procedure and allow for more rapid rehabilitation and return to activities of daily living. Nevertheless, new technologies are accompanied by learning curves and rediscovery of past mistakes. Unicompartmental knee arthroplasty tends to be more technically demanding than total knee arthroplasty, and complications occur with placement of unicompartmental knee devices. This article discusses proper and improper implantation techniques and provides technical guidance and suggestions for improving the outcomes of unicompartmental knee arthroplasty.

    Title Human Periprosthetic Tissues Implanted in Severe Combined Immunodeficient Mice Respond to Gene Transfer of a Cytokine Inhibitor.
    Date June 2005
    Journal The Journal of Bone and Joint Surgery. American Volume
    Excerpt

    BACKGROUND: Periprosthetic tissue formation and local inflammation that are associated with wear debris contribute to the pathogenesis of aseptic loosening of a prosthesis. This study evaluated a retrovirus-mediated gene therapy with use of a novel xenograft-based animal model. METHODS: Human periprosthetic tissues obtained from patients during revision arthroplasty performed because of aseptic loosening of a prosthetic joint were transplanted into the left quadriceps and paravertebral muscles of severe combined immunodeficient (SCID) mice. The engrafted tissues were recovered seven, fifteen, or thirty days after implantation for histological and molecular analyses. The periprosthetic tissues were incubated with retroviruses encoding for human interleukin-1 receptor antagonist (hIL-1Ra) or bacteria beta-galactosidase (LacZ) at 37 degrees C for three hours prior to implantation to evaluate their responses to gene modification. RESULTS: The human periprosthetic tissues were well accepted in SCID mice for up to thirty days, with angiogenesis occurring in the majority of the implanted tissue sections. The histological appearance was consistent between the recovered graft tissue and the original donor tissue. Strong expression of interleukin-1, tumor necrosis factor, and interleukin-6 was detected in the xenografts with use of immunohistochemical stains. Histological analysis revealed that interleukin-1 receptor antagonist gene modification significantly decreased the total number of inflammatory cells (p < 0.01) in engrafted human tissue containing implant wear debris. Real-time reverse transcription-polymerase chain reaction and immunohistochemical staining showed declining expression levels of interleukin-1 and tumor necrosis factor following interleukin-1 receptor antagonist gene transfer in comparison with LacZ-transduced or virus-free controls. CONCLUSIONS: Human periprosthetic tissue can survive in the SCID mouse host for up to thirty days and responds to the interleukin-1 receptor antagonist gene transfer with the amelioration of inflammation.

    Title Simple Techniques for Passing Suture Through Bone.
    Date April 2005
    Journal American Journal of Orthopedics (belle Mead, N.j.)
    Excerpt

    Sutures often must be passed through bone tunnels to repair soft tissue or bone. Three easy, inexpensive, and time-saving suture-passing techniques are described in this article. These techniques, which involve using 1 of 3 readily available instruments (Angiocath, Hewson suture retriever, Keith needle), can be applied in many different orthopedic surgical procedures and may save much time and aggravation in the operating room.

    Title Cement Pressurization After Provisional Repair of Femoral Cortical Defects.
    Date September 2003
    Journal American Journal of Orthopedics (belle Mead, N.j.)
    Excerpt

    Cortical defects are common and problematic in cemented revision hip arthroplasty. Extruded cement can cause thermal injury, pain, and impingement. Decreased cement pressure limits bony interdigitation and leads to loosening. Historically, surgeons have used a finger to contain cement and improve pressure, and decrease porosity, but, with large or multiple defects, fingers are ineffective. Novel solutions--such as wrapping foil suture packaging or half a syringe barrel around the defects--have been previously published. In the study reported here, we used modern cementing techniques, continuous pressure monitoring, and porosity calculations to analyze the utility of the 3 provisional defect-fixation techniques. The foil and the hemisyringe worked as well as a finger (P > .05). All 3 techniques enhanced pressurization and maintained the porosity reduction. Although manually pressurizing cement and feeling resistance provide the surgeon with more tactile feedback, using the gun and a proximal adapter was more effective in improving pressure. Using these provisional defect-fixation techniques as well as a cement gun and proximal adapter can improve cement pressure and decrease porosity. These techniques are particularly useful with large or multiple cortical defects encountered in revision arthroplasty or total hip arthroplasty after open reduction.

    Title The Use of a Constrained Acetabular Component for Recurrent Dislocation.
    Date September 2003
    Journal The Journal of Arthroplasty
    Excerpt

    The poor results of surgical treatment of chronic instability after total hip arthroplasty (THA) led to the development of a constrained acetabular component. In this study, 87 constrained THAs implanted for recurrent instability were reviewed retrospectively. Eighty-five hips were available for follow-up evaluation, with an average follow-up period of 58 months. These 85 hips were evaluated at a minimum of 3 years. Two recurrent dislocations were seen, caused by dissociation of the liner from the shell. Four acetabular components and 1 femoral component were revised. Overall, a 2.4% dislocation rate and an 8.2% revision rate were seen. The recurrent dislocation rate of 2.4% represents a significant improvement over other methods reported. Repeat dislocation was only seen in dissociation of cemented liners into well-fixed shells. We do not recommend this mode of fixation.

    Title Effect of External Sequential Compression Devices on Femoral Venous Blood Flow.
    Date August 2003
    Journal Journal of the Southern Orthopaedic Association
    Excerpt

    Sequential compression devices are used to reduce venous stasis and deep venous thrombosis after joint replacement. Thigh-length, calf-length, and foot compression devices were compared in using ultrasonography after unilateral knee arthroplasty. Simulated muscle activity via active ankle motion was also evaluated. Blood flow volume and velocity were recorded above and below the saphenous vein bifurcation, the division of the superficial and deep systems, allowing evaluation of each. Volume and velocity increased in the superficial and deep systems with all devices. A control group was evaluated to determine differences related to age and surgery. The devices performed similarly in the volunteers. However, active motion performed better than any device. Thus, unlike young, healthy patients, muscle activity alone in the operative population was unreliable in increasing blood flow. Thigh-length, calf-length, and foot compression devices are are effective at increasing femoral blood flow volume and velocity in the deep and superficial venous systems after total knee arthroplasty.

    Title Pull-out and Shear Failure Strengths of Arthroscopic Meniscal Repair Systems.
    Date January 2003
    Journal Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the Esska
    Excerpt

    Meniscal repair is common and recommended in young patients. Suture techniques and fixation devices were developed for stronger, more facile repairs. Three devices (T-Fix, Meniscal Staple, Meniscus Arrow) were biomechanically compared to horizontal PDS suture. Peripheral tears were created in porcine menisci and repaired using the manufacturer's technique. An Instron was used to distract the menisci at 50 mm/min in axial-pullout and longitudinal shear loads. Load to failure curves and peak failure loads were noted. Load to failure in axially loaded pull-out mode was: Staple, 4.195+/-3.70 N; Arrow, 39.755+/-11.37 N; T-Fix, 45.892+/-13.99 N; Suture, 107.65+/-22.37 N. Analysis of variance with post hoc testing revealed Staple failure at lower load than all devices and Suture failure at higher loads than all devices; Arrow and T-Fix were similar. The data varied significantly from that obtained in shear. Shear loads to failure were: Staple, 8.39+/-8.62 N; Arrow, 27.67+/-14.33 N; T-Fix, 57.47+/-17.05 N; Suture, 64.15+/-17.05 N. Analysis of variance, power analysis, and pair-wise multiple comparisons revealed significant differences between: Suture and Staple, Suture and Arrow, and T-Fix and Staple. No differences were noted between Suture and T-Fix, T-Fix and Arrow, or Arrow and Staple. In pullout, Suture and T-Fix maintained better apposition at low loads. As load increased, the menisci separated until device failure. Arrows allowed low load separation but held tissue until failure. Staples failed at low load. For shear, the menisci attempted to reorient parallel to the force. The devices failed in a pull-slide pattern. Suture failed by pull-through. Meniscal repair devices are easy to use and may provide resistance to shear and pull out. The resistance to pullout loads was very different than the resistance to longitudinal shear loads.

    Title Press-fit Stability of Uncemented Hemispheric Acetabular Components: a Comparison of Three Porous Coating Systems.
    Date December 2002
    Journal International Orthopaedics
    Excerpt

    Cementless acetabular components require good initial fixation to allow bony in-growth. The initial press-fit stability, important for designs that do not rely on supplemental fixation, was examined for three designs with different porous coating systems: beads, fiber mesh, and plasma spray. The ability to withstand tangential loads was determined (maximum rim loads: 122-1730 N). The plasma-sprayed acetabular cups withstood the greatest tangential load within the specified range of motion of 150 microm (P<0.01). Differences in surface preparation of titanium acetabular cups may significantly affect the initial stability of the implants in rim loading.

    Title Cemented Total Hip Arthroplasty with Boneloc Bone Cement.
    Date August 2002
    Journal Journal of the Southern Orthopaedic Association
    Excerpt

    Boneloc cement (WK-345, Biomet Inc, Warsaw, Ind) attempted to improve cement characteristics by reducing exotherm during polymerization, lowering residual monomer and solubility, raising molecular weight, and lowering airborne monomer and aromatic amines. To study the efficacy of this cement, a selected group of 20 patients were prospectively enrolled and followed up after hip arthroplasty. All components were cemented. During the enrollment period, approximately 70 other hip arthroplasties were performed. Clinical evaluation was based on the Harris hip score. Radiographic evaluation was based on assessment of position of the components, subsidence, and/or presence of radiolucencies. Patients had follow-up for an average of 42 months (11 to 58 months); 1 was lost to follow-up. Of these, 7 (35%) had failure at last follow-up. Despite its initial promise, Boneloc cement had an unacceptably high failure rate over a relatively short follow-up period and is not recommended for use. Despite the longevity and odor toxicity problems with conventional bone cement, new cement technologies must be approached with caution.

    Title Fatal Pulmonary Embolus After Shoulder Arthroplasty.
    Date August 2001
    Journal The Journal of Arthroplasty
    Excerpt

    Pulmonary embolus after upper-extremity surgery is a rare complication of upper extremity surgery. A case of a fatal pulmonary embolus after shoulder arthroplasty is reported. The embolus originated from a lower-extremity deep venous thrombosis. The cause of the deep venous thrombosis and subsequent pulmonary embolus was attributed to prolonged immobilization in the perioperative period.

    Title Upper Extremity Deep Venous Thrombosis Leading to Pulmonary Embolism After Total Hip Arthroplasty.
    Date March 2001
    Journal The Journal of Arthroplasty
    Excerpt

    Upper extremity deep venous thrombosis most commonly occurs secondary to the presence of subclavian central venous catheters. Of all upper extremity deep venous thromboses, 12% may cause pulmonary embolism; however, pulmonary embolism from a so-called primary thrombosis is uncommon. We report an unusual case of pulmonary embolism after primary deep venous thrombosis in the down arm after total hip arthroplasty.

    Title Use of a Reciprocating Rasp As an Adjunct to Open Acromioplasty.
    Date March 2001
    Journal American Journal of Orthopedics (belle Mead, N.j.)
    Title Biomechanical Analysis of Supracondylar Femoral Fractures Fixed with Modern Retrograde Intramedullary Nails.
    Date March 2000
    Journal Journal of Orthopaedic Trauma
    Excerpt

    OBJECTIVES: Several new retrograde supracondylar intramedullary nails have been developed to specifically address fractures of the distal femur. The nails appear clinically effective, but there are few biomechanical data documenting the stability of the fixation or the mechanical stiffness of the different designs. The goal of this study was to assess the torsional and bending stiffness of four designs of intramedullary nails developed for this application. METHODS: Four nail designs were tested in torsion and bending to determine system stiffness: Ace supracondylar, Richards "five hole" and "multi-hole" supracondylar, and Biomet retrograde. The nails were inserted into cadaveric femurs in which a one-centimeter distraction osteotomy had been created seven centimeters proximal to the condyles. The constructs were then tested on an Instron biaxial testing system. RESULTS: There were no statistically significant differences in bending stiffness among the groups of nails (range 0.79 to 1.18 newtons/meter; p > 0.1). However, the Ace nails (1.10 newtonmeters/degree) did exhibit a statistically lower torsional stiffness compared with the other nails (2.20 to 2.21 newton-meters/ degree; p < 0. 1). No differences were noted as a function of the number of locking holes. CONCLUSIONS: The bending stiffness of four currently available designs of retrograde intramedullary nails does not appear to be dependent on design variations. The torsional stiffness did vary among the four designs, but this was not determined by the number of fixation holes provided. It appears that a well-placed retrograde supracondylar nail of modern design should have sufficient stiffness to support the femur and provide stability during fracture healing.

    Title Geriatric Intertrochanteric Hip Fractures: an Economic Analysis.
    Date November 1999
    Journal American Journal of Orthopedics (belle Mead, N.j.)
    Excerpt

    Hip fractures have a high economic and social cost to society. Rising healthcare costs, coupled with managed healthcare systems, have forced a close inspection of healthcare expenditures. To evaluate the impact of geriatric intertrochanteric hip fractures upon a hospital system, an economic cost-analysis was undertaken. An analysis was made of financial and hospital data of elderly patients who sustained an intertrochanteric hip fracture and subsequently underwent open reduction and internal fixation. Increasing patient age did not correlate with length of stay, overall hospital cost, or net hospital income. When costs were subdivided, there were no statistically significant differences relative to patient age for costs of pharmacy, radiology, respiratory therapy, or operating room supply. There were, however, statistically significant correlations between patient age and costs of the operating room, blood, and anesthesia. During the 36-month study period, a case manager was added to the orthopedic surgical team. There was a trend toward decreased length of stay after the addition of the case manager, but the overall cost of patient care was not affected.

    Title Inexpensive Methods of Repairing Cortical Defects in Cemented Total Joint Replacement.
    Date September 1999
    Journal The Journal of Arthroplasty
    Excerpt

    Inexpensive methods to augment cement pressurization in the face of cortical defects are presented. The first two methods involve the use of disposable plastic syringes and the foil packaging from suture material. The third uses screws that were removed with hardware. The techniques prevent cement extrusion from the cortical defects with minimal stripping of the remaining soft tissues. Methods for using foil packaging to form templates for accurate production of well-fitting cortical inlay grafts and the use of plastic wire ties as temporary fixation devices are also described.

    Title Analysis of Lower Extremity Embolic Material After Total Knee Arthroplasty in a Canine Model.
    Date April 1999
    Journal The Journal of Arthroplasty
    Excerpt

    Emboli assumed to consist of fat, marrow, cement, and bone are generated during total knee arthroplasty. This study collected and identified the constituents of the embolic debris and assessed the effects of intramedullary cutting guides in a canine model. During cemented knee arthroplasties with or without the use of intramedullary guides, all embolic debris was collected in a single lobe of lung. In dogs using intramedullary guides, transesophageal echocardiography revealed a sustained embolic shower, and histologically marked amounts of emboli obstructed the pulmonary vasculature. The emboli were composed of fat cells and hematopoietic cells (marrow elements) interspersed with free fat globules. Marrow elements are the primary constituents of the emboli generated during total knee arthroplasty. Intramedullary guides increased debris generation.

    Title Effect of Epidural Analgesia on Venous Blood Flow After Hip Arthroplasty.
    Date February 1997
    Journal Clinical Orthopaedics and Related Research
    Excerpt

    The effects of postoperative epidural infusions using local anesthetic and narcotic were assessed in reference to lower extremity blood flow. Nineteen patients who underwent unilateral total hip arthroplasty were randomly assigned to receive a postoperative epidural infusion of either 5 microg/ml fentanyl or 5 microg/ml fentanyl plus 0.125% bupivacaine at a rate of 10 ml per hour. The infusions were started after complete resolution of the operative epidural blockade. Femoral venous blood flow volume and velocity were measured above and below the saphenous vein bifurcation using an Acuson #128XP/10 computed sonography system (duplex ultrasound) and proprietary software. Femoral venous blood flow was not affected by the type of infusion and did not increase during the study period. However, femoral venous blood flow volume increased 50% after active flexion and extension of the foot, 10 times in quick succession. The addition of bupivacaine (a local anesthetic that blocks sympathetic afferent nerves) to a postoperative epidural infusion does not augment blood flow from the deep veins of the leg after total hip arthroplasty. Alternatively, lower extremity skeletal muscle activity significantly enhances femoral venous blood flow and may be a useful adjunct in deep venous thrombosis prevention.

    Title Use of Cemented All-polyethylene and Metal-backed Acetabular Components in Total Hip Arthroplasty. A Comparative Study.
    Date December 1996
    Journal The Journal of Arthroplasty
    Excerpt

    The results of 115 primary total hip arthroplasties (97 patients) performed using the Charnley system and contemporary cementing techniques were reviewed. Fifty-five all-polyethylene cups and 60 metal-backed cups were used. The mean follow-up period was 84 months. No statistically significant difference was noted between groups for radiographic loosening and no cup has been revised to date. Survival analysis did not reveal a statistically significant difference between groups. Although all-polyethylene cups had significantly greater polyethylene thickness, no difference was noted for rate of wear. Increased loosening of the metal-backed cups was not observed. Polyethylene thickness is increased by the use of 22-mm heads and this may have accounted for the lack of difference in loosening rates of the all-polyethylene and metal-backed cups.

    Title Arthroscopic Treatment of Peripatellar Fibrosis After Total Knee Arthroplasty.
    Date September 1996
    Journal The Journal of Arthroplasty
    Excerpt

    Forty-eight total knee arthroplasties (42 patients) were treated arthroscopically for symptomatic peripatellar fibrosis. All patients complained of knee pain before surgery. In addition, 47 knees (98%) had clicking or clunking, 35 (73%) had difficulty climbing stairs, and 9 (19%) had motion problems. The results of arthroscopy were 20 good (42%), 9 fair (19%), and 19 poor (40%). The mean follow-up time was 32.8 months (range, 11-75 months). A fourth portal was required in 20 knees (17 patients, 42%), indicating the complexity and difficulty of debridement. No components were found to be loose at the time of arthroscopy. A constellation of symptoms are caused by peripatellar fibrosis. In contrast to past reports, the arthroscopic treatment of peripatellar fibrosis was found to be unpredictable. Debridement of the offending soft tissue did not necessarily guarantee a good result. Arthroscopic management of peripatellar fibrosis is recommended; however, limited and specific surgical goals should be established prior to intervention.

    Title Core Decompression for Osteonecrosis of the Femoral Head.
    Date June 1996
    Journal Clinical Orthopaedics and Related Research
    Excerpt

    A retrospective++ review of core decompression of the femoral head for treatment of osteonecrosis was done. Cause of osteonecrosis, radiographic stage and progression, complications, and clinical results were evaluated. The study was based on 54 hips in 45 patients (98.2% followup rate). All patients reported pain preoperatively. Thirty-five hips (30 patients) were considered to have failed. Of these, 26 hips (23 patients) underwent total hip arthroplasty. The remaining 9 hips (7 patients) had little or no relief of pain and no improvement in function, but had not undergone total hip arthroplasty at last followup. The average time to failure was 11.1 months (2-34 months). Nineteen hips (16 patients) were considered successful. Fifteen hips (12 patients) were graded good to excellent and 4 hips (4 patients) were graded fair in terms of clinical results with an average followup of 47.5 months (12.4-95.7 months). The mean preoperative Hospital for Special Surgery hip score improved from 24.6 points (range, 18-38 points) to 34.2 points (range, 20-40 points). There were 2 intertrochanteric femur fractures in this group (5 and 6 weeks postoperatively). The overall success rate of core decompression in this series was 35.2% (19 of 54 hips, 45 patients). The results of core decompression in this study were poor in general and had an unpredictable effect on disease progression.

    Title A Comparison Study of Treatment of Thoracolumbar Fractures Using the Ace Posterior Segmental Fixator and Cotrel-dubousset Instrumentation.
    Date November 1995
    Journal Orthopedics
    Excerpt

    The results of 26 consecutive thoracolumbar fractures treated with Cotrel-Dubousset instrumentation (CDI) (n = 12) or the ACE Posterior Segmental Fixator (n = 14) with a mean follow up of 20.2 months were analyzed. Preoperatively, no statistically significant difference was noted between the two treatment groups. Postoperatively, no statistically significant difference was noted for improvement of kyphosis (mean: -6.00 degrees ACE, 1.92 degrees CDI), vertebral body height (mean: 17.86% ACE, 18.83% CDI), vertebral body angle (mean: -6.21 degrees ACE, -5.42 degrees CDI), or estimated blood loss (mean: 1544 cc ACE, 1620 cc CDI). All patients with incomplete paraplegia improved by at least one Frankel grade. Statistically significant differences were noted in operative time (mean: 269 minutes ACE, 357 minutes CDI, P < .0005), and in the number of instrumented levels (mean: 3 ACE, 5.8 CDI). All patients exhibited solid fusion radiographically. Thoracolumbar fractures can be effectively treated by either CDI or the ACE Fixator. The ACE Fixator has the advantage of sparing motion segments and decreased operative time.

    Title Bilateral Anterior Dislocation of the Shoulders with Greater Tuberosity Fractures.
    Date February 1995
    Journal Orthopedics
    Title Percutaneous Intramedullary Pinning of Proximal Humeral Fractures.
    Date January 1995
    Journal Orthopaedic Review
    Excerpt

    Proximal humeral fractures can usually be treated closed. However, even with an adequate closed reduction, these fractures are occasionally unstable, fail to remain reduced, and require operative intervention. A percutaneous intramedullary pinning technique is effective in stabilizing these fractures. Two cases that illustrate the adult and pediatric techniques for pin placement/application are presented. In the pediatric population, however, large multiple pins often cannot be used due to the size of the intramedullary canal, and fewer or smaller diameter pins are used.

    Title Appropriate Techniques for Musculoskeletal Tumor Biopsy.
    Date June 1994
    Journal Orthopaedic Review
    Excerpt

    Despite the crucial nature of a biopsy for the diagnosis and treatment of a musculoskeletal tumor, the basic tenets of biopsy technique are frequently not respected. Unfortunately, catastrophic errors in biopsy technique occur frequently. Examples of the more common errors and the correct surgical techniques are discussed.

    Title A Case of Traumatic Spino-pelvic Dissociation.
    Date March 1994
    Journal Journal of Orthopaedic Trauma
    Excerpt

    A case of traumatic spino-pelvic dissociation is reported. The unusual fracture pattern (grade III-B open left sacroiliac joint fracture dislocation, Denis type I longitudinal right sacral fracture, transverse sacral fracture at the S3-4 level, and a left comminuted pelvic wing fracture) led to a complete dislocation of the spine from the pelvis, transection of the left S1 and S2 nerve roots, and intrusion of the cranial portion of the spine into the pelvis. The patient underwent open reduction internal fixation of the spine and the pelvis in combination with general surgical management. Two years postinjury, the patient lives independently and walks with one cane.

    Title Simple Surgical Techniques to Protect the Soft Tissues During Total Knee Arthroplasty.
    Date September 1993
    Journal Orthopaedic Review
    Excerpt

    The surgical techniques involved in total knee arthroplasty are often overshadowed by implant design, metallurgy, and fixation methods. This is especially true when considering the handling of the soft tissues rather than the bony cuts. The authors believe that protection of the soft-tissue structures around the knee is of paramount importance and describe six surgical techniques that they use to accomplish this during total knee arthroplasty.

    Title Technical Tips for the Fixation of Supracondylar Femur Fractures with the Sliding Screw-plate Device.
    Date December 1992
    Journal Orthopaedic Review
    Excerpt

    Supracondylar fractures of the femur are common injuries. When open reduction and internal fixation are required, these fractures become challenging problems. We present four technical tips that help the surgeon obtain good results when open reduction and internal fixation with the screw- and side-plate device are chosen.

    Title Fracture of the S1 Vertebral Body in a Patient with Ankylosing Spondylitis.
    Date July 1992
    Journal Journal of Spinal Disorders
    Excerpt

    We report an unusual case of spinal fracture in ankylosing spondylitis. The fracture occurred through the S1 vertebral body and resembled a traumatic spondylolisthesis. Treatment consisted of prompt operative intervention after extensive diagnostic evaluation. The case emphasizes the difficulty of diagnosing spinal fractures in those with ankylosing spondylitis, the necessity for being alert to the possibility of fracture in this group, and the value of early surgical intervention for sacral fractures with neural deficit.

    Title Evaluation of Component Positioning in Primary Total Hip Arthroplasty Using an Imageless Navigation Device Compared With Traditional Methods.
    Date
    Journal The Journal of Arthroplasty
    Excerpt

    Acetabular orientation affects the success of total hip arthroplasty. Computer-assisted navigation systems may reduce positional errors. Total hip arthroplasty results were analyzed using an imageless navigation system. We hypothesized that reliability and accuracy would improve. One hundred forty-nine total hip arthroplasties were performed using minimally invasive surgical techniques in 3 cohorts: manual (n = 53), initial navigation cases (n = 49), navigation second series (n = 47). Manual patients' cup orientation variation from desired range was -19 degrees to +18 degrees anteversion (SD, 9.1 degrees ), -11 degrees to +25 degrees abduction (SD, 6.7 degrees ). Navigation variation from desired was -18 degrees to +15 degrees (SD, 7.3 degrees ) in group 1 and -15 degrees to +9 degrees (SD, 5.9 degrees ) in group 2 in anteversion and -15 degrees to +13 degrees (SD, 6.1 degrees ) in group 1 and -15 degrees to +11 degrees (SD, 4.7 degrees ) in group 2 in abduction. Results were statistically significant. There were significant differences for operating room time and estimated blood loss, but not incision size or body mass index. Navigation provided controlled, reproducible acetabular alignment; but a learning curve existed in terms of accuracy, estimated blood loss, and operating room time.

    Title Computer-assisted Navigation Software Advancements Improve the Accuracy of Total Knee Arthroplasty.
    Date
    Journal The Journal of Arthroplasty
    Excerpt

    The purpose of this study was to evaluate the effectiveness of software advancements in improving total knee component positioning and limb alignment when using computer-aided navigation. A single total joint fellowship-trained surgeon performed unilateral total knee arthroplasty on 315 patients using conventional techniques or with assistance from computer navigation software. Preoperative and postoperative x-ray measurements were taken and analyzed. Our previous work demonstrated a statistically significant improvement (P < .02) in limb alignment (+/-3 degrees of biomechanical neutral) when using version 2.0 software (93%) when compared with conventional techniques (82%). Further improvement was demonstrated with the version 3.1 software (99%, P < .03). The tourniquet times were recorded for each group and showed a significant improvement with the 3.1 software (conventional = 74 minutes, 2.0 navigation = 90 minutes, and 3.1 navigation = 73 minutes). The Stryker 2.0 software (Stryker Orthopedics, Mahwah, NJ) tourniquet time was statistically significantly longer than either the conventional or the 3.1 group (P < .001). Outcomes-based studies will be required to see if these factors will lead to improved patient function and/or prolonged prosthetic survival rates.

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