TRIA ORTHOPAEDIC CENTER SCHOLARLY ACTIVITY

Transcription

TRIA ORTHOPAEDIC CENTER
SCHOLARLY ACTIVITY
A YEAR IN REVIEW | 2014
We advance orthopaedic care for our patients through innovative education and research,
and measure our performance through patient-centered outcomes.
FOREWORD
TRIA’s philosophy has been to deliver state of the science
musculoskeletal care since our inception in 2005. We evaluate
our results to continuously improve the care we deliver, and
we participate in the development of new knowledge to help
future patients.
In 2009, we renewed our focus on the importance of the
research and education piece of TRIA’s mission.
We have continued to expand on this philosophy over the last 6
years, and we felt it was time to inform our patients and
colleagues our results and efforts on an annual basis.
Marc Swiontkowski, MD
There are various ways in which our researchers can publish
or present their findings:
TRIA CEO
Physician and Researcher
Poster and podium presentations: For various local, regional, and national meetings,
our researchers submit an abstract or summary of their research. These abstracts are
reviewed by a committee. If accepted, results are either summarized in a poster and
displayed at the meeting, or presented to a large group of attendees using PowerPoint.
Publications: Upon conclusion of a research project, the research team co-authors a
paper detailing all the work that was accomplished, which includes background
information, how the study was conducted, what data or information was collected, what
the results are, a discussion of the results, and finally a conclusion of the impact or
implication of these results.
TRIA invests significant financial resources in our Research and Education so we can
deliver outstanding care that is timely, patient-centered, and based on the best evidence
available.
We hope you enjoy the inaugural report of our research accomplishments within our
institute.
TABLE OF CONTENTS
Our Research Team _____________________________________________________________________________________ 1
1st Quarter 2014 Scholarly Activity __________________________________________________________________ 7
2nd Quarter 2014 Scholarly Activity ________________________________________________________________ 13
3rd Quarter 2014 Scholarly Activity _______________________________________________________________ 31
4th Quarter 2014 Scholarly Activity _______________________________________________________________ 36
Afterword ______________________________________________________________________________________________ 41
Current Research Activity ___________________________________________________________________________ 43
OUR RESEARCH TEAM
Our Research Team
BRAD NELSON, MD
INSTITUE MEDICAL DIRECTOR
ORTHOPAEDIC SURGERY/
SPORTS FELLOWSHIP
Dr. Nelson‘s clinical interests include shoulder
instability, cartilage injuries, meniscal
transplants, and ACL injuries and
reconstructions. Dr. Nelson’s research interests
include OCD, shoulder instability, and cartilage
restoration technology.
MEGAN REAMS, MA, OTR/L
INSTITUTE MANAGER
Megan has been managing the TRIA institute for
approximately 6 years and enjoys the variety of
work her team is a part of. From research to
outcomes to the Bio-Skills lab to educational
conferences to residents and fellows, no two
days are the same. In her spare time, Megan
loves digital scrapbooking and spending time
with her husband and two children.
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OUR RESEARCH TEAM
MIKE OBERMEIER, ATC
RESEARCH COORDINATOR
KELSEY SCHNACKENBERG
JOE SCHILZ
VANESSA TOLLE
RESEARCH ASSISTANT
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OUR RESEARCH TEAM
DEB BOHN, MD
HAND FELLOWSHIP
Dr. Bohn’s research interest is in hand and
upper extremity conditions. She enjoys taking
care of hand and arm problems in patients of all
ages, although she has a special interest in
fractures and children’s upper extremity
conditions. Outside of work she enjoys cooking,
gardening, and raising her children.
JOEL BOYD, MD
SPORTS FELLOWSHIP
Dr. Boyd serves as the team physician for the
Minnesota Wild and the Minnesota Vikings. He
is also a United States Olympic Team physician.
Dr. Boyd’s practice and research focuses on his
interest in conditions and injuries of the knee.
In his free time, Dr. Boyd enjoys spending time
with his family, traveling, playing golf, and
watching movies.
NANCY CALLINAN, OTR/CHT
HAND THERAPIST
Nancy is the manager of the Hand Therapy
Department. She enjoys helping her patients
achieve their goals following injury or surgery.
Her interests outside of work include hiking,
biking, traveling, and outdoor adventures.
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OUR RESEARCH TEAM
JEFF HUSBAND, MD
HAND FELLOWSHIP
Dr. Husband is actively involved in the
University of Minnesota Hand Fellowship and
Orthopedic Residency training program. His
practice includes all aspects of upper extremity
surgery including congenital, arthritic,
traumatic and occupational disorders.
JEFF MACALENA, MD
SPORTS FELLOWSHIP
Dr. Macalena is an assistant professor in the
department of orthopaedic surgery at the
University of Minnesota. His clinical interests
are knee ligament and cartilage injuries, sports
injuries, and shoulder ligament injuries. In his
free time, Dr. Macalena enjoys spending time
with his family.
ROBBY SIKKA, MD
ANESTHESIOLOGIST/
RESEARCH SCIENTIST
Dr. Sikka has been involved with sports
medicine research for the past decade working
with high school, college, and professional
teams. He enjoys working with athletes of all
ages and teams to develop unique strategies for
injury prevention, rehabilitation, and pain
management. In his spare time, Dr. Sikka enjoys
spending time with his family, traveling, sports,
and writing.
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OUR RESEARCH TEAM
MARC SWIONTKOWSKI, MD
ORTHOPAEDIC SURGERY
Dr. Swiontkowski specializes in trauma,
fractures, non-unions, mal-unions, children’s
fractures, osteomyelitis, and leg length
inequality. Dr. Swiontkowski and his wife
consider themselves avid hockey fans/parents.
He also enjoys trying to learn how to play golf,
bicycling, home remodeling, birding and
gardening.
MARC TOMPKINS, MD
SPORTS FELLOWSHIP
Dr. Tompkins feels that through research he
gets to be a part of the advances in the field of
orthopaedics. By working with medical
providers in training, he is able to help educate
the next generation. Dr. Tompkins spends his
free time playing music, spending time
outdoors, and traveling with his family. He also
enjoys playing, watching, and providing sideline
coverage in all types of sports.
BRET YONKE, MD
RADIOLOGIST
Dr. Yonke is excited to work in musculoskeletal
radiology, as it is a rapidly evolving field.
Research and continuous learning are some of
the most enjoyable elements in his practice.
When he’s not working, he enjoys spending
time with his wife and three wonderful kids. He
also enjoys both coaching and playing many
activities and sports with his children.
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OUR RESEARCH TEAM
KIM WATERBURY, OTR/CHT
HAND THERAPIST
Kim enjoys the diversity of injuries and
diagnoses involved in treating the upper
extremity. She also appreciates getting to know
patients and helping them return to the
activities that are important in their daily lives.
Outside of work, Kim enjoys making jewelry and
spending time with her family.
MIKE WALSH, MD
SHOULDER SPECIALIST
Dr. Walsh is double fellowship trained in
shoulder surgery and sports medicine. He
enjoys treating athletes and non-athletes with
advanced techniques to return them quickly to
pain-free function. Dr. Walsh is the lead author
of two ongoing shoulder studies, and is also the
lead investigator on a shoulder fractures
outcomes study at TRIA. In his spare time, he
enjoys baseball, fishing, being outdoors, and
spending time with his family.
CO-AUTHORS AND OTHER CONTRIBUTERS
Chad Kurtenback, MD |Sanford Health (former TRIA fellow)
David Olson, MD | University of Minnesota
Dr. Elizabeth Arendt | University of Minnesota
Dr. Gary Fetzer | TRIA Orthopaedic Center
Julie Agel | University of Minnesota
Mark Miner, MD | Park Nicollet Health Services
John Shultz, PA-C | TRIA Orthopaedic Center
Sara Richter | Park Nicollet Health Services
John Steubs, MD | TRIA Orthopaedic Center
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1ST QUARTER 2014 SCHOLARLY ACTIVITY
1st Quarter 2014 Scholarly Activity
In the first quarter of 2014, our researchers published or presented 5 pieces of original
research work.
In January, Dr. Joel Boyd’s research work on a multi-center stem cell research project was
published with many of his colleagues in the Journal of Bone and Joint Surgery. Also in
January, Dr. Joel Boyd and Dr. Robby Sikka, along with one of our former fellows, Dr. Chad
Kurtenbach, published an article about patient-specific instrumentation and return to
activity following unicondylar knee arthroplasty.
In February, Dr. Marc Tompkins published an article in Orthopaedic Journal of Sports
Medicine Open Access looking at transtibial tunnel placement in posterior
cruciate ligament reconstruction. Also this month, Drs. Robby Sikka, Gary
Fetzer, and Joel Boyd attended the NFL Physicians Society meeting in
Indianapolis, Indiana. This meeting is attended by medical staff from all 32
NFL teams. The meeting includes research presentations from team
physicians and medical staff on relevant issues facing football players.
In March, Dr. Marc Tompkins published an article studying outcomes of medial
patellofemoral ligament repair vs. reconstruction in the Journal of Sports Medicine Open
Access.
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Title: Comparison of Peak Core Temperatures and Hydration Status across NFL,
Collegiate, and High School football.
Authors: Austin Krohn, MD; Robby Sikka, MD; Steve Stovitz, MD; Dave Olson, MD; Suzanne
Hecht, MD; Trent Christensen, MD; Shane Maxwell, MD.
Purpose: We hypothesized that the younger, less experienced and less organized high
school athletes would exhibit higher peak core temperatures and be at greater risk for
heat illness. To this date, no study has been completed that includes peak core
temperature comparisons across all three levels of football.
Materials and Methods: Ten professional (P), seven collegiate (C), and five high school
(H) football players participated in the study. Core body temperatures were measured
using ingestible thermistors (HQ Inc, Palmetto, FL). Players also completed a survey to
gauge their understanding of heat illness and hydration. Urine specific gravities and preand post-practice weights were also used to assess hydration. Temperatures were
recorded every fifteen minutes during practice for the first 3-4 days of training camp.
Statistical analysis was performed with SPSS software (version 16.0 for Windows, SPSS,
Inc., Chicago, IL). Correlation coefficients (Spearman’s r value) were calculated between
multiple variables and a p value <.05 was considered statistically significant.
Results: All subjects had elevated core body temperatures ranging from 0.2°F - 5°F above
their normal baseline temperature. The average Tmax for all practices was 101.50° (P)
(+/- 0.41), 101.23° (C) (+/-0.24), and 100.99° (H) (+/-0.30) (p=<.001). As ambient
temperature and wet bulb temperature increased there was a moderate positive
correlation with increased core body temperature (r=.57). High school (33%) and college
athletes (15%) were more likely to have signs of dehydration as noted by elevated urine
specific gravity before practice (1.025 or greater) and after practice (40% and 65%,
respectively), compared to professional athletes (0% for both). High school and college
athletes also had increased percentage weight loss (1.29% and 1.21%) during practice
compared to professional athletes (0.86%) (p=<.001).
Conclusion: While the data did not demonstrate greater average peak core body temps in
the younger athletes, it does demonstrate differences in hydration status of the athletes
across each level.
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2ND QUARTER 2014 SCHOLARLY ACTIVITY
2nd Quarter 2014 Scholarly Activity
In the second quarter of 2014, our researchers published or presented 20 pieces of
original research work.
In April, Dr. Marc Tompkins was an author on an article published in Arthroscopy looking
at tibial tunnel placement during ACL reconstruction. Also in April, Dr. Tompkins had two
podium presentations at the Mid-America Orthopaedic
Association Meeting in San Antonio, Texas. The American
Medical Society for Sports Medicine meeting was also held in
April in New Orleans, Louisiana. Drs. Robby Sikka and David
Olson were proud to present two articles here: “Comparison
of Peak Core Temperatures and Hydration Status across NFL,
Collegiate, and High School Football”; and “Unexpected
Hyperthermia in an NFL Athlete”.
In May, TRIA was well represented at the Minnesota Orthopaedic Society meeting in St.
Paul. We had posters or presentations by Dr. Elizabeth Arendt, Dr. Joel Boyd, Dr. Brad
Nelson, Dr. Robby Sikka, and Dr. Marc Tompkins as well as numerous medical students
and TRIA research staff. The target audience of this conference is orthopaedic surgeons in
Minnesota. This month we also had two articles published. The first article published in
Knee Surgery, Sports Traumatology, and Arthroscopy examined posterolateral corner
reconstruction and tunnel placement by Boyd, Sikka, Tompkins, and Dr. Bret Yonke. The
second article in Journal of Athletic Training followed a case series on femur fractures in
professional athletes, authored by Boyd, Sikka, and Dr. Gary Fetzer. Finally in May, Dr.
Tompkins had two poster presentations displayed at the European Society of Sports
Traumatology, Knee Surgery & Arthroscopy meeting in Amsterdam. There were
approximately 3,400 in attendance at the conference. The target audience of this
conference is orthopaedic surgeons, clinicians, and scientists from around the world.
In June, Dr. Bradley Nelson and Dr. Robby Sikka attended the American Orthopaedic
Association meeting in Montreal, QC, Canada. There were approximately 14,000 in
attendance at the conference. The target audience of this conference is orthopaedic
surgeons whom have made a significant contribution to leadership, education, and
research.
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Title: Secondary Pathology with Time to ACL Reconstruction Surgery
Authors: Julie Agel, MA, ATC; Steven Ralles, BS; Michael Obermeier, MSED, ATC; Marc
Tompkins, MD
Background: Precise locations of chondral and meniscal damage with time to ACL
surgery have not been well described.
Hypothesis/Purpose: The purpose of the study was to determine the relationship
between delay in primary anterior cruciate ligament reconstruction (ACLR) and incidence
of secondary intra-articular pathology. The hypothesis is that patients with increased time
to ACLR from initial injury will exhibit greater incidence of secondary intra-articular
pathology when compared to those who receive surgical intervention promptly after
injury. A second hypothesis is that patients with higher pre-injury activity levels or
increased age will exhibit greater secondary pathology when compared to those with
minimal pre-injury activity levels and younger age.
Study Design: Retrospective Comparative Study
Methods: A retrospective review was performed on 1434 ACL deficient patients who
underwent primary ACLR at a single institution between 2009 and 2013. Patients were
grouped based on time to surgery after initial injury: 0-3 months, 4-12 months and >12
months. Operative notes were used to analyze 10 variables across time to surgery groups:
cartilage damage in the patella, trochlea, medial femoral condyle, lateral femoral condyle,
medial tibial plateau, and lateral tibial plateau; medial and lateral meniscus injury; and the
incidence of procedures involving either the meniscus or cartilage. Patient age and preinjury activity level were also analyzed for the 10 variables based on time to surgery
groups.
Results: An association was noted between time to surgery and increased incidence of
pathology in the trochlea, lateral femoral condyle, medial tibial plateau, and medial
meniscus (P<0.001). Within each age group different significant findings were observed,
but overall positive findings were seen in the same four locations described above. Based
on pre-injury activity level, the less active patients were most at risk for medial meniscus
and trochlear pathology while the more active patients were most at risk for medial tibial
plateau pathology with increased time from injury to ACLR. .
Conclusion: Increasing time from injury to ACLR was associated with increased incidence
of secondary pathology seen in the trochlea, lateral femoral condyle, medial tibial plateau
and medial meniscus. Separate analyses of patient age and pre-injury activity level
showed similar findings, thus supporting the primary analysis.
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Title: Double-row Speed Bridge vs. Double-row technique: A single blinded
comparison of clinical and radiographic outcomes
Authors: Michael Walsh, MD; Alan Hunt, MD Mark Miner, MD; John Shultz, PA-C,
Sara Richter, Megan Reams, MA, OTR/L; Kelsey Schnackenberg, BA
Background: Double Row Rotator cuff repair is evolving rapidly, with multiple techniques and
products employed to securely fix the tendon. Newer, “bridging” techniques have not been
compared to traditional double row techniques for clinical and radiographic outcomes.
Purpose: New bridging techniques will have decreased rates of re-tear, faster recovery of
strength and OR times, and superior clinical outcomes when compared to traditional double row
techniques.
Methods: Between May 2009-April 2010, patients who underwent arthroscopic double row
rotator cuff repair using one of 2 techniques were considered for the study. Group 1 were
repaired using a double row technique using suture anchors. Group 2 were repaired using a
transosseous- equivalent technique (Speed Bridge technique). There were small, medium,
large and massive tears. Patients were followed for 2 years after surgery. Clinical outcomes
were recorded at regular intervals using Western Ontario Rotator Cuff Index (WORC) and
Simple Shoulder test (SST) as validated outcomes measures. Return of strength at regular
intervals was recorded using hand held dynamometer and compared to the non-operative
shoulder (Shoulder Strength Index or SSI). Re-tear was evaluated at 6 months for all patients
using gadolinium enhanced MRI using the rating system of Sugaya. Total operative time for
each procedure was recorded and compared.
Results: Sixty-six patients met the inclusion criteria, with an average age of sixty-five. There
were thirty- two patients in Group 1 and thirty-four patients in Group 2. Clinically, WORC
improved in Group1 from 1028 to 72. In group 2, WORC improved from 1117 to 166. The
difference was not statistically significant at any time interval between the two groups. SST
improved from 60% to 97% and from 49% to 89% for groups 1 and 2 respectively. The
difference was not statistically significant at any time interval between the two groups. The
re-tear rate for Group 1 was 23% vs. 35% for group 2 but this difference was not statistically
significant (P<0.25). Strength improved for both groups, but was faster for Group 2 (p-value?).
Strength Index (SSI) improved for the supraspinatus in the double row group from 75% to 89%
and from 80% to 85% for the Speed Bridge Group. SSI improved for the infraspinatus from
88% to 96% for the double row group and from 87% to 93% for the Speed Bridge group. The
difference was not statistically significant. Average surgical time was 95 minutes for the group 1 and
77 minutes for Group 2 (p value?).
Conclusion: Statistically different clinical results (WORC and SST) were not demonstrated
for either repair method at any time point. Rates of re-tear were higher for the Speed Bridge
technique of rotator cuff tears vs. double row repairs but did not reach statistical significance
(P=0.25). Return of strength improved for both groups however, it was not statistically different
in comparison at measured intervals. Less operating room time compared to traditional double
row techniques were demonstrated for the Speed Bridge technique.
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Title: Total Joint Arthroplasty in an Ambulatory Setting
Authors: Robby Sikka, MD; Chad Kurtenbach, MD; Brad Nelson, MD; Joel Boyd, MD
Introduction: As the number of joint replacements rise there will be increasing pressure on
hospitals and surgery centers to minimize hospital length of stay, reduce costs, and maximize
patient satisfaction and outcomes. Our hypothesis was that admission after total knee
arthroplasty (TKA) or total hip arthroplasty (THA) from an outpatient surgery center to a hotel
post-operatively, would result in improved patient satisfaction, no difference in subjective or
objective patient outcomes in short-term follow-up, and cost savings.
Methods: Between 2010-2013 at an outpatient surgery center, one hundred fifty three patients
undergoing primary TKA and THA or unicompartmental knee arthroplasty were admitted postoperatively to a hotel (Hilton Worldwide, McLean VA) immediately after discharge from the PACU.
All patients had a family member or friend available to stay with them at the hotel the entire postoperative period and were accompanied by a nurse. All patients were ASA I and II with no history
of symptomatic coronary artery disease, sleep apnea, and all had a BMI < 42. There was no
standardization of pain medication used post-operatively If pain was not controlled by oral pain
medication, IM Morphine was given. History of previous difficulty with post-operative pain
management resulted in exclusion from the study.
Results: One hundred twenty-nine patients underwent primary total joint arthroplasty and were
included in the final analysis. Seventeen patients underwent THA and one hundred twelve
underwent TKA. Fifty-four percent of patients required IM pain medication during their stay. The
most common oral pain regimen used included an oral narcotic containing oxycodone compounds
and Vistaril (Pfizer, NY). Thirty-five percent of patients reported nausea which was treated with
oral Zofran (GlaxoSmithKline, Brentford UK). There were nine patients (6.9%) with post-operative
events. There was one superficial joint infection treated with oral antibiotics. Three patients had
post-operative urinary retention. Three patients reported vagal episodes with syncope, one of
which was considered a fall. One patient was admitted after discharge from the hotel with a
pulmonary embolus, and one for bowel obstruction. Ninety-seven percent of patients rated their
overall experience a 4/5 or 5/5 and 99% of patients responded that they would choose this option
again for their procedure. An average cost savings of 20% was achieved, compared to patients
with joint arthroplasty who were treated in the hospital post-operatively over the same time
period, with increasing savings as the number of patients increased (p=.001).
Conclusion: Admission post-operatively following primary total joint arthroplasty to a hotel with
supervised nursing can result in excellent outcomes in a high percentage of patients in a specific
population. Complication rates are not higher than those treated in a hospital post-operatively.
Patient satisfaction is high, and a significant reduction in patient cost can be achieved.
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Title: Changes in Involved and Uninvolved Limb Function During ACL
Reconstruction Rehabilitation, and the Implications for Limb Symmetry
Index Measures
Authors: John Steubs, MD; Eric Rohman, MD; Marc Tompkins, MD
Background: Functional testing is used to assess anterior cruciate ligament (ACL)
reconstruction rehabilitation, with the goal of symmetric ability. The pattern of change in
the uninvolved limb’s function during rehabilitation is not established.
Hypotheses: (1) Involved and uninvolved limb ability increases during rehabilitation, but
the uninvolved limb ability increases to a lesser degree. (2) Hop tests will show larger
initial asymmetry and will improve the most with rehabilitation.
Study Design: Cohort study; Level of evidence, 3.
Methods: This was a retrospective case series of 122 patients who underwent ACL
reconstruction at our ambulatory surgery center and received multiple postoperative
Standard Functional Tests (SFTs) between October 2009 and October 2013. Ten of the 12
individual tests within the SFT battery were analyzed. The patients’ earliest and latest
SFTs were compared for changes in Limb Symmetry Index (LSI) and absolute function in
each limb. We also analyzed the subgroup with SFTs (n = 38) at both 4 and 6 months
postoperatively.
Results: In all patients with multiple SFTs, involved limb performance increased in all
tests except eyes-closed stork. Uninvolved limb performance increased in 4 SFT
component tests and decreased in none. LSI significantly improved in 6 tests, all of which
also showed involved limb improvement that was significant. Of these 6 tests, 5 showed
initial LSI below 90%: single-leg squat, retro step-up, single-leg hop, crossover triple hop,
and timed hop. Retro step-up and single-leg hop showed LSI improvements greater than
10 percentage points. In patients with 4- and 6-month data, involved limb performance
increased in all tests except single-leg triple hop. Uninvolved limb performance increased
in 5 SFT component tests and decreased in none. LSI significantly improved in 4 tests, all
of which had initial LSI below 90%, and showed involved limb improvement that was
significant. Retro step-up, single-leg hop, and crossover triple hop showed LSI
improvements greater than 10 percentage points.
Conclusion: During ACL reconstruction rehabilitation, LSI improvements indicated
absolute increases in involved limb ability and were not attributed to uninvolved limb
deterioration. The single-leg squat, retro step-up, single-leg hop, crossover triple hop, and
timed hop are suggested as highly useful tests, since all showed initial LSI below 90%,
with significant LSI improvement after rehabilitation.
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Title: Return to Play After ACL Injury in National Hockey League Players
Authors: Robby Sikka, MD; Chad Kurtenbach, MD; Brad Nelson, MD; Joel Boyd, MD
Background: Performance outcomes and return to play data have been reported following anterior
cruciate ligament (ACL) injury in professional football and basketball, but have rarely been reported in
professional hockey. The authors hypothesized that performance after ACL reconstruction would be
comparable to prior levels of play in a series of National Hockey League (NHL) players.
Methods: The NHL Injury Surveillance System was utilized to identify all players with ACL injury
between 2006-2010. Medical staffs for all NHL teams were surveyed regarding these injuries. The
medical staffs completed a questionnaire for each injury and statistics were analyzed using multiple
analysis of variance to compare outcomes, performance, and complication rate. A control group was
identified and matched based on performance, career length prior to injury, age, height and weight.
Results: There were 47 players identified by the NHL ISS. There were three goalies, eight defensemen,
and thirty-six wings or centers. The average age of all players was 27.69. The average number of years
played after injury was 2.8 which was decreased compared to the control group (4.4), (p=.004).
Presence of meniscal injury was associated with decreased length of career compared to the control
group (p=.012), and in comparison to patients with isolated ACL injury (p=.002). For wings and
centers, the number of games played in the first full season after injury decreased from 71.2 to 58.2
(p=.05), and in the second season to 59.29 (p=.03). In the first season after injury, assists and total
points decreased from 20.3 and 35.2, to 13.8 (p=.005) and 25.9 (p=.018), respectively. In the second
season after injury, assists and goals decreased to 10.0 (p=.002) and 10.0 (p=.013), respectively.
Compared to controls, the per season averages of goals (p=.001), assists (p=.020), and total points
(p=.004) decreased. Four players (8.5%) had subsequent failure of the reconstruction, and there was a
total re-operation rate of 20%. Five players (11%) did not return to play and four (8.5%) were unable
return to play for a full season.
Conclusion: Most players are able to return to play in the NHL following an ACL injury. However,
career length and performance may be significantly decreased compared to controls. This may
represent a more severe initial injury, and more focused return to play pathways may identify barriers
to return to play.
What is known about this topic: Only one report exists on return to play following ACL injuries in
hockey players. This study does not include a comprehensive dataset of injuries and relied on public
databases to identify injuries. No reports on concomitant injuries, treatment methods, mechanism of
injury, have been described in this population.
What this study adds to the existing knowledge: This study describes the prevalence of ACL injuries
in professional hockey, using the NHL injury surveillance system database. This study further
describes concomitant injury patterns, mechanisms of injury, and compares the data to a control group
of professional hockey players.
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Title: Knee Arthroscopic Posteromedial Portal Placement using the
Medial Epicondyle
Authors: Lanham, Tompkins, Milewiski, Hart, Miller
Purpose: Evaluation of the medial epicondyle as an anatomic landmark for arthroscopic
posteromedial portal placement.
Methods: Portal placement was performed on 10 fresh-frozen cadaveric knees.
Posteromedial portal location was defined as being 2.5 cm inferior and 2.5 cm posterior
from the medial epicondyle with 90 degrees of knee flexion. The distance from the portal
to the saphenous neurovascular bundle was measured. Anthropometric values of the
cadaveric specimens were measured and correlated with the portal to bundle distance.
Results: The posterior horn of the medial meniscus and the tibial PCL insertion were
visualized and easily probed through the portal in all specimens. None of the portals
violated the saphenous neurovascular bundle in any cadaver specimen. The median
distance from the portal to the neurovascular bundle was 29.5 ± 20mm. The correlation
coefficient between cadaveric BMI and the distance from the portal to the neurovascular
bundle was found to be statistically significant (r=0.54, P=0.05).
Conclusion: This portal produced good access to the posteromedial structures in the
knee and no violation of the saphenous neurovascular bundle occurred with
posteromedial portal placement. Patient BMI is related to distance between the portal and
neurovascular bundle.
Level of Evidence: Descriptive Laboratory Study (Level V)
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3RD QUARTER 2014 SCHOLARLY ACTIVITY
3rd Quarter 2014 Scholarly Activity
In the third quarter of 2014, our researchers published or presented four pieces of
original research work.
In July, Dr. Jeff Macalena, Dr. Robby Sikka, and Dr. Marc Tompkins’ research examining the
fibular tunnel trajectory using a cadaveric model was published in Knee Surgery, Sports
Traumatology, and Arthroscopy.
In September, we had two publications. The first by Dr. Marc Tompkins and Dr. Jeff
Macalena in the American Journal of Sports Medicine comparing biomechanical patellar
fixation techniques. Secondly, Dr. Robby Sikka and Dr. Brad Nelson’s article, “Proximal
Tibial Morphology and Correlation with Osteochondritis Dissecans of the Knee” was
published in Knee Surgery, Sports Traumatology, and Arthroscopy.
Also in September, Kim Waterbury, OTR/CHT presented her poster “Beyond the
Research: An Accelerated Rehabilitation Protocol for Patients with
Distal Radius Fracture Treated with ORIF using Volar Locking Plate”
at the Annual Society for Hand Therapy meeting in Boston,
Massachusetts. The target audience of this conference is hand
therapists.
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Title: Beyond the Research: An Accelerated Rehabilitation Protocol for Patients with
Distal Radius Fracture Treated with Open Reduction Internal Fixation using Volar
Locking Plate; A Retrospective Review and Comparison of Outcomes with a Surgeon
Directed Independent Exercise Program
Authors: Kim Waterbury, OTR/CHT; Nancy Callinan, OTR/CHT; Jeffrey Husband, MD; Megan
Reams, MA, OTR/L
PURPOSE: The purpose of this study is to understand clinical outcomes of patients treated with an
accelerated rehabilitation protocol following surgical treatment for distal radius fracture (DRF) with volar
locking plate open reduction internal fixation (ORIF) and compare these outcomes to the outcomes at our
sister rehabilitation facility and published outcomes of a surgeon-directed independent exercise program.
BACKGROUND: Distal radius fractures are among the most common upper extremity fractures treated by
hand therapists. Recent literature has demonstrated that advances in surgical methods using a volar locking
plate ORIF in the treatment of DRF allows earlier initiation of range of motion (ROM) and strengthening as
well as an earlier return to function.
METHODS: This study is a retrospective review of patients with DRF who were treated with ORIF and
received hand therapy using an accelerated rehabilitation protocol between July 2011 and December 2013.
Patients who had surgery at TRIA Orthopaedic Center and hand therapy at TRIA Orthopaedic Center or Park
Nicollet Health Services (PNHS), our sister facility, were included in this review. Electronic medical records
were reviewed to determine if the surgeon ordered an “accelerated” rehabilitation protocol as part of the
post-operative care, therefore meeting inclusion. Patients were excluded if they were less than 18 years old
at the time of surgery or received hand therapy services outside of TRIA Orthopaedic Center or PNHS.
Patients followed an accelerated rehabilitation protocol under the guidance of a hand therapist (Table 1). All
of the hand therapists at TRIA Orthopaedic Center are occupational therapists. Data collection included total
number of hand therapy visits, weeks post-op at time of discharge, and measurements at the time of
discharge for AROM (wrist extension, wrist flexion, supination, and pronation), and grip strength.
RESULTS: Preliminary data review of 373 records of patients who underwent ORIF for the treatment of DRF
at TRIA Orthopaedic Center indicate 255 had orders from their surgeon to follow an accelerated
rehabilitation protocol. Ten of these patients were 18 years of age or younger and were excluded from
further review. Another 42 patients sought therapy services outside of TRIA; 19 of those were treated at
PNHS and are included. Comparison of outcomes at 12 weeks post-op between the original TRIA study
accelerated rehabilitation protocol group and the surgeon-directed independent exercises group show that
patients guided by a hand therapist during their rehabilitation at TRIA have better wrist ROM, strength, and
disability of the arm, shoulder, and hand (DASH) scores (Table 3). Further analysis is needed to determine if
there is statistical significance.
CONCLUSIONS: Early analysis of retrospective data indicates that patients treated with TRIA Orthopaedic
Center’s accelerated rehabilitation protocol following ORIF for DRF are achieving functional ROM and
strength 5 weeks earlier than the results of the surgeon directed independent exercise group.
Page 35
4TH QUARTER 2014 SCHOLARLY ACTIVITY
4th Quarter 2014 Scholarly Activity
In the fourth quarter of 2014, we finished the year strong with four publications of original
research work.
In October, Dr. Jeff Husband, along with former University of Minnesota Resident, Dr. Jess
Brehmer, published an article looking at rehabilitation after distal radius fracture in the Journal of
Bone and Joint Surgery.
In November, Dr. Deb Bohn, along with former University of Minnesota Resident, Dr. Paul Cagle,
published the first article from our outcomes program. This paper examined our carpal tunnel
outcomes program, and was accepted by the Journal of Hand Surgery.
To finish the year, a publication by Dr. Robby Sikka, analyzing forced air warming devices in
orthopaedics was accepted to the Journal of Bone and Joint Surgery. Also in December, Dr. Marc
Tompkins’ article studying the use of Ketorolac in children was published in Consultant for
Pediatrics.
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Page 40
AFTERWORD
Afterword
Research continues to make TRIA different than other
orthopedic practices in the market place. We continue to
pursue research opportunities that have an impact on the
Triple Aim of quality, cost of care, and patient experience. For
example, our research study on distal radius fractures was
published in the Journal of Bone and Joint Surgery in 2014
which focused on all three components of the Triple Aim. We
continue to pursue research opportunities that have an impact
on the Triple Aim.
Our scholarly activity increased by more than 21% in 2014
over the previous year. As we continue to deliver state of the
science musculoskeletal care to our patients, we are seeking
additional local and federal funding opportunities to further
extend our research efforts.
Currently there are a total of 27 ongoing research projects at
TRIA ranging from industry sponsored clinical trials to
investigator initiated prospective studies and retrospective
chart reviews. We have numerous investigators not
mentioned in this 2014 report as their research is still
ongoing. Our dedicated research team continues to provide
guidance to our investigators through the entire study
development process. We are excited for yet another
impressive research year in 2015!
We hope you enjoyed our inaugural report!
Page 41
Brad Nelson, MD
Institute Medical Director,
Physician and Researcher
Megan Reams, MA, OTR/L
Institute Manager
Page 42
CURRENT RESEARCH ACTIVITY
Currently Enrolling
ACL Female Athlete: This study is looking at the long-term outcomes of female athletes who have
undergone an ACL reconstruction to determine the rate of return to sport and the re-rupture rate of the
ACL graft.
DeNovo: The focus of this study is on the improvement in clinical outcomes for treatment of articular
cartilage lesions of the knee using DeNovo NT, which is a FDA-approved, juvenile cartilaginous tissue graft.
Insole: The purpose of this investigation is to document the acceptability and effectiveness of a shoe
insert in a group of patients with significant osteoarthritis of the knee.
LEAP: Determine if a neuromuscular training program, specifically TRIA Lower Extremity Agility
Program (TRIA L.E.A.P.), can be implemented as a post-operative ACL reconstruction tool to provide longterm benefits on lower limb symmetry index and outcome scores.
Low Back Pain: The focus of this study is to determine whether a formal prescriptive treatment
protocol for the hips along with the low back improves outcomes in patients with low back pain.
NeoCart: This study is evaluating the improvement in clinical outcomes for treatment of articular
cartilage lesions of the knee using DeNovo NT, which is a FDA-approved, juvenile cartilaginous tissue graft.
SLAP: This study will increase understanding of patient recovery following surgical treatment of a SLAP
tear in the shoulder for both surgical options. Furthermore, the timing of return to specific activities and
function will be tracked to better counsel patients regarding expectations post-operatively. Finally, this
study will help determine which surgical option is more effective in treating SLAP tears for patients of this
specific age group.
ACL Long-Term Follow-up: Evaluate the long-term outcomes of patients who have undergone an ACL
reconstruction to determine return to sport/activity, graft health, knee function, knee osteoarthritis,
and concomitant knee surgeries.
Chart Review
ACL Inclinational Angle: Retrospective chart review determining the angle of inclination of the native
Anterior Cruciate Ligament (ACL) in the Coronal and Sagittal planes. Establishing the native ACL
inclination angle may help aid surgeons in anatomic reconstruction or identify predisposition for ACL
injuries.
Cortical Button Position: Retrospective chart review analyzing the incidence of cortical button
malposition on postoperative radiographs following Anterior Cruciate Ligament reconstruction.
Meniscus Repair: A retrospective chart review comparing function, satisfaction, and re-operation rate
between post-operative weight bearing protocols. Protocols were based on provider preferences and
patients were divided into two groups; immediate weight bearing as tolerated or protected weight
bearing
Page 43
CURRENT RESEARCH ACTIVITY
Patellar Height: Retrospective chart review to compare patellar height measurements on x-ray and
MRI in a population of first-time lateral patellar dislocation cases compared to a control population. The
scope of this study is to identify factors associated with lateral patella dislocations.
Functional Test ACL, Meniscus Repair & MPFL: This study evaluates the involved and uninvolved
limb scores and how they change during serial standard functional testing following Anterior Cruciate
Ligament reconstruction (ACLR), Meniscus Repair and Medial Patellofemoral Ligament reconstruction.
The aims of this study are to determine changes in scores and evaluate the testing measures for sensitivity
and specificity.
Closed to Enrollment (In follow-up)
Rotator cuff-PRFM: This prospective randomized study focuses on clinical outcomes and healing rates
following rotator cuff repair using a double row of suture anchors. Patients are randomized to receive
either a standard double row repair or a double row repair with supplemental platelet rich fibrin
membrane (PRFM). This study investigates if supplemental PRFM can improve outcomes and reduce retear rates compared to a standard double row repair.
Activity scale: The purpose of this study is to evaluate the ease of use, reliability, and responsiveness to
an activity scale questionnaire, designed to let patient’s self-report the activities of most importance to
them. Developing an activity scale questionnaire can aid providers by understanding how orthopedic
conditions impact patient’s lives both pre and post operatively.
Closed to Enrollment (Data analysis)
ACL Return to Function: The purpose of this study is to evaluate the timing of return to activities of
daily living (ADL) following anterior cruciate ligament reconstruction (ACLR). This study will help
patients and surgeons set realistic expectations for return to ADL’s following ACLR.
KOOS: This study will help establish baseline Knee Injury and Osteoarthritis Outcomes Survey (KOOS)
scores in a US population who do not report knee pain. The aim of this study is to define scores for a
normal patient population which will then be used to compare scores following surgical intervention.
Lisfranc: The purpose of this study it to evaluate the long term results of patients following a lisfranc
dislocation surgery in the foot. Results are measured in relation to patient reported outcome scores, CT
scans measuring osteoarthritis and subsequent medical complications.
Page 44
CONTACT US
TRIA Orthopaedic Center | Research Institute
8100 Northland Drive
Bloomington, MN 55431
952.806.5603 (p)
952.806.5459 (f)
[email protected]
Please join us for one of our research committee meetings where new ideas are discussed.

Sports sub-specialty group/research committee meets the 2nd Monday of every
month at 4p.m.

Shoulder sub-specialty group/research committee meets the 2nd Monday of every
other month (Jan, Mar, May, July, Sept, Nov) at 5p.m.

Hand sub-specialty group/research committee meets the 2nd
Monday of every other month (Feb, Apr, Jun, Aug, Oct, Dec) at 5p.m

TRIA ORTHOPAEDIC CENTER SCHOLARLY ACTIVITY

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