NYP ORTHO 2008

omputer modeling and simulation can helpcustomize and optimize the techniques of total

shoulder replacement (TSR). An ongoing investiga-tion at the Center for Shoulder, Elbow and SportsMedicine at NewYork-Presbyterian Hospital/Columbia University Medical Center that beganwith retrospective studies in the laboratory hasmoved to the operating room. Experts believe thatthe technology could ultimately be transferredthroughout the orthopaedic community and assistin surgical decision making.

The key to successful TSR involves proper ream-ing of the glenoid and placement of the artificialsocket. The innovative use of digitized imagesderived from computed axial tomography (CAT)scans of the glenoid vault and surrounding struc-tures in this process has several advantages, accord-ing to Louis U. Bigliani, MD. “The computer refor-matting in 360-degree views gives precise dimen-sions of the glenoid allowing precise preoperativeplanning for glenoid implant insertion, especially indifficult cases with deformed bone stock,” he noted.

Case HistoryRonald T., an 81-year-old retiree, came to

NewYork-Presbyterian/Columbia from his home inFlorida. Active, in robust health, he had severeosteoarthritis of the right shoulder. He was unableto raise his arm above his head. Pain interfered withsleep and multiple tasks in daily life.

Imaging showed a normal rotator cuff, but with alarge osteophyte on the humeral head. The glenoidhad significant asymmetrical wear, with diminishedvolume and surface area. “This made for a difficultshoulder arthroplasty,” said Dr. Bigliani.

Discussion

In general, TSR can be a demanding procedurebecause the glenoid socket is relatively small,deformed by pathology, and exposure is difficult.“With asymmetrical wear and posterior bone loss ofthe glenoid, it is very difficult to accurately assessthe glenoid vault,” noted Dr. Bigliani.

Computer manipulation of CAT scan imagesinforms surgeons with added precision and providessimulations of implant position and size to maxi-mize bony containment and support of the glenoidwithout obscuring deforming osteophytes.

“Computer simulation enables us to understandthe anatomy better and identify the bony land-marks,” explained Dr. Bigliani. “We know where we

see Shoulder, page 6

INSIDE SPRING 2008

Microsurgery Lab

2 A state-of-the-art teachingfacility for medical

students, residents, and fellows.

Sports Medicine

3 Columbia Orthopaedic surgeons and squash’s

“Tournament of Champions.”

Hand Surgery

4 New recruit to the HandSurgery Service identifies

novel research targets in controversial areas.

Chondroblastoma

5 Orthopaedic surgeons treatan adolescent male with a

bone-deforming disease.

57-year-old woman presented to the Centerfor Shoulder, Elbow and Sports Medicine at

NewYork-Presbyterian Hospital/Columbia UniversityMedical Center with an intra-articular fracture inthe left distal humerus, resulting from a fall in herhome. This active and healthy woman played ten-nis at a competitive level.

Her surgeons—Christopher S. Ahmad, MD, andMelvin P. Rosenwasser, MD—saw the patient as an

ideal candidate for the 2-window paratricipitalapproach to expose and fix her comminuted andunstable distal articular fracture. This technique pro-vides excellent exposure of the intercondylar humer-al fracture, creating windows through intermuscularplanes at the medial and lateral aspects of the tricepstendon while leaving the extensor mechanism intact.This eliminates the need for an olecranon osteotomy

see Elbow, page 5

Case Study: The Two-Windows ApproachA

Case Study: Modeling Shoulder ReplacementC

Digitized image of the shoulder may help surgeons withpreoperative planning for total shoulder replacement.

Phot

o co

urtes

y of

Lou

is U

. Big

liani

, MD

SAVE THE DATEBiomet PediatricTrauma & SpineLecture SeriesNew York CityOctober 24-25, 2008

73rd NYOH Alumni MeetingNew York CityMay 8-9, 2009

For more information on ColumbiaOrthopaedics’ services, visitwww.nyp.org/columbiaortho

RESOURCES FORPROFESSIONALS• Webcasts • CME Activities • Medical Presentations • Specialty Briefings • Newsletters

Visit nyp.org/pro

Affiliated with Columbia University College of Physicians and Surgeons

NEWYORK-PRESBYTERIANCOLUMBIA ORTHOPAEDICS

he Columbia University MicrosurgeryResearch and Training Laboratory at

NewYork-Presbyterian Hospital offers med-ical students, residents, and fellows theopportunity to acquire skills at a state-of-the-art teaching facility, and apply thatexpertise in basic and applied clinicalresearch. In the nearly 30 years since the lab-oratory was founded, the number of traineeshas grown to more than 90 students per yearfrom more than 25 national postgraduateprograms and more than 15 countries.

“This is a skill acquisition laboratory,”explained Yelena Akelina, DVM, MS.“Microsurgery is a technically demanding andprecise skill that requires structured trainingand a lot of practice to achieve proficiency, andeven more for mastery. There are few teachinglaboratories of this size and scope in the coun-try. What sets the Columbia Research Labapart is that it teaches both the technical sur-gical skills as well as the methodology fortranslational research, which is so importantin surgical therapeutics. The laboratory hastrialed and invested in a number of new tech-nologies that are advancing the core knowl-edge of microsurgery as it trains the next gen-eration of surgical subspecialists from manyfields in microsurgery.”

“We have one of the best teaching micro-surgery laboratories in the United States,”added Melvin P. Rosenwasser, MD. “Itattracts surgeons in training throughout thecountry in multiple specialties which requirethis special expertise. One prime example is inthe field of limb salvage after devastatinginjury. We now have many more surgeonsavailable to perform sophisticated soft-tissueor bone-vascularized free tissue transfer, whichmay save patient limbs and shorten disability.Didactics and technology have changed great-ly since I finished my training.”

For example, the laboratory tested aunique high-definition, 3-dimensional real-time imaging system for teaching micro-surgery. The laboratory beta tested the systemfor 1 year and observed students learning in adifferent “heads-up display” style not unlikethe video games that many young surgeonsknow full well. Extensions of this technologymay fuel new advances in microsurgery.

Traditionally, microsurgery is taughtwith dual-head microscopes, allowing onlythe instructor and 1 student access to thesurgical field. With the investigational sys-tem, Dr. Akelina taught multiple students

at the same time, showing the procedures ina unique and more realistic 3-D view.

The system replaces the binocular eye-pieces of standard microscopes, and the cap-tured images from the left and right eye-pieces are projected onto a 40-inch screen asa 3-D image. A surgeon can work by look-ing straight ahead at the screen wearing spe-cial polarized glasses without being “fixed”to the eyepiece; the assistant can still use thesecond eyepiece if needed.

“The system allowed the instructor toexplain and demonstrate the specific teach-ing points more easily on a large-formatscreen,” Dr. Akelina said. The company thatdeveloped the system continues to refine itfor use in orthopaedic microsurgery.

“The imaging system was valuable in theteaching setting,” added Robert Strauch,MD, citing the ability to allow many peopleaccess to the surgical field in 3-D as a keybenefit of the system. “Although plug-insare currently available to project imagesfrom microscope eyepieces onto screens, thisis the first system to do so in 3-D.”

The laboratory’s research capability hasexpanded over the years, thanks to the gener-ous support of the Orthopaedic Research andScientific Foundation initiated and directedby Robert E. Carroll, MD. For example, suchfunding was used to purchase a data-acquisi-tion system that measures blood/fluid flow invessels in animal models as small as 1 mm.The flow meter “has opened a world of oppor-tunity for microvascular research projects inanimal models,” Dr. Akelina said.

One such investigation studies theadjunct use of a collagen conduit wrap fol-lowing arterial reconstruction with a veingraft in a rat model to diminish the incidence

of aneurysmic dilation and early thrombosis.This study has important clinical indicationsfor vascular surgery in increasing long-termpatency of bypass grafts, which employ anintercalary vein graft. Another useful researchtool is the nerve stimulator probe, which allowselectrodiagnostic testing, including elec-tromyography, to assess the nerve injury andrepair projects such as treatment of neuroma.

The microsurgery research lab has maturedby the corpus of ongoing work to offer a 1-year research fellowship. “This fellow’s pres-ence has increased the amount and sophistica-tion of the research output,” Dr. Akelina said.

Maria Codreanu, MD, a general surgeryresident, is the present research fellow andhas augmented her clinical training whilesatisfying her research interests.

“Residents at different levels of trainingcan be challenged by the intellectual andtechnical rigors of the laboratory,” Dr.Codreanu said. “The microsurgical tech-niques mastered in the laboratory have awide range of applications, starting with thecareful handling of tissue, and performanceof different vascular anastomoses, andacquiring knowledge of anesthesia and mon-itoring its effects in vivo.” Surgeons who areinterested in this full-year fellowship shouldcontact Dr. Akelina.

The laboratory offers shorter focusedtechnical courses for residents, fellows, prac-ticing physicians, and other allied medicalprofessionals who wish to acquire basicknowledge and the fundamental skills ofmicrovascular surgery. These courses may beviewed at http://columbiaortho.org/microlab.

Microsurgery Lab Expands Technologies, CapabilitiesT

2 www.nyp.org/columbiaortho

NEWYORK-PRESBYTERIAN COLUMBIA ORTHOPAEDICS

Contributing faculty for this article:Yelena Akelina, DVM, MS; Maria Codreanu, MD;

Melvin P. Rosenwasser, MD; Robert Strauch, MD

Yelena Akelina, DVM, MS, demonstrates a high-definition, 3-dimensional imaging system.

ince 2001, the Center for Shoulder,Elbow and Sports Medicine at NewYork-

Presbyterian Hospital/Columbia UniversityMedical Center has provided medical cover-age for the “Tournament of Champions,” themost prestigious annual squash contest heldin the United States.

Set amid the landmark Vanderbilt Hall ofNew York City’s Grand Central Terminal,the tournament exposes hundreds of thou-sands of commuters to this fast, athletic,exciting, and ascendant but still relativelyuncommon sport. Squash is truly an inter-national game with the top 20 male playersin the world hailing from Egypt, the UnitedKingdom, Australia, France, Scotland,Malaysia, Finland, and the Netherlands.

Orthopaedic care for the tournamenteach year is provided by William N. Levine,MD, and Christopher S. Ahmad, MD. Dr.Levine, the Director of Sports Medicine at

NewYork-Presbyterian/Columbia, recog-nizes that squash players are subject to thetypical array of musculoskeletal injuries,but that contact injuries, including lacera-tions, are also seen. These professional playersrarely wear protective glasses, so cata-strophic eye injuries are possible but rare.

Squash players sustain “a fair amount oftennis elbow, overuse injuries to the shoul-der, rotator cuff injuries, and meniscaltears,” according to Dr. Levine. He shouldknow; he is a player himself. “Elite playersafter years of play develop hip arthritis,which is unique and differs from the normaldegenerative pattern found in other sports,like tennis,” he noted. “It’s caused by thefrequent lunging seen in championship play.Global cartilage loss often results. The onlysalvage is total hip replacement or, in someyounger players, the bone-preserving hipresurfacing option is possible and may allowreturn to play, albeit at a lower intensity.”

NewYork-Presbyterian Columbia Orthopaedicsis a semi-annual newsletter published by NewYork-Presbyterian Hospital. The articlesin this newsletter represent the work of the Columbia University College of Physiciansand Surgeons faculty at NewYork-Presbyterian Hospital/Columbia University MedicalCenter, who are at the forefront of research and practice in the diagnosis, treatment, andrehabilitation of musculoskeletal conditions in adults and children.

NewYork-Presbyterian Columbia Orthopaedics Editorial Board

Columbia University College of Physicians and Surgeons

Sports Medicine Center Boasts Elite Squash CoverageS


3

Melvin P. Rosenwasser, MDEditor-in-ChiefDirector, Orthopaedic Hand and

Trauma, and Microsurgery ServicesRobert E. Carroll Professor of Hand

SurgeryE-mail: [email protected]

Louis U. Bigliani, MDChief, Orthopaedic Surgery Service Director, Center for Shoulder, Elbow and

Sports MedicinePresident, Medical BoardFrank E. Stinchfield Professor

and ChairmanDepartment of Orthopaedic Surgery

E-mail: [email protected]

Francis Y. Lee, MDChief, Tumor and Bone Disease ServiceAssociate Professor of Clinical

Orthopaedic SurgeryVice Chairman for ResearchDirector, Center for Orthopaedic ResearchE-mail: [email protected]

William N. Levine, MDDirector, Sports MedicineAssociate Director, Center for Shoulder,

Elbow and Sports MedicineVice Chairman of Education and Professor

of Clinical Orthopaedic SurgeryE-mail: [email protected]

William B. Macaulay, MDDirector, Center for Hip and

Knee ReplacementAnne Youle Stein Professor of Clinical

Orthopaedic SurgeryE-mail: [email protected]

Christopher B. Michelsen, MDChief, Orthopaedic Spine ServiceChief, Orthopaedic Surgery

The Allen PavilionProfessor of Clinical Orthopaedic SurgeryE-mail: [email protected]

David P. Roye, MDChief, Pediatric Orthopaedic Surgery

Morgan Stanley Children’s Hospital St. Giles Professor of Clinical Pediatric

Orthopaedic SurgeryE-mail: [email protected]

Contributing faculty for this article:Christopher S. Ahmad, MD; William N. Levine, MD

Squa

shP

ics.c

om

Gregory Gaultier of France stretches for the ball at the 2008 Tournament of Champions in New York City. Canada’s Shawn Delierre looks on.

“Elite players after years ofplay develop hip arthritis,which is unique and differsfrom the normal degenera-tive pattern found in othersports, like tennis.”

—William N. Levine, MD

eter Tang, MD, MPH, embodies themodern-day definition of a hand sur-

geon. As such, he considers the upperextremity as a functional unit that requiresholistic care rather than the historical andnonanatomic approach, which focuses treat-ment from the wrist down.

The most recent addition to the HandSurgery Service in the Department of Ortho-paedic Surgery at NewYork-PresbyterianHospital/Columbia University Medical Center,Dr. Tang epitomizes innovation, findingnovel research targets in difficult and contro-versial areas of hand surgery.

“Modern-day hand surgeons are trainedto deal with upper-limb anatomy, physiol-ogy, and mechanics,” said Dr. Tang. “It isobvious that the functionality of the handdepends on the health and integrity of allthe organ systems within the limb enve-lope. In severe crushing, for example, thetreatment algorithm is complex. Is thelimb viable? What is the vascular statusand is there a need for repair? Is therenerve injury and is there need for repair? Isthere a compartment syndrome and do thecompartments need to be released to savemuscle and nerve function? If we salvagethe limb, how can we get bony stability,and is there a need for ligament recon-struction to obtain joint stability? Lastly,how are the soft tissues? Can we get pri-mary wound closure or is there a need for alocal or free flap?”

Dr. Tang’s current research studies shednew light on accepted procedures like theproximal row carpectomy (PRC) for severeosteoarthritis. He has conducted severalstudies to determine the “contact biome-chanics” after PRC. Dr. Tang has evaluatedthe contact pressure, area, and kinematics ofthe intact and PRC wrist in a cadavericmodel. His findings demonstrate that thewrist after PRC is a biomechanically disad-vantaged joint, with high contact pressureon a small contact area, compared with theintact wrist (Figure). However, the PRCwrist has increased translation comparedwith the intact wrist, which may explain thesatisfactory clinical results reported. Thefindings “confirm a hypothesis that has beencited but unproven,” Dr. Tang said.

Using similar laboratory methodology inthe Center for Orthopaedic Research atNewYork-Presbyterian/Columbia, he willstudy the mechanics of another scapholunate

advanced collapse (SLAC) salvage proce-dure—scaphoid excision and 4-bone fusion.

Dr. Tang attended Harvard as an under-graduate and medical school at WeillCornell Medical College. Dr. Tang com-pleted his orthopaedic residency training atthe University of Pittsburgh MedicalCenter (UPMC). He then spent a postgrad-uate fellowship in hand surgery at UPMC.

“What attracted me to the field was theintricate anatomy of the upper extremityand the complex surgeries including micro-surgery, which allows replantation of ampu-tated fingers,” he said. At UPMC, he was

mentored by Joseph E. Imbriglia, MD, whowas a hand fellow of Robert E. Carroll, MD,a founding father of hand surgery and now aprofessor emeritus at Columbia UniversityCollege of Physicians and Surgeons.

“Dr. Carroll has trained a generation ofhand surgeons, and now I am at the sameinstitution after being trained by one of hisstudents,” Dr. Tang said. “I was thrilled tohave this opportunity. NewYork-Presby-terian/Columbia has a legendary history inorthopaedics and hand surgery, and I am hon-ored to be part of its legacy. I have the oppor-

Hand Surgery Recruit Brings Contact Biomechanics ExpertiseP



see Hand, page 6

Figure. X-ray showing an arthritic wrist following proximal row carpectomy.

Imag

es c

ourt

esy

of P

eter

Tan

g, M

D, M

PH

.

“What attracted me to the field was the intricate anatomy of the upper extremity and the complex surgeries includingmicrosurgery, which allows replantation of amputated fingers.”

—Peter Tang, MD, MPH

hondroblastomas, locally destructivebut nonmalignant tumors that tend to

arise in the epiphyses, are fairly rare. Still, asa specialist in pediatric orthopaedic surgeryat Morgan Stanley Children’s Hospital ofNewYork-Presbyterian/Columbia UniversityMedical Center, Joshua E. Hyman, MD, seesseveral cases each year. Adolescent males aremost often affected. According to Dr.Hyman, the diagnosis is typically madebecause the osteolytic growth causes wors-ening pain as it destroys and deforms bone.

Classical symptom recognition helps dif-ferentiate this disease from more commoncomplaints of mechanical knee pain.Imaging can distinguish the chrondroblas-toma from giant cell tumors, aneurysmalbone cysts, and clear cell chondrosarcomas.The following case illustrates how success-ful treatment of chondroblastoma relies onthe expertise of many specialists: pediatricorthopaedic surgeons and musculoskeletaloncologists, as well as adult orthopaedicsurgeons.

Case HistoryCharles B., 15, presented at Morgan

Stanley Children’s Hospital with a 5-month

history of knee pain. He reported swellingin the front of his right knee that radiatedover the distal femur. The knee was tender,without visible skin changes.

No trauma was implicated and theremainder of the exam was noncontributory.“There was nothing remarkable in the histo-ry,” recalled Dr. Hyman, who saw Charles B.at his initial visit. “He was entirely healthy.”

Because the swelling in the knee suggest-ed the existence of a tumor, Dr. Hymancalled for X-rays and a magnetic resonanceimaging (MRI) of the patient’s knee. The X-ray clearly suggested a lesion within thedistal femur while the MRI provided addi-tional information concerning its extent andcharacteristics.

“There are subtle findings on MRI youmight not see on plain X-ray,” said Dr.Hyman. “If there’s evidence of a soft-tissuetumor or soft-tissue extension of the tumor,you will see it on MRI but not on the X-ray.”

Based on the patient’s age, location of thelesion, and the advancing symptoms, chon-droblastoma became the likely diagnosis.This was confirmed via tissue biopsy. Dr.Hyman informed the patient’s father andreferred the patient to Francis Y. Lee, MD,

who specializes in pediatric orthopaedic sur-gery and in treating complex musculoskele-tal tumors such as chondroblastomas. Theobvious advantage of cooperation betweenexperts permitted seamless treatment ofboth tumor excision and an elegant recon-struction of the damaged limb and cartilage.

When Dr. Lee saw the patient, he notedthe tumor’s rapid progression and the artic-ular joint destruction. “The tumor involvedthe articular surface, and the articular carti-lage was destroyed,” Dr. Lee recalled. Hescheduled surgery as the patient had lostthe mobility of his knee.

DiscussionIn chondroblastoma, surgery involves

both excising the tumor and reconstructionof the joint surface using allograft articularconstructs. The graft healed; function wasrestored; and Charles B., was soon able toreturn to full activity.

With chondroblastoma, there is a smallbut not insignificant chance (~5%) of recur-rence. At 2-year follow-up, however, CharlesB., remains healthy.

Case Study: Chondroblastoma Afflicts an Adolescent MaleC

5


with its known and not insignificant compli-cation rates of nonunion, malunion, andhardware migration.

This injury was closed, with no nervedeficits. This is the type of fracture that istypically explored through an olecranonosteotomy. X-rays and computed tomogra-phy scans confirmed the trans-olecranon fossaT-condylar type with trochlear comminution.

In the 2-window paratricipital approach,the window is created by elevating thelong head of the triceps from its attach-ments on the medial ulna. Capsulotomy isperformed along the medial olecranon mar-gin through division of the transverse andposterior medial collateral ligament(MCL). Care is taken to preserve the anteri-or band of the MCL, which is necessary forelbow stability. The lateral window is creat-ed by making an incision along the tricepsaponeurosis and lateral head of the triceps.Capsulotomy is performed along the olecra-non margin without cutting the lateral col-lateral ligaments, elbow extensors, oranconeus. Following these releases, the gentle

rotation of the forearm will access the anteri-or and posterior trochlea for anatomicreassembly of fragments.

The surgeons used this approach toobtain exposure and anatomic reduction ofthe articular surface and then applied pre-contoured column plates for fixation.

OutcomeThe ulnar nerve was released and trans-

posed in a subcutaneous location and

restrained with a fasciocutaneous flap. Stablealignment and fixation were achieved allow-ing early motion. Within 6 weeks of surgery,the patient had regained mobility of 15degrees to 120 degrees. “This patient had anamazing result. She is back to playing tennisand [performing] all her daily routines and isextremely satisfied with the surgery,” notedDr. Ahmad.

Discussion“Intra-articular elbow fractures are a

common presentation and are becomingincreasingly complex given the aging ofthe population and the rising rates ofhigh-energy injuries from motor vehicleaccidents and sports injuries,” explainedDr. Rosenwasser.

Although intra-articular humeral frac-tures are traditionally treated with olecra-non osteotomy, there are known complica-tions, even with perfect technique. Theseinclude delayed or non-union of the olecra-non, malunion with incongruence, andhardware migration with pain.

Contributing faculty for this article:Joshua E. Hyman, MD; Francis Y. Lee, MD

continued from Elbow, page 1

see Elbow, page 7

The 2-window paratricipital approach to the distal humerus.

Triceps muscle,lateral head

Lateral windowincision

Brachioradialis and extensorcarpi radialislongus muscle

Anconeus muscle

Common extensor muscles

Triceps muscle,long head

Medial windowincision

Triceps tendonaponeurosis

Olecranon

Common flexormuscles



tunity to work on the Hand Surgery Servicewith my experienced colleagues, Dr. MelvinP. Rosenwasser and Dr. Robert J. Strauch.NewYork-Presbyterian/Columbia has a greattradition of research and I am excited to con-tribute at this special institution.”

He listed such resources as the Micro-surgery Research and Training Laboratory,initiated by retired Chief, Dr. Harold M.Dick, and the Trauma Training Center,developed by Dr. Rosenwasser, as factors thatattracted him to the Department. “TheDepartment of Orthopaedic Surgery hasgreat resources for research,” noted Dr. Tang.“Part of our goals as an academic institutionis to perform research and advance the fieldto improve patient care.”

“Dr. Tang is joining the tradition ofhand surgery at Columbia, which hasalways been forward-thinking and modernin its approach,” added Dr. Rosenwasser.“He fits this category both by training andby temperament. He is among the groupwho will become the next leaders in handsurgery in America.”

want to enter on the surface, and we knowwhich angle we can go in at, and that helpsus a great deal.”

Computer modeling is used for TSR sur-gery, according to Dr. Bigliani, and it can beused to predict situations where the proce-dure might not succeed due to mechanicalfailure. Software can be used to teach theprocedure details, and these simulation toolsdeveloped here can help to train the greaterorthopaedic community performing shoul-der arthroplasty.

“It’s not quite virtual reality because wedon’t get the tactile feel, for example,” saidChristopher S. Ahmad, MD, who participat-ed in developing the teaching module. “But,we do simulate the steps of the operationrealistically.”

William N. Levine, MD, the other mem-ber of the surgical and research team, addedthat “computer navigation has recentlybecome popular in hip and knee surgery, and

our novel computer-generated research laysdown a foundation for transferring this excit-ing technology from the bench to the ORover the next several years.”

OutcomeRonald T. had just the type of pathology

that was facilitated by the computer mod-eling before surgery. Exposure of the gle-noid proved difficult, and the asymmetricalbone loss required reaming on the anteriorsurface to level for implantation of the

prosthesis. The critical amount of retrover-sion, between 0 and 5 degrees, must beachieved.

“We were able to ream down to that posi-tion,” said Dr. Bigliani. Three peg holeswere drilled to receive the artificial glenoid.Their placement was guided by the comput-er simulation.

After surgery, Ronald T. had an excellent

continued from Hand, page 4

Peter Tang, MD, MPH, and his team perform hand surgery at NewYork-Presbyterian/Columbia.

continued from Shoulder, page 1

see Shoulder, page 8

Contributing faculty for this article:Melvin P. Rosenwasser, MD; Peter Tang, MD, MPH

“Computer simulation enables us to understand the anatomybetter and identify the bony landmarks.”

—Louis U. Bigliani, MD

Louis U. Bigliani, MD, performs computer sim-ulation for total shoulder replacement surgery.

Soft-tissue exposure alone, such as tricepssplitting, “doesn’t give an adequate expo-sure because it is too central and doesn’tallow you to fully see the articular surface,”according to Dr. Ahmad. Triceps reflectionis another option but is mostly used for totalelbow replacement and often leads to defi-ciencies in the extensor mechanism. Varia-tions and combinations of these techniqueshave been described in the literature (J AmAcad Orthop Surg 2006;14[13]:754-765),but they are mostly advocated for simplerextra-articular fractures.

With the paratricipital 2-windowsapproach, surgeons do not “have to violate thetriceps mechanism of the elbow and we don’thave to create a new fracture,” Dr. Ahmad said.The approach developed by Dr. Rosenwasser issimilar to that published by Schildhauer (JOrthop Trauma 2003;17[5]:374-378), butcombines a paratricipital posteromedial accesswith splitting of the triceps lateral to the deepcentral head of the triceps. The advantage ofthis exposure is easy conversion to olecranonosteotomy if necessary.

“Our continual study of anatomy allowsus to evolve techniques based on experience,which can improve clinical outcomes whilereducing complications in the treatment ofchallenging articular fractures of the distalhumerus,” said Dr. Rosenwasser.

7


continued from Elbow, page 5

Contributing FacultyThe following is a list of the practitioners quoted in this issue of the NewYork-Presbyterian Columbia Orthopaedics Newsletter. For more information on their work,please contact them at the e-mail addresses provided.

Christopher S. Ahmad, MDDirector of Biomechanics Research

Center for Orthopaedic ResearchDirector of the Center for Pediatric

and Adolescent Sports MedicineMorgan Stanley Children’s Hospital

Associate Professor of Clinical Orthopaedic SurgeryE:mail: [email protected]

Yelena Akelina, DVM, MSAssociate Director, Microsurgery Training

and Research LaboratoryAssociate Research ScientistInstructor of Clinical MicrosurgeryE:mail: [email protected]

Louis U. Bigliani, MDChief, Orthopaedic Surgery Service Director, Center for Shoulder, Elbow and

Sports MedicinePresident, Medical BoardFrank E. Stinchfield Professor

and ChairmanDepartment of Orthopaedic Surgery

E-mail: [email protected]

Maria Codreanu, MD, PGY3General Surgery ResidentE-mail: [email protected]

Joshua E. Hyman, MDAssociate Attending PhysicianAssociate Professor of Clinical Orthopaedic SurgeryE-mail: [email protected]

Francis Y. Lee, MDChief, Tumor and Bone Disease ServiceAssociate Professor of Clinical Orthopaedic SurgeryVice Chairman for ResearchDirector, Center for Orthopaedic ResearchE-mail: [email protected]

William N. Levine, MDDirector, Sports MedicineAssociate Director, Center for Shoulder,

Elbow and Sports MedicineVice Chairman of Education and Professor

of Clinical Orthopaedic SurgeryE-mail: [email protected]

Melvin P. Rosenwasser, MDDirector, Orthopaedic Hand and Trauma, and

Microsurgery ServicesRobert E. Carroll Professor of Hand SurgeryE-mail: [email protected]

Robert J. Strauch, MDAttending Orthopaedic SurgeonProfessor of Clinical Orthopaedic SurgeryE-mail: [email protected]

Peter Tang, MD, MPHAssistant Attending Orthopaedic SurgeonAssistant Professor of Orthopaedic SurgeryE-mail: [email protected]

NewYork-Presbyterian HospitalColumbia University College of Physicians and Surgeons

1 AP computed tomography scan of lowintercondylar fracture.

2 Lateral computed tomography scan of lowintercondylar fracture.

3 Axial computed tomography scan of low intercondylar fracture.

4 AP X-ray at union.

5 Lateral X-ray at union.

This technique and case cohort series was presented at the 24thannual American Shoulder and Elbow Surgeons Meeting inDallas, TX, in October 2007.

Contributing faculty for this article:Christopher S. Ahmad, MD; Melvin P. Rosenwasser, MD

1 2 3 4

5

functional outcome and is free of pain, withactive forward elevation to 165 degrees. Hehas returned to playing golf and is so satis-fied that he is preparing for TSR on thecontralateral shoulder.

In the final analysis, TSR remains acomplex procedure that requires more skilland experience than humeral head replace-ment, a simpler alternative. Indeed, com-puter simulation may impact the continu-ing controversy over which procedure isbest. A 2007 article in the Journal ofShoulder and Elbow Surgery, authored byDrs. Ahmad, Bigliani, Levine, and othercolleagues at the Center, found that thetotal shoulder arthroplasty is clearly supe-rior (16[4]:396-402). The review, “TotalShoulder Replacement Compared withHumeral Head Replacement for theTreatment of Primary GlenohumeralOsteoarthritis,” examined 23 studies and1,952 patients.

“At our institution,” said Dr. Ahmad,“we strongly feel that resurfacing the entiresocket affords better pain relief.”

NONPROFIT ORG.U.S. Postage PAID

Permit No. 37Utica, NY

NewYork-Presbyterian Hospital622 West 168th StreetNew York, NY 10032

Important news from NewYork-Presbyterian/Columbia Orthopaedics—at the forefront of research and clinical carein the diagnosis, treatment, and rehabilitation of musculoskeletal conditions in adults and children.


continued from Shoulder, page 6

Affiliated with Columbia University College of Physicians and Surgeons

NEWYORK-PRESBYTERIANCOLUMBIA ORTHOPAEDICS

Contributing faculty for this article:Christopher S. Ahmad, MD; Louis U. Bigliani, MD;

William N. Levine, MD.Preoperative radiograph (left) showing severe osteoarthritis with loss of joint space and articular wear.Postoperative radiograph (right) revealing centralization of head correcting posterior wear and subluxation.

“At our institution, we strongly feel that resurfacing the entiresocket affords better pain relief.”

—Christopher S. Ahmad, MD

NYP ORTHO 2008

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