1
|
Paschall L, Carrozzi S, Tabdanov E, Dhawan A, Szczesny SE. Cyclic loading induces anabolic gene expression in ACLs in a load-dependent and sex-specific manner. J Orthop Res 2024; 42:267-276. [PMID: 37602554 DOI: 10.1002/jor.25677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 06/28/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are historically thought to be a result of a single acute overload or traumatic event. However, recent studies suggest that ACL failure may be a consequence of fatigue damage. Additionally, the remodeling response of ACLs to fatigue loading is unknown. Therefore, the objective of this study was to investigate the remodeling response of ACLs to cyclic loading. Furthermore, given that women have an increased rate of ACL rupture, we investigated whether this remodeling response is sex specific. ACLs were harvested from male and female New Zealand white rabbits and cyclically loaded in a tensile bioreactor mimicking the full range of physiological loading (2, 4, and 8 MPa). Expression of markers for anabolic and catabolic tissue remodeling, as well as inflammatory cytokines, was quantified using quantitative reverse transcription polymerase chain reaction. We found that the expression of markers for tissue remodeling of the ACL is dependent on the magnitude of loading and is sex specific. Male ACLs activated an anabolic response to cyclic loading at 4 MPa but turned off remodeling at 8 MPa. These data support the hypothesis that noncontact ACL injury may be a consequence of failed tissue remodeling and inadequate repair of microtrauma resulting from elevated loading. Compared to males, female ACLs failed to increase anabolic gene expression with loading and exhibited higher expression of catabolic genes at all loading levels, which may explain the increased rate of ACL tears in women. Together, these data provide insight into load-induced ACL remodeling and potential causes of tissue rupture.
Collapse
Affiliation(s)
- Lauren Paschall
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Sabrina Carrozzi
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Erdem Tabdanov
- Department of Pharmacology, The Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Spencer E Szczesny
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA
- Department of Orthopaedics and Rehabilitation, The Pennsylvania State University, Hershey, Pennsylvania, USA
| |
Collapse
|
2
|
Yeingst TJ, Arrizabalaga JH, Rawnaque FS, Stone LP, Yeware A, Helton AM, Dhawan A, Simon JC, Hayes DJ. Controlled Degradation of Polycaprolactone Polymers through Ultrasound Stimulation. ACS Appl Mater Interfaces 2023; 15:34607-34616. [PMID: 37432796 PMCID: PMC10496768 DOI: 10.1021/acsami.3c06873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
This study describes the development of an ultrasound-responsive polymer system that provides on-demand degradation when exposed to high-intensity focused ultrasound (HIFU). Diels-Alder cycloadducts were used to crosslink polycaprolactone (PCL) polymers and underwent a retro Diels-Alder reaction when stimulated with HIFU. Two Diels-Alder polymer compositions were explored to evaluate the link between reverse reaction energy barriers and polymer degradation rates. PCL crosslinked with isosorbide was also used as a non-Diels-Alder-based control polymer. An increase of HIFU exposure time and amplitude correlated with an increase of PCL degradation for Diels-Alder-based polymers. Ultrasound imaging during HIFU allowed for real-time visualization of the on-demand degradation through cavitation-based mechanisms. The temperature surrounding the sample was monitored with a thermocouple during HIFU stimulation; a minimal increase in temperature was observed. PCL polymers were characterized using Fourier transform infrared (FTIR) spectroscopy, nuclear magnetic resonance (NMR), differential scanning calorimetry (DSC), optical profilometry, and mechanical testing. PCL degradation byproducts were identified by mass spectrometry, and their cytocompatibility was evaluated in vitro. Overall, this study demonstrated that HIFU is an effective image-guided, external stimulus to control the degradation of Diels-Alder-based PCL polymers on-demand.
Collapse
Affiliation(s)
- Tyus J Yeingst
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Julien H Arrizabalaga
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Ferdousi S Rawnaque
- Graduate Program in Acoustics, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Lindsay P Stone
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Amar Yeware
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Angelica M Helton
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
| | - Julianna C Simon
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
- Graduate Program in Acoustics, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Daniel J Hayes
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
- Materials Research Institute, Millennium Science Complex, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
- The Huck Institute of Life Sciences, Millennium Science Complex, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| |
Collapse
|
3
|
Cognetti DJ, Lynch TB, Rich E, Bedi A, Dhawan A, Sheean AJ. Quadriceps Dysfunction Following Joint Preservation Surgery: A Review of the Pathophysiologic Basis and Mitigation Strategies. Curr Rev Musculoskelet Med 2023:10.1007/s12178-023-09844-0. [PMID: 37243966 PMCID: PMC10382434 DOI: 10.1007/s12178-023-09844-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE OF REVIEW To characterize quadriceps muscle dysfunction associated with knee joint preservation surgery, with a focus on its pathophysiology and promising approaches to mitigate its impact on clinical outcomes. RECENT FINDINGS Quadriceps dysfunction (QD) associated with knee joint preservation surgery results from a complex interplay of signaling, related to changes within the joint and from those involving the overlying muscular envelope. Despite intensive rehabilitation regimens, QD may persist for many months postoperatively and negatively impact clinical outcomes associated with various surgical procedures. These facts underscore the need for continued investigation into the potential detrimental effects of regional anesthetic and intraoperative tourniquet use on postoperative quadriceps function, with an outward focus on innovation within the field of postoperative rehabilitation. Neuromuscular stimulation, nutritional supplementation, cryotherapy, blood flow restriction (BFR), and open-chain exercises are all potential additions to postoperative regimens. There is compelling literature to suggest that these modalities are efficacious and may diminish the magnitude and duration of postoperative QD. A clear understanding of QD, with respect to its pathophysiology, should guide perioperative treatment and rehabilitation strategies and influence ongoing rehabilitation-based research and innovation. Moreover, clinicians must appreciate the magnitude of QD's effect on diminished clinical outcomes, risk for re-injury and patients' ability (or inability) to return to pre-injury level of activity following knee joint preservation procedures.
Collapse
Affiliation(s)
- Daniel J Cognetti
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA.
| | - Thomas B Lynch
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
| | - Elizabeth Rich
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, PA, 17033, USA
| | - Andrew J Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
| |
Collapse
|
4
|
Kowalski C, Ridenour R, McNutt S, Ba D, Liu G, Bible J, Aynardi M, Garner M, Leslie D, Dhawan A. Risk Factors For Prolonged Opioid Use After Spine Surgery. Global Spine J 2023; 13:683-688. [PMID: 33853404 DOI: 10.1177/21925682211003854] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE Our purpose was to evaluate factors associated with increased risk of prolonged post-operative opioid pain medication usage following spine surgery, as well as identify the risk of various post-operative complications that may be associated with pre-operative opioid usage. METHODS The MarketScan commercial claims and encounters database includes approximately 39 million patients per year. Patients undergoing cervical and lumbar spine surgery between the years 2005-2014 were identified using CPT codes. Pre-operative comorbidities including DSM-V mental health disorders, chronic pain, chronic regional pain syndrome (CRPS), obesity, tobacco use, medications, and diabetes were queried and documented. Patients who utilized opioids from 1-3 months prior to surgery were identified. This timeframe was chosen to exclude patients who had been prescribed pre- and post-operative narcotic medications up to 1 month prior to surgery. We utilized odds ratios (OR), 95% Confidence Intervals (CI), and regression analysis to determine factors that are associated with prolonged post-operative opioid use at 3 time intervals. RESULTS 553,509 patients who underwent spine surgery during the 10-year period were identified. 34.9% of patients utilized opioids 1-3 months pre-operatively. 25% patients were still utilizing opioids at 6 weeks, 17.3% at 3 months, 12.7% at 6 months, and 9.0% at 1 year after surgery. Pre-operative opioid exposure was associated with increased likelihood of post-operative use at 6-12 weeks (OR 5.45, 95% CI 5.37-5.53), 3-6 months (OR 6.48, 95% CI 6.37-6.59), 6-12 months (OR 6.97, 95% CI 6.84-7.11), and >12 months (OR 7.12, 95% CI 6.96-7.29). Mental health diagnosis, tobacco usage, diagnosis of chronic pain or CRPS, and non-narcotic neuromodulatory medications yielded increased likelihood of prolonged post-op opioid usage. CONCLUSIONS Pre-operative narcotic use and several patient comorbidities diagnoses are associated with prolonged post-operative opioid usage following spine surgery. Chronic opioid use, diagnosis of chronic pain, or use of non-narcotic neuromodulatory medications have the highest risk of prolonged post-operative opioid consumption. Patients using opiates pre-operatively did have an increased 30 and 90-day readmission risk, in addition to a number of serious post-operative complications. This data provides spine surgeons a number of variables to consider when determining post-operative analgesia strategies, and provides health systems, providers, and payers with information on complications associated with pre-operative opioid utilization.
Collapse
Affiliation(s)
- Christopher Kowalski
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Ryan Ridenour
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Sarah McNutt
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Djibril Ba
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Guodong Liu
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Jesse Bible
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Michael Aynardi
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Matthew Garner
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Douglas Leslie
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Aman Dhawan
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| |
Collapse
|
5
|
Harris JD, Brand JC, Cote M, Waterman B, Dhawan A. Guidelines for Proper Reporting of Clinical Significance, Including Minimal Clinically Important Difference, Patient Acceptable Symptomatic State, Substantial Clinical Benefit, and Maximal Outcome Improvement. Arthroscopy 2023; 39:145-150. [PMID: 36603987 DOI: 10.1016/j.arthro.2022.08.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/31/2022] [Accepted: 08/05/2022] [Indexed: 12/12/2022]
Abstract
Patient-reported outcome measures (PROM) need to be responsive, reliable, and validated for the specific condition or treatment. PROMs also need to exhibit a dose-dependent response across a diverse patient population, unlimited by floor and ceiling effects. Statistically significant differences between compared groups might not always represent clinically important differences. Measures of clinical significance reflect a spectrum of patient satisfaction after an intervention. A noticeable difference to the patient is assessed with minimal clinically important difference (MCID), patient satisfaction by patient acceptable symptomatic state (PASS), and a "considerable" improvement by substantial clinical benefit (SCB). Clinical relevance measured by these clinically significant outcomes (CSO) are limited by ceiling effects. Maximal outcome improvement (MOI) might more accurately account for patients with higher baseline or preoperative PROMs, thereby limiting ceiling effects. The acts of measuring (and reporting) patient-centered endpoints may actually be of greater importance than collecting objective clinician-measured data. As the old surgeon's aphorism goes, "nothing ruins good results like good follow-up."
Collapse
Affiliation(s)
- Joshua D Harris
- Houston Methodist Orthopedics & Sports Medicine, Orthopedic Surgery, 6445 Main St., Outpatient Center, Suite 2500, Houston, TX, 77030, U.S.A
| | | | - Mark Cote
- UConn Health, Farmington, Connecticut, U.S.A
| | - Brian Waterman
- Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, U.S.A
| | - Aman Dhawan
- Penn State College of Medicine, Department of Orthopaedics and Rehabilitation, Hershey, Pennsylvania, U.S.A
| |
Collapse
|
6
|
Ridenour R, Kowalski C, Ba D, Liu G, Bible J, Garner M, Leslie D, Aynardi M, Dhawan A. Opioid Use, Perioperative Risks, and Associated Postoperative Complications in Foot and Ankle Surgery. Foot Ankle Spec 2022; 15:528-535. [PMID: 33307812 DOI: 10.1177/1938640020977988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Opioid abuse has become a national crisis. Published data demonstrate that patients undergoing foot and ankle surgery are left with excess narcotic medications postoperatively. The purpose of our study was to evaluate factors associated with prolonged postoperative opioid use following foot and ankle surgery and identify associations between preoperative opioid use and postoperative complications. METHODS MarketScan commercial claims and encounters database was searched to identify foot and ankle patients. Preoperative comorbidities were queried and documented. Patients utilizing opioids 1 to 3 months prior to surgery were identified. Adjusted odds ratios and 95% CIs were calculated using multivariable logistic regression to determine associations between opioid use (preoperatively and postoperatively), readmission, and complications. RESULTS A total of 112 893 patients were included in the study. Preoperative use had a statistically significant association with postoperative use out to 1 year. Tobacco use, chronic pain, mental health diagnosis, and nonopioid medications had a statistically significant association with postoperative use. Preoperative opioid use had a statistically significant association with readmission and postoperative complications. CONCLUSION Our study found a number of factors associated with prolonged postoperative opioid use (preoperative use, tobacco use, chronic pain, mental health disorders, and certain nonopioid medications). We identified an association between preoperative opioid use and postoperative complications and readmission. LEVELS OF EVIDENCE Prognostic Level IV Evidence.
Collapse
Affiliation(s)
- Ryan Ridenour
- Department of Orthopaedics, Penn State Hershey Medical Center, Pennsylvania
| | | | - Djibril Ba
- Department of Orthopaedics, Penn State Hershey Medical Center, Pennsylvania
| | - Guodong Liu
- Department of Orthopaedics, Penn State Hershey Medical Center, Pennsylvania
| | - Jesse Bible
- Department of Orthopaedics, Penn State Hershey Medical Center, Pennsylvania
| | - Matthew Garner
- Department of Orthopaedics, Penn State Hershey Medical Center, Pennsylvania
| | - Douglas Leslie
- Department of Orthopaedics, Penn State Hershey Medical Center, Pennsylvania
| | - Michael Aynardi
- Department of Orthopaedics, Penn State Hershey Medical Center, Pennsylvania
| | - Aman Dhawan
- Department of Orthopaedics, Penn State Hershey Medical Center, Pennsylvania
| |
Collapse
|
7
|
Zeller AN, Neuhaus MT, Weissbach LVM, Rana M, Dhawan A, Eckstein FM, Gellrich NC, Zimmerer RM. Correction to: Patient-Specific Mandibular Reconstruction Plates Increase Accuracy and Long-Term Stability in Immediate Alloplastic Reconstruction of Segmental Mandibular Defects. J Maxillofac Oral Surg 2022; 21:1096. [PMID: 36896089 PMCID: PMC9989060 DOI: 10.1007/s12663-021-01563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 12/01/2022] Open
Abstract
[This corrects the article DOI: 10.1007/s12663-019-01323-9.].
Collapse
Affiliation(s)
- A N Zeller
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - M T Neuhaus
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - L V M Weissbach
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - M Rana
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Düsseldorf, Germany
| | - A Dhawan
- Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, India
| | - F M Eckstein
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - N C Gellrich
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - R M Zimmerer
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
8
|
Dhawan A, Molkentine D, Hefner A, Pifer P, Bahri R, Molkentine J, Pickering C, Sandulache V, Skinner H. p16 Regulates Transcription Factor Sp1 Function to Affect Outcome in Oropharyngeal Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
9
|
Tucker J, McCullen A, Kennedy P, Koroneos Z, Wee HB, Dhawan A, Atkins H, Lewis GS, Garner MR. The effect of cigarette smoke versus vaporized nicotine on healing of a rat femur. Injury 2022; 53:3102-3108. [PMID: 36030094 DOI: 10.1016/j.injury.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 07/01/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Little data exists regarding the effects of vaporized nicotine on healing. Our goal was to compare vaporized nicotine, combusted nicotine and control with respect to bone healing in a rat femur fracture model. MATERIALS AND METHODS Forty-five male Sprague Dawley rats were divided into three equal cohorts. Rats were exposed to two cigarettes daily, an equivalent dose of vaporized nicotine, or control, six days a week. Exposures occurred for 4 weeks prior to iatrogenic femur fracture and intramedullary repair. Four additional weeks of exposure occurred prior to sacrifice. Radiographic, biomechanical and histologic analysis was conducted. RESULTS No significant difference between the three groups was identified for total mineralized bone volume (p = 0.14), total volume of mature bone (p = 0.12) or immature bone (p = 0.15). Importantly, less total mineralized bone volume and immature bone volume was seen in the vaporized nicotine group compared to combusted tobacco, but results were not significant. Biomechanical testing revealed no significant difference in group torsional stiffness (p = 0.92) or maximum torque (p = 0.31) between the three groups. On histologic analysis, chi-square testing showed no significant difference in any category. CONCLUSIONS This exploratory study compared combusted nicotine, vaporized nicotine and a control on rat femur fractures. While no statistically significant differences were identified, there were trends showing less total mineralized bone volume and immature bone volume in the vaporized nicotine group compared to the other groups. Additional study is warranted based on our findings.
Collapse
Affiliation(s)
| | | | - Patrick Kennedy
- HCA Virginia Health System, Lewisgale Medical Center, Salem, VA, USA
| | | | - Hwa Bok Wee
- Penn State College of Medicine, Hershey, PA, USA
| | - Aman Dhawan
- Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | | | - Matthew R Garner
- Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
| |
Collapse
|
10
|
Arrizabalaga JH, Smallcomb M, Abu-Laban M, Liu Y, Yeingst TJ, Dhawan A, Simon JC, Hayes DJ. Ultrasound-Responsive Hydrogels for On-Demand Protein Release. ACS Appl Bio Mater 2022; 5:3212-3218. [PMID: 35700312 PMCID: PMC10496416 DOI: 10.1021/acsabm.2c00192] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The development of tunable, ultrasound-responsive hydrogels that can deliver protein payload on-demand when exposed to focused ultrasound is described in this study. Reversible Diels-Alder linkers, which undergo a retro reaction when stimulated with ultrasound, were used to cross-link chitosan hydrogels with entrapped FITC-BSA as a model protein therapeutic payload. Two Diels-Alder linkage compositions with large differences in the reverse reaction energy barriers were compared to explore the influence of linker composition on ultrasound response. Selected physicochemical properties of the hydrogel construct, its basic degradation kinetics, and its cytocompatibility were measured with respect to Diels-Alder linkage composition. Focused ultrasound initiated the retro Diels-Alder reaction, controlling the release of the entrapped payload while also allowing for real-time visualization of the ongoing process. Additionally, increasing the focused ultrasound amplitude and time correlated with an increased rate of protein release, indicating stimuli responsive control.
Collapse
Affiliation(s)
- Julien H Arrizabalaga
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Molly Smallcomb
- Graduate Program in Acoustics, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Mohammad Abu-Laban
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Yiming Liu
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Tyus J Yeingst
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
| | - Julianna C Simon
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
- Graduate Program in Acoustics, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Daniel J Hayes
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
- Materials Research Institute, Millennium Science Complex, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
- The Huck Institute of the Life Sciences, Millennium Science Complex, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| |
Collapse
|
11
|
Pifer P, Kumar M, Yang L, Xie T, Frederick M, Hefner A, Beadle B, Dhawan A, Molkentine D, Molkentine J, Myers J, Pickering C, Heymach J, Skinner H. Focal Adhesion Kinase Drives Resistance to Therapy in HPV-Negative Head and Neck Squamous Cell Carcinoma in a p53-Dependent Manner. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2021.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
12
|
Dhawan A. Editorial Commentary: Clinical Improvements of Superior Capsular Reconstruction Are Not Due to Maintained Dynamic Acromiohumeral Distance. Arthroscopy 2022; 38:276-277. [PMID: 35123708 DOI: 10.1016/j.arthro.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Abstract
Biomechanical data often help inform clinical decision-making in orthopaedic surgery. However, there are times when the biomechanical data and clinical data do not align. This is seen in cases of statistical but clinically irrelevant differences. This is also seen at times in cases of demonstrated clinical improvements with a poorly understood mechanism. Superior capsular reconstruction has gained significant traction since the original description in 2012. It has taken a central role in the armamentarium of treatment options of irreparable rotator cuff tears. There is robust published literature on the time zero biomechanics of superior capsular reconstruction and its stabilizing effects on the glenohumeral joint, especially with regards to superior migration of the humeral head. There also is demonstrated good early patient-reported outcomes with superior capsular reconstruction. However, the cause and effect may not be as simple as the biomechanical studies may suggest, and the underlying mechanism of why the superior capsular reconstruction appears to improve early outcomes remains poorly understood. These mechanisms are important to understand in order to inform technique changes and improvements and help us optimize treatment of the patient with an irreparable rotator cuff tear.
Collapse
|
13
|
Dhawan A. Editorial Commentary: Early Detection and Treatment Improves Short-Term Outcomes After Shoulder Anchor Arthropathy, but an Ounce of Prevention Is Worth a Pound of Cure. Arthroscopy 2021; 37:3421-3422. [PMID: 34863379 DOI: 10.1016/j.arthro.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/15/2021] [Indexed: 02/02/2023]
Abstract
Anchor arthropathy is a rare, but devastating, complication after arthroscopic labral repair and shoulder stabilization. Early recognition and treatment in the form of removal of anchor and suture material, loose bodies, and potential revision stabilization significantly improve short-term outcomes. The entity of anchor arthropathy may be difficult to diagnose, and a high index of suspicion is needed when a patient presents postoperatively with pain and stiffness beyond atypical for their time in rehab. In the end, while early treatment can be favorable, prevention with meticulous attention to detail on anchor placement, position, and potential use of knotless anchors is strongly recommended.
Collapse
|
14
|
Kennedy P, Saloky K, Yadavalli A, Barlow E, Aynardi M, Garner M, Bible J, Lewis GS, Dhawan A. Nicotine Exposure Via Electronic Cigarettes Significantly Impedes Biomechanical Healing Properties of Tendon Healing in a Rat Model. Arthroscopy 2021; 37:3170-3176. [PMID: 33940121 DOI: 10.1016/j.arthro.2021.03.071] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the biomechanical and histologic effects on Achilles tendon repair of inhaled combusted tobacco versus nicotine exposure via electronic cigarette versus a control group in a small-animal model (Sprague-Dawley rat). METHODS Fifty-four Sprague-Dawley rats were randomized into 3 groups: combusted tobacco, e-cigarettes, or control. Experimental rats were exposed to research cigarettes or e-cigarette vapor in a smoking chamber for 4 weeks. Surgical transection and repair of the Achilles tendon were then completed, followed by 2 additional weeks of exposure. Achilles tendons were harvested, and biomechanical tensile testing was performed. Histologic evaluation was completed, including hematoxylin-eosin staining, trichrome staining, and immunohistochemistry analysis for type I and type III collagen. RESULTS The control group showed the highest mean tensile load to failure, at 41.0 ± 10.4 N (range, 18.3-55.1 N); the cigarette cohort had the second highest mean, at 37.3 ± 11.1 N (range, 14.0-54.7 N); and finally, the vaping group had the lowest mean, at 32.3 ± 8.4 N (range, 17.8-45.1 N). One-way analysis of variance showed a significant difference in load to failure when comparing the control group with the e-cigarette group (P = .026). No statistical difference was detected between the control group and cigarette group (P = .35) or between the e-cigarette group and cigarette group (P = .23). Stiffness and qualitative histologic analysis showed no difference among groups. CONCLUSIONS This investigation shows that in a rat model, nicotine exposure via e-cigarette significantly impedes the biomechanical healing properties of Achilles tendon surgical repair. CLINICAL RELEVANCE The results indicate that although e-cigarettes are often used as a perceived "safer" alternative to smoking, their use may have a detrimental effect on tendon load to failure.
Collapse
Affiliation(s)
- Patrick Kennedy
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A..
| | - Kaitlin Saloky
- Geisinger Commonwealth School of Medicine, Geisinger Health System, Scranton, Pennsylvania, U.S.A
| | - Aditya Yadavalli
- Department of Anesthesia and Perioperative Medicine, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A. (d)Department of Emergency Medicine, Zucker School of Medicine, Northwell Southside Hospital, Bay Shore, New York, U.S.A
| | - Erin Barlow
- Department of Anesthesia and Perioperative Medicine, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A. (d)Department of Emergency Medicine, Zucker School of Medicine, Northwell Southside Hospital, Bay Shore, New York, U.S.A
| | - Michael Aynardi
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Matthew Garner
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Jesse Bible
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| |
Collapse
|
15
|
Harris JD, Cote MP, Dhawan A, Hohmann E, Brand JC. Nearly One-Third of Published Systematic Reviews and Meta-analyses Yield Inconclusive Conclusions: A Systematic Review. Arthroscopy 2021; 37:2991-2998. [PMID: 33887412 DOI: 10.1016/j.arthro.2021.03.073] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a systematic review that determines the percentage of published orthopedic surgery and sports medicine systematic reviews and meta-analyses that have a conclusive conclusion. METHODS A systematic review was performed using PRISMA guidelines. Six high-quality orthopedics journals were chosen for analysis over a 10-year eligibility period. Systematic reviews and meta-analyses published in these journals were included in the investigation. Narrative, scoping, and umbrella reviews were excluded. A systematic review or meta-analysis was defined as having an inconclusive conclusion if the conclusion in the manuscript body or abstract was stated directly as inconclusive, indeterminate, unknown, or having a lack of evidence (or no evidence). A conclusive conclusion stated a direct answer to the study's primary and/or accessory outcomes. Due to the categorical nature of the data, comparisons were made using χ2 test and logistic regression. RESULTS There were 1,108 systematic reviews/meta-analyses analyzed (30.9 ± 70.3 studies analyzed per review). More reviews (69.9%) were published with conclusive conclusions rather than without (30.1%). More reviews were surgical (73%) rather than nonsurgical. The United States and North America published the most reviews by country and continent, respectively. There were statistically significant differences between countries (highest proportion with China) and continents (highest proportion with Asia) based on the number of conclusive conclusions in published reviews, respectively. There were no significant differences in the proportion of conclusive conclusion reviews between the 6 analyzed journals. Australia published the largest proportion on nonsurgical reviews. The British Journal of Sports Medicine published a significantly higher proportion of nonsurgical reviews than the other 5 journals. There was no temporal relationship with the proportion of conclusive conclusion reviews. CONCLUSIONS This systematic review observed that only 70% of orthopedic systematic reviews and meta-analyses published in 6 high-quality orthopedic journals over a 10-year eligibility period had conclusive conclusions. LEVEL OF EVIDENCE Level IV, systematic review and/or meta-analysis of studies with Levels I to IV.
Collapse
Affiliation(s)
- Joshua D Harris
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, U.S.A..
| | - Mark P Cote
- UConn Musculoskeletal Institute, Human Soft Tissue Research Laboratory, UConn Health, Farmington, Connecticut, U.S.A
| | - Aman Dhawan
- Penn State Hershey Bone and Joint Institute, Hershey, Pennsylvania, U.S.A
| | - Erik Hohmann
- Valiant Clinic, Houston Methodist, City Walk, Dubai, United Arab Emirates
| | | |
Collapse
|
16
|
Stauch CM, Ammerman B, Sepulveda D, Aynardi MC, Garner MR, Lewis G, Morgan D, Dhawan A. Biomechanical Effects of Δ9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD), the Major Constituents of Cannabis, in a Sprague Dawley Rat Achilles Tendon Surgical Repair Model: A Pilot Study. Am J Sports Med 2021; 49:2522-2527. [PMID: 34097540 DOI: 10.1177/03635465211016840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of cannabis is common among athletes and the US population at large. Cannabinoids are currently being evaluated as alternatives to opioid medications for chronic pain management. However, the effects of recreational and/or medical use of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) on musculoskeletal injury and healing remain largely unknown. HYPOTHESIS/PURPOSE The purpose of this study was to evaluate the biomechanical effects of CBD and THC on tendon-to-tendon healing in a rat Achilles tendon repair model. The hypothesis was that rats administered CBD would demonstrate decreased tensile load to failure of surgically repaired Achilles tendons compared with the THC and control groups. STUDY DESIGN Controlled laboratory study. METHODS A total of 33 Sprague Dawley rats underwent Achilles tendon surgical transection and repair and were randomized to receive subcutaneous injection of THC, CBD, or vehicle once daily starting on the day of surgery and for 5 total days. After sacrifice, biomechanical tensile load-displacement testing was performed to determine Achilles tendon load to failure and stiffness. Data were analyzed by 1-way analysis of variance. RESULTS The THC group demonstrated the highest median load to failure, 18.7 N (95% CI, 15.3-19.2 N); the CBD group had the second highest at 16.9 N (95% CI, 15.1-19.8 N), and the control group had the lowest at 14.4 N (95% CI, 12.1-18.3 N). Stiffness was highest in the THC group at 4.1 N/mm (95% CI, 2.7-5.1 N/mm) compared with 3.6 N/mm (95% CI, 2.9-4.1 N/mm) for the CBD group and 3.6 N/mm (95% CI, 2.8-4.3 N/mm) for the control group. No statistically significant differences for strength and stiffness were observed between the groups. CONCLUSION In this pilot study using an animal tendon-to-tendon repair model, neither THC nor CBD resulted in altered biomechanical characteristics compared to control. CLINICAL RELEVANCE Cannabinoids do not appear to adversely affect Achilles tendon healing.
Collapse
Affiliation(s)
- Christopher M Stauch
- Department of Orthopedics and Rehabilitation, Center for Orthopedic Research and Translational Sciences (CORTS), Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Diana Sepulveda
- Department of Anesthesia and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Michael C Aynardi
- Department of Orthopedics and Rehabilitation, Center for Orthopedic Research and Translational Sciences (CORTS), Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Matthew R Garner
- Department of Orthopedics and Rehabilitation, Center for Orthopedic Research and Translational Sciences (CORTS), Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Gregory Lewis
- Department of Orthopedics and Rehabilitation, Center for Orthopedic Research and Translational Sciences (CORTS), Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Daniel Morgan
- Department of Orthopedics and Rehabilitation, Center for Orthopedic Research and Translational Sciences (CORTS), Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Aman Dhawan
- Department of Orthopedics and Rehabilitation, Center for Orthopedic Research and Translational Sciences (CORTS), Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
17
|
Ridenour R, Kowalski C, Yadavalli A, Ba D, Liu G, Leslie D, Bible J, Aynardi M, Garner M, Dhawan A. Preoperative Opioid Use Is Associated With Persistent Use, Readmission and Postoperative Complications After Arthroscopic Knee Surgery. Arthroscopy 2021; 37:1567-1572. [PMID: 33340677 DOI: 10.1016/j.arthro.2020.12.187] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate factors associated with prolonged opioid use after arthroscopic knee surgery and to identify associations between preoperative usage and postoperative complications. METHODS The MarketScan commercial database was searched to identify patients who underwent arthroscopic knee surgery from 2005 to 2014 (based on Current Procedure Terminology code). Preoperative comorbidities including Diagnostic and Statistical Manual of Mental Disorders mental health disorders, chronic pain, chronic regional pain syndrome, obesity, tobacco use, non-narcotic medications and diabetes were queried and documented. Patients who filled opioid prescriptions 1 to 3 months before surgery were identified. Patients who filled opioid prescriptions after surgery were identified. Adjusted odds ratios and 95% confidence intervals were calculated using multivariable logistic regression analysis to determine factors associated with prolonged postoperative opioid use. RESULTS In total, 1,012,486 patients who underwent arthroscopic knee surgery were identified, and we determined which of these patients were on preoperative opioids. Preoperative opioid usage was associated with a statistically significant increased risk of usage out to 1 year. There was a statistically significant association between postoperative usage and preoperative variables (mental health diagnosis, smokers, chronic pain, chronic regional pain syndrome, and use of non-narcotic medications). There was a statistically significant association between preoperative opioid use and 90-day readmission and postoperative complications. CONCLUSION In this study, we found that patients taking opioids 1 to 3 months before arthroscopic knee surgery have increased risk of postoperative use. Additionally, chronic opioid use, chronic pain, or use of non-narcotic medications has the highest risk of postoperative opioid use. Finally, preoperative use was associated with an increased risk of 90-day readmission. EVIDENCE Prognostic Level IV Evidence.
Collapse
Affiliation(s)
- Ryan Ridenour
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A..
| | - Christopher Kowalski
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Aditya Yadavalli
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Djibril Ba
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Guodong Liu
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Douglas Leslie
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Jesse Bible
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Michael Aynardi
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Matthew Garner
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| |
Collapse
|
18
|
Tripathi R, Rao R, Dhawan A, Jain R. Sleep problems in opioid dependent patients maintained on buprenorphine. Eur Psychiatry 2021. [PMCID: PMC9475826 DOI: 10.1192/j.eurpsy.2021.1486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IntroductionOpioid dependent individuals frequently complain of sleep problems in withdrawal and during abstinence.ObjectivesThe objectives were to assess the subjective sleep parameters among buprenorphine-maintained opioid-dependent patients and to correlate it with socio-demographics, concomitant drug use and treatment related variablesMethodsUsing a cross-sectional study design, 106 hundred six opioid-dependent patients maintained on buprenorphine for at least six months and on same dose in past month were interviewed. Sleep was assessed by Pittsburgh sleep quality index (PSQI) and Epworth sleepiness scale. Association between subjective sleep parameters, socio-demographics, concomitant drug use and treatment related variables was also studied.ResultsAll participants were males. Their mean age was 41.1 years (SD:14.3). The mean duration of illicit opioid use was 10 years (IQR: 5,22). About 63.2% (n=67) had PSQI scores more than 5 denoting sleep problem. The scores obtained in Epworth Sleeping Scale were in normal range. Mean subjective total sleep time of the sample was 403.5 (SD 94.8) minutes and median sleep latency was 35 (IQR 18.8, 62.5) minutes. Subjective total sleep time was significantly higher in participants who had use tobacco in the past three months (p value=0.03) and who were in moderate ASSIST risk category (p value=0.04). Subjective sleep latency was significantly higher (p value=0.04) in participants who had used opioids in last three months. It was observed that age was a significant predictor of subjective total sleep time and OST compliance was a significant predictor of sleep latency.ConclusionsA sizeable proportion of opioid dependent patients on buprenorphine have sleep problems
Collapse
|
19
|
Abstract
OBJECTIVE Treatment of chondral injury is clinically challenging. Available chondral repair/regeneration techniques have significant shortcomings. A viable and durable tissue engineering strategy for articular cartilage repair remains an unmet need. Our objective was to systematically evaluate the published data on bioprinted articular cartilage with regards to scaffold-based, scaffold-free and in situ cartilage bioprinting. DESIGN We performed a systematic review of studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and ScienceDirect databases were searched and all articles evaluating the use of 3-dimensional (3D) bioprinting in articular cartilage were included. Inclusion criteria included studies written in or translated to English, published in a peer-reviewed journal, and specifically discussing bioinks and/or bioprinting of living cells related to articular cartilage applications. Review papers, articles in a foreign language, and studies not involving bioprinting of living cells related to articular cartilage applications were excluded. RESULTS Twenty-seven studies for articular cartilage bioprinting were identified that met inclusion and exclusion criteria. The technologies, materials, cell types used in these studies, and the biological and physical properties of the created constructs have been demonstrated. CONCLUSION These 27 studies have demonstrated 3D bioprinting of articular cartilage to be a tissue engineering strategy that has tremendous potential translational value. The unique abilities of the varied techniques allow replication of mechanical properties and advances toward zonal differentiation. This review demonstrates that bioprinting has great capacity for clinical cartilage reconstruction and future in vivo implantation.
Collapse
Affiliation(s)
- Yang Wu
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, USA,The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, USA
| | - Patrick Kennedy
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Nicholas Bonazza
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Yin Yu
- Institute for Synthetic Biology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, People’s Republic of China,University of Chinese Academy of Sciences, Beijing, People’s Republic of China
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ibrahim Ozbolat
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, USA,The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, USA,Biomedical Engineering Department, Penn State University, University Park, PA, USA,Materials Research Institute, Penn State University, University Park, PA, USA,Ibrahim Tarik Ozbolat, Penn State University, W313 Millennium Science Complex, University Park, PA 16802, USA.
| |
Collapse
|
20
|
Dhawan A. Editorial Commentary: Back to the Future With the Medial Patellofemoral Complex. Arthroscopy 2020; 36:3016-3018. [PMID: 33276889 DOI: 10.1016/j.arthro.2020.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/16/2020] [Indexed: 02/02/2023]
Abstract
The desire to better re-create the native anatomy in orthopaedic surgery-and especially knee ligament reconstruction-was an area of great debate and discussion approximately 10 years ago in anterior cruciate ligament (ACL) reconstruction. Our better and more detailed understanding of the anatomy, especially the insertional anatomy, of the ACL fueled the debate over the best surgical technique to maximize function, improve patient outcomes, and reduce long-term morbidity. While these discussions are still ongoing, detailed study of the medial patellofemoral complex (MPFC) anatomy is bringing us "back to the future" with similar discussions on how to best re-create this anatomy. Although specific techniques and surgical risks versus rewards will continue to be debated, our improved understanding of the anatomy of the MPFC, similar to our improved understanding of the ACL, ultimately will improve how MPFC reconstruction is performed and improve patient outcomes.
Collapse
|
21
|
Zeller AN, Neuhaus MT, Weissbach LVM, Rana M, Dhawan A, Eckstein FM, Gellrich NC, Zimmerer RM. Patient-Specific Mandibular Reconstruction Plates Increase Accuracy and Long-Term Stability in Immediate Alloplastic Reconstruction of Segmental Mandibular Defects. J Maxillofac Oral Surg 2020; 19:609-615. [PMID: 33071511 PMCID: PMC7524954 DOI: 10.1007/s12663-019-01323-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/18/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of the current study was to evaluate potential differences in the accuracy of mandibular reconstruction and long-term stability, with respect to different reconstructive procedures. METHODS In total, 42 patients who had undergone primary segmental mandibular resection with immediate alloplastic reconstruction, with either manually pre-bent or patient-specific mandibular reconstruction plates (PSMRP), were included in this study. Mandibular dimensions, in terms of six clinically relevant distances (capitulum [most lateral points], capitulum [most medial points], incisura [most caudal points], mandibular foramina, coronoid process [most cranial points], dorsal tip of the mandible closest to the gonion point) determined from tomographic images, were compared prior to, and after surgery. RESULTS Dimensional alterations were significantly more often found when conventionally bent titanium reconstruction plates were used. These occurred in the area of the coronoid process (p = 0.014). Plate fractures were significantly (p = 0.022) more often found within the manually pre-bent group than within the PSMRP group (17%/0%). CONCLUSION The results suggest that the use of PSMRP may prevent rotation of the proximal mandibular segment, thus avoiding functional impairment. In addition, the use of PSMRP may potentially enhance the long-term stability of alloplastic reconstructions.
Collapse
Affiliation(s)
- A. N. Zeller
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - M. T. Neuhaus
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - L. V. M. Weissbach
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - M. Rana
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Düsseldorf, Germany
| | - A. Dhawan
- Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, India
| | - F. M. Eckstein
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - N. C. Gellrich
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - R. M. Zimmerer
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
22
|
Wu Y, Ayan B, Moncal KK, Kang Y, Dhawan A, Koduru SV, Ravnic DJ, Kamal F, Ozbolat IT. Scaffold‐Free Bioprinting: Hybrid Bioprinting of Zonally Stratified Human Articular Cartilage Using Scaffold‐Free Tissue Strands as Building Blocks (Adv. Healthcare Mater. 22/2020). Adv Healthc Mater 2020. [DOI: 10.1002/adhm.202070081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
23
|
Wu Y, Ayan B, Moncal KK, Kang Y, Dhawan A, Koduru SV, Ravnic DJ, Kamal F, Ozbolat IT. Hybrid Bioprinting of Zonally Stratified Human Articular Cartilage Using Scaffold-Free Tissue Strands as Building Blocks. Adv Healthc Mater 2020; 9:e2001657. [PMID: 33073548 PMCID: PMC7677219 DOI: 10.1002/adhm.202001657] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 01/24/2023]
Abstract
The heterogeneous and anisotropic articular cartilage is generally studied as a layered structure of "zones" with unique composition and architecture, which is difficult to recapitulate using current approaches. A novel hybrid bioprinting strategy is presented here to generate zonally stratified cartilage. Scaffold-free tissue strands (TSs) are made of human adipose-derived stem cells (ADSCs) or predifferentiated ADSCs. Cartilage TSs with predifferentiated ADSCs exhibit improved mechanical properties and upregulated expression of cartilage-specific markers at both transcription and protein levels as compared to TSs with ADSCs being differentiated in the form of strands and TSs of nontransfected ADSCs. Using the novel hybrid approach integrating new aspiration-assisted and extrusion-based bioprinting techniques, the bioprinting of zonally stratified cartilage with vertically aligned TSs at the bottom zone and horizontally aligned TSs at the superficial zone is demonstrated, in which collagen fibers are aligned with designated orientation in each zone imitating the anatomical regions and matrix orientation of native articular cartilage. In addition, mechanical testing study reveals a compression modulus of ≈1.1 MPa, which is similar to that of human articular cartilage. The prominent findings highlight the potential of this novel bioprinting approach for building biologically, mechanically, and histologically relevant cartilage for tissue engineering purposes.
Collapse
Affiliation(s)
- Yang Wu
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Bugra Ayan
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Kazim K Moncal
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Youngnam Kang
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Srinivas V Koduru
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
- Department of Cellular and Molecular Physiology, Penn State College of Medicine, Hershey, PA, 17033, USA
| | - Dino J Ravnic
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Fadia Kamal
- Center for Orthopedic Research and Translational Science, Department of Orthopedics and Rehabilitation, Penn State University, College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
- Department of Pharmacology, Penn State University, College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Ibrahim T Ozbolat
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
- Biomedical Engineering Department, Penn State University, University Park, PA, 16802, USA
- Materials Research Institute, Penn State University, University Park, PA, 16802, USA
| |
Collapse
|
24
|
Dhawan A. Editorial Commentary: Sometimes You Don't Know What You've Got Until It's Gone-The Effect of Missing Data in "Big Data" Studies. Arthroscopy 2020; 36:1240-1242. [PMID: 32370886 DOI: 10.1016/j.arthro.2020.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 02/18/2020] [Indexed: 02/02/2023]
Abstract
Big-data studies are powerful tools for comparative-effectiveness research, but because of the large number of included patients, they risk falsely identifying a difference when none exists because large sample sizes may result in statistically significant differences that have little clinical importance. Other limitations of big-data studies include lack of generalizability because of inclusion of only specific patient populations, lack of validated outcome measures, recording bias or clerical error, and vast troves of missing data. As such, the methods and results of big-data studies require careful scrutiny to ensure that the conclusions are correct.
Collapse
|
25
|
Bonazza N, Smuin DM, Sterling N, Ba D, Liu G, Leslie DL, Hennrikus W, Dhawan A. Epidemiology of Surgical Treatment of Adolescent Sports Injuries in the United States: Analysis of the MarketScan Commercial Claims and Encounters Database. Arthrosc Sports Med Rehabil 2020; 1:e59-e65. [PMID: 32266341 PMCID: PMC7120859 DOI: 10.1016/j.asmr.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose To determine whether there is increasing surgical management of adolescent sports injuries and whether the average age of surgical patients is decreasing. Methods The Truven Health MarketScan Database was searched from 2008 to 2014 for patients 10 to 19 years of age using the International Classification of Disease, 9th Revision codes and Current Procedure Terminology, 4th Edition, codes for operative treatment for the following conditions: anterior cruciate ligament (ACL) injuries, knee collateral ligament (KCL) injuries, meniscal injuries, Osgood–Schlatter syndrome, and elbow ulnar collateral ligament injuries. Patients identified were characterized by sex, age, year of injury, and type of residence (urban vs rural) based on metropolitan statistical areas. Results A total of 516,892 patients sustained 1 of the identified injuries, and 133,541 (25.8%) patients underwent a related surgery. KCL and meniscal injuries demonstrated a consistent increase in the rate of surgical intervention (P < .0001). Average age of surgical intervention did not increase or decrease overall for any diagnosis. Female adolescents were more likely to undergo surgery for KCL injuries (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.58-1.79, P < .0001), Osgood–Schlatter syndrome (aOR 1.8, 95% CI 1.38-2.39, P < .0001), and ACL injuries (aOR 1.5, 95% CI 1.45-1.52, P < .0001), whereas male adolescents were more likely to undergo surgery for meniscal injuries (aOR 1.3, 95% CI 1.24-1.30, P < .0001) and ulnar collateral ligament injuries (aOR 1.1, 95% CI 1.06-1.23, P < .0005). Patients in rural areas were more likely to undergo surgical intervention for ACL and meniscal injuries (P < .0001) and KCL injuries (P = .02). Conclusions We found that surgical treatment of 5 common sports injuries remains stable, with only KCL injuries and meniscal injuries showing an increase in surgical incidence. Average age of surgical intervention did not change significantly over the 7-year time span for any diagnosis. Level of Evidence Level IV, Cross Sectional Study.
Collapse
Affiliation(s)
- Nicholas Bonazza
- Penn State Hershey Bone & Joint Institute, Hershey, Pennsylvania, U.S.A
| | - Dallas M Smuin
- Penn State Hershey Bone & Joint Institute, Hershey, Pennsylvania, U.S.A
| | - Nicholas Sterling
- Penn State Hershey Bone & Joint Institute, Hershey, Pennsylvania, U.S.A
| | - Djibril Ba
- Penn State Hershey Bone & Joint Institute, Hershey, Pennsylvania, U.S.A
| | - Guodong Liu
- Penn State Hershey Bone & Joint Institute, Hershey, Pennsylvania, U.S.A
| | - Douglas L Leslie
- Penn State Hershey Bone & Joint Institute, Hershey, Pennsylvania, U.S.A
| | - William Hennrikus
- Penn State Hershey Bone & Joint Institute, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Penn State Hershey Bone & Joint Institute, Hershey, Pennsylvania, U.S.A
| |
Collapse
|
26
|
Dhawan A. Editorial Commentary: Innovations in Anchor Design-Are Patients Really Benefiting? Arthroscopy 2020; 36:962-963. [PMID: 32247427 DOI: 10.1016/j.arthro.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 02/02/2023]
Abstract
Vented open-architecture suture anchors provide theoretical benefits over traditional screw-in solid anchors to include improved osseous ingrowth, elution of marrow elements to enhance biology at the repair site, and easier revision because of reduced anchor material. However, there is no evidence that open-architecture anchors result in improvements in patient-reported outcomes or early cytokine and marrow element release into the subacromial space compared with traditional screw-in solid anchors. Although innovation and evaluation of new technologies are paramount to surgical progress, decisions on implant use should be based on factors including cost, impact on revision, and surgeon familiarity because frequently, clinical differences based on patient-reported outcomes are not appreciated between anchor types or designs.
Collapse
|
27
|
Dhawan A. Editorial Commentary: Surgeons Should Not "Underpromise" to "Overdeliver": High Preoperative Patient Expectations Correlate With Improved Orthopaedic Surgical Outcomes. Arthroscopy 2019; 35:3259-3260. [PMID: 31785754 DOI: 10.1016/j.arthro.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 02/02/2023]
Abstract
Despite our understanding of patient-specific, anatomic, and surgical factors that can influence surgical outcomes, there remains a significant amount of variability in patient satisfaction and outcome after any orthopaedic surgical procedure. This variability is in large part due to psychosocial factors. There is a growing volume of literature demonstrating the importance of psychosocial factors to include anxiety, depression, attitudinal factors, expectations, patient-perceived control, self-efficacy, knowledge, and expectations. Many of these factors are modifiable, and it is critical that we as providers understand the depth and breadth of these psychosocial factors, and their influence, on our patient's surgical outcomes. Surgeons should not "underpromise" to "overdeliver," because high preoperative patient expectations have a positive predictive value for improved orthopaedic surgical outcomes.
Collapse
|
28
|
Bonazza NA, Smuin DM, Joshi R, Ba D, Liu G, Leslie DL, Dhawan A. Surgical Trends in Articular Cartilage Injuries of the Knee, Analysis of the Truven Health MarketScan Commercial Claims Database from 2005-2014. Arthrosc Sports Med Rehabil 2019; 1:e101-e107. [PMID: 32266346 PMCID: PMC7120850 DOI: 10.1016/j.asmr.2019.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/29/2019] [Indexed: 02/03/2023] Open
Abstract
Purpose To evaluate trends in procedures for the treatment of chondral injuries of the knee using the MarketScan database in the hope that further work can be performed to refine the indications for chondral intervention Methods The MarketScan Research Database was searched using Current Procedure Terminology, 4th edition, codes to identify patients who underwent chondral procedures of the knee from 2005-2014. Combined procedures, including meniscal transplant or osteotomy, were also identified. Patients were characterized by gender, age group and year of initial procedure. A χ2 test was used to evaluate differences in surgical trends between individual patient groups delineated by age and gender. The Cochran-Armitage trend test was used to identify significant differences in surgical trends yearly. Results Of 148,373,254 unique patients, 520,934 patients underwent a total of 599,119 procedures. Arthroscopy with debridement/shaving of articular cartilage decreased in proportion from 75% of all procedures in 2005 to 51% of all procedures in 2014 (P < .0001). Open osteochondral allograft saw the greatest change during the study period; a higher number of females than males underwent condral procedures (P < .0001). Patients aged 45-54 underwent the most procedures (32.9% of all procedures). A total of 483 patients underwent chondral procedures in conjunction with meniscal transplant with variable incidence during the study period. A total of 1,418 patients underwent chondral procedures in conjunction with osteotomy; cumulative incidence decreased from 4.5 procedures per 1,000,000 patients/year in 2005 to 2.6 procedures per 1,000,000 patients/year in 2014 (P < .0001). Conclusions Knee arthroscopy with debridement/shaving of articular cartilage remains the most common procedure performed. Although open allograft and autograft transplantation saw a sustained increase in incidence, the overall incidence of cartilage procedures, as well as those performed with osteotomies, declined. Level of Evidence Level IV, cross-sectional study.
Collapse
Affiliation(s)
- Nicholas A Bonazza
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Penn State Health, Pennsylvania State College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Dallas M Smuin
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Penn State Health, Pennsylvania State College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Rajat Joshi
- Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Djibril Ba
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Guodong Liu
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Douglas L Leslie
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Penn State Health, Pennsylvania State College of Medicine, Hershey, Pennsylvania, U.S.A.,Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Coronal and sagittal malalignment in the setting of anterior cruciate ligament (ACL) deficiency alters knee biomechanics and is shown to increase stress and strain on the native ACL and on the ACL graft during reconstruction. The purpose of this review was to determine the role and indications of high tibial osteotomy to correct coronal and/or sagittal plane malalignment with ACL reconstruction. RECENT FINDINGS Recent literature illustrates that an increase in varus malalignment and increased posterior tibial slope increases the biomechanical stress that is seen in a native or reconstructed ACL graft. It has been proposed to correct the sagittal and coronal malalignment by employing a high tibial osteotomy either prior to or at the time of ACL reconstruction to correct these deformities and to decrease the stress placed on the reconstructed ACL graft. The use of high tibial osteotomy for deformity correction creates a more stable knee for ACL reconstruction and has been shown to have good outcomes with regard to post-operative pain, stability, satisfaction scores, and function.
Collapse
Affiliation(s)
- Michal Klek
- Department of Orthopaedics, Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
| | - Aman Dhawan
- Department of Orthopaedics, Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| |
Collapse
|
30
|
Hacken B, Onks C, Flemming D, Mosher T, Silvis M, Black K, Stuck D, Dhawan A. Prevalence of MRI Shoulder Abnormalities in Asymptomatic Professional and Collegiate Ice Hockey Athletes. Orthop J Sports Med 2019; 7:2325967119876865. [PMID: 31637270 PMCID: PMC6787880 DOI: 10.1177/2325967119876865] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The literature demonstrates a high prevalence of asymptomatic knee and hip findings on magnetic resonance imaging (MRI) in athletes. Baseball pitchers are shown to have a high prevalence of asymptomatic shoulder MRI findings, but the incidence of asymptomatic shoulder MRI findings has not been systematically evaluated in nonthrowing contact athletes. Purpose/Hypothesis The purpose of this study was to determine the prevalence of shoulder abnormalities in asymptomatic professional and collegiate hockey players. We hypothesized that, similar to overhead throwing athletes, ice hockey players will have a high prevalence of asymptomatic MRI findings, including labral, acromioclavicular (AC), and rotator cuff pathology on MRI. Study Design Cross-sectional study; Level of evidence, 4. Methods A total of 25 asymptomatic collegiate and professional hockey players (50 shoulders) with no history of missed games or practice because of shoulder injury, pain, or dysfunction underwent bilateral shoulder noncontrast 3.0-T MRI. MRIs were read blinded by 2 board-certified radiologists at 2 separate time points, 3 months apart, to determine the prevalence of abnormalities of the joint fluid, bone marrow, rotator cuff tendon, biceps tendon, labrum, AC joint, and glenohumeral joint. Interrater and intrareader reliability was determined, and regression analysis was performed to identify the prevalence and relationship to stick-hand dominance. Results Labral abnormalities were seen in 25% of the shoulders. AC joint abnormalities and rotator cuff findings were noted in 8% and 6% of shoulders, respectively. One shoulder was noted to have a biceps tendon abnormality, and 1 shoulder demonstrated glenohumeral joint chondral findings. Interrater reliability coefficients were 0.619 for labral abnormalities. Intrareader reliability kappa coefficients were 0.493 and 0.718 for both readers, respectively, for labral abnormalities. Regression analysis was performed and revealed that the overall shoulder pathology was more common in the nondominant stick hand (top stick hand) (coefficient -0.731; P = .021). Conclusion Professional and collegiate ice hockey players had an overall prevalence of labral abnormalities in 25% of their shoulders, with findings more often found in the nondominant stick hand. Rotator cuff abnormalities were uncommon in ice hockey players. These findings differ significantly from published reports examining professional baseball players and other overhead sports athletes.
Collapse
Affiliation(s)
- Brittney Hacken
- Department of Orthopedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Cayce Onks
- Department of Orthopedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.,Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Donald Flemming
- Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Timothy Mosher
- Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Matthew Silvis
- Department of Orthopedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.,Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin Black
- Department of Orthopedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dan Stuck
- Hershey Bears, Hershey Entertainment and Resort Company, Hershey, Pennsylvania, USA
| | - Aman Dhawan
- Department of Orthopedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
31
|
Hong A, Liu JN, Gowd AK, Dhawan A, Amin NH. Reliability and Accuracy of MRI in Orthopedics: A Survey of Its Use and Perceived Limitations. Clin Med Insights Arthritis Musculoskelet Disord 2019; 12:1179544119872972. [PMID: 31523134 PMCID: PMC6728666 DOI: 10.1177/1179544119872972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 11/17/2022]
Abstract
Over the past decade, the use of magnetic resonance imaging (MRI) as a diagnostic tool has been increasing significantly in various fields of medicine due to its wide array of applications. As a result, its diagnostic efficacy and reliability come into question. Specifically, in the field of orthopedics, there has been little discussion on the problems many physicians face while using MRIs in practice. To gauge the perceived limitations of MRI, we designed a decision analysis to analyze the utility of MRIs and estimate the number of inconclusive MRIs ordered within an orthopedic practice to explore potential alternative avenues of diagnosis. A survey of 100 board-certified practicing orthopedic surgeons given at 2 national conferences was designed to assess the value, reliability, and diagnostic utility of MRIs in preoperative planning in shoulder and knee surgery. Of those surveyed, 93% reported that there was believed to be a problem with the accuracy of an MRI in the setting of a prior surgery and/or if previous hardware was present specifically pertaining to the knee or shoulder. The most common indications of concern regarding knee or shoulder MRI reliability among this sample group were previous patient hardware (19%), a previous surgery (16%), and a chondral defect (11%). In addition, when asked how many MRIs were believed to be inconclusive based on previous surgery/hardware alone in the last 6 months of practice, an average of 19 inconclusive MRIs was reported. This study summarizes some of the concerns of MRI use in the orthopedic community and attempts to add a unique perspective on the attitudes, decision-making, and apparent economic problems that they face as well as uncover specific instances where MRIs were determined to be unreliable and incomplete in aiding the diagnosis and treatment algorithm.
Collapse
Affiliation(s)
- Andrew Hong
- School of Medicine, Loma Linda
University, Loma Linda, CA, USA
| | - Joseph N Liu
- Loma Linda University Medical Center,
Loma Linda, CA, USA
| | - Anirudh K Gowd
- Wake Forest University Baptist Medical
Center, Winston-Salem, NC, USA
| | - Aman Dhawan
- Penn State Health Milton S. Hershey
Medical Center, Hershey, PA, USA
| | - Nirav H Amin
- Loma Linda University Medical Center,
Loma Linda, CA, USA
- Veterans Affairs Loma Linda Healthcare
System, Loma Linda, CA, USA
| |
Collapse
|
32
|
Kennedy P, Joshi R, Dhawan A. The Effect of Psychosocial Factors on Outcomes in Patients With Rotator Cuff Tears: A Systematic Review. Arthroscopy 2019; 35:2698-2706. [PMID: 31500758 DOI: 10.1016/j.arthro.2019.03.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 03/08/2019] [Accepted: 03/14/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether psychosocial factors affect patient-reported outcomes in individuals with rotator cuff tears or after rotator cuff repair. METHODS A systematic review was conducted using a computerized search of the PubMed and Web of Science electronic databases in adherence with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Articles were then evaluated based on inclusion and exclusion criteria. The Newcastle-Ottawa Scale was used to assess study quality and risk of bias. Because of study heterogeneity and varied levels of evidence, meta-analysis was not possible. RESULTS Of 980 identified articles, 15 met the inclusion and exclusion criteria. In those reported, the visual analog scale correlation with distress scales ranged from -0.476 to 0.334, depending on outcome, with a trend toward increased pain in patients with distress. The depression subscale of the Hospital Anxiety and Depression Scale was negatively correlated with the American Shoulder and Elbow Surgeons score in 2 of 3 studies (-0.309 to 0.235). Six studies evaluated the presence of psychosocial factors and their correlation with patient-reported outcomes prior to surgery. These showed a significant correlation between rotator cuff pathology and psychological distress (i.e., depression or anxiety) as identified on standardized patient-reported outcome measures. Nine studies evaluated psychosocial factors either before and after surgery or only postoperatively. Of these 9 studies, 3 found no statistically significant differences in outcomes as related to psychosocial factors. In contrast, 6 of 9 reported an association between outcomes and psychosocial factors. Moreover, 2 of these 6 studies reported a direct relationship between patient expectations and outcomes, with 1 of these 2 studies finding that higher expectations improved baseline scores on the mental component summary of the Short Form 36 (r = 0.307). One study found significant differences in mental status in patients with rotator cuff tears based on age and sex. CONCLUSIONS This review found that most studies support that psychosocial factors do significantly influence the level of disability and pain experienced by patients preoperatively; however, 3 of 9 studies showed significant improvements in postoperative pain and function even with significant psychosocial confounders. These studies, however, do support that there is a direct relation between patient expectations and outcomes in rotator cuff surgery. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
Collapse
Affiliation(s)
- Patrick Kennedy
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A..
| | - Rajat Joshi
- Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| |
Collapse
|
33
|
Norton R, Honstad C, Joshi R, Silvis M, Chinchilli V, Dhawan A. Risk Factors for Elbow and Shoulder Injuries in Adolescent Baseball Players: A Systematic Review. Am J Sports Med 2019; 47:982-990. [PMID: 29630388 DOI: 10.1177/0363546518760573] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence of shoulder and elbow injuries among adolescent baseball players is on the rise. These injuries may lead to surgery or retirement at a young age. PURPOSE To identify independent risk factors for elbow and shoulder injuries in adolescent baseball players. A secondary aim was to determine whether the literature supports the Major League Baseball and USA Baseball Pitch Smart guidelines. STUDY DESIGN Systematic review. METHODS A systematic review was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines utilizing MEDLINE, SPORTDiscus, and Web of Science. Because of study heterogeneity, a quantitative synthesis was not performed. A qualitative review was performed on 19 independent risk factors for elbow and shoulder injuries in adolescent baseball players. Level of evidence was assigned per the Oxford Centre for Evidence-Based Medicine Working Group, and risk of bias was graded per the Newcastle-Ottawa Scale. RESULTS Twenty-two articles met criteria for inclusion. Of the 19 independent variables that were analyzed, age, height, playing for multiple teams, pitch velocity, and arm fatigue were found to be independent risk factors for throwing arm injuries. Pitches per game appears to be a risk factor for shoulder injuries. Seven independent variables (innings pitched per game, showcase participation, games per year, training days per week, pitch type, shoulder external rotation, and shoulder total range of motion) do not appear to be significant risk factors. The data were inconclusive for the remaining 6 variables (weight, months of pitching per year, innings or pitches per year, catching, shoulder horizontal adduction, and glenohumeral internal rotation deficit). CONCLUSION The results from this study demonstrate that age, height, playing for multiple teams, pitch velocity, and arm fatigue are clear risk factors for throwing arm injuries in adolescent baseball players. Pitches per game appears to be a risk factor for shoulder injuries. Other variables are either inconclusive or do not appear to be specific risk factors for injuries.
Collapse
Affiliation(s)
- Ryan Norton
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christopher Honstad
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Rajat Joshi
- Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Matthew Silvis
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Vernon Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
34
|
Mandal P, Parmar A, Ambekar A, Dhawan A. Substance use among treatment seeking Indian adolescent girls: Are they unique? Asian J Psychiatr 2019; 41:17-19. [PMID: 30870647 DOI: 10.1016/j.ajp.2019.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/23/2019] [Accepted: 03/04/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Substance use among adolescents is on the rise across the globe along with a diminution of gender gap observed earlier posing a huge public health burden. Unfortunately, there is a paucity of literature on adolescent substance use. The literature is even sparse about substance use among adolescent girls. The current study aims to provide a glimpse of the profile and pattern of substance use among Indian adolescent girls seeking treatment for substance use problems in a specialty addiction treatment centre in India. MATERIALS AND METHODS This study is retrospective in design. Information regarding socio-demographics and substance use were extracted from the medical records of adolescent girls (≤ 19 years) who sought treatment for substance use problems during 2004-2018, at the adolescent clinic of a tertiary addiction treatment centre located in north India was retrieved carried out. The data was statistically analysed using SPSS. RESULTS A total of 28 girls sought treatment during this period. The mean age of the girls was 15.89 ± 2.72 years. Most of the girls were students (6/28) or had never started working (12/28). Majority of them were coming from an urban background (89.3%) and were educated up to 10th class (85.5%). A total of 17 (60.7%) girls sought treatment for opioids use of which 11 were using illicit opioids like heroin and five (29.9%) of them reported taking opioids by injecting route primarily. History of past abstinence attempts, and treatment attempt were present in very few of them (10.7% and 14.3%). CONCLUSION Our study suggests a distinct substance use profile of adolescent girls. There is a need for further systematic studies to assess their clinical needs.
Collapse
Affiliation(s)
- Piyali Mandal
- Department of psychiatry Room no 4096, All India Institute of Medical Sciences Ansari Nagar, 110029, New Delhi, India
| | - A Parmar
- Department of psychiatry Room no 4096, All India Institute of Medical Sciences Ansari Nagar, 110029, New Delhi, India
| | - A Ambekar
- Department of psychiatry Room no 4096, All India Institute of Medical Sciences Ansari Nagar, 110029, New Delhi, India
| | - A Dhawan
- Department of psychiatry Room no 4096, All India Institute of Medical Sciences Ansari Nagar, 110029, New Delhi, India.
| |
Collapse
|
35
|
Dhawan A, Scott J, Sundaresan P, Veness M, Porceddu S, Hau E, Ahern V, Harris A, Buffa F, Gee H. Are Signatures of Radiosensitivity Ready for Routine Clinical Use? a Pragmatic Comparison of Clinical, Pathological and Gene Signature Predictors of Outcome in Oropharynx Head and Neck Cancers. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.06.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
36
|
Abstract
Background: Pediatric sports specialization, defined as intense year-round training in a single sport as a result of excluding other sports for more than 8 months per year, is common in the United States. There are demonstrated physical and social risks to early pediatric sports specialization (defined as before age 12 years). While thought to be needed to acquire appropriate experience and excel in a given sport, there remains little information on when athletes at the highest levels of their sport specialized. This study aimed to define when professional and collegiate ice hockey players specialized. Hypothesis: Early sports specialization before age 12 years will not be common among elite-level (professional and collegiate) ice hockey players. Study Design: Retrospective cross-sectional survey study. Level of Evidence: Level 3. Methods: Male professional and collegiate ice hockey players within 1 National Hockey League organization and 2 National Collegiate Athletic Association (NCAA) organizations who were 18 years of age or older completed a survey at training camp detailing their history of sports participation and specialization. Results: A total of 91 athletes participated in the study (mean age, 22.8 years; range, 18-39 years). The mean age at the start of any sports participation was 4.5 years, and the mean age of sports specialization was 14.3 years. The mean age of specialization in the professional group, the NCAA Division I group, and the NCAA Division III group was 14.1, 14.5, and 14.6 years, respectively. Conclusion: Early pediatric sports specialization is not common in elite-level (professional and collegiate) ice hockey players. Clinical Relevance: Early pediatric sports specialization before age 12 years is not necessary for athletic success in professional and collegiate ice hockey. This study provides further evidence supporting the recommendations of the American Medical Society for Sports Medicine, American Academy of Pediatrics, and American Orthopaedic Society for Sports Medicine against early sports specialization.
Collapse
Affiliation(s)
- Sarah Black
- Penn State College of Medicine, Sports Medicine, Hershey, Pennsylvania
| | - Kevin Black
- Penn State College of Medicine, Sports Medicine, Hershey, Pennsylvania
| | - Aman Dhawan
- Penn State College of Medicine, Sports Medicine, Hershey, Pennsylvania
| | - Cayce Onks
- Penn State College of Medicine, Sports Medicine, Hershey, Pennsylvania
| | - Peter Seidenberg
- Penn State College of Medicine, Sports Medicine, Hershey, Pennsylvania
| | - Matthew Silvis
- Penn State College of Medicine, Sports Medicine, Hershey, Pennsylvania
| |
Collapse
|
37
|
Dhawan A. Editorial Commentary: Will New Technology Improve Outcomes or Are All-Suture Rotator Cuff Surgery Anchors Like a New Set of Golf Clubs? Not a Question for the Biomechanics Lab. Arthroscopy 2018; 34:2782-2783. [PMID: 30286878 DOI: 10.1016/j.arthro.2018.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 07/17/2018] [Indexed: 02/02/2023]
Abstract
Failure of rotator cuff repairs may be attributed to biological, mechanical, or rehabilitative reasons. New all-suture anchors have several theoretical benefits that make them potentially attractive for use in rotator cuff repair. As their mechanical strength results from the anchor deploying as a button or molly bolt against the inner cortical bone, it stands to reason that decortication performed for the purposes of improved repair biology may be particularly detrimental to the initial time-zero biomechanics of all-suture anchors. It is unclear whether the statistically significant all-suture biomechanics seen with and without decortication translate clinically.
Collapse
|
38
|
Manem VSK, Dhawan A. Modelling recurrence and second cancer risks induced by proton therapy. Math Med Biol 2018; 35:347-361. [PMID: 29106564 PMCID: PMC6132082 DOI: 10.1093/imammb/dqx006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 04/09/2017] [Accepted: 06/05/2017] [Indexed: 12/30/2022]
Abstract
In the past few years, proton therapy has taken the centre stage in treating various tumour types. The primary contribution of this study is to investigate the tumour control probability (TCP), relapse time and the corresponding secondary cancer risks induced by proton beam radiation therapy. We incorporate tumour relapse kinetics into the TCP framework and calculate the associated second cancer risks. To calculate proton therapy-induced secondary cancer induction, we used the well-known biologically motivated mathematical model, initiation-inactivation-proliferation formalism. We used the available in vitro data for the linear energy transfer (LET) dependence of cell killing and mutation induction parameters. We evaluated the TCP and radiation-induced second cancer risks for protons in the clinical range of LETs, i.e. approximately 8 $\mathrm{keV/\mu m}$ for the tumour volume and 1-3 $\mathrm{keV/\mu m}$ for the organs at risk. This study may serve as a framework for further work in this field and elucidates proton-induced TCP and the associated secondary cancer risks, not previously reported in the literature. Although studies with a greater number of cell lines would reduce uncertainties within the model parameters, we argue that the theoretical framework presented within is a sufficient rationale to assess proton radiation TCP, relapse and carcinogenic effects in various treatment plans. We show that compared with photon therapy, proton therapy markedly reduces the risk of secondary malignancies and for equivalent dosing regimens achieves better tumour control as well as a reduced primary recurrence outcome, especially within a hypo-fractionated regimen.
Collapse
Affiliation(s)
- V S K Manem
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - A Dhawan
- Department of Oncology, University of Oxford, Oxford, UK
| |
Collapse
|
39
|
Gibson PS, Quaglia A, Dhawan A, Wu H, Lanham‐New S, Hart KH, Fitzpatrick E, Moore JB. Vitamin D status and associated genetic polymorphisms in a cohort of UK children with non-alcoholic fatty liver disease. Pediatr Obes 2018; 13:433-441. [PMID: 29761652 PMCID: PMC6032876 DOI: 10.1111/ijpo.12293] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/20/2018] [Accepted: 04/04/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Vitamin D deficiency has been associated with non-alcoholic fatty liver disease (NAFLD). However, the role of polymorphisms determining vitamin D status remains unknown. OBJECTIVES The objectives of this study were to determine in UK children with biopsy-proven NAFLD (i) their vitamin D status throughout a 12-month period and (ii) interactions between key vitamin D-related genetic variants (nicotinamide adenine dinucleotide synthase-1/dehydrocholesterol reductase-7, vitamin D receptor, group-specific component, CYP2R1) and disease severity. METHODS In 103 paediatric patients with NAFLD, serum 25-hydroxyvitamin D (25OHD) levels and genotypes were determined contemporaneously to liver biopsy and examined in relation to NAFLD activity score and fibrosis stage. RESULTS Only 19.2% of children had adequate vitamin D status; most had mean 25OHD levels considered deficient (<25 nmol·L-1 , 25.5%) or insufficient (<50 nmol·L-1 , 55.3%). Patients had significantly lower 25OHD levels in winter months (95% CI: 22.7-31.2 nmol·L-1 ) when compared with spring (30.5-42.1 nmol·L-1 ; P = 0.0089), summer (36.3-47.2 nmol·L-1 ; P < 0.0001) and autumn (34.2-47.5 nmol·L-1 ; P = 0.0003). Polymorphisms in the nicotinamide adenine dinucleotide synthase-1/dehydrocholesterol reductase-7 (rs3829251, rs12785878) and vitamin D receptor (rs2228570) genes were independently associated with increased steatosis; while a group-specific component variant (rs4588) was associated with increased inflammation in liver biopsies. CONCLUSIONS Children with NAFLD in the UK have particularly low winter vitamin D status, with vitamin D insufficiency prevalent throughout the year. Polymorphisms in the vitamin D metabolic pathway are associated with histological severity of paediatric NAFLD.
Collapse
Affiliation(s)
- P. S. Gibson
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical SciencesUniversity of SurreyGuildfordUK,Pediatric Liver, GI and Nutrition CentreKing's College London School of Medicine at King's College HospitalLondonUK
| | - A. Quaglia
- Institute of Liver StudiesKing's College London School of Medicine at King's College HospitalLondonUK
| | - A. Dhawan
- Pediatric Liver, GI and Nutrition CentreKing's College London School of Medicine at King's College HospitalLondonUK
| | - H. Wu
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical SciencesUniversity of SurreyGuildfordUK
| | - S. Lanham‐New
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical SciencesUniversity of SurreyGuildfordUK
| | - K. H. Hart
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical SciencesUniversity of SurreyGuildfordUK
| | - E. Fitzpatrick
- Pediatric Liver, GI and Nutrition CentreKing's College London School of Medicine at King's College HospitalLondonUK
| | - J. B. Moore
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical SciencesUniversity of SurreyGuildfordUK,School of Food Science and NutritionUniversity of LeedsLeedsUK
| |
Collapse
|
40
|
Dhawan A, Mukherjee B, Patwardhan S, Majdi J, Holley R, Joiner W, Harris-Love M, Sikdar S. Ultrasound sensing-based intuitive proportional control: An evaluation study with upper-extremity amputees. Ann Phys Rehabil Med 2018. [DOI: 10.1016/j.rehab.2018.05.1101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
41
|
Bonazza NA, Homcha B, Liu G, Leslie DL, Dhawan A. Surgical Trends in Arthroscopic Hip Surgery Using a Large National Database. Arthroscopy 2018; 34:1825-1830. [PMID: 29580743 DOI: 10.1016/j.arthro.2018.01.022] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/09/2018] [Accepted: 01/12/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the practice trends in hip arthroscopy, including femoroplasty, acetabuloplasty, and labral repair Current Procedure Terminology, 4th edition (CPT-4), codes that have been implemented since many of the previous studies were published, without concerns for Hawthorne or observer effect as can be seen during a board collection window, and in a larger volume of patients with a more comprehensive database than previous published data. METHODS The MarketScan Commercial Claims and Encounters database was searched using CPT-4 codes to identify patients who underwent any arthroscopic hip procedure from 2008 to 2013. Patients identified were characterized by gender, age group, and year of the initial procedure. Regression analysis was used to evaluate differences in surgical trends between individual patient groups delineated by age and gender. The Cochran-Armitage trend test was used to identify significant differences in surgical trends seen yearly. RESULTS A total of 62,782 arthroscopic hip procedures in 31,569 surgeries in 27,997 patients were identified and included from 2008 through 2013. The number of surgeries in the database increased every year. After changes to CPT coding in 2011, femoroplasty became the most common procedure in 2012, comprising 28% of all procedures performed in 2013. Patients ages 40 to 49 underwent the most procedures (7,467, 27%). Females were more likely to undergo any arthroscopic procedure during the study period (.068% vs .041%, P < .0001). A total of 2,754 patients (10%) underwent a second surgery during the study period. A total of 1,625 patients (6%) underwent a total hip arthroplasty following an arthroscopic procedure during the study period. CONCLUSIONS Arthroscopic hip procedures continue to increase, with femoroplasty, labral repair, and acetabuloplasty being the 3 most common procedures performed. Females are more likely to undergo any procedure, and labral repair is now performed more commonly than labral debridement. LEVEL OF EVIDENCE Level IV, cross-sectional study.
Collapse
Affiliation(s)
- Nicholas A Bonazza
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, Pennsylvania, U.S.A
| | - Brittany Homcha
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, Pennsylvania, U.S.A
| | - Guodong Liu
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Douglas L Leslie
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, Pennsylvania, U.S.A..
| |
Collapse
|
42
|
Dhawan A. Author Reply: Research Pearls: The Significance of Statistics and Perils of Pooling-"Know Your Audience". Arthroscopy 2018; 34:1008. [PMID: 29622241 DOI: 10.1016/j.arthro.2018.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 01/29/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Aman Dhawan
- Penn State College of Medicine, Hershey, Pennsylvania
| |
Collapse
|
43
|
Rothermel SD, Smuin D, Dhawan A. Are Outcomes After Meniscal Repair Age Dependent? A Systematic Review. Arthroscopy 2018; 34:979-987. [PMID: 29273257 DOI: 10.1016/j.arthro.2017.08.287] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/19/2017] [Accepted: 08/19/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine if the failure rate and functional outcome after arthroscopic meniscus suture repair are age dependent. METHODS A systematic review was conducted using a computerized search of the electronic databases MEDLINE and ScienceDirect in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data from each included study were recorded on a standardized form. Studies were included if they (1) were English-language studies in peer-reviewed journals, (2) used a distinct age cut-off to evaluate outcome of meniscal surgery for those above and below the specified cut-off, and (3) used meniscal repairs using suture based technique with inside-out, outside-in, or all-inside techniques. Review papers, case reports, technique papers, non-English language publications, abstracts, and data on meniscal repairs using meniscal screws, arrows, or darts were excluded. RESULTS 15 of 305 identified articles met the inclusion/exclusion criteria. There were 1,141 menisci treated in 1,063 patients. Seven and 8 studies met the inclusion/exclusion criteria for analysis for the age thresholds of 25 years and 30 years, respectively, demonstrating no difference in failure rates relative to age threshold. Four of 6 studies that met analysis criteria found no difference in failure rates above or below an age threshold of 35 years. No significant difference in failure in patients younger than 40 than patients older than 40 was found for 4 of the 5 studies in that arm of the review. CONCLUSIONS Analysis of the composite data in this systematic review reveals that no significant difference exists when evaluating meniscal repair failure rate as a function of age above or below the given age thresholds. LEVEL OF EVIDENCE Level IV, systematic review of level III and IV studies.
Collapse
Affiliation(s)
- Shane D Rothermel
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A..
| | - Dallas Smuin
- Penn State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| |
Collapse
|
44
|
Bonazza NA, Lewis GS, Lukosius EZ, Roush EP, Black KP, Dhawan A. Effect of Transosseous Tunnels on Patella Fracture Risk After Medial Patellofemoral Ligament Reconstruction: A Cadaveric Study. Arthroscopy 2018; 34:513-518. [PMID: 29100765 DOI: 10.1016/j.arthro.2017.08.267] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/16/2017] [Accepted: 08/16/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether (1) tunnels that breach the anterior cortex of the patella result in increased fracture risk and (2) transosseous tunnels drilled across the patella significantly reduce the tensile force needed to fracture the patella. METHODS Twenty-six fresh-frozen cadaveric human patellas were randomized to 1 of 3 groups: a control group with unmodified patellas, a group with 2 transverse tunnels (TT) that did not breach the anterior cortex, and a group with 2 TT that breached the anterior cortex of the patella (PA). Patellas were connected in series to a load cell via freeze clamp attachments to the quadriceps and patellar tendons. Pull was fixed at 45° with the patella set in the trochlear groove of a synthetic femur. Patellas were loaded cyclically, then to failure. RESULTS Twenty-six patellas were tested (mean age = 71.4 years; range = 37-95, standard deviation [STD] = 11.5 years). PA patellas were more likely to fracture through the tunnel than TT patellas (100% vs 25%, P = .033). Control, TT, and PA groups failed at 1,915 N (STD = 508 N), 1,901 N (STD = 884 N), and 1,640 N (STD = 625 N), respectively. There was no statistically significant difference in overall load to failure between control and TT (P = .969), control and PA (P = .321), and TT and PA (P = .488) groups. CONCLUSIONS Transosseous patellar tunnels for medial patellofemoral ligament reconstruction that breached the anterior cortex were more likely to fracture during longitudinal load than those that did not breach the anterior cortex. However, we found no statistically significant difference in the tensile load to failure between native patellas and patellas with either type of transosseous tunnel. CLINICAL RELEVANCE The results of this study show that breaching the anterior cortex during transosseous drilling increases the risk of a patellar fracture occurring through the transosseous tunnel.
Collapse
Affiliation(s)
- Nicholas A Bonazza
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, Pennsylvania, U.S.A
| | - Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Eric Z Lukosius
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, Pennsylvania, U.S.A
| | - Evan P Roush
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Kevin P Black
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, Pennsylvania, U.S.A..
| |
Collapse
|
45
|
Iansante V, Mitry RR, Filippi C, Fitzpatrick E, Dhawan A. Human hepatocyte transplantation for liver disease: current status and future perspectives. Pediatr Res 2018; 83:232-240. [PMID: 29149103 DOI: 10.1038/pr.2017.284] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/02/2017] [Indexed: 12/16/2022]
Abstract
Liver transplantation is the accepted treatment for patients with acute liver failure and liver-based metabolic disorders. However, donor organ shortage and lifelong need for immunosuppression are the main limitations to liver transplantation. In addition, loss of the native liver as a target organ for future gene therapy for metabolic disorders limits the futuristic treatment options, resulting in the need for alternative therapeutic strategies. A potential alternative to liver transplantation is allogeneic hepatocyte transplantation. Over the last two decades, hepatocyte transplantation has made the transition from bench to bedside. Standardized techniques have been established for isolation, culture, and cryopreservation of human hepatocytes. Clinical hepatocyte transplantation safety and short-term efficacy have been proven; however, some major hurdles-mainly concerning shortage of donor organs, low cell engraftment, and lack of a long-lasting effect-need to be overcome to widen its clinical applications. Current research is aimed at addressing these problems, with the ultimate goal of increasing hepatocyte transplantation efficacy in clinical applications.
Collapse
Affiliation(s)
- V Iansante
- DhawanLab, Paediatric Liver GI and Nutrition Center and MowatLabs, Institute of Liver Studies, King's College London, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, UK
| | - R R Mitry
- DhawanLab, Paediatric Liver GI and Nutrition Center and MowatLabs, Institute of Liver Studies, King's College London, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, UK
| | - C Filippi
- DhawanLab, Paediatric Liver GI and Nutrition Center and MowatLabs, Institute of Liver Studies, King's College London, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, UK
| | - E Fitzpatrick
- DhawanLab, Paediatric Liver GI and Nutrition Center and MowatLabs, Institute of Liver Studies, King's College London, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, UK
| | - A Dhawan
- DhawanLab, Paediatric Liver GI and Nutrition Center and MowatLabs, Institute of Liver Studies, King's College London, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, UK
| |
Collapse
|
46
|
Brown L, Rothermel S, Joshi R, Dhawan A. Recurrent Instability After Arthroscopic Bankart Reconstruction: A Systematic Review of Surgical Technical Factors. Arthroscopy 2017; 33:2081-2092. [PMID: 28866342 DOI: 10.1016/j.arthro.2017.06.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 05/04/2017] [Accepted: 06/20/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Recurrent instability remains of concern after arthroscopic Bankart reconstruction. We evaluated various technical factors including anchor design, anchor material, number of anchors used, and interval closure on risk of recurrent instability after arthroscopic Bankart reconstruction. METHODS A systematic review of MEDLINE and Cochrane databases was conducted, following PRISMA guidelines. Extracted data were recorded on a standardized form. Methodological index for non-randomized studies (MINORS) and Newcastle-Ottawa Scale (NOS) were used to assess study quality and risk bias. Because of study heterogeneity and low levels of evidence, meta-analysis was not possible. Pooled weighted means were calculated and individual study evaluation and comparisons (qualitative analysis) were performed for systematic review. RESULTS Of 2097 studies identified, 26 met criteria for systematic review. Pooled weighted means revealed 11.4% versus 15% recurrent instability with 3 or more suture anchors versus fewer than 3 anchors, 10.1% versus 7.8% with absorbable versus nonabsorbable suture anchors, respectively, and 8.0% versus 9.4% with knotless versus standard anchors, respectively. Interval closure did not qualitatively decrease recurrent instability or decrease range of motion. CONCLUSIONS Our systematic review reveals that despite individual study, and previous systematic reviews pointing to the contrary, the composite contemporary published literature would support no difference in the risk of recurrent instability after arthroscopic Bankart reconstruction with rotator interval closure, differing numbers of anchors used for the repair, use of knotless versus standard anchors, or use of bioabsorbable versus nonabsorbable anchors. We recommend surgeons focus on factors that have been shown to modify the risk factors after arthroscopic Bankart reconstruction, such as patient selection. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
Collapse
Affiliation(s)
- Landon Brown
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Shane Rothermel
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Rajat Joshi
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A..
| |
Collapse
|
47
|
Dhawan A. Editorial Commentary: Arthroscopic Simulation Training Need Not Be Expensive to Be Effective. Arthroscopy 2017; 33:2024-2025. [PMID: 29102016 DOI: 10.1016/j.arthro.2017.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 02/02/2023]
Abstract
In a randomized controlled trial of arthroscopic training tools, the low-cost/low-fidelity Cigar Box Arthroscopy Trainer demonstrated equivalent efficacy to the validated, and more expensive, Anatomic Knee Arthroscopy Trainer (AKAT) in the training of novice arthroscopists using a validated scoring system, the Basic Arthroscopic Knee Skill Scoring System. As simulation training and formal surgical skills training is now mandatory, residency and fellowship programs are required to incorporate training modules and equipment to maximize learning while minimizing potential for patient harm. Low-cost, low-fidelity simulation tools such as this may provide a solution to do so while minimizing costs and maximizing educational returns on investment. The value in simulation training will be in its synergistic ability to augment the traditional apprenticeship model of resident and fellow training.
Collapse
|
48
|
Abstract
The long head of the biceps (LHB) tendon is a potential source of shoulder pain encountered by orthopaedic surgeons. A multitude of approaches to addressing LHB tendinopathy have been described. These include various surgical techniques such as tenodesis versus tenotomy, an arthroscopic versus an open approach, and differing methods of tenodesis fixation. Our preferred approach to addressing LHB tendinopathy is through a mini-open approach using a double-loaded 4.5-mm suture anchor. This Technical Note with accompanying video describes our technique for performing this procedure, as well as supporting clinical evidence and technical pearls.
Collapse
Affiliation(s)
| | - Aman Dhawan
- Address correspondence to Aman Dhawan, M.D., Penn State Hershey Orthopaedics, 30 Hope Dr, Hershey, PA 17033, U.S.A.Penn State Hershey Orthopaedics30 Hope DrHersheyPA17033U.S.A.
| |
Collapse
|
49
|
Smuin DM, Swenson RD, Dhawan A. Saucerization Versus Complete Resection of a Symptomatic Discoid Lateral Meniscus at Short- and Long-term Follow-up: A Systematic Review. Arthroscopy 2017; 33:1733-1742. [PMID: 28865577 DOI: 10.1016/j.arthro.2017.03.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/12/2017] [Accepted: 03/31/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the surgical outcomes of symptomatic discoid menisci after total meniscectomy, saucerization, and suture repair of tears of a discoid meniscus at short- and long-term follow-up. METHODS A systematic review was conducted using the Pubmed and ScienceDirect databases in adherence with Preferred Reporting Items of Systematic Reviews and Meta-Analysis guidelines. Short- and long-term follow-up were defined as an average follow-up of <4 years and >4 years, respectively. Pooled quantitative synthesis was performed on studies that reported results of total meniscectomy and saucerization in the same study. A systematic review was performed on studies that reported data on saucerization, total meniscectomy, and/or repair. RESULTS A total of 19 studies for the short term and 22 for the long term were identified that met inclusion criteria for qualitative review. Of these, 4 short-term and 5 long-term studies were included in the quantitative synthesis. No significant differences in Ikeuchi scores are seen in the short-term studies between saucerization and total meniscectomy; however, the long-term studies did find a statistical difference favoring saucerization (P < .001). The differences noted between the preoperative and postoperative Lysholm scores in the short term were 24.1 (95% conflict of interest: 10.25-37.95) in 3 studies and 22.38 (95% conflict of interest: 17.68-27.07) in the 4 long-term studies for saucerization. Suture repair with saucerization versus saucerization without suture repair revealed a statistical difference in only 1 of 5 studies. CONCLUSIONS Long-term data demonstrate significantly improved patient reported outcomes in favor of saucerization over total meniscectomy. Suture repair of tears of a lateral discoid meniscus does not demonstrate improved outcomes over partial meniscectomy without repair. Considering the cost of repair and lack of demonstrated improvement, based on the limited available data, we do not recommend repair of the abnormal anatomy in a torn lateral discoid meniscus. LEVEL OF EVIDENCE Level IV, systematic review.
Collapse
Affiliation(s)
- Dallas M Smuin
- Penn State College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Richard D Swenson
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Penn State Hershey Bone and Joint Institute, Hershey, Pennsylvania, U.S.A..
| |
Collapse
|
50
|
Datta P, Ozbolat V, Ayan B, Dhawan A, Ozbolat IT. Bone tissue bioprinting for craniofacial reconstruction. Biotechnol Bioeng 2017; 114:2424-2431. [DOI: 10.1002/bit.26349] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/03/2017] [Accepted: 06/06/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Pallab Datta
- Center for Healthcare Science and TechnologyIndian Institute of Engineering Science and Technology ShibpurHowrah711103West BengalIndia
| | - Veli Ozbolat
- Engineering Science and Mechanics DepartmentPenn State UniversityUniversity ParkPennsylvania
- The Huck Institutes of the Life SciencesPenn State UniversityUniversity ParkPennsylvania
- Ceyhan Engineering FacultyMechanical Engineering DepartmentCukurova UniversityAdanaTurkey
| | - Bugra Ayan
- Engineering Science and Mechanics DepartmentPenn State UniversityUniversity ParkPennsylvania
- The Huck Institutes of the Life SciencesPenn State UniversityUniversity ParkPennsylvania
| | - Aman Dhawan
- Orthopedics and RehabilitationPenn State UniversityHersheyPennsylvania
| | - Ibrahim T. Ozbolat
- Engineering Science and Mechanics DepartmentPenn State UniversityUniversity ParkPennsylvania
- The Huck Institutes of the Life SciencesPenn State UniversityUniversity ParkPennsylvania
- Biomedical EngineeringPenn State UniversityUniversity ParkPennsylvania
- Materials Research InstitutePenn State UniversityUniversity ParkPennsylvania
| |
Collapse
|