Steadman�Hawkins Sports Medicine Foundation

Spring/Summer 2003Volume 9

In This Issue:

� NFL Charities AwardGrant for ShoulderResearch

� Colorado GovernorProclaims Steadman-Hawkins Days

� Microfracture: Less Pain,More Gain

� New Technology Aids inRotator Cuff Repair

� The Benefits of RegularExercise

Cindy Nelson: Skiing or Golf,Staying the Course Editor’s note: The following profile is based on an interview by Richard Needham. Mr. Needham is editorof Skiing Heritage magazine and the health newsletterArthritis Advisor.

Not many skiers would equate a

world-class downhill with a leisurely

stroll on the links. And not many

golfers would consider the act

of putting an exercise in reading

mountain terrain. Cindy Nelson sees

things differently.

Sports and Wellness

Patients in the News

Steadman-Hawkins Research Update

An International Center for Research and Education—Keeping People Active

Common Cycling Injuriesand Their Prevention By: Scott Bartel, MSPT

Editor’s note: Scott Bartel, a physical thera-pist at Howard Head Sports MedicineCenters in Vail, specializes in sports injuryrehabilitation and prevention. He races bicy-cles recreationally.

Although a winter full of downhill activitiesmay feel like it’s kept you fit, summercycling requires a different set of musclegroups and fiber types. As with skiing, ifproper off-season training isn’t performed,your body will usually feel a little beat upfollowing your initial summer cycling ses-sions. If unprepared, you’ll likely experi-ence a season of chronic injuries and lessenjoyable cycling.

Three of the most important factorsthat play into a successful season ofcycling, whether recreational or competi-tive, include proper off-season training,

Tendon, Ligament andCartilage Repair: A Previewof Previously ReportedConcepts and a New Lookat “Tissue Engineering” By Juan J. Rodrigo, M.D., and Alfred Kuo, M.D., Ph.D.

Editor’s note: Dr. Rodrigo is professor ofOrthopaedic Surgery at the School ofMedicine, University of California (Davis)and a member of the Steadman�HawkinsSports Medicine Foundation’s ScientificAdvisory Committee.

Tendons and ligaments are the tissues thatare most frequently injured in sports andother high-performance work activities.The tears frequently do not heal and gaps,or defects, occur. Nearby tendons or liga-ments can be shifted into the defect, butmore recently biological reconstruction ofthe defects with cells and tissue engineer-ing has been investigated.

(cont. pg 12)

(cont. pg 11)

(cont. pg 8)

Cindy Nelson Photo: Mike Crabtree

Photo: John Kelly

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What a Difference a DayMakes

Remember that song? How about: What a dif-ference 15 years make? This year Steadman�

Hawkins Sports Medicine Foundation(SHSMF) celebrates its 15th anniversary.More than that, SHSMF celebrates 15 years of commitment to the passion that spurred Dr.Steadman to found SHSMF: the desire to keeppeople of all ages physically active throughorthopaedic research and education in arthritis, healing, rehabilitation and injuryprevention.

While this passion and dedication hasbrought a steady stream of accolades andawards to the Foundation, the real accoladesgo to you—our friends and supporters,whose financial commitment is at the heart of SHSMF’s ability to fulfill its purpose.

It is our greatest wish to earn your con-tinued support for our next 15 years andbeyond. We’re setting our sights on manyfuture accomplishments together. To makeyour partnership fulfilling, financially andphilanthropically, we are pleased to present a variety of gift plans that will enable you to continue your support even beyond yourlifetime.

Gifts for the Future

BequestsA fundamental attribute of your will is its

ability to protect loved ones while helpingsecure the future of SHSMF through abequest. As you consider your plans forSHSMF, you may want to discuss the followingbequests with your advisor: • A specific percentage bequest, expressed

as a percentage of your estate, allowsappreciation in your estate during your lifetime to be passed through.

• A specific bequest is a specific dollaramount or asset.

• A combination specific dollar and per-centage bequest provides at least a specific dollar amount for SHSMF as well as a percentage bequest to allow appreciation to be passed through.

• A residuary bequest expresses your gift as all or part of the property remaining in your estate after debts, expenses, andpercentage and specific bequests have been paid.

Gifts That Return Income To You

Charitable Gift Annuity — ImmediatePayment (IGA)

Your gift of cash or securities can fund anIGA and, in return, SHSMF contractuallyagrees to pay you (and another if youchoose) a lifetime income. An added benefitis that part of the income payment is usuallytax-free. This gift annuity produces an incometax charitable deduction for a portion of yourgift. And using long-term, appreciated securi-ties renders additional tax savings throughreduced capital gains tax liability.

Charitable Gift Annuity — DeferredPayment (DGA)

A DGA is similar to an IGA except that itallows you to make a gift today and arrangefor your income to begin on a date in thefuture, which you select. The commitment ofyour gift today entitles you to claim an imme-diate income tax deduction even if the incomedoes not begin for some time.

Charitable Remainder Trust (CRT)A CRT is an irrevocable, legal agreement

in which you can designate SHSMF to receivethe trust’s principal at the end of the trust’sterm. Trusts can be established with gifts ofcash, securities, or real estate. Once estab-lished, you select:• The trust’s rate of return.• Whether it will pay fixed or variable income

to you (and/or another if you choose). • Whether it will last for a specific number

of years or the lifetime of the income recipient(s).

In addition to income benefits, there are also income, capital gains and estate taxbenefits.

Other Gifts for the Future

Life InsuranceGifts of life insurance represent a gener-

ous gift with little to no current out-of-pocketcost plus the potential benefit of an incometax deduction. You can give a fully paid-uppolicy or one on which premiums are stillbeing paid.

Retirement PlansGifts of retirement plans can be an excel-

lent strategy for preserving the value of yourestate for family and loved ones. You canname SHSMF a beneficiary at any time withoutimpacting plan arrangements.

Charitable Lead Trust (CLT)This unique trust makes an annual

income payment to SHSMF. The payment canbe a fixed amount or an amount that reflectsa fixed percentage of the trust’s annual fairmarket value. At the end of the trust’s term,generally a number of years, you or your beneficiaries (typically family members)receive the trust principal. Depending uponwho receives the principal, the CLT may also provide an income tax deduction or gifttax benefits.

As you can see, there are many opportu-nities to support SHSMF’s future. For moreinformation or gift illustrations, please contact John M. McMurtry, vice president forProgram Advancement, at 970-479-5781 orvia E-mail at: john.mcmurtry@shsmf.org.

Orthopaedic Health Care in Developing NationsAn Inside Look at CubaBy Timothy O’Brien, M.D.

Editor’s note: Dr. O’Brien has just completed hisfellowship year with the Steadman�HawkinsSports Medicine Foundation and Steadman-Hawkins Clinic. He graduated cum laude fromHarvard University with a degree in govern-ment, attended Brown School of Medicine, andcompleted his orthopaedic surgery residency atthe University of California at San Francisco. Hehas been a leader in many volunteer and com-munity-based projects. Following his Fellowship,Dr. O’Brien will open his practice at AlpineOrthopaedics in Bozeman, Mont.

Recently, I had the opportunity to travel toCuba to attend the annual Cuban orthopaedicconference, which serves as one of the major conferences for all of Latin America.Dr. John Feagin, professor emeritus of DukeUniversity and a member of the Steadman-Hawkins Scientific Advisory Committee, wasthe keynote speaker. He graciously invited meto join him in this adventure, one of his manyoverseas mission efforts.

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The convention consisted of several daysof lectures on various topics, fromorthopaedic trauma to sports medicine topediatrics. Following Dr. Feagin’s invitation, Iwas asked to give a talk at the conference.Since I have had the chance to enhance myknowledge and skills in arthroscopy in Vailwith Drs. Steadman, Hawkins and Sterett, Ichose to speak on the subject of microfrac-ture. With the help of Karen Briggs at theSteadman�Hawkins Sports MedicineFoundation, I was able to give a presentationthat included Dr. Steadman’s long-termresults with cartilage regeneration. In addi-tion, with the help of Karen Melhart of theaudiovisual department, I was able to showan excellent intra-operative video, explainingthe technique in detail. Since arthroscopy isstill very much a developing art in Cuba, thelecture and video clips were well received.

Several techniques exist to regeneratecartilage. Unfortunately, many of themrequire very specialized instruments and costupwards of $20,000 U.S. The advantage of themicrofracture technique developed by Dr.Steadman is that it can be performed withoutthe expense and resources needed for manyof the other techniques. Not only are theresults equal to if not better than those ofother published techniques, microfracturealso lends itself to being performed in under-developed countries.

In addition to teaching the Cuban sur-geons, we also learned much about the prac-tice of orthopaedics in Cuba and about thepeople and the country itself. We had achance to interact with Cuban surgeons onboth a professional and social level. Since theCuban revolution was led by intellectuals —including Che Guevera, who was a medicaldoctor — medicine has always been highlyregarded and well funded under Castro’sregime.

Despite its categorization as an underde-veloped nation, medicine in Cuba is unsur-passed by any other non-industrialized nation.Although the country has few resources, it hasno fewer than 11 medical schools and actual-ly exports doctors to other countries. Infantmortality rates, which are often used as ameasure of living standards, are on par withthose of the United States and better thanmany countries in Europe. In addition, lifeexpectancy is also on the same level as theUnited States.

In the year 2000, I had the opportunity totravel to rural South Africa as part of my resi-dency training program at the University ofCalifornia. There I worked with orthopaedicsurgeons from several underdevelopednations. By far, the Cuban surgeons weretechnically and intellectually superior to sur-geons from the other countries. Despite limit-ed resources, Cuba’s doctors perform to veryhigh standards.

Unfortunately, 80 percent of the world’sorthopaedic surgeons care for only 20 per-cent of the world’s population. Clearly, thisleaves most of the world underserved interms of orthopaedic care. Even in developednations, it often takes years for patients toreceive the orthopaedic surgeries that theyneed. Much of the care in the underdevel-oped world is necessarily focused on trauma,infections, and birth abnormalities. Thereare few resources left to even consider jointreplacement or sports-related injuries.

It is my hope, and the hope of manyorthopaedic surgeons, that this disparity canbe resolved. The largest effort is being madeby Orthopaedic Overseas, which is a branchof Health Volunteers Overseas, a nonprofitgovernment organization with headquarters inWashington, D.C. Throughout the world, sev-eral sites have been established with thecooperation of local governments in an effortto promote better health care. Opportunitiesexist for orthopaedic surgeons to spend aweek, a month, a year or more on a volunteerbasis to provide care to the other 80 percentof the world. It is a chance to care forpatients without paperwork or insurance con-cerns, and it allows us to get back to the truereason that most of us chose our careers.

With that in mind, it is a future goal toestablish our own Steadman-Hawkins over-seas site staffed with a rotating group of for-mer Fellows who are now in their own prac-tice. With more than 130 Fellows to date, itwould be possible to share our knowledgewith surgeons from all over the world andcare for patients who have real needs butnothing to offer but their gratitude. The reali-ty, as anyone who has been involved with vol-unteerism on any level will attest, is that youalways learn more than you teach and youalways get back more than you give.

Colorado Governor OwensProclaims June 27-30”Steadman�Hawkins SportsMedicine Foundation Days”

The work and achieve-ments of theSteadman�HawkinsSports MedicineFoundation were official-ly recognized at thehighest level of Coloradostate government thissummer as Governor BillOwens issued anHonorary Proclamation,declaring June 27-30 as“Steadman�HawkinsSports Medicine Foundation Days.”

The proclamation, issued on May 28,states that the Foundation “is recognizedthroughout the world as a center of excel-lence in orthopaedic sports medicine andresearch,” as well as “a valuable medicalresource for the State of Colorado.”

The June 27-30 dates coincided with theFoundation’s “Colorado Classic” festivities, afour-day athletic, cultural and culinary extrav-aganza throughout the Vail Valley, celebratingthe organization’s 15th anniversary.

The proclamation also recognizes theFoundation’s dedication to keeping people ofall ages physically active through orthopaedicresearch and education, in addition to pio-neering new surgical procedures and thedevelopment of more cost-effective and effi-cient surgical and rehabilitative techniques.The proclamation recognizes the dedicationand commitment of the Foundation over thepast 15 years, as well as the promise that thefuture holds.

Founded in 1988 by internationallyrenowned orthopaedic surgeon Dr. J. RichardSteadman, the Steadman�Hawkins SportsMedicine Foundation has undertaken signifi-cant research in the treatment and preventionof osteoarthritis, along with developing newrehabilitation protocols.

The Foundation’s Fellowship Program hastrained more than 130 highly skilled sur-geons, who now practice worldwide, whilealso hosting more than 2,000 visiting physi-cians and scientists from around the globe forcourses and seminars.

Governor Owens

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Arthritis Self-ManagementPrograms Produce ResultsBy Karen K. Briggs, B.S., M.B.A.

Editor’s note: Karen Briggs is director of ClinicalResearch at the Steadman�Hawkins SportsMedicine Foundation. She recently graduatedwith a master’s in Public Health from theUniversity of Northern Colorado. As part of hermaster’s program, she developed a communityhealth education program entitled ”Inform,educate and empower our community in thefight against arthritis.”

According to the Centers for Disease Controland Prevention, arthritis and related condi-tions affect one in six people. It estimatesthat by 2020, as current baby boomers age,60 million Americans will have developedarthritis. Not only is arthritis the leadingcause of disability in the United States, it alsois responsible for significant health-carecosts. The goal of many treatment programsis to reduce impairments and disabilitieswhile reducing health-care expenditures. In order to reduce the burden of arthritis,awareness of disability reduction or preven-tion programs for arthritis sufferers needs tobe heightened.

Self-Management ProgramsSelf-management programs are health

education programs designed to providearthritis sufferers with the knowledge, skillsand confidence to manage their disease. Self-management programs, taught in a group orindividual setting, focus on basic diseaseinformation, how to deal with the arthritisand its consequences, problem-solving, com-municating with providers, and adopting andmaintaining health-related behaviors such asexercise, relaxation and energy-saving tech-niques. Many of these programs are designedto complement services provided by health-care providers. Internet-based, interactiveself-management programs are also beingdeveloped.

Studies have shown that these programsproduce positive results. In a study of onesuch program delivered in the UnitedKingdom, participants demonstrated improve-ments in physical and psychological well-being and reduced pain and fatigue. Theseimprovements were maintained up to 12months following enrollment in the program.

The Arthritis Self-Management Program,developed by Kate Lorig, Ph.D., and adoptedby the Arthritis Foundation in 1981, has beenextensively studied. Research has shown thatprogram participants reduced their pain by12 percent to 19 percent in the course of onemonth to four years. It has also been shown

that participants have undergone fewer physi-cian visits and have experienced a decrease indepression. Several studies have also demon-strated the cost-effectiveness of this program.In a study of patients with osteoarthritis, visitsto physicians dropped by 39 percent, an esti-mated saving of $189 per participant. Inanother study of patients in an HMO, partici-pants in a self-management program savedmore than $1,150 in health-care expendituresover the period of one year.

Although these programs save money forthe patient and reduce the burdens of arthri-tis, it is estimated that fewer than 1 percent ofindividuals with arthritis have taken a course.This may be due to the perception that arthri-tis is unmanageable, lack of knowledge of theprograms and their benefits, and other barri-ers. These programs give patients a criticalrole in management of their arthritis and pro-vide physicians an additional tool in helpingtheir patients in their fight against arthritis.Self-management programs can complementtraditional treatments and reduce costs, butawareness and access to these programsneeds to be increased.

NFL Charities Awards Grantfor Shoulder Research:Study Will Use SophisticatedComputer Model

For the 11th successive year, NFL Charities, thecharitable foundation of the National FootballLeague, has awarded a substantial researchgrant to the Steadman�Hawkins SportsMedicine Foundation for new and continuingwork on the causes, treatments and preven-tion of sports-related injuries. The researchproject, “Force in the Upper ExtremityMuscles with Intact and Ruptured BicepsTendons: Part II” is a continuation of a 2002grant from NFL Charities to broaden ourknowledge of how to treat bicep tendoninjuries. The principal investigators are Drs. Richard J. Hawkins, Kevin B. Shelburneand Michael R. Torry of the Steadman�

Hawkins Sports Medicine Foundation and Dr.Marcus Pandy of the University of Texas.

The study will utilize a sophisticated

model of the upper extremity to quantify andexplain the roles of the individual muscles ofthe shoulder and elbow in standard motions.This complex computer model was developedby Dr. Marcus Pandy and Dr. Brian Garner atthe University of Texas at Austin.

The goal of this investigation is to quantifythe functional roles and interactions of thebiceps tendons (long head and short head)and the subscapularis muscle on glenohumer-al joint reaction forces during active armmotions. This study will help elucidate thespecific role and relative contributions of thesubscapularis to shoulder stability and func-tion in an intact shoulder, and a biceps rup-tured and tenodesed shoulder; allowing physi-cians to inform patients who sustain theseinjuries of the relative risks and benefits ofboth conservative and surgical treatment.

Upon full completion, this project will beone of the most comprehensive analyses of thefunctional role of the biceps brachii muscleand subsequent treatments, both surgical and conservative, as well as the functionalroles of the subscapularis rotator cuff musclein normal and abnormal glenohumeral jointfunction.

This joint research effort between theUniversity of Texas and the Steadman�

Hawkins Sports Medicine Foundation hasalready produced several quality abstracts thatwere recently presented by Takashi Yanagawa,M.A. (currently full time Staff Scientist of the Foundation and former student of Dr.Pandy’s). “The next year and a half will bevery exciting for our research group, as thisresearch is beginning to capture the attentionof noted shoulder specialists around theworld” states Dr. Torry. “This type of researchis no small endeavor and we are extremelyproud of Takashi and the strides he and hiscollaborators at the University of Texas havemade in developing and applying one of theworld’s most comprehensive shoulder modelsin orthopedics today”.

Future applications of the computer modelinclude simulating muscle and joint mechan-ics in the rotator cuff-deficient shoulder. Forexample, understanding the altered mechanicsof the deltoid following rotator cuff tear is crit-ical to the rehabilitation of persons who havelimited range of motion at the glenohumeraljoint. Experimental studies are also beingundertaken in parallel to carefully validate theresults obtained from the computer simula-tions. In vivo data from bone-pin motionexperiments performed on healthy subjectsare being compared with the predictions ofthe shoulder model to evaluate the accuracy ofthe model simulations.

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Publications, Presentationsand Research

Annual Meeting of the AmericanAcademy of Orthopaedic SurgeonsThe Foundation is once again on track to set arecord for the number of presentations andpublications accepted by medical and scientif-ic research, education and communicationsorganizations.

New Orleans was the location andFebruary 5-9 were the dates of the 70thAnnual Meeting of the American Academy ofOrthopaedic Surgeons (AAOS), an organiza-tion representing 17,000 members. As in pastyears, the Foundation was well represented bythe Clinical Research Department, which pre-pared eight poster exhibits and presentationsthat were made by Foundation principals forthis annual meeting.

Academy Highlights: Richard J. Hawkins, M.D., authored

the paper The Relative Risk of GlenohumeralArthritis in Patients With ShoulderInstability. Co-authors included Michelle L.Cameron, M.D.; Karen K., Briggs, M.B.A.,M.P.H.; and Marilee P. Horan. This studydemonstrated the increased risk of arthritis inpatients with shoulder instability, particularlyolder patients. This information is useful whencounseling patients regarding the risk ofarthritis following the onset of shoulder insta-bility (Source: Annual Meeting Proceedings,American Academy of Orthopaedic Surgeons).

J. Richard Steadman, M.D., was theauthor of two papers. The first was Lysis ofPretibial Patellar Tendon Adhesions(Anterior Interval Release) to Treat AnteriorKnee Pain after ACL Reconstruction. He wasjoined by co-authors Sumant G. Krishnan,M.D.; Peter J. Millett, M.D.; KimberlyHydeman; and Matthew Close. Pretibial patel-lar tendon adhesions after ACL reconstructioncan be a debilitating source of anterior kneepain and poor functional results. The abstractconcludes: “We have altered our postoperativeACL rehabilitation program to include aggres-sive emphasis on patellar and patellar tendonmobilization exercises. Operative intervention(anterior interval release) has been shown inthis series to result in significantly improvedfunction.

The second paper by Dr. Steadman wasPatient Satisfaction and FunctionalOutcome after Microfracture of theDegenerative Knee. Co-authors includedBruce S. Miller, M.D.; Karen K. Briggs, M.B.A.,M.P.H.; Jason W. Folk, M.D.; and Juan J.Rodrigo, M.D. The microfracture technique isan effective surgical option for the treatmentof degenerative chondral lesions of the knee(Source: Annual Meeting Proceedings,American Academy of Orthopaedic Surgeons).

Poster presentations included three by Dr. Hawkins. The first, Determinants ofPatient Satisfaction with Outcome afterRotator Cuff Surgery, was co-authored byJames D. O’Holleran, M.D.; Mininder S.Kocher, M.D.; Marilee P. Horan; and Karen K.Briggs, M.B.A., M.P.H. In assessing the out-come of rotator cuff surgery from the perspec-tive of patient satisfaction, the abstract con-cludes: “We would emphasize the importanceof patient-derived subjective assessment ofsymptoms and function” (Source: AnnualMeeting Proceedings, American Academy ofOrthopaedic Surgeons).

The second poster by Dr. Hawkins,Rupture of the Subscapularis Tendon AfterShoulder Arthroplasty: Diagnosis, Treatmentand Outcome, was co-authored by Bruce S.Miller, M.D.; Thomas A. Joseph, M.D.; ThomasJ. Noonan, M.D.; and Marilee P. Horan. Thecomplication of symptomatic subscapularisrupture following shoulder arthroplasty intro-duces the need for additional surgery and aperiod of protected or delayed rehabilitation.Although symptoms were adequatelyaddressed with appropriate surgical treatment,decreased functional outcomes were observedwhen compared to age-matched patients whounderwent uncomplicated shoulder arthro-plasty (Source: Annual Meeting Proceedings,American Academy of Orthopaedic Surgeons).

The third poster by Dr. Hawkins, ACritical Review of the Recurrence ofGlenohumeral Instability after OpenSurgical Procedures: One Surgeon’sExperience, was co-authored by Sumant G.Krishnan, M.D.; and Marilee P. Horan. Recentreports by other authors seem to concur thatthe results of open instability operations arenot as successful as once thought. The pub-lished results with the arthroscopic treatmentof instability approach, and may even better,these outcomes with longer-term follow-up(Source: Annual Meeting Proceedings,American Academy of Orthopaedic Surgeons).

William I. Sterett, M.D., authored theposter presentation Posterior Tibial SlopeFollowing Medial Opening Wedge ProximalTibial Osteotomy for Varus Arthrosis of theKnee. Co-authors included Thomas A. Joseph,M.D.; Bruce S. Miller, M.D.; and Valerie Rich.This study suggests that, in addition to correct-ing knee alignment in the coronal plane,medial opening wedge osteotomies of the tibiamay alter saggital alignment by increasing pos-terior tibial slope. Clinically, this may result ina loss of knee extension (Source: AnnualMeeting Proceedings, American Academy ofOrthopaedic Surgeons).

An interesting topic in orthopaedics hasbeen the application of heat to treat shoulderinstability. Dr. Hawkins was the author of theexhibit Electrothermal ArthroscopicShoulder Capsulorrhaphy (ETAC): AMinimum Two-Year Follow-Up. Co-authorsincluded Sumant G. Krishnan, M.D.; SperoKaras, M.D.; Marilee P. Horan; and Thomas J.Noonan, M.D.

Because of high failure rates, Dr. Hawkinsnow augments ETAC with capsular plicationand/or rotator interval closure in posteriorand MDI instability and lengthens initialimmobilization periods to improve outcomes(Source: Annual Meeting Proceedings,American Academy of Orthopaedic Surgeons).

American Orthopaedic Society forSports Medicine (AOSSM) meeting,February 6-7, New Orleans, Louisiana

At the AOSSM meeting, Dr. Hawkins co-authored the presentation A CriticalReview of the Recurrence of GlenohumeralInstability after Open Surgical Procedures:One Surgeon’s Experience. Other authorsincluded Sumant G. Krishnan, M.D.; andMarilee P. Horan (see poster presentationabove).

American Academy of OrthopaedicSurgeons Multimedia EducationCenter

The Academy accepted 26 teaching videopresentations. Two of these videos were produced by the Foundation, and the videoAnatomic Lateral LigamentousReconstruction of the Ankle UtilizingAutologous Hamstring Graph, by Michael J.Curtin, M.D.; Robert T. Burks, M.D.; andKaren Mehlhart was one of three 2003 distin-guished award winners. Congratulations tovideo services producer Karen Mehlhart!

Steadman-Hawkins Update

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The other video accepted was UlnarCollateral Ligament Reconstruction of theElbow: The Docking Procedure, by Michael J.Curtin, M.D.; Sumant J. Krishnan, M.D.;Richard J. Hawkins, M.D.; David W. Altchek,M.D.; and Karen Mehlhart.

2003 International Society ofArthroscopy, Knee Surgery andSports Medicine (ISAKOS) Meeting,Auckland, New Zealand, March 10-14.

ISAKOS is an international organization ofsurgeons established to develop, support andpromote charitable, scientific and literaryworks that further the knowledge ofarthroscopy, knee surgery and orthopaedicsports medicine. The meeting was the Society’sFourth Biennial Congress and was attended by1,200 orthopaedic surgeons.

Two papers were accepted for presenta-tion at the ISAKOS meeting. The first paperwas Patient Satisfaction and FunctionalOutcome after Microfracture of theDegenerative Knee, by Bruce S. Miller, M.D.; J. Richard Steadman, M.D.; Karen K. Briggs,M.B.A., M.P.H.; Jason W. Folk, M.D.; and JuanJ. Rodrigo, M.D.

The second paper was entitled TheRelative Risk of Glenohumeral Arthritis inPatients with Shoulder Instability and wasco-authored by Michelle L. Cameron, M.D.;Karen K. Briggs, M.B.A., M.P.H.; Marilee P.Horan; and Richard J. Hawkins, M.D.

The Arthroscopic Association of NorthAmerica (AANA) Annual Meeting,Phoenix, Arizona, Spring 2003.

AANA is an Accreditation Council forContinuing Medical Education that exists topromote, encourage, support and foster,through continuing medical education, thedevelopment and dissemination of knowledgein the discipline of arthroscopic surgery.

One paper and one poster were acceptedat AANA for presentation: Accuracy ofRotator Cuff Diagnoses on the Basis ofPhysical Exam With and Without MRI, byC.B. Smith-Teunis, M.D.; John W. Xerogeanes,M.D.; and Richard J. Hawkins, M.D.

Poster: Correlation Between the 2000IKDC Score, Lysholm Score, and PatientSatisfaction, by Karen K. Briggs, M.B.A.,M.P.H.; and J. Richard Steadman, M.D.

2003 Annual Meeting of theAmerican Orthopaedic Society forSports Medicine (AOSSM), San Diego,California, July 20-23.

The American Orthopaedic Society forSports Medicine, a national organization oforthopaedic surgeons specializing in sportsmedicine, includes both national and interna-tional leaders in sports medicine. The AOSSMworks closely with many other sports medi-cine specialists and clinicians, including familyphysicians, emergency physicians, pediatri-cians, athletic trainers and physical therapists,to improve the identification, prevention, treat-ment and rehabilitation of sports injuries.

The AOSSM Annual Meeting accepted the following abstracts for presentation:

Association Between GlenohumeralArthritis and the Grade of Translation inPatients with Longstanding AnteriorInstability of the Shoulder, by MichelleCameron, M.D.; Karen K. Briggs, M.B.A.,M.P.H.; Marilee P. Horan; and Richard J.Hawkins, M.D.

Reliability, Validity and Responsivenessof the Lysholm Score for Chondral Disordersof the Knee, by Mininder S. Kocher, M.D.;Karen K. Briggs, M.B.A., M.P.H.; and J. RichardSteadman, M.D.

Complications after HTO, by William I.Sterett, M.D.; Valerie Rich; and ElizabethBarry.

Poster: Accuracy of Rotator CuffDiagnoses on the Basis of Physical ExamWith and Without MRI, by C.B. Smith-Teunis,M.D.; John W. Xerogeanes, M.D.; and RichardJ. Hawkins, M.D.

Karen Briggs, M.B.A., M.P.H., directorof Clinical Research, also reports that in 2003the following papers have been accepted forpublication in peer-review journals:

Arthroscopy: “Outcomes of patients treat-ed arthroscopically by microfracture for trau-matic chondral defects of the knee: average11-year follow-up,” by J. Richard Steadman,M.D.; Karen K. Briggs, M.B.A., M.P.H.; Juan J.Rodrigo, M.D.; Mininder S. Kocher, M.D.; TomJ. Gill, M.D.; and William G. Rodkey, D.V.M.

American Journal of Sports Medicine:“The Prevalence of GlenohumeralOsteoarthrosis with Shoulder Instability,” byMichelle L.Cameron, M.D.; Mininder S.Kocher, M.D.; Karen K. Briggs, M.B.A., M.P.H.;Marilee P. Horan; and Richard J. Hawkins, M.D.

American Journal of Sports Medicine:“Reproducibility and Reliability of theOuterbridge Classification for GradingChondral Lesions of the Knee,” by Michelle L.Cameron, M.D.; Karen K. Briggs, M.B.A.,M.P.H.; and J. Richard Steadman, M.D.

Orthopedics: “Decreased Range of MotionFollowing Acute vs. Chronic Anterior CruciateLigament Reconstruction,” by William I.Sterett, M.D.; K.S. Hutton, M.D.; Karen K.Briggs, M.B.A., M.P.H.; and J. RichardSteadman, M.D.

American Journal of Knee Surgery: “TheMicrofracture Technique in the Treatment ofFull-Thickness Chondral Lesions of the Kneein National Football League Players,” by J. Richard Steadman, M.D.; Spero Karas, M.D.;Bruce S. Miller, M.D.; Ted Schlegel, M.D.;Karen K. Briggs, M.B.A., M.P.H.; and Richard J.Hawkins, M.D.

American Journal of Knee Surgery:“Effect of Functional Bracing on SubsequentKnee Injury in Professional Skiers: AProspective Cohort Study,” by Mininder S.Kocher, M.D.; William I. Sterett, M.D.; KarenK. Briggs, M.B.A., M.P.H.; David Zurakowski,Ph.D.; and J. Richard Steadman, M.D.

Michael Torry, Ph.D., director of theBiomechanics Research Laboratory, reportsthat the following papers and abstracts are inreview or have been accepted for publicationand presentation in peer-review publicationsand organizations:

PublicationsClinical Biomechanics: “Gait Re-Training

ACL Reconstructed Individuals,” by Michael J.Decker, M.S.; Michael Torry, Ph.D.; Tom J.Noonan, M.D.; and J. Richard Steadman, M.D.

Journal of Shoulder and Elbow Surgery:“Clinical Evaluation of Upper and LowerSubscapularis Muscle Activity During the Lift-Off and Belly Press Tests,” by J. T. Tokish,M.D.; Michael J. Decker, M.S.; Michael R.Torry, Ph.D.; Henry E. Ellis; and Richard J.Hawkins, M.D.

American Journal of Sports Medicine:“EMG Evaluation of Select RehabilitationExercises for the Subscapularis Muscles,” byMichael J. Decker, M.S.; Michael R. Torry,Ph.D.; J. T. Tokish, M.D.; Henry E. Ellis; andRichard J. Hawkins, M.D.

Research Quarterly for Exercise andSport: “Predicting the Minimum Rate ofLoading During Walking,” by Michael J.Decker, M.S.; Michael R. Torry, Ph.D.; Thomas

7

J. Noonan, M.D.; William I. Sterett, M.D.; andJ. Richard Steadman, M.D.

Arthritis Care and Research : “GenderDifferences in Loading Rates During Walking”by Michael J. Decker, M.S.; Michael R. Torry,Ph.D.; Thomas J. Noonan, Ph.D.; William I.Sterett, M.D.; and J. Richard Steadman, M.D.

Abstracts/PresentationsAmerican College of Sports Medicine,

Rocky Mountain Chapter, Denver, Colo., Feb. 20-23, 2003: “Surgical Treatment,Rehabilitation and Functional Gait Analysis ofHigh Tibial Osteotomy,” by William I. Sterett,M.D.; Michael R. Torry, Ph.D.; Kevin B.Shelburne, Ph.D.; and Takashi Yanagawa, M.S.

Injuries in Winter Sports Symposia,National Science Foundation, Denver, Colo.,Feb. 20-23, 2003: “Biomechanics of Skiingand Skiing Injuries,” by Don Corenman, M.D.;Michael R. Torry, Ph.D.; Kevin B. Shelburne,Ph.D.; and Takashi Yanagawa, M.S.

The American Society of MechanicalEngineers, Summer BioengineeringConference, Key Biscayne, Fla., June 25-29,2003: “Effects of Tendon Rupture on MaximalIsometric Elbow Flexion and ForearmSupination Torque,” by Takashi Yanagawa,M.S.; Marcus G. Pandy, Ph.D.; Kevin B.Shelburne, Ph.D.; Richard J. Hawkins, M.D.;and Michael R. Torry, Ph.D.

The American Society of MechanicalEngineers, Summer BioengineeringConference, Key Biscayne, Fla., June 25-29,2003: “Estimation of Muscle and JointReaction Force During Arm Abduction: AMusculoskeletal Model Approach,” by TakashiYanagawa, M.S.; Marcus G. Pandy, Ph.D.; KevinB. Shelburne, Ph.D.; Richard J. Hawkins,M.D.; and Michael R. Torry, Ph.D.

The American Society of MechanicalEngineers, Summer BioengineeringConference, Key Biscayne, Fla., June 25-29,2003: “Theoretical Analysis of the Flexed KneePattern in ACL-Deficient Gait,” by Kevin B.Shelburne, Ph.D.; Michael R. Torry, Ph.D.;Takashi Yanagawa, M.S.; and Marcus G. Pandy, Ph.D.

NFL Physicians Society, Indianapolis,Ind., Feb. 20-23, 2003: “Biomechanics of theUpper Extremity,” by Richard J. Hawkins,M.D.; Michael R. Torry, Ph.D.; TakashiYanagawa, M.S.; and Kevin B. Shelburne, Ph.D.

AwardsA paper authored by the members of theSteadman-Hawkins staff placed second in the

Richard B. Caspari Award competition for bestupper-extremity paper at the 2003International Society of Arthroscopy, KneeSurgery and Sports Medicine Meeting inAuckland, New Zealand, March 10-14. Entitled“The Relative Risk of Glenohumeral Arthritisin Patients with Shoulder Instability,” thepaper was authored by Michelle Cameron,M.D.; Karen K. Briggs, M.B.A., M.P.H.; MarileeP. Horan; and Richard J. Hawkins, M.D.

Karen Briggs, M.B.A., M.P.H., has beennominated for the 2003 Retirement ResearchFoundation Student Research Award for herabstract entitled “Physical Activity Goals inPatients Seeking Treatment for Osteoarthritisof the Knee.” Congratulations are also dueKaren, who received her master’s degree inPublic Health from the University of NorthernColorado in May. She has also been named tothe Colorado Department of Public Health’sArthritis Advisory Council.

The American Academy ofOrthopaedic Surgeons MultimediaEducation Center selected the teachingvideo, Anatomic Lateral LigamentousReconstruction of the Ankle UtilizingAutologous Hamstring Graph, as one of threeaward winners. The award was made at the70th Annual Meeting of the American Academyof Orthopaedic Surgeons, Feb. 5-9 in NewOrleans. Authors include Michael J. Curtin,M.D.; Robert T. Burks, M.D.; and KarenMehlhart.

MediaNational and international media continue tofocus on the work of the Steadman�HawkinsSports Medicine Foundation and its physi-cians, especially since many of the world’ssoccer stars have been making theirway to Vail, Colo., for treatment.Journalist David Powell of TheTimes of London flew to Vail lastDecember to do a story on Dr. J.Richard Steadman and theFoundation. Of Dr. Steadman,Powell wrote in the Dec. 16 edition of The Times,“Ronaldo, Alessandro DelPiero, Oliver Kahn and LotharMatthäus are among those whogive Dr. Steadman a football celebri-ty patient list second to none.

“Footballers — Craig Bellamy is thelatest premier player to be seen here —have grown Dr. Steadman’s reputation in

Europe, although his work in other sportsgoes back 30 years.

“Dr. Steadman has a modesty to match hisskills,” says Powell.

The Basel Zeitung interviewed Dr.Steadman in its Jan. 28 edition during his visitto the Third International Knee Congress inBasel, Switzerland. Dr. Steadman was alsopresent to celebrate famed Swiss orthopaedicsurgeon Dr. Werner Müller’s 70th birthday. The interview begins, “When the ligament of aprofessional player from the German champi-on FC Bayern München soccer club is injured,the player travels to Vail, Colorado. There, heis taken in by Dr. Richard Steadman.” Dr.Steadman was asked if he had become an“honorary member” of FC Bayern. “I have agood connection with the club,” he said. “Therelationship is built on mutual trust.”

The leading German soccer publicationKicker interviewed Dr. Steadman for a featureentitled “Dr. Knie” which appeared in the Feb. 3 edition. The article was timely becauseDr. Steadman has treated 20 former or cur-rent soccer stars from Germany’s famedBundesliga. In the interview, Dr. Steadman wasasked why he specialized in the knee. Hisreply: “The knee operation was and is todaythe most common operation in orthopaedics.That is appealing.”

The trade publication OrthopaedicReview featured the Clinic and Foundation inan article entitled “A Perfect Location” in theJanuary/February issue.

Chris Evert Tennis Clinic

Chris Evert, one of the top female players intennis history, brought the skills and tech-nique that carried her to 18 career GrandSlam titles to the Vail Valley on June 29,where she and her sister Clare conducted afree tennis clinic for the community. Theevent took place at the Sonnenalp Golf Club atSingletree in conjunction with the Steadman-Hawkins Colorado Classic 15th anniversarycelebration.

“For me, she pretty much brought backthe fundamentals of the game,” said RogerDadlani, who played, years ago, in high

school. “Chris and her sister are some of thenicest people I’ve ever met. They were verypatient and helpful.”

Ranked No. 1 in the world for sevenyears, Evert’s 18 Grand Slam titles includeseven French Open championships, six U.S.Open wins, three Wimbledon crowns and twoAustralian Open victories. She captured atleast one Grand Slam singles title for 13 con-secutive years, setting a record for both men’sand women’s professional tennis.

“Doctors Steadman and Hawkins arefamous for their research,” said Evert.“They’re two of the greatest surgeons in theworld — more advanced in their field thananybody else.” Evert’s husband, Andy Mill, aformer member of the U.S. Ski Team, hasundergone nine knee surgeries. “They’vehelped so many athletes to live normal livesagain,” said Evert. “My husband and I reallybelieve in their work” (Source, AndrewHarley, Vail Daily).

Chris Evert teaches fundamentals during Colorado Classic celebration. Photo Courtesy of Ken Lawdermilk, Vail Daily.

8

and appropriate pre- and post-riding stretches.

Off the bike, strength and conditioningtraining are critical to a cycling program.Among the benefits are prevention of overuseinjuries, a more powerful pedal stroke, andincreased strength to push up those longmountain passes. A good gym programthroughout the winter and spring monthsshould include a weight program for legstrengthening and aerobic spinning. Legstrengthening should include a balancebetween anterior and posterior leg muscula-ture exercise and combine strength trainingwith endurance training. If unfamiliar with theuse of weights, consult a personal trainer fortheir proper use.

A balanced weight program shouldinclude gluteal, hamstring, quadriceps andgastrocnemius (calf) muscle groups. Prior toeach leg-strengthening workout (and prior toriding), begin with appropriate stretches foreach of the above-mentioned muscle groups.The simplest and safest leg-strengtheningexercises can be performed on machines,though we will provide suggestions for free-weight exercises as well.

StretchingStretching prior to and after riding is as

critical to maintaining an injury-free season asany other factor. Lower-extremity muscletightness and chronic overuse injuries can bereduced through a proper stretching program.Common problems for cyclists include iliotib-ial band syndrome, chondromalacia patella,quadriceps tendonitis, and patellar tendonitis,among others. Tendonitis is an inflamma-tion of the connective tissue between muscleand bone. It is often the result of repetitivestress or trauma occurring over time withoutrelief. Chondromalacia is irritation of articu-lar cartilage, often due to wear over time.

Several common stretches can be used toreduce the incidence of these problems. Theiliotibial band consists mainly of a band ofconnective tissue between the hip and knee onthe lateral side of the leg. It is a common siteof irritation among cyclists and can result inlateral knee pain, also known as iliotibialband friction syndrome. Tightness usuallypresents itself as the inability to adduct the hipin an extended position.

To stretch this tissue, stand with the affected side facing away from the wall, crossthe inside leg over the outside leg, and gentlypush the affected hip away from the wall. Mostcommonly, a stretch will be felt near the hipon the lateral surface. Another method is to lieon your back with the affected leg extended,bring the leg in and rotate the leg inward, thenroll the foot inward. You can use a towel tohold the foot if unable to reach the foot forthis stretch. As with any stretch, hold the posi-tion for 20-30 seconds.

Strengthening ExercisesWith all exercises, setting the lower

abdominal muscles/transverse abdominismuscles and maintaining proper lifting pos-ture are important to prevent back injury. Toset the transverse abdominis, pull the bellybutton towards your spine while breathingevenly.

Gluteal muscles: • Hip extension – Standing with resistance

against the back of the thigh, extend the legbackward against the resistance.

• Hip abduction – While standing, raise theleg out to the side away from the midline ofthe body.

Quadriceps: • Leg press – While seated, place feet approx-

imately shoulder-width apart. Do not bendknees past 90 degrees.

• Squats – Keep feet shoulder-width apart,with toes turned slightly out. Do not bendthe knees past 90 degrees.

• Lunges – Step with a medium stride forwardon the front leg. The front knee shouldremain behind the toe. Return to a standingposition.

• Reverse lunges – Step back with a mediumstride. Use the forward leg to perform acontrolled lowering motion.

Hamstrings:• Curls – Slowly flex both knees by pulling the

heels toward the buttocks. (These can beperformed while either prone or seated.)

Gastrocnemius and Soleus: • Standing calf raises – While standing on a

step, rise up on your toes with or withoutweight resistance.

(Cycling Injuries cont. from pg. 1)(Update cont. from pg. 7)

Iliotibial Stretch

Leg Press

Lunges

Calf Raises9

The Benefits of RegularExercise: A Healthy HeartBy Laurence W. Gaul, M.D., F.A.C.C.

Editor’s note: Dr. Gaul, an employee of theDenver Cardiology Group, began his career in medicine as a paramedic at the Vail ValleyMedical Center. He has been a practicing cardi-ologist for 10 years and is the cardiovascularconsultant to the U.S. Ski Team and team physician for the U.S. Nordic Ski Team.

This newsletter has included many articles on how individuals can improve functionalcapacity and maximize their enjoyment of lifethrough an active lifestyle, especially from anorthopaedic standpoint. For years, my friends and I have often joked that we stayactive to make sure that the only physician we ever need is an orthopaedist and not me, a cardiologist.

At this juncture, I think it’s worth sometime discussing the benefits of this sort oflifestyle and, specifically, how dedicated exer-cise programs might benefit us. For manyyears, the American Heart Association hasencouraged people to exercise routinely, andyet — as pointed out in the Jan. 4, 2003,Journal of the American Medical Association— obesity and diabetes have become a majorproblem throughout the United States. Ourculture is not one that fosters activity. A visit-ing German medical student once told me ofa trip he had taken that day with his room-mate, who asked him to join him while hewent to the bank and the market. The bankwas about 400 meters away and the marketabout one mile. He was astonished to see thatthis healthy, fit young man planned to drivehis car for only a one-mile trip. Here in theWest, distances are farther, but nonethelessmost people are inclined to ride elevators,take escalators and drive their cars. Many willspend large amounts of money on home exer-cise equipment and health club memberships.Often the health club membership goesunused and the exercise equipment becomesa clothes hanger.

Fortunately, for those of us who live inVail the situation is somewhat different.Several years ago, a visiting doctor asked meif there were any obese people in Vail. I toldhim there were very few, which led to a dis-cussion of exercise. He had recently com-pleted an evaluation of 10,000 patients at theMayo Clinic on a standard exercise test. Theaverage time clinic patients spent on a tread-

mill was 7 minutes 38 seconds. He was aston-ished to learn that here, at an elevation of8,150 feet, the average time patients spend ona treadmill is approximately 12.5 minutes.Even our patients who consider themselves“couch potatoes” by and large are far moreactive than people elsewhere. That said, overthe age of 40, cardiovascular disease remainsthe number one cause of death. Yes, even in Vail.

Much has been written about the role ofexercise in preventing cardiovascular disease.I am not convinced that it prevents cardiovas-cular disease; however, I am 100 percentconvinced that it minimizes the chance ofmyocardial infarction and sudden death.Evidence for this is ample, as the followingstory will attest.

A friend of mine was an avid cyclist, cov-ering between 250 and 400 miles per week,even in winter. He had high but untreatedcholesterol. One morning he was awakenedat 4 o’clock by crushing substernal chestpain. It went away after an hour, and he won-dered if it could have been his heart. He triedto ride over Independence Pass to Aspen.The pain returned, so he went home. Thispattern repeated over several days, and even-tually he sought medical attention. A heartcatheterization revealed a blockage in thearteries that we call the “widow maker.” Hehad 100 percent blockage in the artery thatsupplies the front side of his heart. Throughcycling, he had built up massive collateralblood vessels around his blockage, effectivelybypassing it. When the artery completelyclosed off, he lived. Other studies have shownthat exercise increases an enzyme that has anantioxidant potency 10,000 times that of vita-min E. This may be part of the mechanism bywhich exercise helps.

If exercise is so good, what should we do?A friend — a former Olympic Nordic skier —started walking 45 minutes a day at the age of15, a minimum of four days a week, becausehe realized that all the people he knew wholived a long, healthy life did the same. Hecontinued this even while training for theSquaw Valley Olympics. Now 50 years havepassed and he has missed only three weeks.

Walking — as well as running, hiking,swimming, bicycling, rowing or whatever yourjoints will tolerate — is the cornerstone ofcardiovascular exercise. Many studies havebeen done, and controversy exists, as to howmuch exercise you need, and at what intensi-ty. Recent studies have shown that intensity of

Health MattersA general guideline for strength training is

to lift a weight with which you can maintainproper form for three sets of 8-10 repetitions.As the season approaches, and the goal is topromote endurance as well as strength, youshould progress to three sets of 15-30 repeti-tions. Strength training should be performed2-3 times per week, though this may diminishas cycling time increases in the summer.

Pho

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10

Foundation Hosts GermanSurgeons Ormed Sponsors Two-DaySymposium on SurgicalTechniques, Education andResearch.

Twenty-five physicians from Germany visitedthe Steadman�Hawkins Sports MedicineFoundation in February to observe surgicaltechniques and learn more about Foundationresearch. Corporate partner Ormed, GmbH &Co. KG of Germany, a distributor oforthopaedic and sports medicine products,sponsored the educational session for leadingGerman sports medicine physicians.

These herbal therapies werethe forerunners of “modern”anti-inflammatory medicines.In 1899, in an attempt to helphis father’s rheumatism, achemist at the Bayer Companysynthesized salicylic acid, oraspirin, the active compoundin willow bark. Aspirin thusbecame the first and onlypharmaceutical agent for painand inflammation into the middle of the 20thcentury.

Despite its effectiveness, aspirin has a sig-nificant gastrointestinal toxicity, which limitsits utility in many people and has necessitatedthe search for a safer alternative. That searchculminated in the discovery of cortisone,which has dramatic anti-inflammatory effectsin rheumatoid arthritis. For this important dis-covery, Dr. P. Hench won the Nobel Prize inmedicine in 1950, marking the first and onlytime this prestigious honor was awarded inthe field of arthritis and rheumatic diseases.However, enthusiasm waned for this treatmentbecause of the untenable side effects (dia-betes, infection, osteoporosis) experiencedwith long-term use. The need existed for notonly a safer aspirin, but a safer cortisone.

The story progresses to 1963, when phar-maceutical drug research into inflammation inanimal models gave rise to a new class oftherapeutic agents, nonsteroidal anti-inflam-matory drugs (NSAIDs). Phenylbutazone andindomethacin were the first two drugs intro-duced. Further research in the 1970s led tothe discovery that NSAIDs inhibited cyclooxy-genase, a key enzyme that promoted the devel-opment of substances (prostaglandins) whichhastened inflammation. However, prosta-glandins also were responsible for protectingthe lining of the stomach and normal functionof platelets, a blood-clotting cell. NSAIDs pro-liferated in the 1970s and 1980s.Unfortunately, so did the incidence of fatalbleeding and perforated ulcers.

More recently, two forms of cyclooygenaesehave been discovered: COX-1 enzyme, which isresponsible for maintaining the normal liningof the stomach, and COX-2, which is involvedmainly in promoting the inflammatoryprocess. The therapeutic implication was thatif you could selectively inhibit COX-2 youcould impair inflammation without damagingthe integrity of the stomach. Two COX-2 specif-ic inhibitors, celecoxib (Celebrex) and rofe-coxib (Vioxx) were studied and available by

1999. Two long-term ulcer tri-als indicated that the incidenceof bleeding or perforatedulcers for rofecoxib and cele-coxib (while not takingaspirin) was reduced by 50percent when compared to theuse of traditional NSAIDsNaprosyn and ibuprofen.

Within the past year athird COX-2 inhibitor —

valdecoxib (Bextra) — has become availableand there are others currently under investiga-tion. Have we truly found a safer NSAID? Itwould appear so, at least from the point ofview of treating ulcers. However, when thesedrugs are used, patients must be monitoredfor other possible side effects, including fluidretention and elevation of blood pressure. For patients at risk for stroke or heart attack,low-dose aspirin is still prescribed.

The American College of Rheumatologyand the American Pain Society currently rec-ommend the use of COX-2 specific inhibitorsin all patients who have tried and failed acourse of acetaminophen (Tylenol) forosteoarthritis. Though NSAIDs are the main-stay for treating arthritis, adjunctive nonphar-macologic interventions, such as exercise,physical therapy, glucosamine and injectablecortisone or hyaluronate (Synvisc/Hyalgen)are often helpful. Our search for safer thera-peutics has been the paramount focus whenusing medicines intended to enhance the qual-ity of life. In treating chronic inflammatorydiseases, we intend to adhere to the adage“Doctor, do no harm.”

TWO LONG-TERM ULCER

TRIALS INDICATED THAT THE

INCIDENCE OF BLEEDING OR

PERFORATED ULCERS FOR

ROFECOXIB AND CELECOXIB

(WHILE NOT TAKING ASPIRIN)

WAS REDUCED BY 50 PERCENT

WHEN COMPARED TO THE USE

OF TRADITIONAL NSAIDS

NAPROSYN AND IBUPROFEN.

(The Benefits of Regular Exercisecont. from pg. 9)

exercise is inversely related to development ofsymptomatic coronary artery disease. In otherwords, the harder you work, the less likelyyou are to die of a heart attack. Additionally,recent evidence has shown that strength train-ing, especially with relatively light weights andhigher repetitions, is beneficial not only forthe joints but also for the cardiovascular sys-tem. The exercise benefits for hypertension,while few, are also consistent and well docu-mented. Additionally, there may be a favorableimpact on a person’s lipid profile (this maybe genetically determined, since not everyoneresponds).

Although I have never been able to con-firm it, it is rumored that Dr. Paul DudleyWhite, one of the giants of modern cardiolo-gy, never used an elevator and was seen fre-quently running up and down the stairs atMassachusetts General Hospital. His reason-ing: All activity is good, and even smallamounts done consistently over a lifetimehelp. I follow much the same philosophy,although many of my patients think I’m a bitoff the deep end about it. In between my cra-zier endeavors, I walk the stairs, walk to thebank, hike in the hills, etc.

For those who say they do not haveenough time, find it. With a little planning,almost everyone can find the equivalent of 45minutes a day, four days a week, to go for awalk. Simple activities do not require going toa gym, changing clothes, showering, etc. Theimportant thing is to find something you like — then, as the Nike shoe commercialsays, “Just do it.” If you only have 20 minutesavailable, use them. Short periods of exercise,added up over time, can pay big dividends.

The Search for a Safer AspirinBy Kenneth Paul Glassman, M.D.

Editor’s note: Dr. Glassman is an associate clini-cal professor in the Department of Medicine atthe University of Colorado Health SciencesCenter and an assistant director of the ClinicalResearch Unit. He is in private practice at theDenver Arthritis Clinic in Denver.

From time immemorial, the treatment of painand inflammation has long been a paramountfocus of medical providers. Ancient civiliza-tions used multiple plant species, especiallywillow bark, to accomplish this objective.

11

Genzyme Biosurgery/WyethNew Corporate Sponsors ofthe Steadman�Hawkins SportsMedicine Foundation

Genzyme Biosurgery, a division of GenzymeCorp., one of the leading businesses in therapidly emerging field of sophisticatedbiotechnology products, and Wyeth, one ofthe world’s largest research-driven pharma-ceutical and health-care-products firms, havejoined forces as corporate sponsors of theSteadman�Hawkins Sports MedicineFoundation. Wyeth is considered a leader inthe discovery, development, manufacturingand marketing of pharmaceuticals, vaccines,biotechnology products and nonprescriptionmedicines.

“We’re excited about the relationshipbetween Wyeth and the Foundation,” saidJohn Johlfs, Wyeth Musculoskeletal SpecialtyDistrict Manager, “and our mutual involve-ment in such activities as the annual FellowsConference, a Public Education SpeakerSeries, and the shared goal of providing beneficial health care through research and education.

“For me, there are a lot of similaritiesbetween golf and skiing,” says the former skiOlympian and eight-handicap golfer. “I read aputt the same way I read a line in a downhillcourse. There’s the pitch, the break, thegrain, all those things I used to do at 60 milesan hour and now do in putting — but thingsare a lot safer on the green.”

It’s a unique way of looking at things. But then, Cindy Nelson is unique. She was thefirst American — woman or man — to win a World Cup downhill, she is a seven-timenational champion, she was a member of fourWinter Olympic teams and four WorldChampionships teams (and medalled threetimes in those events), she is the first skier towin a World Cup Super G, and she is the firstwoman to serve as Chief of Course for amajor alpine ski competition (1989 WorldAlpine Championships). But one of her mostmemorable firsts, she’ll tell you, was beingthe first elite athlete to come under the careof Dr. Richard Steadman. That was in 1973, atDr. Steadman’s clinic at Lake Tahoe, Calif.,and the two have been close friends, andmutual admirers, ever since. Eleven surgerieslater (nine knees, two ankles), Cindy is now a

“Being involved in the continuing effortsto investigate the causes, prevention and med-ical intervention of osteoarthritis is a worthyand lofty goal, and we’re very proud to be apart of it.”

Genzyme Biosurgery produces two prod-ucts for the treatment of damaged knee joints:Synvisc®(hylan G-F 20) and Carticel®(autologous cultured chondrocytes). Bothproducts have made a significant contributionto clinical orthopaedics.

Synvisc is a biomaterial used in the treat-ment of pain caused by osteoarthritis of theknee. Carticel employs a patient’s own carti-lage cells to treat knee cartilage defects.

“As a recognized leader in the biologicalmanagement of cartilage injuries, GenzymeBiosurgery is proud to support theSteadman�Hawkins Sports MedicineFoundation in their efforts to further advancethe science of orthopaedics in the world,”said Ron Wiesner, Western Regional SalesDirector, Genzyme Biosurgery.

“Part of the Foundation’s mission,” saysWilliam G. Rodkey, D.V.M., director of BasicScience Research,” is to share the knowledgewe generate from our research. That includesdemonstrating recently developed proceduresto visiting specialists. Our visitors, each ofwhom is a prominent orthopaedic surgeon,viewed knee procedures being performed byDrs. Steadman and Hawkins via a live televi-sion feed from the operating rooms to theconference room’s big screen. Later, they metto discuss the cases with Dr. Steadman. Thiskind of interface will undoubtedly improveinternational communication of these break-through procedures.” Among those viewedwere Dr. Steadman’s microfracture procedureand an ACL repair by Dr. Hawkins.

Other topics presented in an academicsession included functional knee bracing andhigh tibial osteotomy by Dr. Jason Folk, thecollagen meniscus implant by Dr. Rodkey, andcomputer modeling by Dr. Michael Torry.

Frank Bömers, director of marketing andinternational sales for Ormed, believes thevisit helped answer technical questions aboutthese new techniques. Said Bömers, “There isno substitute for watching procedures liveand then being able to discuss and ask ques-tions of the man who pioneered the tech-niques.”

“Our plan,” he added, “is to bring sur-geons annually to visit Steadman-Hawkins sothat their cutting-edge procedures willbecome better known throughout Germany.We hope the visiting surgeons, many of whomare sports team doctors, will share theirexperience with colleagues at home.”

Founded in1992, Ormed hasthree subsidiariesand 65 distributioncenters throughoutGermany. The compa-ny specializes inmanufacturing anddistributing passive-motion devices andother therapeutic sys-tems, braces andsplints, and medicalbreakthrough surgi-cal technology in car-tilage repair. Therental service team

organizes outpatient treatment, includinginstructions on care and treatment of thera-peutic modalities following surgery. Ormed’sphilosophy encompasses the development ofinnovative products, a carefully trained staffand sales force, and a well-established rentalservice throughout Germany. The company isa market leader in Germany for continuouspassive-motion devices.

(Cindy Nelson cont. from pg. 1)

Ormed sponsored symposium for German physicians.

Articular cartilage lines the end of bones atjoints, serving to transmit loads and providenear-frictionless movement of joints. Cartilagedoes not have a blood supply and has anextremely limited ability to heal. While carti-lage injury does not occur as commonly astendon or ligament injuries, the defects canlead to arthritis. While many procedures havebeen developed to treat cartilage damage,none returns a joint to its original state. Sincesuch injuries are common and often lead to

12

John Welaj Chief OperatingOfficer

John Welaj, who haslived in the VailValley for 14 years,was appointed COOof the Steadman�

Hawkins SportsMedicineFoundation early in2002. Prior to that,John served as CFOfor the Steadman-Hawkins Clinic, which experienced significantgrowth and expansion during his tenure.From 1997 to 2002 the Steadman-HawkinsClinic added three full-time physicians,opened a satellite office in Breckenridge, andpartnered with three clinics in Denver. Duringthat period John had responsibility for man-aging the financial infrastructure, which need-ed to accommodate a 20 percent annualgrowth in revenues. John also spent sixmonths as administrator of the Steadman-Hawkins Denver Clinic.

Meet our Staff

John’s most rewarding accomplishment,however, has been his impact on the Vailcommunity. He has been instrumental indeveloping sports medicine outreach pro-grams for local high schools, the VailRecreational District, and many other localorganizations.

John has always had a strong interest andtalent in sports, inherited from his father, LouWelaj. Lou played professional baseball in theBrooklyn Dodgers organization, where he wasa teammate of legends Jackie Robinson, DukeSnider and Pee Wee Reese. Lou is alsoenshrined in the Seton Hall University AthleticHall of Fame, where he played baseball andbasketball.

Raised in Denver, John attended andplayed basketball at Mullen High School,where he was recruited by Hall of Fame bas-ketball coach Pete Carril to attend PrincetonUniversity. At Princeton, he wrote his seniorthesis on the harmful effects of performancedrugs in sports. John graduated in 1988 andhas maintained a lifelong interest in a careerrelated to sports and medicine. After movingto Vail and working at Vail Valley MedicalCenter, he earned an MBA from DenverUniversity in 1993.

Long impressed with the Steadman-Hawkins culture, philosophy and familyatmosphere, John joined the Clinic in 1995and has managed most of its financial opera-tions. “I’m very thankful to Steadman-Hawkins’ physicians for keeping me active. Ican say I’ve personally experienced the heal-ing effects of microfracture and several otherknee procedures.” John continues to stay veryactive year-round in skiing, beach volleyball,mountain biking, and fly-fishing.

I made an agreement with a couple of thegirls who play in the same league that weadopt a ‘powder day’ rule to get out on skismore often. This past season I skied 78 days,so things are improving. I’m determined notto let either sport get out of balance.”

Keeping things in balance, of course,means being able to summon up thoseimages of golf as skiing and skiing as golf thatCindy easily sees but others often don’t. “It’smore than being out in the elements,” shesays. “In skiing, if you don’t think you canmake a pre-jump, you take a different line. Ingolf, if you can’t make it to the green in oneshot, you use different clubs. In both, youplay for your strengths and protect againstyour weaknesses. Your strategy for how yougo down the mountain should be the same ashow you play the game of golf. You take intoconsideration sun, temperature, wind, yourmoods and all the distractions you havearound you. In skiing, it’s tough to control thedistractions — in golf, there’s an etiquettethat takes care of that — but otherwise thesports are a lot alike.”

(Cindy Nelson cont. from pg. 11)

(Tendon, Ligament and CartilageRepair cont. from pg. 1)

member of the board of the Steadman�

Hawkins Sports Medicine Foundation. “That,” says Cindy, “means a lot to me,

because I’ve come to understand what it takesto get people back on their feet. The workthat I’ve been privy to at the Foundation —the treatment as well as the prevention ofinjuries — has been enormously rewarding.And for me, as a board member, to be able tobring to the Foundation some of my experi-ence as an athlete, as well as my knowledgeof Dr. Steadman’s genius, has been equallyrewarding.

“Dr. Steadman has pioneered so manyprocedures and affected so many lives so pos-itively. Creating the Foundation was a hugestep and an important part of his dream. TheFoundation has become an educational toolby which Dr. Steadman’s genius can bepassed on to orthopaedists all over theworld.”

A lot of what the Foundation has passedon to others has also been responsible forkeeping Cindy Nelson in the game. Fourteenyears with the U.S. Ski Team (she was namedto the team at the age of 15), hers has been aremarkable career, which really took off afterher defeat of Austrian downhill powerhouseAnnemarie Moser-Proell in 1974. NoAmerican had ever won a World Cup down-hill, and it proved to Cindy that she couldcompete with, and win against, the world’sbest.

Cindy retired from racing in 1985 tobecome Ambassador of Skiing at Vail, Colo.Soon after, she was promoted to Director ofSkiing for Vail and Beaver Creek. She enjoyedthe do-everything nature of the position,working with the resorts’ marketing, realestate, ski school and mountain operationsdepartments. It also provided her with anopportunity to take up something new in herlife—the game of golf, an endeavor she calls“the most humbling, most frustrating, mostrewarding game I’ve ever played.”

Today, Cindy has her own consulting busi-ness. She’ll also tell you that just as importantas her downhill win was to her in 1974, theday she shot one under par on her homecourse at Eagle-Vail was equally a high pointin her life. In fact, her fanatic devotion to golfsometimes worries her. Last year, she played85 rounds of golf and logged 50 days of ski-ing. “I wasn’t skiing enough,” says Cindy, “so

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arthritis in young, healthy patients, cartilagerepair is an area of intense investigation.

Three biological factors are required forthe repair of a tissue, whether it is cartilage,ligaments or tendons: (1) cells, (2) cytokines(growth and differentiation factors), and (3) a scaffold or matrix to support the cells. Alltissue repair strategies, directly or indirectly,include these components. Microfracture, forinstance, relies on the formation of a bloodclot at the site of injured cartilage. This “super-clot” is thought to provide growth factors aswell as a scaffold for cells from the bone marrow cavity to fill and repair the chondral(cartilage) injury. In this case, the body provides all three components for formation of repair tissue.

Cells are the key component in the repairprocess. In the right environment, cells arecapable of synthesizing both the cytokines andscaffolds required to create a functional tissue.The two classes of cells used for cartilagerepair are chondrocytes (cartilage cells) andmesenchymal stem cells. The two classes ofcells used for tendon or ligament repair arefibroblasts and mesenchymal stem cells.Chondrocytes may be used to repair an injuredjoint by taking a plug of cartilage from anuninjured site and transplanting it to the dam-aged area (mosaicplasty). Similarly, tendonscan be transferred to deficient ligamentdefects. In this case, the cells are moved withtheir pre-existing scaffold and factors.Alternatively, cells from a harvested area ofcartilage may be isolated, multiplied in the lab-oratory, and then reinserted into a chondraldefect (autologous chondrocyte implantation).Using chondrocytes has the advantage of pro-viding cells that are capable of forming authen-tic cartilage. The obvious disadvantages ofthese techniques are that a tendon or an unin-jured area of cartilage must be damaged toprovide chondrocytes and fibroblasts, andthere is a limited supply of these cells.

To circumvent these problems, manyresearchers are focusing on mesenchymalstem cells. These cells are progenitor cells thatcan develop into a variety of tissue types,including bone, tendon and cartilage. Underthe right laboratory conditions, stem cells iso-lated from bone marrow, muscle, skin andeven fat take on the appearance of the cellsneeded in the defect. In contrast to the harvestof chondrocytes, harvest of these tissues canoccur with minimal morbidity to a patient. Forexample, a tablespoon of fat could be takenfrom the waist or buttock without harm.However, it remains to be seen whether theycan develop into functional repair tissue.

Cytokines will also play a key role inrepairing tissue defects. These protein factorscan enhance both the growth and metabolismof the repair cell. In addition, they can directstem cells to express some of the characteris-tics of the repair cell. Cytokines can be pro-duced in the laboratory using recombinantDNA technology. These recombinant proteinscan be injected directly into joints, and theymay enhance the healing of cartilage injuries.The disadvantage of injecting cytokines is thatthe injected proteins often are diluted ordegraded, thereby necessitating multiple injec-tions. Therefore, new, longer-lasting formula-tions of these factors are being developed.

An alternative to using recombinantcytokines is to provide them using gene therapy. As Dr. McIlwraith discussed previously(see Fall/Winter 2001 Newsletter), gene thera-py is a technique in which the gene for a spe-cific protein (such as a cytokine) is introducedinto a cell. This in turn provides the instruc-tions for the cell to manufacture this protein.Compared with protein injections, gene thera-py provides a longer action, since the treatedcells are able to continuously make the desiredgene product. On the downside, the virusesused to introduce new genes may damagecells, induce immune reactions, or change thegenetic make-up of cells.

Scaffolds are the final component of tissuerepair. These provide an environment for cellsto develop into repair tissue. Many scaffoldsare being developed and tested in cartilagerepair, including natural molecules such ascollagen and hyaluronic acid (both of whichare components of cartilage, tendons and liga-

ments) as well as biodegradable syntheticmaterials.

Tissue engineering is the science of creat-ing living tissue to replace, repair or augmentdiseased tissue. Using a combination of cells,factors and scaffolds, researchers seek todevelop tissues that can be surgically implant-ed to replace injured cartilage or ligaments.Such tissues are still in the developmental stage and have not yet been approved for clinical use.

In one possible strategy for engineeringreplacement of damaged tissue (Figure 1),stem cells would be isolated from an expend-able site such as fat. These stem cells would begrown in the laboratory. During this time,cytokine treatment would be used to firstinduce these cells to multiply, and then toassume a fibroblast of chondrocyte. Thesecytokines could be provided by either addingrecombinant protein or by using gene therapy.The cells would then be seeded onto a scaffold(sponge), which would further stimulate themto take on cartilage-like or ligament-like char-acteristics. Genes would be added to the cellsat this point as well. Following a period ofgrowth under appropriate mechanical and bio-logical conditions, the cell-seeded matrixwould then be surgically implanted in a tissuedefect, thereby restoring the function of theinjured structure.

While the best solution to cartilage or ligament repair remains to be determined, it is clear that biologic approaches such as celltherapy, cytokine therapy and gene therapy will play a significant role in this importantresearch.

Tissue Engineering

Figure 1. Stem cells are isolated from fat.

14

New Technology EnablesTotally Arthroscopic RotatorCuff Repair By Paul WilliamsMediaLine Communications

For 41-year-old Denver software engineerScott Sartin, physical activity has always been away of life — biking, skiing, piloting smallaircraft and exercising in general are amonghis passions. But a nasty skiing injury inDecember of 2001, which tore his left rotatorcuff, left Scott unable to do many of the activi-ties he enjoys.

“I’m left-handed,” he says, “sobeing unable to move my left armmore than six inches out from mybody without excruciating pain was abig deal. I found myself using my rightarm to literally lift my left hand up tothe desk to work on the computer. Itwas awful.”

Aided by over-the-counter pain medica-tion, Scott left the injury untreated for fourmonths — thinking it was just a severe strain.

“With no increased mobility in sight andno end to the pain, I knew I needed to havesomething done if I was going to pilot a planeor ski again,” he says. “I was hoping I wouldn’thave to have major, open surgery, and amazingly, Dr. Ted Schlegel at the Steadman-Hawkins Clinic in Denver introduced me tosomething new that was minimally invasive —and effective.”

Each year, an estimated four million peo-ple in the United States seek medical attentionfor shoulder injuries. Of those, nearly 300,000undergo surgical repair of the rotator cuff.The vast majority of these surgeries are performed by open surgical techniques. Less-invasive arthroscopic rotator cuff repair hasshown promise as an alternative to invasiveprocedures, but it has not become common-place, largely because it is technically difficultto perform — visibility is difficult and thecomplex knot-tying procedures involved leavemany surgeons frustrated.

Indeed, Dr. Richard Hawkins of theSteadman-Hawkins Clinic in Vail reports thatsurgeons have long sought a means to per-form minimally invasive, arthroscopic surgeryto repair torn rotator cuffs without having totie knots at all. “Having to tie knots duringarthroscopic rotator cuff repairs has been arecurring obstacle for many surgeons,” hesays. “We’ve mastered certain arthroscopictechniques, but they are not for every surgeon

and it is a difficult procedure to teach. Allorthopaedic surgeons perform better cuffrepairs with open procedures than witharthroscopic procedures. That simple fact hasbasically prevented the more difficult, lesseffective arthroscopic option from becomingmore widely used.”

However, thanks to a series of ground-breaking biomedical innovations and animalstudies, a handful of shoulder experts acrossthe country, including Drs. Hawkins andSchlegel, are pioneering a system that helpssimplify minimally invasive, totally arthroscop-ic rotator cuff repair while aiming to matchthe outcomes of open procedures.

Working with Southern California-basedOpus Medical, the AutoCuff™ System wasdeveloped, animal studies with Colorado StateUniversity were commissioned, and a newarthroscopic technique is now being used torepair torn rotator cuffs at the Steadman-Hawkins clinics. The just-launched, FDA-approved technology enables surgeons to per-form rotator cuff repair without open surgeryor knot-tying of any kind.

Working with Dr. Simon Turner, professorof Clinical Sciences at Colorado StateUniversity, Drs. Hawkins and Schlegel con-ducted a healing study on sheep with simulat-ed torn rotator cuff repairs conducted usingthe AutoCuff System. The study culminatedwith positive results.

“The animal studies we performed atColorado State University were invaluable,”says Dr. Schlegel. “From these studies it was

possible to determine the specific capabilitiesof the instrumentation used for our proposedarthroscopic procedures. This research pro-vided us the confidence that we needed toassure us that the technique was safe andeffective for patients.”

“The results of the animal study wereencouraging,” says Dr. Hawkins. “We realizedwe now had a technology that enabled us toperform a repair on the rotator cuff that wasequal in result to an open procedure, but per-formed arthroscopically.

The system itself is comprised of twoinstruments, the SmartStitch™ SuturingDevice and the Magnum™ Knotless FixationImplant. When used together, they eliminatethe shortcomings of current shoulder repairdevices. The SmartStitch Suturing Device deliv-ers a unique “incline” mattress stitch directlyinto the tissue in a matter of seconds. The sur-geon then loads and deploys the MagnumImplant, a device containing an internal mech-anism that provides cinchable and reversiblesuture tension to achieve an excellent tissue-to-bone interface result — without knots.

When Opus performed demonstrations ofthe AutoCuff System at the American Academyof Orthopaedic Surgeons in February, theirbooth was literally swarmed by interested sur-geons. Officially launched that same month,the AutoCuff System has now been utilized byover 25 surgeons in more than 200 patientsnationwide. Dr. Hawkins says that Steadman-Hawkins Fellows are now all being taught thesystem and that the outlook is good for more

Scott Sartin

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surgeons to adopt the technique nationwide.“The very nature of this device encourages

increased usage of the arthroscopic tech-nique,” says Dr. Hawkins. “In my opinion,many surgeons previously resigned to opensurgery will try arthroscopic procedures as aresult of enabling technology being madeavailable to them.”

After an arthroscopic procedure per-formed by Dr. Schlegel and utilizing the OpusAutoCuff system, Scott Sartin, who is onceagain piloting planes, biking and, yes, skiing,is among the early success stories.

“It’s hard to believe that Dr. Schlegel wasable to return my left arm to full mobility with-out performing an open procedure,” he says.“I’m even weightlifting again — and I can tellyou that my left arm is now stronger than myright!”

Dr. Schlegel explains that most rotator cuffinjuries are in fact not caused by accidentslike Scott’s. “More often they result from over-use injuries,” he says. “Rotator cuff injuriesare prevalent because, as we age, structuressuch as the rotator cuff become more suscep-tible to injury. It’s our hope that as arthro-scopic rotator cuff repairs become more com-mon, individuals will seek treatment for theirtorn rotator cuff rather than live with chronicpain.”

“To match the result of an open proce-dure,” says Dr. Hawkins, “we’ve been facedwith developing a system that enables us toeasily place a good stitch, provide strong fixa-tion, and avoid knot-tying. The AutoCuffSystem meets those criteria. The good newsfor patients is that, thanks to the advent of this technology and the highly positive resultsof the animal studies performed with SimonTurner at Colorado State University, it lookslike this option is about to become more commonplace.”

Long-Term ResultsMicrofracture Knee Repair: LessPain, More Gain Bruce JancinDenver Bureau, Family Practice News

TORONTO — The microfracture techniquefor the repair of articular damage in the kneeshows impressive benefits in a series of ath-letes followed for 11-plus years, Dr. J. RichardSteadman reported at a symposium of theInternational Cartilage Repair Society.

The 71 patients underwent microfracturefor acute severe symptomatic traumatic chon-dral defects without degenerative joint diseaseor anterior cruciate ligament injury. At a meanof 11.3 years after surgery, they continued toshow marked functional improvement andreduced pain, said Dr. Steadman, director ofthe Steadman-Hawkins Clinic and SportsMedicine Foundation in Vail, Colo.

The group’s mean score on a 10-pointactivities-of-daily-living scale went from 5.3preoperatively to 8.1 at 11.3 years. Thepatients’ ability to perform strenuous workrose from 5.2 to 7.9, and their ability to com-pete in strenuous sports rose from 4.2 to 7.1.The patients’ Lysholm score, a widely usedmeasure of functional outcome, rose from 59 to 89.

Most importantly, no functional deteriora-tion was noted between the 2- and 11-yearfollow-ups. Three-quarters of patients todaydescribe their surgical knee as feeling normal, as if it had never been operated on.

“It seems to be a tough, durable repair process that lasts over time,” said Dr. Steadman.

Dr. Steadman also presented another studyinvolving 14 National Football League players,in whom he performed microfracture. Theplayers were followed for a mean of 6.5 yearsand a maximum of 14 years afterward.

Preoperatively, the players’ mean Lysholmscore was 54, climbing to 92 at follow-up. Butthe most important outcome measure in thisgroup of pro athletes was this: Thirteen of the14 were able to return to the NFL, where theyaveraged another six seasons and 74 games of play.

“We felt that this was a validation of theprocedure. These are supersized athletes —their average weight was about 275 pounds —and we felt that this must be pretty durable tis-sue if it’s holding up as well as it did forthem,” Dr. Steadman said.

The microfracture procedure, which isalso effective in patients with degenerative

joint disease, is done arthroscopically. First, it entails shaving away all unstable

cartilage at the lesion site to create a circum-ferentially stable rim to the defect.

Next, the calcified cartilage at the base ofthe lesion is completely removed. Any underly-ing sclerotic bone is burred off.

Finally, an arthroscopic pick or awl isemployed to create a series of 2mm- to 4mm-deep microfractures 3-4mm apart in the sub-chondral bone.

“If you don’t get punctate bleeding,” saidDr. Steadman, “you need to go a little deeper.”

A slow rehabilitation making early andextensive use of continuous passive motionand eight weeks without weight bearing is crit-ical to success, he added.

The concept is that the microfracturesallow release of mesenchymal stem cells fromthe bone marrow, which under the influenceof synovial fluid and the subchondral bonebecome chondrocytes capable of forming collagen-rich cartilage.

Dr. Steadman developed the microfractureprocedure and has done more than 2,000cases.

“It’s technically not complicated. It’ssomething that virtually any experiencedorthopaedic surgeon should be able to per-form equally as well as perhaps more skilledsurgeons. And it doesn’t burn any bridges interms of follow-up procedures if it doesn’twork satisfactorily,” the surgeon commented.

Dr. Steadman added that he is convincedthat long-term outcomes in patients undergo-ing microfracture today will be significantlybetter than in the series he is now reportinginvolving patients operated upon more than adecade ago. Studies in horses during the lastseveral years have led to technical improve-ments in the procedure, the most important ofwhich is a new emphasis upon meticulouspreparation of the lesion bed.

Reprinted from Family Practice News, October 15, 2002, copyright 2002 by InternationalMedical News Group, an Elsevier company.

Microfracture holes are 3-4 mm apart.A fat droplet is released from the marrow.

Procedure is finished as sclerotic bone isremoved, leaving punctate bleeding. Photos courtesy Dr. J. Steadman

ADMINISTRATION

James Silliman, M.D.Chief Executive Officer

John Welaj, M.B.A.Chief Operations Officer

Karyll NelsonBioSkills Laboratory Director and ExecutiveAssistant

DEVELOPMENT

John G. McMurtry, M.A., M.B.A. Vice President for Program Advancement

Rachele PalmerDevelopment Assistant/Data Base Administrator

Amy RutherDevelopment Coordinator

BASIC SCIENCE

William G. Rodkey, D.V.M. Director

CLINICAL RESEARCH

Karen K. Briggs, M.B.A., M.P.H. Director

Marilee Horan Research Associate

BIOMECHANICS RESEARCH LABORATORY

Mike Torry, Ph.D. Director of Biomechanics Research Laboratory

Kevin B. Shelburne, Ph.D.Senior Staff Scientist

Takashi Yanagawa, M.S.Research Fellowship/Internship

EDUCATION

Greta CampanaleDirector

TECHNICAL RESOURCES

Jean Claude Moritz Information Systems Manager

VISUAL SERVICES

Joe KaniaCoordinator

Karen Mehlhart Coordinator

The Steadman�Hawkins Sports Medicine Foundation is dedicated to keeping people of all ages physically active through orthopaedicresearch and education in the areas of arthritis, healing, rehabilita-tion and injury prevention.

Mark Your Calendar

Summer 2004 Steadman-Hawkins Colorado Classic, Celebrating aLifetime of Excellence. The Steadman�HawkinsSports Medicine Foundation presents an evening ofVail Valley cuisine, music, golf and the opportunity tobid on dreams of a lifetime. For more information,contact Rachele Palmer at (970) 479-5809; E-mail to:rachele.palmer@shsmf.org, coloradoclassic.org

August 2004 Third Vail Cartilage Symposium. For more informa-tion, call Greta Campanale, (970) 479-5782;E-mail to: greta.campanale@shsmf.org

Your Legacy, Our Future. Please remember Steadman�Hawkins SportsMedicine Foundation in your will, trust or otherestate plan.

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Steadman�Hawkins Sports Medicine Foundation is a tax-exempt 501 (c) (3) charitable organization dedicated to keeping people active.