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Award winners (from left to right): James R. Kang, MD; Amanda Goldin, MD; Kevin C. Parvaresh, MD; Darren Thomas, MC, USN; Christopher Renninger, MC, USN; Grant Cochran, MC, USN; Jeremy D. Shaw, MD; and James R. Ficke, MD (OREF Visiting Professor).
Courtesy of CAPT D.C. Covey, MD, MC, USN (Ret.)

AAOS Now

Published 5/1/2017
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CAPT D. C. Covey, MD, MC, USN (Ret.); LCDR Lucas S. McDonald, MC, USN

Resident Investigators Showcase Their Research

A report on the 2016 OREF/ORS Southwest Region Resident Research Symposium
Last fall, the fourth annual Orthopaedic Research and Education Foundation (OREF)/Orthopaedic Research Society (ORS) Southwest Region Resident Research Symposium was held in San Diego, California.

The event showcased resident researchers from the University of California (UC) San Diego; Stanford University; University of California, UC San Francisco; Naval Medical Center San Diego; and Loma Linda University. Papers were judged by clinical and basic science faculty members from UC San Diego; Naval Medical Center San Diego; and by OREF Visiting Professor James R. Ficke, MD, Robert A. Robinson Professor and director, department of orthopaedic surgery at Johns Hopkins University, School of Medicine, in Baltimore.

Hosted by Steven R. Garfin, MD, chairman and distinguished professor, department of orthopaedic surgery, UC San Diego, the OREF/ORS Southwest Region Resident Research Symposium has continued to grow since its inception in 2009. This year, 26 residents were selected to present at the symposium.

The number of excellent abstracts was impressive, and the winners in both the clinical and basic science categories presented high-quality research, which the judges recognized. Participating residents found the event both rewarding and stimulating. 

"The symposium was a great experience," said Kevin Parvaresh, MD, a UC San Diego resident. "The conference provided a unique avenue for residents to share ideas and stimulate future research collaboration. It was a great way to gain valuable podium experience."

"OREF put on an excellent competition this year," agreed LCDR Grant Cochran, MC, USN, a resident from the Naval Medical Center San Diego. "The presentations were high quality and diverse. It was an honor to be a part of it." 

James R. Kang, MD, a resident from Stanford University, added, "The OREF/ORS Resident Research Symposium was a tremendous experience. I appreciated the opportunity to meet fellow residents from other residency programs and to learn about their great research projects. I am truly inspired to be amongst a group of peers that will continue to change our field in the future."

Congratulations to the winners!
The judges named the following winners, each of whom received an honorarium:

Basic Science—1st Place: Amanda Goldin, MD, UC San Diego, for "Ewing Sarcoma: A New Treatment with a Dual Phosphoinositide 3-Kinase/Bromodomain and Extraterminal Domain Inhibitor."

The study: Increased activity of the Phosphoinositide 3-kinase (PI3K) pathway and Bromodomain and Extra-Terminal (BET) proteins has been suggested in Ewing sarcoma (ES); however, no current treatments target these pathways. The study goal was to show the efficacy of a dual PI3K/BET inhibitor in ES. Through in vitro and in vivo studies, the researchers found a significant decrease in tumor growth with use of the inhibitors as indicated by cell proliferation, protein expression, tumor photon density and volume, histology, and periosteal reaction. Having previously entered into phase I trials with children with neuroblastoma, the investigators' findings suggest that PI3K/BET inhibitors will be effective and should be utilized in trials with children with ES.

2nd Place: James R. Kang, MD, Stanford Hospital and Clinics, for "Bennett Fractures: A Biomechanical Model and Its Relevant Ligamentous Anatomy." 

The study: The investigators hypothesized that the ulnar collateral ligament (UCL) is the primary ligamentous attachment to the Bennett fracture fragment, rather than the anterior oblique ligament (AOL), as has traditionally been reported. Six fresh-frozen cadaveric wrists were tested with a materials testing system. Bennett fractures were successfully created in all (six) cadaveric specimens. All fractures were displaced and intra-articular. The UCL was a robust ligament consistently attached to the palmar beak fragment, whereas the AOL was thin and variably attached. Pronation and radial abduction of the metacarpal reduced fracture displacement. This is the first reported study that reproducibly creates a cadaveric Bennett fracture model. The UCL was the main ligamentous structure attached to the palmar beak fragment. Tensioning this ligament reduced fracture displacement. The AOL was not a significant contributor to fracture creation or reduction.

3rd Place: Kevin Parvaresh, MD, UC San Diego, for "Analysis of Acetabular Ossification from the Tri-Radiate Cartilage and Secondary Centers."

The study: No studies have utilized advanced imaging to characterize the appearance and closure of the secondary ossification centers of the acetabulum. In the study, patients who underwent pelvic CT scans were retrospectively reviewed. Males between 8 years and 16 years and females between 6 years and 16 years of age were included. CT scans were assessed for the appearance and closure of the three acetabular secondary ossification centers [anterior (os pubis), superior (os ilium), and posterior (os ischium)] and closure of the triradiate cartilage (TRC). In all, 159 CT scans met inclusion criteria (66 males and 93 females). The median age of appearance of the secondary ossification centers was as follows: posterior (10.1 females, 12.8 males), anterior (10.7 females, 13.4 males), and superior (11.1 females, 13.6 males). The median age of closure of the secondary ossification centers was as follows: posterior (12.8 females, 13.6 males), anterior (12.8 females, 13.9 males), superior (14.5 females, 13.9 males), and TRC (14.5 females, 14.3 males). The researchers concluded that acetabular secondary ossification centers appear starting with the posterior, then the anterior, followed by the superior, with almost all centers closing just before the TRC. They also noted that closure generally occurs 2 years earlier in females than males.

Clinical Science—1st Place: LCDR Grant Cochran, MC, USN, Naval Medical Center San Diego, for "Retrospective Review of Low Energy Lisfranc Injuries in a Young Athletic Population: Primary Arthrodesis versus Open Reduction Internal Fixation."

The study: Primary arthrodesis (PA) has shown better short-term outcomes than open reduction, internal fixation (ORIF) in high-energy Lisfranc injuries, but no comparable literature exists for low-energy injuries. The purpose of this study was to retrospectively compare ORIF to PA in young, athletic patients with Lisfranc injuries. Thirty-two low-energy Lisfranc injuries in military personnel were identified. The researchers compared injury patterns, treatments, complication rates, fitness test scores, return to military duty rates, and Foot and Ankle Ability Measure (FAAM) scores. PA was performed in 14 patients and ORIF was performed in 18 patients. Eighty-eight percent of patients were able to return to military duty. The PA group returned at an average of 4.5 months, compared with 6.7 months in the ORIF group (P = 0066). There were no differences between the two groups in FAAM scores at an average of 35 months.

2nd Place: LCDR Darren Thomas, MC, USN, Naval Medical Center San Diego, for "Retrospective Analysis of Hip Arthroscopy Patients with Femoral Acetabular Impingement in a Military Population." 

The study: Femoral acetabular impingement (FAI) can lead to damage of the cartilage and labrum of the hip joint. The researchers' objective was to compare patient outcomes with Simple Assessment Numeric Evaluation (SANE) scores and demographic data against return to duty (RTD) for military patients who underwent hip arthroscopy after a diagnosis of FAI. A retrospective review of patients who underwent hip arthroscopy for FAI between 2009 and 2014 at one institution was undertaken. A total of 503 surgeries were performed (179 females, 324 males) with a mean follow-up of 2.5 years. The RTD rate for males was 45 percent and 23 percent for females. Infantry and Special Forces showed improved RTD rates compared to administrative occupations. Average improvement in SANE score was 37 points. The average postoperative SANE score for RTD was 87 points and 72 points for those not returning to duty (P < 0.0001). The researchers concluded that hip arthroscopy for the management of FAI is effective for pain relief but not for returning service members to full duty. They also found that lower RTD rates are associated with lower SANE scores.

3rd Place (Tie): LT Christopher Renninger, MC USN, Naval Medical Center San Diego, for "Operative and Nonoperative Management of Achilles Tendon Ruptures in Active Duty Military Population: A Retrospective Study."

The study: This study retrospectively compared surgical and nonsurgical management of Achilles ruptures in a military population. Achilles tendon injuries were identified at a single institution from January 2011 to January 2014. Rates of deep vein thrombosis (DVT), re-rupture, other complications, and return to duty (including time) were compared. Fifty-seven male patients (27 surgical and 30 nonsurgical) with a mean age of 31 years were included. There were no wound complications or significant differences in rates of re-rupture, DVT, return to duty, or other complications. The researchers found that surgical management allowed a return to duty on average one and a half months earlier (6.7 vs 8.2 months) than nonsurgical management (P = 0.04).

3rd Place (Tie): Jeremy D. Shaw, MD, UC San Diego, for "Intraoperative Methylene Blue Staining Allows for Visualization of Microbial Biofilm-Associated Tissue in Periprosthetic Joint Infection."

The study: The purpose of this study was to assess methylene blue (MB)-guided surgical debridement as a novel biofilm detection and eradication strategy in periprosthetic joint infection (PJI). A prospective-cohort of 16 total knee arthroplasty (TKA) patients meeting Musculoskeletal Infection Society (MSIS) criteria for PJI who were undergoing the first stage of a 2-stage exchange arthroplasty were included. Dilute MB (10 percent) was instilled in the knee prior to débridement; residual dye was removed and stained tissue was debrided. Paired tissue samples were collected from the femur, tibia, and capsule during débridement (stained) and after débridement (unstained). Samples were analyzed by neutrophil count, semi-quantitative culture, and quantitative polymerase chain reaction (qPCR) for Staphylococcal-species. The mean patient age was 64 years and the mean follow-up was 10.3 months. Across all samples, significantly more bacteria were found in MB-stained vs. unstained tissue based on semi-quantitative culture (Wilcoxon ranked-sign test, n=96, P = 0.0017). qPCR for Staphylococcal-species showed a 9-fold enrichment in MB-stained tissue (n = 30, P = 0.0007). Tissue pathology found a mean of 53±66PMNs/HPF in MB-stained vs 4±22PMNs in unstained tissue (n = 96, P < 0.0001). The primary infection was cleared in all patient subjects, and all underwent reimplantation. According to the researchers, these results demonstrate that MB preferentially stains bacterial biofilm-associated tissue in the context of PJI, suggesting a role for MB in providing a visual index of surgical débridement. 

CAPT D.C. Covey, MD, MC, USN (Ret.),of the department of orthopaedic surgery, UC San Diego, served as local event coordinator of the 2016 OREF/ORS Southwest Region Resident Research Symposium. He can be reached at dcovey@ucsd.edu

LCDR Lucas S. McDonald, MC, USN, of the department of orthopaedic surgery, Naval Medical Center, San Diego, served as a moderator of the 2016 OREF/ORS Southwest Region Resident Research Symposium. He can be reached at lucas.s.mcdonald.mil@mail.mil