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Biologics in Sports Medicine—Introduction

Disclosures Laura A. Vogel declares no conflicts of interest; Mary Beth R. McCarthy receives intellectual property royalties from Arthrex, Inc. Augustus D. Mazzocca is a paid consultant for Arthrex, Inc. and Orthofix, Inc. and receives research support from Arthrex, Inc. Introduction Biologic therapies have been an area of interest within sports medicine for many years as a means to maintain function in both active and aging…

Allograft Tissue Safety and Technology

Disclosure Statement Dr. Moore, Mr. Samsell, and Dr. McLean are employees of LifeNet Health, a nonprofit organization. Introduction Biologic tissues are among the many clinical options available to orthopedic surgeons, with over 1 million annual implants of human allografts alone. Such biologic tissues may be considered structural, for example, tendons or cortical bone struts, or nonstructural, such as ground demineralized bone matrices (DBMs) or amniotic membranes.…

Biologics in Orthopaedic Surgery

Bone Marrow Aspirate Concentrate Bone marrow aspirate concentrate (BMAC) is derived from fluid obtained from bone marrow. Given the source of origin, BMAC contains a composition of cells—mesenchymal stem cells (MSCs), hematopoietic stem cells, endothelial progenitor cells, white blood cells, and red blood cells. Equally important, BMAC, along with a strong source of cells, also contains platelets, cytokines, and growth factors such as bone morphogenic proteins…

Growth Factors

Introduction There have been significant advancements over the last several decades in the field of orthopedic surgery with regard to our understanding of biomechanics, tissue healing, and the pathogenesis of musculoskeletal diseases. Biologics and regenerative medicine have received significant attention over the last decade with an aim to accelerate the healing process and potentially reverse degenerative processes. As research continues into current technologies such as bone…

FDA Regulations and Their Impact

Disclosure Statement Anz: Consultant for Arthrex; Pinegar: no disclosures. Introduction Progress of biologics in orthopaedic surgery, or orthobiologics, currently faces a delicate balance involving providers sprinting to apply clinically and profit on unproven technologies and the marathon of technology development through translational medicine. Weighing the balance is the orthopedic community and government regulatory bodies, while aspiring to move the front lines of patient care forward in…

Surgical and Endovascular Intervention for Arteriovenous Graft Thrombosis

Historical Background As of 2007, 527,000 patients received treatment for end-stage renal disease in the United States. During this same year, approximately 1500 access interventions were performed per 1000 patients. With the exception of dialysis itself, the most commonly performed procedures on patients with end-stage renal disease are open or endovascular interventions directed at maintenance of arteriovenous access. The modern era of hemodialysis began with the…

Distal Revascularization Interval Ligation Procedure

Historical Background The steal phenomenon was first described in 1969 by Storey and associates after creation of a Brescia-Cimino-Appel autogenous access. Steal can be a potentially limb-threatening event and must be promptly evaluated and treated if clinically significant. The goals for treating steal syndrome are twofold: restoration of antegrade flow sufficient to maintain distal perfusion and maintenance of the access for dialysis. Steal is seen more…

Unconventional Venous Access Procedures for Chronic Hemodialysis

Historical Background Despite the success of the Brescia-Cimino type subcutaneous arteriovenous fistula in 1962, the absence of suitable forearm vessels in many patients led to the evaluation of alternative conduits. In 1969 May and colleagues described the creation of a forearm arteriovenous fistula using autogenous saphenous vein. This was soon followed by the evaluation of nonautogenous conduits, including the bovine carotid heterograft, as described by Chivitz…

Basilic and Femoral Vein Transposition

Historical Background In 1976 Dagher and colleagues reported a series of 23 upper arm basilic vein transpositions for hemodialysis. The procedure did not achieve widespread acceptance until after the first National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines were published in 1997. The first large series of femoral vein transpositions was published by Gradman and associates in 2001. The procedures are analogous but differ…

Forearm Loop Graft and Brachial Artery–Axillary Vein Interposition Graft

Historical Background Kolff’s development of hemodialysis in the 1930s led to a series of advances in the care of patients with end-stage renal disease (ESRD). Although native arteriovenous fistulas and homografts were initial cannulation options for dialysis access, the availability of prosthetic grafts in the 1970s afforded a number of new access sites. Nonetheless, this new type of access generated a new set of complications and…

Radial Artery–Cephalic Vein and Brachial Artery–Cephalic Vein Arteriovenous Fistula

Historical Background Although Kolff and colleagues reported the development of a hemodialysis machine for renal replacement therapy in 1944, maintenance hemodialysis did not become a reality for another 2 decades because of a lack of reliable vascular access. Simple venipuncture was initially employed, but peripheral veins would not support the flow rates necessary for dialysis. The Scribner-Quinton shunt was the earliest solution proposed and consisted of…

Sclerotherapy

Historical Background Sclerotherapy is the chemical ablation of abnormal veins. The modern goal of therapy is an irreversible fibrotic occlusion, followed by reabsorption of the target vessel. Sclerotherapy is an old technique revolutionized by recent technological advances. Elsholz performed the first known endovenous treatment when he used a chicken bone needle and pigeon bladder syringe in 1665 to treat venous ulcers. Pravaz invented the syringe in…

Surgical Treatment of Lower Extremity Deep and Perforator Vein Incompetence

Historical Background In 1968 Kistner was the first to describe direct surgical repair of incompetent deep venous valves. Indirect valve repair was first popularized in the early 1980s after report of the axillary vein transfer technique, which was followed by Gloviczki and colleagues’ description of angioscope-assisted external repair of venous valves in 1991. Surgical interruption of incompetent perforating veins to mitigate the effects of venous hypertension…

Endovenous Thermal Ablation of Saphenous and Perforating Veins

Historical Background Venous valve anatomy was first described in the 1500s, but with the exception of compression wraps, treatment for chronic venous disease (CVD) was not considered until several centuries later. Trendelenburg described saphenous vein ligation in 1891 as a treatment of varicose veins, but it was soon recognized to be associated with a high recurrence rate. Ligation and stripping of the entire saphenous vein became…

Varicose Vein Stripping and Ambulatory Phlebectomy

Historical Background By the 1890s Trendelenburg not only had developed the compression test to evaluate saphenous vein reflux but also had performed great saphenous vein ligations using a transverse upper thigh incision, thus establishing the foundation for surgical treatment of varicose veins. In 1916 Homans described ligation of the saphenofemoral junction as it is commonly practiced today. A major advancement was contributed by Mayo, who postulated…

Endovascular Treatment of Iliofemoral and Femoral-Popliteal Deep Vein Thrombosis

Historical Background Anticoagulation has long been considered the gold standard for treatment of lower extremity deep vein thrombosis (DVT). This therapy is effective at preventing DVT extension, pulmonary embolism, and DVT-related death. However, because anticoagulation does not dissolve thrombus, clot resolution is slow, relying on the intrinsic thrombolytic pathways. Although this is sufficient for isolated calf DVT, prolonged venous obstruction can lead to pronounced long-term morbidity…

Transjugular Intrahepatic Portosystemic Shunt Procedure

Historical Background In 1969 Rosch and colleagues reported the first transjugular portal venography and portacaval shunt placement in a canine model. At that time, they foresaw the potential therapeutic benefits of transjugular intrahepatic portosystemic shunt (TIPS) placement and recognized the importance of selecting the appropriate stent material for optimal shunting. In 1982 Colapinto and co-workers performed the first TIPS in a 54-year-old man with cirrhosis and…

Surgical Reconstruction of the Inferior Vena Cava and Iliofemoral Venous System

Historical Background The first direct venous reconstruction using a saphenous vein graft for “postphlebitic stasis” was reported in 1954 by Warren and Thayer. In the late 1950s and 1960s venous reconstructions for benign occlusions using a cross-pubic venous bypass were introduced by Palma and Esperon in Uruguay and later popularized in the United States by Dale. Although Perl first described the entity of venous leiomyosarcoma in…

Surgical Reconstruction for Superior Vena Cava Syndrome

Historical Background In 1757 Hunter was the first to describe a patient with compression of the superior vena cava (SVC) by a large syphilitic aortic aneurysm leading to thrombosis. In 1954 Schechter reported a series of 400 patients with SVC syndrome of which 75% were due to malignant neoplasm, predominantly primary lung tumors. Initial descriptions of surgical reconstruction of the SVC using polytetrafluoroethylene (PTFE), Dacron, or…