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• Female athletes have more stress fractures than their male counterparts. Stress fractures are more common in women with abnormal menstrual cycles.
• Anterior cruciate ligament (ACL) tears are 4-6 times as common in female than in male athletes. Non-contact ACL tears in women are largely due to problems in their patterns of muscle use.
• The faculty of the Department of Orthopaedics and Sports Medicine at the University of Washington are dedicated to making physical activity safe and enjoyable for women of all ages and abilities.

• Sarcomas are tumors that arise in the musculoskeletal system. Ewing’s sarcoma is the second most common variety of bone cancer in children and young adults.
• Ewing’s sarcoma is classified as a malignancy (cancer) due to its ability to invade and destroy local tissues and its propensity to spread (metastasize) to remote tissues, usually the lungs.
• Despite advances in chemotherapy, radiation therapy and limb-salvage surgery, only about 50% of children with Ewing’s sarcoma survive beyond 5 years after diagnosis.
• Ewing’s sarcoma is caused by a group of related genetic defects (mutations). The most common mutation involves an abnormal exchange (translocation) of DNA between chromosomes 11 and 22. This mutation results in production of an abnormal protein referred to as EWS/FLI1. EWS/FLI1 is referred to as a fusion protein since it consists of portions of two different proteins (EWS and FLI1)
• We have discovered that EWS/FLI1 in and of it self appears to be sufficient to cause Ewing’s sarcoma and it related tumors.
• Similar fusion genes and proteins cause other cancers such as leukemia and sarcomas of cartilage and fat. Ewing’s sarcoma serves as an ideal model to study all of these tumors.
•  Therapies that specifically target these fusion proteins show promise as potential treatments for a variety of cancers. We are now testing one of these therapies, developed in our laboratory, in mice that have been implanted Ewing’s sarcoma.

• A car crash may be an "accident" but the way in which forces are transferred to the occupants and their resulting injuries are not accidental - they are defined by the laws of physics and mechanics.
• Research into the biomechanics of injury and the incorporation of innovations such as frontal and side airbags, lap and shoulder belts, and booster seats for children have reduced injury and death from motor vehicle crashes.
• Today, however, significant numbers of people still suffer neck "whiplash" injuries in rear end impacts and serious head, chest, thigh, leg, foot and pelvic injuries in side "T-bone" crashes.
• Discoveries in the Department of Orthopaedics and Sports Medicine are defining the mechanics of these collisions and enabling improvements in vehicle safety equipment.

• Unstable pelvic ring injuries are unusual and potentially fatal injuries.
• Death may occur early after pelvic injury due to associated injuries and/or uncontrolled pelvic related bleeding.
• Poor clinical outcomes in patients with unstable pelvic fractures are blamed on associated nerve injuries, pelvic deformity, and incomplete healing.
• Realignment (reduction) and stable fixation of unstable pelvic ring fractures optimizes early and long-term clinical results.
• Pelvic fracture surgery is complicated for many reasons.
• Stable fixation of pelvic ring injury is founded on both clinical and mechanical research carried out by the faculty of Orthopaedics and Sports Medicine.
• Acetabular (hip socket) fractures are difficult injuries to treat effectively because of their deep and complex anatomy.
• Displaced and unstable acetabular fractures are treated with fracture reduction (realignment) and stable fixation constructs.
• Accurate reduction and stable fixation of acetabular fractures avoids traction, allows early patient mobilization, and lowers the risk of post-traumatic hip arthritis.

• Collagen, the protein polymer underlying the mechanical strength of essentially all tissues, comes in many different varieties. The highly evolved frameworks of bone and cartilage are examples.
• Defects in collagen, from genetic abnormalities to acquired proteolytic damage, are key to understanding many common human diseases, for example brittle bones (osteoporosis) or worn out joints (osteoarthritis).
• Our basic research on collagen has led to new approaches for monitoring bone metabolism clinically and advances in knowledge on the basic science of cartilage.
• Examples of such bench-to-bedside progress include the development of a whole new class of biomarkers for assessing bone breakdown in osteoporosis, a sophisticated test for a rare inherited form of brittle bones and insights on the unique structure of collagens in joint cartilages that explain their longevity.
• In the next decade a breakthrough is likely in understanding the mechanism by which bone cells mineralize collagen with potential new approaches for preventing and treating osteoporosis.
• Likewise progress defining mechanisms that underlie the destruction of the collagen fabric of articular cartilage in osteoarthritis and of intervertebral discs in the painful spine will lead to new therapeutic approaches.

• Arthritis of the hip refers to the destruction of cartilage between the femoral head (ball of the thigh bone) and the acetabulum (hip socket of the pelvis). Hip arthritis affects millions, causing pain and stiffness, and results in difficulty performing normal activities, such as walking, dressing, and getting in and out of a car. Patients are often unable to enjoy recreational activities, such as golf, cycling, and hiking.
• Arthritis of the hip can result from several causes; the most common is osteoarthritis, while rheumatoid disease, injury or fracture, and avascular necrosis are other frequent causes. Many patients with hip arthritis can be managed with non-operative interventions, such as changing activity, medication, or physical therapy. However, when pain and disability become severe, patients can choose to have hip replacement surgery. A successful hip joint replacement can restore comfort and function, with long lasting and durable results. About 300,000 patients undergo hip replacement every year in the United States.
• The surgeons of the Department of Orthopaedics and Sports Medicine are using newer "minimally-invasive" approaches that appear to permit faster and less-painful recovery following total hip replacement surgery.
• Our arthritis surgery team is working to discover ways to prevent functional limitations for patients with arthritis, by identifying patients at risk, by minimizing the progression of the condition, and by speeding the recovery from hip reconstructive surgery.

• Pediatric hip disease is major source of adult hip arthritis.
• Arthritis from pediatric hip disease can usually be prevented by proper screening and care of the child’s hip.
• The faculty at Seattle’s Children’s Hospital and Regional Medical Center (CHRMC) are discovering new ways to prevent and manage pediatric hip problems in ways that enables children to grow up with comfortable and functional hip joints.

• Impaired muscle function has been associated with delayed bone healing and non union of fractures.
• We have developed a novel in vivo model and used it to demonstrate that transient paralysis of the quadriceps muscle leads to delayed fracture healing.
• The development of this novel model provides the first opportunity to directly explore the cellular mechanisms underlying the relation between muscle impairment and compromised bone healing.
• We are working to translate this discovery into clinical practice.

• Fractures of the shaft of the femur (thigh bone) typically occur as the result of high-energy trauma in young patients. The common mechanisms of injury are motor vehicle accidents, motorcycle crashes, and falls from height.
• Femur fractures are often associated with potentially life-threatening injuries to the chest, abdomen, head or pelvis.
• When femur fractures were treated by bed rest and traction, they were complicated by pneumonia, bedsores, and bowel and bladder problems.
• Treatment by traction often resulted in failure to heal (non-union), and poor restoration of the normal alignment (shortening, angulation and rotation). Our faculty adapted a German technique for treatment of fractures of the femoral shaft that consisted of driving a metal spike (intramedullary nail) down the inside of the bone. We further discovered that intramedullary nailing could be accomplished with only a small incision cosmetically satisfactory incision. This method of immediate stabilization of the fracture enables the patient to get out of bed, avoiding the complications of bed rest. This method dramatically reduces the risk of non-union and malunion.
• Our faculty have taught our approach to intramedullary nailing to surgeons around the world, resulting in a dramatic drop in the complications from this serious injury.
• We are striving to discover ways to further advance the care of femur fractures by developing approaches for the management of more complex injuries, such as those with many fragments, those that extend into the joint, and those that are associated with major skin and soft tissue damage.
• Our faculty, residents and fellow alumni have become contributors in the international community of academic surgeons pursuing improved management of the injured patient, including the Orthopaedic Trauma Association, the AO (Arbeitsgemeinschaft für Osteosynthesefragen) Foundation, the Orthopaedic Research Society, the American Academy of Orthopaedic Surgeons, and the American Orthopaedic Association.

• Knee arthritis refers to the loss of the normal cartilage between the femur (thigh bone) and the tibia (leg bone). It is a common cause of difficulty with activities of daily living, such as walking, dressing, and getting in and out of a car as well as the inability to enjoy recreational activities, such as golf, cycling, and hiking.
• Most patients with knee arthritis can be managed with non-operative interventions, such as activity modifications, pills, or injections. When the knee arthritis becomes more severe, some patients elect to have knee replacement surgery. A successful knee joint replacement can restore comfort and function.
• Newer "minimally-invasive" approaches to the knee appear to permit faster and lesspainful recovery following total knee replacement surgery.
• We are working to discover ways to prevent functional limitations for patients with arthritis of the knee, both by minimizing the progression of the condition as well as by speeding the recovery from reconstructive surgery.

• Healthy knees are something that we all take for granted, but getting a knee injury can often take us right off the ice and straight into the penalty box!
• The knee is made up of three bones, the distal femur (or bottom end of the thigh bone), the proximal tibia (or the top end of the shin bone), and the patella (more commonly called the knee cap).
• Tremendously strong ligaments hold the relationships between the distal femur and the proximal tibia, yet allow the knee to bend and straighten as a smooth, stable and comfortable hinge.
• Large fibrocartilagenous structures called menisci are located between the distal femur and proximal tibia. They help maintain joint stability and transmit loads between the two bones.
• Strong muscles and tendons cross the knee joint to give us power when doing activities as simple as getting out of a chair, or as complex as running through the defensive line toward the end zone.
• Knee injuries can range from a simple sprain of the ligaments as may occur after a small trip and fall, to complete ligament ruptures that are commonly seen during sporting events, to complex fractures that occur after falls from a height, high-energy sports activities like skiing, or car accidents.
• One of the many challenging fracture patterns that occurs around the knee involves the upper end of the shinbone know as the tibial plateau.
• Orthopaedic trauma surgeons at the University of Washington are discovering new and less invasive methods for reassembling and stabilizing knees with these complex fractures so that the patient can regain his or her lost comfort and function.

• A compartmental syndrome is a condition in which increased pressure in a confined space compromises the circulation and function of the contents of that space.
• Compartmental syndromes most often arise when swelling of muscle occurs in a part of the arm or leg that is confined by a tough tissue known as fascia.
• Compartmental syndromes are common causes of permanent disability following injuries such as fractures of the leg, fractures of the forearm and arm, dislocation of the elbow or knee, and prolonged pressure on the arm or thigh.
• Compartmental syndromes may also arise from excessive exercise, such as prolonged running or marching.
• The most practical and sensitive method for evaluating an arm or leg for possible compartmental syndrome is repeated clinical examination looking for (1) pain out of proportion to what would be expected from the clinical situation, (2) weakness of the muscles in the compartment, (3) diminished sensation in the distribution of the nerves running through the compartment, (4) pain on passive stretch of the muscles in the compartment, and (5) tenseness on palpation of the compartment
• If untreated, compartmental syndromes can lead to permanent deformity and loss of function, including both strength and sensation in the hand or foot.
• Because tissue has a very limited tolerance for increased pressure, the diagnosis of compartmental syndrome needs to be made promptly and surgical decompression needs to be carried out within hours of its onset.
• Once a compartmental syndrome is present, elevation of the limb above the heart further compromises the circulation to the compressed tissues.
• When a large amount of muscle dies as a result of a compartmental syndrome (rhabdomyolysis), there is a risk of kidney failure.
• In conditions where the risk of compartmental syndrome is high, preventative treatment, known as prophylactic fasciotomy is considered.

• Fractures of the tibial pilon are injuries than involve the ceiling or top of the ankle joint. These are distinguished from "ankle fractures" which involve the sides or malleoli at the ankle joint.
• Tibial pilon fractures are usually the result of high energy trauma. Typical mechanisms of injury are falls from height (for example, falls from a ladder, roof, or building), motor vehicle crashes, or motorcycle crashes. Sometimes they occur from other activities such as snow skiing.
• These injuries are incredibly difficulty to manage due to the amount of damage to the joint, the unforgiving nature of operating in this region, and the large number of potentially devastating complications.
• Restoration of the normal anatomy following a fracture of the roof of the ankle joint is challenging. If left untreated, patients can expect to have poor function, deformity, and difficulty with walking.
• The goals of treatment include restoration of the normal osseus anatomy of the ankle, as well as reconstruction of the joint surface. Avoidance of complications is difficult.
• Multiple studies have shown that the treatment for these injuries has a high complication rate. This has resulted in alterations in treatment that have improved results.
• The faculty of the Department of Orthopaedics and Sports Medicine at Harborview Medical Center have played and continue to play a key role in discovering safer and more effective methods for managing these serious injuries.

• Prior to the modern era of orthopedic trauma care, fractures of the foot were not anatomically aligned. Instead they were treated by immobilization in a plaster cast using crutches for protected weight bearing until the fractures were healed.
• Little attention was paid to the results of treatment in economic terms or in terms of quality of the patient’s life.
• We learned that displaced fractures treated in this casual manner often result in a stiff, deformed foot with post-traumatic arthritis with great limitations in functions of daily living, recreation and work.
• We found that many injuries of the small bones in the foot (tarsal bones) were overlooked because of their odd shapes and overlying shadows on x-rays.
• We have discovered better methods for diagnosing foot injuries and better and less invasive methods for surgical treatment of fractures and dislocations of the foot.
• These methods reduce the risk of arthritis and deformity while allowing the foot to be mobilized more quickly.
• The improvements are yielding reduced healing times and better long-term function.

• Deformities of the child’s foot are common:
  • Surgeons at the University of Washington Department of Orthopaedics and Sports Medicine have been discovering and applying effective methods for managing these deformities to optimize the chances for the child to develop a more normal foot.
  • Foot deformities may be congenital (genetically programmed and present at birth) or developmental (caused by nerve or muscle disorders and develop over time).
  • Sometimes the foot appears to be deformed, but the ‘abnormal’ appearance is only an anatomic variation that corrects spontaneously as the child matures. Identifying these variations is important to avoid over-treatment.
  • If surgery is required to manage the deformity, the distortions in each segment of the foot must be carefully defined and the treatment based on sound biological and biomechanical principles.
• Clubfoot is the most common congenital foot deformity:
  • Until very recently, the standard approach to clubfoot deformity correction was the application of a series of partially effective stretching casts, followed by extensive surgery in the infant. This treatment resulted in a foot that was stiff and became painful over time.
  • The present international standard treatment approach the Ponsetti Method - is a series of 4-8 casts followed by simple, minimally invasive release of the Achilles tendon. This method results in a flexible, strong, well corrected foot that remains comfortable and functional for decades.
• Flexible flatfoot (FFF) is the normal shape of the foot in most babies and at least 20% of adults. It rarely, if ever, causes pain or functional disability and should, therefore, be considered an anatomic variation rather than a deformity:
  • The longitudinal arch of the foot increases in height spontaneously in most children during the first 10-12 years of life.
  • There is no evidence that special ‘orthopaedic’ shoes, orthotics, or any other intervention can create or elevate the arch in a child’s foot.
  • FFF with a short, or contracted, Achilles tendon accounts for approximately 25% of FFF in adolescents and adults. This combination of deformities can cause pain and functional disability.
  • Joint preserving surgery that corrects the flatfoot shape and lengthens the Achilles tendon is used to relieve the pain and improve function.
• Cavus foot deformity refers to a longitudinal arch that is higher than normal. It frequently causes pain and functional disability: Cavus is the result of a nerve or muscle disorder in almost all cases and is, therefore, often progressive (gets worse with time). Treatment for the pain and disability of cavus foot requires surgery that addresses both the shape abnormalities and the unbalanced muscle forces.

• Musculoskeletal conditions are the #1 reason patients visit doctors. Over 28 million new cases of musculoskeletal impairment are reported each year. One out of 7 Americans is affected with a musculoskeletal condition. Musculoskeletal conditions cost an estimated $254 billion every year.
• Individuals with musculoskeletal conditions usually present themselves first to primary care physicians.
• Family medicine, primary care internal medicine and primary care pediatrics are the most common specialties chosen by medical students.
• Many primary care physicians are uncomfortable with the evaluation and ambulatory management of common conditions such as frozen shoulder, recurrent ankle sprains, or low back pain.
• The Department of Orthopaedics and Sports Medicine in concert with the Departments of Biological Structure, Physical Medicine and Rehabilitation, Family Medicine, and Internal Medicine have been national leaders in assuring that our medical students have a foundation in musculoskeletal medicine.
• Our research in musculoskeletal medicine education has helped us discover knowledge gaps and define curricular changes to better prepare students for careers in primary care medicine with enhanced competency in musculoskeletal medicine.

• Carpal tunnel syndrome is a very common disease causing numbness and tingling in the fingers.
  • Patients often report a “pins and needles” sensation in their index and middle fingers. It commonly wakes them up at night.
  • Traditionally, the surgical treatment of carpal tunnel syndrome has been with a large open incision in the palm. - At the University of Washington Hand Center we have worked hard to perfect a minimally invasive surgery for the treatment of carpal tunnel syndrome.
  • Endoscopic surgery for carpal tunnel syndrome involves only a minimal incision at the wrist and provides a more rapid return to use of the hand.
• Arthritis of the base of the thumb is another common condition that affects our patient’s hands.
  • It can be a painful, often debilitating disease that prevents patients from using their hands normally.
  • At the University of Washington Hand Center we have developed a new form of joint replacement for thumb arthritis.
  • Our studies have shown that patients are very satisfied with this procedure.

• The wrist is one of the most complex joints in the body, including a total of ten bones and the ligaments joining them (Figure 1).
• Any one of these bones can be broken, and any one of the ligaments stabilizing these bones can be torn.
• Often these injuries occur in young, active persons who do not initially realize the severity of their wrist injury, and who do not seek medical attention until their pain does not improve.
• If fractures or complete ligament tears are diagnosed early, it may be possible to repair them directly and achieve a good outcome, with nearly normal wrist function.
• If left untreated, fractures or ligament injuries in the wrist can result in bones moving out of position and eroding wrist cartilage. This condition, known as post-traumatic arthritis, generally requires more extensive treatment than simple bone or ligament repair.
• Treatment for post-traumatic wrist arthritis may include removal of the arthritic bones or surgically fusing some of the bones together. Fusion may reduce the pain, but also reduces the motion of the wrist.
• We have discovered that early diagnosis and prompt treatment of wrist injuries are the keys to restoring comfort and function to the injured wrist.

• Fractures of the elbow often involve the upper ends of the forearm bones - the radius and the ulna.
• The upper end of the radius takes the form of a rotating joint surface called the radial head.
• The upper end of the ulna is in the form of a stabilizing concavity with the olecranon process at one end and the coronoid process at the other.
• The radial head and the coronoid process are primary bony stabilizing features of the elbow joint.
• Injuries of the radial head and coronoid process can lead to a painful and unstable elbow joint.
• The faculty of the Department of Orthopedics and Sports Medicine are discovering improved methods for evaluating, understanding and managing injuries to these key elements of the elbow joint.

• Shoulder arthritis is a disabling condition that prevents otherwise healthy individuals from sleeping, carrying out activities of daily living and from enjoying sports and other physical activities. In this condition, the normally smooth cartilage surfaces of the ball and socket of the shoulder are lost because of injury, degeneration, inflammation, or surgical misadventure. As a result, the joint loses the characteristics essential for normal function: flexibility, strength, stability and smoothness.
• As recently as fifty years ago, the treatment for shoulder arthritis was nothing more than exercises in which the patient leaned over swinging a heavy weight held in the hand to try to pull the damaged joint surfaces apart. The modern era of shoulder replacement began in the 1950’s, when Charles S. Neer II introduced a smooth metal ball to replace the damaged joint surface with a stem to fix the ball to the arm bone.
• Since then, the art and science of joint replacement for the different types of shoulder arthritis has and continues to progress rapidly. Many of the key discoveries are taking place at the University of Washington, where a particular emphasis is placed on minimally invasive, biological approaches to joint reconstruction directed at the best possible return of the shoulder to comfort and function.

• Each year many individuals lose parts of their arms or legs because of tumors, injuries or infections.
• Surgeons of the Department of Orthopaedics and Sports Medicine are continuing to discover better methods for restoring function to individuals who have lost their limbs.
• Traditional upper extremity prostheses use power from straps attached to the shoulders to control the movement at the elbow and the grasping device that replaces the lost hand.
• Myoelectric prostheses use signals from active muscle contractions in the affected limb to control the movements of the prosthesis
• Individuals with below elbow amputations have always performed well with myoelectic prosthesis:
  • Amputation below the elbow retains some portion of volar and dorsal forearm muscle that contracts and generates an electrical signal when the brain thinks about closing or opening the hand.
  • This results in a more natural ‘brain thought ? forearm muscle contracture ? myoelectric signal to the prosthesis ? hand action’ pathway.
  • Learning and operating the forearm level prosthesis is often fluid and logical.
• Individuals with above elbow amputations have struggled with myoelectic prosthesis:
  • While some muscle still remains to generate a signal when thinking elbow-up and elbow-down, these is insufficient muscle remaining to respond when the brain thinks "hand-open" or "hand-close".
  • As a result, the normal above elbow amputee has only a "2 signal arm", without the ability to generate signals for hand function.
  • Using alternative pathways to operate the prosthetic hand required alternative brain thoughts not previously associated with hand function. Often biceps and triceps function was used to operate the elbow in one mode , and then by cocontracting the muscles a switch could be made to a second mode to operate the hand.
  • Switching modes, using elbow thoughts to operate the hand in mode 2, and nonsimultaneous elbow and hand function is slow and frustrating.
  • Learning and operating the forearm level prosthesis was difficult and the resulting mental calisthenics remained taxing and frustrating even after extensive training.
• Targeted nerve transfer surgery restores hand function signals in existing upper arm muscles:
  • We have discovered that we can ‘re-engineer’ muscles remaining in the arm by transferring nerves to them so that they generate more naturally the signals necessary to control the prosthesis.
  • Removal of the musculocutaneus motor nerve from the medial biceps, then transferring the median nerve to the motor point allows nerve in growth making the medial biceps a median nerve innervated muscle.
  • After 3 to 4 months the residual medial biceps in the upper arm amputation will contract when the brain thinks about hand closing.
  • Removal of the motor branch to the lateral triceps, and transferring the distal radial nerve to the motor point will likewise create a muscle segment to contract with hand open brain thoughts.
  • Above elbow amputee now has a 4 signal arm that can generate elbow-up, elbow- down, hand-open and hand-close signals with normal brain thoughts.
  • Simultaneous elbow and hand function is possible. - Training and uses of a myoelectric prosthesis is more fluid, and natural

• Loss of the cartilage of the ankle joint causes severe pain and stiffness, making it difficult for the patient to stand, walk, and run.
• This loss of cartilage can be caused by
  • Injuries to the ankle joint or to the bones and ligaments that stabilize and support it. Such injuries are by far the most common causes of ankle arthritis, pointing to the need for their prevention as well as early and expert management so that the risk of this complication is minimized.
  • Congenital problems, such as clubfoot or Charcot-Marie-Tooth disease. - Systemic inflammatory disease, such as rheumatoid arthritis, gout, hemachromatosis, or psoriasis.
• The team at the S.T. Hansen, Jr. Foot and Ankle Institute is committed to discovering better ways to prevent ankle arthritis and to restore comfort and function to patients who are disabled by this condition.